NSG 3029 FOUNDATIONS OF NURSING RESEARCH
POWERPOINT PRESENTATION RUBRIC
CRITERIA
Introduction to the research articles
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10
States authors, title, publication of the articles
Article #1
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Purpose
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Background and significance of the problem
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Methodology
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Interpretation of findings
Article #2
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Purpose
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Background and significance of the problem
•
Methodology
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Interpretation of findings
Synthesis of information
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Compares and contrasts both articles and their
components
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Synthesize information in both articles to develop
and present a unique perspective on the topics
Recommendation for the future research
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POSSIBLE
POINTS
Summary of recommendations from both articles
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EARNED
POINTS
Application of research articles in nursing practice
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30
Outlines the research findings for the use in nursing
practice
PowerPoint presentation quality
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PowerPoint presentation is organized, wellconstructed, legible, and directed to RNs
(classmates)
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Presentation is not more than 15 min at length with a
maximum of 15 slides
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Slides are easy to understand with catchy design
and graphics
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Reference slide is done per APA guidelines
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Slide references are correctly cited on the slide
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200
TOTAL:
Feedback:
Critical Analysis of Two
Peer-Reviewed Research Articles
[Students’ Names]
Articles Reviewed
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•[Article #2= must be APA format]
Article #1: Purpose
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Article #1: Background and
Significance of the Problem
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Article #1: Methodology
•Sampling Technique
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•Sample Characteristics
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•Setting
–[type here]
Article #1: Interpretation of
Findings
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Article #2: Purpose
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Article #2: Background and
Significance of the Problem
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Article #2: Methodology
•Sampling Technique
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•Sample Characteristics
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•Setting
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Article #2: Interpretation of
Findings
•[BULLETS only = type answer here]
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Synthesis of Information
•[Compare and contrast both articles = i.e.
compare & contrast the methodology used,
between these articles, which research utilized
better research technique?; is Article #1’s results
similar or different from Article #2’s results; etc.]
Synthesis of Information
•[Combine, “synthesize,” the information in the
research articles to develop an argument or a
unique perspective on a topic]
Recommendations for Future
Research
•[recommendations MUST be a summary from
BOTH research articles]
•Bullets ONLY
•Bullets ONLY
•Bullets ONLY
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Application of Research Articles in
Nursing Practice
1.[text here]
2.[text here]
3.[text here]
4.[text here]
5.[text here]
6.[text here]
7.[text here]
References
•Your texts here MUST be written in an APA, 6th
ed format. Please refer to your notes and
visit the library.
Research
Stress in hospice at home nurses:
a quahtative study of their experiences
of their work and wellbeing
Karen Tunnah, Angela Jones, Rosalynde Johnstone
P
alliative care nursing can be a rewarding
but emotionally stressful specialty in which
to work, and therefore stress and burnout
may contribute to issues of staff sickness and
retention. Studies have shown that although staff
perceive themselves as coping, many nurses do
experience compassion fatigue and burnout
(Abendroth and Flannery, 2006; Edmunds,
2010). The purpose of this study was to undertake an assessment of hospice at home nurses'
experiences and wellbeing while caring for palliative and dying patients. Anecdotal evidence
identified a lack of education and training
regarding self-help strategies in the local nursing
team. Clinical supervision is available for the
team but uptake had been poor. The literature
includes studies undertaken with palliative care
nurses working in a hospice environment, but
few published studies have looked specifically at
hospice nurses working out in the community.
Background
Nursing has been described in many studies as a
demanding and stressful profession, particularly
for those working in direct clinical care (Hawkins
et al, 2007; Edmunds, 2010). Compassion fatigue
may be triggered by becoming overly empathetic
with patients, having unreal expectations of
outcomes, and experiencing personal crises
(Abendroth and Flannery, 2006). It may affect an
individual caring for someone who is experiencing a traumatic event such as dying. A nurse may
experience helplessness and react by turning off
his or her emotions.
Compassion fatigue is also often linked to
burnout, which can be defined as: emotional
exhaustion, sometimes accompanied by a
cynical approach, that can be experienced by
individuals in a caring role (Maslach and
Jackson, 1991). Burnout may affect the mental
and physical health of the nurse, which could
ultimately affect the quality of their nursing
care (Maslach and Jackson, 1991). Some have
also suggested that burnout is contagious
International Journal of Palliative Nursing 2012, Voi 18, No 6
Abstract
The literature has evaluated studies of hospice nurses and stress but
very few studies have focused on community hospice nurses. This
study explored hospice at home nurses' experiences of caring for
palliative and dying patients. Hospice at home nurses working in the
community across North West Wales were interviewed and a
grounded theory approach was used to categorise the data into the
following themes: job satisfaction, Stressors, coping strategies, and
support. Recommendations arising from the study include encouraging
the use of clinical supervision, attendance at multidisciplinary meetings,
and the provision of stress-awareness training, and raising awareness of
the role of hospice at home nurses in primary care. Implementation of
these recommendations might be beneficial for staff wellbeing. Further
work would identify whether such recommendations can help to
prevent sickness and promote staff retention.
Key words: Hospice at home nurses # Stress and coping • Dying
patients • Qualitative methods
and can be communicated from one nurse to
another (Bakker et al, 2005).
Palliative care nursing is often viewed as a
psychologically distressing and stressful specialty
(Gambles et al, 2003). Palliative care nurses are
fully aware that all the patients in their care have
an incurable illness with a life-limiting prognosis
and are expected to die. Furthermore, national
strategies such as the UK's End of Life Care
Strategy (Department of Health, 2008) promote
high-quality care for all adults at the end of life,
which includes conditions with complex needs.
This may pose further challenges and stresses for
palliative care staff. However, it is now recognised that the benefits of early intervention and
symptom control in the palliative patient help to
maintain quality of life (World Health
Organization, 2002). Also, studies suggest that
palliative care staff report lower levels of burnout
than other specialties, including oncology and
intensive care nursing (Vachon, 1995).
Lower levels of distress have also been
reported for hospice nurses than for staff
Karen Tunnah is
Hospice at Home
Nurse; Angela Jones is
Clinical Nurse
Manager; Rosalynde
Johnstone is Project
Manager, Betsi
Cadwalader University
Health Board, Palliative
Care Department,
Bodfan Eryri Hospital,
Caernarfon, Gwynedd
LL55 2YE, Wales
Correspondence to:
Rosalynde Johnstone
Rosalynde.johnstone®
wales.nhs.uk
283
Research
^Studies have
shown that
although staff
perceive
themselves as
coping, many
nurses do
experience
compassion
fatigue and
burnout...*
working in other areas, whicb implies that
hospices are positive environments in which to
work (Payne, 2001). The same study examined
Stressors, coping, and demographics in relation to
burnout and hospice nurses. It found that Stressors such as conflict with staff made the greatest
contribution to burnout. The importance of not
labelling an individual as coping 'well' or 'badly'
in relation to burnout has also been highlighted,
as this can oversimplify the coping/burnout
relationship (Payne, 2001).
The participants in the study reported here
were hospice at home nurses working in the community setting, which is not compatible with the
nurses in Payne (2001). The role of the hospice at
home nurse embraces the biopsychosocial
approach to human functioning, particularly in
relation to illness or disease (Engel, 1977). The
importance of psychosocial factors in nursing is
recognised, and tbe development of a close, holistic relationship with patients is encouraged
(Aldridge, 1994; Luker, 1997). This can take a
considerable amount of time (Skilbeck and
Payne, 2003). Hospice at home nurses can spend
between 1 and 2 hours with the patient and their
family on a first visit. Subsequent visits may be
shorter or longer depending on the needs of the
patient and tbe disease progression. Toward
the end of life the hospice at home nurse may
need to make multiple extended visits on one day.
The emotional element of 'getting to know'
patients and their families is difficult to define,
not least because of the lack of clarity surrounding the terminology. The phrase 'emotional care
and support' is used interchangeably with
'psychological care and support' or 'psychosocial
care' (Skilbeck and Payne, 2003). However, different meanings can be attributed to each term
depending on the contexts and theoretical backgrounds. The term 'emotional labour' draws on a
sociological background and is used to represent
hard work, and indeed the difficulty of caring for
patients at tbe end of life has been acknowledged
(Froggatt, 1998; Jones, 2001a). Emotional labour
places demands on the individual as tbey are constantly creating and sustaining relationships with
patients who subsequently die. Tbe nurse tben
has the continuous task of assimilating the loss of
the patient and of the relationship. Dealing with
the demands of this emotional 'yo-yo' may
gradually erode one's resilience and result in
stress-related issues for the nurse. However, tbe
emotional labour involved in palliative care
is often underestimated and undervalued
(Henderson, 2001).
Mechanisms for coping with this aspect of
nursing dying patients are varied and well
284
documented (James, 1993; McNamara et al,
1995; Froggatt, 1998; Jones, 2001b). The benefit
of staff training in self-care tbrough counselling
sessions and stress inoculation training is recognised (Ablett and Jones, 2007; Desbiens and
Fillion, 2007). It bas been suggested that the
opportunity for reflective practice in end-of-life
care may help staff come to terms with the
emotional impact of tbe work (Jones, 2001b).
Some researchers suggest that a stress-resistant
personality type and personal factors such as
hardiness and a sense of stability and structure
may enable hospice nurses to be buffered from
the stressful effects of palliative care nursing
(Ablett and Jones, 2007). Factors that promote
resilience and wellbeing in nurses could be developed through training and supervision (Ablett
and Jones, 2007). Clinical supervision and reflection are recognised as viable mechanisms for
supporting palliative care nurses (Jones, 2001b).
However, there is a lack of agreement concerning
definitions, models, and use of clinical
supervision. Known variously as 'mentorship',
'supervision by manager', and 'reflective practice',
clinical supervision was very popular in the late
1990s; however, little is known about how or
wbetber it is used by clinical nurse specialists
(Yegdicb and Cusbing, 1998; Skilbeck and Payne,
2003; Jones, 2006).
Aim
The aim of the study was to explore the feelings
and experiences of hospice at home nurses when
providing palliative nursing care for patients in
tbe community. Tbe study sought to identify key
issues that contribute toward stress in hospice at
home nurses working in primary care.
Method
Qualitative methodology was used as this is more
suited to exploratory studies of people in their
natural settings. The potential participants were a
team of hospice at bome nurses working in the
community across a large rural area in North
West Wales.
Ethics
The study was presented to the North Wales
Research Ethics Committee-West and a favourable opinion was awarded subject to management
permission being granted. The study was given
full management permission in accordance with
NHS research governance arrangements.
Research team
The research team comprised the nursing team
leader (with management, clinical, and research
International Journal of Palliative Nursing 2012, Voi 18, No 6
Research
experience), the project manager (with management
and research experience), and a hospice at home
nurse (with clinical experience).
Items in i-jlics were used as prompts for the inier^iewer in the event that the
intervie'Vre had dfficulty responding to th= question.
Participants
The hospice at home nursing team in North West
Wales comprises ten qualified nurses and one
health-care assistant. All had worked in the palliatiye care setting for a minimum of 12 months.
The nurses deliver 'hands on' nursing care in
collaboration with various community nursing
teams, providing symptom control and advice for
patients and their carers in the community. Their
work sometimes necessitates travelling distances
between 10 and 110 miles per day.
The nurses were informed of the study and
invited to participate at the regular nurses' meeting by their colleage, the first listed author. It was
made clear that they were under no obligation to
take part and that they could withdraw at any
time during or after the study without having to
provide a reason and without fear of compromising their working relationships. Confidentiality
was assured both verbally and in writing, with
the usual exception of disclosure of any unsafe,
unethical, or illegal practice.
Age:
Gencer
General nursing experience:
Hospice njrsing experience:
QualificitJDns:
Area of v^ork:
I a) Can you tell m 2 about a good working day as a. hcspice nurse?
/) What wojtd yoL say contributed towards mating it c good day?
I b) Can >ou tell me about your worst working day as a hospice nurse?
i) Whatwojtd
yoL say contributed towards mailing it your worst doy?
2) How do you leel your work affects y
/) Woutd yoj soy iz affects you physicatly?
In what na/?
ii) WouHycu soy i effects you mentally?
In what wa/?
3) Hov» do you cope with an emotionally d^mandng day?
Data collection
/) Woutd yoj soy you totk to work colleagues?
Each nurse was asked to participate in a taperecorded semi-structured interview lasting a
maximum of 45 minutes. The interviews were
conducted by the palliative care project manager.
This position has no professional responsibility
for tbe nursing team (managerial or otherwise)
and is external to the hospice at home nursing
service. The interviews all took place in the palliative care department in a quiet designated room
at times convenient for the nurses and fitting in
with their clinical duties. As the interviews could
prove to be emotional or distressing, the nurses
were offered the opportunity of counselling.
There is currently an arrangement between an
independent counselling service and the Health
Board to provide free counselling sessions for
Health Board employees.
ii) Would ycu say »oo talk to family?
Tbe interview schedule is provided in Box 1. The
interview comprised a list of open-ended questions,
guided by tbe interviewer. Interviewer prompts
were included to avoid long silences during the
interview process. Leading questions were avoided.
The questions were managed in a conversational
style to maximiseflexibilityand versatility.
Data analysis
The transcripts of each interview were analysed
using the grounded theory approach initially
developed by Glaser and Strauss (1967). Tbis
International journal of Palliative Nursing 2012, Vol 18, No 6
Hi) VVou.'c jau soy you talk to your mar\ager?
iv) VVou.'c jou soy you totk to friends?
4) Hov» w o u l d youi say you cope w i t h t h e p i y s i i a l demands of y o u r w o r k i n g day?
/) Woutd yoj soy ycu exercise, watk, cycle or gc to the g/m'
ii) Would ycu say »ou relox m a warm both?
Hi) Wou.c jrou say yoj switch off in front of the TV?
iv) Would ycu soy ."ou catch up with outstandhg househo/d /obs such os ckoning or gardening?
5) Hov" would youi say you cope with the psychological demands oí your working day?
i) Would you soy you browse the internet?
it) Would ycu say rou discuss your day with others?
Hi) Wou,c you say yo j meditate or use any other form z-fmentol exercise.'
iv) WOU.Û you soy yoj hove on eorly night?
approach :s favoured in nursing and the isodal
sciences >wing tc the systematic and structured
way that the data are collected and analysed.
The term 'grounded theory' refers to the idea
that the data are not obtained from tl-.e researchers' preconceived hypothesis but are discovered
or derived!. Themes that are repeatedly present or
notably ¿bsent in the data are deemed significant
enough to be categorised and each aisce oJ data
285
Research
6) How would you say you oope ./vith the demands: put on you by other health
professionals?
7) How do you feel your job impacts on your famil/ life?
8) How does continually nursing dying patients affect your daily life?
9) During your time as a hospice at home nurse ha/e there been any training or
support events that you felt »vere beneficie ?
10) Is there anything further that you wou d like t o discuss?
i) Do you have any suggestions ttiat would improve yoir daily work experience?
11) Is there anything you would '/f:e to see put n place to improve your daily work experience?
Thank you for participating in thi; study.
is constantly compared with another until no
further new data aie discovered.
Data analysis was carried out following
transcription of all of the interviews. The transcripts were typed verbatim with the exception of
participant names, which were omitted. The transcripts v/ere independently read and re-read for
familiarity b^ individual members of the research
teair, who were blmd to each others' critique of
the data until the^ met to discuss the content
of the transcripts.
The ckta were analysed by an open coding
procedure in which the first step of the analysis
is conceptúalisaticn of the data. Concepts are
identified through analytical procedures such as
isking quest.ons about the data and looking for
differences £.nd sirüilarities between phenomena,
events, and incidents through constant comparison. The common themes that emerged from the
data were tl'.en grouped together for identification and labelled with an abstract name to
produce categories.
Meticulous reccrds of the research process
were mainiained with the aim that other
researchers would be able to analyse the data
and reach the sam; conclusions. Analysis triangularion by the different members of the team
was intended to ensure reliability and reduce
bias and error.
Results and discussion
Of the ten registered nurses in the hospice at
home nursing team, seven participated in the
study. One nurse '^as excluded because she had
a rcle in tiie research team, one nurse was
286
absent on maternity leave, and one nurse
declined to participate. The reason given for
non-participation was that the nurse preferred
the interview to be conducted in Welsh. This
option was not available to the study without
introducing extra financial costs and increasing
potential bias. All of the nurses were female, and
they had an average age of 54 years (range
41-62 years). All were registered nurses at a
minimum, with a mean of 24 years of nursing
experience (range 10-39 years).
There was unanimous consensus among the
research team that four super-ordinate themes
emerged from the data:
O Job satisfaction
O Stressors
O Coping strategies
O Support.
Job satisfaction
Job satisfaction was identified as an important
determinant of the nurses' stress levels. Several
of the nurses discussed the merits of 'making
a diffeirence':
'When you've walked in and there's a crisis, the
patient is in pain, family in distress, they are
not coping, they are frightened. By the time
you have left the home, having sorted out the
pain, the symptom control issues and you've
calmed the waters ... the families are happy.'
Nurse 2
'I mean we can make things better. We can't
change what's happening but we can make a
difference.' Nurse 7
'If you can nurse someone at home and make
them as comfortable as possible in their last
days of life, it's a privilege to do it ... it's well
worth everything you do.' Nurse 1
Similar views from nurses regarding the
rewards of nursing dying patients were reported
in a study from Taiwan (Wu and Volker, 2009).
These Thai nurses acknowledged the job
satisfaction and sense of self-worth obtained
from helping their patients achieve a good death.
However, it should be noted that there are significant differences between the cultures and
approaches to end-of-life care between a hospice
in Taiwan and the setting of- the present study.
Another study that investigated stress in palliative care nurses also identified a theme called
'making a difference' (Ablett and Jones, 2007). In
the study reported here the nurses' commitment
to their work and the sense of being in control of
International Journal of Palliative Nursing 2012, Vol 18, No 6
Research
the work situation were indicated as being a
source of job satisfaction. Contact with dying
patients was also indicated to be a key source of
job satisfaction by Grunfeld et al (2005).
Prioritising the workload was important for
the nurses in the present study to be able to
manage their day effectively:
'The distances that you are travelling between
patients and the requests for input can be
demanding. You've got to be assertive and say
'No, I can't physically do that.' You need to
prioritise patient care and then go with that
priority.' Nurse 1
The large distances involved in the nurses'
daily work and the collaboration with a
number of community nursing teams, all with
different demands, can result in increased activity and stress for the hospice at home nurses. A
study of district nurses found that they had
similar experiences when caring for dying
patients (Burt et al, 2008).
Stressors
The nurses identified conflict with colleagues
from outside the team and difficulty communicating with the GPs and district nurses as a
source of stress:
'The GPs can be difficult to get hold of and they
are not always proactive, and without that, then
your job is almost impossible to do.' Nurse 2
Nurse 7 identified that district nurses are now
also so busy that palliative patients are missing
out on visits:
'That's quite stressful, when you tell a colleague
that a patient is going down or whatever, they
don't hear, because they don't want to hear
what you are saying.'
In a recent study, 'fellow workers not doing
their job' was among the top identified Stressors,
along with feelings of isolation (Martens, 2009).
Nurse 1 described occasionally feeling lonely
and isolated:
'Maybe you don't want to talk so much when
you finish your shift. I think it does affect you.'
Nurse 7
Conversely, another nurse denied feeling
mentally affected by the job:
'I think that it is down to experience, age and
maturity. If the work started to worry me ...
that's when I stop.' Nurse 4
Sources of emotional labour and occupational
stress in female hospice nurses were also identified by Payne (2001). The most frequent Stressor
was 'death and dying', then 'inadequate preparation', followed by conflict with doctors and
nurses. The least problematic Stressors were 'lack
of support' and 'uncertainty of treatment'.
However, organisational factors such as a high
workload and lack of resources and support have
been identified as a significant source of stress for
hospice nurses by other studies (Hawkins et al,
2007). Occupational stress is recognised as a
major reason for ill health; however, it must also
be noted that the stresses experienced are
context-dependent (Desbiens and Eillion, 2007;
Martens, 2009). Consequently, it is important
that the introduction of any coping strategies
decreases stress and promotes positivity,
encouraging a beneficial response.
Coping strategies
The nurses identified the need to 'switch off
after work:
'It's very sad really, you know when it comes to
the end of their life it can hit you emotionally,
but I don't take it home and think about it for
hours.' Nurse 1
'I can switch off at the end of the day, I've
always been able to do it because I don't think
you do your patients any good if you're fretting
too much and can't do your job properly the
following day.' Nurse 3
Many of the nurses said that walking and
exercise were means to help them unwind after a
difficult day:
'It depends on the patient, on their family,
it depends whether your local colleagues
are working as well or whether you are on
your own.'
'I find exercise helps. I go to the gym twice a
week in the morning and I find that really
helps.' Nurse 7
Many of the nurses commented that the job
was 'mentally draining'—more so than working
in a different clinical scenario.
Other after-work relaxation methods included
watching television, listening to music, and
attending craft lessons.
International ¡ournal of Palliative Nursing 2012, Voi 18, No 6
nurses
identified
conflict with
colleagues
from outside
the team and
difficulty
communicating
with the GPs
and district
nurses as a
source of
stress...*
287
Research
^Increased use
of clinical
supervision
and reflection
is indicated,
along with the
provision of
stress-awareness
training.*
It has long been established that there is a
medium-to-high risk of hospice nurses experiencing compassion fatigue, but also that healthy
professional 'distancing' learned from years of
nursing experience and 'self-care' can balance out
Stressors (Abendroth and Flannery, 2006).
However, it has also been reported that the job of
dealing with multiple deaths and accompanying
the dying does not seem to have a major affect
on palliative care nurses (Desbiens and Fillion,
2007). Furthermore, stress levels are similar to or
lower than in nurses working in other fields.
Support
The nurses identified support from colleagues as
being important for their coping:
'I chat with my colleague and the district nurses
... make sure we have lunch together in the
office so that we can chat and you know say
how we feel, so that helps.' Nurse 5
Nurse 3 worked in a particularly isolated rural
area and found that:
'Coming and mixing with the other people that
you work with in the department weekly, is actually more beneficial probably than anything else.'
Other nurses also found support among family
and friends:
'My husband and I we do discuss things if I
have got something on my mind. I would tell
him ... without naming names, that's how I
unload properly.' Nurse 6
The majority of the nurses in Wu and Volker's
(2009) study identified the importance of seeking
peer support, especially if there is a difficult case,
and support from colleagues was also recognised
in Payne's (2001) study. Social support has been
found to be an important coping strategy,
and supervision and support groups should be
encouraged as an approach to coping with stress
(Hawkins et al, 2007). The use of reflection in
and on practice for the nurses in the present study
takes place both informally among the team and
formally at the weekly multidisciplinary team
meeting. The team meeting is recognised as being
a safe and supportive place to discuss a variety
of problems related to practice and complex
symptom management (Arber, 2007).
288
nurses. From these, various recommendations
can be made. Care providers should promote
regular attendance at weekly multidisciplinary
team meetings and, where relevant, local monthly
team meetings including the palliative care
consultant and Macmillan nurses as well as hospice at home nurses. Meetings can be held in the
local place of work, supplementary to the weekly
multidisciplinary team meeting. Increased use of
clinical supervision and reflection is indicated,
along with the provision of stress-awareness
training. Raising awareness of the role of the hospice at home nurse in the primary care setting is
also relevant, as conflict outside the palliative
care team and communication difficulties
between the hospice at home nurses and primary
care teams were identified as a source of stress
for the hospice at home nurses.
Limitations
This study was undertaken in a relatively small
team of hospice at home nurses working closely
with one another to provide a community palliative nursing service across a wide geographical
area of North West Wales. For pragmatic reasons
the project manager conducted the study interviews. Although known to the team members, the
project manager does not have a clinical relationship with the nursing team members. Using an
existing member of the team to undertake the
role of interviewer may have had positive and
negative effects. Being interviewed by a familiar
person may be less threatening, leading to a more
relaxed discussion. Alternatively the nurses may
have felt inhibited because they knew the interviewer, although during the interview process the
interviewer had no sense that the nurses felt
awkward in any way.
Despite the interview transcripts being
anonymised and the order of the transcripts
randomised for each researcher, in one or two
cases it was still possible for the researchers to
identify the interview participant. This familiarity
was present to some degree for all three of the
researchers; however, each researcher was blinded
to their colleagues' critiques of the transcripts.
Interestingly, consensus was quickly apparent
when the researchers met to discuss the outcomes
of the study. During discussion of the transcripts
and identification of common themes there was
agreement that saturation had been reached and
no loss of data was apparent in the conclusions
drawn from the transcripts.
Recommendations
Conclusion
The study highlighted a number of factors that
contribute to the wellbeing of hospice at home
End-of-life care is everyone's business, from
generalist to specialist, regardless of care setting.
International journal of Palliative Nursing 2012, Voi 18, No 6
Research
With increasing emphasis being placed on achieving
preferred place of care at time of deatb, tbe
hospice at home nurse represents a critical
resource tbat is valuable not only to patients but
also their families and health professionals.
Further studies are needed to ascertain the potential of the recommended interventions to improve
the wellbeing of hospice at home nurses. @i
Acknowledgments
The authors wish to acknowledge the participation of the
hospice at home nursing team, without whose contribution
this study would not have been possible. Acknowledgment
is also due to the NHS organisation R&D department for
sponsoring the study.
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Research for Practice
The Relationship of Burnout, Work
Environment, and Knowledge to SelfReported Performance of Physical
Assessment by Registered Nurses
Anita G. Fennessey
etween 210,000 and 440,000
patients die annually from
preventable harm that
occurred during hospitalization
(Allen, 2013). The Joint Commission (2013) identified inadequate
patient assessment as a primary
cause of sentinel events. Assessment, the first step of the nursing
process, is the systematic and ongoing collection of patient data
(Nugent & Vitale, 2014). Accurate,
ongoing physical assessment must
be performed to achieve positive
patient outcomes. Thorough physical assessment is the foundation for
all planned nursing intervention
and provides the framework for
comparison of subsequent findings
during hospitalization.
Several positive outcomes have
been attributed to registered nurses’
(RNs) consistent performance of
thorough physical assessment. They
include improved nurse-physician
collaboration, decreased adverse
medical events, and better patient
outcomes (Giberson, Yoder, & Lee,
2011). However, research also has
found nurses do not use even onehalf of the assessment skills they
learned in school (Birks, Cant,
Ainsley, Chung, & Davis, 2013).
Burnout has been identified as a
contributor to RNs’ inability to perform assessment skills consistently
and thoroughly. High burnout levels also have been linked to lower
job satisfaction, increased judgment
errors, and decreased work efficiency (Rosales, Labrague, & Rosales,
2013). Because burnout impacts job
performance, overall quality of
patient care also may be affected
B
346
Physical assessment by registered nurses plays a key role in preventing sentinel events. Variables that may affect nurses’ ability to perform physical assessment consistently were examined.
(Morse, Salyers, Rollins, MonroeDevita, & Pfahler, 2012; Patterson,
2011). However, no specific studies
link burnout to performance of
physical assessment skills by RNs.
Literature Review
A literature review was conducted
for 2011-2016 using Medline (OVID),
Medline (PubMed), CINAHL, and
EBSCO. Keywords included physical
assessment skills, work environment,
burnout, nursing assessment, and
knowledge. The search included only
articles written in English. Multiple
studies were analyzed and reviewed
prior to selecting specific studies relevant to this research.
Garrosa, Moreno-Jiménez, Rodriguez-Muñoz, and Rodriquez-Carvajal (2011) discussed the link of role
stress to burnout, recognizing the
engagement process in relation to
role stress had not been studied adequately. The purpose of their crosssectional study was to investigate
the relationship of role stress and
personal resources to burnout and
engagement processes among nurses. Data were obtained from 508
nurses in various general hospitals
in Madrid. Role stress was found to
be related more to burnout, while
personal resources such as emotion-
al competence were associated with
engagement. These findings helped
to link role stress with physical
assessment as part of the nurse’s
role performance.
Woodhead, Northrop, and Edelstein (2016) reported exposure of
long-term care nursing staff to
increased levels of occupational
stress as well as burnout. Using the
Job Demands-Resource Model of
Burnout, they investigated the relationship among job demands, job
resources, and burnout. Data were
collected from 250 nursing staff of a
long-term care facility. Hierarchical
linear regression analyses indicated
job demands such as greater occupational stress were linked to higher
levels of emotional exhaustion,
increased depersonalization, and
decreased personal accomplishment. Job resources (e.g., support
from supervisors, family members)
were linked to higher levels of personal accomplishment and lower
levels of emotional exhaustion.
Researchers concluded measures to
decrease burnout should include
focusing on stress and social support outside the work environment.
The author of the current study recognized occupational stress can
impact job performance negatively.
Anita G. Fennessey, DrNP, RN, CNE, is Nursing Instructor/Course Coordinator, Abington
Memorial Hospital Dixon School of Nursing, Abington, PA.
September-October 2016 • Vol. 25/No. 5
The Relationship of Burnout, Work Environment, and Knowledge to Self-Reported
Performance of Physical Assessment by Registered Nurses
Mijakoski and colleagues (2015)
noted burnout may be related to
increased exposure to chronic emotional and interpersonal workplace
stressors. They investigated the relationship among burnout, job
engagement, job pressures, and
workplace culture to demonstrate
differences between physicians and
nurses working in a general hospital
in Skopje, Republic of Macedonia.
The Maslach Burnout Inventory
and Utrecht Work Engagement
Scale were used to measure burnout
and job engagement, respectively.
Work demands were measured with
the Hospital Experience Scale, and
workplace culture was measured
using the Competing Values Framework. Higher scores of dedication
and organizational work demands
were found in physicians, while
nurses demonstrated higher scores
of clan organizational culture.
However, burnout correlated negatively for nurses and physicians
with clan organizational culture. By
arranging sufficient job demandresources interaction, authors concluded burnout could be prevented
and improved job engagement
achieved. By improving job engagement and decreasing burnout, then,
overall job performance (including
physical assessment) also may
improve.
A gap exists in the literature
regarding the performance of physical assessment. The researcher for
the current study has observed
nurses rushing through physical
assessment, increasing the risk for
possible inaccuracy. Exact variables
contributing to RNs’ poor or inaccurate performance of physical assessment skills have not been identified
specifically. However, deficiencies
in nursing performance have been
linked to increased stress, time constraints, nurse-to-patient ratios, and
burnout (The Joint Commission,
2012). Research should determine if
a relationship exists among RNs’
burnout, knowledge, and organizational attributes, and consistent
performance of their physical
assessment skills.
Purpose
The purpose of this study was to
explore the relationship of RN
burnout, knowledge of physical
assessment skills, and work environment to self-reported physical
assessment skill performance.
Methods
Design and Sample
This descriptive correlational
study used a cross-sectional data
collection survey. Descriptive surveys were used to collect interval
ratio data. Demographic data
enabled the investigator to determine if a link existed between
length of experience, types of experience, education, and RNs’ skill in
performing physical assessment.
A convenience non-probability
sample was recruited from two hospitals (one surburban, one urban)
comparable in size and number of
RNs. Approximately 1,400 RNs at
study institutions qualified for the
study. Statistical power analysis
determined a sample of 100 RNs
would be representative of the population to provide scientific basis to
calculate power. This calculation
was based on a desired power of
80% for a median effect size (r=0.25,
p=0.05) (Gaskin & Happel, 2014).
Inclusion criteria were RNs practicing for more than 2 continuous
years; currently employed on a
medical-surgical, telemetry, or critical care unit; currently employed 16
or more hours per week; clinical
nurse, including charge nurse; and
ability to understand the consent
process.
Measures
Demographic data were collected
on an investigator-generated form,
to include nurse’s age, sex, hours
worked per week, years as an RN,
entry level of nursing education,
highest level of education, and current RN role.
The Oldenburg Burnout Inventory (OLBI) was used to measure the
degree of professional nurse burnout (Demerouti, Bakker, Vardokou,
& Kantas, 2003). The OLBI assesses
September-October 2016 • Vol. 25/No. 5
two core dimensions of burnout:
exhaustion and disengagement.
Exhaustion is described as an end
result of extreme physical and emotional stress. Disengagement is defined as the separation of self from
work, indicating possible lack of
interest. The OLBI contains 16items (eight each in exhaustion and
disengagement subscales) rated on a
Likert-scale (1=strongly disagree,
5=strongly agree); a higher rating
indicates a higher degree of burnout. Internal consistency was
acceptable with Cronbach’s alpha
over 0.70 (Reis, Xanthopoulou, &
Tsaousis, 2015).
The Nursing Work Index Revised
(NWI-R) was used to measure organizational attributes that may affect
RNs’ ability to perform physical
assessment consistently (Aiken &
Patrician, 2000). The NWI-R is a 57item instrument rated on a Likert
scale (1=strongly agree, 4=strongly disagree). It has overall Cronbach’s
alpha of 0.96.
The 28-item Physical Assessment
Performance Questionnaire (PAPQ)
was used to test RNs’ perceived
knowledge and ability to perform a
complete physical assessment
(Yamauchi, 2001). For each of the
28 physical assessment items using
a 5-point Likert scale, questions
addressed the following: knowledge
and ability to perform the skill, frequency of use for each physical
assessment item, and extent of
respondents’ perceived need for
each physical assessment item. At
the time of instrument development, content validity, clarity, and
item discrimination were confirmed by three nurse educators and
three practicing nurses. Each item
of the physical assessment questionnaire was independent, so
internal consistency among items
was not needed.
A Physical Assessment Knowledge Test (PAKT) was developed as
an attachment to the PAPQ. PAKT
included 10 NCLEX-style multiplechoice items to assess RNs’ basic
knowledge of assessment physiology. Items were generated from the
Logic Extension Resource (LXR) test
bank. The LXR program provides
347
Research for Practice
statistical analysis for each test
question. The average Kuder Richardson-20 correlation statistic for
the PAKT was 0.73 to 0.90, with an
average item point biserial score
from +0.228 to +0.346.
Procedures
After receiving Institutional Review Board approval from Abington
Memorial Hospital (AMH; Abington, PA) and Hahnemann University Hospital (HUH; Philadelphia,
PA), the co-investigator distributed
information fliers to RNs at study
hospitals through e-mail, or by
placing fliers in nurses’ mailboxes
or randomly handing fliers directly
to nurses. RNs were informed participation was completely voluntary. Those who chose to participate
accessed a survey link, which
opened to an introduction/ consent
form explaining the study’s purpose. The form also listed inclusion
criteria to allow RNs to determine if
they were eligible to participate and
continue, or were not eligible or did
not want to participate and thus
exit the web site.
Data Analysis
Demographics and study variables were tabulated using descriptive statistics, summary scores, graph
displays, and frequency distributions
for each consequence and demographic variable. Analysis was based
on a multiple linear regression
design to explore if the relationship
of the independent variables (knowledge of physical assessment skills,
nurse burnout, organizational attributes) significantly correlated to the
dependent variable (performance of
physical assessment skills). Additional correlations were completed
to explore relationships of the subconcepts burnout (exhaustion and
disengagement), work environment
(autonomy, control, nurse-physician
collaboration, organizational support), and demographics (years of
experience).
Results
Of 1,100 potential participants
from AMH and HUH, only 150 RNs
initiated the survey (11% response
348
Variable
TABLE 1.
Bivariate Correlations
Work Environment Composite (1)
(1)
Physical Exam Performance Composite (2)
(2)
-0.06
Knowledge Test Composite (3)
Burnout Composite (4)
(3)
0.11
0.07
(4)
0.21
-0.17
-0.07
Coefficients rounded at second decimal point for convenient presentation.
* p = 0.05
rate). Participants were predominantly women (n=134, 93%) and
held an associate degree (n=40,
27%) or baccalaureate degree in
nursing (n=60, 41%). Most worked
in medical-surgical nursing (n=56,
38%) or critical care nursing (n=47,
32%) and had 6-10 years of experience (n=34, 23%).
No statistical significance was
found in this study. For example,
results did not indicate nurses who
scored higher on the PAKT performed physical assessment skills
more consistently (r=0.07; see Table
1). Also no relationship was found
between RN burnout and performance of physical assessment skills
(r= -0.17). Additionally, an association was not found between RNs’
perception of the work environment and performance of physical
assessment skills (r= -0.06).
However, on post-hoc analysis of
the demographic data to the PAPQ,
subscales of frequency of use and
extent of need from the PAPQ were
statistically significant for RNs who
worked on the critical care and
telemetry units compared to RNs
who selected “Other” on the demographic data form (e.g., pediatrics,
neurology, oncology, geriatrics) (see
Table 2). Findings indicated RNs
who work in telemetry and critical
care settings perceived a need for
physical assessment skills and thus
may perform physical assessment
skills more frequently compared to
nurses in other areas. The difference
in frequency of performing assessment and extent of need between
critical care and telemetry RNs and
RNs from pediatrics, neurology,
oncology, and geriatrics has clinical
significance because patients on
these units are considered vulnerable and generally experience more
complications (Allen, 2013). Findings indicated these patients were
not assessed frequently and thus
were at higher risk for adverse
events.
Another finding emerged from
the post-hoc analysis. When expert
RNs (defined as prepared at the
graduate level with more than 5
years of clinical experience as nurse
educators at a program accredited
by the National League for Nursing
Commission for Nursing Education
Accreditation) reviewed the PAPQ
and listed the top 10 physical
assessment skills to be performed
every day, a discrepancy was found
between what they viewed as
important and what RNs in this
study viewed as important. Results
of this survey were compared to the
frequency-of-use subscale of the
PAPQ completed by RNs in this
study. Expert RNs and the RNs in
this study similarly selected eight
skills. Consequently, the significance was in the skills not selected
by RNs in this study. RNs in the
study believed assessing for pitting
edema and observing gait were of
higher priority than assessing pupil
response and pulse deficit. This discrepancy could impact patient safety, especially if a patient had a pulse
deficit which was not assessed
before the patient was taken out of
bed to observe his or her gait.
Discussion
This study evaluated self-reported frequency of use, knowledge,
and extent of need for physical
assessment. Even though no statisti-
September-October 2016 • Vol. 25/No. 5
The Relationship of Burnout, Work Environment, and Knowledge to Self-Reported
Performance of Physical Assessment by Registered Nurses
TABLE 2.
Physical Assessment Performance Questionnaire Scores by Group
Variable
Extent of Knowledge*
Other
Group**
Medical-surgical
Critical care
Progressive care
Telemetry
Other
Frequency of Use
Mean
Standard
Deviation
38
75.9
7.8
14
35
10
10
79.2
73.4
74.9
9.4
7.1
7.7
6.7
13.9
32
104.0
12.5
Telemetry
10
107.4
15.1
Medical-surgical
37
90.5
8.8
Medical-surgical
Critical care
Progressive care
Critical care
Progressive care
Telemetry
13
72.9
88.6
Other
Extent of Need
N
38
9
12
33
9
10
98.2
103.8
82.8
92.4
92.8
94.7
17.7
5.7
14.9
9.0
9.1
6.0
* No significant differences in extent of knowledge among groups.
** The group classified as “Other” was significantly different (p
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