TABLE OF CONTENTS

1. Title Page
- Title of the Concept Paper
- Your Name
- Subject

2. Background of Study
- Introduction of concept paper
- Need for the Study
- Background

3. Preliminary Literature Review

4. Project Vision

5. Statement of Problem Objectives

6. Abridge Methodology

7. Timeline

8. References
 PURPOSIVE COMMUNICATION COURSEWORK

University of Perpetual Help System Laguna

Biñan City, Laguna

In Partial Fulfillment of the Requirements for the Course

PURPOSIVE COMMUNICATION
for the degree of Bachelor of Science in Nursing

A Concept Paper
“A Phenomenological Study: Nurses and the Distress inside the
Emergency Room.”

Submitted by:
JAYNE FELINE J. GRIBADOR
BSN-N1B

Submitted to:
Dra. Lolita Lontok-Cunanan
For Academic and Professional Purposes

MAY 4, 2023
SECOND SEMESTER
 I. INTRODUCTION

ED nurses have a challenge in their job as patients' representatives and

advocates when choices about their treatment are being made. In order to
ensure that patients receive the finest medical care possible while in the hospital,
nurses try to act as patient advocates (White, 2016). Additionally, nurses possess
moral integrity, which serves as their foundation for acting in accordance with
their professional responsibilities. However, when ED nurses face difficulties in
making decisions that are consistent with their moral integrity due to a variety of
obstacles, it will cause ED nurses to experience moral conflicts related to their
actions (White, 2016). The moral conflict experienced will be a moral dilemma
when there is a difference between the nurse's decision and actions, so the
nurse will be in a moral conflict. According to White (2016) and Zavotsky & Chan
(2016), the condition will cause the nurse moral distress. When a nurse's
professional aspirations are impeded, moral discomfort, according to Corley
(2002), happens. The emergency department is a place that provides health care
services with a constantly changing population of patients, and critical conditions
cannot be predicted (Robinson & Stinson, 2016). As a result, the professional
role of nurses is hindered by internal, external, and clinical situations, causing
nurses to fail to take actions, feel morally uncomfortable, and have a moral
distress effect. Other difficulties that cannot be anticipated include patients who
are not in emergency situations, crowding, short staffing, violence, and the need
for nurses to have strong analytical skills and adapt quickly to changing
circumstances (Zavotsky & Chan, 2016; White, 201). No. 856 from the RI
Ministry of Health Menkes / SK / IX / 2009 established service requirements for
emergency departments, which included treating patients precisely and quickly
within 5 minutes of their arrival. The fact that many patients haven't been given
beds and are waiting a long time for treatment presented a challenge for the
nurses. According to a literature study, emergency department nurses are more
likely than other nurses to experience moral distress (McAndrew et al., 2016). ED
nurses frequently have to assist families in making decisions about terminally ill
patients with minimal knowledge, which presents a moral conundrum for ED
nurses. Families often struggle to decide what to do while maintaining their moral
integrity. (White, 2016; Zavotsky & Chan, 2016; McAndrew, Leske, & Schroeter,
2016). The three factors that contribute to moral discomfort in nurses are Clinical
settings, nurse internal restrictions, and external constraints such institutional
policies are all factors that affect nurses' ability to perform (Hamric, Borchers, &
Epstein, 2012). Previous research (Hamric, Borchers, & Epstein, 2012;
Emaliyawati, E., & Mirwanti, R, 2019; Wolf et al., 2016) has shown that nurses
experience moral anguish because they are unable to offer health services in the
way they would like. The long-term effects of moral distress cause health care
providers to experience burnout and eventually quit their jobs (Kilcoyne &
Dowling, 2007; Fernandez-Parsons et al., 2013b). Nurses overcome moral
distress by rejecting responsibilities that impact moral distress situations and
frequently occur problems making nurses limited to handling. Basically, nurses
cannot always meet all service demands for a vulnerable patient, who needs
professional and appropriate care. There are numerous factors that affect nurses'
morale and institutional misery. This study's goal was to recognize moral distress
in emergency department nurses.
 II. NEED FOR THE STUDY

According to a descriptive survey by (2011) that included nurses and doctors of

EDs (n=103), "aspects of the work environment" such as poor rostering,
workload, shift work, frequency at which doctors rotate, overcrowding, traumatic
events, and inter-staff conflict were the most common causes of stress in EDs
strife, a failure to function as a team, and weak managerial abilities. Other
frequent stressors include patient hostility and violence, a child's death or
resuscitation, managing critically ill patients, managing violent patients, and
managing aggressive patients. Dealing with significant incidents or experiencing
sudden or tragic death. When researching EDs in ranked workplace violence
against staff as the leading cause of stress, followed by a heavy workload, an
inappropriate skill mix, and the need for more time off to manage multiple
casualty incidents, fatalities, child sexual abuse, and high-acuity patient care. In
order to better understand the sources of workplace stress and the coping
mechanisms used by nurses working in accident and emergency rooms,
Gholamzadeh et al. (2011) undertook a study. Problems with the physical
environment, work load, rage elicited during interactions with patients or their
family members, exposure to health and safety risks, lack of support from nursing
administrators, the absence of a corresponding physician in the emergency
room, and a lack of suitable equipment were discovered to be the stress-causing
factors

III. BACKGROUND
Moral anguish does not entirely happen automatically because it depends on the
nurses' capacity to reflect on their feelings (Wilkinson, 1989). This has to do with
how nurses evaluate moral wrong or right and think about it (Corley, 2002; Mare,
2016). It's possible for nurses who have suffered psychological harm and lost
their ability to care for patients to lose their moral sensitivity, which prevents them
from feeling moral distress. Moral stress is triggered by moral issues with nurses
at important times (Mare, 2016). High sensitivity among nurses may lead to
greater patient commitment and the development of moral competence, reducing
the likelihood of moral discomfort. When nurses believe they possess high moral
standards but lack moral acumen, this will also be another condition. cause moral
discomfort in nurses (Corley, 2002). The consistency of interaction with the
situation was another factor that led to low moral distress in ED nurses, therefore
it is anticipated that qualitative research would uncover further scenarios where
ED nurses violate their moral convictions. According to Jameton's (1993)
classification of moral distress, which maintains that there is initial distress and
reactive distress, moral discomfort that occurs repeatedly in the health
professions leads in the reaction of cumulative reactive distress. Moral distress
prevents a person from fully overcoming a difficult situation. Failure in these
circumstances typically leaves behind unpleasant things and is referred to as
moral residue. When nurses keep compromising their morals, moral residues
develop, which cause nurses to lose their moral convictions. Next, if the situation
persists, moral residues will build up and eventually have a crescendo effect in
which they disprove one's moral beliefs (Epstein & Hamric, 2013; Mare, 2016).
Coping strategies have a significant impact on moral distress. When nurses are
faced with morally challenging situations, moral discomfort sets in. The nurse can
then decide what action to take based on moral principles, however it turns out
that the action cannot be carried out based on perception. Nurses experience
terrible emotions and psychological disorders as a result of their inaction. The
result of these circumstances causes nurses to develop coping mechanisms
(Mare, 2016; Wilkinson, 1989). The study did not, however, uncover the coping
mechanisms employed by ED nurses. Therefore, it is hoped that the study will be
carried out by identifying the nurses used for coping in order to minimize moral
distress in ED nurses.
IV. PROJECT VISION
Stress for nurses is not a psychological myth, but rather a physiological reality,
according to an assessment of the available sources.

Such stress even led to violence and verbal abuse at work, according to a
retrospective written assessment of all 163 emergency department personnel
working in 1996 at an urban inner-city tertiary care facility .

ED nurses experience significant levels of job stress, as evidenced by morning

salivary cortisol levels, according to a study that examined the physiological link
between salivary cortisol levels and work stress in ED nurses

In a study to look into the neuroendocrine reactions in emergency caregivers

during emergency situations, it was found that handling patients in direct
life-threatening situations during the morning hours resulted in greater endocrine
reactions than handling patients who were not in direct life-threatening situations.

The Remedy have clarified the current and future roles of the emergency nurse,
emphasizing the need to increase nursing wages, staff scheduling, improve
emergency nurse-to-patient ratios, reward emergency nurses financially for their
contributions, create internships for nurses who are new to emergency nursing,
and invest in nursing education.

Staff burnout is influenced by a number of critical factors, including age,

vocational training, and years of experience Recently, "System complexity" has
been proposed as a practical and technically possible assessment for tracking
and controlling surge capacity in the ED.
For ER nurses to reduce professional anxiety and to improve personal and
professional satisfaction, experiential interventions to build mindfulness skills,
emotion regulation variety and flexibility in a clinical context, and the cognitive
side of empathy are advised. Future studies should evaluate the efficacy of novel
multi-factorial therapies that help ER nurses develop their emotional control,
mindfulness, and empathy.

V. PRELIMINARY LITERATURE REVIEW

Workplace stress is a major issue in healthcare, particularly for nurses. The

milieu that emergency wards generate may be difficult for the medical staff that
work there. To address a certain event, our brain must have an immediate
response. On a person's work and health, stress can have both beneficial and
detrimental impacts. The personnel may suffer if they are exposed to stressful
situations repeatedly. Staff personnel working in the emergency department (ED)
may be significantly impacted by stressful events. Aggression, violence, patient
death, or taking part in CPR can all result in emotionally and physically taxing
situations. 52 (51%) of the ED staff (n=103), according to Healy and Tyrrell's
2011[1] research, reported experiencing stress at work "frequently" or "very
frequently," while an additional 22 reported doing so 37 people (37%) said they
occasionally had the problem. They came to the conclusion that emergency care
is stressful since 97% of the emergency workers who worked in the ED reported
experiencing stress there. Burnout symptoms may result from how workers
respond to ongoing stress. 8.2% of the nursing staff (n=61) from an emergency
department showed indications and symptoms of burnout, according to Jodas
and Lourenço Haddad (2009)[2]. The remaining 54.1% had a high risk of
burnout, whereas 37.7% had a low risk of developing a condition. A recent
cross-sectional survey of emergency nurses in the US (n=114) was conducted by
Hooper et al. (2010)[3]. According to the authors, 86% of emergency nurses
experience high levels of weariness, and more than 80% of them have moderate
to high degrees of burnout.

VI. STATEMENT OF THE PROBLEM OBJECTIVES

It is important for hospital and nursing administrators to address the factors that
contribute to job stress and burnout, placing emphasis on job satisfaction and
work organization to lessen the burden of psychosocial factors in this regard. The
study showed that there was an increased prevalence of MSDs among
emergency nurses, which was predicted by increased job demand and
associated with a higher level of burnout. According to Gholamzadeh et al.,
self-control and positive reappraisal were the two strategies used by nurses the
most frequently to manage their stress. Strategies to control their everyday
stressors in acute care are urgently needed in order to improve the personal and
professional outcomes of advanced registered nurses (Trousselard et al.
2015[8]). To identify contributing causes of stress-health consequences that can
be addressed for preventative interventions, emergency departments should
undergo routine employment and organizational screenings. The ability to make
decisions, skill discretion, adequate work standards, perceived remuneration,
and social support from supervisors all outweigh personal qualities as significant
predictors of job satisfaction, work engagement, and a decreased intention to quit
among emergency nurses. The patient's external environment is proven to be
more stressful than an emergency situation. Hospitals must assess these
requirements to enable lessened stress among emergency nurses.
VII. ABRIDGE METHODOLOGY

The study used a cross-sectional design and was quantitatively descriptive. The
total sampling approach is used to choose samples. 51 responses were among
the ED nurses in a Type A hospital in Bandung City. In this study, questionnaire
sheets were utilized to collect data. The questionnaire included statement items
to gauge moral distress as well as questions about the respondents'
characteristics (age, sex, length of work experience, ED, education level, special
certificate, and religion). The Distress Scale-Revised, which had 21 items and
was intended for use by other healthcare professionals, expanded its use outside
of intensive care units and sought to identify the causes of moral distress
(Hamric, Borchers, & Epstein, 2012). A Likert scale with a 0–4 scale was used to
measure the Distress Scale–Revised. Back-translation techniques, validity
content, and face validity have been used because this instrument has never
been used in Indonesia. Utilizing univariate and bivariate statistical tests, data
was analyzed.

A cross-sectional study is a style of research design in which you gather

information from a large number of individuals all at once. In cross-sectional
research, variables are observed without being changed. Cross-sectional studies
are a common tool used by researchers in the social sciences, including
economics, psychology, medicine, and epidemiology. Cross-sectional studies
gather information from numerous subjects all at once.
VIII. TIMELINE

Timeline A Phenomenological Study: Nurses and the Distress inside the Emergency
Room.

ACTIVITY DATE

Phase of Project Planning January-March 2023

Data Gathering Stage 15 March 2023

Phase of Data Analysis 15 April 2023

Phase of Findings and Discussion First week of May

Writing Reports Phase May 2023

Phase of Presentation and Publication June 2023

Considering each phase lasting for the time allotted,the project would take around 5
months to complete. Still, due to unforeseen events or modifications to the project's
scope, this timeline may change.
IX. REFERENCE

1.(PDF) Nurses’ Moral Distress in the Emergency Department (researchgate.net)

2. (PDF) Workplace Stress for Nurses in Emergency Department (researchgate.net)

3. Protecting emergency room nurses from burnout: The role of dispositional

mindfulness, emotion regulation and empathy - PubMed (nih.gov)

4. Cross-Sectional Study | Definitions, Uses & Examples (scribbr.co.uk)

5. Stress in emergency departments: experiences of nurses and doctors - PubMed

(nih.gov)

6. Cross-Sectional Study | Definitions, Uses & Examples (scribbr.co.uk)

7. Emotions and feelings in critical and emergency caring situations: a qualitative

study | BMC Nursing | Full Text (biomedcentral.com)