Lived Experiences of Nurses Working Off-Peak Hours

What is Lived Experience of Nurses Working Off-Peak Hours Tashma E Watson PhD RN CSSM University of Phoenix College of Doctoral Studies

THE PROBLEM A study by (O brien et al, 2017) found that nurses working during off peak hours on medical surgical units often feel increased stress due to the decrease in available support as well as having to spend increased time completing non-nursing related tasks (O brien, Mitchell, Skinner, Ghaly, Haas, McDermott, May & Haines, 2017). Currently there is little research related to the experiences of nurses working during off peak hours.

PURPOSE The purpose of this hermeneutic phenomenological study is to understand the experiences of nurses who provide patient care during off-peak hours. Scholars have examined off-peak nursing, but few have focused specifically on the provision of nursing care during this time.

THEORETICAL FRAMEWORK: JEAN WATSON S THEORYOF HUMAN CARING CONCEPTS OF THE THEORY WILL HELP THE RESEARCHER GAIN AN UNDERSTANDING OF THE EXPERIENCES OF THE NURSES WHO WORK DURING THE OFF- PEAK SHIFTS TRANSPERSONAL CARING MOMENTS (WATSON, 2018) TEN CARITAS PROCESSES (WATSON, 2018)

Literature Review Scholars have examined off-peak nursing, but few have focused specifically on the provision of nursing care during this time. Research is scarce regarding the experiences of nurses who work off-peak hours. Search Terms Weekend effect in the operating room Operating room patient outcomes Off peak Staffing

Research Articles O'Brien, L., Mitchell, D., Skinner, E., Haas, R., Ghaly, M., McDermott, F., May, K., & Haines, T. (2017). What makes weekend allied health services effective and cost-effective (or not) in acute medical and surgical wards? Perceptions of medical, nursing, and allied health workers.BMC Health Services Research. https://doi.org/10.1186/s12913-017-2279z Taylor, M., Hopman, W., & Yach, J. (2016). Length of stay, wait time to surgery and 30-day mortality for patients with hip fractures after the opening of a dedicated orthopedic weekend trauma room. Canadian Journal of Surgery, 59(5), 337-341. https://doi.org/10.1503/cjs.017014 Cho, E., Chin, D., Kim, S., & Hong, O. (2016). Relationships of nurse staffing level and work environment with patient adverse events. The Journal of Nursing Scholarship, 48(1). https://doi.org/10.1111jnu/12184 Zapf, M., Kothari, A., Markossian, T., Gupta, G., Blackwell, R., Wai, P., Weber, C. E., Driver, J., & Kuo, P. (2015, August). The weekend effect in urgent general operative procedures. Surgery, 158(2), 508-514. https://doi.org/10.1016/j.surg.2015.02.024 Dalton, M., McDonald, E., Bhatia, P., Davis, K., & Schuster, K. (2016). Outcomes of acute care surgical cases performed at night. The American Journal of Surgery, 212, 831-836. https://doi.org/10.1016/j.amjsurg.2016.02.024

Hermeneutic Phenomenology Research Method and Design Max Van Manen, Theoretical Framework Semi-structured interviews Sample

Demographic Data Participants Educational Levels Number of Participants Holding Degree Highest Degree in Nursing Associate Degree 2 Bachelor s Degree 7 Master s Degree 1 Doctoral Degree 1 Years of Nursing Experience Demographic Data Years of experience in Nursing Years in the OR N Minimum Maximum M SD 11 5 42 21.81 11.42565 11 2.5 40 19.95 10.41515

Van Manens Six Step Data Analysis 1. Focused attention to the research, maintain alignment of the research with the research question researcher consistently referred to the research question to ensure that newly emerging themes are in alignment with the research question and methodology conducted through the detailed review of audio transcriptions, field notes, and analysis of transcriptions 2 Immersion into the data, 3 reflection on essential themes review of documents and notes associated with each interview experience wrote out any key statements and presented significant statements in the results section. The researcher used NVivo software to organize the themes and the data the was associated with each theme. 4 Identify key statements and separated them for presentation 5 Maintenance of awareness of biases and preconceived notions The researcher maintained a reflective journal to acknowledge personal biases and reflect personal thoughts and notions. 6Complete understanding of phenomenon The researcher continued to read and re-read notes, transcriptions and themes identified to complete understanding of the phenomenon.

Results 6 Themes Identified. We work as a team ME53 explained You have to work as a team and or and respect each other. Participant DM01 echoed this statement, saying you need a good team, and a good tech who can help you get through the shift. No one to rely on ME53 observed that you have to try to make the decisions and you have to wonder if the decision is okay; BH37 stated, Well you have to do what you have to do, because there is nobody else there. Being responsible for everything Participant BW20 noted that you are literally doing everything: If a patient suddenly deteriorates, the circulator may have to take the lead and step up and run a code. Participant BC79 continued: When you have no one else to do it. So, you re literally doing everything for that patient.

Results Continued Safety is the primary concern Participant TJ98 also shared their colleagues emphasis on patient safety: The most important thing is care to my patients and optimize. Participant KT19 observed that you always focus on doing the best job you can or the patient and the family. Limited Resources and Support Participant ZL01 shared , The only a person of any person above that would be like your house supervisor but you can't do much, so you'd be basically you write down you know the incident and then addressing it the next day probably. Participant DG48 shared, you could tell when they were having a rough night, we would just go up and help even though we weren t the ones on. Participant SG13 shared: there were times when we couldn t even get a bathroom break. It was non-stop. Self-Care Neglect Participant ME35 observed that sometimes you don t have time to take care of myself especially if there's some cases. Emergency cases. One night I did a case for 24 hours straight, no relief, no break. We were on call. Participant DM01 stated: I had to learn to take care of me. My husband taught me that it s not selfish to take of yourself first. You have to take care of you so you can be able to take care of your family and anyone else. Participant SG13 shared, : no, no, I can't sleep. I have to come in to double check everything because there was a big thing. Participant AA18 shared, I m not really good at that. You come home and you completely exhausted. And my feet are killing me and my legs are killing me and everything hurts

Transcript Interviewer: How do you take care of yourself during or even after you've had one of those kind of challenges or night shifts . So now let's talk about the other thing you just brought out . You get pulled in all these different directions . You use that word stress . AA18: I don't do a good job . I think a lot of us don't . AA18: not like the medical field . He does not like me talking about gross go letters and . Post exploding and things like that but he is very gracious and he lets me just talk and I'll grant . And . Sometimes yell and on and on and on and he'll just hear me like Yeah . You're Adele's sweetheart and . Just . Give me freedom to to just explode I guess vent . And . I'm not it . Has . A . I am blessed with a wonderful husband who does a fantastic job at letting me decompress and he's not in the medical field at all . He does AA18: speaking that's one of the big ways . I'm also kind of a bit of an introvert and oftentimes . Very very important . I'm I m a verbal processor and I didn't realize that until I actually married him . And so that's before emotionally AA18: nothing helps with my height my sanity . I wish that I . I wish that I could incorporate physicality into that care routine or or coping mechanisms but I find it extremely difficult to come home from something like that . And you completely exhausted . And my feet are killing me and my legs are killing me and everything hurts . And I don't want to go to the gym and I don t want to go for walk . I don t want to lift weights . I don't want to do yoga . I just want to lay down and sleep . And . That's really it's something that is so useful and valuable and good and healthy and it's so hard to do when you're exhausted . And . I haven't figured out . That . Just coming home and sitting on the couch and having a cup of tea and my cats climbing all over me and just staring out the window doing AA18: I'm doing it out process for me to get me to do that . AA18: crisis response team that is way too formalized but looking when there are traumatic things to having a decompression time and having the team talk about what happened process what happened . I said we we are not a high trauma facility . A few weeks ago we had a couple of c sections with fetal demise that the team had to take care of . Yeah it was early . I wasn't on that team but those are really really hard and emotionally traumatizing experiences . Yeah . We've also had some pretty pretty bad gunshot wounds that have come through and stabilize the patient basically just throwing sutures in place and then shipped them to larger facilities that can handle stuff like that . I guess there is some something that one of my co-workers is working on doing with my organization . They're . Kind of . It's not it's not a AA18: And I think the last one they gave twenty two units of blood completely ran out of blood in the hospital . AA18: to talk about it it's just kind of you do it and then you move on . That's all there is . So my co-worker is Steve and he is working on getting something in place that we could have a response team and have some people come to talk about the experience to work through it to try to process it. We didn t Have any left . And again most traumatic experience and there's not really any mechanism in place to help people process that or

Data Saturation Tool Total Interview time Saturation Yes or No Number of Pages of transcription Dissertation/research Journal Entry Evidence Your thoughts on Saturation Yes or No Peer Reviewer suggest Saturation Yes or No Participant # 5 5 8 5 11 4 6 1.TJ98 2. BC79 3. AA18 4. BH37 5. DG48 6. ME53 7. DM01 13:33 18:26 27:00 28:49 35:49 14:05 29:10 No No No No No No Participant describes experiences of minimal resources and support and having to prioritize and make decisions. No No No No No No No No No No No No No Yes Participant talks about experiences with labor and delivery, speed and stress and having to work quickly in difficult situations. 8. ZL01 5 16:16 No Yes Participant described similar experiences related to complicated cases such as labor and delivery where nurses have to manage both mother and child as the only nurse. The participant also discussed teamwork and relying on the tech and members of the surgical team. 9. BW20 5 12:00 No Yes Participant described similar experiences of teamwork and effective communication between members of the surgical team. Participant also described concerns related to self-care, patient safety, and coordination of support and resources 10. KT19 6 16:07 Yes Yes Participant described similar experiences of teamwork and effective communication between members of the surgical team. Participant also described concerns of self-care, feeling like you have to do everything. 11.SG13 6 16:45 Yes Yes

NURSING LEADERSHIP NURSING EDUCATION NURSING RESEARCH Implications HOSPITAL LEADERSHIP PATIENT CARE AND OUTCOMES

This study revealed that there may be additional opportunities to assist nurses in their ability to better care for themselves and ultimately care for others. May provide leadership with the opportunity to understand the concerns of nurses and particularly those who are directly responsible for providing care during off-peak hours. Significance of Study There may need to be greater emphasis on the importance of self care and the ability of the caregiver to be able to take care of themselves.

Recommendations for Future Research Additional research can be done to understand the roles of all personnel in the operating room as the teamwork dynamic appears to be of interest and importance in the operating room. There should be additional exploration of the experiences of operating room and all healthcare personnel when patient outcomes are less than expected. Generational shift in nursing, with emphasis on autonomy

The researcher also relied on the truthfulness of the information provided by the participants during the interview process. Potential Study Limitations The ability of study participants to recall accurately and completely events associated with the phenomenon Another limitation was that participants had to feel comfortable sharing their experiences, with no fear of impact on their employment status (O Brien et al., 2017).

IT APPEARS THAT OVER THE YEARS THERE HAS BEEN A CHANGE IN THE DYNAMICS OF INTERACTION IN THE OPERATING ROOM QUESTION THE USE OF A QUALITATIVE RESEARCH DESIGN BECAUSE, DURING RECRUITMENT ONE OF THE BIGGEST CHALLENGES FOR THIS PROCESS WAS THE PEER REVIEW AND AUDIT PROCESSES. Reflections SCHEDULING INTERVIEWS, WITH PERSONNEL IN DIFFERENT TIME ZONES

Conclusion The results of the study added information related to the role of the circulating nurse in the OR and, more importantly, to the experiences of nurses who work in the acute care setting during off-peak hours. The results of this study also revealed that there are significant opportunities to provide support for the nurses providing care. There may be a need for the profession to do more to support those providing care and assist them with the development of pathways to self-care.

Current Application Self Care of the nurse leader during a disaster? Self care of nurses and essential personnel during the COVID-19 pandemic? Self care of care providers How has qualitative research changed

References Brunot, V., Landreau, L., Corne, P., Platon, L., Besnard, N., Buzancais, A., Doubin, D., Serre, J. E., Molinari, N., & Klouche, K. (2016). Mortality associated with off-peak admissions to ICU with on-site intensivist coverage: Results of a nine-year cohort study (2006-2014). PLOS Medicine, 11(12). https://doi.org/10.1371/journal.pone.0168548 Cho, E., Chin, D., Kim, S., & Hong, O. (2016). Relationships of nurse staffing level and work environment with patient adverse events. The Journal of Nursing Scholarship, 48(1). https://doi.org/10.1111jnu/12184 Jean Watson Caring Science Institute https://www.watsoncaringscience.org/ (2020) O'Brien, L., Mitchell, D., Skinner, E., Haas, R., Ghaly, M., McDermott, F., May, K., & Haines, T. (2017). What makes weekend allied health services effective and cost-effective (or not) in acute medical and surgical wards? Perceptions of medical, nursing, and allied health workers.BMC Health Services Research. https://doi.org/10.1186/s12913-017-2279z Taylor, M., Hopman, W., & Yach, J. (2016). Length of stay, wait time to surgery and 30-day mortality for patients with hip fractures after the opening of a dedicated orthopedic weekend trauma room. Canadian Journal of Surgery, 59(5), 337-341. https://doi.org/10.1503/cjs.017014 Zapf, M., Kothari, A., Markossian, T., Gupta, G., Blackwell, R., Wai, P., Weber, C. E., Driver, J., & Kuo, P. (2015, August). The weekend effect in urgent general operative procedures. Surgery, 158(2), 508-514. https://doi.org/10.1016/j.surg.2015.02.024

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