Healthcare professionals quitting careers over overcrowding stress

Nurses working in emergency departments (EDs) have had to ration their care of patients “to a dangerous degree” and often face moral distress and even burnout, according to a new study.

The research, based on interviews with nurses in three EDs across the country, shows that, in some cases, nurses simply walk away from their profession because of the stress of working in overcrowded settings.

The findings show emergency nurses are often forced to engage in a sliding scale of care resulting in reduced dignity for patients.

“When nurses were unable to find temporary solutions or their efforts were constrained by institutional factors, they engaged in compromising caring which involves stepping back care and reduced surveillance of patients,” the report said.

“Nurses used covering as an attempt to maintain minimal levels of surveillance. When nurses face overwhelming workloads due to overcrowding, they used rationing care to prioritise the sickest patients. This resulted in reduced dignity and privacy for patients, and nurses having to front for the system and apologise for the poor standards of care delivered.”

The research found the main concern of nurses experiencing moral distress is balancing the competing demands of emergency patients and admitted patients, or the competing demands of maintaining patient flow and patient overcrowding respectively.

The report said the views of the nurses show the HSE has little hope of attracting back graduates from overseas unless it overhauls a system that has led to the “normalisation” of patients on trolleys and a “huge perceived disconnect” between nurses and management within hospitals.

The study, entitled Understanding Emergency Nurses’ Experiences of Moral Distress, was conducted by Gerard White, an advanced nurse practitioner working in Cork University Hospital.

Carried out as part of a PhD at NUI Galway, it features the views of 36 staff nurses, clinical nurse managers, and advanced nurse practitioners in three EDs.

As many as six of the nurses Mr White interviewed subsequently walked away from the profession, with the study noting how “rationing of care involves compromising caring to a dangerous degree where patients receive substandard care or no care at all”.

He said that while ED overcrowding was not unique to Ireland, the issue was so acute here it was having a “cumulative effect” on nurses, contributing to the “huge turnover” in nursing numbers and problems in retaining staff.

“It is completely a brain drain,” he said, referring to a “loss of collective knowledge”, adding that when he began working in EDs, most of his peers had 10 to 15 years’ experience, whereas now it is five or six.

“The nurse very much identifies with the patient and if they are suffering they empathise with that and feel that,” he said. “When your hands are tied and you can’t [provide adequate care], it is the exact opposite of what you should do. They feel they have somehow left the patient down.”

Mr White said nurses often reached “a critical juncture” where they either have to walk away, or they begin to “see the patient as dehumanised”.

The study showed that when nurses engage in rationing care in response to patient overcrowding in the ED, it consists of preserving life and trying to avoid harm for the sickest patients only, with no care being offered to other, more stable patients.

This extreme level of compromising caring leads to immense frustration among emergency nurses as they are unable to perform their duties in an efficient manner and feel guilty at the poor quality of care provided.

Mr White said overcrowding and other issues in the healthcare system needed to be addressed and added: “What my study found is one of the key things is if they were listened to and had an involvement in care, that was enough to keep them in the job.”