International Journal of Nursing Practice 2001; 7: 342–348
R E S E A R C H PA P E R
How do nurses deal with their emotions on a burn unit? Hermeneutic inquiry Camille Cronin RN, DipHE, BSc, MSc (Nursing) Research Assistant, Department of Nursing Studies, University College Cork, National University of Ireland, Cork, Republic of Ireland Accepted for publication February 2001 Cronin C. International Journal of Nursing Practice 2001; 7: 342–348 How do nurses deal with their emotions on a burn unit? Hermeneutic inquiry Burn unit nurses work in an emotionally exhausting environment and are frequently exposed to emotional trauma. Emotion is a difficult concept to define. This study used a hermeneutic-phenomenological approach to establish the experiences of nurses working on a burn unit to find out how they deal with their emotions.The findings suggest that nurses have little or no time to deal with their emotional experiences.This study has shown that current support services might be ineffective. Nurses realize that they have emotions. They also recognize the need to address these emotions. Recommendations for nursing practice are made as a result of these findings. Key words: burn unit, hermeneutic phenomenology.
INTRODUCTION The purpose of this study was to examine how nurses that are caring for patients with burns deal with their emotions.The study aimed to investigate the types of support that nurses receive and whether or not they require more support. Qualitative research methodology was conducted on a regional burn unit in the UK.
Context Working on a burn unit can evoke considerable amounts of stress and emotion.1,2 The mention of someone suffering burns conjures up images of extreme pain and disfigurement. Therefore, the atmosphere surrounding burn units is very intense. The unit specializes in the care of acutely injured individuals and can involve caring for
Correspondence: Camille Cronin, Department of Nursing Studies, University College Cork, National University of Ireland, Cork, Republic of Ireland. Email: [email protected]
people who are critically ill. Burn units are filled with an array of sensory stimuli, machinery and monitors. Daily, nurses encounter stressful events, including daily dressing changes, listening to those in pain and meeting the disfigured, as they are central figures in the care of patients.3,4 These situations involve emotional intimacy imparted with a smile or a caring hand/word, and nurses must quickly learn to accept these situations.5 Nurses suppress their emotions in order to care, irrespective of their personal attitudes towards themselves, individual patients, circumstances and conditions.6 Davidson and Jackson postulate that nurses working under such extreme conditions are likely to experience increased fear of death, fear of mutilation and feelings of powerlessness.7 In a comparative study on the emotional reactions of patients’ pain with burn units and neonatal intensive-care units, exposure was found to cause emotional distress, which has implications for patient care and the health of nurses.8 Consequently, emotions in the workplace need to be recognized and removed from the stereotypical beliefs that these types of reactions are irrational.9 Emotional
Nurses’ emotions on a burn unit
labour can be seen to have far-reaching effects on nurses. Total repression of emotions is not possible, and this needs to be acknowledged. There is both anecdotal and empirical evidence about nurses working on burn units; however, there is a paucity of rigorous research conducted in this area.3,4,8,10–14 The majority of related research comes from other clinical areas such as intensive-care settings and emergency units. Occupational stress, including atmosphere and intensity of work, critically ill patients, increasing workloads and shortage of staff and resources appear to be consistent issues.15–20 This does not answer the question of how nurses in burn units cope with their emotions. The research suggests that nurses do not have the opportunity or the time to deal with their emotions, and that nurses need to have time to reflect on their experiences. As a result of the lack of research in this area, this study is of relevance to nurses working on burn units and other intensive-care settings.
METHODS Hermeneutic phenomenology was the method of inquiry chosen and was used to examine how nurses deal with their emotions on a burn unit. Phenomenological research does not attempt to validate preconceived theories, but rather provides descriptions of emotions (phenomena), which are faithful representations of nurses’ experiences. Nursing and hermeneutic phenomenology share the beliefs and values that people are whole and that they create their own particular meanings.21 Hermeneutic phenomenology is interested in people’s lived intersubjective experiences in their worlds.This is related to nurses’ concerns of and interpretation of peoples’ experience in everyday life. Five registered nurses working on a burn unit were randomly selected and interviewed to elicit their experiences. Their experience on the unit varied from 1 to 8 years, with ages spanning 25–40 years. Length of experience varied, as did seniority, with positions ranging from junior staff nurse to senior sister. Each interview lasted 1–1.5 h and was tape-recorded and transcribed. Phenomenologists recognize that it is impossible to avoid researcher-bias and accept that it is a part of hermeneutic phenomenology.22,23 By immersing oneself in the phenomena, there is a risk of getting entangled with all of the experiences. The relationship between researchers and respondents can enhance or threaten credibility.24 In close relationships with respondents, the
Table 1 Ricoeur’s four principles of distancing First form of distancing Second form of distancing Third form of distancing Fourth form of distancing
Transcription of dialogue: it becomes text and is fixed Relationship between the written text and the original speaker The text is freed from the original audience Addressed to a wider audience, all readers
researcher is likely to elicit an honest account of their experiences.25 Data were analysed using Ricoeur’s26 textual interpretation in an attempt to clarify and/or make sense of an object of study.21 The object of study must be text. A text is any discourse (conversation or speech) transcribed into writing. The task of hermeneutic phenomenology is to describe and explain human phenomena, for example, the nurse working on a burn unit.Written descriptions of the phenomena (text) become the objects of interpretation. The four principles of distancing by Ricouer are shown in Table 1.26 This implies that the text needs to be interpreted in a different way. The text is seen as a whole, which means that words acquire meaning in the context of sentences, and sentences acquire meaning in the context of paragraphs and of the text as a whole.Thus by ‘freeing the text’ from its context, the reader is able to see the sum of the parts as a whole. The text is treated as a ‘worldless entity’ where emphasis is placed on internal relationships within the text.26 Data, that is, sentences and paragraphs, are allocated to categories based on their relationships with one another. Categories are compared and contrasted, and further integration evolves. Ricoeur states that analysis carries ‘out the segmentation of the work (horizontal aspects), and establish various levels of integration of the parts in the whole (hierarchical aspects)’.26 Furthermore, interpretation of the text leads to understanding. Through this approach, ‘the concern is not what the text describes (explanation) but what the text discloses (understanding)’.27 By critical examination, the task of hermeneutic interpretation is to gain a deeper meaning of this phenomenon.
DISCUSSION Findings are discussed and narrative data (all in quoted italics) have been used to describe the nurses experiences
Table 2 Framework of content analysis and themes that emerged from the narrative data Themes
does not mean behaving irrationally, it represents pure emotional release of feelings. Burnard addressed this emotional release as catharsis in the intensive-care setting.29 The following excerpt illustrates the difficulties with defining emotion:
Emotion Stress Detaching oneself Ethical issues Death Clinical area Patient with burn injury Burn unit Staff shortages The nurse Experience Being a nurse Personal character Support Support Home Rationale Justification Procedures People Children Family and relatives Other people
with respect to some of the themes. The framework that emerged from the analysis in Table 2 was developed from the transcripts.
Unseen exposure The burn unit appears to be a very emotional and isolated place. Emotions can manifest, making the unit a very stressful environment in which to work. As expressed by one nurse, ‘. . . the unit is a box. Hence, anything within the box can build up and then that is where I feel that emotions and things can become stressful’. Sharp suggests that nurses need to be aware of the manifestation of stress in order to anticipate support for patients, relatives and colleagues.28 The findings suggest that nurses have different interpretations of the meaning of emotion. Being ‘emotional’
Emotion is quite a hard word to define isn’t it? Emotions and feelings are very intertwined. I have a lot of mixed emotions if working on the unit, in the capacity that I do work sometimes I go through frustration, a bit of guilt, a bit of anger, elation, being on a high. You know so it’s a whole range of emotions.
Strongman also affirms this.30 However, although the nurses are affected in this way and have emotions and feelings, it was generally felt that emotions should not be expressed. Small discussed the invisibility of emotional labour within the National Health Service (NHS) and how it was carried out within the framework of physical tasks.31 In this study, one nurse referred back to her training ‘. . . if there was anything that upset you, then you would have to quietly make your exit and not make a scene’. Another said, ‘You know nurses weren’t meant to cry at work, nurses aren’t meant to show any emotions’. The nurses accepted that emotions exist but they have their place. Kettles’ study of nurses shows that emotions are used to facilitate coping with patients, but does not suggest that nurses are aware of their own emotions, contrary to the findings in this study.32 For example, one participant said, ‘I am probably more self-aware of my emotions and that might be because I am aware of my stress levels a lot’. Stress was linked with how nurses deal with emotions. By the very nature of the burn unit and its work, nurses who are involved with the care of burn victims know that stress is a part of this type of nursing.14 This was evident in this study, as illustrated in the following comment, ‘I find that I get quite stressed when I’m dealing with children, a big burn particularly.’ Furthermore, new staff have found this area of work particularly stressful. For example, . . . when you first start there, the stress levels are coping with the wounds and the size of the wounds, how it looks and coping with relatives who are not coping with it and trying to explain things, etc.
Stress appears to be induced by particular situations or people. Lally and Pearce have identified a variety of factors
Nurses’ emotions on a burn unit
such as overwhelming workload and conflict between nursing staff as major causes of stress in the Intensive Therapy Unit (ITU) setting.17,33 It seems fair to suggest that the burn unit in this study yielded similar findings. For example, ‘I sort of feel that it doesn’t take as much for me to get cross with, not individuals, but with the situation . . .’ or ‘. . . it’s you’re next trauma or crisis is coming up before the last one has finished very often, and I find that quite stressful’.
other clinical areas. Nurses who stay on the unit have usually worked on the unit for some years (1–13 years). This experience accumulates and helps nurses to deal with their emotions.
Von Baeyer’s11 survey of perceived stress and coping strategies among burn unit nurses showed that the more experienced the nurse was, the less benefit gained from stress management training. This questions whether or not experience helps nurses to deal with their emotions. Certain personality characteristics are evident on the unit, including confidence, control and hardiness. ‘But then you get to a point where you feel confident and you feel that you are in control, whatever is thrown at you.’ Another nurse said, ‘. . . you have to toughen up and you have to be prepared to stick your neck out and stand by what you think, what you know is right’. Brack et al. found that staff must appear both tough and nurturable to promote patient compliance and facilitate burn care.13 Bernstein suggests that nurses pass through stages of adjustment and, eventually, those who remain accept and are committed to the work of the burn unit.5 Korbasa suggests that commitment, control and the challenge are elements of hardiness.34 This element of hardiness fits in with Folkman’s individual belief of having control and the process of cognitive appraisal.35 However, there are times when it becomes too much and staff burnout.30 This is evident in this study ‘I realize that there are weak spots. And whether those weak spots are there because, when I say weak I don’t mean weak as in you know . . . jinks in my armour.’ One nurse said,‘. . . if anything . . . I realize that I’m not quite as infallible as I thought I was . . .’. Many nurses hide their feelings because they do not wish to appear weak in front of colleagues, or fear being labelled.
The burn unit has its own characteristics and pattern of work. It goes from one extreme to the other. I liked the variety, I liked the fact that things change and you can be all right one minute, busy the next.You never know from one day to the next what you’ve got on.
Also, there is the pace of work to consider. For example, ‘. . . everyone is running around like a lunatic, but say you’ve just done . . . an escharotomy, you just done a dressing’. The burn unit can be surmised in this excerpt, I think that it is a different type of work. It’s not you’re run of the mill medical, surgical nursing.There is no routine.You never know what’s coming in.
The findings of this study are consistent with an explorative study on what nurses perceive as stress factors on a burn unit.14 By virtue of working on a burn unit, the nurses are affected by a variety of things that they see and do. One participant commented, I think this is a place where you do get affected by what you see. I mean that I’m affected by it all time.You know,even if it isn’t serious, I’m still affected by it.
For others, it is just the pure intensity of the work that affects them. One nurse said, The other times as well is when you’re on continuously, it’s in every shift you are put into an intensive care room.When the intensity is quite strong in those rooms, you have no time to unwind. 12 h shifts, even though you’re getting breaks, you never can switch off.
The nurse Each nurse working on the burn unit brings their experience, whether it’s from their own background or from
I think that people are older and they have a lot more life experience, perhaps can be a lot more sympathetic to the kind of traumas that the patient are going through about changes in their lives, about disfigurements, just loss of control and issues like that.
Support The burn unit ‘. . . is a bit like a family’.There appears to be a strong informal network among colleagues, and this was found in supporting research.3,14,17,28 Support is found during coffee breaks, in changing rooms or during talks with friends outside of the unit. However, some suggest this form of support is unhealthy.36,37 Other research
among nurses has shown positive relationships between stress reactions and lack of social support from colleagues.38,39 Perhaps this is now reflective of the increasing turnover of registered nurses from specialized units.40–43 There have been support services such as occupational health, counsellors and clinical psychologists available for nursing staff; however, these services have poor attendance rates and subsequently are fazed out. Spencer revealed similar findings in the ITU setting.44 One participant in this study said, ‘The counsellors have tried, we don’t talk to them. They will come to you and try to start a conversation.’ Another nurse said, ‘. . . we had a counsellor come in and I felt that it was just a waste of time.’ Despite this, Tringali advocates the presence of a psychiatric nurse to facilitate a supportive atmosphere.10 Regardless of these rather negative attitudes, it is believed that there is scope for alternative means of support. For example, ‘it would be good if we could take people to one side and kind of run through case histories . . . they could ask more questions or express more opinions.’ However, the findings of this study strongly suggest that nurses are on their own in terms of finding support. ‘I think that is more of people finding their own support’ or ‘We are very much left to find our own support.’ It is up to the individual nurse to make the decision to look for support and find the time to give support to others. One nurse said,‘. . . there is no time for any support.You know, formally, on a shift.’ Demerouti et al. have suggested that supervisors can play key roles in creating a healthy working environment.20 Some nurses are able to leave work and all that happened behind, but others find it difficult. They have a hard day and have been busy, and something has upset them. Sometimes it is easier to deal with these feelings at home. Perhaps they can deal with this by talking to a partner, a friend outside work or participating in some form of physical exercise. There is little evidence to support these findings in burn nursing; however, Spencer acknowledges these findings in the ITU setting.44 In this study, one nurse said, ‘I might go home and get upset about it, but I wouldn’t do it while I was at work.’Another nurse said,‘I tend to curl up in the corner of the sofa with a coffee and just sit and watch TV. But while I’m watching TV, my mind is still turning over, going over and over’. Others found the journey between work and home important. It was valued as a time for silence and to think about nothing.
CONCLUSION The findings from this study have highlighted the unpredictable nature of burn-unit nursing.The environment poses both physical and psychological demands. Hermeneutic phenomenology has captured the lived experience of five nurses.They describe the job as stressful and emotionally demanding, and feel that they do have emotional reactions to the experiences encountered at work. The nurses had different interpretations of the meaning of emotions, and while some felt capable of dealing with them, others had not been dealing with them adequately. The nurses felt that there is not enough time to express emotions, and that this is reason enough to suggest a change. The nurses have to rely on themselves to find formal support. Informal support structures are a strength of the unit and found within networks of colleagues. This is not available to all nurses. Generally, nurses who work on the unit develop friendships over a number of years. Newly recruited nurses go through a period of adjustment, and have no support.The nurses suggest that support is available at home from partners, and family and friends outside of work. This is not available to everyone, and it should be questioned whether or not this type of support is adequate. Nurses need to realize that they have feelings and emotions, and that it is time to acknowledge them. The research suggests that nurses need to examine their own feelings before they are able to help others. The nurses suggest that there is scope for further support. It was suggested that the responsibility for making the decision regarding formal support lies with each nurse. Support can be strengthened and stress alleviated by incorporating informative teaching groups, thereby alleviating emotional burdens. Nurses need to have time-out from the unit to discuss emotionally difficult situations and problems. Holding regular debriefing sessions was one solution identified where clinical cases and incidents are reviewed. Through reflective learning, discussion of scenarios and assimilation, learning can become an integral part of the burn unit. This can educate new staff and also inform existing staff, aid retention and prevent turnover of staff, prevent emotional trauma and reduce sickness, absenteeism, and burnout. Nurses cope because they have to and recognize that they need a form of support. It is time for nurses to make time for support. Based on the findings of this research, it is recommended that further research is necessary in similar clinical settings.
Nurses’ emotions on a burn unit
ACKNOWLEDGEMENTS The author would like to thank all of the nurses who participated in this study.
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