{"id":1489,"date":"2022-12-15T09:59:46","date_gmt":"2022-12-15T09:59:46","guid":{"rendered":"https:\/\/mpelembe.net\/?p=1489"},"modified":"2022-12-15T09:59:55","modified_gmt":"2022-12-15T09:59:55","slug":"its-like-being-in-a-warzone-ae-nurses-open-up-about-the-emotional-cost-of-working-on-the-nhs-frontline","status":"publish","type":"post","link":"https:\/\/mpelembe.net\/index.php\/its-like-being-in-a-warzone-ae-nurses-open-up-about-the-emotional-cost-of-working-on-the-nhs-frontline\/","title":{"rendered":"\u2018It\u2019s like being in a warzone\u2019 \u2013 A&E nurses open up about the emotional cost of working on the NHS\u00a0frontline"},"content":{"rendered":"

Kate Kirk<\/a>, University of Leicester<\/a><\/em><\/span><\/p>\n

As nurses prepare to strike<\/a> for the first time, an A&E nurse and lecturer in Organisational Behaviour in Healthcare writes about the stress, fear, grief and guilt they feel every day working on the frontline of an NHS in crises.<\/strong> <\/p>\n

<\/p>\n

\n
\n

I noticed how I used the phrase \u2018warzone\u2019 quite a few times, when you\u2019ve got trolleys everywhere \u2026 full of patients and you don\u2019t know where to turn next. What to do for whom next, and I have said it\u2019s like being in a warzone because you can imagine it. That\u2019s what it would be like in a field hospital \u2026 what do I do next? You know it\u2019s dangerous but you\u2019ve just got to do the best you can do. And I\u2019ve heard other people use that term as well. Just how it makes you feel but something kicks in and you just get on with it. <\/p>\n<\/blockquote>\n

This was how one nurse in her 40s described an Accident and Emergency (A&E) department to me, and it sounded all too familiar. <\/p>\n

The resuscitation area in the emergency department is a hive of time-critical activity as staff weave around one another at pace. The sheer din is intense: a symphony of alarms, voices and crying out \u2013 all varying in pitch and volume, competing with one another. The bays are awash with wires, pipes, medical equipment and pumps to give various medication. <\/p>\n

This is the norm. But some nights will always stand out above the others. Once, while I was on shift, a three-year-old girl in a nearby resuscitation bay was receiving treatment for meningitis. Following a substantial and sustained attempt at resuscitation by the paediatric team, she died. <\/p>\n

I wasn\u2019t caring for her directly, but it was apparent from the noise how the treatment was progressing and when, ultimately, it was unsuccessful. The screams and cries of grief from the girl\u2019s parents were heard above all other noise when staff broke the news to them that their child was dead. It was unforgettable. <\/p>\n

\n

This story is part of Conversation Insights<\/em><\/strong>
\n
The Insights team generates long-form journalism<\/a> and is working with academics from different backgrounds who have been engaged in projects to tackle societal and scientific challenges.<\/em><\/p>\n

\n

Many of the adult patients were too unwell to know what was going on. So, despite the communal awareness among staff of the enormous distress close by, we carried on caring for our other patients, offering them the \u201creassuring face\u201d and warmth they expected. I stood behind one of the curtains for a few moments and swallowed hard at the sounds of the suffering. And that was it. Sadness and distress at the death of a child had to be suppressed for the sake of the other patients.<\/p>\n

On the drive home I reflected on the emotional complexity it requires to be a nurse. The need to hide sorrow while juggling great workloads, the pressure of organisational targets and other patients\u2019 seemingly less critical needs requires intense effort and emotional control. That effort is exhausting and draining.<\/p>\n

This tragic incident was just one of many similar experiences I have encountered over my 11-year career as an A&E nurse. Heartbreaking and emotionally complex stories like this happen every day in A&Es up and down the country. Nurses have to conceal myriad feelings as standard just to get through their shifts. This includes harrowing, disturbing and traumatic emotion as described in the story above, but also fear and anxiety when they feel overwhelmed and have to deal with aggressive situations. Nurses experience joy and relief when a patient recovers against the odds but frequent guilt and shame at being unable to deliver the standard of care they desire. <\/p>\n

The exploration of emotional labour in emergency care has underpinned my subsequent<\/a> research career<\/a>. It has motivated me to explore and support this under-recognised area of nursing practice.<\/p>\n

\u201cEmotional labour<\/a>\u201d is a theory coined by sociologist Arlie Hochschild who defines it as \u201cthe management of feeling to create a publicly observable facial and bodily display\u201d. When that toddler died of meningitis, myself and the other nurses did our own emotional labour by suppressing our true emotions to ensure the other patients in our care felt reassured. In other words, we remained \u201cprofessional\u201d.<\/p>\n

But the nurses I spoke to are not only dealing with emotions related to grief and bereavement. Because of the crisis facing the NHS, many feel they can\u2019t do their job properly and so have overwhelming feelings of guilt too. A male nurse in his 30s told me: <\/p>\n

\n

You can\u2019t be the sort of nurse you might want to be \u2026 You can\u2019t nurse people properly in the ED (emergency department) \u2026 You don\u2019t have the staff or facilities to do that and it\u2019s just getting worse \u2026 I think it\u2019s one of the major things that make it a hard place to work because you feel that you\u2019re not doing the best for the people you\u2019re looking after \u2026 it can actually grind you down. As nurses, you want to care for people. You want to make a difference.<\/p>\n<\/blockquote>\n

\n \"Black
\n A workforce in crisis.<\/span>
\n Shutterstock\/jotamadrid<\/a><\/span>
\n <\/figcaption><\/figure>\n

NHS in crisis<\/h2>\n

A recent analysis<\/a> by The Kings Fund showed the extreme pressure the NHS is under. More patients than ever are experiencing delays in cancer diagnosis and treatment and longer waiting times<\/a> in \u201cnon-urgent care\u201d.<\/p>\n

These pressures have an impact on patients, but also affect those tasked with delivering care. Nurses are quitting in record numbers<\/a>. By 2030-31 half a million extra healthcare staff<\/a> will be needed to meet the pressures of demand \u2013 a 40% increase in existing workforce. Health and social care staff are exhausted and the workforce is depleted<\/a>. The negative impact of this crisis cannot be underestimated for both staff and patients.<\/p>\n

When nurse staffing is short or lacking in the required skills due to issues like high staff turnover and sickness, research shows<\/a> that patient mortality is higher and patient experience is poor<\/a>.<\/p>\n

Nurses working in short-staffed areas are twice as likely<\/a> to be dissatisfied with their jobs, to show high burnout levels, and to report low or deteriorating quality of care in their hospitals. This becomes a vicious cycle as these experiences fuel more staff to leave. <\/p>\n

Sickness absence rates<\/a> in the NHS are higher than in the rest of the economy and 47% of staff felt unwell in the last 12 months as a direct result of workplace stress. One study has shown levels of Post Traumatic Stress Disorder similar to those experienced by soldiers<\/a> in Afghanistan.<\/p>\n

A recent evaluation<\/a> found that poor mental health and wellbeing among medical staff is costing the NHS about \u00a312.1 billion per year.<\/p>\n

Accident and Emergency<\/h2>\n

In England, NHS patient attendance to A&E has followed an upward trajectory over the last 70 years. In 2019-20 there were 25 million<\/a> attendances, compared to 21.5 million attendances in 2011-12.<\/p>\n<\/p>\n

Patient attendance has been growing exponentially in the last ten years. This, together with rises<\/a> in patients who need admitting to hospital for routine care, fewer<\/a> hospital beds and staffing pressures has resulted in unsafe patient overcrowding<\/a> in A&Es. Research<\/a> has shown how overcrowding increases adverse clinical outcomes including death, medical error and decreased patient satisfaction.<\/p>\n

The most recent figures for 2022-23<\/a> show the worst A&E performance (waiting longer than four hours) on record.<\/p>\n

Perhaps unsurprisingly then, those working in emergency care are more likely than other healthcare workers to experience poor wellbeing<\/a>, suffer psychological illness<\/a> and to quit<\/a> their jobs.<\/p>\n

Nurses open up<\/h2>\n

According to the Royal College of Physicians, NHS staff are the greatest asset<\/a> of the NHS and are fundamental to delivering high-quality care. Staff go \u201cthe extra mile<\/a>\u201d as standard: they work without breaks, come in on their days off and often stay unpaid, long after shifts have finished.<\/p>\n

My PhD<\/a> aimed to understand<\/a> the experiences of nursing staff in A&Es and how they managed their emotions to cope with these challenges and still meet patient expectations. This is critical because emotional labour, in particular, is linked<\/a> to wellbeing and burnout. <\/p>\n

I worked with a team of academics to undertake an ethnographic observation study across two large NHS trusts in the UK. This involved 200 hours of observation and 36 in-depth interviews. We spoke to A&E nurses of all seniority and support staff in both organisations. We found that the nursing staff \u201cdid\u201d intense emotional labour routinely in their work. As one male nurse in his 30s explained:<\/p>\n

\n

\u2026 you know, you see quite a lot of bad things. You deal with a lot of complex things and \u2026 you do have to put up a front, a very professional front, and you have to deal with different levels of communication as well. You\u2019ll get someone with mental health problems one minute, get someone with a broken finger the next minute, someone\u2019s collapsed \u2026 Then you just have to mould yourself into a different personality \u2026 to communicate with [each patient], to get on their level of need \u2026 you\u2019ve got to go from zero to hero, as far as I\u2019m concerned \u2026 Never knowing somebody to doing something really, really intimate \u2026 So you\u2019ve got to get to know them really quickly, for them to be able to trust you.<\/p>\n<\/blockquote>\n

The nurses adapted their emotional response to support a vast spectrum of patient need. Among these complex and intense emotions, we heard examples of nurses who felt scared, guilty and endless examples of nurses being short on time and resource, feeling stressed, and grieving over patients who died. They hid their true feelings to make sure their patients felt safe and to build trust \u2013 whatever the circumstances. They moved at pace between groups of patients and adapted their appropriate \u201cprofessional\u201d response. <\/p>\n

We collected data over a six-month period and found that the nurses used various metaphors to describe experiences of managing their emotion in A&E. We found some key themes.<\/p>\n

Guilt and shame<\/h2>\n

Nurses described to us how sometimes the environment can feel overwhelming, using that \u201cwarzone\u201d phrase to explain their experiences. This sense of relentlessness and \u201ccombat\u201d has implications for the nurses emotional labour too. Their nursing values (related to providing care and compassion) are conflicted with the realities of contemporary practice. The standards of care possible amid the operational pressures don\u2019t reflect these nursing values (built on warm and reassurance).<\/p>\n

The nurses I spoke to weren\u2019t able to deliver the quality of care they wanted to. This means they needed to suppress the associated frustration and guilt. There was a sense of genuine sadness and even shame that they couldn\u2019t give their patients the time or connection they longed to.<\/p>\n

This former nurse said one incident in particular \u201cchanged her outlook on A&E\u201d and led to her thinking, \u201cI can\u2019t work here anymore\u201d.<\/p>\n

\n

It was a really, really busy winter day \u2026 trolleys were stacked \u2026 and right in the middle I had a little old lady in her 90s who suddenly deteriorated and I could do nothing but stand in the middle of all the trolleys, in front of all of those people, holding her, shouting for help. I just thought that if that was my grandmother, I\u2019d be disgusted.<\/p>\n<\/blockquote>\n

Assembly line<\/h2>\n

Instead of meaningful patient and nurse relationships, the care delivered in A&E often feels transactional and lacking emotional connection. Interactions were quick and task based. Again this results in the nurses feeling dissatisfied and often guilty. Jill Maben<\/a>, a professor of health services and nursing, found<\/a> that when nurses are unable to deliver the care they want to, it doesn\u2019t line up with their values. This disconnect (between values and reality) can be a reason why nurses leave the profession.<\/p>\n

The clinical realities of the nurses work went against their deep moral values and the desire to care. This was reflected by many of the nurses I met, including a female nurse in her 40s, who said: <\/p>\n

\n

I\u2019ve actually used that term assembly line \u2013 it\u2019s like a production line of patients \u2026 you\u2019ve got [ambulance] crews coming in constantly \u2026 You take handover from the crew, do the basics, move on to your next patient. Take handover, do the basics, move on to your next patient. You might not even see that patient again \u2026 it means there\u2019s a definite lack of care there \u2026 I go home feeling very unsatisfied because you\u2019ve not cared for people, you\u2019ve just checked their observations, given them any immediate treatment they need, but the actual caring aspect of it, you\u2019ve not really done any of that.<\/p>\n<\/blockquote>\n

For some of the A&E nurses interviewed in the study, the inability to deliver the standard of care they wanted to was unmanageable and they left. One told me she quit because A&E was so busy it meant ignoring some people who were waiting long hours. She said:<\/p>\n

\n

I think you need to be quite stony-hearted because it\u2019s a hard place to work \u2026 I care too much. I can\u2019t walk past somebody that says \u2018can you help me?\u2019 and unfortunately you don\u2019t have time. In A&E, you don\u2019t have time to stop for every person who says \u2018excuse me\u2019. You need to be able to walk past people \u2026<\/p>\n<\/blockquote>\n

Stress and fear<\/h2>\n

Sometimes the nurses said they were scared: scared of the overwhelming workload as well as the threats and intimidation they received from patients. One of the nurses, in her early 20s, described how she \u201cput on a front\u201d to her patients. She did this to hide any anxiety around her inability to cope. She was protecting her patients from her true emotion and as a result, making sure they felt safe:<\/p>\n

\n

I suppose from the outside it could appear that you\u2019re managing well, you\u2019re getting to your patients, you\u2019re putting on a front, you\u2019re smiling, you\u2019re happy. You present yourself. You tell them what the plan is, what\u2019s going to happen, what to expect next. Then you\u2019re whisking off to take the next patient or moving on to another area. So, yeah \u2026 patients\u2019 or relatives\u2019 perception could be that it doesn\u2019t look as busy because they don\u2019t see what\u2019s going on behind the scenes. They don\u2019t see what resus [resuscitation] is like, that there\u2019s minus three beds in there \u2026 Or the walk-in side \u2026 there could be probably five or six people in the waiting room wanting to know why they\u2019ve not been seen straightaway because it doesn\u2019t look busy, whereas resus is just behind the doors and there could be massive traumas going off.<\/p>\n<\/blockquote>\n

She said it was important not to let patients see that they were \u201cstressed and flustered\u201d because \u201cit gives them reassurance \u2026 to show patients that you\u2019re confident and you can get on with it\u201d.<\/p>\n

Again the nature of this emotional labour (this time suppressing fear and anxiety) is guided, in part by the need to protect and reassure patients under their care. Another nurse, in his 30s added:<\/p>\n

\n

\u2026you\u2019re actually like a parent to everybody. You\u2019re everybody\u2019s mum or dad. So on the surface you do have to look calm and you have to look like you\u2019re in control because they\u2019re vulnerable and you can\u2019t be panicking because it\u2019s just not going to solve anything, whereas underneath you might not have a clue what to do, but you have to come up with something and you might be crapping yourself \u2026 it\u2019s just a mask, isn\u2019t it?<\/p>\n<\/blockquote>\n

For some, the extraordinary feeling of stress involved is overwhelming but the nurses stay calm and professional outwardly, as described by a female nurse in her 30s: <\/p>\n

\n

It\u2019s a mixture of stress. Sometimes you just feel like you just don\u2019t know where to start. Sometimes in the environment where it\u2019s overcrowded like that, you can feel very enclosed and it can feel quite pressurised because \u2026 you can feel like everyone is looking at you.<\/p>\n<\/blockquote>\n

She added that the same amount of pressure and noise could amount to \u201ctorture\u201d for some people.<\/p>\n

But sometimes the stress was related to fear and anger when dealing with an aggressive and abusive patient. Again the nurses emotion remained hidden and out of sight of the patient and others in the waiting room. One nurse described an incident on a particularly busy night with man who was getting tired of waiting with a minor injury.<\/p>\n

She offered him assistance, as he was struggling to walk. But he shouted at her in front of a full waiting room, including children: \u201cWhy don\u2019t you just fuck off and die?\u201d<\/p>\n

\n \"Graphic
\n The \u2018emotional labour\u2019 it can take to be a nurse can lead to burnout.<\/span>
\n Shutterstock\/OlenasArt<\/a><\/span>
\n <\/figcaption><\/figure>\n

The nurse was shocked. The entire waiting room was staring back at her. She said she couldn\u2019t speak and that her \u201cblood was boiling\u201d but she was also frightened. She couldn\u2019t engage with him so she walked away, afraid she would shout back or cry if she tried to speak. \u201cHad I been outside of work, I wouldn\u2019t let people speak to me like that,\u201d she said. <\/p>\n

She added that if those unruly and abusive patients were shown a baby being resuscitated in the next room they might rethink their behaviour and show more respect. <\/p>\n

Grief and trauma<\/h2>\n

But all feelings must be managed, even sadness and grief \u2013 perhaps these emotions above all.<\/p>\n

\n

If you came into [A&E] and a nurse started blubbering because of your story, what would you feel like as a patient? So, we probably are good at emotions but actually we\u2019re good at not showing them. It doesn\u2019t mean to say we don\u2019t feel them \u2026 The more competent you become as a nurse, the more you actually learn that you have to suppress that \u2026 If you get a baby that comes in and the parents are screaming and crying, they don\u2019t want the nurse doing the same thing. They want the nurse to be efficient, to know what they\u2019re doing and to assist them. They do not need an emotional wreck to be dealing with them.<\/p>\n<\/blockquote>\n

This female nurse said that managing emotions like this meant some nurses might sometimes come across as \u201chard\u201d and \u201ccold\u201d.<\/p>\n

But being able to relate personally to the patient or their family, although helpful for the patient, can take a heavy toll on the nurse. One nurse got upset when telling me about the time she was pregnant with her little boy and was resuscitating a baby.<\/p>\n

\n

Yeah. That was a baby. It sticks with you. It definitely does. I was looking after another one \u2026 that was having seizures. It was a one-year-old little one in resus, and when I finished my shift, I\u2019d gone home, but it was on my mind all night and I was wanting to ring back and check. Obviously, I\u2019ve got no connection to that little one \u2026 you can relate it to your own children as well, put yourself in those parents\u2019 shoes.<\/p>\n<\/blockquote>\n

Compassion fatigue<\/h2>\n

Operational pressures in A&E and elsewhere in the health service squeeze the time nurses have with their patients. The fact many are unable to deliver the standard of care they long to contributes to nurses leaving the profession as described above.<\/p>\n

And those nurses who stay can become so burned out that they can suffer with compassion fatigue<\/a>: a protective mechanism in which nurses become emotionally \u201cshut down\u201d and as a result, can fail to notice and respond accordingly to trauma and suffering. This shows that the health \u2013 particularly the mental health \u2013 of nurses and doctors can directly impact patient care.<\/p>\n

We need to understand the emotional complexity of nursing and other healthcare work. In understanding it, we can value it. <\/p>\n

Nurses are not angels<\/a>, they are human beings, with the accompanying full spectrum of emotions. At their best they can offer life-changing support and compassion. But they need the resources and support. There is only so much stress, fear, grief and trauma a person can cope with before burning out completely. <\/p>\n

\n
\n \"\"
\n <\/span><\/p>\n<\/figcaption><\/figure>\n

For you: more from our Insights series<\/a>:<\/em><\/p>\n