Article, Emergency Medicine

Work-related stressors and occurrence of adverse events in an ED

a b s t r a c t

Objective: The purpose of this study was to investigate the relationship between 12 work-related stressors and the occurrence of adverse events in an emergency department (ED).

Methods: Nurses and physicians, working in an ED at a Danish regional hospital, filled out a questionnaire on occurrence and emotional impact of 12 work-related stressors after each shift during a 4-week period. The questionnaire also instructed the participants to describe any adverse events that they were involved in during the shift.

Results: Two hundred fourteen adverse events were reported during the 979 studiED shifts. During the same period, only 27 adverse events were reported to the mandatory national reporting system, and only 10 of these were duplicates. A high variability of stressors and emotional impact among the different groups of participants was found. Linear regression analysis showed an association between involvement in adverse events and the occurrence and emotional impact of stressors across groups, whereas no significant association was found for age, seniority, shift type, or length.

Conclusion: The study showed an association between the occurrence and impact of 12 work-related stressors and involvement in adverse events across the groups of participants. Furthermore, the study showed that most adverse events were not reported to the mandatory national reporting system.

(C) 2013

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].

? The project was funded by Trygfonden (grant no. 7-10-0949).

* Corresponding author.

E-mail address: [email protected] (K.J. Nielsen).

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.

0735-6757/$ – see front matter (C) 2013 http://dx.doi.org/10.1016/j.ajem.2012.10.002

Table 1

Participants

No of persons

Respondents

Mean age (SD)

Mean seniority at hospital (SD)

No. of shifts

Reports

Nurses, admission

43

43 (100%)

43.7 (8.4)

12.3 (8.0)

554

379 (68%)

Nurses, ward

55

53 (96%)

41.1 (8.1)

7.2 (5.8)

609

441 (72%)

Medical specialists

11

8 (73%)

46.0 (11.0)

1.4 (1.8)

82

46 (56%)

Junior physicians

15

15 (100%)

29.1 (1.7)

0.4 (0.3)

166

113 (68%)

Total

124

118 (95%)

41.0 (9.2)

7.6 (7.4)

1411

979 (69%)

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.

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 200000 persons and serves 16000 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 cardiology) are diagnosed and treated at the ED, with backing from physicians from other de- partments. Only patients with diseases that cannot be fully treated within 24 hours are referred to other departments. Around 70% of all acute patients are discharged directly from the ED. Thus, a well- functioning ED is dependent upon good clinical and working relations between the different departments.

The nurses in the ED worked either in the admission or bed ward, whereas the medical physicians covered both places. All nurses and physicians working in the ED were instructed to fill out a short questionnaire at the end of each shift in a 4-week period from May 9, 2011, until June 5, 2011. Besides type (day/evening/night) and length of shift (8/12 hour), the questionnaire asked whether 12 specific work-related stressors had occurred during the shift. If a stressor had occurred, the participants were asked to indicate the emotional impact of the stressor on a 5-point scale ranging from ‘Not at all stressful’ to ‘Extremely stressful’. This was done to address the individual variability in stress response. The questionnaire also instructed the participants to describe any errors or adverse events that they were involved in during the shift. The questionnaire took less than a minute to complete, if no adverse events were recorded.

A total of 98 nurses from the admission and bed ward, 11 medical specialists, and 15 junior physicians worked at the ED during the study period. Of these, 118 filled out one or more questionnaires giving a participation rate of 95% (see Table 1). The 118 persons

worked a total of 1411 shifts in the study period and filled out a total of 979 questionnaires (average, 8.3; range, 1-19), which gives a response rate of 69%.

The 12 work-related stressors used in this study were chosen through 3 different sources: firstly, the main stressors from other studies on stress in EDs [10,11] were identified; secondly, through qualitative interviews with some of the participants before the study; and finally, a 2-week pilot study with an early version of the questionnaire was performed with a sample of junior physicians from the ED. After the pilot, the participants were encouraged to comment on the questionnaire and add extra stressors. As each participant was required to fill out the questionnaire repeatedly over a 4-week period, shortness and ease of completion were a priority to avoid dropout. Therefore, the list of stressors was limited to 12, although other studies have used up to 52 stressors [5]. The 12 stressors included in the study reflected both workload, professional conflicts and coping with emotional demands (see Table 2).

Reported events were assessed by the first 4 authors indepen- dently to ensure that they both qualified as adverse events and occurred in the ED. This was followed by a group discussion until consensus was reached on each reported event. A total of 21 events were discarded in this process. All adverse events at Danish hospitals are required to be reported to the national Danish reporting system (the Danish Patient Safety Database). The reports are made locally by nurses and physicians. We collected all the officially reported adverse events from the ED during the study period directly from the database. These were assessed by the first and third author to ensure that they qualified as adverse events and were localized to the ED. A total of 5 events were discarded in this process. Subsequently, the research group categorized all the adverse events in 6 categories based on the national standards (an adaptation of the World Health Organization’s International Classification for Patient Safety classifi- cation). Furthermore, the hospital’s quality consultant, who normally processes the officially reported adverse events, assigned both an actual and potential Safety Assessment Code (SAC) [12] score to each adverse event based on actual/potential harm and frequency. Safety Assessment Code scoring is a method to evaluate the seriousness of the reported adverse events and is routinely assigned to all officially

Table 2

Frequency of stressors and average emotional impact for the 4 groups of participants

Frequency (%) Emotional impact (1-5)

Nurses, admission

Nurses, ward

Medical specialists

Junior physicians

Nurses, admission

Nurses, ward

Medical specialists

Junior physicians

Work frequently interrupted

56

48

67

39

2.86

2.30

2.79

2.36

Did not complete all work tasks

32

14

33

4

2.60

2.78

3.25

2.20

Noise

30

13

24

30

2.93

2.81

2.45

2.71

Insufficient opportunity for work planning

25

11

38

14

2.81

2.65

3.13

2.53

Felt insufficiently prepared to handle

25

12

30

26

2.93

2.82

2.54

2.64

work tasks

Too busy to do the job in the best way

24

14

35

11

3.13

3.13

3.38

2.75

Lack of help and support

12

4

37

8

2.93

2.60

3.19

3.22

Emotionally demanding patients

11

11

24

8

2.68

2.52

2.60

2.56

Criticized or verbally attacked by others

11

5

15

6

2.58

2.58

3.29

3.14

Bad working relations within own unit

8

6

24

9

2.79

2.96

3.27

3.60

Bad working relations with other units

8

4

26

5

3.00

2.67

3.50

2.60

Violence or threats of violence

3

3

7

3

2.58

2.00

3.67

2.33

Table 3

Number of reported adverse events

Table 5

SAC scores for the adverse events reported in the questionnaire and to the national database during the study period

No. of AE % shifts with AE % persons with AE

Nurses, admission 63 14 67

Nurses, ward

106

19

58 score

Questionnaire

Database

Both

Questionnaire

Database

Both

Medical specialists

31

39

63

(n = 214)

(n = 27)

(n = 10)

(n = 214)

(n = 27)

(n = 10)

SAC

Actual risk (%) Potential risk (%)

Junior physicians 14 12 60

Total 214 17 63

Abbreviation: AE, adverse event.

reported adverse events. Safety Assessment Code scores range from 1 (low risk) to 3 (high risk).

Statistical analyses

Random effect linear regression analysis was used to model the association between stressors and involvement in adverse events using individual level data while taking into consideration that the repeated measurements on each individual might be correlated. The same procedure was used to identify group difference in the reporting of adverse events on shifts and in the occurrence of work-related stressors and their emotional impact. All analyses were performed in STATA 12.1 (StataCorp. 2011. College Station, TX).

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]), whereas no differences were found between admission nurses and junior physicians or junior physicians and ward nurses. The exact same pattern was found for the emotional impact of stressors, where medical specialists expressed significantly higher emotional impact than the other 3 groups, whereas admission nurses experienced more emotional impact than ward nurses.

A total of 214 adverse events were reported during the 979 shifts (see Table 3). Test of group differences showed that medical specialists experienced a higher percentage of shifts with adverse events than the junior physicians (diff, 0.26; 95% CI [0.09-0.43]), ward nurses (diff, 0.18 [0.02-0.39]), and admission nurses (diff, 0.23 [0.08- 0.39]). The last 3 groups did not differ. Sixty-three percent of participants were involved in at least 1 adverse event during the 4- week study period.

A total of 27 adverse events were reported by the ED staff to the obligatory national database during the study period. However, when reading and comparing them directly to the 214 adverse events reported in the questionnaires, only 10 of the adverse events were duplicates. The reported adverse events were categorized based on the national standards, which showed that Clinical processes,

Table 4

Comparison of adverse events reported in the questionnaire and to the national database during the study period

1

84

89

90

42

41

40

2

16

11

10

47

52

50

3

1

0

0

12

7

10

SAC-scores: 1, low risk; 2, intermediate risk; 3, high risk.

administrative processes, and communication and documentation were the main types of events (see Table 4).

The SAC scores assigned to events reported in the questionnaires and the national database are shown in Table 5.

To assess the relationship between the occurrence and impact of stressors and involvement in adverse events, we performed a linear regression corrected for repeated observations and adjusted for possible confounders (shift type, shift length, age, and seniority). The 2 stressor measures (occurrence and emotional impact) were strongly correlated (correlation, 0.93) so the analyses were performed separately for occurrence and emotional impact. Linear association between the stressors and adverse events was evaluated by likelihood ratio test for linear trend. Interaction between the linear effect of the stressors and group of participants was examined, but the group specific effects did not differ significantly. The strength of the association between adverse events and occurrences of stressors and between adverse events and emotional impact were similar, and therefore, only the results from the analysis with emotional impact are shown here. The full model included either occurrence or emotional impact from stressors, shift type, shift length, age, seniority, and participant group (data not shown). Because no significant association was found for age or seniority, these variables were removed from the final model (see Table 6). Shift type and length were kept in the model as confounders, although no significant association was found for them either.

The results showed the same strength in the linear association between the emotional impact of stressors and the occurrence of adverse events for all four groups of participants. However, the level of association varies across the 4 different groups of participants, with ward nurses and medical specialists generally having a somewhat higher occurrence of adverse events (see Fig. 1)

As there were significant differences in age and seniority between the different subgroups (see Table 1), subgroup analyses were performed to investigate the associations between age, seniority, and involvement in adverse events further. The analyses showed a reversed u-shaped association between age and the occurrence of

Table 6 The final model specifying the relationship between the involvement in adverse events, emotional impact of stressors, and group

Stressors Coefficient (95% CI) SE

Questionnaire Database Both

Clinical processes

72 (34%)

13 (48%)

3 (30%)

Administrative processes

57 (27%)

5 (19%)

5 (50%)

Communication and documentation

47 (22%)

5 (19%)

1 (10%)

Medication

30 (14%)

4 (15%)

1 (10%)

Other (nonspecific)

7 (3%)

0 (0%)

0 (0%)

Medical equipment

1 (0%)

0 (0%)

0 (0%)

Total

214 (100%)

27 (100%)

10 (100%)

Likelihood ratio test ?2(7) = 33.39; P = .000.

Emotional impact Shift type

Day

0.06 (0.04-0.09)

0.00

0.039

Evening

0.02 (-0.04 to 0.09)

0.033

Night Shift length

8 h

0.03 (-0.02 to 0.09)

0.00

0.032

12 h Group

Nurses, admission

-0.03 (-0.09 to 0.03)

0.00

0.032

Nurses, ward

0.08 (0.00-0.15)

0.036

Medical specialists

0.19 (0.03-0.35)

0.081

Junior physicians

0.01 (-0.10 to 0.11)

0.030

Constant

0.11 (0.05-0.17)

0.030

0,8

0,7

Occurrence of adverse events

0,6

0,5

0,4

0,3

0,2

0,1

0

-1 0 1 2 3 4 5 6 7

Emotional impact (std)

Nurses, Admission Nurses, Ward

Medical specialists junior doctors

interrupted. However, the emotional impact of interruptions was not very high, which might be because interruptions are so frequent in EDs that they are seen as a normal part of the job [13,14]. This is in line with the study of stressors in an ED of Flowerdew et al [10], where none of the respondents mentioned interruptions as a stressor. So some of the stressors might be seen as ‘coming with the territory’ and thus not have much emotional impact compared with less common or expected stressors, for example, bad working relations or being criticized or verbally attacked. This might be reflected in the ranking of the emotional impact of the stressors. For the medical specialists, the 2 stressors with the highest emotional impact were ‘violence or threats of violence’ and ‘bad working relationships with other units’. As stated earlier, good clinical and working relations with other units are crucial for a well-functioning ED, so it is not surprising that it is stressful when this is not the case. For junior physicians, ‘bad working relationships within own unit’ and ‘lack of help and support’ were rated as the most stressful. However, for both groups of physicians, the averages are

Fig. 1. The level of association between emotional impact of stressors and occurrence of adverse events for the 4 groups of participants.

adverse events for medical specialist (the quadratic of age showed a significant association with the involvement in adverse events; coefficient, -0.002; P = .008). All other groups showed no significant associations between age and adverse events. Subgroup analysis on seniority data showed a similar reversed u-shaped association between the seniority and the occurrence of adverse events for medical specialist (the quadratic of seniority was significantly associated with the involvement in adverse events; coefficient, 1.62; P = .002) and ward nurses (coefficient, 0.03; P = .009). The admission nurses showed a nonsignificant negative association between seniority and adverse events (coefficient, -0.04; P = .16).

Discussion

The study showed a significant association between the occur- rence 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 occurrence of adverse events for medical specialist that cannot be explained, although the fact that only 8 medicals specialists participated might cause reporting bias by single individuals (with specific ages) to skew the data. The subgroup analysis for seniority showed the same results, and again, the medical specialist’s results might be skewed by single individuals. Furthermore, the seniority data were based on employment at the hospital under study, and the medical specialists all had relatively low seniority. This was because they had been recruited externally due to emergency medicine being a new specialty in Denmark, and the ED had only been functioning for 2 years. So the seniority data are not representative for the medical specialist’s seniority as physicians. The nurses for the ED were recruited internally so their seniority was more representative for their experience as nurses. The reversed u-shaped association between seniority and adverse events for the ward nurses might seem surprising; however, generally, the result is in accordance with prior results showing a negative association between adverse events and seniority [5], which is also what is seen for the admission nurses, although the association is nonsignificant.

We found a high variability of stressors and emotional impact

among the different participants. This might be a reflection of the unpredictable and shifting working conditions in an ED and has also been found in a comparable study [11]. One general trend across all 4 groups was that the most frequent stressor was being frequently

based on very few occurrences of most of the stressors, so there is a high degree of uncertainty about the specific rating.

For both groups of nurses, ‘bad working relationships’ and ‘too busy to do the job in the best way’ were the most stressful, the only difference being that the bad working relations were with other units for admission nurses and within own unit for ward nurses. The stressor ‘too busy to do the job the best way’ is an indicator of nursing workload, which previously has been shown to be associated with higher rates of nonfatal adverse patient outcomes [2].

The medical specialists reported both the highest number of stressors and the highest emotional impact. This is probably due to the medical specialist’s key role in the functioning of the ED. A similar trend is seen on the nursing side, where admission nurses reported a higher occurrence of stressors and a higher emotional impact than ward nurses, which probably reflects the different nature of the work in an emergency admission and a bed ward.

One surprising result was that junior physicians, who are the youngest and most inexperienced group in the ED, generally reported fewer and emotionally less demanding stressors. One possible explanation for this is that there was a well-functioning training and educational program at the ED under study.

Only 5% (10/214) of the adverse events reported in the question- naires were also reported to the obligatory national reporting system. The large discrepancy could be because the adverse events reported in the questionnaires were less serious than the ones reported to the official system. However, there were no significant differences for either actual or potential risk when comparing the distribution of SAC scores of events reported in the questionnaire to the national database or to events reported in both (see Table 5). There is no indication that events reported in the questionnaires were less severe than those found in the official reporting system. The larger number of adverse events reported in the questionnaires is more likely to be an indication of underreporting to the national database.

The current study points at the medical specialist as the group exposed to the highest occurrence and emotional impact from work- related stressors. This calls for a specific focus on the working conditions for this pivotal group and generally (for all groups in the ED) on minimizing stressors that are not a natural part of the job in an ED, such as bad working relations both internally and with other units. Thus, EDs might benefit from a focus on ‘non-technical’ skills such as communication and conflict resolution to minimize stress and adverse events.

Limitations

The current study has a number of limitations. First of all the occurrence and impact of stressors and involvement in adverse events were measured simultaneously and as self-reported data, which creates a risk of overestimating the association due to common

method bias [15]. In addition, the applied data collection method, where data were reported at the end of the shift, does not allow for causal inference, only identification of association. So whether the stressors or their emotional impact causes adverse events or the opposite is the case cannot be determined based on this study. Furthermore, the measure of adverse events was probably not complete, as data from the national database showed that only 10 of the 27 officially reported adverse events could be found in our material. This indicates that underreporting of adverse events is also a problem in our data, although we have 7 times as many adverse events as the official reporting system. There is also relatively little data from medical specialist and junior physicians, which makes the estimates for these groups uncertain, although the trends in the data were similar to the ones seen in the nurse sample. Finally, the data come from a single Danish ED and may not generalize to other settings or countries, as every institution might have more or fewer stressors and/or different types of stressors.

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.

Appendix A. Sample questionnaire

References

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  4. McVicar A. Workplace stress in nursing: a literature review. J Adv Nurs 2003;44: 633-42.
  5. Wu TY, Fox DP, Stokes C, Adam C. Work-related stress and intention to quit in newly graduated nurses. Nurse Education Today 2012;32:669-74.
  6. Berland A, Natvig GK, Gundersen D. Patient safety and job-related stress: a FoCUS group study. Intensive Crit Care Nurs 2008;24:90-7.
  7. Firth-Cozens J, Greenhalgh J. Doctors’ perceptions of the links between stress and lowered clinical care. Soc Sci Med 1997;44:1017-22.
  8. Arora S, Sevdalis N, Nestel D, Woloshynowych M, Darzi A, Kneebone R. The impact of stress on surgical performance: a systematic review of the literature. Surgery 2010;147:318-30.
  9. Harvey A, Bandiera G, Nathens AB, LeBlanc VR. Impact of stress on resident performance in simulated trauma scenarios. J Trauma Acute Care Surg 2012; Publish Ahead of Print.
  10. Flowerdew L, Brown R, Russ S, Vincent C, Woloshynowych M. Teams under pressure in the emergency department: an interview study. Emergency Medicine Journal 2011.
  11. Wrenn K, Lorenzen B, Jones I, Zhou C, Aronsky D. Factors affecting stress in emergency medicine residents while working in the ED. Am J Emerg Med 2010;28:897-902.
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  13. Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions are emergency physicians “interrupt-driven” and “multitasking”? Acad Emerg Med 2000;7:1239-43.
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    Date: / – 201 ID no

    Type of shift: ? Day

      • Evening Start of shift: :
      • Night End of shift: :

    Indicate for each of the following events, whether the event has occurred during the just completed shift. If you answer “Yes” to an event, then please rate who emotionally stressful it was for you.

    No

    Yes

    Not at all

    stressful

    A little

    stressful

    Somewhat

    stressful

    Very

    stressful

    Extremely

    stressful

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    My work was frequently interrupted I did not complete all work tasks

    There was too much noise to concentrate on work tasks I had insufficient opportunity for work planning

    I felt insufficiently prepared to handle the work tasks I have been too busy to do the job in the best way

    I lacked sufficient help and support from co-workers to perform work tasks

    I handled emotionally demanding patients

    I was criticized or verbally attacked by others

    I experienced bad working relations within own unit I experienced bad working relations with other units I was subjected to violence or threats of violence

    Have you been involved in any adverse events during the just completed shift? ? No (stop here)

    ? Yes (go to q3)

    3 Describe the adverse event(s):

    Information about the patient (if relevant)

    Age

    Describe the adverse event in your own words:

    Sex

    Diagnosis

    Co-morbidity

    Triagecolor

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