Chapter 3 Research results, findings, statements and supporting literature
This chapter describes the qualitative findings of the research, including the results of the focus group discussions, field notes and individual interviews. The data analyses are discussed with reference to literature in the preceding chapters relevant to the research findings. The data analyses provide greater clarity on the facilitation of conscious awareness among critical care nurses.
Attention is drawn to the following significant aspects of the different categories, subcategories and sub-subcategories that follow:
Statements contained in the individual categories were made, and are quoted, in relation to the facilitation of conscious awareness among CCNs.
Categories and subcategories were derived from the raw data. Literature support was obtained after categories and subcategories were established.
Statements are quoted without being edited, with the result that language, style and grammar may be colloquial and non-academic.
For the sake of clarity, Table 3.1 depicts the categories, subcategories and sub-subcategories obtained from open coding of data from the sample of CCNs. The same data texts are sometimes found in different categories, if categories overlap.
The objective of this chapter is to explain the findings of the research. A comprehensive description of the coding approach and research methodology was given in Chapter 2.
The findings are discussed in the light of previous research findings in order to identify similarities and differences between this research and previous research. A comprehensive literature review is included in this chapter to support specific findings.
DISCUSSION OF RESULTS OF THE QUALITATIVE DATA
The discussion focuses on facilitating conscious awareness among critical care nurses. Findings of this research are divided into major categories and subcategories and will be discussed under the following headings:
The findings of this research are divided into five categories, namely:
Perceptions about stress
Needs of CCNs
Contributory factors to stress in the critical care environment
Effects of stress
Perceptions of stress
This category refers to data obtained form participants about their perceptions of stress. Sub-categories further emerged from the data indicating how nurses perceive stress in the CCUs. The subcategories (as indicated in table 3.1) will be discussed.
A person’s response to any stressor will be influenced by his or her perception of that event and the ability to process the experience, attach meaning to it and integrate it into existing belief systems, to act positively, and to adapt to it (Rutter 1985:597). Resilience does not lie in the avoidance of stress, but in dealing with stress in an appropriate, responsible and confident way. However, findings indicate that developmental links play a significant role in the prevention of and therapeutic intervention in stress management (Rutter 1985:597).
Negative affect as a response to unpleasant emotions and pessimism could account for a personality style such as hardiness. The hardiness theory predicts a strain reaction that differentiates itself from negative affectivity at the level of measurement. The hardiness questionnaire’s results might indicate the resiliency of individuals as reflected in the dimensions of commitment, control and challenge (Maddi & Khoshaba 1994:274).
Vulnerability is expressed by the use of ineffective and maladaptive coping patterns that lead to immuno-suppressive behaviours. Adverse life experiences reflect personal involvement in negatively perceived circumstances. Such experiences include negative life events, social identities and strains in interpersonal relationships. The person is more likely to experience adverse life circumstances if adequate personal coping patterns are lacking. The inability to control distressful circumstances, or the dysphoric affect that accompanies such experiences, is reflected in the characteristic use of inadequate or maladaptive coping patterns.
Some of the major tenets of stress theory include the following:
Stress is neither an external stimulus, nor an internal response, nor an intervening variable, but a general label for a whole area of problems that include the stimuli that produce stress reactions and the processes that intervene between the stimuli and responses.
Psychological stress is distinguished from other types of stress by the intervening variable of threat that leads the person to anticipate some harmful condition.
Areas about the harmful condition are assessed by cognitive processes of appraisal. The first level of appraisal determines whether a threat exists and whether or not the person is under stress, the second level of appraisal assesses and directs coping mechanisms (Rapa 2000:49-53).
Perceptions of stress will be discussed under the following five subcategories:
Eustress or distress (18.104.22.168)
Stress measurement (22.214.171.124)
Physical and emotional symptoms (126.96.36.199)
Inability to function (188.8.131.52)
Eustress or distress
Participants related their perceptions about stress and vaguely described eustress (good stress) as being able to cope with stressors within an adrenaline flow, and distress (bad stress) as being unable to cope with stress. The majority of the participants experienced their work environment as posing challenges and being stimulating, whereas other participants regarded the work environment as being a high-risk environment where they were exposed to internal and external stressors on a daily basis. Anxiety states caused an inability to function effectively and efficiently.
CCNs made the following statements regarding eustress and distress:
(Vir my is daai tipe stres, ‘n goeie stres. Ek leef op daai stres, op daai adrenalien.)
For me that stress is a good stress. I live on that stress, on that adrenaline.
I think there is a difference between good stress and bad stress, hmmm, keeps you on the go, keeps you going, it makes you, you know, you keep deadlines, you keep going.
I think, hmmm, bad stress is what comes out in you physically, you know, you are inevitable, you know, you scream at people, may be”.
Cooper (1999:540) states that the meaning of the concept “stress” is unclear and there is no specific universal acceptance of this meaning. Cox (1978) adds that stress is comprehended by all when used in a general context, and by few people when used in a specific context (Cooper 1999:540).
Stress is not entirely bad or good; Selye (1974) distinguished between good, growth-producing stress, also known as “eustress”, and bad or harmful stress known as “distress”. Moderate amounts of stress could be significant stimuli or growth-producing challenges for some people. A certain level of stress is necessary for people to function productively.
However, Buggy (1999:26) describes individuals who feel driven, focusing on work only and mentally preoccupied with work, unable to switch off. These individuals develop physical and emotional symptoms because they experience stress as distress. Everly and Lating (1995:3) maintain that excessive stress (distress) and its various physical manifestations account for more than 80% of all visits to health-care professionals. Distress also accounts for approximately 14% of all occupational disease workers’ compensation claims, while the benefit payments for stress-related disorders average more or less twice those of physical disorders. The authors describe excessive stress as a plague to health-care workers and to society.
Buggy (1999:26) discusses how people could be unaware that they might be forcing their bodies and minds to their absolute limits, misunderstanding the flow of adrenaline for energy. This author adds:
… It’s a jungle out there in the workplace, only the strongest survive … In order to remain competitive and survive the workplace, we drive and push ourselves into an endocrinological state that profoundly impacts on our mind and body system …When adrenaline and all the other chemicals that are released to enhance our performance are triggered and flood our system, we get a quick fix to help us cope and it affects our whole system. The problem is in too many quick fixes which gets us literally hooked on our own adrenaline. It becomes a habit and we become stuck in a groove, perpetually pushing, perpetually buzzing, caught in an endless series of temporary highs.
Stress is a complicated, individualised and personal experience (Mitchell & Everly 1996:18). As we have pointed out, Selye (1974) refers to positive, motivating stress arousal as eustress, and stress which leads to dysfunction or disease as distress. He is of the opinion that not all stress is bad; in fact the absence of stress may lead to death. Strümpher (1999c:7) associates distress with physical disease and dysfunction, which result in absenteeism in the workplace.
Not all people experience stress equally. Veith (1997a:30) contends that while critical incidents may affect only one or two individuals, other events may affect everyone in the situation. Mitchell (1983:36-38) refers to studies in which 85% of personnel who experienced acute reactions recovered within a few weeks, while others took several months to recover from critical incidents. However, 2% to 4% experienced harmful emotional symptoms that affected their jobs, their families and themselves.
People who are naturally more anxious, uncertain, dependent, non-assertive, or inflexible are apparently less likely to cope with stressful events in their lives than others (Allan, Robertson, Orr & Levenstein 1999:138). Disasters for one individual might be perceived as challenges by others, depending on their cognitive perceptions (Allan et al 1999:138).
Difficulty in measuring stress has a subjective meaning for many CCNs; their perceptions of stress indicate that stress is difficult to measure and cannot be understood or controlled by the quantity experienced.
Measuring the amount of stress is difficult, since CCNs perceive, react and interpret critical incidents differently and are affected in various ways (Harvey 1996:4; Walker 1990:121).
Events that are interpreted and understood by CCNs and other health-care workers who have experienced similar critical incidents will change their perceptions on life and how stress may be measured and the abilities for coping or non-coping (Harvey 1996:4).
How do you measure the stress you know, you can’t say … but you only work twice a week, you can’t have stress. You work six days a week, you can have stress, hmm, you do, but how do you measure the stress.
The APA (1994:236) gives the following distinctive criteria for an acute stress disorder (see Table 3.2).
Maslach Burnout Inventory
Van Servellen and Leake (1993:169) describe a survey done on 237 nurses from 18 units in seven hospitals using the Maslach Burnout Inventory. Nurses on the AIDS, SICU, oncology SICUs, medical ICUs and general medical nursing units exhibit similar levels of distress on the burnout subscales. Medical ICU nurses scored on the personal accomplishment subscales (PL 0,05). Job tension was a predictor of exhaustion (PL 0,001). Working in a medical ICU indicated that race was controlled (PL 0,05) and working in an AIDS SICU was predictive of exhaustion in a multivariate context (PL 0,05). Working in an ICU environment resulted in negative feelings of accomplishment that were independent of cultural and racial effects.
Foa, Cashman, Jaycox and Perry (1997:445) report that several structured interviews and self-report measures have been developed to diagnose PTSD or to assess its severity. Psychometric properties of the traumatic diagnostic scale assess the diagnostic criteria for PTSD in the DSM-IV (APA 1994:236). The most commonly used interviews include the PTSD Symptom Scale – Interview (PSS-1) done by Foa, Riggs, Dancu and Rothbaum (1993), the PTSD Interview (PTSD-1) by Watson, Juba, Manifold, Kucala and Anderson (1991) and referred to in Foa et al (1997:451). The Structured Clinical Interview and Diagnostic Interview Schedule provide data about the severity of posttraumatic stress symptoms. Although these psychometric tests have indicated adequate reliability and validity on combat veterans, validity and reliability for other trauma victims require further investigation in order to justify these scales on persons other than war veterans.
Laws and Hawkins (1995:32) point out that the advantage of the PTSD over other self-report measures lies in using the criteria of the DSM-IV in the examination of psychometric properties in a large sample of male and female victims of multiple causes of trauma, as well as in the duration of symptoms, characteristics of the trauma and dysfunctions in daily living. If CCNs cannot work through the stress of the death of one patient before the next patient dies, their levels of stress might be cumulative and become unbearable. Such stress could be addressed during debriefing sessions. Laws and Hawkins (1995:32-33) state that multiple critical incidents may have a cumulative effect on a nurse’s emotional psyche, making it difficult to trace the origins of psychological stress to any single event. The diagnosis of PTSD remains a complex phenomenon. Effective assessment must be completed before crisis intervention, debriefing or long-term planning and evaluation are implemented. There are clinical, financial, legal and theoretical demands for accurate diagnosis of PTSD. Misdiagnosis is costly for the individual and the health organisation.
A rating scale is used in conjunction with the semistructured interview for assessment and diagnosis of PTSD. The General Health Questionnaire – 28 (CG HQ-28) and the Impact of Events Scale (IES) are used to assess PTSD. A score of 9 or more is indicative of PTSD. A corrective assessment could lead to an effective therapeutic intervention (Finnegan 1998:218).
Physical and emotional symptoms
The effects of stress on physical and emotional health were described by participants as negative and were highlighted as frustration, irritability, anger, and becoming emotional, fearful, over-sensitive and temperamental.
These were captured in the following statements:
I think the burnout period, it’s only the ashes that’s left and now to try and fix a thing that’s already being burnt out, you’re going to take ten times more effort to fix a person that’s already being burnt out than seeing a person going through the phase on his way to being burnt out. They first wait and see that you’re burnt out and then want to fix things …
Due to the stress and things, I must tell you, there’s ten times more friction. You can see every now and then, people are at each other’s throats, and that’s the worst because you hurt a person because of the frustrations you’ve got inside of you, not that you have anything against anyone.
… you damage your own persons around you.
You are irritable, you know you scream at people may be.
You don’t even know who’s where anymore and you have to keep your head and not forget anything, please don’t forget anything.
… the temper gets shorter.
One gets more weepy …
… and they were actually scared of me, know and well I’m not somebody to be scared of.
(Dit moet iewers uit, uitbars of uitlek, of iewers moet jou gedrag wys dat jy hierdie gevoelens het.)
It must burst or break out, or your behaviour should show that you are having those feelings.
(Nee hulle is very highly stressed en amper hmm, die woord wat ’n mens kan gebruik gevoelig, oorgevoelig.)
No they’re very highly stressed and nearly, hmm, the word one can use is sensitive, over-sensitive.
One participant relates this to pent-up physical and emotional feelings that need to be expressed:
(Dit moet iewers uit, uitbars of uitlek, of iewers moet jou gedrag wys dat jy hierdie gevoelens het.)
It must come out burst or break out, or somewhere your behaviour must show that you are having these feelings.
During the past few decades mental health professionals have gradually become aware of the stressors that negatively affect emergency personnel. As a result of this increasing awareness, several mental health professions have developed interest in emergency and critical health workers’ coping strategies (Kaplan 1991:916-917).
Selye’s (1974) general adaptation syndrome (GAS) is the first of a series of reactions the body exhibits when exposed to prolonged stress. This model has placed influential emphasis on stress research, owing to the provision of a general theory of physiological reactions to a wide range of stressful situations over time, and a physiological mechanism linking stress and illness (Baum 1994:653).
During a stress response, the hypothalamus is stimulated, which activates both the anterior pituitary gland and the autonomic nervous system causing the release of epinephrine and norepinephrine. The anterior pituitary gland releases adrenocorticotropic hormone (ACTH) which is a stimulant to the adrenal cortex and allows the release of steroids or anti-inflammatory hormones. Somatotropin (STH) stimulates the adrenal cortex and causes the release of steroids that trigger an inflammatory response. The sympathetic part of the autonomic system is activated when the body reacts in a “fight or flight” response. This is identified by an increase in heart rate, increase in respiratory rate, an elevated blood pressure and a redistribution of the blood from peripherical areas of the body into the head and trunk of the body.
The GAS (Selye 1974) consists of three stages.
The first stage, the alarm reaction, is similar to the fight or flight response, mobilising glucosides and adrenalin to energise the body. After a period of time the body’s reserves become depleted, leading to fatigue and exhaustion.
Table of contents
Chapter 1Orientation to the research
1.2 GENERAL BACKGROUND TO THE STUDY
1.3 PROBLEM STATEMENT
1.4 OBJECTIVES OF THIS RESEARCH
1.5 DEFINITIONS OF TERMS USED IN THIS RESEARCH STUDY
1.6 ASSUMPTIONS OF THIS RESEARCH
1.7 SIGNIFICANCE OF THIS RESEARCH
1.8 RESEARCH DESIGN AND METHODOLOGY
1.9 ORGANISATION OF THE RESEARCH REPORT
Chapter 2 Research design and methodology
2.3 AIM OF THE RESEARCH
2.4 RESEARCH DESIGN
2.5 RESEARCH METHOD
2.6 ETHICAL CONSIDERATIONS
2.7 TRUSTWORTHINESS OF THE RESEARCH
2.8 RESEARCH METHOD AND INSTRUMENT: PHASE II
Chapter 3 Research results, findings, statements and supporting literature
3.2 DISCUSSION OF RESULTS OF THE QUALITATIVE DATA
Chapter 4 Conclusions, limitations and recommendations
4.2 AIMS OF THE RESEARCH
4.6 CONCLUDING STATEMENTS
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