Original ContributionWork-related stressors and occurrence of adverse events in an ED☆
Introduction
The psychosocial work environment has increasingly been recognized as an important contributing factor for the occurrence of errors and adverse events at hospitals, thereby linking work environment and patient safety [1], [2].
A lot of research on work environment in the nursing profession has focused on stress [3], [4] often with a focus on burnout or turnover with the intention to identify effective interventions and/or improve educational practices. For instance, research has shown that newly graduated nurses experience a higher level of work-related stressors than experienced nurses, which is correlated with intention to quit and might also be related to poor patient safety outcomes [5]. However, the link to patient safety outcomes is often underdeveloped and not specified in details, although nurses themselves report that work-related stress is a risk factor for patient safety [6]. The most consistently identified sources of stress in nursing are workload, leadership/management, professional conflicts, and coping with emotional demands, which are core characteristics of the nursing profession [4]. However, other stressors, such as shift work and lack of reward, have also appeared in the literature [4].
Within the medical profession, it has been reported that 36% of hospital physicians have experienced recent incidents where stress negatively affected patient care [7]. A literature review found that surgeons were subject to many intraoperative stressors, which compromised performance and patient safety, especially in novice surgeons [8]. The same was recently found in emergency medicine residents where acute stress impaired performance in a simulated complex clinical setting and thereby became a potential threat to patient safety [9]. Flowerdew et al [10] also found that emergency department (ED) staff reported being subject to a wide range of stressors, the most common being time pressure, workload, staff shortage, and lack of teamwork, which echoes general findings within nursing. Likewise, correlations between stress and adverse events have been found in emergency medicine residents working in an ED [11].
Wu et al [5] found that demanding care, such as care for difficult or dying patient, was reported as the most stressful aspect of nursing, whereas hospital-related tasks, which encompassed administrative demands, such as requirements to be involved in research and/or committees, were the least stressful. However, the emotional impact of stressors might differ considerably between individuals dependent upon personality, prior experience, coping mechanisms, and the availability of social and managerial support. The same event might, therefore, not be experienced as a stressor or have the same emotional impact for 2 different individuals or for the same individual at 2 different points of time.
The purpose of the current study was to investigate the relationship between the occurrence and emotional impact of 12 work-related stressors and the occurrence of adverse events in an ED.
Section snippets
Methods
The study setting was an ED at a Danish regional hospital, composed of an emergency admission and an emergency bed ward. The ED has a catchment area of approximately 200 000 persons and serves 16 000 patients annually, of which 400 are traumas. This is a new way of organizing acute hospital admissions in Denmark and had only been functioning for 2 years at the time of the study. All acute patients with referral diagnosis covering general surgery, orthopedic surgery, and internal medicine (except
Results
Table 2 shows the occurrence of the 12 stressors and their average emotional impact for each of the 4 groups of participants. Test of group differences showed that medical specialists experienced more stressors on each shift than junior physicians (difference [diff], 2.04; 95% confidence interval [CI] [0.83-3.26]) and both ward (diff, 2.34 [1.26-3.42]) and admission nurses (diff, 1.30 [0.21-2.39]). Admission nurses also experience more stressors than ward nurses (diff, 1.04 [0.52-1.56]),
Discussion
The study showed a significant association between the occurrence and emotional impact of 12 work-related stressors and involvement in adverse events in an ED.
Prior research has shown an effect of age and seniority on the occurrence of adverse events [5], [8]. This could not be replicated in our study, where age and seniority did not make it in to the final model, as there was no effect across groups. The subgroup analysis showed an unexpected reversed u-shaped association between age and the
Conclusion
The study shows an association between the occurrence and impact of work-related stressors and involvement in adverse events across the 4 groups of participants. This was found, although the occurrence and emotional impact of stressors differed significantly between groups. Furthermore, the study shows that most adverse events are not reported to the obligatory Danish reporting system.
Acknowledgments
The project was funded by Trygfonden (grant no. 7-10-0949). The authors would like to thank quality consultant Anna Marie Fink and the staff at the ED for their willing participation in this project.
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