Work-related trauma: the experiences of perioperative nurses

Using a Novel Gameplay Intervention to Target Intrusive Memories After Work-Related Trauma: Iterative Qualitative Analysis of Intensive Care Unit Staff Experiences

BACKGROUND

Many intensive care unit (ICU) staff experience intrusive memories following work-related traumatic events, which can lead to long-term mental health outcomes and impact work functioning. There is a need for interventions that target intrusive memories in this population; however, factors such as mental health stigma and difficulty in fitting interventions into busy schedules can pose barriers. The Brief Gameplay Intervention For National Health Service Intensive Care Unit Staff Affected By COVID-19 Trauma (GAINS) study tested a brief, digital imagery-competing task intervention (including computer gameplay) with the aim of reducing the recurrence of intrusive memories, which holds promise for overcoming some of these barriers.

OBJECTIVE

This substudy aims to explore barriers and facilitators to the uptake and practical use of the intervention by ICU staff, along with its acceptability, and iteratively explore the impact of intervention optimizations to further refine the intervention.

METHODS

The GAINS study is a randomized controlled trial comparing access to a brief digital imagery-competing task intervention for 4 weeks with usual care followed by delayed access to the intervention. The participants were ICU staff who worked during the COVID-19 pandemic and experienced intrusive memories. All participants were sent a questionnaire at 4 weeks to gather data about intervention acceptability. Nested within the randomized controlled trial, a subset of 16 participants was interviewed, and data were analyzed using thematic analysis drawing from a framework approach.

RESULTS

Both quantitative and qualitative data indicated high acceptability of the intervention. Intervention use data show that, on average, staff were able to target approximately 73% (3.64/4.88) of their intrusive memories and engaged with the Tetris component for the full 20 minutes per session. Overall, on the acceptability questionnaire, staff found the intervention easy to use, helpful, and highly acceptable. The interviews generated four themes: approach to the intervention, positives of the intervention, negatives of the intervention, and improvements and optimizations. Findings highlighted barriers that ICU staff experienced: stigma, feeling weak for seeking help, not wanting colleagues to know they were struggling, and skepticism. However, they provided suggestions on how barriers could be overcome and discussed the advantages of the intervention when compared with other treatments. Although participants described many positive aspects of the intervention, such as being easy to use, enjoyable, and leading to a reduction in the frequency or intensity of intrusive memories, they also raised practical issues for implementation.

CONCLUSIONS

The intervention has the potential to overcome stigma and reduce the frequency of intrusive memories after traumatic events among ICU staff. Further refinement is needed to improve the adoption and reach of this intervention. A limitation is that we could not interview the National Health Service staff who were unable or unwilling to take part in the trial.

"It Is Difficult to Always Be an Antagonist": Ethical, Professional, and Moral Dilemmas as Potentially Psychologically Traumatic Events among Nurses in Canada

AIMS

We explore social and relational dynamics tied to an unexplored potentially psychologically traumatic event (PPTE) that can impact nurses' well-being and sense of their occupational responsibilities: namely, the moral, ethical, or professional dilemmas encountered in their occupational work.

DESIGN

We used a semi-constructed grounded theory approach to reveal prevalent emergent themes from the qualitative, open-ended component of our survey response data as part of a larger mixed-methods study.

METHODS

We administered a national Canadian survey on nurses' experiences of occupational stressors and their health and well-being between May and September 2019. In the current study, we analyzed data from four open text fields in the PPTE section of the survey.

RESULTS

In total, at least 109 participants noted that their most impactful PPTE exposure was a moral, professional, and/or ethical dilemma. These participants volunteered the theme as a spontaneous addition to the list of possible PPTE exposures.

CONCLUSIONS

Emergent theme analytic results suggest that physicians, other nurses, staff, and/or the decision-making power of patients' families can reduce or eliminate a nurse's perception of their agency, which directly and negatively impacts their well-being and may cause them to experience moral injury. Nurses also report struggling when left to operationalize patient care instructions with which they disagree.

IMPACT

Nurses are exposed to PPTEs at work, but little is known about factors that can aggravate PPTE exposure in the field, impact the mental wellness of nurses, and even shape patient care. We discuss the implications of PPTE involving moral, professional, and ethical dilemmas (i.e., potentially morally injurious events), and provide recommendations for nursing policy and practice.

Development of Survey Scales for Measuring Exposure and Behavioral Responses to Disruptive Intraoperative Behavior

OBJECTIVES

Disruptive intraoperative behavior has detrimental effects to clinicians, institutions, and patients. How clinicians respond to this behavior can either exacerbate or attenuate its effects. Previous investigations of disruptive behavior have used survey scales with significant limitations. The study objective was to develop appropriate scales to measure exposure and responses to disruptive behavior.

METHODS

We obtained ethics approval. The scales were developed in a sequence of steps. They were pretested using expert reviews, computational linguistic analysis, and cognitive interviews. The scales were then piloted on Canadian operating room clinicians. Factor analysis was applied to half of the data set for question reduction and grouping. Item response analysis and theoretical reviews ensured that important questions were not eliminated. Internal consistency was evaluated using Cronbach α. Model fit was examined on the second half of the data set using confirmatory factor analysis. Content validity of the final scales was re-evaluated. Consistency between observed relationships and theoretical predictions was assessed. Temporal stability was evaluated on a subsample of 38 respondents.

RESULTS

A total of 1433 and 746 clinicians completed the exposure and response scales, respectively. Content validity indices were excellent (exposure = 0.96, responses = 1.0). Internal consistency was good (exposure = 0.93, responses = 0.87). Correlations between the exposure scale and secondary measures were consistent with expectations based on theory. Temporal stability was acceptable (exposure = 0.77, responses = 0.73).

CONCLUSIONS

We have developed scales measuring exposure and responses to disruptive behavior. They generate valid and reliable scores when surveying operating room clinicians, and they overcome the limitations of previous tools. These survey scales are freely available.

Prevalence and predictors of exposure to disruptive behaviour in the operating room

PURPOSE

Disruptive intraoperative behaviour ranges from incivility to abuse. This behaviour can have deleterious effects on clinicians, students, institutions, and patients. Previous investigations of this behaviour used underdeveloped tools or small sampling frames. We therefore examined the prevalence and predictors of perceived exposure to disruptive behaviour in a multinational sample of operating room clinicians.

METHODS

A total of 134 perioperative associations in seven countries were asked to distribute a survey examining five types of exposure to disruptive behaviour: personal, directed toward patients, directed toward colleagues, directed toward others, or undirected. To compare the average amount of exposure with each type, we used a Friedman's test with select post hoc Wilcoxon tests. A negative binomial regression model identified socio-demographic predictors of personal exposure.

RESULTS

Of the 134 organizations approached, 23 (17%) complied. The total response rate was estimated to be 7.6% (7465/101,624). Almost all (97.0%; 95% confidence interval [CI], 96.6 to 97.4) of the respondents reported exposure to disruptive behaviour in the past year, with the average respondent experiencing 61 incidents per year (95% CI, 57 to 65). Groups reporting higher personal exposure included clinicians who were young, inexperienced, female, non-heterosexual, working as nurses, or working in clinics with private funding (all P < 0.05).

CONCLUSION

Perceived exposure to disruptive behaviour was prevalent and frequent, with the most common behaviours involving speaking ill of clinicians and patients. These perceptions, whether accurate or not, can result in detrimental consequences. Greater efforts are required to eliminate disruptive intraoperative behaviour, with recognition that specific groups are more likely to report experiencing such behaviours.

Disruptive behaviour in the perioperative setting: a contemporary review

Purpose

Disruptive behaviour, which we define as behaviour that does not show others an adequate level of respect and causes victims or witnesses to feel threatened, is a concern in the operating room. This review summarizes the current literature on disruptive behaviour as it applies to the perioperative domain.

Source

Searches of MEDLINE^®, Scopus™, and Google books identified articles and monographs of interest, with backreferencing used as a supplemental strategy.

Principal findings

Much of the data comes from studies outside the operating room and has significant methodological limitations. Disruptive behaviour has intrapersonal, interpersonal, and organizational causes. While fewer than 10% of clinicians display disruptive behaviour, up to 98% of clinicians report witnessing disruptive behaviour in the last year, 70% report being treated with incivility, and 36% report being bullied. This type of conduct can have many negative ramifications for clinicians, students, and institutions. Although the evidence regarding patient outcomes is primarily based on clinician perceptions, anecdotes, and expert opinion, this evidence supports the contention of an increase in morbidity and mortality. The plausible mechanism for this increase is social undermining of teamwork, communication, clinical decision-making, and technical performance. The behavioural responses of those who are exposed to such conduct can positively or adversely moderate the consequences of disruptive behaviour. All operating room professions are involved, with the rank order (from high to low) being surgeons, nurses, anesthesiologists, and “others”. The optimal approaches to the prevention and management of disruptive behaviour are uncertain, but they include preventative and professional development courses, training in soft skills and teamwork, institutional efforts to optimize the workplace, clinician contracts outlining the clinician’s (and institution’s) responsibilities, institutional policies that are monitored and enforced, regular performance feedback, and clinician coaching/remediation as required.

Conclusions

Disruptive behaviour remains a part of operating room culture, with many associated deleterious effects. There is a widely accepted view that disruptive behaviour can lead to increased patient morbidity and mortality. This is mechanistically plausible, but more rigorous studies are required to confirm the effects and estimate their magnitude. An important measure that individual clinicians can take is to monitor and control their own behaviour, including their responses to disruptive behaviour.

Australian perioperative nurses' experiences of assisting in multi-organ procurement surgery: a grounded theory study

INTRODUCTION/BACKGROUND

Multi-organ procurement surgical procedures through the generosity of deceased organ donors, have made an enormous impact on extending the lives of recipients. There is a dearth of in-depth knowledge relating to the experiences of perioperative nurses working closely with organ donors undergoing multi-organ procurement surgical procedures.

AIM

The aim of this study was to address this gap by describing the perioperative nurses experiences of participating in multi-organ procurement surgical procedures and interpreting these findings as a substantive theory.

DESIGN

This qualitative study used grounded theory methodology to generate a substantive theory of the experiences of perioperative nurses participating in multi-organ procurement surgery.

SETTING

Recruitment of participants took place after the study was advertised via a professional newsletter and journal. The study was conducted with participants from metropolitan, rural and regional areas of two Australian states; New South Wales and Western Australia.

PARTICIPANTS

Thirty five perioperative nurse participants with three to 39 years of professional nursing experience informed the study.

METHODS

Semi structured in-depth interviews were undertaken from July 2009 to April 2010 with a mean interview time of 60 min. Interview data was transcribed verbatim and analysed using the constant comparative method.

RESULTS

The study results draw attention to the complexities that exist for perioperative nurses when participating in multi-organ procurement surgical procedures reporting a basic social psychological problem articulated as hiding behind a mask and how they resolved this problem by the basic social psychological process of finding meaning.

CONCLUSION

This study provides a greater understanding of how these surgical procedures impact on perioperative nurses by providing a substantive theory of this experience. The findings have the potential to guide further research into this challenging area of nursing practice with implications for clinical initiatives, management practices and education.

Critical incidents among intensive care unit nurses and their need for support: explorative interviews

AIMS

This article aims (a) to get insight into intensive care nurses' most critical work-related incidents, (b) their reactions and coping and (c) perceived support, in a Dutch intensive care unit.

BACKGROUND

Research about the impact of critical incidents has largely been aimed at ambulance and emergency nurses; knowledge about intensive care nurses in this respect is scarce. Persistent stress reactions after critical incidents may cause symptoms of post-traumatic stress disorder, depression and anxiety. Unresolved problems may also cause poor behaviour towards patients. In response, nurses reduce work hours or even resign. Social support alleviates emotional problems, but little is known about actual support perceived.

DESIGN

This study is a qualitative explorative study.

METHOD

Thematic analysis of semi-structured interviews was performed among a purposive sample of 12 intensive care nurses in a university hospital in The Netherlands.

FINDINGS

Four main themes have been identified in critical incidents: high emotional involvement in patient-related incidents (in contrast to major life-threatening events as such), avoidable incidents, sub-standard patient care and intimidation. Themes discerned in nurses' reactions after critical incidents were physical reactions, emotional reactions and cognitive/behavioural reactions. After critical incidents, nurses talked with colleagues, friends or relatives, but would have appreciated additional support.

CONCLUSIONS

Incidents under emotionally demanding circumstances are among the most difficult situations, but may not be recognized as critical incidents by colleagues. Both adequate and inadequate coping strategies, with long-lasting problems after critical incidents, were reported. Feelings of anger, shame and powerlessness, may have hindered recovery. Talking to colleagues was perceived to be helpful, but intensive care nurses' need for support was insufficiently met.

RELEVANCE TO CLINICAL PRACTICE

Managers should acknowledge the effects of critical incidents on intensive care nurses and take preventive measures: reducing critical incidents, improving open communication, imposing a buddy-system for collegial support, and timely evaluating the necessity of professional help.

The impact of organisational and individual factors on team communication in surgery: a qualitative study

BACKGROUND

Effective teamwork and communication is a crucial determinant of patient safety in the operating room. Communication failures are often underpinned by the inherent differences in professional practices across disciplines, and the ways in which they collaborate. Despite the overwhelming international support to improve team communication, progress has been slow.

OBJECTIVE

The aim of this paper is to extend understanding of the organisational and individual factors that influence teamwork in surgery.

DESIGN

This qualitative study used a grounded theory approach to generate a theoretical model to explain the relations between organisational and individual factors that influence interdisciplinary communication in surgery.

SETTING AND PARTICIPANTS

A purposive sample of 16 participants including surgeons, anaesthetists, and nurses who worked in an operating room of a large metropolitan hospital in south east Queensland, Australia, were selected.

METHODS

Participants were interviewed during 2008 using semi-structured individual and group interviews. All interviews were recorded and transcribed. Using a combination of inductive and deductive approaches, thematic analyses uncovered individual experiences in association with teamwork in surgery.

RESULTS

Analysis generated three themes that identified and described causal patterns of interdisciplinary teamwork practices; interdisciplinary diversity in teams contributes to complex interpersonal relations, the pervasive influence of the organisation on team cohesion, and, education is the panacea to improving team communications.

CONCLUSIONS

The development of shared mental models has the potential to improve teamwork in surgery, and thus enhance patient safety. This insight presents a critical first step towards the development teambuilding interventions in the operating room that would specifically address communication practices in surgery.

Operating Theater Culture

Health service delivery in the operating theater is vulnerable to shortages because of the unique environment, postregistration training requirements, and the occupational subculture that characterizes social relations. The aim of this mini-ethnography is to explore characteristics of organizational culture of the operating theater and how this culture is communicated and sustained. The field setting is an eight-theater department in a major hospital in Queensland, Australia. Informants include nurses, orderlies, trainee and consultant surgeons, and anesthetists. Three themes related to primacy of knowledge and competence, social order, and situational control are important cultural indicators in this highly specialized milieu. The level to which members are able to assimilate and meet role expectations depends on the amount of knowledge and experience they possess. A lack of acceptance has the potential to affect members' willingness to continue working in the operating theater, and consequently, may contribute to existing nursing shortages in this specialty.

Assertiveness training to prevent verbal abuse in the OR

THE HIGH INCIDENCE OF VERBAL ABUSE directed toward perioperative nurses by surgeons has been the subject of recent research studies. REPEATED INCIDENTS of verbal abuse in the OR contribute to increased incidence of errors, low morale, and high turnover among nursing staff members. ASSERTIVENESS TRAINING that focuses on conflict resolution and communication skills is an effective method of coping with verbal abuse. EACH MEMBER is a vital part of the perioperative team. Any disruption to the team, including verbal abuse, can compromise patient safety. Collaboration among team members is critical to ensure safe patient outcomes.

Operation Safe Haven: the needs of nurses caring for refugees

Nurses played a significant role in providing care to Kosovar and East Timorese refugees at the East Hills Reception Centre in Sydney, Australia, during Operation Safe Haven in 1999-2000. To ascertain the needs of nurses in this setting, 13 nurses participated in two focus group interviews, and two in-depth interviews were conducted with nursing managers. Qualitative thematic analysis was conducted on the resulting transcripts. Nurses reported that, overall, they had the necessary clinical skills but needed specific refugee health profiles and training in culturally competent and trauma-sensitive care. The nurses experienced trauma-related, cultural, environmental and role-related stressors. They used a variety of informal psychosocial supports but reported the need for ongoing counselling and debriefing. While clinical skills were considered important, nurses identified other factors as having more impact on their ability to provide comprehensive care for traumatized refugees, particularly their role as client advocates.

Bullying and harassment in perioperative settings

This article explores the concepts of bullying and harassment, defines the terms and their implications, and explores similarities and differences between the two. It also examines pertinent legislation and identifies strategies to raise awareness and optimise a bullying and harassment-free perioperative environment. Bullying and harassment in the workplace was the focus of this presentation at NATN Congress 2002. Challenging behaviours involving patients and carers is another topic in itself.

Uncovering the secret: giving voice to the experiences of nurses who misuse substances

AIM OF THE STUDY

The aim of this study was to gain insight into the experience of being a nurse with a substance misuse problem.

RATIONALE

Several members of the research team work in a withdrawal programme specifically designed for nurses by nurses. Gaining insight into nurses' experiences will contribute to the development of appropriate guidelines to assist with prevention, identification and intervention strategies.

BACKGROUND

Published research is almost exclusively from North America. Much of it represents work completed in the 1980s, with very few research-based accounts from the perspective of nurses, highlighting that this is a poorly researched and understood problem in Australia.

RESEARCH METHODS

This phenomenological study used in-depth, unstructured interviews either face to face or via the telephone with a purposive sample of 12 nurses who had experienced problem substance use.

FINDINGS

Five major themes were identified: nurses' justification for using substances, the fear surrounding being 'discovered', the personal meaning for nurses, the professional impact and the turning point in their road to recovery.

DISCUSSION

The five themes derived from the data are inextricably linked to the nature of nursing and of the nursing workplace. Information about potential risk factors and the experiences of nurses with substance misuse problems is critical to the development of prevention and treatment strategies.

CONCLUSIONS

Issues of occupational health and safety are raised due to the increasingly demanding and often traumatic nursing work environment. Fears about stigma and loss of their nursing identity highlight nurses' perceptions that treatment programmes are often punitive in nature. Guidelines for the workplace addressing issues such as confidentiality, stress reduction and strategies for handling situations where a colleague is suspected of having a problem are beginning steps that will help address the problem of substance misuse in the nursing profession.