Understanding Workplace Reciprocity of Emergency Nurses: A Qualitative Study

Purpose:  

Emergency Departments (ED) are unpredictable environments and are well-known for instantaneous change.  At one moment, the ED may be relatively quiet and then suddenly ambulances and helicopters arrive with multiple patients from a serious car accident.  Typically, nurses are the first healthcare provider encountered by the patient.  Given the rapid changes, this is an environment with high levels of stress and more so for the ED nurse (Browning, Ryan, Thomas, Greenberg, & Rolniak, 2007; Spence, Laschinger, & Havens, 1997).

EDs are open for patient care all day, every day.   The flow of patients and their reasons for presenting to the ED for care is not predictable.  Multiple patients can present to an ED with a variety of healthcare problems and concerns.  Prioritization of patient care in EDs is based on the patient’s acuity level.  Acuity levels are designated by the patient’s presenting illness or injuries.  This is termed triage.  Triage sorts patients according to the severity of illness or injury and how rapidly they require treatment (Sheehy, 2003). 

ED RNs care for a multitude of patients at any stage of care.  The number of patients in an ED is a census.  The census of an ED includes patients who are:  awaiting triage, have been triaged and are awaiting care, have had encountered the healthcare provider and care is in progress or pending results of diagnostic tests, are admitted to the hospital and are awaiting bed assignments, and are pending discharge.  The census can change at any time as can the acuity level.

Any ED can rapidly transition from low acuity and census levels into high acuity and high census levels at any point during a nurse’s shift.  The unpredictability of the environment can impact the relationships of the workplace.  Unpredictable environments can create stressful situations within workplace relationships.  Continued exposure to high levels of stress may have negative effects on organizations (Manzoni & Eisner, 2006; Piko, 1999).  Reciprocity is a crucial component of relationships (Chow & Chan, 2008; Flap & Völker 2001).  Reciprocity yields productivity.  For emergency nurses to maintain effective workplace performance, reciprocity is present within workplace relationships (Bowey & Easton, 2007).  Reciprocal workplace relationships facilitate productivity, efficiency, and improved consumer outcomes (Back & Flache, 2008; Carpenter, Bowles, Gintis, & Hwang, 2009; Meeker, 1983).  One question propelled this study:  What is the emergency nurse’s experience of workplace reciprocity? 

There is a paucity of research on nurses working in the ED.  Most research is clinically based regarding competency and patient outcomes (Dent, 2010; Johnson & Bakas, 2010; Kratz & Mason, 2010; Pines, Shofer, Isserman, Abbuhl, & Mills, 2010).  As patient care is the focus and there is a lack of research among healthcare providers, exploring the lived experience of reciprocity among emergency nurses contributed to the current literature on workplace reciprocity.  Additionally, the study enhanced the literature on emergency nursing and provides more information regarding the healthcare work environment.

Methods:  

Nurses with three or more years of current emergency nursing experience were recruited using a purposive technique to obtain a convenient sample.  Purposive sampling is essential to naturalistic inquiry.   Random sampling is not appropriate for conducting a naturalistic inquiry (Erlandson, Harris, Skipper, & Allen, 1993).  My focus was to discover the experience of workplace reciprocity among emergency nurses.  Purposive sampling technique allowed me to deliberately search for participants because of certain qualities.  For this study, currently practicing emergency nurses with three or more years of experience, who were willing to discuss their experiences of workplace reciprocity, were recruited.  A sampling method specific to purposive sampling is snowball sampling.  Snowball sampling, which is used when studying social groups, relies on referrals from initial participants to solicit another who has experienced similar attributes of the phenomena of interest; thus providing rich data from in-depth interviews (Babbie, 2001; Munhall, 2007; Streubert & Carpenter, 1995).  Each participant was interviewed.  The data was analyzed and interpreted using Giorgi’s Phenomenological Methodology to gain an understanding of the lived experience of workplace reciprocity of emergency nurses.  In order to psychologically understand an experience, the experience must be described (Giorgi & Giorgi, 2003).  According to Giorgi, exploration of an individual’s experience allows for subjective meanings to emerge (Giorgi, 1985).  Giorgi’s method assisted in clarifying experiences from a psychological perspective.  The Giorgi method was not used to interpret or predict outcomes.  This method was used to illuminate and understand the lived experience of those interviewed.  Specifically, how the participant relived the experience through storytelling.

Results:

The participants in this study shared their experiences of working with other emergency nurses to better understand workplace reciprocity.  The final step in Giorgi’s method is synthesis of the essences.  Caring is essential to the profession of nursing.  For any nurse, the focus is caring for patients.  The ED RNs’ identified that although patient care is the focus, caring for the other ED RN is also important in their workplace relationships.  Caring to perform as a reciprocal experience, bridging relationships to gain a sense of connection and to enhance the workplace relationship and how nurses work together (workplace reciprocity).  Three aspects impact on caring and workplace reciprocity:  technology, balancing, and the ED culture. The technology used in an ED setting affect feelings of caring among ED nurses; thus affecting workplace reciprocity.  To have a good team takes a specific balance of nurses, who have personalities and experience that can enhance or hinder the ability to create connections and to allow for bridging of relationships of ED RNs’ to foster workplace reciprocity.  The culture of the ED, each work shift and the impact that the institution sets forth can affect workplace reciprocity. 

The concept of study, workplace reciprocity, was woven throughout all of the essences and when synthesized it identified itself to be an integral part of workplace relationships of ED RNs.  Workplace reciprocity between and among ED RNs is influenced by the ED environment, balancing, and technology on caring for patients and each other as seen in the bridging and connection for the purpose of creating and maintaining workplace relationships.

Conclusion:

Understanding workplace relationships can provide insight into ED culture, balance, and technology impact on the essential essence of caring that nurses possess, which affect the bridging and connections that ED RNs require for workplace relationships.   Allowing ED RNs to have control over their environment may yield better outcomes, which are always patient related.  To provide balance, assessing ED RN personalities and performance at frequent intervals may aide in retention of staff and prevent burnout of ED RNs.  Technology is in place to support nursing practice, not to impede on workplace relationships and care of patient.  Recognizing and remembering that the patient, not the computer, is the priority is essential to nursing practice regardless of specialty.  Although patient care is primary focus, the business of healthcare is employee focused as to improve consumer outcomes.  Take care of the employees and they will take care of the consumer, the patient.  Workplace relationships need to be established and nurtured for efficient, productive and effective outcomes.  Those outcomes are always patient related for the ED RN.

Two further studies are recommended to examine workplace relationships of ED RNs.  An ethnographic study to explore the culture of ED nursing could enlighten the essence of ED Culture identified in this current study.  As previously discussed, ED culture affects the caring essence in which the ED RN workplace relationship exits.  The second study recommended is a phenomenological study to gain insight into the experience of being an ED RN.  Gaining insight into the perspective of being an ED RN may enlighten the essence of balance identified in this study.  Individually and jointly, these two proposed studies could not only add to the literature of nursing workplace relationships but also provide understanding of providing quality patient care in a rapidly changing environment.