Emergency department nurses’ experiences of occupational stress: A qualitative study from a public hospital in Bangkok,Thailand

Abstract

BACKGROUND:

Occupational stress has been a health-related issue among nurses for many decades. Emergency department nurses are frequently confronted with occupational stress in their workplace; in particular, they encounter stressful situations and unpredictable events. These encounters could make them feel more stressed than nurses in other departments. Research considering occupational stress from the perspective of Thai emergency department nurses is limited.

OBJECTIVE:

This study aimed to explore nurses’ perceptions of occupational stress in an emergency department.

METHODS:

A qualitative approach was used to gain an understanding of nurses’ experiences and perceptions regarding stress in their workplace. Semi-structured interviews were used for data collection. Twenty-one emergency department nurses working in a public hospital in Thailand were interviewed, and the data were analyzed using content analysis.

RESULTS:

The findings comprised three themes: (1) perceived stress, (2) consequences of stress, and (3) stress management.

CONCLUSIONS:

The results of this study can be used by hospital management to help them adopt effective strategies, such as support programs involving co-workers/supervisors, to decrease occupational stress among emergency department nurses. Future research that explores each of the themes found in this study could offer a more comprehensive understanding of nurses’ occupational stress in the emergency department.

Keywords

Stressor workplace nursing profession

1 Introduction

Stress is defined as an environmental stimulus that affects individuals and can provoke physical and psychological stress reactions [1]. Individuals perceive stress and experience stress reactions when their coping efforts are unsuccessful [1]. Stress in the workplace can be called occupational stress, which is defined as a harmful force that pushes a person beyond their psychological or physical well-being and occurs when the requirements of a job do not match the worker’s resources, capabilities, and needs [2 –4]. Increased occupational stress is a growing trend that has recently become a persistent global problem [3, 4]. The consequences of occupational stress can lead to poor physical and psychological health for individual employees and can also affect work organizations. In addition, an individual’s suffering, ill-health, and stress can cause absenteeism, high employee turnover, and low productivity [5 –7]. These consequences lead to jobdissatisfaction, decreased work ability, difficulties in social relationships and a low quality of life foremployees [7 –9].

Stress is particularly common among people who work in health care professions, including the nursing profession [9 –11]. Because of the nature of the nursing profession, nurses directly confront severe illness, suffering, grief, and death [12] and have an increased risk of workplace violence [13]. Nursing should therefore be considered a highly stressful occupation. Ito et al. [14] reported that nursing staff members feel stressed by a quantitative and qualitative job overload similar to that of physicians; however, they receive insufficient support from supervisors and coworkers and show the highest degree stress responses among healthcare professions.

Consequently, nurses encounter work situations with a high degree of stress, which can negatively impact their health. Previous research indicates that stress affects nurses’ physical and psychological health [15, 16]. Other studies have reported that the consequences of occupational stress in nurses are absenteeism and high staff turnover, which have an economic impact on the organization [17], decrease the quality of patient care, and decrease job satisfaction [8 , 18]. Furthermore, occupational stress in the nursing professions can lead to emotional exhaustion or burnout [19], which in turn may lead to a poor quality of nursingcare [20].

1.1 Occupational stress among emergency department nurses

An emergency department (ED) provides a full range of medical treatment facilities and specializes in the acute care of patients. Patients present without prior notice, either by their own means or by ambulance, at all times of day. Because of the unplanned nature of a patient’s arrival, the department must provide initial treatment for a broad spectrum of illnesses and injuries. Some patients may require immediate attention to address acute life-threatening conditions. Because of the nature of the ED, its nurses frequently confront unpredictable challenges and crisis situations, including sudden death, severe patient conditions, violence, trauma, and overcrowding, simultaneously and/or on a daily basis [21, 22]. These events are categorized as a high-demand job for ED nurses due to the Job Demand-Control-Support (JDCS) model [23] and may increase the chance of ED nurses becoming much more stressed than nurses who work in general areas [21, 22]. The JDCS model was developed by Karasek and Theorell [23]. It is one of the most influential work-related stress models and is supported by many empirical studies [24 –26]. The JDCS model describes the interaction of three dimensions: a) job demand, which refers to the workload or time pressure; b) job control, which is divided into two aspects: skill discretion, which refers to the opportunity for the employee to use his or her skills in the workplace, and decision authority, which refers to the employee’s autonomy in making task-related decisions; and c) social support at work, which refers to the overall levels of helpful social interaction available on the job from both co-workers and supervisors [23, 27]. The relationships among the three dimensions can produce a great deal of strain and harm to workers’ well-being [23]. Generally, the JDCS model describes an interaction between demands, supports and control at work. When the demand is high and the level of control and social support is low, employees have a greater risk of experiencing stress [23, 26].

It is assumed that occupational stress among nurses, including ED nurses, is caused by an imbalance between job demands, job control, and social support [28]. A previous study based on the JDCS model showed that ED nurses report more time pressure and physical demands, lower decision authority, less adequate work procedures and less reward compared with the general hospital nursing population [29]. These consequences increase the vulnerability of both physical and psychological health among ED nurses [29] and are related to poor patient care outcomes [21, 22].

1.2 The consequences of occupational stress in the ED

The physiological and psychological health of ED nurses is influenced by workplace stress [22]. McVicar [30] described the physiological effects of stress, such as cardiovascular problems, metabolic disorders, and gastrointestinal problems. These problems are related to the degree of stress that an individual experiences. Psychological effects, such as increased arousal, feelings of uneasiness, emotional exhaustion, depression, fatigue and burnout are also described in relation to stress. Furthermore, a previous study has shown that stressful incidents lead to a high rate of nurse turnover in the ED [31]. Gillespie and Melby [32] found that the effects of stress on ED nurses might lead to burnout, distress or anger and, eventually, absenteeism. Likewise, occupational stress has been shown to lead to a higher incidence of smoking among ED nurses comparedwith nurses in other departments [33]. Helps [34] found that ED nurses take more sick leave, smoke more and consume more alcohol, and report a decrease in overall health and well-being compared with nursesin general.

1.3 Occupational stress among nurses in Thailand

In Thailand, nursing and midwifery are ranked among the top echelons of the professional hierarchy in the health care system; nurses account for 70% of all health personnel in the Thai health care system [35]. As in other countries, Thai nurses may have to confront stressful or critical situations. A previous study by Lembert et al. [36] demonstrated that the two most stressful experiences in the workplace for Thai nurses are the workload and observation of patients’ deaths. Nantsupawat et al. [35] reported that almost one in four nurses (from a sample of 5,247) are dissatisfied with their job, and close to 40% of them experience burnout. Furthermore, the workplace environment affects nurses in Thailand; hospitals have unfavorable work environments, including inadequate staffing, resources, and organizational support. This leads to burnout and a fair or poor quality of nursing care [35]. Another previous study showed that nurses in Thai hospitals continue to experience high levels of stress from a lack of adequate organizational-departmental support or opportunities to participate directly in decision-making that ultimately affects their patients [37]. In addition, Tyson and Pongruengphant [37] concluded that workload, involvement with life and death situations, management interruptions, tasks that are beyond nurses’ competence, and the frequent need to perform doctors’ functions are all causes of stress among nurses in both public and private hospitals in Thailand. According to another study from Thailand [38], 63.4% of nurses experience high levels of stress. Factors associated with such stress levels are high expectations and demands and disrespect from patients, colleagues and supervisors. Additionally, 41.8% of Thai nurses report high job stress that leads to their own poor mental health, and 10.3% of them need to leave the profession [39].

In accordance with previous studies, stress exposure among nurses might lead to both ill health for individual nurses and poor patient care performance [35, 37]. However, these previous studies in Thailand describe nurses’ stress in the broader arena of the hospital, not specifically in the ED [35 –39]. Consequently, research into nurses’ working life is limited with regard to ED nurses’ perspective. The aim of this study is to explore the nurses’ perception of occupational stress in an ED in a public hospital in Bangkok, Thailand.

2 Methods

To explore ED nurses’ perceptions and experiences occupational stress in the ED, a qualitative research design was used. This approach aims to explore knowledge and phenomena through individuals’ experiences in their everyday lives [40].

2.1 Sampling and participants

A purposive sampling technique was used to recruit the study participants. The inclusion criteria were ED nurses, regardless of gender, with at least a bachelor’s degree in nursing science who were working full-time in an ED and had at least one year of experience in emergency care. The participants in the study included 21 ED nurses who were working full-time at a public hospital in Bangkok, Thailand; 17 were female and 4 were male, and their ages ranged from 23 to 55 years. All participants had a bachelor’s degree in nursing science, and one had a master’s degree in another discipline. Two of the participants were in the process of studying for a master’s degree in nursing science. The participants’ experience in emergency care ranged from one year to more than 21 years. All of the selected ED nurses who were invited to attend the interviews agreed to participate. The demographic data of the informants is shown in Table 1.

2.2 Data collection

The data were collected using semi-structured individual interviews with open-ended questions. The open-ended questions aimed to elucidate the participants’ experiences of occupational stress in the ED, including stress factors, the consequences of occupational stress, and the participants’ solutions for stress relief. The interview guide was based partly on previous research on occupational stress [21 , 41–44]. Semi-structured interviews were conducted, and follow-up questions, such as “Could you describe that experience?”, “How does this situation make you feel stress?”, and “Do you have anything to share?” were asked to obtain a better understanding of the participants’ experiences. The interviews were conducted between April 2012 and May 2012 as a part of a master’s thesis [45]. A private room in the ED was used for the first threeinterviews; thereafter, a quiet corner in the ED staff break room was used for the rest of the interviews. All 21 interviews were recorded using an audio-digital recorder and transcribed verbatim. The interviews ranged from 45 minutes to one hour in length.

2.3 Data analysis

The data were analyzed using content analysis to create a conceptual form for describing the phenomenon of the occupational stress among ED nurses at a public hospital in Bangkok, Thailand [46]. The analysis process started with obtaining a sense of the whole data set; the audio-recordings were listened to repeatedly and transcribed verbatim. The transcribed data then were divided into meaning units; that is, the words, statements, and paragraphs that reflect the principal meaning of the participants’ responses [40, 47]. The meaning units were condensed and then interpreted to determine the underlying meaning of the text. The similarities and differences among the groups of interpreted condensed meaning units were connected and compared to formulate sub-themes. Ultimately, sub-themes that reflected the same meanings were classified and grouped together. Thereafter, groups of sub-themes were reflected on and discussed further by all of the authors, and the groups of sub-themes that reflected phenomena were categorized into themes. One example of the analysis process is shown in Table 2.

2.4 Ethics

The participants were informed about the study’s purpose and methods, confidentiality, and the right to withdraw from the research study at any time. Informed consent was obtained prior to the interview. The research ethics board of the concerned public hospital in Bangkok, Thailand approved this study, with the certification of institutional ethics review No. IRB/IEC reference 7/2556.

3 Findings

The following three themes regarding occupational stress among the participants were identified: (1) Perceived stress, (2) Consequences of stress, and (3) Stress management. An overview of the findings is shown in Table 3.

3.1 Perceived stress

The participants described the circumstances that were related to stress in the ED; these included heavy workload, situations involving patients and their relatives, violence in the ED, no opportunities to improve professional skills, low income, and relationships in the nursing team. Each of these circumstances is described below.

3.1.1 Heavy workload

The participants referred to the workload related to their tasks and responsibilities as nurses, especially when they were assigned to be a charge nurse. They often had to perform many tasks simultaneously, and the stress level differed according to those tasks and responsibilities.

“As an in-charge nurse, you have many responsibilities, including bed management, floor management and cooperation with other departments, both their nurses and physicians. So it is quite stressful.”

The participants shared their perceptions of the workloads in the ED; in particular, they reported that there were too many work tasks with a limited time to accomplish those tasks. For example, typical tasks might include providing treatment and completing patient documents, while simultaneously performing another task assigned by the head nurse. The outpatient department (OPD) was closed during the evening shift, which led to higher numbers of patients and increased workloads in the ED.

The ED nurse participants described having the role of the mediator between physicians, the patient and the patient’s relatives. This was a key stressor in the ED, adding more responsibilities and further increasing their workload.

“Some physicians are fussy; I am in the middle of the physician and patient. Sometimes the patient and relatives need information about the physician’s orders and opinions, but if I ask the physician, he does not listen to me. I, therefore, need to finally deal with the patients and their relatives.”

Furthermore, the participants indicated that stress in the ED was related to performing tasks outside the nursing role. They had the opportunity to use their full skill set in nursing care but they had limited decision authority because they had to perform some of the physicians’ roles, particularly when waiting for the physician to attend the patient. Some of these tasks were illegal, but they had to perform them to address an immediate problem and save a patient’s life. They perceived that such experiences were an uncontrolled situation in their workplace.

“I have to perform a physician’s role, such as suturing a wound. It’s quite stressful. If there’s no complication, then that’s fine, but if something happens incorrectly, then I might get sued…. This is the uncontrolled situation here; you inevitably have to do it [the physician’s role], otherwise the patients will get worse if we keep waiting for the physician and do nothing”.

“I have to perform the physician’s role because I have to save a patient’s life; of course I feel stressed. For example, if I attend a patient and he has very low blood pressure and presents signs of hypovolemic shock, then I provide him intravenous therapy while waiting for a physician…. While I am waiting for the physician to attend the patient, which sometimes cannot immediately happen because there is a shortage of physicians in this hospital, then I have to treat a patient by myself, such as when I encounter a patient with breathing difficulty and wheezing sounds are noted. Then, I provide the patient bronchodilator medication without a prescription to help him. It is stressful to do this, but I have to save the patient’s life”.

A shortage of nursing staff and an overload of patients in the ED were associated with a heavy workload. According to the participants, this shortage of nursing staff resulted in increased tasks and responsibilities for ED nurses, which meant they had to perform several additional tasks during limited working hours.

“We have so many patients to take care of, but we have shortages of nursing staff, so there is an imbalance. Therefore, we have to work overtime and take fewer days off.”

3.1.2 Situations involving patients and their relatives

The participants claimed that the expectations and behavior of patients and their relatives were stressors in the ED. The ED provides treatment according to the severity of symptoms (triage); however, patients and their relatives frequently misunderstood this system. Patients with non-urgent symptoms must wait so that the more urgent or emergent patients receive treatment first.

“Patients and patient’s relatives do not understand our care system. They want their family member to get treatment as fast as the emergent patients, at the same time. One time, I told them that our team was resuscitating a cardiac arrest patient, and they said that their family member was almost dead but in that case, the patient just simply had a headache.”

The participants also addressed the delayed admission system of other hospital departments, which resulted in patients remaining in the ED after they had been treated. The participants had to continue caring for them while receiving new patient admissions. This led to patient obstructions in the ED and additional workloads. Furthermore, the sudden death of a patient also caused the participants stress. If a patient presented with a non-urgent condition, but then their condition changed rapidly and they died, this caused incredible stress and guilt for the nurses.

“I, of course, feel stress when I have to resuscitate a patient. Sometimes he or she will just suddenly have a cardiac arrest in front of me, and if I provideCPR and that patient cannot be resuscitated and dies, then I walk away stressed and think about what I could have possibly missed in my nursing education.”

3.1.3 Violence in the ED

Violence was another cause of occupational stress in the ED. The participants described cases of physical assaults in their workplace. Those cases involving fighting, aggressive disorders, and being attacked by ED visitors; such encounters were perceived as violence, which caused the nurses to feel unsafe and to experience more stress.

“Fighting cases that come to the ED make me feel highly stressed…. If there is a fighting case in the ED, in my true feelings I do not want to address this situation because it is a risk to me, and I feel unsafe. If I get hurt, who will take the responsibility for this?… I feel stressed when faced with an aggressive patient; I am afraid that he willharm me”

3.1.4 No opportunities to improve professional skills

There was no support from the organization to improve the staff’s skills or potential. The participants had to finance their own training to gain more skills in and knowledge of emergency care.

“No advancements in professionalism here. What I mean is that I have to find a chance to improve my professional skills by myself, for example, by pursuing a master’s degree or other professional vocational and specialist training. There is no support from my organization.”

3.1.5 Low income

The ED nurse participants at the public hospital mentioned that income was associated with stress, as they were paid less than nurses in other departments; for example, nurses working in oxygenized ventilation care received additional pay.

“Income and work tasks are a controversy. Compared with other nurses in other departments at this hospital, the other nurses get paid more and they have a lighter workload than those of us in the ED….. Here, we do not get any extra beneficial pay for ventilation care.”

3.1.6 Relationships in the nursing team

The participants addressed problems related to differences in seniority status and poor relationships among the nursing staff in the ED. Differences in habits and working styles made it difficult to cooperate.

“It is hard to manage when there is conflict between the nursing staff. Presently, there is still conflict here. Some people do not want to talkto others.”

3.2 Consequences of stress

The participants disclosed the consequences of stress exposure, which affected their physical health, mental health, family relationships, job satisfaction, and the quality of their nursing care.

3.2.1 Impacts on physical health

The ED nurse participants described the effects of stress on their physical health. Stress in the ED often led to gastrointestinal problems, muscular pain, fatigue, headaches, and changes in their sleeping patterns that encouraged them to take sleeping pills.

“Stress made me constipated, and I could not pass stools for two weeks, which lead to hemorrhoids. I feel fatigued, aching and sore all over my body, and if I forget about it, I think it will get better. However, each day now I have to take medication to remedy the real effects of stress.”

3.2.2 Impacts on mental health

Stress in the ED led to an unstable emotional status among the participants. The emotional changes described in this study included irritability, feeling upset or angry, aggression, and the inability to control one’s emotions.

“When I have stress, my face is unwelcoming…. there are influences upon my emotions, and I may be more aggressive and feel upset…. When I feel stressed, I have unstable emotions. I get angry and aggressive so easily. I think it [stress] affects my mental health more than my physical health…. Stress… well, it gives me a headache sometimes, but not so often, but the emotions… yes! Aggressive, upset, shouting at co-workers. I think it has less effect on my physical health, but my mental health is easily influenced by stress.”

3.2.3 Impacts on family relationships

Occupational stress can affect the work-home balance, and the participants preferred to be alone in a private space and no longer wished to participate in family activities. They reported that they often liked to be alone and did not want to talk to anyone in the family when they felt stressed.

“When I got back home, I would remain silent. I would not speak with anyone in my house. Sometimes, I just complained to myself…. When I feel stressed from my work, I am not in a mood to do anything. Even when I get back home, I will stay in my room and will not join the family’s activity, such as having dinner, watching television; I want to be alone to calm my mind.”

3.2.4 Influences on job satisfaction

Workplace stress often made the ED nurse participants want to resign from their job because they felt discouraged and tired as a result of their workloads, lower incomes, and feeling undervalued.

“I think about resignation quite frequently. My friend, who works in another hospital, told me that her workplace pays more money and does not have a workload like mine.”

3.2.5 Effects on the quality of nursing care

Stress in the ED led to a decrease in the quality of nursing care, including non-holistic care, misinformation, malpractice, below-standard care delivery, delayed nursing care and a reduction in abilities as a result of decreased concentration and focus.

“Stress affects my patient care on each shift. For example, if I have worked for two consecutive shifts, I will tire towards the end of the second shift. My gentle nursing technique is on a decrease, and my attention is reduced. Therefore, I concentrate less on my patients and their holistic care, and I will focus only on their physical needs. The mental and social part of my caring is much less focused, and so I might not get necessary information from the patient. I consider that malpractice and below standard! … I cannot concentrate on nursing care when I feel stressed! It is like I have no idea what am I going to do, like a confused person. This has almost caused an error innursing care.”

3.3 Stress management

According to the interviews, the participants adopted either individual or collective stress managementstrategies.

3.3.1 Individual coping strategies

The participants had developed individual stress management coping strategies for both workplace situations and daily life situations. The coping strategies for workplace situations included avoiding the situation, walking away from the situation, and taking a break. The coping strategies for daily life situations included going to sleep, consuming alcohol, and trying to participate in relaxing activities.

“When I have so much stress, I will take a break, drink some water or eat something that refreshes me, and after such a break, I feel better. Like walking away from the stressful situation for a while and then back to that situation to solve the problem”

“If I feel so stressed, I will listen to music, rock music. If I am at a workplace, I will go to the suture room, be there alone and listen to rock music…. For me, to manage stress, after I finished the shift I would get out of the house, meet friends and have a beer or whisky. That helps a lot!”

3.3.2 Stress management with colleagues

When the participants felt stressed, they talked and debriefed with one another, particularly with a close friend at work, and this helped them feel better. There was no departmental or organizational support in the hospital to address stress. There was a psychiatric unit in the hospital, but that provided counseling for patients only.

“There is no stress management available like that; mostly, I have just talked with colleagues. Sometimes, having talked with them, I feel better later. It is like I have released my tensions.”

4 Discussion

4.1 Working context and work characteristics in the ED

The findings of this study reveal the experiences and perceptions of stress among the participating ED nurses. The participants perceived their heavy workload as a stressor in the workplace. This workload includes treating and caring for patients, managing patients’ documents, and performing other tasks assigned by the head nurse. The participants stated that they were responsible for too many tasks in the ED and that they were unable to complete all of these tasks during their limited work time, resulting in a heavy workload and related stress in the ED. Previous studies have also reported that a heavy workload is a powerful source of stress for ED nurses [21 , 45].

The tasks that ED nurses perform vary greatly because of the dynamic and unpredictable nature of the ED, and the participants experienced this variability as a stressor. The participants who worked as charge nurses also experienced greater workloads more often than the other nurses because they were responsible for various tasks, such as departmental management and cooperation with other departments, in addition to their regular nursing tasks. Furthermore, the findings show that the participants frequently had to take on the physician’s role to save a patient’s life, as there was an inadequate number of physicians in the hospital. These situations in which the ED nurses had to perform tasks beyond their abilities and professional knowledge caused stress. It should be noted that such situations added to an already heavy workload because these extra responsibilities were required in addition to nursing tasks. This finding was supported by a previous study [37] that found performing tasks beyond their competencies and abilities can cause stress for an ED nurse. However, although the participants felt stressed when they had to perform some physician’s tasks, they were willing to do so to save a patient’s life. Such situations can be considered role stress, as described by Riahi [48], which results from experiences that require an individual to perform a role for which he or she lacks the necessary abilities or resources.

Although the participants mentioned that they had the opportunity to use their full skill set in nursing care, they had limited decision-making authority and were unable to select their work tasks. This circumstance is referred to as low job control, and according to the JDCS model [23], is characteristic of a high-strain job (i.e., high job demand and low job control). The participants in this study have a high-strain job, which contributed to their stress. The sudden death of a patient, particularly the death of a child or a baby, has been previously indicated as a stressor in the ED [21, 41]; however, the participants in this study found the sudden death of patients of any age or gender very stressful.

A shortage of nursing staff was perceived as a stressor in this study and was also associated with a heavy workload, as fewer ED nurses were available to perform the tasks necessary to provide complete nursing care in the ED. In agreement with the results from this study, previous research [20, 34] indicates that a shortage of nursing staff in the ED is related to a heavy workload and leads to occupational stress among ED nurses. Furthermore, the delayed admission system in the hospital meant that treated patients could not be efficiently transferred to other departments, resulting in a high number of patients that obstructed the ED. Previous studies [22 , 42] have also found that delayed patient admission and inadequate numbers of beds in the hospital contribute to an obstruction of patients in an ED. Therefore, the number of patients in the ED was often higher than expected and led to increased workloads and stress.

Conflict and violence were reported to be stressors for ED nurses. Violence, in particular, has been previously reported as a stressor in EDs [21, 49]. Lancman et al. [13] have reported that aggressive or any other types of attack, including verbal and physical violence, reflect the state of tension among ED nurses. The present study considered only the physical violence that caused the participants to feel unsafe when they encountered violent situations. Circumstances involving conflict also caused stress; such situations included conflict between the ED nurses and physicians that arose when the ED nurses had to perform a physician’s role when treating a patient or act as a coordinator between physicians and patients. ED nurses and physicians do work collaboratively but at different professional hierarchal levels, meaning that ED nurses have less negotiating power than physicians, and this may lead to conflict [50]. In addition, a poor relationship among members of a nursing team was found to be a stressor among the ED nurses who participated in this study. Differences in seniority among the nurses led to some weak professional relationships, as senior nurses tended to use their position of power to control juniors, which in turn led to conflict among the nursing staff. Conflict among nursing staff can create vulnerability within an ED nursing team [51]. This finding was in accordance with previous studies that found that poor professional relationships with colleagues are a source of occupational stress in the ED [34, 41].

Patients’ and the family members’ misunderstandings or expectations of the ED triage system seemed to create stress among the ED nurses who participated in this study. The participants experienced this situation and perceived it as a source of stress in their workplace. This result is in accordance with a previous research [31]. The treatment system in an ED requires staff to treat patients according to the severity of their symptoms. Thus, some patients with non-urgent conditions must wait for treatment while more acute patients are cared for. However, patients often misunderstand the ED’s treatment system and expect to receive treatment immediately; those patients pressured the ED nurses about their treatment. This situation, in which patients and their relatives who had been waiting a long time for treatment would complain and put pressure on ED nurses, was also reported by Lim et al. [44]. Such negative encounters may result from the hospital’s failure to provide adequate information about the ED service system to patients andtheir relatives.

4.2 Organizational and occupational stress in the emergency department

The organizational management of the public hospital was associated with occupational stress among the participants. One of the main stressors related to organizational support was low income; this stressor was also reported in previous studies [35 –37]. According to the participants, their income was inappropriately low compared with that of the ward nurses. This was mainly because the ED nurses, unlike ward nurses, received no additional pay e.g. caring for a patient with ventilator-assisted breathing. Thus, their total income was lower than that of ward nurses despite their perceived higher workload.

Moreover, the participants claimed that there was inadequate support from either the department or the hospital for skill development, such as pursuing a master’s degree or completing additional specialist training. Experienced insufficient support from supervisors and coworkers might contribute to high stress responses among nursing professionals [14]. As in the study by Ross-Adjie et al. [41], insufficient skill improvement in the professional environment served as a stressor in the ED. The perceived inadequate support in this study is also in line with low social support in the JDCS model. Consequently, this circumstance may support the iso-strain hypothesis of the JDCS model, which describes how a job characterized by high demands, low control and low social support leads to a high risk of illness and reduced well-being among workers [23].

4.3 Consequences of occupational stress

The findings of this study suggest that the participants believe that stress in their workplace is connected to their psychophysiological health and had led to gastrointestinal problems, insomnia and the need for sleeping pills, headaches, and emotional changes, including irritability, uncontrollable emotions, and feeling upset, angry, or aggressive. These findings are in agreement with many previous studies that have indicated that occupational stress impacts ED nurses’ physiological and psychological health [17, 22].

In this study, the participants stated that occupational stress affected their mental health to a greater degree than their physical health. Ross-Adjie et al. [41] showed that balancing family issues and work is a stressor for ED nurses; the findings of this study also show that occupational stress can affect the work-home balance, and many participants preferred to be alone in a private space and no longer wished to participate in family activities.

The findings also indicate that occupational stress affects job satisfaction. The participants wanted to resign from their current workplace because they felt discouraged, tired from their heavy workloads, frustrated about their low income and offended by patients and some colleagues. This outcome has also been well documented in other studies [17, 18], indicating that decreased job satisfaction may lead to a higher turnover rate among nursing staff, which ultimately contributes to shortages in nursing staff. However, Adriaenssens et al. [29] have suggested that perceived rewards and social support from supervisors prove to be strong determinants of job satisfaction, work engagement and lower turnover intention among emergency nurses. Thus, improving social support and providing a well-balanced reward system may reduce ED nurses’ intentions to leave and prevent worsening shortages of ED nurses. Although the participants had considered resignation, they said that they wished to continue working in emergency care and indicated they might resign from their current hospital and find work in the ED of another hospital that offered better monetary compensation and a lower workload. Surprisingly, no one mentioned resigning from the nursing profession altogether.

The quality of nursing care also seems to be affected by occupational stress, a finding that is congruent with the previous research [17 , 35]. The participants indicated that occupational stress in the ED led to a decreased quality of nursing care, including non-holistic care, misinformation, malpractice, below-standard or delayed nursing care, and a reduction in their abilities because of reduced concentration, which caused confusion.

This study also identified several coping strategies used by the ED nurses, including walking away, taking a break, and engaging in relaxing activities. While they were on the frontline at work in the ED, the participants said that they would walk away from the stressful situation and try to calm down. They then returned to the situation to solve the problem. The act of walking away from stressful situations can be regarded as coping strategy. Walsh et al. [52] have also reported that denial and withdrawal are coping methods used by both nurses and physicians. However, the coping strategies used by the ED nurses in this study were related to emotional-focus coping and problem-focus coping; as Lazarus [1] has discussed, when an individual encounters a stressful situation, he/she will use emotional-focus coping followed by problem-focus coping. Similar to the findings in the study by Helps [34], this study showed that ED nurses consumed alcoholic beverages as a coping strategy to release stress.

The participants in this study were not offered any professional support, such as counseling or debriefing, when stressful situations occurred in the ED. There was a psychiatric unit in the hospital that did provide counseling, but it was reserved for patients only. Interestingly, it was noted that the participants were more willing to talk with their colleagues, especially with close and trusted ones, than to seek organizational supports. They perceived debriefing with their peers as the best stress management strategy in their workplace; Ross-Adjie et al. [41] also concluded that debriefing is an effective method of stress management after critical incident-induced stress in the workplace.

However, the participants reflected on and suggested ways to reduce stress in their workplace. They focused on enhancing organizational support, such as staffing management, formal debriefings in the ED, and task regulation. Furthermore, they indicated that the hospital directors should offer extra payment to compensate ED nurses for the specific competency required to deal with the critical patients. The participants perceived that such organizational actions could improve ED nurses’ work life, health and well-being.

4.4 Methodological considerations

The findings of this study illustrate the nature of occupational stress among Thai ED nurses. One of the strengths of this study was its credibility [40]. The 21 ED nurses who participated in this study volunteered to participate. The participants were demographically diverse in terms of work experience, educational background, age, and gender. This demographic diversity provided a variety of data sources and may enhance the study’s credibility [40]. Moreover, the findings of this study were discussed among researchers and colleagues in an academic seminar. Such discussion can reduce researchers’ bias and ensure the accuracy of the meaning of the phenomena [40]. According to our academic seminar and member check, the findings illustrate and add understanding about the occupational stress among ED nurses, specifically those in a public hospital in Bangkok, Thailand.

To prevent cross-language barriers in the research, all of the interview data were transcribed verbatim into Thai, and the transcripts were read carefully several times and then translated into English by the first author (NY), who is a native Thai speaker. The English translation was checked and approved by a professional linguist to prevent cross-language loss in the study. This repetitive task ensured that the researchers would gain a thorough overview of the transcripts, and safeguarded against the common risk of translation distortion [40, 53]. Furthermore, throughout the data analysis process, all of the researchers read and checked the data repeatedly and discussed the findings with one another to reduce bias and minimize inconsistencies of the data and thus improve dependability and confirmability [40].

Although this study’s sample size was small, the data achieved saturation. According to a qualitative methodology, the transferability of this study is a limitation [40]. The findings cannot be transferred directly to describe experiences of occupational stress among ED nurses in private hospitals. ED nurses in such hospitals have different workplace environments from the participants in this study, including a different social class and demography of patients, different emergency care strategies related to the health care scheme in Thailand, and different physician consult systems and organizational supports. Consequently, ED nurses in private hospitals might perceive occupational stress differently from the participants of this study, who were ED nurses in a public hospital.

5 Conclusion

This study showed that ED nurses work in a highly demanding job, with little job control or social support in the workplace. The findings of this study suggest that ED nurses frequently experience occupational stress. The major stressor for the participating public hospital ED nurses was a heavy workload. Occupational stress in the ED also contributed to physical and psychological ill-health among the ED nurses and was associated with poor nursing care. The results of this study could be useful for developing stress management programs for ED nurses at public hospitals; such programs to reduce stress and support ED nurses in an appropriate way. In addition, stress management programs should focus on reducing job demands, increasing job control, and improving social support at the workplace. Such programs may improve ED nurse’s health and well-being and organizational productivity, which results from efficient and effective nursing care. Furthermore, future studies should explore each of these stressful situations to acquire an in-depth understanding of stressors.

Footnotes

Acknowledgments

The authors wish to thank all participants in this study; without their contribution, it would not have been possible to undertake the research.

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