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Mälardalen University Doctoral Dissertation 238
Occupational stress among Thai emergency department nursesDevelopment and validation of an instrument for measuring stressors in emergency departments
Nuttapol Yuwanich
Nu
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AL STR
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AI EM
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SES2017
ISBN 978-91-7485-351-3ISSN 1651-4238
Address: P.O. Box 883, SE-721 23 Västerås. SwedenAddress: P.O. Box 325, SE-631 05 Eskilstuna. SwedenE-mail: [email protected] Web: www.mdh.se
I am a nursing instructor in Adult and Elderly Health Nursing at the School of Nursing Science, Rangsit University, Thailand. I granted a Master’s degree in caring/nursing science at Mälardalen University in 2012. I have been working as a nurse for almost 3 years and during that time I worked in medical and surgical nursing at the Department of Surgical Intensive Care Unit, Private Hospital, Thailand. I have also worked as a registered nurse at the airport of Thailand for 1 year, and as a flight nurse for almost 1 year at the Fox Flight Company and Asia Air Ambulance.
During my years as a registered nurse, I have encountered with stressful situations at a workplace. This triggers my curiosity about the causes of stress in a critical care setting, and I intend to explore them. This insight has led me into this project, and I hope to be able to contribute an evidence base knowledge regarding occupational stress in emergency departments, which might be helpful for the emergency nurses and the health care organizations.
Back cover
I am a nursing instructor in Adult and Elderly Health Nursing at the School of Nursing Science, RangsitUniversity, Thailand. I granted a Master’s degree in car-ing/nursing science at Mälardalen University in 2012. Ihave been working as a nurse for almost 3 years and duringthat time I worked in medical and surgical nursing at theDepartment of Surgical Intensive Care Unit, PrivateHospital, Thailand. I have also worked as a registered nurseat the airport of Thailand for 1 year, and as a flight nursefor almost 1 year at the Fox Flight Company and Asia AirAmbulance.
During my years as a registered nurse, I haveencountered with stressful situations at a workplace. This triggersmy curiosity about the causes of stress in a critical care setting, andI intend to explore them. This insight has led me into this project, and I hope to be able to contribute an evidence base knowledgeregarding occupational stress in emergency departments, which might be helpful for the emergency nurses and the health care organizations.
Mälardalen University Press DissertationsNo. 238
OCCUPATIONAL STRESS AMONG THAIEMERGENCY DEPARTMENT NURSES
DEVELOPMENT AND VALIDATION OF AN INSTRUMENT FORMEASURING STRESSORS IN EMERGENCY DEPARTMENTS
Nuttapol Yuwanich
2017
School of Health, Care and Social Welfare
Copyright © Nuttapol Yuwanich, 2017 ISBN 978-91-7485-351-3ISSN 1651-4238Printed by E-Print AB, Stockholm, Sweden
Mälardalen University Press DissertationsNo. 238
OCCUPATIONAL STRESS AMONG THAI EMERGENCY DEPARTMENT NURSESDEVELOPMENT AND VALIDATION OF AN INSTRUMENT FOR
MEASURING STRESSORS IN EMERGENCY DEPARTMENTS
Nuttapol Yuwanich
Akademisk avhandling
som för avläggande av filosofie doktorsexamen i vårdvetenskap vid Akademinför hälsa, vård och välfärd kommer att offentligen försvaras fredagen den
10 november 2017, 13.15 i Tentum, Mälardalens högskola, Eskilstuna.
Fakultetsopponent: Professor emeritus Töres Theorell,Stressforskningsinstitutet Stockholms universitet
Akademin för hälsa, vård och välfärd
AbstractWorking at an emergency department has some characteristics, which may generate stress. In this thesis, the stressors for emergency nurses were evaluated and an instrument was developed for measuring their impact. In order to gain a deeper understanding regarding the occupational stress among emergency nurses, a descriptive qualitative design with semi-structured interviews were used in two studies (I, II), one at a private and the other at a public hospital in Thailand. Three main categories of stressors were identified, related to the activity at the emergency departments, to human factors and to perceived consequences of these factors. Nurses in both private and public hospitals frequently experienced occupational stress, which influenced their psychophysiological health, and resulted in incomplete nursing care. Since no validated instrument had been published for measuring stressors in emergency nurses’ workplace, a scoping literature review was performed and a questionnaire for this purpose was developed, based on the review and the results from the interviews (I and II). The questionnaire was validated (III) and the influence of socio-economic factors were evaluated (IV). Four-hundred and five emergency nurses in Thailand completed a questionnaire containing 59 items. The responses were analyzed using 1) item generation, 2) content and face validity and test-retest reliability and 3) evaluation of the internal consistency and construct validity of the instrument. An exploratory factor analysis was performed on 200 of these responses and a confirmatory factor analysis on the remaining 205. The analysis provided a final four-factor solution with 25 items distributed among the factorsLife and death situations, Patients’ and families’ actions and reactions, Technical and formal support, andConflicts. The statistical evaluation (Cronbach’s alpha and intra-class correlation coefficient) indicatedgood homogeneity and stability. The type of organization, educational level and average incomewere associated with stressor related to Life and Death situations. Stressor related to Patients’ andfamilies’ actions and reactions was predicted by educational level. While sociodemographic variableshad no influence on stressor related to Technical and formal support and Conflicts. Future researchregarding patient safety should focus on both emergency nurses’ and patients’ perspectives regardingconsequences of occupational stress related to patient safety. Different perspectives may create aknowledge-base which can be used to develop guidelines or protocols aiming at reducing nurses’ stressand prevent its consequence, such as poor patient safety.
ISBN 978-91-7485-351-3ISSN 1651-4238
1
Mälardalen University Doctoral Dissertation 238
Occupational stress among Thai
emergency department nurses: Development and validation of an instrument for measuring
stressors in emergency departments
Nuttapol Yuwanich
2
Let us never consider ourselves finished nurses....
We must be learning all of our lives.
Florence Nightingale
3
ABSTRACT
The purpose of this dissertation is to explore the stressors for Thai emergency
nurses and to develop and validate an instrument aimed at measuring specific
stressors for emergency nurses. This dissertation consists of two qualitative
and two quantitative research studies. Data are drawn from individual open-
ended interviews (studies I, II) and cross-sectional and correlational studies
(studies III and IV).
To gain a deeper understanding of occupational stress among emergency
nurses, we conducted a descriptive qualitative study with semi-structured in-
terviews (studies I and II). Twenty-one emergency nurses in a public hospital
and 15 from two private hospitals in Bangkok, Thailand, were interviewed.
The transcribed interviews were analysed using content analysis, and the re-
sults from the interviews were conceptualised into three main categories:
emergency department-related stressors, human-related stressors and multiple
perceived consequences of emergency department-related stressors. Emer-
gency nurses in both private and public hospitals (studies I and II) frequently
experienced occupational stress, which influenced their psychophysiological
health and resulted in incomplete nursing care. The similarities of the occupa-
tional stressors experienced by emergency nurses at both types of hospitals
may be related to the nature of emergency departments. The differences in the
nurses’ experiences of occupational stress and organisational support may be
due to differences in management systems, rewards systems and types of com-
pensation in public and private hospitals.
To the best of our knowledge, there is no published, validated instrument for
measuring stressors in emergency nurses’ workplace. A new instrument,
therefore, was developed and validated (study III). The methodology of this
study comprised three phases: 1) item generation; 2) content and face validity
and test-retest reliability; and 3) evaluation of the internal consistency and
construct validity of the instrument. Exploratory factor analysis with varimax
rotation was performed on data from 200 emergency nurses. Thirty-one items
with factor loadings > 0.60 in exploratory factor analysis were retained and
further tested with confirmatory factor analysis on data from 205 emergency
nurses. Cronbach’s alpha values and intra-class correlation coefficients were
calculated. Exploratory factor analysis provided a five-factor solution,
whereas confirmatory factor analysis provided a final four-factor solution with
25 items distributed among four factors: life-and-death situations, patients’
4
and families’ actions and reactions, technical and formal support and conflicts.
Cronbach’s alpha values ranged from 0.89 to 0.93 per factor, and the intra-
class correlation coefficient was 0.89, indicating good homogeneity and sta-
bility.
In study IV, the instrument was used to explore to what extent sociodemo-
graphic variables may influence the experience of specific stressors for Thai
emergency nurses. The type of organisation, educational level and average
income were associated with stressors related to life-and-death situations.
Stressors related to patients’ and families’ actions and reactions were pre-
dicted by educational level, while sociodemographic variables had no influ-
ence on stressors related to technical and formal support and conflicts.
Future research regarding patient safety should focus on the perspectives of
both emergency nurses and patients regarding the consequences of occupa-
tional stress for patient safety. Difference perspectives may create a
knowledge base which can be used to develop guidelines or protocols aimed
at reducing nurses’ stress and preventing its consequence, such as low patient
safety. The potential for positive stress in emergency nurses’ workplace needs
to be further explored, particularly how it affects nurses’ health and caring
performance.
Keywords: emergency nurses, occupational stress, questionnaires, private
hospitals, public hospitals, scale development, validation.
5
LIST OF PAPERS
This dissertation is built on the following four scientific papers, which are
referred to by Roman numerals in the text.
I Yuwanich, N., Sandmark, H., & Akhavan, S. (2016). Emergency
department nurses’ experiences of occupational stress: A quali-
tative study from a public hospital in Bangkok, Thailand. Work,
53(4), 885–879. doi:10.3233/WOR-152181
II Yuwanich, N., Akhavan, S., Nantsupawat, W., & Martin, L.
(2017). Experiences of occupational stress among emergency
nurses at private hospitals in Bangkok, Thailand. Open Journal
of Nursing, 7(6), 657–670. doi:10.4236/ojn.2017.76049
III Yuwanich, N., Akhavan, S., Elfström, M., Nantsupawat, W.,
Martin, L., & Sandborgh, M. (2017). Development and psycho-
metric properties of the Stressor Scale for Emergency Nurses.
Manuscript submitted for publication.
IV Yuwanich, N., Akhavan, S., & Martin, L. (2017). The influence
of sociodemographic factors to specific stressors for emergency
department nurses: A cross-sectional study. Manuscript.
Reprints were made with permission from the respective publishers: IOS Press
(study I) and Scientific Research Publishing (study II).
6
CONTENT
INTRODUCTION ........................................................................................ 10
BACKGROUND .......................................................................................... 11
Health care and welfare system in Thailand............................................. 11
Public and private hospitals ................................................................. 13
Emergency care ................................................................................... 13
Emergency nursing ................................................................................... 14
Stress and health ....................................................................................... 16
Stressors ............................................................................................... 17
Health................................................................................................... 18
Influence of stress on health ................................................................ 18
Occupational stress ................................................................................... 19
Occupational stress in the nursing profession .......................................... 20
Patient safety and occupational stress among nurses ............................... 21
Occupational stress and emergency nursing ............................................ 22
Theoretical perspectives ........................................................................... 23
RATIONALE FOR THE DISSERTATION................................................. 26
AIM ............................................................................................................... 27
METHODS ................................................................................................... 28
The setting ................................................................................................ 28
Study design ............................................................................................. 29
Studies I and II ......................................................................................... 30
Participants and setting ........................................................................ 30
Data collection ..................................................................................... 31
Data analysis ........................................................................................ 32
Study III.................................................................................................... 32
Item generation and response format ................................................... 32
Participants and setting ........................................................................ 33
Data collection ..................................................................................... 36
Procedure ............................................................................................. 36
Data analysis ........................................................................................ 37
Study IV ................................................................................................... 38
Participants and setting ........................................................................ 38
Data collection ..................................................................................... 38
7
Data analysis ........................................................................................ 39
Ethical considerations .............................................................................. 39
FINDINGS .................................................................................................... 40
Stressors ................................................................................................... 40
Multiple perceived consequences of emergency-department-related stress
.................................................................................................................. 41
Ways of coping with occupational stress ................................................. 42
Stressor measurement ............................................................................... 42
Sociodemographic factors and stressors ................................................... 43
DISCUSSION ............................................................................................... 46
Methodological discussion ....................................................................... 46
Studies I and II ..................................................................................... 46
Study III ............................................................................................... 47
Study IV ............................................................................................... 49
Reflections on the results ......................................................................... 49
Job demand-control-support model and stress among Thai emergency
nurses ................................................................................................... 49
Human-related stressors....................................................................... 51
Occupational stress related to health and welfare ................................ 52
CONCLUSIONS .......................................................................................... 56
FUTURE RESEARCH ................................................................................. 58
IMPLICATIONS .......................................................................................... 59
ACKNOWLEDGEMENTS .......................................................................... 61
SAMMANFATTNING PÅ SVENSKA ....................................................... 63
SUMMARY IN THAI .................................................................................. 65
REFERENCES ............................................................................................. 68
8
LIST OF ABBREVIATIONS
AIC Akaike information criterion
ANS Autonomic nervous system
CFA Confirmatory factor analysis
CFI Comparative fit index
CNS Central nervous system
CSMBS Civil Servant Medical Benefits Scheme
ED Emergency department
EFA Exploratory factor analysis
GIF Goodness of fit index
ICC Intra-class correlation coefficient
I-CVI Index of content validity
JDCS Job demand-control-support
KMO Kaiser-Meyes-Olkin
SP Social protection
RMSEA Root mean square error of approximation
SPSS Statistical Package for the Social Sciences
SSEN Stressor Scale for Emergency Nurses
SSS Social Security Scheme
9
UCS Universal Coverage Scheme
WHO World Health Organization
10
INTRODUCTION
This dissertation is aimed at contributing to knowledge in the related areas of
the care sciences and health and welfare. The main objectives of the disserta-
tion are to identify possible specific stressors for nurses in emergency depart-
ments (ED), describe their consequences for emergency nurses’ health, organ-
isations and nursing care and to develop and validate a questionnaire for meas-
uring stressors in EDs. A combination of qualitative and quantitative research
methodologies was used to gain a broader, deeper understanding of occupa-
tional stress in EDs in the Thai context. Presently, Thai nurses face stressors
in the workplace, such as high workload, excessive work tasks and low in-
come. This situation is detrimental and has led Thai nurses to go on strike for
their rights several times since 2011. The consequences of stress can affect
nurses at both the individual level (e.g. ill health and burnout from stress) and
the organisational level (e.g. poor patient safety, nursing staff shortages and
intent to leave one’s current nursing job and low patient safety). Although the
knowledge in this dissertation is derived from one specific area of nursing, it
describes specific situations regarding emergency nurses’ stress and may help
complete the picture of Thai nurses’ stress. The author hopes that this
knowledge can be useful for those in the public and private sectors seeking to
improve working conditions in EDs, reduce stress factors and develop a suit-
able welfare strategy for emergency nurses and perhaps nurses in general in
Thailand.
11
BACKGROUND
This chapter on the background of this dissertation describes the health status
and welfare system of the study setting and then the health care and welfare
system in Thailand, followed by the health workforce in Thailand. The con-
cepts of stress and occupational stress are described and discussed in relation
to individual health. The relationships among occupations, nurses, emergency
nurses and patient safety outcomes are described based on evidence from pre-
vious studies and related literature. Finally, the job demand-control-support
(JDCS) model is described and linked to the methodology of this dissertation.
Health care and welfare system in Thailand
Thailand is in South-eastern Asia and has a population of approximately 67
million people. It ranked as an upper-middle-income country in 2011 (World
Bank, 2011), with a total gross domestic product of $395.2 billion in 2015.
Although the economic status of Thailand tends to improve annually, poverty
is still present, with more than 80% of the population living in rural areas (7.3
million people). In 2017, the Thai government launched the Twelfth National
Economic and Development Plan 2017–2021, which emphasises the develop-
ment and reform of the social structure with the aim to achieve equality of
well-being among the Thai people. Achieving sustainable development goals
is the main strategy of this plan. The government wishes to maintain harmony,
well-being and equality among the Thai people by implementing this plan
from 2017 and expects to achieve effective outcomes within five years that
last for 20 years (Royal Thai Government Gazette, 2017).
Despite existing poverty-reduction programmes, poverty remains due to inad-
equate governance performance (Sittha, 2012). This leads to income inequal-
ity and a lack of equal opportunities to access basic social services, such as
health care, education and the old age allowance (World Bank, 2014). Bud-
dhism is the dominant religion in Thailand (95%), while 3% of the population
adheres to Islam, and the rest to Christianity, Hinduism and other religions
(Sakunphanit & Suwanrada, 2011). The aging population is increasing and
12
makes up 13.96% of the Thai population, with a life expectancy of approxi-
mately 75 years (World Health Organization, 2014).
The welfare system in Thailand differs from the welfare systems in Western
countries, such as Sweden. The Thai welfare system, which emerged as a so-
cial protection (SP) system during the economic crisis in 1997, can be catego-
rised into two systems: contributory transfer programmes and noncontributory
transfer programmes (Paitoonpong, Chawla, & Akkarakul, 2010). These pro-
grammes are aimed at providing benefits to the Thai population, including
social security (social insurance), social assistance (i.e. assistance to poor fam-
ilies, the elderly and those with disabilities), social services (i.e. schools and
health care services) and labour protection (i.e. unemployment and maternity
leave) (Pongsapich, Leechanawanichphan, & Bunjongjit, 2002). Although SP
is intended to provide benefits to the Thai population, it does not provide a
universal benefit to the whole population as the Swedish welfare system does
(Swedish Institute, 2012). In fact, the SP system provides multi-pillar benefits
and social welfare, so Thai people belonging to different social classes or
working in different contexts (i.e. the public and private sectors) receive dif-
ferent SP benefits (Paitoonpong et al., 2010).
The health care system in Thailand is focused on primary health care, and the
network of health institutions provides good overall coverage. The health care
system is an entrepreneurial market-driven system and comprises a mixture of
public and private health care providers and financing agencies. However,
most health care services are provided by a public domain supported by the
government, which mostly pays salaries and makes capital investment (Sa-
kunphanit & Suwanrada, 2011). The Thai population accesses health care ser-
vices through three main schemes: the Universal Coverage Scheme (UCS),
Social Security Scheme (SSS) and Civil Servant Medical Benefits Scheme
(CSMBS). The UCS covers the Thai people working in the informal sector,
whether rich or poor, and provides health care to those not covered by any
other public health protection scheme. The SSS covers formal employees in
the private sector. The CSMBS is a tax-funded programme that provides ben-
efits for active and retired military personnel, police officers and civil servants
and their parents, spouses and up to three children younger than 18 years old.
In addition to these schemes, there is an alternative choice to access the health
care system through private health insurance and employer-provided health
insurance (National Statistical Office, 2013). The usage of private health in-
surance has increased from 2.3% in 2006 to 5.3% in 2013 (National Statistical
Office, 2013).
13
Public and private hospitals
Health care services in Thailand are provided at several types of facilities,
such as health care centres, private clinics and hospitals. Of these, hospitals
play the most significant role in providing health care services, and most hos-
pitals in the country are public. In 2010, there were 1,009 public hospitals
under the administration of the Ministry of Public Health (88%), while the
remaining 12% were under the administration of other ministries, such as the
Ministry of Defence and the Ministry of Justice (Bureau of Policy and Strat-
egy, 2011). The government’s tax revenue system is the principal source of
health care funds for public hospitals. Amid economic expansion in Thailand,
the private health sector has grown, contributing to an increase in private hos-
pitals (Bennett & Tangcharoensathien, 1994; Pannarunothai & Mills, 1998;
Sakunphanit & Suwanrada, 2011). The National Statistical Office (2012) re-
ported that there are 321 private hospitals in Thailand, and of these, 98 are
located in Bangkok. The financing system of private hospitals involves cus-
tomer (patient) payments, either direct or indirect through private health in-
surance, employer-provided health insurance or the SSS (Ramesh & Wu,
2008).
Emergency care
In case of emergencies, Thai citizens may use any nearby public hospital with-
out paying service fees to access emergency care services as the UCS covers
the payment. However, if people are in need of emergency care services, and
there are only private hospitals nearby, they may not freely choose any private
hospital to receive emergency care. They may receive emergency care ser-
vices only when their health care scheme (e.g. SSS, CSMBS or private health
insurance) is registered with contracted private hospitals (Boslaugh, 2013).
This pattern of accessing emergency care services can cause delayed treatment
and result in high risk of death and disability for patients.
Consequently, in April 2017, the Ministry of Public Health issued the Univer-
sal Coverage for Emergency Patients (UCEP) policy, aimed at reducing the
limitations on accessing emergency care services in private hospitals (Na-
tional Institute for Emergency Medicine, 2017a). The UCEP policy requires
that private hospitals treat emergency patients for free for the first 72 hours.
Thus, emergency patients can go or be transferred to any nearby private hos-
pital to receive emergency care services for 72 hours without paying. How-
ever, this is a pilot policy, and private hospitals that provide emergency care
14
services under the UCEP policy must be funded by three organisations, the
National Health Security Office, Social Security Office and Comptroller Gen-
eral’s Department (National Institute for Emergency Medicine, 2017a). To
prevent misunderstandings regarding the symptoms of emergency patients,
the National Institute for Emergency Medicine (2017b) listed six symp-
toms/conditions that define emergency illnesses or conditions: unconscious-
ness; difficulty breathing; acute chest pain; drowsy, pallor, coldness and sei-
zures; acute stroke (e.g. weakness and difficulty speaking); and any life-threat-
ening symptoms involving the respiratory, cardiovascular or nervous system.
In conclusion, emergency patients who meet these six criteria of emergency
illness or conditions may access emergency care services in either nearby pub-
lic or private hospitals under the regulations of the UCEP policy. They receive
free emergency care services for the first 72 hours. After 72 hours of care,
patients who need further treatment are referred to hospitals where they are
registered. Patients who prefer to receive ongoing treatment at the private hos-
pitals providing them with emergency care must pay the remaining treatment
costs (National Institute for Emergency Medicine, 2017a).
Emergency nursing
The ED provides a full range of medical treatment facilities and specialises in
acute care around the clock for patients who present without prior appointment
either on their own or by ambulance (Castledine & Close, 2010). The typical
patients who attend the ED are undiagnosed and unknown to the emergency
health care professionals, and most make unexpected and unplanned ED visits
(Croskerry, Cosby, Schenkel, & Wears, 2009). Patients may arrive with a va-
riety of medical symptoms; some patients present in an unconscious state, and
some present with serious medical conditions and need immediate treatment.
In general, most patients visiting the ED have acute illnesses, trauma or inju-
ries from any type of accident (Croskerry et al., 2009).
Due to the variety of patients’ medical symptoms and the unlimited types of
illness in the ED, a triage system is applied as a management strategy to screen
and prioritise the patients who have the most urgent medical problems and
need immediate treatment (Ganley & Gloster, 2011). In the past, triage sys-
tems were used on the battlefield to evaluate the injured and classify them in
priority order. More recently, field triage has been adopted and applied in hos-
pital settings and becomes an active part of most EDs (Marett, 2000). The term
15
triage can be defined as a method of prioritising care of patients (or victims in
the case of disasters) based on their medical condition, illness, symptoms, se-
verity and prognosis, as well as the available resources. This method is in-
tended to identify patients’ need for resuscitation, assign patients to the appro-
priate area of care or treatment, prioritise patients and initiate diagnostic or
therapeutic measures as appropriate (Mace & Mayer, 2007). Many triage sys-
tems are widely used in EDs. The five-level triage system is recommended for
use as it is more effective than three-level triage system (Travers, Waller,
Bowling, Flowers, & Tintinalli, 2002). The five-level triage system comprises
the resuscitation (critical), emergent, urgent, non-urgent and referred (fast
track) levels.
Nurses in the ED, or emergency nurses, play an important role in caring for
ED patients, especially those with crisis conditions. Emergency nurses are
trained and educated in a specific course for emergency care. They must have
competences in emergency nursing practice, which consist of triage skills; as-
sessment; diagnosis; teamwork; provision of nursing care of a broad scope and
focused on emergency care (e.g., medical, surgical, obstetric, gynaecological,
paediatric, psychiatric and geriatric care); and identification of health care
problems in crisis situations (Fazio, 2010). Marett (2000) suggested that emer-
gency nurses must possess outstanding interpersonal skills as patients com-
monly attend the ED unexpectedly. Moreover, emergency nursing requires
sensitivity, patience, flexibility and a firm respect for human beings (Marett,
2000).
Although emergency medical service has been developed in Thailand for al-
most ten years, there is a reported shortage of emergency physicians. Conse-
quently, emergency nurses are the front-line health care personnel who pro-
vide care and initial treatment to patients who attend the ED. Emergency
nurses must provide nursing care with specific skills, including advanced
health assessment, triage, emergency nursing care, advanced cardiac life sup-
port, decision making and handover of patients to other departments and
health care facilities (Vibulwong & Rittiwong, 2014). To gain these skills,
nurses who intend to work in the ED need to attend training programmes.
Thai emergency nurses, whether they work in the public or the private sector,
must provide nursing care under the Professional Nursing and Midwifery Act.
The legislation states that they must give nursing care to individuals, families
16
and the community through the following actions: (1) provide education, ad-
vice and counselling and solve health problems; (2) assist individuals physi-
cally and mentally, including manage a proper environment, to solve problems
associated with illness, alleviate symptoms, facilitate rehabilitation and pre-
vent the spread of disease; (3) administer immunisations and treatment as ap-
propriate for primary medical care; and (4) help physicians perform treatment
(Thailand Nursing and Midwifery Council, 1997, p. 1).
Considering the characteristics of the ED, the fourth practice mentioned in
the Professional Nursing and Midwifery Act (1997) appears to be the initial
concern for Thai emergency nurse. Thai emergency nurses, therefore, can be
considered to be important health personnel in the ED who assist physicians
in performing treatment. Emergency nurses have become significant middle-
level care providers who can fill the gap amid physician shortages and the
need for cost-effective care (Pagaiya & Noree, 2009). Although the nurse–
patient ratio is planned to reach 1:400 in 2019, there is a nursing shortage of
approximately 43,250 positions (Srisuphan & Sawaengdee, 2012). The nurs-
ing shortage and the requirement to perform tasks beyond their competences
may contribute to the high workload and stress of Thai emergency nurses
and nurses in other departments (Tyson & Pongrengphant, 2004).
Stress and health
The concept of stress can be described from different angles. Commonly, its
definitions fall into three main categories: stimulus-based, response-based,
and interactional definitions. Stimulus-based definitions are derived from the
engineering perspective and are related to the physics of the elasticity of sub-
stances. In this category, stress is defined as an aspect of the environment that
causes a strain reaction to an individual exposed to the stressful stimulus
(Payne & Horn, 2007). The stimulus-based definition is simple but has limited
ability to explain the complexities of the stress process.
Selye (1975) offered a response-based definition of stress: an organism’s re-
action to a given stimulus. Selye described this reaction through the concept
of general adaptation syndrome (GAS). GAS views stimuli as stressors, and
when an organism is stimulated by a stressor, a stress reaction occurs (Selye,
1975). Stress is broken down into distress, which is negative stress and results
in ill health, and eustress, which is positive stress and can enhance health (Se-
lye, 1975; Payne & Horn, 2007).
17
The interactional definitions of stress propose that it is an interaction between
the external environment (a stimulus) and the person. The person–environ-
ment fit (P-E fit) model is a stress model related to the interactional defini-
tions. The P-E fit model defines stress as the degree of mismatch between a
person and the environment (Payne & Horn, 2007). One of the most widely
used interactional definitions of stress was introduced by Lazarus and Folk-
man (1984). They defined stress as a particular relationship between a person
and the environment that the person appraises as taxing or exceeding their
resources and harming their well-being (Lazarus & Folkman, 1984). Accord-
ing to this concept of stress, a person perceives and interprets events in the
environment as stress through making cognitive appraisals, which can be di-
vided into primary and secondary appraisals. The primary appraisal concerns
the determination and assessment of events occurring in the environment,
while the secondary appraisal involves assessment of the person’s ability to
cope with the event. In other words, people only experience stress if they per-
ceive and regard events as stressful and feel that they are unable to cope with
them. The stress process described through cognitive appraisals, therefore,
cannot be fully understood without mentioning the process of coping (Folk-
man & Lazarus, 1980). Coping is defined as the process of managing the de-
mands that an event appraised as stressful places upon the individual and is
categorised into emotional- and problem-focused coping (Folkman & Laza-
rus, 1980, 1991; Lazarus, 2006).
Stressors
In the stress definitions, stressors are usually mentioned as the sources that
cause stress. Selye (1975) defined stressors as stimuli from the environment
surrounding an organism. Cooper et al. (2001) viewed stressors as any force
that pushes a psychological or physical factor beyond its range of stability,
which can produce a strain (stress) within the individual. Pacák and Palkovits
(2001) described stressors as any factor or event that threatens an individual’s
health or reduces normal functioning. In summary, a stressor can be seen as a
source or factor that causes stress. Individuals perceive and interpret events
occurring in the environment as stressors through their appraisals. Thus, peo-
ple perceive and interpret stress differently, and stress can affect individual
health and well-being.
18
Health
Health is a broad concept which has been defined differently over time. The
World Health Organization (WHO, 1948) defines health as a state of complete
physical, mental and social well-being, not merely the absence of disease or
infirmity (WHO, 1948). The WHO’s definition of health introduces a concept
of well-being that has physical, mental and social dimensions. However, these
dimensions are difficult to measure; for example, health in the social dimen-
sion is hard to define. Another criticism of the WHO’s health definition is that
complete well-being in all dimensions seems impossible; therefore, no one is
healthy (Larson, 1999). The WHO’s definition of health is rather old fash-
ioned as populations have undergone demographic transitions, and the nature
of disease has changed considerably since 1948. Huber et al. (2011) suggested
that the WHO’s health definition should be reformulated to take into account
the capacity to cope, maintain and restore personal integrity, equilibrium and
sense of well-being. This definition aligns with Antonovsky’s (1996) saluto-
genic model, which focuses on people’s resources and capacities to create
their own health. Thus, health can be a person’s perceived ability to adapt to
live their life and achieve personal well-being.
Influence of stress on health
Stress can influence individuals’ physiological and psychological health
(Kenny, Carlson, McGuigan, & Sheppard, 2000; Lovallo, 2005). A study pro-
vided evidence that 33.7% of nearly 186 million adults in the United States
perceived stress to affect their health, both physical and psychological (Keller
et al., 2012). Physiological ill health is associated with the physiological re-
sponses to stress, which are comprised of two components: neutral pathways
and hormonal transmission. In the neural pathway, an individual encounters a
stressful situation or perceives stress, and the hypothalamus in the central
nervous system (CNS) activates the autonomic nervous system (ANS) con-
sisting of the sympathetic and parasympathetic pathways. The two branches
of the ANS tend to function in opposite ways; the sympathetic branch is in-
volved with bodily excitation and expenditures, whereas the parasympathetic
division is concerned with reducing bodily activity and saving energy
(Stratakis & Chrousos, 1995). Stressful situations potentially induce the sym-
pathetic division to activate the inner part of the adrenal gland (adrenal me-
dulla), resulting in the secretion of the hormone catecholamine through the
bloodstream. Catecholamine consists of two chemicals, epinephrine (adrena-
line) and norepinephrine (noradrenaline), and contributes to increasing blood
19
sugar levels, cardiac output, heart rate and blood supply to the brain. These
reactions prepare the body for the fight-or-flight response (Bamber, 2007;
Bartlett, 1998; Kenny et al., 2000; Lovallo, 2005).
Another pathway of physiological responses to stress is hormonal transmis-
sion. The endocrine system plays an important role in secreting hormones in
the human body (Stratakis & Chrousos, 1995). This stress response pathway
is much slower than the neural pathway but is more closely associated with
chronic (longer response) stressors. The hypothalamus in the CNS stimulates
the pituitary gland, resulting in the release of hormones. The major hormone
related to stress is the adrenocorticotropic hormone, which induces the cortex
of the adrenal gland (the outer part of the adrenal gland) to secrete another
hormone, corticosteroid (Lyons & Meeran, 1997). Corticosteroid consists of
two subgroups: mineralocorticoid and glucocorticoid. Mineralocorticoid reg-
ulates bodily fluids and electrolytes, while glucocorticoid controls blood sugar
and pressure, inhibits normal inflammatory responses and allergic reactions
and is involved in the immune system (Lyons & Meeran, 1997; Stratakis &
Chrousos, 1995).
The sympathetic pathway induces physiological responses to stress, possibly
causing muscle pain and irritable bowel syndrome (Bamber, 2007; Kenny et
al., 2000). Furthermore, previous studies have shown that stress is related to
cardiovascular diseases (Everson-Rose & Lewis, 2005) and metabolic syn-
drome (Chandola, Brunner, & Marmot, 2006; Rosmond et al., 2003). The res-
piratory system also responds to stress, which can lead to hyperventilation
(breathing faster rate than the body needs). This breathing pattern can contrib-
ute to an imbalance of the body’s acid–base control (Kenny et al., 2000). Ad-
ditionally, stress can affect individuals’ psychological health and emotion
(Lazarus, 1993). Stress evokes negative emotions, including anger, fright,
anxiety, guilt, shame, sadness, envy, jealousy and disgust. Each emotion is the
result of a different set of troubled conditions in life, and each involves differ-
ent harms or threats. Individuals react to stressors and express their emotions
differently depending on their appraisals (Lazarus, 1993; Lazarus & Folkman,
1984).
Occupational stress
Stress in the workplace, or occupational stress, has been an issue of great con-
cern for many years. Occupational stress has increased due to the world finan-
cial crisis, which affected almost all countries, professions and categories of
20
workers, as well as families and societies (Mohajan, 2012). Occupational
stress can be defined as the potentially deleterious psychophysiological re-
sponses that occur when job requirements do not match workers’ capabilities,
resources or needs (Sauter et al., 2009). Generally, the causes of occupational
stress, known as psychosocial hazards, consist of job content, workload, work-
place, work schedule, control, work environment and equipment, organisa-
tional culture and function, organisational role, career development, home–
work interface and interpersonal relationships at work (European Risk Obser-
vatory, 2010). Cartwright and Cooper (1997) categorised six primary causes
of work-related stress: organisational factors, the home–work interface, career
development, factors intrinsic to the job itself, role in the organisation and
relationships at work.
Occupational stress can influence the organisational level and the individual
level of the worker (Beheshtifar & Nazarian, 2013; European Parliament
Committee on Employment and Social Affairs, 2013). The consequences of
occupational stress on the individual level include unwanted feelings and be-
haviour, physiological and psychological ill health and social problems, while
the negative impacts of occupational stress on the workplace comprise poor
or low productivity and other organisational costs (Beheshtifar & Nazarian,
2013). Occupational stress may also cause absenteeism among workers and is
related to decreased organisational productivity. The Medibank Private (2008)
reported that stress-related absenteeism costs the Australian economy $5.12
billion a year and another $4.48 billion a year for organisations to hire new
staff. A report on work-related stress and cardiovascular disease in Europe
claimed that they result in €1.06 billion in health care costs among European
countries (Nichols et al., 2012).
Occupational stress in the nursing profession
The nursing profession involves
actions to people, related to caring and helping when they are sick,
including rehabilitation, disease prevention and health promotion, as
well as assisting physicians to perform curative treatment. In doing
so, it shall be based on scientific principles and the art of nursing.
(Thailand Nursing and Midwifery Council, 1997, p. 1)
Hingley (1984) stated that the ‘nursing profession confronts stark suffering,
grief, and death as few other professions do. Many nursing tasks are mundane
21
and unrewarding. Many are, by normal standards, distasteful, even disgusting,
others are often degrading; some are simply frightening’ (p. 19). This state-
ment reflects the workload that nurses face and can be seen as work-related
stress which affects nurses’ physical and psychological health (Happell et al.,
2013).
The consequences of occupational stress for nurses include absenteeism, high
staff turnover, ill health, decreased quality of care and lower job satisfaction,
which is the most common consequence of occupational stress in nursing pro-
fessions (AbuAlRub, 2004). Wright, Bretthauser, and Cote (2006) noted that
dissatisfaction in nursing is mostly related to the quality of care provided and
nursing shortages which result in increased workload. In addition to leading
to absenteeism and turnover, dissatisfaction among nurses has economic con-
sequences. According to Salmond and Ropis (2005), ‘stress has been esti-
mated to cause half of workplace absenteeism and 40% of turnover, which is
projected to cost the U.S. economy $200–$500 billion annually’ (p. 302). Gel-
sema et al. (2006) supported that occupational stress in the nursing profession
is related to changes in work conditions and leads to changes in nurses’ health,
well-being and job satisfaction, resulting in emotional exhaustion or burnout.
These, in turn, lead to poor-quality nursing care and low patient safety (Hall,
Johnson, Watt, Tsipa, & O’Connor, 2016; Poghosyan, Clarke, Finlayson, &
Aiken, 2010).
Patient safety and occupational stress among nurses
Patient safety is defined as doing no harm to patients and their families and
preventing errors and adverse effects for patients during health care (WHO
Europe, 2017). Patient care refers to quality of care and preventable effects on
patient safety. Health care providers’ health status and well-being seem to be
factors related to low patient safety. For example, moderate to high levels of
burnout among health care providers are associated with low patient safety,
including medical errors (Hall et al., 2016; National Institute for Health Re-
search, 2016).
Nurses are health care providers who provide care in close contact with pa-
tients, so they have a high chance of unintentionally delivering poor care and
causing low patient safety, especially when they are stressed and fatigued at
work (Cropley, 2015). Occupational stress and the work environment have a
strong interrelationship with nurses’ stress at work. A negative or poor work
22
environment (e.g. low wages, shortages of necessary medical equipment and
lack of adequate rest) (Lu et al., 2015) contribute to stress in nurses and affect
nursing care and performance and patient safety (Kirwan, Matthews, & Scott,
2013). In contrast, positive or good work environments perceived as healthy
generate many positive outcomes for nurses and patients, including high-qual-
ity patient care, staffing, communication, collaboration, respect, teamwork
and job satisfaction (Ulrich, Lavandero, Woods, & Early, 2014). Excessive
work hours are one factor related to negative work environments as they can
be seen as a workplace policy that nurses have to follow. Working for long
hours can adversely affect nursing care performance, sometimes resulting in
unintended negative consequences for patient care (Bae & Fabry, 2014; Chan,
Jones, & Wong, 2013). Sometimes, nurses have to work extended work hours
due to workplace policy (as in Thai hospitals). Extended work hours have neg-
ative consequences for nurses (e.g. stress, poor health and emotional exhaus-
tion) and patients (e.g. patient identification and communication error) (Kuna-
viktikul, Chitpakdee, Srisuphan, & Bossert, 2015).
Excessive work tasks are also commonly reported to be a stressor for nurses
(Trousselard et al., 2016) and can be related to the job demands due to the
JDCS model (Karasek & Theorell, 1990). Completing work and task demands
significantly contributes to stress and negatively affect nurses’ ability to pro-
vide all the required care in a timely fashion. These demands include high
physical workloads and unexpected tasks, such as phone calls, patient requests
and immediate medical administration (Verrall et al., 2015).
Occupational stress and emergency nursing
Given the nature of the ED and the unplanned attendance and unpredictable
illnesses of patients, emergency nurses provide initial treatment for a broad
spectrum of illnesses and injuries. Some, such as life-threatening conditions,
may require immediate attention to patient. Consequently, emergency nurses
work in a high-stress environment and inevitably are simultaneously and daily
confronted with crisis situations, such as sudden patient death and resuscita-
tion, violence, injury, trauma, overcrowding and physical assaults by patients
and visitors (Freeman, Fothergill-Bourbonnais, & Rashotte, 2014; Healy &
Tyrrell, 2011). These factors may cause more stress and burnout among emer-
gency nurses than nurses in other departments (Adriaenssens, De Gucht, &
Maes, 2015a, 2015b; Adriaenssens, De Gucht, Van Der Doef, & Maes, 2011)
and other health care professionals, such as physicians (Hamdan, Abu Hamra,
23
& Hamra, 2017). The top five causes of stress for ED nurses are handling mass
casualties, caring for patients with acute illness, violence against staff, heavy
workload and poor skill mix and the deaths or sexual abuse of children (Ross-
Adjie, Leslie, & Gillman, 2007).
Stress influences the physiological and psychological health of emergency
nurses. The physiological effects of stress include high blood pressure, in-
creased heart rate, weight gain or loss, indigestion, coronary heart disease and
gastric disorder. These effects are dependent on where the individual’s expe-
rience is on the stress continuum (Potter, 2006). The psychological effects in-
clude increased arousal, feelings of uneasiness, emotional exhaustion, depres-
sion, fatigue and burnout (Adriaenssens et al., 2015b; Freeman et al., 2014).
Moreover, stress leads to absenteeism and high turnover among emergency
nurses (Rugless & Taylor, 2011). Nurses can become irritable and short-tem-
pered, creating difficulties in relationships with other health care professionals
(Rosenstein & Naylor, 2012) and leading to decreased quality of care (Gates,
Gillespie & Succop, 2011). Moreover, occupational stress negatively affects
emergency nurses’ health behaviour; compared to nurses in other departments,
emergency nurses smoke more (Berkelmans, Burton, Page, & Worrall-Carter,
2011), take more sick days, consume more alcohol and experience lower over-
all health and well-being (Helps, 1997).
Theoretical perspectives
Job demand-control (-support) model
The JDCS model, developed by Karasek (1979), posits that the relationship
between job demand and job control is an essential job characteristic which
influences an employee’s well-being. The goal of this model is to determine
the occurrences of psychological strain in workplace contexts. The interaction
of two dimensions, job demand and job control has to be considered (Häusser,
Mojzisch, Niesel, & Schulz-Hardt, 2010). Job demand refers to workload or
time pressure, while job control is divided into two components: skill discre-
tion, which refers to the opportunities for employees to use their skills in the
workplace, and decision authority, which refers to employees’ autonomy to
make task-related choices by themselves (Karasek, 1979). Karasek (1979) de-
scribed the interactions of two dimensions in job situations. High demand and
low control lead to high risk of illness and reduced well-being (high strain
24
job). However, if a job has low demand and high control (low strain job), ad-
verse reactions are rather unlikely, and the situation can lead to passivity and
boredom.
The relationship of these two dimensions leads to two hypothesises. The strain
hypothesis emphasises the increased physical or psychological strain and re-
duced well-being of employees who work in high-strain jobs (see the left
lower quadrant in Figure 1). The buffer hypothesis predicts buffering of con-
trol, which reduces the negative impact of job demands on well-being (Ka-
rasek & Theorell, 1990). More recently, the job demand-control model (JDC)
has been developed to add a third dimension of social support (Karasek &
Theorell, 1990). With this third dimension, the JDC model became the job
demand-control-support (JDCS) model, which predicts work situations em-
phasising high demand, low control and low social support (iso-strain job).
The relation of these three dimensions can cause the most strain and be harm-
ful to employee well-being (Karasek & Theorell, 1990). Generally, the JCDS
model describes the interactions between demands support and control at
work. High demand and low control and social support lead to high risk of
stress (Choi et al., 2011; Jonge & Kompier, 1997; Karasek & Theorell, 1990;
Luchman & González-Morales, 2013; Van Der Doef & Maes, 1999).
Based on the interrelations of these dimensions, this model supports three hy-
potheses: the strain, iso-strain and buffer hypotheses. The strain hypothesis is
that high job demand and low job control cause high risk for psychological
strain and physical illness. The iso-strain hypothesis holds that high job de-
mand, low job control and low social support contribute to greater risk of psy-
chophysiological illness. Finally, the buffer hypothesis posits that control and
social support buffer the negative effect of high strain on well-being (Karasek
& Theorell, 1990; Luchman & González-Morales, 2013). The JDCS model
predicts that those who are exposed to high levels of psychological demand
and have low levels of job control (including decision authority and skill dis-
cretion) are likely to suffer from ill health. Karasek (1979) explained that the
interaction between high demand and low control creates a high-strain situa-
tion in the workplace, which may lead to negative health outcomes (Theorell
& Karasek, 1996). High control is also believed to buffer the effect of high
demands on health outcomes.
In summary, the JDCS model emphasises the importance of daily environ-
mental stressors specific to the workplace (Theorell & Karasek, 1996). In this
case, the stressors can be related to stimuli (Selye, 1975) and the events that
25
occur in the workplace environment that a person appraises (Lazarus & Folk-
man, 1984). Karasek and Theorell (1990) argued that job demand and job con-
trol align with the psychological dimension. This means that individuals ex-
perience stress at work when they perceive high job demand and low control
in the workplace. These can be seen as stressors when a person appraises them
as threats to personal health and well-being. This notion is in accordance with
the cognitive appraisal described by Lazarus and Folkman (1984).
This model, therefore, is appropriate to describe the circumstances relevant to
stress among nurses at work. This dissertation is focused on workplace stress-
ors for emergency nurses. To strengthen the findings of this dissertation, the
JDCS model is considered to be appropriate to describe and reflect the expe-
riences and situations of emergency nurses related to stressors in the ED.
Figure 1. Psychological demand–decision
latitude model (Theorell & Karasek, 1996).
26
RATIONALE FOR THE DISSERTATION
Occupational stress among nursing professionals appears to be a global prob-
lem. Presently, there is a relatively large amount of knowledge in this area.
Most empirical studies on nurses’ workplaces in Asian countries, including
Thailand, though, elaborate knowledge from the perspectives of nurses in
more general contexts (e.g. medical-surgical units and nursing homes).
Knowledge regarding emergency nurses’ stress, therefore, tends to be limited.
This dissertation marks an attempt to explore these stressors and to develop
and validate an instrument to measure stressors among emergency nurses in
Thailand. This analysis is intended to generate suggestion for changes in, for
instance, organisation, social support and education to reduce stress among
emergency nurses, which may prevent nursing errors and maintain patient
safety. The studies focus on emergency nurses as they provide nursing care in
an environment which can be extremely busy, constantly changes and facing
unpredictable demands for patient care. These increase the chances that emer-
gency nurses will become much more stressed than nurses who work in gen-
eral areas.
Concerning stressor measurements for emergency nurses, several question-
naires measure work-related stress and measure stress among nurses. How-
ever, to the best of our knowledge, there is no instrument specifically designed
to examine stressors among emergency nurses in Thailand. This leads to our
objective to develop and validate an instrument to investigate emergency
nurses’ occupational stress from a Thai perspective and in a Thai context. The
studies in this dissertation are aimed at providing an evidence base on occu-
pational stress in ED, which might be helpful for health care organisations
concerned about job dissatisfaction, absenteeism and turnover among emer-
gency nurses. Improvements in these areas may lead to improved nursing care
quality, ultimately resulting in enhanced well-being in patients.
27
AIM
The overall aim of this dissertation is to explore the stressors for Thai emer-
gency nurses and to develop and validate an instrument for measuring stress-
ors for emergency nurses. The specific aims of each study are:
Study I To explore emergency nurses’ perceptions of occupational
stress in an ED at a public hospital in Bangkok, Thailand.
Study II To explore nurses’ experiences of occupational stress in EDs
in private hospitals in Bangkok, Thailand.
Study III To develop and test the psychometric properties of a question-
naire-based instrument for identifying stressors for emer-
gency nurses.
Study IV To explore the potential relationships between socioeconomic
variables and Thai emergency nurses’ experiences of specific
stressors.
28
METHODS
The setting
EDs in both public and private hospitals in Thailand are the setting of this
dissertation. Health care services in the public sector in Thailand are provided
through either hospitals or health centres classified into three levels of services
by the Ministry of Public Health. The first level consists of primary care units
or health centres. These health care facilities are located in rural areas and
intended to provide primary care, outpatient services and to transfer patients
to the next level of health care facilities as needed (Wibulpolprasert, 2011).
On the second level of health care facilities are community hospitals, which
are located by district and are classified by the number of beds. Large com-
munity hospitals have 90–150 beds, medium community hospitals 60 beds,
and small community hospitals 10–30 beds. Community hospitals provide
basic medical services and transfer patients to higher-level hospitals in cases
that require advanced care. The third level of health care facilities consists of
general or regional hospitals (also known as the tertiary care level) that pro-
vide advanced and comprehensive medical care under one roof. General hos-
pitals are located in provinces or main districts and have 200–500 beds. Re-
gional hospitals are located in provincial centres and have at least 500 beds
(Wibulpolprasert, 2011). The private sector applies the same classification by
hospital level and size used by the Ministry of Public Health.
In this dissertation, secondary and tertiary health care facilities were the se-
lected study setting as hospitals on these levels provide emergency care
through EDs and offer a variety of treatments and health care services. The
study participants working in these hospitals, therefore, were likely to have a
diversity of experiences in emergency care and a broad perspective on stress-
ful situations. For studies I and II, three hospitals in Bangkok (one public and
two private hospitals) were chosen. In studies III and IV, secondary and ter-
tiary hospitals in the four main regions in Thailand were included (Table 1).
29
Table 1. Number of hospitals in four main regions in studies III and IV.
Region
(n)
Hospital type Responses
Participation Non-participation
Public Private Public Private Public Private
Central (18) 13 5 10 1 3 4
North-eastern
(15)
13 2 5 - 8 2
Northern (4) 2 2 2 1 - 1
Southern (16) 10 6 10 6 - -
Total (53) 38 15 26 9 11 7
Study design
Studies I and study II had an explorative, descriptive, qualitative design with
a deductive approach. Studies III and IV had a descriptive cross-sectional and
correlational design using quantitative methods. An overview of the details of
studies I, II, III and IV is shown in Table 2.
Table 2. Overview of the two qualitative and two quantitative studies.
Study Participants Data collection
methods
Analysis
I 21 emergency
nurses in a public
hospital
Individual interviews
with open-ended
questions
Content analysis
II 15 emergency
nurses in two pri-
vate hospitals
Individual interviews
with open-ended
questions
Content analysis
III 405 emergency
nurses at public and
private hospitals in
Thailand
Three phases: 1) item
generation and pre-
liminary validation of
items; 2) pilot testing;
and 3) evaluation of
the construct validity
and reliability of the
instrument
Descriptive statistics, I-
CVI, coefficient alpha,
ICC, EFA, and CFA
IV 205 emergency
nurses at public and
private hospitals in
Thailand
Stressor Scale for
Emergency Nurses
Descriptive statistics
and multiple regression
analysis
I-CVI = Item validity index; ICC = Intra-class correlation coefficient; EFA =
Exploratory factor analysis, CFA = Confirmatory factor analysis
30
Studies I and II
Participants and setting
Study I
The participants were recruited through purposive sampling. The inclusion
criteria were emergency nurses of any gender, with at least a bachelor degree
in nursing science, working full-time in an ED, with at least one year of expe-
rience in emergency care. The reason for choosing a large public hospital was
the diversity of patients’ conditions and treatments, the participants’ de-
mographics and nursing care experiences. The included hospital had more
than 600 inpatient beds and provided a variety of treatments, including spe-
cialised and general health care services. The participants in study I were 21
emergency nurses working full-time at this public hospital in Bangkok, Thai-
land. They included 17 women and four men and ranged in age from 23 to 55
years. All the participants had bachelor degrees in nursing science, and one
had a master degree in another discipline. Two participants were studying for
master degrees in nursing science. The participants’ years of experience in
emergency care ranged from 1 year to more than 21 years. All the emergency
nurses invited agreed to participate in the interviews.
Study II
The same recruitment procedure and inclusion criteria used in study I were
applied to select the participants in study II. Two large private hospitals were
selected to ensure representation of diverse nursing care experiences and pa-
tient demographics, conditions and treatments. The two hospitals had more
than 200 inpatient beds each and provided a variety of treatments and health
care services. The participants who worked in these hospitals, therefore, were
likely to have diverse experiences in emergency care and a broad perspective
on stressful situations. All the ED nurses (n = 28) working in these two hos-
pitals were invited to participate, but 11 who had less than one year of experi-
ence in emergency care were excluded, and two ED nurses were not willing
to participate. Twelve women and three men with a median age of 27 years
(range: 20–39 years) agreed to participate in this study. Nine nurses worked
at a private hospital in the central area of Bangkok, and the other six worked
at a private hospital in a suburban area of Bangkok. All had bachelor degrees
in nursing science and worked full time. Their emergency care experience
ranged from 1 to 10 years.
31
Data collection
The interview guide for the studies I and II (see Table 3) was formulated based
on previous research relevant to the JDCS model (Karasek & Theorell, 1990)
and occupational stress among emergency nurses (Dwyer, 1996; Healy & Tyr-
rell, 2011; Helps, 1997; Lim, Hepworth, & Bogossian 2011; Lindström et al.,
2000; Ross-Adjie et al., 2007). Follow-up questions were asked to better un-
derstand the participants’ experiences. The timing of the interviews was dur-
ing work shifts, which included morning, evening and night shifts. To obtain
data and access the research setting, the researcher needed assistance and fa-
cilitation from a gatekeeper (Holloway & Wheeler, 2010; Munhall, 2012), in
this case, an emergency nurse at each hospital who participated in the studies.
The interviews were carried out at private room in the EDs or private locations
of the participants’ choice. All the interviews were performed during 2012 and
2013. In study I, the interviews ranged from 45 minutes to one hour. In study
II, the interviews lasted 25–80 minutes.
Table 3. Interview guide.
1. Could you tell me about your job description and your responsibilities in
your position?
2. Do you think you have control over your work tasks? Work situation?
Working hours?
3. Can you choose your work tasks? How?
4. Could you tell me what is stressful in your workplace according to your
perceptions?
5. Could you please describe why these factors cause stress in your work-
place?
6. Does the stress in your workplace influence your health? In what way
does it affect your health?
7. Does your workplace offer you resources, possibilities and facilities to
cope with work stress? If yes, what? If no, why?
Follow-up questions:
1. Could you describe that experience?
2. How do you feel about this situation?
3. How does this situation make you feel stress?
32
Data analysis
The interviews (studies I and II) were analysed using qualitative content anal-
ysis (Graneheim & Lundman, 2004). This analysis method emphasises the
similarities and differences in texts and, in these studies, was used to concep-
tually describe the nurses’ experiences of occupational stress. All the inter-
views were conducted, audio-recorded and transcribed verbatim by the PhD
student (NY). They were then translated into English to determine conceptual
equivalence and reviewed by a professional linguist to confirm their accuracy
and consistency. Words, statements and paragraphs that reflected the essential
meanings of the participants’ responses and were relevant to the study aims
were identified as meaning units. These meaning units were condensed, ab-
stracted and labelled with codes. The various codes were compared and cate-
gorised into sub-categories (sub-themes in study I) and categories (themes in
study I). An example of the content analysis is shown in Appendix I.
Study III
This study had a cross-sectional, correlational study design that involved three
phases: 1) item generation; 2) content and face validity and test-retest reliabil-
ity; and 3) evaluation of the instrument’s internal consistency and construct
validity. The study was conducted from March 2015 to June 2017. The outline
of the development process is shown in Appendix II.
Item generation and response format
In phase I, the preliminary item pool for the Stressor Scale for Emergency
Nurses (SSEN) was generated based on a scoping literature review, as de-
scribed by Davis, Drey and Gould (2009), and the themes/categories and sub-
themes/sub-categories from the results of studies I and II. Key terms used to
search for relevant articles were ‘occupational stress OR work stress OR stress
at work’ AND ‘nurs*’ AND ‘emergency room OR emergency department OR
accident and emergency department’. A total of 25 studies (see Appendix III
and IV), including both qualitative and quantitative studies, were selected and
used for item generation.
The respondents described the extent to which they perceived items as stress-
ful. The chosen response format was a 6-point numerical rating scale that
ranged from 0 (‘not at all’) to 5 (‘to a very high degree’). A continuous rating
33
scale was chosen to prevent the participants from choosing a neutral rating,
which would have decreased the sensitivity of the measurement (Streiner &
Norman, 2008).
Participants and setting
For content validation of the preliminary items (Phase II), five experts were
chosen (see the demographic characteristics of the experts in Table 4). These
experts had experience conducting research and a good understanding of the
ED context. Face validity was evaluated by the same five experts and four
emergency nurses, two from a public hospital and two from a private hospital.
Table 4. Demographic information of the expert participants who evalu-
ated the content and face validity of the first version of the questionnaire.
Variable
Expert
Expert #1 Expert #2 Expert #3 Expert #4 Expert #5
Age (years) 57 63 40 55 48
Gender Female Female Male Female Female
Education MSc and di-ploma in ad-
vanced prac-
titioner nurs-ing in medi-
cal-surgical
nursing
PhD MSc BSc MSc
Current
occupation
Registered
nurse (gov-
ernment agency)
University
teacher (gov-
ernment agency)
Registered
nurse (gov-
ernment of-ficer)
Registered
nurse (gov-
ernment of-ficer)
Registered
nurse (pri-
vate organi-sation)
Position in the
organisation
Registered
nurse, profes-sional level;
nurse super-
visor
Senior lec-
turer; associ-ate professor
in the Faculty
of Nursing
Registered
nurse, pro-fessional
level
Registered
nurse, senior professional
level; head
nurse of the ED at a pub-
lic hospital
Registered
nurse, senior level; head
nurse of the
ED at a pri-vate hospital
Years of experience in re-
search
17 32 3 10 0.5
Emergency care experience or
understanding of
the context
Yes Yes Yes Yes Yes
34
For evaluation of the test-retest reliability of the questionnaire (phase II or
pilot testing), convenience sampling was used to recruit participants who ful-
filled the criteria as emergency nurses in either public or private hospitals in
Thailand, with at least one year of emergency care experience. Thirty emer-
gency nurses from one public (n = 16) and two private hospitals (n = 14) were
invited, and all agreed to participate (see Table 5).
For evaluation of construct validity (phase III), the rule of thumb was applied
to select a proper sample size for factor analysis. Accordingly, a sample size
of 200 was considered to be acceptable (Hair, Black, Babin, & Anderson,
2010). Convenience sampling was used to recruit participants who met the
same inclusion criteria as in the pilot test (phase II). EDs in hospitals in four
regions in Thailand were randomly selected. Fifty-three hospitals (38 public
and 15 private hospitals) were contacted, and 27 public hospitals and eight
private hospitals responded and agreed to participate in the study. Of the total
491 questionnaires, 422 were returned, and 405 participants (see Table 5) sub-
mitted completed questionnaires, for a response rate of 82%. The data set of
405 participants was split in half. The first 200 completed questionnaires were
used to perform exploratory factor analysis (EFA), and the remaining 205 con-
firmatory factor analysis (CFA) (Kellar & Kelvin, 2013).
35
Table 5. Demographic characteristic of the participants in phase II (pilot
test, n = 30) and III (n = 405).
Variable N (%) Mean (SD)
(n = 30) (n = 405) (n = 30) (n = 405)
Age (years) 36.9
(8.4)
33.9 (8.7)
Sex
Male
Female
2 (7)
28 (93)
49 (12.1)
356 (87.9)
Employment status
Full time
Part time
29 (97)
1 (3)
402 (99.3)
3 (0.7)
Work position
Practitioner level
Management level
Others
27 (90)
2 (7)
1 (3)
357 (88.1)
24 (5.9)
24 (5.9)
Years of nursing ex-
perience
14.5
(9.7)
11.4 (8.9)
Years of emergency
care experience
11.8
(7.5)
9.4 (7.8)
Average working
hours per month
258.4
(91.3)
253.3 (63.4)
36
Data collection
The content and face validity of the questionnaire (phase II) was evaluated by
five experts and four emergency nurses, with the latter evaluating only face
validity. The five experts rated the content validity of the items on a four-point
scale: 1 = not relevant, 2 = somewhat relevant, 3 = quite relevant and 4 =
highly relevant. To evaluate face validity, open-ended questions were added:
‘Please give your comments and reflections on each statement in this instru-
ment (the 59-item pool of the SSEN) regarding clarity, layout and readability’.
‘Is there anything that you think should be revised’?
Test-retest reliability (phase II) refers to the correlation between two sets of
scores from the instrument, with a two-week interval between measurements
(Cook & Beckman, 2006; DeVon et al., 2007). In this study, the participants
(n = 30) were asked to complete the questionnaire twice two weeks apart. They
were also asked how long it took them to complete the questionnaire.
Construct validity and internal consistency reliability (phase III) was tested
with 405 selected emergency nurses from four main regions in Thailand.
Procedure
Data were collected in May and December 2015 for phase II and April 2016
and June 2017 for phase III. The initial procedure was performed similarly in
phases II and III. The PhD student arranged for a contact person at each hos-
pital, who agreed to participate either by phone or at face-to-face meeting and
described the study purpose and inclusion criteria for recruiting participants.
The contact persons in this study were emergency nurses, ED head nurses,
nurse directors and hospital secretaries at the included hospitals.
In phase II, the 30 participants who agreed to participate received an envelope
containing an information sheet, a consent form, and the questionnaire (59-
item pool). The respondents were asked to complete the questionnaire in a
comfortable place at a time convenient for them and to do the questionnaire
twice two weeks apart. The contact person at each hospital distributed the
questionnaires to the participants and collected them when the first measure-
ment was completed. Two weeks after the first measurement, the contact per-
sons distributed the questionnaire to the participants a second time. The sec-
ond questionnaires completed were collected by the contact persons and then
submitted to NY.
37
In phase III, 491 envelope packages including the questionnaire (59-item
pool), information sheet and consent form were sent to the contact persons at
all the participating hospitals. The contact persons at the hospitals then dis-
tributed the envelope packages to the participants as described in the inclusion
criteria. The participants were asked to completely answer the questionnaire
at a convenient time and place and then put the form in a preaddressed enve-
lope and return it to the contact person. The contact person collected the ques-
tionnaires and sent them to NY by regular mail.
Data analysis
An index of content validity per item (I-CVI) was calculated to measure the
degree to which the instrument items had an adequate operational definition
of the measurement construct and relevant content for the domains in the in-
strument (Polit, Beck, & Owen, 2007). This index was based on the number
of experts who gave an item a rating of either 3 or 4 on a 4-point relevance
scale, divided by the total number of experts. An I-CVI value of 0.78 or higher
was regarded as acceptable (Polit et al., 2007). Face validity was evaluated
based on the comments and reflections on each statement by five experts and
four emergency nurses. Next, the items were reviewed and revised following
the experts’ and emergency nurses’ recommendations.
The coefficient alpha (Cronbach’s alpha) was calculated to evaluate the inter-
nal consistency of the instrument (Kimberlin & Winterstein, 2008). A
Cronbach’s alpha value of ≥ 0.70 was regarded as acceptable (DeVon et al.,
2007; Tavakol & Dennick, 2011). The test-retest reliability was assessed by
calculating the intra-class correlation coefficient (ICC) between the two da-
tasets collected over a two-week interval. The ICC measures the degree of the
relationship between measurements in terms of the consistency of absolute
agreement. Thus, an ICC of ≥ 0.70 indicates good stability and correlation
between the first and second measurements (DeVon et al., 2007; Yen & Lo,
2002).
EFA with varimax rotation using principal component analysis as an extrac-
tion method was performed to test the construct validity of the instrument. The
purpose of EFA is to investigate the underlying structure of the pattern of cor-
relations among the observed variables (Tabachnick & Fidell, 2007), reduce
the number of items and emphasise the apparent factors (Fabrigar, Wegener,
MacCallum, & Strahan, 1999). Before EFA, Bartlett’s test of sphericity with
P < 0.05 and the Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy
38
of ≥ 0.6 were performed (Tabachnick & Fidell, 2007). The number of ex-
tracted factors was determined by examining eigenvalues > 1, the scree test
and the Monte Carlo simulation for parallel analysis (DeVellis, 2012; Fabrigar
et al., 1999). The factors were rotated with the orthogonal (varimax) rotation
with Kaiser Normalisation, and the cut-off point for the factor loadings was
0.60 or higher (Hair et al., 2010; Tabachnick & Fidell, 2007). Descriptive sta-
tistics were used to characterise the participants and to evaluate item proper-
ties such as skewness and kurtosis.
CFA was performed to test and confirm the factor structure from EFA. The
adequacy of the CFA model was assessed through fit indices, including chi-
square (χ2), χ2/df, the goodness of fit index (GIF) (Bentler & Bonnett, 1980),
the comparative fit index (CFI) and the root mean square error of approxima-
tion (RMSEA) (Hu & Bentler, 1999). The chi-square statistic should be non-
significant but is also sensitive to sample size (Bentler, 1990). We, therefore,
also used χ2/df, with a cut-off < 3 for minimally acceptable ratios, as suggested
by Kline (1998). A value of 0.9 or greater indicates acceptable fit for a CFA
model in the GFI and CFI (Bentler & Bonnett, 1980). According to the
RMSEA rule of thumb, a value of < 0.08 represents a marginal fit, while a
value of > 0.10 indicates a poor fit (Hu & Bentler, 1999). The final CFA model
was compared with two alternative models to verify the best fit (Hair et al.,
2010; Tabachnick & Fidell, 2007). The Akaike information criterion (AIC)
was used to estimate the quality of each model, and the lowest AIC value was
considered to represent the best model fit (Hu & Bentler, 1999).
Statistical Package for the Social Sciences (SPSS), version 22.0, was used for
the analyses. A p-value < 0.05 was regarded as statistically significant.
Study IV
Participants and setting
The participants and setting in this study were the same as in the validation
phase (phase III) in study III.
Data collection
The data collection and procedure in this study were the same as in the vali-
dation phase (phase III) in study III.
39
Data analysis
Data were analysed using SPSS (Chicago, IL., USA), version 22.0. Descrip-
tive statistics were used to calculate the mean score for each factor in the
SSEN. To investigate the association between sociodemographic variables
and the experience of specific stressors for Thai emergency nurses, multiple
regression analysis with the stepwise method was performed (Kellar & Kel-
vin, 2013). All the sociodemographic variables (independent variables) were
tested with each stressor in the SSEN (dependent variables). Analysis of var-
iance was calculated to test the significance level of model fit, and the regres-
sion coefficient was calculated to describe the influence of sociodemographic
variables on stressors in the SSEN (Kellar & Kelvin, 2013).
Ethical considerations
Studies I and II underwent ethical review by the Regional Ethical Review
Board in Uppsala, Sweden, (Dnr. 2013/087) and the research ethics commit-
tees of the included hospitals in Thailand (IRB/IEC reference 7/2556). For
studies III and IV, ethical approval was granted by the ethics or research com-
mittees of the provincial public heath offices (KB-IRB2016/05.0107) and the
included hospitals in Thailand. The studies were conducted in accordance with
the Helsinki Declaration. Before the interviews, the study aim and the research
design were explained to the participants both verbally and on an information
sheet. Written consent was obtained before the interviews to ensure that the
participants fully understood the study aim and agreed to participate.
The participants were also informed about the right to withdraw from the study
at any time as needed, without giving an explanation. To ensure confidential-
ity, the participants were assigned code numbers used instead of their names
in data analysis (Munhall, 2012; Polit & Beck, 2012). All the questionnaires
were saved and stored in a computer file, which required a username and pass-
word to access the data. As well, the data are reported on a group level.
The author was aware of that during the interviews, the participants might
perceive some questions as uncomfortable. The nurses, therefore, had the right
to not answer any question.
40
FINDINGS
The findings from the four studies reflected Thai emergency nurses’ experi-
ences of occupational stress. The experiences were related to the causes of
stress (stressors), stress reactions and ways of coping with occupational stress.
An instrument that can measure specific stressors for emergency nurses was
developed and validated based on the identified stressors. Sociodemographic
variables influenced the experience of specific stressors among Thai emer-
gency nurses.
Stressors
The stressors for Thai emergency nurses were classified as ED-related stress-
ors and human-related stressors (mentioning later in the dissertation). These
stressors involved the ED environment (i.e. the characteristics of an ED, work
tasks and workload) and organisations’ management system (i.e. rewards sys-
tems and types of compensation).
The findings from the interviews (studies I and II) explored stressors in the
experiences of public- and private-hospital emergency nurses. The major
stressors in public hospitals (study I) were violence in the workplace and
heavy workload. The latter consisted of simultaneously performing many
tasks, including some roles of physicians, while providing nursing care, com-
pleting patient documents and doing another tasks assigned by head nurses.
Due to the characteristics of work in the ED, patients arrive with unpredictable
conditions which may be severe. The public- and private-hospital emergency
nurses (studies I and II) described that they often had to perform immediate
medical procedures, especially while waiting for physicians to attend patients.
In such cases, the participants performed physicians’ roles, instead of the nurs-
ing role. They described this situation as a stressor related to uncontrollable
situations at work.
41
The characteristics of work in the ED were also reported to be a source of
stress in private hospitals (study II). Working in the ED requires providing
urgent nursing care to critically ill patients, so the nurses worked under pres-
sure in unpredictable situations. Multiple work tasks and excessive work hours
were described as stressors, and in particular, tasks beyond the nursing role
made the participants experience high levels of stress.
The organisational management system was identified as a stressor for emer-
gency nurses. The imbalance between the number of nurses and patients was
one factor reported in private hospitals (study II). The private hospital direc-
tors had no plans to hire more emergency nurses, and this resulted in inade-
quate nursing staff to cover shifts and high workload for emergency nurses. In
addition, financial issues were reported to be a cause of stress. In public hos-
pitals, the nurses described an imbalance between workload and income, while
nurses at private hospitals expected to earn more extra pay. These findings
revealed differences in organisational support and stress management between
public and private hospitals.
Multiple perceived consequences of emergency-
department-related stress
The stress reactions found in this dissertation were associated with the emer-
gency nurses’ health and reactions to their workplace and work performance.
The described stressors in the ED contributed to stress reactions related to in-
dividuals’ ill health, including physical, psychological and social dimensions
(work–life conflicts). Stress reactions affected nurses’ performance, resulting
in non-holistic care, misinformation, malpractice, substandard care delivery,
delayed nursing care and reduced ability due to a loss of concentration and
focus.
Uncertainty about resignation was also reported as a reaction to occupational
stress. The nurses in both types of hospitals (studies I and II) stated that they
were considering resigning from their current workplaces. Some indicated that
they might leave private hospitals and work as emergency nurses at public
hospitals instead. Similarly, the nurses at public hospitals stated that they
might leave their jobs and work as emergency nurses at private hospitals in-
stead.
42
Ways of coping with occupational stress
The participants (studies I and II) described coping strategies for occupational
stress in the workplace, including classic avoidance and distraction. In con-
trast, talking and debriefing with their colleagues, head nurses and nurse su-
pervisors recalled the classic mechanism of seeking social support, which was
experienced as the best way to cope with stress at work. In addition to debrief-
ing and avoiding stressful situations, the participants in private hospitals (II)
explained that they turned stress into a challenge and kept thinking positively.
Stress could function as a challenge to overcome, proving individuals’ com-
petency.
Stressor measurement
The results of study III yielded the validated instrument called SSEN, a self-
administered questionnaire for determining the extent to which a situation in
the ED is a stressor for emergency nurses. EFA provided a five-factor solution
that accounted for 58% of the cumulative variance. The model structure re-
sulting from EFA was further analysed and confirmed by CFA. The fit indices
showed that the final model had acceptable fit, and the final CFA model was
compared with two alternative models. The AIC value indicated that four-fac-
tor final model was the best model compared to the two alternative model
solutions (see Table 6). The final CFA results provided a four-factor solution
with 25 items. The factors were life-and-death situations, patients’ and fami-
lies’ actions and reactions, technical and formal support and conflicts.
Cronbach alpha coefficients for the SSEN factors ranged from 0.89 to 0.95.
In this dissertation, stressors related to patients’ and families’ actions and re-
actions were found to be the most important stressors in both public and pri-
vate hospitals. The second most important stressors were related to technical
and formal support, followed by life-and-death situations, and conflicts. Table
7 shows the four factors and examples of the items.
43
Sociodemographic factors and stressors
The instrument developed in study III was used to explore the potential rela-
tionships between socio-economic variables and Thai ED nurses’ experience
of specific stressors (study IV). The sociodemographic backgrounds of the
participating emergency nurses (organisation type, educational level and av-
erage income) were associated with stressors related to life-and-death situa-
tions. Educational level was associated with stressors related to patients’ and
families’ actions and reactions, while sociodemographic variables had no in-
fluence on stressors related to technical and formal support and conflicts.
Table 6. Results of confirmatory factor analysis of the final model and alterna-
tive models.
Model χ2 P χ2/df GFI CFI RMSEA
(CI)
AIC
Four-factor
final model
658.90 0.00 2.49 0.80 0.91 0.08
(0.07–0.09)
658.90
One second-
order factor
678.68 0.00 2.55 0.79 0.91 0.08
(0.07–0.09)
796.68
One general
factor
1503.93 0.00 5.57 0.55 0.74 0.15
(0.14–0.15)
1613.93
GFI = Goodness of fit index; CFI = Comparative fit index; RMSEA = Root
mean square error of approximation; AIC = Akaike information criterion
44
Table 7. Confirmatory factory analysis results for the four-factor solution with factor loadings, ex-
plained variances, Cronbach alpha values of 0.89–0.93 per factor and the mean score of each factor.
Factors Question topic Fac-
tor
load-
ing
Ex-
plained
variance
Cronbach
alpha
Mean (SD)
(n = 205)
n =
200
n =
205
Life-and-death sit-
uations (F1)
0.91 0.91 3.05
(± 0.16)
Cardiopulmonary resusci-
tation
0.88 0.78
Death and dying 0.89 0.79
A patient with a critical
illness
0.84 0.71
Disaster 0.72 0.52
An accident involving
multiple people
0.68 0.46
Suicide attempt
0.77 0.60
Patients’ and fam-
ilies’ actions and
reactions (F2)
0.92 0.93 3.55
(± 0.15)
Encountering verbal as-
sault
0.80 0.64
Witnessing colleagues be-
ing verbally assaulted
0.87 0.75
Witnessing colleagues be-
ing physically assaulted
0.88 0.78
Encountering physical as-
sault
0.83 0.69
High performance de-
mands and expectations
0.82 0.68
Photo and/or video re-
cording posted in a nega-
tive way on social media
0.76 0.58
Lack of understanding of
the triage process
0.65 0.42
Complaints about nursing
performance
0.78 0.61
45
Table 7. Confirmatory factory analysis results for the four-factor solution with factor loadings, ex-
plained variances, Cronbach alpha values of 0.89–0.93 per factor and the mean score of each factor
(continued).
Factors Question topic Fac-
tor
load-
ing
Ex-
plained
variance
Cronbach
alpha
Mean (SD)
(n = 205)
n =
200
n =
205
Technical and for-
mal support (F3)
0.89 0.91 3.29
(± 0.15)
Broken medical equip-
ment
0.78 0.61
Lack of clear policies 0.81 0.65
Lack of necessary medi-
cal equipment
0.80 0.64
Lack of support from
the supervisor or head
nurse
0.81 0.65
Lack of support from
the organisation man-
ager or director
0.80 0.65
Conflicts (F4) 0.91 0.93 2.83
(± 0.35)
Being criticised and/or
blamed by a physician
0.92 0.86
Being criticised and/or
blamed by a nursing col-
league
0.92 0.85
Being criticised and/or
blamed by a supervisor
or head nurse
0.90 0.82
Feeling uncomfortable
with working with a col-
league
0.69 0.47
Having a conflict with
the physician in charge
of a patient
0.83 0.69
Feeling uncomfortable
with working with the
attending physician
0.70 0.49
46
DISCUSSION
Methodological discussion
Studies I and II
A qualitative study design is useful for describing individuals’ experiences
and providing deeper understanding of individuals’ personal experiences
within an area of interest (Holloway & Wheeler, 2010; Munhall, 2012). To
increase the quality of this study, the criteria for trustworthiness described by
Lincoln and Guba (1985), including credibility, dependability, confirmability
and transferability, were applied.
The findings in studies I and II illustrated the experiences of occupational
stress among Thai emergency nurses. The strength of these studies was their
credibility as data were collected from 36 emergency nurses in both public
(n=21) and private (n=15) hospitals in Bangkok, Thailand. The data were di-
verse as the participants were both men and women, with varied educational
levels, emergency care experiences and areas of hospital settings (Holloway
& Wheeler, 2010). Additionally, throughout the data analysis, all the research-
ers repeatedly read and checked the data and discussed the findings to reduce
bias and minimise inconsistencies in the data, thereby improving the depend-
ability and confirmability of the study (Lincoln & Guba, 1985; Holloway &
Wheeler, 2010).
A possible weakness was that the transcripts were translated from Thai into
English by NY. To prevent language barriers in the research, all the interview
data were transcribed verbatim in Thai by the first author, who was a native
speaker of Thai. The transcripts were then read carefully several times and
translated into English by NY, and the English translation was checked and
approved by a professional Thai linguist to prevent language loss in the stud-
ies. This repetition of tasks ensured that the researchers thoroughly reviewed
the transcripts, safeguarding against the risk of translation distortion that often
occurs (Squires, 2009). The small sample size in both studies (studies I and II)
47
makes it difficult to generalise the findings; therefore, the transferability of
these two studies is noted as a limitation (Holloway & Wheeler, 2010).
Study III
In phase II, content and face validity were evaluated by four emergency nurses
and five experts in the field of emergency nursing. Although some of the five
chosen experts had little research experience, and not all were experts in stress
research, they had worked in EDs for a long period of time and were familiar
with the context. To strengthen the face validity of the instrument, four emer-
gency nurses were invited to evaluate it. Face validity pertains to how test
respondents perceive it, so it should be judged by individuals representing the
respondents in question, not by experts in the field (Kimberlin & Winterstein,
2008). To enhance this phase, an alternative is to apply the Delphi technique,
or group communication and discussion among experts with the aim to build
consensus regarding the model, guideline or instrument (Hsu & Standford,
2007). The feedback process in the Delphi technique allows experts to reas-
sess their previous judgements and to consider changing or modifying the text
or statement in the instrument or questionnaire. Modifications can be done
either by individual panel members in the same group or by panel members in
another group (Hsu & Standford, 2007). Applying this technique in the vali-
dation phase of the SSEN made the face validity more rigorous and clear as
the instrument was reassessed several times.
The construct validity of the instrument was tested through EFA with data on
200 emergency nurse participants. Bartlett’s test of sphericity and KMO con-
firmed that sample size was adequate for this test; therefore, the results could
be considered to be reliable (Tabachnick & Fidell, 2007). Although Kaiser’s
(1960) criterion and the parallel analysis using Monte Carlo simulation online
software suggested extracting 6–10 factors, we decided to select only 5 factors
based on the results from the scree test. This was done to avoid overestimated
factor extraction (Tabachnick & Fidell, 2007). As well, a five-factor solution
accounted for 58% of cumulative variance, reaching the recommended com-
mon variance explained (Tinsley & Tinsley, 1987). Other validity testing
methods could have been used, such as concurrent validity, which measures
how well the SSEN compares to a well-established instrument, or predictive
validity, which evaluates stress reactions such as fatigue, burnout, absentee-
ism, work performance and intention to leave the current job. Given the time
constraints of the current study, it was not possible to use these validity tests.
48
Although the 34 items in the SSEN were derived from EFA, some possibly
important items were eliminated as their factor loading values were less than
0.6. The eliminated items (e.g. patients and their relatives cannot make pay-
ments due to hospital policy) may be important stressors for emergency nurses
in private hospitals (study II). This issue may be as fewer private-hospital
nurses than public-hospital nurses (n = 91 of 405) participated in phase III.
Consequently, the cumulative variance in this item was inadequate for running
EFA and caused low factor loading (0.12–0.43). In addition to an adequate
sample size (Tabachnick & Fidell, 2007), therefore, the homogeneity of the
participants should be considered when selecting study participants to prevent
unexpected measurements when performing factor analysis.
CFA provided a final model with a four-factor solution and acceptable values
for most fit indices. Although the covariance between error terms should not
be allowed to co-vary freely (Hair et al., 2010), we allowed some items in our
study to share their covariance as the meaning of the items were similar. Let-
ting error terms co-vary can violate the assumptions of the measurement,
though the fit indices become better. However, in a complex situation such as
the stressful ED setting, it seems realistic that some pairs of items mirrored
other concepts rather than the specific stressors intended; therefore, we did not
think that the assumptions of the measurement were seriously violated (Hair
et al., 2010; Tabachnick & Fidell, 2007). Although the GFI value of the final
model was slightly lower than the cut-off point (0.80), our final model had the
lowest AIC value (658.90) compared to the two alternative models. This result
indicated that the best model solution was found in the current study (Hu &
Bentler, 1999). Cronbach’s alpha values ranged from 0.89 to 0.93 per factor,
and the ICC was 0.89, indicating good homogeneity and stability for the final
25-item instrument (DeVon et al., 2007; Tavakol & Dennick, 2011).
The strength of this study was that the final model of the SSEN was confirmed
by CFA, whereas not all existing instruments have been confirmed by this
method. To the best of our knowledge, only one existing measure of nurses’
stress has been confirmed by this method (Admi, Eilon, Renker, & Unhasuta,
2016). Furthermore, we performed CFA using a separate sample from the
EFA sample.
The limitation of the SSEN was related to its content validity. It was evaluated
by Thai experts and might be validated differently in other contexts, such as
49
Western or East Asia countries. We recommend reassessing the content valid-
ity of the SSEN before using in other contexts.
Study IV
A possible limitation of study IV was the sampling technique. The data in this
study came from the same data set used in study III to develop and validate
the SSEN (Yuwanich et al., 2017a). The data were collected through conven-
ience sampling, which may limit the generalisability of the study results
(Etikan, Musa, & Alkassim, 2016). The small number of nurses working at
the management level should also be taken in consideration when trying to
generalise the results.
Reflections on the results
The results are reflected on and discussed through the theoretical framework
related to health and welfare.
Job demand-control-support model and stress among Thai
emergency nurses
The results in this dissertation describe Thai emergency nurses’ experience of
stress, including stressors, multiple perceived consequences of ED-related
stress and ways to cope with occupational stress. Stressors are a major concern
in this dissertation, and the identified stressors can be discussed based on the
JDCS model. Job demand is considered to be an important stressor in the
model and refers to workload or time pressure. The stressors identified in this
dissertation are related to the workplace (i.e. workload and excessive work
tasks with limited time) and to humans (i.e. conflict with other health care
personnel and disrespect from patients and their relatives). These stressors can
be related to psychological job demand in the JDCS model and can have major
impacts on health and performance outcomes (Häusser et al., 2010; Karasek
& Theorell, 1990). The findings also concern the other two elements in the
JDCS model: job control and social support. Job control is associated with
skill discretion and decision-making authority, and social support at work re-
fers to the overall level of helpful social interactions with either co-workers or
supervisors (Karasek & Theorell, 1990).
50
The emergency nurses in public and private hospitals inevitably encountered
heavy workload under time pressures, and their decision-making authority
was limited although they were fully skilled in nursing care. These factors
were associated with poor job control, particularly low decision-making au-
thority in the workplace. This finding is consistent with the work of Adri-
aenssens et al. (2011) and supports the high strain hypothesis of the JDCS
model, which states that high job demand and low job control lead to psycho-
physiological ill health among employees (Karasek & Theorell, 1990;
Luchman & González-Morales, 2013).
Regarding the support dimension of the JDCS model (Karasek & Theorell,
1990), the emergency nurses in the interview studies (studies I and II) received
support from other emergency nurses, nurse supervisors, ED head nurses and
nurse managers. This support included debriefing and handling stressful situ-
ations and was experienced as efficient stress management. These findings are
consistent with those of Healy and Tyrrell (2013). This experience, therefore,
was not in line with the iso-strain hypothesis that high job demand, low job
control and low social support cause great risk of stress at work (Karasek &
Theorell, 1990). Although the private-hospital managers provided some activ-
ities aimed at relieving stress, the participants commented that it was insuffi-
cient (study II). In contrast, the participants at the public hospitals perceived a
lack of organisational support from hospital directors. These findings could
indicate that private hospitals have different support systems than public hos-
pitals.
The SSEN items (study III) can be related to the JDCS model as they were
partly generated from the results of studies I and II, using a deductive approach
(Munhall, 2012) based on the JDCS model with the aim to explore ED nurses’
experiences of work-related stress. For example, in factor 3, technical and
formal support, the item ‘lack of clear care policy for treating a patient’, re-
flected the job demand dimension, while the item ‘no support from colleagues
in the ED’ reflected the support dimension. However, the SSEN items cannot
display the interactions between each dimension as shown in the JDCS model.
It, therefore, cannot be used to describe strain and the iso-strain hypothesis in
the JDCS model (Karasek & Theorell, 1990).
The sociodemographic backgrounds of the emergency nurses, including or-
ganisation type (public or private), educational level and average income, ap-
peared to have a relationship to the stressors in the SSEN. The participants’
51
sex, age, work position and emergency care experience had no influence on to
what degree they perceived the stressors itemised in the SSEN.
Organisation type (public or private) was associated with stressors related to
life and dead situations. This is in line with a previous study reporting that
nurses working in public and private hospitals have different levels of occu-
pational stress (Nabirye, Brown, Pryor, & Maples, 2011). In other words, the
emergency nurses in both types of organisations (public and private hospitals)
perceived life-and-death situations as occupational stress differently due to
management of trauma and non-trauma patients with critical condition and
other crisis situations (Yuwanich, Akhavan, Nantsupawat, & Martin, 2017b).
The emergency nurses’ educational background was found to be a significant
sociodemographic factor associated with stressors related to patients’ and
families’ actions and reactions. This finding is supported by previous studies
showing that nurses with high educational levels (i.e. master degrees) experi-
ence occupational stress (Nabirye et al., 2011) and exhibit high job strain and
low control at work (Sakkomonsri, Suwan-Ampai, & Kaewboonchoo, 2016;
Trousselard et al., 2016). This dissertation shows that educational level and
work position could be related as most nurses at the management level held
master degrees and primarily dealt with patients and their relatives when prob-
lems occurred. According to the findings from our pervious qualitative study
(Yuwanich et al., 2017b), when patients could not pay for services, the ED
nurses at the practitioner level requested that their nurse supervisors contact
other hospitals where the patients could receive health care services under
their health care scheme. This situation can explain why emergency nurses
who had master degrees and worked at a management level inevitably encoun-
tered stressful situations even as they had to complete their tasks. This finding
is in line with the JDCS model of high job demand and low control (Karasek
& Theorell, 1990).
Human-related stressors
The human-related stressors for emergency nurses involved patients, their rel-
atives and other health care personnel in and outside the ED. Situations in-
volving patients and their relatives were reported to be a common stressor in
the ED. Patients and their relatives’ misunderstanding of triage system was
reported to be a common stressor (studies I and II). However, only the nurses
in private hospitals (study II) described patients and relatives’ behaviour as
related to stress. This finding clarified that patients and their relatives had high
52
demands and expectations as they paid high prices for medical and nursing
services. Sometimes those behaviours had detrimental effects on the nurses.
When exploring the experienced stressors, using the SSEN (study IV), pa-
tients’ and families’ actions and reactions were shown to be the most im-
portant stressor for the participating emergency nurses. This result was sup-
ported by previous studies (Adriaenssens et al. 2015b; Yuwanich et al. 2016).
Some items in this factor, such as encountering verbal assault by patient and/or
their relatives, were related to violence in the ED. Albashtawy (2013) found
that verbal violence was the most common violent event related to stress in
the ED. In addition to patients’ and their relatives’ reactions, patients in critical
and crisis conditions were found to cause stress for nurses at both types of
hospitals.
Another human-related stressor was conflicts among emergency nurses and
other health care personnel in either the ED or other departments (studies I
and II). The most common stressful situation related to conflict that the nurses
experienced as a stressor was nurse–physician conflict which also has been
described in previous studies (Hamdan et al., 2017; Happell et al., 2013; Healy
& Tyrrell, 2011). Interestingly, the results from stressor measurement using
the SSEN showed that conflict was found to be the lowest significant stressor
for the emergency nurses (study IV).
Occupational stress related to health and welfare
The findings showed that stressors at the ED affected Thai emergency nurses,
leading to several reactions. The stressors found were in line with the general
definition of stressor as factors or events that threaten individuals’ health or
diminish normal functioning (Pacák & Palkovits, 2001). Furthermore, the
stressors found were in accordance with Selye (1975) and Lazarus (2006),
who viewed stressors as environmental stimuli with the potential to causes
stress to individuals. The stress caused by environmental stimulus can be de-
scribed through the JDCS model. It posits that stress at work (job strain) is
caused by the interaction of high levels of job demands (e.g. too many work
tasks under time limit) and low control (e.g., the inability to make any deci-
sions at work) (Karasek, 1979). In this dissertation, occupational stress had
impacts on emergency nurses’ psychophysiological health. This experience is
in line with the JDCS model, which holds that the interaction between high
job demand and low control at work impairs workers’ health (Karasek & The-
orell, 1990; Luchman & González-Morales, 2013).
53
Although the JDCS model supports that job strain affects emergency nurses’
psychophysiological health, the pathway or mechanism of health impairment
cannot be described through this model. The imbalance of job demand and job
control, though, results in environmental stressors, which can be viewed as
environmental stimulus, and can cause stress when appraised as a threat to
personal health and well-being (Lazarus & Folkman, 1984). A possible way
to describe stress-related health impairment is to discuss it from the physio-
logical perspective. Stimuli that occur at work have the potential to induce the
neural and hormonal pathways and lead to physical and psychological re-
sponses (Bamber, 2007; Stratakis & Chrousos, 1995). These responses ex-
plain why the emergency nurses in this dissertation had psychophysiological
ill health related to occupational stress.
In addition to psychophysiological ill health, the stress experiences found in
this dissertation indicated work–life conflict resulting from occupational
stress. This finding supported results from previous studies showing that oc-
cupational stress affects individual health, families and society (Mohajan,
2012; Sauter et al., 2009).
It is clear that occupational stress affects Thai emergency nurses’ health, but
health is a broad concept, and its definition has changed over time. To describe
emergency nurses’ health related to occupational stress, a suitable concept of
health is needed. The most widely used health concept is the WHO’s (1948)
definition of health as a state of complete physical, mental and social well-
being. However, using this health concept to describe the emergency nurses’
health related to occupational stress in this dissertation appeared to be impos-
sible as the possible completeness of those elements contrasted with the find-
ings. From this perspective, it may appear that the emergency nurses had only
poor health.
Another health concept from Antonovsky’s (1996) salutogenic model is con-
sidered. This concept focuses on the sense of coherence (SOC) and the ability
to use resources to create one’s own health in a crisis situation or condition
(Antonovsky, 1996). Turning to the findings, the emergency nurses reflected
that they experienced health impairment related to occupational stress but at-
tempted to find some resources to maintain their health and ability to work in
the ED. Support from talking with and debriefing colleagues, head nurses and
nurse supervisors was described as a coping strategy by the emergency nurses.
This coping strategy was experienced as effective stress management, as de-
scribed by Healy and Tyrrell (2013), and was related to the available resources
54
in the salutogenic model (Antonovsky, 1996). Based on the assumptions of
the salutogenic model, this coping strategy can be viewed as a resource that
helped increase the nurses’ SOC with aim to defend against any factor that
damaged health (Lindström & Eriksson, 2006). It can be explained as the
emergency nurses’ attempt to maintain their health while working in a stress-
ful workplace by using the available resource to cope with occupational stress.
This discourse accords with a previous study finding that health care students
reported high levels of SOC when using active coping and indicated enjoying
a good health education environment (Gambetta-Tessini, Mariño, Morgan, &
Anderson, 2016).
The occupational stress found among Thai emergency nurses in this disserta-
tion was caused health impairment and work–life conflicts, which were related
to negative stress or distress, as described by Selye (1975). Moreover, we
found that occupational stress in the ED contributed to negative work-related
responses, including poor nursing care performance and uncertainty concern-
ing resignation from one’s current nursing job. These negative responses are
congruent with previous studies (Kirwan et al., 2013; Kwak, Chung, Xu, &
Ean-Jung, 2010; Verrall et al., 2015) and may be related to a shortage of emer-
gency nurses (Sawatzky & Enns, 2012). The nurses’ negative work-related
responses may influence Thai health care system by resulting in an inadequate
health workforce and poor-quality health services. This situation may indicate
that the nurse shortage in Thailand will become worse in the future as at pre-
sent, the nursing profession has approximately 43,250 empty positions (Sri-
suphan & Sawaengdee, 2012). Moreover, the negative responses to stress
were related to poor-quality nursing care in both types of hospitals. Stress-
related excessive work tasks and high workload among nurses, in particular,
led to non-holistic care, misinformation, malpractice and substandard perfor-
mances, which can all cause low patient safety (Kirwan et al., 2013; Verrall et
al., 2015).
In stress appraisal and coping, individuals who perceive stress try to find ways
to cope with it (Lazarus & Folkman, 1984). This dissertation also found that
the nurses used coping strategies to alleviate occupational stress. Nurses who
encountered stressful situations walked away from them in the coping method
called avoidance (Healy & McKay, 2000). However, the nurses discussed that
after they walked away from these stressful situations at work, they returned
to face the situations and solve the problems. This problem solving in our
55
findings was congruent with previous research finding that nurses’ coping pat-
tern includes seeking support, problem solving and self-control (Lim, Bogos-
sian, & Ahern, 2010). This coping pattern was also described as emotion- and
problem-focused coping (Folkman & Lazarus, 1980; Lazarus, 2006). Alt-
hough emotion-focused coping is used initially, individuals tend to employ
both forms of coping to deal with stressful encounter (Folkman & Lazarus,
1991). Accordingly, the emergency nurses ultimately adopted problem-fo-
cused coping to handle stress. These findings are supported by previous stud-
ies reporting that the most frequently used coping methods among nurses are
problem-focused (Lim et al., 2010; Ashker, Penprase, & Salman, 2012).
Interestingly, the findings from study II revealed another coping strategy: a
positive reaction to occupational stress. The emergency nurse participants de-
scribed that when they encountered stressful situations at work, they turned
stress into a challenge, viewing it as an opportunity to demonstrate profes-
sional competence. This different reaction to stress was described by Selye
(1975), who stated that individuals’ reactions to stress differ according to their
adaptation to the stressor. This reaction by nurses is a positive reaction to
stress, or eustress (Lim et al., 2010), which has rarely been found in research
on nurses’ stress. This finding could be a contribution of new knowledge from
this study.
Karasek and Theorell (1990) adopted a different viewpoint regarding positive
stress–response than Selye’s GAS model (Selye, 1975). The JDCS model
shows that even amid high job demands, workers have the ability to control
or make decisions at work and seek good support, which can lead to active
learning at work (Karasek & Theorell, 1990). Thus, it can be presumed that
nurses in private hospitals (study II) may have good support from colleagues
and supervisors and a level of job control to buffer job demand and react pos-
itively to stress.
56
CONCLUSIONS
Emergency nurses in Thai private and public hospitals frequently experienced
occupational stress, and these experiences could be described through the
JDCS model. Heavy workload, delayed admissions to other departments, dif-
ficulties working in multidisciplinary contexts and problems related to pa-
tients and their relatives were reported as stressors. The similarities of the oc-
cupational stressors experienced by the emergency nurses at both types of hos-
pitals may be related to the nature of the ED.
Unlike the nurses in public hospitals, the nurses in private hospitals did not
experience violence at the ED and complained less about low salaries. How-
ever, private-hospital nurses described patients’ and their relatives’ frustration
and dissatisfaction with not receiving the care and emergency medical services
for which they paid dearly for as the main stressors, which could lead to ethical
dilemmas for nurses. Although the Ministry of Public Health has launched the
UCEP policy to solve payment problems for emergency care services in pri-
vate hospitals, some private hospitals have not adopted this policy. Conse-
quently, emergency nurses in these private hospitals still inevitably encoun-
tered this ethical dilemma. Disrespect from patients and their relatives was
also a stressor not encountered in public-hospital settings.
The responses to and consequences of stress among emergency nurses were
similar, including psychophysiological ill health, consideration of leaving
one’s current emergency nursing job and reduced quality of nursing care.
However, only nurses at private hospitals felt positively challenged and en-
couraged by certain stressful situations. This positive response to stress has
rarely been found among nurses and is new knowledge contributed by this
dissertation.
Emergency nurses in both types of hospitals mostly received support from
close colleagues, head nurses and nurse supervisors. Organisational support
was not present in public hospitals but was reported to be present to a degree
57
in private hospitals. Similarly, the nurses desired additional support, espe-
cially financial support (e.g. extra payment for specific competences) as com-
pensation for stressful work. The difference in the nurses’ experiences of sup-
port may be due to differences in the two type hospitals’ management systems,
rewards and compensation.
The empirical knowledge from the two qualitative studies was useful and con-
tributed practical knowledge, such as the development of a new instrument
(study III). The further measurement by using the new instrument provided
evidence that the stressors related to patients’ and families’ actions and reac-
tions were the most important stressors for the participating emergency nurses.
Furthermore, sociodemographic factors were important influences on the spe-
cific stressor for Thai ED nurses (IV).
The specific instrument to measure stressors among emergency nurses devel-
oped in this dissertation is a new contribution to the knowledge of stressors in
EDs. The comparison of private and public hospitals contributes to better un-
derstanding of the experience of occupational stress among Thai emergency
nurses.
58
FUTURE RESEARCH
Patient safety should be further studied to understand both emergency nurses’
and patients’ perspectives regarding the consequences of occupational stress
for patient safety. Different perspectives may create a knowledge base which
can be used to develop guidelines or protocols aimed at reducing nurses’ stress
and preventing its consequence, such as low patient safety. As well, positive
stress in nurses’ workplace needs to be further explored, particularly how it
affect nurses’ health and caring performance.
The SSEN is intended to identify stressors for emergency nurses so that they
can be addressed, and the work environment or situation modified. To evalu-
ate changes in perceived stressors, the predictive validity of the SSEN for
stress reactions (e.g. fatigue, burnout, absenteeism, work performance and in-
tention to leave one’s current job) should be evaluated.
59
IMPLICATIONS
The results from studies I and II can be useful and beneficial for public and
private hospitals to develop stress management programmes and policies and
guideline procedures related to the prevention and management of occupa-
tional stress for emergency nurses. This could reduce stress and support emer-
gency nurses in appropriate ways. The current studies (studies I and II)
demonstrate that emergency nurses work in a stressful environment. This en-
vironment affects the job characteristics in the ED, which are important deter-
minants of occupational stress and have health-related and organisational con-
sequences. Managing the work environment thus may tend to diminish stress
and prevent ill health related to occupational stress.
Patients’ and their relatives’ misunderstandings of the triage system in the ED
are another major stressor identified in the studies. To reduce misunderstand-
ings, information about the triage system should be developed and distributed
to patients and their relatives. Such information could not only diminish mis-
understanding, but we believe that it could also increase patients’ satisfaction.
Healy and Tyrrell (2013) reported that debriefing is important to reduce occu-
pational stress for nurses in the ED. The results in studies I and II also show
that debriefing by colleagues and supervisors can reduce the experience of
stress in the ED. Consequently, the development of debriefing programmes
may be useful to manage occupational stress in the ED.
The interview studies (studies I and II) identify the consequences of occupa-
tional stress among ED nurses, particularly feelings of uncertainty about
whether to leave or continue working at their current workplace or to leave
the profession. These can lead to higher turnover and shortages of ED nurses.
We, therefore, suggest that policymakers, as well as organisations in both the
public and the private sectors, take greater responsibility for work-related
stress by attempting to reduce the causes of stress and to provide employees
with appropriate support. As the nurses in the study (II) suggested, organisa-
tions should consider increasing the nursing staff to create a better balance
between the number of patients and nurses. Doing so may reduce workload,
60
mitigate the cause of stress and ultimately prevent nurses from leaving their
jobs. The study findings may be beneficial for developing and implementing
policies and guidelines to prevent and manage occupational stress in the ED.
For example, policies regarding work task should be created or revised to reg-
ulate emergency nurses’ assigned tasks and to ensure their right to choose to
perform only nursing care tasks and not other tasks outside nursing care. We
believe that such policies could reduce the multiple tasks among emergency
nurses and ultimately prevent the cause of stress.
The SSEN (studies III and IV) developed to measure specific stressors for
emergency nurses can be used by organisations and researchers. The instru-
ment is useful for emergency head nurses, nurse managers and hospital direc-
tors to identify the current stressors in the ED in their organisations. The meas-
urement results can be used to discuss and plan to reduce stressors for emer-
gency nurses. Together with the predictors in study IV, it should be taken into
account when planning and providing stress management in the workplace.
61
ACKNOWLEDGEMENTS
First and foremost, I thank all the emergency nurses who willingly participated
in these studies and shared their experiences with me. Without their participa-
tion and contributions, no valuable knowledge could be generated by this dis-
sertation.
I express my deep appreciation to Mälardalen University, Sweden, and Rang-
sit University, Thailand, for giving me the greatest opportunity in my life to
become a PhD student. I also thank Assistant Professor Ampaporn Nam-
wongprom, dean of School of Nursing Science, Rangsit University, Thailand,
for giving me precious suggestions and support throughout my PhD journey.
I genuinely express deep thankfulness and gratitude to my principal supervi-
sor, Professor Lene Martin, for all her support, valuable instruction, intellec-
tual guidance and kindness. She is my role model of a great researcher, and
all of these great experiences will remain in my memory forever.
I wish to thank my co-supervisors, Associate Professor Sharareh Akhavan and
Associate Professor Walaiporn Nantsupawat, who encouraged me to apply to
participate in a doctoral programme and who gave devoted work and construc-
tive guidance throughout this dissertation. I again thank all of my supervisors
for encouraging and empowering me to trust in myself, be independent and be
more confident. As a researcher, I feel privileged to have had all of you to rely
on during my studies.
I thank Dr Maria Sandborgh and Associate Professor Magnus Elfström for
precious suggestions, reflections, discussions and support during the develop-
ment of the new instrument and psychometric properties test. Of course, these
were difficult tasks, but with their help and support, I learned many new things
and am now confident in calling myself a ‘psychometric guy’.
62
I extend my deepest gratitude to Professor Bengt Fridlund and Associate Pro-
fessor Kerstin Isaksson for critical discussions at the midway reviews; Profes-
sor Margareta Asp for interesting discussions during PhD seminars; and Pro-
fessor Henrik Eriksson for critical conversations at the final review.
I thank Ratree Tong-Yu and Kim, who helped collect data in studies III and
IV; and Dr Manaporn Chatchumni, a nursing researcher at Rangsit University,
and Nattakit Papatijaturon, a statistician at the Office of Disease Prevention
and Control 2, Phitsanulok Thailand, who checked and confirmed the statistic
results of study IV. I also thank my precious Swedish classmates, Dr Rose-
Marie Johansson-Pajala, Dr Annelie Gusdal, Lena Talman, Camilla Remsten,
Calorine Eklund, Maria Elvén, Maria Norfjord van Zyl, Charlotta Åkerlind,
Dr Anna-Karin Andersson, Dr Anna Stålberg, Sylvia Olsson and those whom
I forgot to mention here for all their support. I express my sincere gratitude to
Dr Atcharawadee Sriyasak, Dr Jiraporn Choowong, Dr Pornpun Manasus-
chakul and Weerati Pongthippat (Vicky) for kindly supporting and assisting
in data collection. I also thank Dr Kulnaree Hanpatchaiyakul and Anchalee
Titasan for their support and kindness.
I am grateful to all my Swedish friends and family for their friendship and
support while making me feel at home in Sweden. Thank you, Carl-Johan
Kruse, Anna-Louise Kruse, Ola Persson, Maria Persson, Calse F Persson, Jes-
sica Ho, Peter Larsson, Elisabeth Buck, Zentti Bittait, Grisen and Andrew and
those whom I forgot to mention here. I thank Pheerawat, Krisanupat,
Nathamon, Phatcharapron, Narumon, Mahunnop, Ploynapas and Metinee for
their friendship and great support from Thailand during my PhD journey.
Most importantly, I express my deepest love and gratitude to my mother and
my family for giving unconditional love and always being beside me along
the journey. I hope that my grandpa can read this dissertation from some-
where. I am sure that he would be proud of me. Lastly, all the greatest experi-
ences that I gained during my PhD journey and my life in Sweden will always
be remembered.
63
SAMMANFATTNING PÅ SVENSKA
Syftet med denna avhandling är att identifiera stressorer hos thailändska akut-
sjuksköterskor och att utveckla och validera ett instrument för att mäta speci-
fika stressorer för akutsjuksköterskor.
Avhandling består av fyra studier, två kvalitativa och två kvantitativa. Data är
baserade på individuella intervjuer (studie I, II) och tvärsnitts- och korrelat-
ionsstudier (studie III, IV). För att få en djupare förståelse om arbetsrelaterad
stress bland akutsköterskor användes en beskrivande kvalitativ design med
semi-strukturerade intervjuer (studie I, II). Tjugoen akutsköterskor på ett of-
fentligt sjukhus och 15 från två privata sjukhus i Bangkok, Thailand, intervju-
ades. De transkriberade intervjuerna analyserades med hjälp av innehållsana-
lys och resultaten sammanfattades i tre huvudkategorier, akutavdelningsrela-
terade stressorer, person-relaterade stressorer och ett flertal stressorer, till följd
av verksamheten på akutavdelningar.
Akutsjuksköterskor på både privata och offentliga sjukhus (studie I och II)
upplevde ofta arbetsrelaterad stress, som påverkade deras psykofysiologiska
hälsa och orsakade brister i omvårdnaden av patienter. Likheten mellan ar-
betsrelaterade stressorer, som akutsköterskorna upplevde på båda typerna av
sjukhus, kan förklaras av akutavdelningarnas speciella verksamhet. Skillna-
derna i sjuksköterskornas erfarenheter av arbetsrelaterad stress och organisat-
ionsstöd kan bero på skillnader mellan de offentliga och privata sjukhusen i
ledningssystem, belöningssystem och form av ersättning.
Så vitt vi vet finns det inte något validerat instrument för att mäta stressorer
på akutsjuksköterskor arbetsplatser. Därför utvecklades och validerades ett
nytt instrument (studie III). Metoderna i denna studie bestod av tre faser, 1)
generering och kategorisering av frågor 2) innehålls och ytaanalys och repe-
terbarhet och övergripande giltighet, samt 3) utvärdering av instrumentets in-
terna konsistens och begreppsvaliditet. För den explorativa faktoranalysen
(med varimaxrotation) användes svaren från 200 akutsköterskor. Trettioen
faktorer med faktorvikt > 0,60 i den explorativa faktoranalysen testades vidare
med konfirmatorisk faktoranalys av svaren från 205 akutsköterskor.
Cronbach’s alpha-värden och intra-class koefficienter beräknades. Den explo-
rativa faktoranalysen gav en fem-faktorslösning och den konfirmatoriska fak-
toranalysen gav en slutlig fyra-faktorslösning med 25 kategorier fördelade på
64
faktorerna Liv- och dödsituationer, Patientens och familjens handlingar och
reaktioner, Tekniskt och formellt stöd och Konflikter. Cronbach’s alfa-vär-
dena varierade mellan 0,89 - 0,93 per faktor och korrelationskoefficienten var
0,89, vilket indikerar god homogenitet och stabilitet.
I den sista studien användes instrumentet för att undersöka i vilken utsträck-
ning sociodemografiska variabler påverkar upplevelsen av specifika stressorer
för thailändska akutsköterskor (studie IV). Organisation, utbildningsnivå och
genomsnittlig inkomst var förknippade med stressorer relaterade till Livs- och
dödssituationer. Stressorer relaterad till Patienternas och familjernas hand-
lingar och reaktioner samvarierade med utbildningsnivå. Sociodemografiska
variabler hade ingen påverkan på stressorer i samband med tekniskt och for-
mellt stöd resp. konflikter.
Fortsatt forskning kring patientsäkerhet på akutmottagningar bör fokusera
både på akutsjuksköterskans och patientens perspektiv med beaktande av kon-
sekvenserna av arbetsrelaterad stress på patientsäkerheten. Olika perspektiv
kan skapa en kunskapsbas som kan bidra till utvecklandet av riktlinjer med
syfte att minska stress hos akutsjuksköterskor och förebygga dess konsekven-
ser, såsom låg patientsäkerhet. Den positiva stressen på akutsjuksköterskornas
arbetsplats behöver ytterligare undersökas med avseende på hur det påverkar
sjuksköterskornas hälsa och omvårdnad.
Nyckelord: akutsköterskor, arbetsrelaterad stress, frågeformulär, privata
sjukhus, offentliga sjukhus, instrumentutveckling, validering.
65
SUMMARY IN THAI
บทคดยอภาษาไทย
ดษฎนพนธนมวตถประสงคเพอศกษาปจจยทท าใหเกดความเครยดของพยาบาลทปฏบตงาน
ณ แผนกอบตเหตและฉกเฉนในประเทศไทย และเพอพฒนาและตรวจสอบเครองมอวจยทใช
ในการวดปจจยทท าใหเกดความเครยดทเฉพาะส าหรบพยาบาลทปฏบตงาน ณ แผนก
อบตเหตและฉกเฉน ดษฎนพนธเลมนประกอบดวยการศกษาวจยเชงคณภาพสองเรองและ
การศกษาวจยเชงปรมาณสองเรอง ขอมลทใชในการศกษาดงกลาวไดมาจากการสมภาษณ
สวนบคคลโดยใชค าถามปลายเปด (การศกษาท 1 และ 2) และจากการศกษาแบบภาคตดขวาง
และการศกษาแบบหาความสมพนธ (การศกษาท 3 และ 4) ในการศกษาท 1 และ 2 ผวจย
ท าการศกษาโดยใชวจยเชงคณภาพแบบพรรณนา เกบขอมลโดยการสมภาษณดวยค าถาม
แบบกงโครงสรางโดยมวตถประสงคเพอใหไดขอมลเชงลกเกยวกบความเครยดของพยาบาล
ทปฏบตงาน ณ แผนกอบตเหตและฉกเฉน กลมตวอยางทสมภาษณประกอบไปดวยพยาบาล
ทปฏบตงาน ณ แผนกอบตเหตและฉกเฉนในโรงพยาบาลรฐบาลจ านวน 21 คน โรงพยาบาล
เอกชนจ านวน 15 คน ผวจยใชการวเคราะหเนอหาในการวเคราะหขอมลทไดจากการ
สมภาษณเชงลก ผลจากการวเคราะหขอมลประกอบไปดวยสามองคประกอบหลกดงน 1)
ปจจยทเกยวของทท าใหเกดความเครยดในแผนกอบตเหตและฉกเฉน 2) ปจจยทเกยวของท
กอใหเกดความเครยดในระดบบคคล และ 3) การรบรเกยวกบผลกระทบของปจจยท
กอใหเกดความเครยดทเกยวของในแผนกอบตเหตและฉกเฉน ผลการวจยพบวาพยาบาลท
ปฏบตงาน ณ แผนกอบตเหตและฉกเฉน ทงในโรงพยาบาลรฐบาลและโรงพยาบาลเอกชนม
ประสบการณทเกยวของกบความเครยดในทท างาน ซงความเครยดนนสงผลกระทบตอ
สขภาพกายและสขภาพจต ซงสงผลตอความพรองในปฏบตการพยาบาล นอกจากนพบวา
พยาบาลทปฏบตงาน ณ แผนกอบตเหตและฉกเฉน ทงในโรงพยาบาลรฐบาลและ
66
โรงพยาบาลเอกชนมประสบการณความเครยดทคลายคลงกน อาจจะเกดจากลกษณะการ
ใหบรการของแผนกอบตเหตและฉกเฉน สวนประสบการณทมความแตกตางกนในดาน
ความเครยดและการสนบสนนจากองคกร อาจจะเปนผลมาจากระบบการจดการขององคกร
การใหรางวลเพอเปนแรงจงใจ และการจายเงนทดแทนทแตกตางกนระหวางโรงพยาบาล
รฐบาลและโรงพยาบาลเอกชน
จากการทบทวนวรรณกรรมทเกยวของพบวายงไมมเครองมอส าหรบประเมนปจจยท
กอใหเกดความเครยดของพยาบาลทปฏบตงาน ณ แผนกอบตเหตและฉกเฉน ดงนนใน
การศกษาท 3 ผวจยจงไดพฒนาและทดสอบคณภาพเครองมอเพอประเมนปจจยทกอใหเกด
ความเครยด โดยประกอบไปดวยขนตอนดงน 1) การสรางขอค าถาม 2) การตรวจสอบความ
เทยงตรงตามเนอหา ความเทยงตรงทปรากฏภายนอกและความคงทของเครองมอวจยซงใช
วธการทดสอบซ า และ 3) การประเมนคาความเชอมนของเครองมอวจยจากการวเคราะห
ความสอดคลองภายในเนอหาและการวเคราะหเชงโครงสราง โดยผวจยไดท าการวเคราะห
องคประกอบเชงส ารวจและหมนแกนโดยวธเนนการเปลยนสดมภจากขอมล 200 ชดจากการ
ตอบแบบสอบถามของพยาบาลทปฏบตงาน ณ แผนกอบตเหตและฉกเฉน จากผลการ
วเคราะหดงกลาวท าใหเหลอขอค าถามทงหมดทมคาน าหนกองคประกอบมากกวา 0.6
จ านวน 31 ขอและไดท าการวเคราะหเพมเตมโดยวธการวเคราะหองคประกอบเชงยนยนจาก
ขอมล 205 ชดทไดจากการตอบแบบสอบถามของพยาบาลทปฏบตงาน ณ แผนกอบตเหต
และฉกเฉน จากการวเคราะหองคประกอบเชงส ารวจท าใหไดองคประกอบทงสน 5
องคประกอบ สวนผลจากการวเคราะหองคประกอบเชงยนยนท าใหไดองคประกอบทงหมด
4 องคประกอบ โดยประกอบไปดวย 25 ขอค าถามซงแบงเปน องคประกอบทเกยวของกบ
สถานการณทเกยวของกบความเปนและความตาย องคประกอบทเกยวของกบการกระท าและ
การแสดงพฤตกรรมของผปวยและญาต องคประกอบทเกยวของกบการสนบสนนทางดาน
เทคนคและทางการสนบสนนอยางเปนทางการ และองคประกอบทเกยวของกบความขดแยง
นอกจากนผวจยยงไดทดสอบคาสมประสทธแอลฟาและคาความเชอมนของเครองมอวจย
โดยการทดสอบซ าซงพบวาคาสมประสทธแอลฟาอยระหวาง 0.89 ถง 0.93 ตอองคประกอบ
67
คา Intra-class Correlation Coefficient (ICC) มคาเทากบ 0.89 แสดงใหเหนวาเครองมอวจย
ใชวดปจจยทท าใหเกดความเครยดตอพยาบาลในแผนกอบตเหตและฉกเฉนมคาความเชอมน
อยในเกณฑดมาก
เครองมอวจยทพฒนาขนใหมในการศกษาท 3 ไดถกน ามาใชในการศกษาท 4 โดยม
วตถประสงคเพอศกษาปจจยสวนบคคลตอการรบรถงปจจยทกอใหเกดความเครยดท
เฉพาะเจาะจงของพยาบาลทปฏบตงาน ณ แผนกอบตเหตและฉกเฉนในประเทศไทย จากผล
การศกษาพบวาลกษณะขององคกร ระดบการศกษา และรายไดเฉลยมความสมพนธกบปจจย
ทท าใหเกดความเครยดทเกยวของกบความเปนและความตาย สวนระดบการศกษาเปนปจจย
ท านายของปจจยทท าใหเกดความเครยดทเกยวของกบการกระท าและการแสดงพฤตกรรม
ของผปวยและญาต ในขณะทปจจยสวนบคคลไมมผลใดๆตอองคประกอบทเกยวของกบการ
สนบสนนทางดานเทคนคและการสนบสนนอยางเปนทางการ และองคประกอบทเกยวของ
กบความขดแยง
การศกษาในอนาคตทเกยวของกบความปลอดภยของผปวยควรมงเนนถงมมมองจากตว
ผปวยเองและพยาบาล โดยศกษาถงผลกระทบจากความเครยดในทท างานซงจะสงผลตอ
ความปลอดภยของผปวย ทงนมมมองทหลากหลายอาจน าไปสการสรางองคความร ท
สามารถน าไปสรางและพฒนาแนวทางการปฏบตเพอลดความเครยดในพยาบาล และปองกน
ผลกระทบจากความเครยดซงอาจจะสงผลตอผปวย เชน ความปลอดภยของผปวย ใน
ขณะเดยวกนผวจยแนะน าวาควรท าการศกษาเพมเตมในเรองของความเครยดเชงบวกทสงผล
กระทบตอสขภาพและการพยาบาล ส าหรบพยาบาลทปฏบตงาน ณ แผนกอบตเหตและ
ฉกเฉน
ค าส าคญ: พยาบาลแผนกอบตเหตและฉกเฉน ความเครยดในทท างาน แบบสอบถาม
โรงพยาบาลรฐบาล โรงพยาบาลเอกชน การพฒนาเครองมอวจย การตรวจสอบเครองมอวจย
68
REFERENCES
AbuAlRub, R. F. (2004). Job stress, job performance, and social support
among hospital nurses. Journal of Nursing Scholarship, 36(1), 73–
78. doi:10.1111/j.1547-5069.2004.04016.x
Admi, H., Eilon, Y., Renker, P., & Unhasuta, K. (2016). Stress measurement
among charge nurses: Developing a cross-cultural tool. Journal of
Advanced Nursing, 72(4), 926–935. doi:10.1111/jan.12845
Adriaenssens, J., De Gucht, V., & Maes, S. (2015a). Causes and conse-
quences of occupational stress in emergency nurses, a longitudinal
study. Journal of Nursing Management, 23(3), 346–358.
doi:10.1111/jonm.12138
Adriaenssens, J., De Gucht, V., & Maes, S. (2015b). Determinants and prev-
alence of burnout in emergency nurses: A systematic review of 25
years of research. International Journal of Nursing Studies, 52(2),
649–661. doi:10.1016/j.ijnurstu.2014.11.004
Adriaenssens, J., De Gucht, V., Van Der Doef, M., & Maes, S. (2011). Ex-
ploring the burden of emergency care: Predictors of stress-health
outcomes in emergency nurses. Journal of Advanced Nursing,
67(6), 1317–1328. doi:10.1111/j.1365-2648.2010.05599.x
Albashtawy, M. (2013). Workplace violence against nurses in emergency
departments in Jordan. International Nursing Review, 60(4), 550–
555. doi:10.1111/inr.12059
Antonovsky, A. (1996). The salutogenic model as a theory to guide health
promotion. Health Promotion International, 11(1), 11–18.
doi:10.1093/heapro/11.1.11
Ashker, V. E., Penprase, B., & Salman, A. (2012). Work-related emotional
stressors and coping strategies that affect the well-being of nurses
working in hemodialysis units. Nephrology Nursing Journal, 39(3),
231–236.
Bae, S. H., & Fabry, D. (2014). Assessing the relationships between nurse
work hours/overtime and nurse and patient outcomes: Systematic lit-
erature review. Nursing Outlook, 62(2), 138–156. doi:10.1016/j.out-
look.2013.10.009
Bamber, M. R. (2007). CBT for occupational stress in health professionals:
Introducing a schema-focused approach. New York, NY:
Routledge.
Bartlett, D. (1998). Stress perspectives and process. Philadelphia, PA: Open
University Press.
69
Beheshtifar, M., & Nazarian, R. (2013). Role of occupational stress in organ-
izations. Interdisciplinary Journal of Contemporary Research in
Business, 4(9), 648–657.
Bennett, S., & Tangcharoensathien, V. (1994). A shrinking state? Politics,
economics and private health care in Thailand. Public Administra-
tion and Development, 14(1), 1–17. doi:10.1002/pad.4230140101
Bentler, P. M. (1990). Comparative fit indexes in structural models. Psycho-
logical Bulletin, 107(2), 238–246. doi:10.1037/0033-
2909.107.2.238
Bentler, P. M., & Bonett, D. G. (1980). Significance tests and goodness of fit
in the analysis of covariance structures. Psychological Bulletin,
88(3), 588–606. doi:10.1037/0033-2909.88.3.588
Berkelmans, A., Burton, D., Page, K., & Worrall-Cater, L. (2011). Regis-
tered nurses’ smoking behaviors and their attitudes to personal ces-
sation. Journal of Advanced Nursing, 67(7), 1580–1590.
doi:10.1111/j.1365-2648.2010.05592.x
Boslaugh, S. (2013). Health care systems around the world: A comparative
guide. Thousand Oaks, CA: Sage.
Bureau of Policy and Strategy. (2011). Public health statistics: Hospital and
medical establishments with beds by type of administration, 2006–
2010. Retrieved from http://bps.moph.go.th/sites/de-
fault/files/moph_stat_54_3.1.pdf
Cartwright, S., & Cooper, C. (1997). Managing workplace stress. Thousand
Oaks, CA: Sage.
Castledine, G, & Close, A. (2010). Oxford handbook of adult nursing. New
York, NY: Oxford University Press.
Chan, E. A., Jones, A., & Wong, K. (2013). The relationships between com-
munication, care and time are intertwined: A narrative inquiry ex-
ploring the impact of time on registered nurses’ work. Journal of
Advanced Nursing, 69(9), 2020–2029. doi:10.1111/jan.12064
Chandola, T., Brunner, E., & Marmot, M. (2006). Chronic stress at work and
the metabolic syndrome: Prospective study. BMJ, 332(7540), 521–
525. doi:10.1136/bmj.38693.435301.80
Choi, B., Östergren, P-O., Canivet, C., Moghadassi, M., Lindeberg, S., Kara-
sek, R., & Isacsson, S-O. (2011). Synergistic interaction effect be-
tween job control and social support at work on general psycholog-
ical distress. International Archives of Occupational and Environ-
mental Health, 84(1), 77–89. doi:10.1007/s00420-010-0554-y
Cook, D. A., & Beckman, T. J. (2006). Current concepts in validity and reli-
ability for psychometric instruments: Theory and application.
American Journal of Medicine, 119(2), 166.e7–166.e16.
doi:10.1016/j.amjmed.2005.10.036
Cooper, C.L., Dewe, P.J., & O’Driscoll, M.P. (2001). Organizational stress:
A review and critique of theory, research and applications. Cali-
fornia: Sage Publications.
70
Cropley, S. (2015). Nursing fatigue: Avoiding patient safety risks. Texas
Board of Nursing Bulletin, 46(2), 1–7.
Croskerry, P., Cosby, K. S., Schenkel, S. M., & Wears, R. L. (2009). Patient
safety in emergency medicine. Philadelphia, PA: Lippincott Wil-
liams & Wilkins.
Davis, K., Drey, N., & Gould, D. (2009). What are scoping studies? A re-
view of the nursing literature. International Journal of Nursing
Studies, 46(10), 1386–1400. doi:10.1016/j.ijnurstu.2009.02.010
DeVellis, R. F. (2012). Scale development: Theory and applications (3rd ed.).
Thousand Oaks, CA: Sage.
DeVon, H. A., Block, M. E., Moyle-Wright, P., Ernst, D. M., Hayden, S. J.,
Lazzara, D. J., & ... Kostas-Polston, E. (2007). A psychometric
toolbox for testing validity and reliability. Journal of Nursing
Scholarship, 39(2), 155–164. doi:10.1111/j.1547-
5069.2007.00161.x
Dwyer, T. M. (1996). Stress in the rural emergency room. Australian Jour-
nal of Rural Health, 4(4), 270–274. doi:10.1111/j.1440-
1584.1996.tb00222.x
Etikan, I., Musa, S. A., & Alkassim, R. S. (2016). Comparison of conven-
ience sampling and purposive sampling. American Journal of The-
oretical and Applied Statistics, 5(1), 1–4.
doi:10.11648/j.ajtas.20160501.11
European Parliament Committee on Employment and Social Affairs. (2013).
Occupational health concerns: Stress-related and psychological
problems associated with work. Retrieved from http://www.euro-
parl.europa.eu/RegData/etudes/etudes/join/2013/507455/IPOL-
EMPL_ET(2013)507455_EN.pdf
European Risk Observatory. (2010). European survey of new and emerging
risks: Managing safety and health at work. Retrieved from
https://osha.europa.eu/en/node/6745/file_view
Everson-Rose, S. A., & Lewis, T. T. (2005). Psychosocial factors and cardi-
ovascular diseases. Annual Review of Public Health. 26, 469–500.
doi:10.1146/annurev.publhealth.26.021304.144542
Fabrigar, L. R., Wegener, D. T., MacCallum, R. C., & Strahan, E. J. (1999).
Evaluating the use of exploratory factor analysis in psychological
research. Psychological Methods, 4(3), 272–299.
doi:10.1037/1082-989X.4.3.272
Fazio, J. (2010). Emergency nursing practice. In P. K. Howard & R. A.
Steinmann (Eds.), Sheehy’s emergency nursing: Principles and
practice (6th ed.). Philadelphia, PA: Elsevier.
Folkman, S., & Lazarus, R. S. (1980). An analysis of coping in a middle-
aged community sample. Journal of Health and Social Behavior,
21(3), 219–239.
71
Folkman, S., & Lazarus, R. S. (1991). Coping and emotion. In A. Monat &
R. S. Lazarus (Eds.), Stress and coping: An anthology (3rd ed., pp.
207–227). New York, NY: Columbia University Press.
Freeman, L., Fothergill-Bourbonnais, F., & Rashotte, J. (2014). The experi-
ence of being a trauma nurse: A phenomenological study. Intensive
and Critical Care Nursing, 30(1), 6–12.
doi:10.1016/j.iccn.2013.06.004
Gambetta-Tessini, K., Mariño, R., Morgan, M., & Anderson, V. (2016).
Coping strategies and the salutogenic model in future oral health
professionals. BMC Medical Education, 16(1), 1–8.
doi:10.1186/s12909-016-0740-z
Ganley, L., & Gloster, A. S. (2011). An overview of triage in the emergency
department. Nursing Standard, 26(12), 49–56.
doi:10.7748/ns2011.11.26.12.49.c8829
Gates, D. M., Gillespie, G. L., & Succop, P. (2011). Violence against nurses
and its impact on stress and productivity. Nursing Economic$, 29(2),
59–67.
Gelsema, T. I., Van Der Doef, M., Maes, S., Janssen, M., Akerboom, S., &
Vergoevan, C. (2006). A longitudinal study of a job stress in the
nursing profession: Causes and consequences. Journal of Nursing
Management, 14(4), 289–299. doi:10.1111/j.1365-
2934.2006.00635.x
Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in
nursing research: Concepts, procedures and measures to achieve
trustworthiness. Nurse Education Today, 24(2), 105–112.
doi:10.1016/j.nedt.2003.10.001
Hair, J. F., Black, W. C., Babin, B. J., & Anderson, R.E. (2010). Multivari-
ate data analysis: A global perspective (7th ed.). Upper Saddle River,
NJ: Pearson Education.
Hall, L. H., Johnson, J., Watt, I., Tsipa, A., & O’Connor, D. B. (2016).
Healthcare staff wellbeing, burnout, and patient safety: A systematic
review. PLOS One, 11(7), 1–12. doi:10.1371/journal.pone.0159015
Hamdan, M., Abu Hamra, A., & Hamra, A. A. (2017). Burnout among
workers in emergency departments in Palestinian hospitals: Preva-
lence and associated factors. BMC Health Services Research,
17(407), 1–7. doi:10.1186/s12913-017-2356-3
Happell, B., Dwyer, T., Reid-Searl, K., Burke, K. J., Caperchione, C. M., &
Gaskin, C. J. (2013). Nurses and stress: Recognizing causes and
seeking solutions. Journal of Nursing Management, 21(4), 638–647.
doi:10.1111/jonm.12037
Häusser, J. A., Mojzisch, A., Niesel, M., & Schulz-Hardt, S. (2010). Ten
years on: A review of recent research on the job demand-control (-
support) model and psychological well-being. Work & Stress, 24(1),
1–35. doi:10.1080/02678371003683747
72
Healy, C. M., & McKay, M. F. (2000). Nursing stress: The effects of coping
strategies and job satisfaction in sample of Australian nurses. Jour-
nal of Advanced Nursing, 31(3), 681–688. doi:10.1046/j.1365-
2648.2000.01323.x
Healy, S., & Tyrrell, M. (2011). Stress in emergency departments: Experi-
ences of nurses and doctors. Emergency Nurse, 19(4), 31–37.
doi:10.7748/en2011.07.19.4.31.c8611
Healy, S., & Tyrrell, M. (2013). Importance of debriefing following critical
incidents. Emergency Nurse, 20(10), 32–37.
doi:10.7748/en2013.03.20.10.32.s8
Helps, S. (1997). Experiences of stress in accident and emergency nurses.
Accident & Emergency Nursing, 5(1), 48–53. doi:10.1016/S0965-
2302(97)90064-3
Hingley, P. (1984). The humane face of nursing. Nursing Mirror, 159(21),
19–22.
Holloway, I., & Wheeler, S. (2010). Qualitative research in nursing and
healthcare (3rd ed.). Chichester, UK: Wiley-Blackwell.
Hsu, C. C., & Sandford, B. A. (2007). The Delphi technique: Making sense
of consensus. Practical Assessment, Research & Evaluation,
12(10), 1–8.
Huber, M., Knottnerus, J. A., Green, L., van der Horst, H., Jadad, A. R.,
Kromhout, D., ... & Schnabel, P. (2011). How should we define
health? BMJ: British Medical Journal, 343(d4163), 1–3.
doi:10.1136/bmj.d4163
Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance
structure analysis: Conventional criteria versus new alternatives.
Structural Equation Modeling: A Multidisciplinary Journal, 6(1),
1–55. doi:10.1080/10705519909540118
Jonge, J. de., & Kompier, M. A. J. (1997). A critical examination of the De-
mand-Control-Support Model from a work psychological perspec-
tive. International Journal of Stress Management, 4(4), 235–258.
doi:10.1023/B:IJSM.0000008152.85798.90
Kaiser, H. F. (1960). The application of electronic computers to factor analy-
sis. Educational and Psychological Measurement. 20(1), 145–151.
doi:10.1177/001316446002000116
Karasek, R. A. (1979). Job demand, job decision latitude and mental strain:
Implications for job redesign. Administrative Science Quarterly,
24(2), 285–308. doi:10.2307/2392498
Karasek, R. A, & Theorell, T. (1990). Healthy work: Stress, productivity,
and the reconstruction of working life. New York, NY: Basic
Books.
Kellar, S. P., & Kelvin, E. A. (2013). Munro’s statistical methods for health
care research (6th ed.). Philadelphia, PA: Wolters Kluwer
Health/Lippincott Williams & Wilkins.
73
Keller, A., Litzelman, K., Wisk, L. E., Maddox, T., Cheng, E. R., Creswell,
P. D., & Witt, W. P. (2012). Does the perception that stress affects
health matter? The association with health and mortality. Health
Psychology, 31(5), 677–684. doi:10.1037/a0026743
Kenny, D., Carlson, J. G., McGiugan, F. J., & Sheppard, J. L. (2000). Stress
and health: Research and clinical applications. Amsterdam, Neth-
erlands: Harwood Academic Publishers.
Kimberlin, C., & Winterstein, A. (2008). Validity and reliability of measure-
ment instruments used in research. American Journal of Health-
System Pharmacy, 65(23), 2276–2284. doi:10.2146/ajhp070364
Kirwan, M., Matthews, A., & Scott, P. A. (2013). The impact of the work
environment of nurses on patient safety outcomes: A multi-level
modelling approach. International Journal of Nursing Studies,
50(2), 253–263. doi:10.1016/j.ijnurstu.2012.08.020
Kline, R. B. (1998). Principles and practice of structural equation modeling.
New York, NY: Guilford.
Kunaviktikul, W., Chitpakdee, B., Srisuphan, W., & Bossert, T. (2015). Pre-
ferred choice of work setting among nurses in Thailand: A discrete
choice experiment. Nursing & Health Sciences, 17(1), 126–133.
doi:10.1111/nhs.12144
Kwak, C., Chung, B. Y., Xu, Y., & Eun-Jung, C. (2010). Relationship of job
satisfaction with perceived organizational support and quality of
care among South Korean nurses: A questionnaire survey. Interna-
tional Journal of Nursing Studies, 47(10), 1292–1298.
doi:10.1016/j.ijnurstu.2010.02.014
Larson, J. (1999). The conceptualization of health. Medical Care Research
and Review, 56(2), 123–136. doi:10.1177/107755879905600201
Lazarus, R. S. (1993). From psychological stress to the emotions: A history
of changing outlooks. Annual Review of Psychology, 44(1), 1–22.
Lazarus, R. S. (2006). Stress and emotion: A new synthesis. New York, NY:
Springer.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New
York, NY: Springer.
Lim, J., Bogossian, F., & Ahern, K. (2010). Stress and coping in Australian
nurses: A systematic review. International Nursing Review, 57(1),
22–31. doi:10.1111/j.1466-7657.2009.00765.x
Lim, J., Hepworth, J., & Bogossian, F. (2011). A qualitative analysis of
stress, uplifts and coping in the personal and professional lives of
Singaporean nurses. Journal of Advanced Nursing, 67(5), 1022–
1033. doi:10.1111/j.1365-2648.2010.05572.x
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Beverly Hills,
CA: Sage.
Lindström, B., & Eriksson, M. (2006). Contextualizing salutogenesis and
Antonovsky in public health development. Health Promotion Inter-
national, 21(3), 238–244. doi:10.1093/heapro/dal016
74
Lindström, K., Elo, A-L., Skogstad, A., Dallner, M., Gamberale, F., Hot-
tinen, V… Ørhede, E. (2000). User’s guide for the QPSNordic:
General Nordic questionnaire for psychological and social factors
at work. Copenhagen, Denmark: Aka-print A/S, Århus.
Lovallo, W. R. (2005). Stress & health: Biological and psychological inter-
actions (2nd ed.). Thousand Oaks, CA: Sage.
Lu, D., Sun, N., Hong, S., Fan, Y., Kong, F., & Li, Q. (2015). Occupational
stress and coping strategies among emergency department nurses
of China. Archives of Psychiatric Nursing, 29(4), 208–212.
doi:10.1016/j.apnu.2014.11.006
Luchman, J. N., & González-Morales, M. G. (2013). Demands, control, and
support: A meta-analytic review of work characteristics interrela-
tionships. Journal of Occupational Health Psychology, 18(1), 37–
52. doi:10.1037/a0030541
Lyons, F. M., & Meeran, K. (1997). The physiology of the endocrine sys-
tem. International Anesthesiology Clinics, 35(4), 1–22.
Mace, S. E., & Mayer, T. A. (2007). Triage. In J. Baren, S. Rothrock, J.
Brenan & L. Brown. (Eds.), Pediatric Emergency Medicine (pp.
1087–1096). Philadelphia: Saunders.
Marett, B. E. (2000). Emergency nursing more than meets the eye. Retrieved
from http://www.nsna.org/Portals/0/Skins/NSNA/pdf/Ca-
reer_emer_nurse.pdf
Medibank Private. (2008). The cost of workplace stress in Australia. Re-
trieved from http://www.medibank.com.au/client/docu-
ments/pdfs/the-cost-of-workplace-stress.pdf
Mohajan, H. K. (2012). The occupational stress and risk of it among the em-
ployees. International Journal of Mainstream Social Science, 2(2),
17–34.
Munhall, P. L. (2012). Nursing research: A qualitative perspective (5th ed.).
Sudbury, MA: Jones & Bartlett Learning.
Nabirye, R. C., Brown, K. C., Pryor, E. R., & Maples, E. H. (2011). Occupa-
tional stress, job satisfaction and job performance among hospital
nurses in Kampala, Uganda. Journal of Nursing Management,
19(6), 760–768. doi:10.1111/j.1365-2834.2011.01240.x
National Institute for Emergency Medicine. (2017a). UCEP. Retrieved from
http://www.niems.go.th/en/View/Con-
tentDetails.aspx?CateId=109&Conten-
tId=25600421032711704&Page=0
National Institute for Emergency Medicine. (2017b). UCEP (in Thai lan-
guage). Retrieved from http://www.niems.go.th/th/Up-
load/File/256004031407566383_j3yHVFeurA0UD0aJ.jpg
National Institute for Health Research. (2016). Patient safety 2030. Re-
trieved from http://www.who.int/patientsafety/news_events/ps-
2030-report.pdf?ua=1
75
National Statistical Office. (2012). The 2012 private hospital survey. Re-
trieved from http://service.nso.go.th/nso/nsopub-
lish/themes/files/privatehostpital55.pdf
National Statistical Office. (2013). The 2013 survey on health and welfare.
Retrieved from http://web.nso.go.th/en/survey/data_sur-
vey/570718_The%202013%20Sur-
vey%20on%20Health%20and%20Welfare.pdf
Nichols, M., Townsend, N., Luengo-Fernandez, R., Leal, J., Gray, A., Scar-
borough, P., & Rayner, M. (2012). European cardiovascular dis-
ease statistics 2012. Brussels, Belgium: European Heart Network,
European Society of Cardiology, and Sophia Antipolis.
Pacák, K., & Palkovits, M. (2001). Stressor specificity of central neuroendo-
crine responses: Implications for stress-related disorders. Endo-
crine Reviews, 22(4), 502–548. doi:10.1210/er.22.4.502
Pagaiya, N., & Noree, T. (2009). Thailand’s health workforce: A review of
challenges and experiences. Washington, DC: World Bank.
Paitoonpong, S., Chawla, A., & Akkarakul, N. (2010). Social protection in
Thailand—current state and challenges. In M. G. Asher, S. Oum &
F. Parulian (Eds.), Social protection in East Asia—current state
and challenges (pp. 265–291). ERIA Research Project Report
2009-9, Jakarta, Indonesia: ERIA.
Pannarunothai, S., & Mills, A. (1998). Researching the public/private mix in
health care in a Thai urban area: Methodological approaches.
Health Policy and Planning, 13(3), 234–248.
doi:10.1093/heapol/13.3.234
Payne, S., & Horn, S. (2007). Health communication: Theory and practice.
New York: Open University Press.
Poghosyan, L., Clarke, S., Finlayson, M., & Aiken, L. H. (2010). Nurse
burnout and quality of care: Cross-national investigation in six
countries. Research in Nursing & Health, 33(4), 288–298.
doi:10.1002/nur.20383
Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and as-
sessing evidence for nursing practice (9th ed.). Philadelphia, PA:
Wolters Kluwer Health/Lippincott Williams & Wilkin.
Polit, D. F., Beck, C. T., & Owen, S. V. (2007). Is the CVI an acceptable in-
dicator of content validity? Appraisal and recommendations. Re-
search in Nursing & Health, 30(4), 459–467.
doi:10.1002/nur.20199
Pongsapich, A., Leecanawanichphan, R., & Bunjongjit, N. (2002). Social
protection in Thailand. In E. Adam, M. von Hauff & M. John
(Eds.), Social protection in Southeast and East Asia (pp. 313–330).
Retrieved from http://library.fes.de/pdf-files/iez/01443009.pdf
76
Potter, C. (2006). To what extent do nurses and physicians working within
the emergency department experience burnout: A review of the lit-
erature. Australian Emergency Nursing Journal, 9(2), 57–64.
doi:10.1016/j.aenj.2006.03.006
Ramesh, M., & Wu, X. (2008). Realigning public and private health care in
Southeast Asia. Pacific Review, 21(2), 171–187.
doi:10.1080/09512740801990238
Rosenstein, A., & Naylor, B. (2012). Incidence and impact of physician and
nurse disruptive behaviors in the emergency department. Journal
of Emergency Medicine, 43(1), 139–148.
doi:10.1016/j.jemermed.2011.01.019
Rosmond, R., Wallerius, S., Wanger, P., Martin, L., Holm, G., & Björntorp,
P. (2003). A 5-year follow-up study of disease incidence in men
with an abnormal hormone pattern. Journal of Internal Medicine,
254(4), 386–390. doi:10.1046/j.1365-2796.2003.01205.x
Ross-Adjie, G., Leslie, G., & Gillman, L. (2007). Occupational stress in the
ED: What matters to nurses? Australian Emergency Nursing Jour-
nal, 10(3), 117–123. doi:10.1016/j.aenj.2007.05.005
Royal Thai Government Gazette. (2017). The twelfth national economic and
development plan 2017–2021. Retrieved from http://www.ratchakitcha.soc.go.th/DATA/PDF/2559/A/115/1.PDF
Rugless, M., & Taylor, D. (2011). Sick leave in the emergency department:
Staff attitudes and the impact of job designation and psychosocial
work conditions. Emergency Medicine Australasia, 23(1), 39–45.
doi:10.1111/j.1742-6723.2010.01372.x
Sakkomonsri, J., Suwan-Ampai, P., & Kaewboonchoo, O. (2016). Factors
associated with job stress among ambulance nurses in Bangkok,
Thailand. Bangkok Medical Journal, 12, 33–38.
Sakunphanit, T., & Suwanrada, W. (2011). The universal coverage scheme.
In The International Labour Organization (ILO), Sharing innova-
tion experiences: Successful social protection floor experiences,
Vol. 18 (pp. 385–400). New York, NY: Global South-South Devel-
opment Academy.
Salmond, S., & Ropis, P. E. (2005). Job stress and general well-being: A
comparative study of medical-surgical and homecare nurses. Medi-
cal-Surgery Nursing, 14(5), 301–309.
Sauter, S., Murphy, L., Colligan, M., Swanson, N., Hunell, J., Scharf, F., …
Tisdale, J. (2009). Stress… at work (NIOSH). Cincinnati, IL:
DHHS (NIOS-)-CDC.
Sawatzky, J-A. V., & Enns, C. L. (2012). Exploring the key predictors of re-
tention in emergency nurses. Journal of Nursing Management,
20(5), 696–707. doi:10.1111/j.1365-2834.2012.01355.x
Selye, H. (1975). Stress and distress. Comprehensive Therapy, 1(8), 9–13.
Sittha, P. V. (2012). Governance and poverty reduction in Thailand. Modern
Economy, 3(5), 487–497. doi:10.4236/me.2012.35064
77
Squires, A. (2009). Methodological challenges in cross-language qualitative
research: A research review. International Journal of Nursing
Studies, 46(2), 277–287. doi:10.1016/j.ijnurstu.2008.08.006
Srisuphan, W., & Sawaengdee, K. (2012). Recommended policy-based solu-
tions to shortage of registered nurses in Thailand. Thai Journal of
Nursing Council, 27(1), 5–12.
Stratakis, C. A., & Chrousos, G. P. (1995). Neuroendocrinology and patho-
physiology of the stress system. Annals of the New York Academy
of Sciences, 771(1), 1–18. doi:10.1111/j.1749-
6632.1995.tb44666.x
Streiner, D. L., & Norman, G. R. (2008). Health measurement scales: A
practical guide to their development and use (4th ed.). New York,
NY: Oxford University Press.
Swedish Institute. (2012). The Swedish model: Perspectives on the interna-
tional relevance of Sweden’s social paradigm. Retrieved from
https://eng.si.se/wp-content/uploads/sites/4/2013/01/The-Swedish-
model-english-version-2012-0204-sise.pdf
Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics (5th
ed.). Boston, MA: Pearson.
Tavakol, M., & Dennick, R. (2011). Making sense of Cronbach’s alpha. In-
ternational Journal of Medical Education, 2, 53–55.
doi:10.5116/ijme.4dfb.8dfd
Thailand Nursing and Midwifery Council. (1997). Thailand professional
nursing and midwifery act B.E. 2528 (1985) Revision of the act
B.E. 2540 (1997). Retrieved from
http://www.tnc.or.th/files/2014/08/page-9830/the_profes-
sional_act_2528_2540_pdf_26494.pdf
Theorell, T., & Karasek, R. A. (1996). Current issues relating to psychoso-
cial job strain and cardiovascular disease research. Journal of Oc-
cupational Health Psychology, 1(1), 9–26. doi:10.1037/1076-
8998.1.1.9
Tinsley, H. E. A., & Tinsley, D. J. (1987). Use of factor analysis in counsel-
ing psychology research. Journal of Counseling Psychology, 34(4),
414–424. doi:10.1037/0022-0167.34.4.414
Travers, D. A., Waller, A. E., Bowling, J. M., Flowers, D., & Tintinalli, J.
(2002). Five-level triage system more effective than three-level in
tertiary emergency department. Journal of Emergency Nurs-
ing, 28(5), 395–400. doi:10.1067/men.2002.127184
Trousselard, M., Dutheil, F., Naughton, G., Schoeffler, P., Cosserant, S.,
Amadon, S., & Dualé, C. (2016). Stress among nurses working in
emergency, anesthesiology and intensive care units depends on
qualification: A job demand-control survey. International Archives
of Occupational and Environmental Health, 89(2), 221–229.
doi:10.1007/s00420-015-1065-7
78
Tyson, P. D., & Pongruengphant, R. (2004). Five-year follow-up study of
stress among nurses in public and private hospitals in Thailand. In-
ternational Journal of Nursing Studies, 41(3), 247–254.
doi:10.1016/S0020-7489(03)00134-2
Ulrich, B. T., Lavandero, R., Woods, D., & Early, S. (2014). Critical care
nurse work environments 2013: A status report. Critical Care
Nurse, 34(4), 64–79. doi:10.4037/ccn2014731
Van Der Doef, M., & Maes, S. (1999). The job demand-control (-support)
model and psychological well-being: A review of 20 years of em-
pirical research. Work & Stress, 13(2), 87–114.
doi:10.1080/026783799296084
Verrall, C., Abery, E., Harvey, C., Henderson, J., Willis, E., Hamilton, P., ...
& Blackman, I. (2015). Nurses and midwives perceptions of
missed nursing care—a South Australian study. Collegian, 22(4),
413–420. doi:10.1016/j.colegn.2014.09.001
Vibulwong, P., & Rittiwong, T. (2014). A competency evaluation of partici-
pants from the emergency nurse training program at Boromaraja-
jonani College of Nursing, Bangkok. Journal of Boromarajajonani
College of Nursing, Bangkok, 30(1), 72–85.
Wibulpolprasert, S. (2011). Thailand health profile 2008–2010. Retrieved
from http://wops.moph.go.th/ops/thp/thp/en/in-
dex.php?id=288&group_=05&page=view_doc
World Bank. (2011). Thailand overview. Retrieved from
http://www.worldbank.org/en/news/press-release/2011/08/02/thai-
land-now-upper-middle-income-economy
World Bank. (2014). Countries: Thailand. Retrieved from
http://www.worldbank.org/en/country/thailand
World Health Organization. (1948). Constitution of WHO: Principles. Re-
trieved from http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-
en.pdf?ua=1
World Health Organization. (2014). Countries: Thailand. Retrieved from
http://www.who.int/countries/tha/en/
World Health Organization, Europe. (2017). Patient safety. Retrieved from
http://www.euro.who.int/en/health-topics/Health-systems/patient-
safety/patient-safety
Wright, P. D., Bretthauser, K., & Cote, M. J. (2006). Reexamining the nurse
scheduling problem: Staffing ratios and nursing shortage. Journal
of the Decision Science Institute, 37(1), 39–70. doi:10.1111/j.1540-
5414.2006.00109.x
Yen, M., & Lo, L. H. (2002). Examining test-retest reliability—an intra-class
correlation approach. Nursing Research, 51(1), 59–62.
doi:10.1097/00006199-200201000-00009
79
Yuwanich, N., Akhavan, S., Elfström, M., Nantsupawat, W., Martin, L., &
Sandborgh, M. (2017a). Development and psychometric properties
of the Stressor Scale for Emergency Nurses. Manuscript submitted
for publication.
Yuwanich, N., Akhavan, S., Nantsupawat, W., & Martin, L. (2017b). Expe-
riences of occupational stress among emergency nurses at private
hospitals in Bangkok-Thailand. Open Journal of Nursing, 7(6),
657–670. doi:10.4236/ojn.2017.76049
Yuwanich, N., Sandmark, H., & Akhavan, S. (2016). Emergency department
nurses’ experiences of occupational stress: A qualitative study
from a public hospital in Bangkok, Thailand. Work, 53(4), 885–
879. doi:10.3233/WOR-1521
8
0
Ap
pen
dix
I.
Exa
mp
le o
f co
nte
nt
an
aly
sis
81
Appendix II.
Phases of development and validation of the instrument in study III
(Yuwanich et al. 2017a)
1. Item generation: A preliminary 74-item pool was generated from the literature review
and interviews (Yuwanich et al., 2016, 2017b).
2. Content and face validity: Content validity was evaluated by five domain experts.
Face validity was evaluated by 5 domain experts and four emergency nurses.
3. Pilot testing: Test-retest reliability was evaluated on 30 emergency nurses.
Phase 1
Phase 2
4. Construct validity and internal consistency:
These were evaluated on 405 emergency nurses.
Phase 3
8
2
A
pp
en
dix
III
.
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Em
ergen
cy n
urs
es r
eport
ed m
ore
tim
e pre
ssure
and
physi
cal
dem
ands,
low
er d
ecis
ion a
uth
ori
ty,
less
ad-
equat
e w
ork
pro
ced
ure
s an
d f
ewer
rew
ards
than
a
gen
eral
-hosp
ital
nurs
ing p
op
ula
tio
n.
Dec
isio
n-m
ak-
ing a
uth
ori
ty,
skil
l d
iscr
etio
n,
adeq
uat
e w
ork
pro
ce-
dure
s, p
erce
ived
rew
ard
s an
d s
oci
al s
upport
by s
u-
per
vis
ors
pro
ved
to b
e st
rong d
eter
min
ants
of
job
sati
sfac
tio
n,
work
engag
emen
t an
d l
ow
er t
urn
over
inte
nti
on i
n e
mer
gen
cy n
urs
es.
8
3
Ap
pen
dix
III
.
Det
ail
s on
th
e re
searc
h a
rtic
les
in t
he
scop
ing l
iter
atu
re r
evie
w
Au
thors
/cou
ntr
ies
Stu
dy a
pp
roach
A
im
Sam
ple
M
ain
fin
din
gs
Bai
ley,
Murp
hy a
nd P
oro
ck
(2011
)
Unit
ed K
ingdo
m
Qual
itat
ive
stud
y:
obse
rva-
tio
ns
and i
nte
rvie
ws
To e
xp
lore
how
em
ergen
cy n
urs
es m
anag
e th
e
emo
tio
nal
im
pac
t o
f dea
th a
nd d
yin
g i
n e
mer
-
gen
cy w
ork
and
to p
rese
nt
a m
odel
for
dev
el-
op
ing e
xper
tise
in e
nd
-of-
life
car
e del
iver
y
28 E
D n
urs
es
Bar
rier
s th
at p
reven
t th
e tr
ansi
tio
n t
o e
xper
tise
co
n-
trib
ute
d t
o o
ccupat
ional
str
ess
and c
an l
ead t
o b
urn
-
out
and w
ithdra
wal
fro
m p
ract
ice.
Dec
lerc
q,
Meg
anck
, D
ehee
gher
and V
an H
oord
e (2
011
)
Bel
giu
m
Cro
ss-s
ecti
onal
stu
dy,
quan
tita
tive
app
roac
h
To c
om
par
e th
e re
spec
tive
contr
ibuti
ons
of
an
ind
ivid
ual
’s s
ub
ject
ive
resp
onse
and t
he
fre-
quen
cy o
f ex
posu
re t
o c
riti
cal
inci
den
ts t
o t
he
dev
elop
men
t o
f sy
mp
tom
s o
f P
TS
D
136 D
utc
h-s
pea
kin
g n
urs
es a
nd
amb
ula
nce
per
sonnel
Str
esso
rs t
hat
eli
cite
d t
he
most
inte
nse
eff
ects
wit
hin
this
pop
ula
tio
n w
ere
those
invo
lvin
g c
hil
dre
n a
nd
those
when
work
ers
enco
unte
red l
imit
atio
ns
in s
up
-
pli
es a
nd r
eso
urc
es.
Ther
e w
as n
o r
elat
ionsh
ip b
e-
twee
n t
he
freq
uen
cy o
f cr
itic
al i
nci
den
ts e
nco
un-
tere
d a
nd t
he
occ
urr
ence
of
PT
SD
sym
pto
ms.
Gat
es,
Gil
lesp
ie a
nd S
ucc
op
(2011
)
Unit
ed S
tate
s
Cro
ss-s
ecti
onal
stu
dy,
quan
tita
tive
app
roac
h
To e
xam
ine
how
vio
lence
by p
atie
nts
and v
is-
itors
is
rela
ted t
o E
D n
urs
es’
work
pro
duct
iv-
ity a
nd s
ym
pto
ms
of
PT
SD
230 E
D n
urs
es
Of
nurs
es,
94%
exhib
ited
at
leas
t o
ne
PT
SD
sym
p-
tom
aft
er a
vio
lent
even
t, w
ith 1
7%
hav
ing s
core
s
hig
h e
no
ugh t
o b
e co
nsi
der
ed p
robab
le f
or
PT
SD
. In
addit
ion,
ther
e w
ere
signif
ican
t in
dir
ect
rela
tio
nsh
ips
bet
wee
n s
tres
s sy
mp
tom
s an
d w
ork
pro
duct
ivit
y.
Gev
ers,
Van
Erv
en,
De
Jonge,
Maa
s an
d D
e Jo
ng (
2010
)
The
Net
her
lands
Cro
ss-s
ecti
onal
surv
ey
stud
y,
quan
tita
tive
ap-
pro
ach
To d
eter
min
e th
e co
mb
ined
eff
ect
of
acute
and c
hro
nic
job d
eman
ds
on a
cute
job s
trai
ns
exper
ience
d d
uri
ng m
edic
al e
mer
gen
cies
and
thei
r co
nse
quen
ces
for
ind
ivid
ual
tea
mw
ork
beh
avio
ur
23 e
mer
gen
cy n
urs
es a
nd 2
5
emer
gen
cy p
hysi
cian
s
Hig
h a
cute
job d
eman
ds
infl
uen
ced e
ffec
tive
team
-
work
beh
avio
ur
duri
ng m
edic
al e
mer
gen
cies
.
Acu
te e
mo
tio
nal
dem
ands
resu
lted
in a
cute
job
stra
in.
Alt
ho
ugh a
cute
co
gnit
ive
and p
hysi
cal
stra
ins
wer
e al
so d
etri
men
tal,
eff
ecti
ve
team
work
beh
avio
ur
was
esp
ecia
lly i
mped
ed b
y a
cute
em
oti
onal
str
ain.
Gho
lam
zadeh
, S
har
if a
nd
Deh
ghan
Rad
(20
11)
Iran
Des
crip
tive
surv
ey,
quan
ti-
tati
ve
appro
ach
To i
nves
tigat
e th
e so
urc
es o
f jo
b s
tres
s an
d
the
adopte
d c
op
ing s
trat
egie
s o
f nurs
es w
ork
-
ing i
n a
n a
ccid
ent
and e
mer
gen
cy d
epar
tmen
t
90 E
D n
urs
es
The
foll
ow
ing s
tres
sors
wer
e re
port
ed:
work
load
,
pro
ble
ms
rela
ted t
o t
he
physi
cal
envir
onm
ent,
iss
ues
dea
ling w
ith p
atie
nts
and
thei
r re
lati
ves
and
han
dli
ng
thei
r an
ger
, ex
posu
re t
o h
ealt
h a
nd s
afet
y h
azar
ds,
lack
of
suppo
rt f
rom
nurs
ing a
dm
inis
trat
ors
, ab
sence
of
the
resp
onsi
ble
physi
cian
in t
he
ED
and l
ack o
f
equip
men
t.
8
4
Ap
pen
dix
III
.
Det
ail
s on
th
e re
searc
h a
rtic
les
in t
he
scop
ing l
iter
atu
re r
evie
w (
con
tin
ued
)
Au
thors
/cou
ntr
ies
Stu
dy a
pp
roach
A
im
Sam
ple
M
ain
fin
din
gs
Gar
cía-
Izq
uie
rdo a
nd R
íos-
Rí-
squez
(201
2)
Spai
n
Cro
ss-s
ecti
onal
stu
dy,
quan
tita
tive
app
roac
h
To e
xam
ine
the
rela
tio
nsh
ip a
nd
pre
dic
tive
pow
er o
f var
ious
psy
choso
cial
jo
b
stre
ssors
fo
r th
e th
ree
dim
ensi
ons
of
burn
out
in e
mer
gen
cy d
epar
tmen
ts
191 E
D n
urs
es
Em
oti
onal
exhau
stio
n,
cynic
ism
and r
educe
d p
rofe
s-
sio
nal
eff
icac
y w
ere
report
ed t
o b
e pre
dic
tors
fo
r b
urn
-
out.
Exce
ssiv
e w
ork
load
and l
ack o
f em
oti
onal
sup-
port
pre
dic
ted
dim
ensi
ons
of
emoti
onal
exhau
stio
n.
Cynic
ism
had
fo
ur
pre
dic
tors
: in
terp
erso
nal
confl
icts
,
exce
ssiv
e w
ork
load
, co
ntr
act
type
and
lac
k o
f so
cial
suppo
rt.
Fin
ally
, var
iab
ilit
y i
n r
educe
d p
rofe
ssio
nal
ef-
fica
cy w
as p
red
icte
d b
y t
hre
e var
iab
les:
inte
rper
sonal
confl
icts
, la
ck o
f so
cial
support
and t
ype
of
shif
t
work
ed.
Hea
ly a
nd T
yrr
ell
(2011
)
Irel
and
Des
crip
tive
surv
ey
des
ign,
quan
tita
tive
ap-
pro
ach
To r
eport
on a
stu
dy o
n n
urs
es’
and d
oct
ors
’
atti
tudes
to a
nd e
xper
ience
s o
f w
ork
pla
ce
stre
ss i
n t
hre
e E
Ds
in I
rela
nd a
nd t
o o
ffer
som
e su
gges
tio
ns
on h
ow
str
ess
amo
ng E
D
staf
f ca
n b
e re
duce
d
90 E
D n
urs
es a
nd 1
3 E
D p
hy-
sici
ans
The
effe
cts
of
stre
ssfu
l in
ciden
ts i
n E
D s
taff
can
be
pro
found.
Wit
nes
sing a
ggre
ssio
n,
vio
lence
and
the
dea
th o
f pat
ients
and
par
tici
pat
ing i
n r
esusc
itat
ion c
an
be
emoti
onal
ly a
nd p
hysi
call
y d
em
and
ing.
Hunsa
ker
, C
hen
, M
aughan
and
Hea
sto
n (
2015)
Unit
ed S
tate
s
Cro
ss-s
ecti
onal
stu
dy w
ith
a no
nex
per
imen
tal,
de-
scri
pti
ve,
pre
dic
tive
des
ign
To d
eter
min
e th
e pre
val
ence
of
com
pas
sio
n
sati
sfac
tio
n,
com
pas
sio
n f
atig
ue
and b
urn
out
in E
D n
urs
es t
hro
ugho
ut
the
Unit
ed S
tate
s
and t
o e
xam
ine
whic
h d
em
ogra
phic
and
work
-rel
ated
co
mpo
nen
ts a
ffec
t th
e dev
elo
p-
men
t o
f co
mpas
sio
n s
atis
fact
ion,
com
pas
sion
fati
gue
and b
urn
out
in t
his
nurs
ing s
pec
ialt
y
284 E
D n
urs
es
Low
man
ager
suppo
rt w
as a
sig
nif
icant
pre
dic
tor
of
hig
her
lev
els
of
burn
out
and c
om
pas
sio
n f
atig
ue
amo
ng e
mer
gen
cy n
urs
es,
whil
e hig
h m
anag
er s
uppo
rt
contr
ibute
d t
o g
reat
er c
om
pas
sio
n s
atis
fact
ion.
Ko
gie
n a
nd C
edar
o (
2014
)
Bra
zil
Cro
ss-s
ecti
onal
stu
dy,
quan
tita
tive
app
roac
h
To d
eter
min
e th
e psy
choso
cial
fac
tors
of
work
rel
ated
to h
arm
cau
sed i
n t
he
physi
cal
do
mai
n o
f th
e q
ual
ity o
f li
fe o
f nurs
ing p
ro-
fess
ional
s w
ork
ing i
n a
pub
lic
ED
189 E
D n
urs
es
Low
inte
llec
tual
dis
cern
men
t, l
ow
soci
al s
upport
and
exper
ienci
ng h
igh
-dem
and j
obs
and p
assi
ve
jobs
wer
e
the
mai
n r
isk f
acto
rs t
hre
aten
ing t
he
physi
cal
do
mai
n
of
qual
ity o
f li
fe.
8
5
A
pp
en
dix
III
.
Det
ail
s on
th
e re
searc
h a
rtic
les
in t
he
scop
ing l
iter
atu
re r
evie
w (
con
tin
ued
)
Au
thors
/cou
ntr
ies
Stu
dy a
pp
roach
A
im
Sam
ple
M
ain
fin
din
gs
Kow
alen
ko
, G
ates
, G
ille
spie
,
Succ
op a
nd M
entz
el (
2013)
Unit
ed S
tate
s
Lo
ngit
ud
inal
, re
pea
ted
-
mea
sure
s des
ign,
quan
tita
-
tive
app
roac
h
To d
escr
ibe
the
inci
den
ce o
f vio
lence
in E
D
hea
lth c
are
wo
rker
s o
ver
nin
e m
onth
s
213 E
D w
ork
ers
(117 E
D
nurs
es)
Physi
cal
thre
ats
wer
e re
port
ed a
s vio
lent
even
ts i
n t
he
ED
. S
ignif
ican
t d
iffe
rence
s in
vio
lent
even
ts w
ere
re-
port
ed b
etw
een r
egis
tere
d n
urs
es a
nd m
edic
al d
oct
ors
and p
atie
nt
care
ass
ista
nts
. R
egis
tere
d n
urs
es f
elt
less
safe
than
med
ical
doct
ors
(P
= .
0041)
Lav
oie
, T
albot
and M
athie
u
(2011
)
Can
ada
Qual
itat
ive
stud
y w
ith
sem
i-st
ruct
ure
d i
nte
rvie
ws
To i
den
tify
sup
port
act
ivit
ies
for
emer
gen
cy
nurs
es w
ho h
ave
bee
n e
xp
ose
d t
o t
raum
atic
even
ts t
o p
reven
t P
TS
D
12 E
D n
urs
es
ED
nurs
es d
escr
ibed
tra
um
atic
even
ts a
s both
wit
-
nes
ses
and v
icti
ms.
The
conte
xt
surr
ound
ing t
rau
mat
ic
even
ts i
nfl
uen
ced p
erce
pti
ons
of
them
. P
eer
support
,
psy
choed
uca
tio
n a
nd E
D s
imula
tio
ns
wer
e id
enti
fied
as s
upport
aft
er e
xp
osu
re t
o t
raum
atic
even
ts.
Lu e
t al
. (2
015
)
Chin
a
Cro
ss-s
ecti
onal
stu
dy,
quan
tita
tive
app
roac
h
To d
escr
ibe
the
rela
tio
nsh
ip b
etw
een c
op
ing
stra
tegie
s an
d o
ccupat
ional
str
ess
amo
ng E
D
nurs
es i
n C
hin
a
113 E
D n
urs
es
The
stre
ssors
of
ED
nurs
es w
ere
most
ly d
ue
to t
he
na-
ture
of
the
nurs
ing s
pec
ialt
y (
2.9
7 ±
0.5
5)
and i
ts
work
load
and t
ime
dis
trib
uti
on (
2.9
7 ±
0.5
8).
Too
much
wo
rk,
crit
icis
m,
inst
rum
ent
equip
men
t sh
ort
-
ages
, nig
ht
shif
ts a
nd p
rofe
ssio
nal
ran
k c
once
rns
wer
e
the
fact
ors
infl
uen
cing o
ccupat
ional
str
ess
wit
h r
e-
spec
t to
posi
tive
cop
ing s
tyle
s. T
oo m
uch
work
and i
s-
sues
wit
h m
edic
al i
nsu
rance
fo
r E
D n
urs
es w
ere
the
fact
ors
infl
uen
cing o
ccupat
ional
str
ess
wit
h r
espec
t to
neg
ativ
e co
pin
g s
tyle
s.
Nie
lsen
, P
eder
sen,
Ras
muss
en,
Pap
e an
d M
ikkel
sen (
20
13)
Den
mar
k
Des
crip
tive
surv
ey,
quan
ti-
tati
ve
appro
ach
To i
nves
tigat
e th
e re
lati
onsh
ip b
etw
een 1
2
work
-rel
ated
str
esso
rs a
nd t
he
occ
urr
ence
of
adver
se e
ven
ts i
n a
n E
D
118 E
D w
ork
ers
(98 E
D
nurs
es)
The
stud
y r
ecord
ed 2
14
ad
ver
se e
ven
ts d
uri
ng t
he
979
stud
ied s
hif
ts.
Hig
h v
aria
bil
ity o
f st
ress
ors
and e
mo
-
tio
nal
im
pac
t am
ong t
he
dif
fere
nt
gro
ups
of
par
tici
-
pan
ts w
as f
ound
.
Oli
vei
ra,
Ach
ieri
, P
esso
a, M
i-
randa
and A
lmei
da
(201
3)
Bra
zil
Qual
itat
ive
stud
y w
ith o
b-
serv
atio
ns
and s
emi-
stru
c-
ture
d i
nte
rvie
ws
To e
xp
lore
the
under
stan
din
g o
f th
e so
cial
repre
senta
tio
ns
of
nurs
es i
n t
he
ED
and t
hei
r
rela
tio
nsh
ip t
o s
tres
s
10 E
D n
urs
es
Thre
e th
emes
—w
ork
over
load
, pre
cari
ousn
ess
of
in-
terp
erso
nal
rel
atio
nsh
ips
and l
ack o
f m
oti
vat
ion i
n t
he
work
pla
ce—
wer
e fo
und a
nd d
escr
ibed
as
situ
atio
ns
rela
ted t
o s
oci
al r
epre
senta
tio
ns
and s
tres
s.
Per
eira
et
al.
(2014)
Bra
zil
Cro
ss-s
ecti
onal
stu
dy,
quan
tita
tive
app
roac
h
To a
sses
s occ
upat
ional
str
esso
rs a
mo
ng
nurs
es w
ork
ing i
n u
rgen
t an
d e
mer
gen
cy c
are
faci
liti
es
49 n
urs
es i
n u
rgen
t an
d e
mer
-
gen
cy c
are
unit
s
ED
nurs
es w
ork
ing i
n a
hig
hly
co
mp
lex h
ealt
h c
are
faci
lity
iden
tifi
ed p
erfo
rman
ce o
f nurs
ing c
are
as t
he
most
im
port
ant
stre
ssor.
Those
work
ing i
n a
hea
lth
care
fac
ilit
y w
ith m
ediu
m c
om
ple
xit
y c
onsi
der
ed a
c-
tivit
ies
rela
ted t
o s
taff
man
agem
ent
to b
e st
ress
ors
.
8
6
Ap
pen
dix
III
.
Det
ail
s on
th
e re
searc
h a
rtic
les
in t
he
scop
ing l
iter
atu
re r
evie
w (
con
tin
ued
)
Au
thors
/cou
ntr
ies
Stu
dy a
pp
roach
A
im
Sam
ple
M
ain
fin
din
gs
Popa,
Rae
d,
Purc
area
, L
ala
and
Bob
irnac
(201
0)
Ro
man
ia
Cro
ss-s
ecti
onal
surv
ey
stud
y,
quan
tita
tive
ap-
pro
ach
To i
nves
tigat
e fa
cto
rs a
nd l
evel
s o
f occ
upa-
tio
nal
str
ess
in e
mer
gen
cy m
edic
al w
ork
ers
4693 e
mer
gen
cy c
are
per
sonnel
(260 E
D n
urs
es)
Hig
h r
isk o
f b
urn
out
consi
sted
of
hig
h e
moti
onal
ex-
hau
stio
n a
nd h
igh d
eper
sonal
isat
ion.
Poss
ible
exp
la-
nat
ions
for
this
mig
ht
be
linked
to h
igh p
atie
nt
flow
,
emer
gen
cy d
epar
tmen
t cr
ow
din
g,
long w
ork
ho
urs
and i
nd
ivid
ual
par
am
eter
s, s
uch
as
copin
g m
echa-
nis
ms,
soci
al d
evel
op
men
t an
d w
ork
envir
on
men
t.
Ram
acci
ati,
Cec
cagno
li a
nd
Addey
(2015
)
Ital
y
Qual
itat
ive
stud
y w
ith p
he-
no
men
olo
gic
al a
ppro
ach
To i
nves
tigat
e th
e fe
elin
gs
exper
ience
d b
y
nurs
es a
fter
ep
isodes
of
vio
lence
in t
he
work
-
pla
ce
9 E
D n
urs
es
ED
nurs
es f
elt
that
vio
lent
epis
odes
wer
e in
evit
able
.
Fac
ing s
uch
ep
isodes
led
to f
eeli
ngs
of
bei
ng v
uln
er-
able
, fe
ar,
angry
, lo
nel
ines
s an
d a
lac
k o
f su
pport
fro
m m
anag
em
ent.
Thes
e fe
elin
gs
wer
e des
crib
ed a
s
long
-las
ting e
ffec
ts.
Gen
der
dif
fere
nce
s w
ere
also
found t
o p
lay i
mp
ort
ant
role
s in
em
oti
onal
re-
sponse
s.
Rugle
ss a
nd T
aylo
r (2
011
)
Aust
rali
a
Obse
rvat
ional
stu
dy,
quan
-
tita
tive
appro
ach
To e
xam
ine
pat
tern
s o
f an
d a
ttit
udes
to s
ick
leav
e ta
ken
by E
D a
nd o
ther
hosp
ital
sta
ff a
nd
to c
om
par
e E
D d
oct
ors
’ an
d n
urs
es’
psy
cho
-
soci
al w
ork
cond
itio
ns
158 E
D s
taff
mem
ber
s (8
7 E
D
nurs
es)
The
hig
h r
ate
of
sick
lea
ve
amo
ng E
D n
urs
es m
ight
be
rela
ted t
o t
hei
r co
nsi
der
able
psy
cho
logic
al j
ob
dem
and a
nd p
erce
ived
lac
k o
f su
per
vis
or
sup
port
.
Co
mpar
ed w
ith E
D n
urs
es,
ED
doct
ors
had
sig
nif
i-
cantl
y m
ore
job i
nse
curi
ty a
nd s
uper
vis
or
sup
port
but
less
psy
cho
logic
al j
ob d
eman
d (
p <
0.0
5).
Saw
atzk
y a
nd E
nns
(201
2)
Can
ada
Cro
ss-s
ecti
onal
surv
ey
stud
y,
quan
tita
tive
ap-
pro
ach
To e
xp
lore
the
fact
ors
that
pre
dic
t th
e re
ten-
tio
n o
f nurs
es w
ork
ing i
n E
Ds
261 E
D n
urs
es
Of
the
resp
onden
ts,
25%
wil
l pro
bab
ly o
r d
efin
itel
y
leav
e th
eir
curr
ent
ED
jobs
wit
hin
the
nex
t yea
r. E
n-
gag
em
ent
pla
yed
a c
entr
al r
ole
in E
D n
urs
es’
inte
n-
tio
n t
o l
eave
and w
as a
ssoci
ated
wit
h j
ob s
atis
fac-
tio
n,
com
pas
sio
n s
atis
fact
ion,
com
pas
sio
n f
atig
ue
and b
urn
out
(p <
0.0
5).
8
7
Ap
pen
dix
III
.
Det
ail
s on
th
e re
searc
h a
rtic
les
in t
he
scop
ing l
iter
atu
re r
evie
w (
con
tin
ued
)
Au
thors
/cou
ntr
ies
Stu
dy a
pp
roach
A
im
Sam
ple
M
ain
fin
din
gs
Wes
tphal
et
al.
(2015)
Sw
itze
rlan
d
Des
crip
tive
surv
ey,
quan
ti-
tati
ve
appro
ach
To e
xam
ine
whet
her
min
dfu
lnes
s pro
tect
s
agai
nst
the
impac
t o
f w
ork
-rel
ated
str
ess
on
men
tal
hea
lth a
nd b
urn
out
in e
mer
gen
cy
nurs
es
50 E
R n
urs
es
Inte
rper
sonal
co
nfl
ict
was
rep
ort
ed t
o b
e th
e m
ain
stre
ssor.
Nurs
es w
ork
ing m
ore
co
nse
cuti
ve
day
s
since
tak
ing t
ime
off
wer
e at
hig
h r
isk f
or
dep
res-
sio
n,
and t
hose
rep
ort
ing m
ore
wo
rk-r
elat
ed i
nte
r-
per
sonal
confl
icts
wer
e at
hig
h r
isk f
or
burn
out.
Min
dfu
lnes
s w
as a
ssoci
ated
wit
h r
educe
d a
nxie
ty,
dep
ress
ion a
nd b
urn
out.
Wolf
, D
elao
and P
erhat
s (2
014
)
Unit
ed S
tate
s
Qual
itat
ive
des
crip
tive
ex-
plo
rato
ry d
esig
n,
nar
rati
ve
inq
uir
y a
pp
roac
h
To b
ette
r under
stan
d t
he
exper
ience
of
emer
-
gen
cy n
urs
es w
ho h
ave
bee
n p
hysi
call
y o
r
ver
bal
ly a
ssau
lted
whil
e pro
vid
ing p
atie
nt
care
in U
nit
ed S
tate
s E
Ds
46 E
D n
urs
es
Envir
onm
enta
l, p
erso
nal
and c
ue
reco
gnit
ion w
ere
iden
tifi
ed a
s th
e th
emes
. O
ver
all,
nurs
es b
elie
ved
that
vio
lence
was
endem
ic t
o t
hei
r w
ork
pla
ce a
nd
that
bo
th l
imit
ed r
eco
gnit
ion o
f cu
es i
nd
icat
ing a
hig
h-r
isk p
erso
n o
r en
vir
onm
ent
and a
cult
ure
of
ac-
cepta
nce
of
vio
lence
wer
e bar
rier
s to
mit
igat
ion.
Zam
pie
ron,
Gal
eazz
o,
Turr
a an
d
Buja
(2
010)
Ital
y
Cro
ss-s
ecti
onal
stu
dy,
quan
tita
tive
app
roac
h
To q
uan
tify
the
per
ceiv
ed a
ggre
ssio
n t
ow
ards
nurs
es w
ork
ing i
n t
wo I
tali
an h
ealt
h c
are
in-
stit
uti
ons
and t
o v
erif
y t
he
hypoth
esis
of
an
asso
ciat
ion b
etw
een t
he
char
acte
rist
ics
of
ag-
gre
ssors
and t
he
type
of
aggre
ssio
n
595 n
urs
es a
t tw
o h
ealt
h c
are
inst
ituti
ons
(38 E
D n
urs
es)
Nurs
es (
more
oft
en f
em
ale
nurs
es w
ork
ing i
n t
he
ED
and i
n g
eria
tric
and p
sych
iatr
ic u
nit
s) h
ad e
xper
i-
ence
d a
ggre
ssio
n i
n t
he
pre
vio
us
yea
r (4
9%
), o
f
whic
h 8
2%
was
ver
bal
. A
ggre
ssio
n a
t w
ork
was
re-
late
d t
o f
atig
ue,
str
ess
and w
ork
dis
sati
sfac
tio
n.
88
Appendix IV.
References in the scoping literature review
Adriaenssens, J., De Gucht, V., & Maes, S. (2015). Causes and consequences of
occupational stress in emergency nurses, a longitudinal study. Journal of
Nursing Management, 23(3), 346–358.
Adriaenssens, J., De Gucht, V., & Maes, S. (2012). The impact of traumatic events
on emergency room nurses: Findings from a questionnaire survey. Inter-
national Journal of Nursing Studies, 49(11), 1411–1422.
Adriaenssens, J., De Gucht, V., Van Der Doef, M., & Maes, S. (2011). Exploring
the burden of emergency care: Predictors of stress-health outcome in
emergency nurses. Journal of Advanced Nursing, 67(6), 1317–1328.
Bailey, C., Murphy, R., & Porock, D. (2011). Professional tears: Developing emo-
tional intelligence around death and dying in emergency work. Journal
of Clinical Nursing, 20(23–24), 3364–3372.
Declercq, F., Meganck, R., Deheegher, J., & Van Hoorde, H. (2011). Frequency of
and subjective response to critical incidents in the prediction of PTSD in
emergency personnel. Journal of Traumatic Stress, 24(1), 133–136.
Gates, D. M., Gillespie, G. L., & Succop, P. (2011). Violence against nurses and
its impact on stress and productivity. Nursing Economic$, 29(2), 59–67.
Gevers, J., Van Erven, P., De Jonge, J., Maas, M., & De Jong, J. (2010). Effect of
acute and chronic job demands on effective individual teamwork behav-
iour in medical emergencies. Journal of Advanced Nursing, 66(7), 1573–
1583.
Gholamzadeh, S., Sharif, F., & Dehghan Rad, F. (2010). Sources of occupational
stress and coping strategies among nurses who are working in admission
and emergency departments in hospitals affiliated to Shiraz University
of Medical Sciences, Iran. Iran Journal of Nursing and Midwifery Re-
search, 16(1), 41–46.
García-Izquierdo, M., & Ríos-Rísquez, M. I. (2012). The relationship between psy-
chosocial job stress and burnout in emergency departments: An explora-
tory study. Nursing Outlook, 60(5), 322–329.
89
Appendix IV.
Reference lists of the scoping literature review (continued)
Healy, S., & Tyrrell, M. (2011). Stress in emergency departments: Experiences of
nurses and doctors. Emergency Nurse, 19(4), 31–37.
Hunsaker, S., Chen, H. C., Maughan, D., & Heaston, S. (2015). Factors that influ-
ence the development of compassion fatigue, burnout, and compassion
satisfaction in emergency department nurses. Journal of Nursing Scholar-
ship, 47(2), 186–194.
Kogien, M., & Cedaro, J. J. (2014). Public emergency department: The psychoso-
cial impact on the physical domain of quality of life of nursing profession-
als. Revista Latino-Americana de Enfermagem, 22(1), 51–58.
Kowalenko, T., Gates, D., Gillespie, G. L., Succop, P., & Mentzel, T. K. (2013).
Prospective study of violence against ED workers. American Journal of
Emergency Medicine, 31(1), 197–205.
Lavoie, S., Talbot, L. R., & Mathieu, L. (2011). Post‐traumatic stress disorder
symptoms among emergency nurses: Their perspective and a ‘tailor‐
made’ solution. Journal of Advanced Nursing, 67(7), 1514–1522.
Lu, D. M., Sun, N., Hong, S., Fan, Y. Y., Kong, F. Y., & Li, Q. J. (2015). Occupa-
tional stress and coping strategies among emergency department nurses of
China. Archives of Psychiatric Nursing, 29(4), 208–212.
Nielsen, K. J., Pedersen, A. H., Rasmussen, K., Pape, L., & Mikkelsen, K. L.
(2013). Work-related stressors and occurrence of adverse events in an ED.
American Journal of Emergency Medicine, 31(3), 504–508.
Oliveira, J. D., Achieri, J. C, Pessoa Jr., J. M., Miranda, F. A. N. D., & Almeida,
M. D. G. (2013). Nurses’ social representations of work-related stress in
an emergency room. Revista da Escola de Enfermagem da USP, 47(4),
984–989.
Pereira, D. S., Araújo, T. S. S. L., Gois, C. F. L. G., Prata, J., Rodriguez, E. O. L.,
& Santos, V. D. (2014). Occupational stressors among nurses working in
urgent and emergency care units. Revista Gaúcha de Enfermagem, 35(1),
55–61.
90
Appendix IV.
Reference lists of the scoping literature review (continued)
Popa, F., Raed, A., Purcarea, V. L., Lala, A., & Bobirnac, G. (2010). Occupa-
tional burnout levels in emergency medicine—a nationwide study and
analysis. Journal of Medicine and Life, 3(3), 207–215.
Ramacciati, N., Ceccagnoli, A., & Addey, B. (2015). Violence against nurses in
the triage area: An Italian qualitative study. International Emergency
Nursubg, 23(4), 274–280.
Rugless, M., & Taylor, D. M. (2011). Sick leave in emergency department: Staff
attitudes and the impact of job designation and psychosocial work condi-
tions. Emergency Medicine Australas, 23(1), 39–45.
Sawatzky, J. A. V., & Enns, C. L. (2012). Exploring the key predictors of reten-
tion in emergency nurses. Journal of Nursing Management, 20(5), 696–
707.
Westphal, M., Bingisser, M. B, Feng, T., Wall, M., Blakley, E., Bingisser, R, &
Kleim, B. (2015). Protective benefits of mindfulness in emergency room
personnel. Journal of Affective Disorders, 175, 79–85.
Wolf, L. A., Delao, A. M., & Perhats, C. (2014). Nothing changes, nobody cares:
Understanding the experience of emergency nurses physically or ver-
bally assaulted while providing care. Journal of Emergency Nursing,
40(4), 305–310.
Zampieron, A., Galeazzo, M., Turra, S., & Buja A. (2010). Perceived aggression
towards nurses: A study in two Italian health institutions. Journal of
Clinical Nursing, 19(15–16), 2329–2341.