Abstract
The phenomena of overcrowded Emergency Room have worsened with the immigration of health care professionals out of the Island of Puerto Rico. There are not enough nurses for the massive number of patients that arrive daily. Consequently, there is patient overflow to hallways for more than two weeks, and nurses find it difficult to provide pain management. To support this project the model of adaptation of Callista Roy theory serves to identify relevant concepts behaviors and integrate research findings to make easier recommendations aimed at improving the quality of service offered by the nursing staff. The quantitative descriptive transversal project seeks to address the following research question ”What is the relationship between pain management and an overcrowded emergency room with hallway overflow? A random sample using the fish bowl draw method is employed to select the participants out of a small population. The sample will complete a questionnaire on their socio-demographic profile and examination questions on the relationship between nursing pain management and an emergency room with hallway overflow. To investigate the relations between variables the Pearson Product Moment Correlation will be employed to obtain the relation between two sets of data. Furthermore, to determine the strength or weakness of association and best fit. The project expects to drive the attention of politicians, stakeholders, policy writers and focus it on the ER overcrowding phenomena that interfere with nurse’s health care implementation. Also, the study is expected to describe new knowledge about pain management in an overcrowded ER with patient overflow in the hallway. Findings are expected to strengthen the pain management strategies used in an overcrowded ER. This study may also be used to support other investigations on the subject.
An Examination on the Relationship Between Nursing Pain Management and an Emergency Room with hallway Overflow
by
Zaida Ruiz
MS, Universidad Metropolitana de Bayam”n 2014
BS, Universidad Sagrado Corazon 2012
Proposal Submitted in Partial Fulfillment
of the Requirements for the Degree of Doctor of Nursing Practice
Walden University
June 2017
Dedication
I dedicate this project to the one that helped me stayed up late while doing my homework and kept me in health during this doctoral journey. The one that gave me ideas when I had to write so much. The one who provided me with the strength to work and study at the same time (it was not easy, but he held my hand and said, ‘come on, one more step I will do it with you’). The one who helped me understand all the chapters in the books I had to read. The one who gave me such excellent professors, each and one of them helped shape the doctor I am today. The one who put me at Walden University. I dedicate this project to GOD.
Acknowledgements
Thanks, from the heart to all the people that God put in my path to support me in this goal. Especially my husband Pedro Ruiz who encouraged me all the way thru, my son Joshua Ruiz his wife Sandra Delgado who believed I could do it. My daughter Attalia Ruiz who is very glad I finished the program. My grandkids and great grand kid who take me as an example, and want to follow my academic path. I want to thank Walden University, for staying up late with me waiting for me to finish my writings, posting, and applications. Thank you, Support Center, for answering questions, doubts and providing information I needed. I want to thank my professors profoundly; they work so hard to shape the students, and they do such an excellent job. I learned so much from them. Some impacted my life as well. I like to acknowledge Dr. Scott Lamprecht, Dr. Mary Tilbury, Dr. Loretta Jones, Dr. Cheryl Jones, Dr. Sue Bell. I want to give special thanks to Dr. Del Grace and Dorothy Hawthorne-Burdine they encouraged me and believed in me, I am so ever thankful. I want to thank the president of Universidad Central de Bayamon, Dr. Lillian Negron and the Dean of Academics Dr. Luz Valentin who authorized my doctorate study while working with them as the Chief Nurse Administrator of the nursing program, and for fully paying the doctorate program. First thanks to Linda Martinez the Dean of Academics secretary who processed the requisition for payment, and Jessica Ojeda who makes the payments online. Dra Judith Torres who is always ready to offer support. Dr. Pedro Robles and Dr. Floridalia Vidal who are always willing to answer research questions. I deeply thank all the nurses at my practicum site, The Emergency Department at Hospital Municipal and my Preceptor Rolando Gonzalez for allowing me to apply my doctoral knowledge as I completed my practicum hours under his supervision. Thank you all for your support.
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Table of Contents
Section: l 1
Introduction 1
Purpose 3
Research Question 4
Research Objective 4
Specific objectives 4
Definitions 4
Nature of the Doctoral Project 5
Significance 6
Social implications 6
Limitations 7
Summary 7
SECTION II 8
REVIEW OF SCHOLARLY EVIDENCE 8
Introduction 8
Specific literature 8
General literature 10
Theoretical framework: 12
Research 13
Summary 16
SECTION III 17
APPROACH 17
Introduction 17
Project Design / Method 17
Population and sampling 17
Inclusion Criteria 18
Exclusion criteria 18
Instrument 18
Validity and reliability of the instrument 18
Data Collection 19
Human Rights Protection 20
Precautions to minimize risks 21
Data analysis 21
Project Evaluation Plan 22
Summary 22
References 23
Section: l
Introduction
Migration of health care professionals out of the island of Puerto Rico has worsened the overcrowded phenomena that inflict the emergency rooms of hospitals throughout the island. In Puerto Rico as well as in the United States, emergency departments are designed to receive everyone in need of medical care regardless background, race, religion or financial status. Especially, patients without insurance that uses the Emergency Room (ER) as their primary care. Consequently, ER nurses work under severe pressure to deliver care to an incredible number of patients. The Emergency Department staff accelerate the flow of work to meet the health care demands of inflow of patients. Nurses find it difficult executing pain management care when overcrowding occurs. These events represent the tip of the iceberg in the Iceberg metaphor. This phenomenon has roots that pass the water level of the Iceberg and anchored in the system structure. Behavior evaluation is necessary to examine further the variables responsible for the events. (Kelly, 2011).
Problem
The problem is the pain management in a full emergency room with hallway overflow for more than two weeks. A full ER results in disproportionate pain management care, one reason is the nurse patient ratio, most emergency rooms in Puerto Rico have two nurses per shift. Per experts, the ERs of the United States, as well as Puerto Rico had more than 136 million patients in 2011 compared to 129.8 million in 2010 and most likely will have an increase of 140 million ER visits. At this rate, nurses will continue working in overcrowded conditions. Further investigation on this subject could raise a flag big enough to go below the organizational water line to change system structures (Kelly, 2011). It is essential to consider that working in ER requires highly trained professionals. However, the multiple health events and overflow occurring in the emergency departments can affect the performance and working capacity of nurses, which
directly or indirectly may affect the patients. The Johns Hopkins University Schools of Nursing (JHUSON), and the Johns Hopkins Hospital (JHH). Developed a model which some of the Evidence Base Practice (EBP) goals are; (1) to assure the highest quality of care (2) to promote patient satisfaction (3) to make the job easier (Newhouse, Dearholt, Poe, Pugh, & White, 2005). Although nurses used this model as a problem-solving approach, implementing it is difficult because of the rush and intensity overcrowded ER brings. Several authors agree that nursing professionals are highly affected by the uneasiness of their work (Gil-Monte, 2002; Gholamzadeh, Sharif & Dehgham, 2010).
Pain management requires a high emotional demand that combined with hard working hours make it hard to alternate with psychological well-being (Hernandez Cerezo & Lopez, 2007). Furthermore, constant direct contact with the suffering and death of patients; problems that arise with co-workers; and the number of patient in the hallway affect directly or indirectly the nurse’s quality of life. Nurses under this situation could carry out their responsibilities and activities inefficiently resulting in adverse consequences (Moustaka & Constantinidis, 2010). Furthermore, the high workload makes nurses overworked which is conducive to work accidents, exhaustion, and occurrence of absences (Robazzi, Mauro, Scco, Dalri, Freitas & Terra, 2012). It is important to recognize that individualization of the patient is essential for the efficient management of acute pain. Effective acute pain management depends on formal protocols and management guidelines generated in each institution and quality programs to evaluate the effectiveness of pain management (Castillo Galvez & Garcia, 2012). However, if there is an overload of patients in the emergency room, it can affect pain management and consequently, jeopardize patient’s health and outcomes. Furthermore, addressing these issues allows the complexity of work risks so that recommendations can be used to prevent permanent health worker’s effects (De Cassia, Almedia, Oliverira & Do Campo, 2014).
Purpose
The goal of this project is to describe the relationship between Nursing Pain Management and an Emergency Room overcrowded with hallway overflow and put it in writing for other researchers to continue investigating the subject since there is not many in Puerto Rico. Therefore, more rigorous researches are necessary to do a deeper needs assessment thru out all the ERs in Puerto Rico. Deeper researching will help identify the antecedents of the gap and help develop programs that prevent or eliminate health risk situations such as the one discussed in this project (Bartholomew, Parcel, Kok & Gottlieb, 2006). Daily, nurses face high demand of patients. Therefore, many of the patients must wait for long hours in the hallways of hospitals to receive care. Some seat outside the ER, on the floor regardless the hour or weather. Nurses must step out of the ER to call out the patient by number. When the patient response she brings out a wheelchair to help expedite the patient inside the ER. The situation creates mental pressure and physical demands on nursing staff that are responsible for providing professional care for these acute and chronically ill clients. The expectation of this project is to draw attention from stakeholders and politicians toward the problem emergency room of Puerto Rican hospitals are encountering when overcrowding occurs. Faced with the reality that represents overcrowding emergency rooms and its relationship with pain management. The research establishes the following question and objectives:
Research Question
”What is the relationship between pain management and a full emergency room with hallway overflow?
Research Objective
‘ To determine the relationship between nurse’s pain management and a full emergency room with hallway overflow.
Specific objectives
‘ To identify factors that promote overcrowding in the Emergency Room.
‘ To observe nurses pain management implementations when overcrowding occurs.
Definitions
‘ Pain: Pain is a feeling known to all of us and is “a sensory-emotional experience and an unpleasantness produced by an actual tissue damage ” (IASP, 2011).
‘ The severity of pain: expression is referring to the degree of pain and suffering the patient refers; also, called pain intensity (OMS, 2012).
‘ Emergency Room: The emergency department has the function of receiving, examination, assessment and treatment of patients requiring emergency medical care because of an accident or sudden illness and cannot be treated as an outpatient or be placed in scheduled (Zambrano, 2012).
‘ Management: To forecast, to organize, to plan, to coordinate, to command, to control (Fayol, 1930).
‘ Overcrowding: Being filled, having more things or people than needed, a state of congestion (Collins Dictionary, 2017).
Nature of the Doctoral Project
Castillo Galvez & Garcia (2012) explained that pain is the main reason for consultation in the emergency department and emergency room, taking in response to self-medicate patients before being served. The literature indicates that patients in emergency departments around the world do not always receive an optimal pain management care. The pain management implementation in an ER that overflow with patients to the hallway is a challenge. It requires the full integration of pain management techniques and the translate knowledge about new pain management. Although the project is a quantitative descriptive transversal study, it is worth mentioning that other studies carried out in the United States mentioned the cause and effect of a full emergency room. The studies used the fishbone diagram in Figure 1 to represents some of the causes and effects of an ER with hallway overflow. Per Kelly (2011), the problem is the head of the fish, and the cause and effect are the fish bones which are divided by the spine. Expectations of achieving a better understanding through the demonstration of the causes and consequences are evident in Figure 1. The causes are on the bottom side of the fish diagram, and the effects are on the top part. From the head, back of the fish diagram, it shows that lack of nurses increases the number of patient per shift. Puerto Rico has a 1 to 20 ratio (on a regular floor, furthermore, ER is two nurses per shift). It also shows, that delaying patient discharges causes boarding in the emergency room.
What’s more, the discontinuation of the Hill-Burton Act can contribute to filling emergency rooms to capacity. The EMTALA law helps promotes emergency room overflow.
Promotes Overflow Hospital full Boarding Nurse to Patient ratio
to Capacity
EMTALA Hill-Burton Act Delayed Discharges No enough Nurses
Figure 1. Fishbone diagram is showing Cause and Effect of an emergency room with hallway overflow.
Significance
The study aims to contribute to society considering that Emergency Department is usually the first-place where patients arrive in search of medical attention. The overcrowdings phenomenon in the ER justifies the need for changing approaches. The evidence base knowledge supports that a nurse with the high workload is vulnerable to errors when implementing pain management and treatment for patients. The project expects to captivate the attention of politicians, stakeholders, policy writers and focus it on the ER overcrowding phenomena that interfere with nurse’s health care implementation. For the researcher, the project helps uncover critical areas about the subject not discovered before.
Social implications
Pain is one of the reasons for greater consultation in emergency rooms. If there is a delay in pain treatment, grave consequences on the mental and physical health of patients and families who suffer can occur. Overcrowding emergency room decreases the flow of nurse’s care thus creating a delay in pain mana
gement.
Limitations
One of the limitations anticipated is the time factor. The subjects participating might not have available time, due to the high demand of patients they are required to care for in the emergency rooms. Another limitation is the small sample size.
Summary
The descriptions found in this chapter can show the background of the research problem, the problem statement, justification, and objectives of the proposed study. Furthermore, the theoretical and conceptual framework. Also, working in an emergency room with patient overload has adverse effects on nurses working in emergency units in hospitals in Puerto Rico. In the next chapter review of the literature is presented.
SECTION II
REVIEW OF SCHOLARLY EVIDENCE
Introduction
The literature review discussed includes research studies and compiled statistics related to the research topic. The development of the literature review follows the recommendations of Polit & Hungler (2011), which defines the literature review as the element that allows the researcher to know in depth the research topic.
Specific literature
Tissue injury that leads to pain is the result of a process called nociception, which has four phases: transduction, transmission, modulation, and perception. With transduction, the pain stimulus translates into an electrical signal on the free end of the nerves, also called nociceptors. Nociceptors are present in every somatic and visceral tissue. With the transmission, the electrical signal goes through nerve fibers to the central nervous system (IASP, 2011). Pain is the symptom that most often leads the patient to consult. It warns the patient that something is not working properly and requires reacting to suppress the cause that produces it. Nociception is the perception of pain. The nociceptors are receptors, structures or sensory organs that capture the pain or other unpleasant sensations and transmit it to the sensory neurons of the peripheral nerves (White, 2002).
Per Bravo (2010), Nurses should properly assess the pain symptoms. Instruments to measure the pain intensity must be available. Nurses must have the necessary knowledge to administer the right treatment efficiently. Nurses must assess and record the response to treatment as well. Also, they should develop and implement protocols for evaluation and treatment of pain. On the other hand, effective analgesic interventions and documentation of responses to these interventions will be subject to more thorough analysis. The adjusted dose intravenous opioids do not mask important clinical findings, do not increase rates of misdiagnosis or delay the appropriate surgical interventions. The protocols include analgesic interventions initiated by nurses can produce faster pain relief (IASP, 2011).
It is possible that adequate pain control requires the use of opioids short-term immediate release. The long-term opioid therapy is not advisable. Initial aggressive analgesic treatment allows early patient mobility and avoids prolonged bed rest. The combination of NSAIDs and intravenous opioids is superior to using either single modes, resulting in a fast pain relief and less nausea and vomiting (IASP, 2011). Nurses should get verbal or written information from the patient. The behavior individual with pain is agitation, restlessness, nervousness, gestures, crying and screaming. Nurses can use instruments to measure the autonomic nervous system responses to pain (increased blood pressure, heart, and respiratory rate). The personal description of the patient is probably the best indicator of pain. If a person says he has pain, it is likely to be true (White, 2010).
Types of Pain
Acute pain is of recent onset time and alerts the individual of the existence of trauma, injury or ongoing pathology establishment. In contrast, chronic pain is when the pain takes a long time (more than six months) without having a clear start date. Chronic pain is said to be benign if the causal process is not life threatening. Neuropathic pain is a form of chronic pain that is due to different diseases, such as diabetes, cancer and immunological diseases among others. Furthermore, it could cause injury to a peripheral nerve and lead to the transmission of pain impulses without there being any event that stimulates nociceptors (White, 2010).
Consequences of pain
‘ Vasoconstriction causes blood pressure to increase.
‘ Increased stimulation of the sympathetic nervous system increases heart rate. The autonomic nervous system regulates heart activity, blood flow and inhibition of digestive processes).
‘ Inhibition of the digestive process caused by nutritional disorders
‘ Hyperventilation with increased blood pH values and as a result, muscle spasms and or loss of consciousness (IASP, 2011).
‘An impairment of the immune system and defense mechanisms occurs if the pain is constant for an extended period.
General literature
The emergency care systems in hospitals have been affected by an increase in demand for its services worldwide; the causes of this problem are different. However, saturation leads to lower quality of service and an increase in mortality associated with timeouts. A key element concerns health personnel, who perform this type of classification, because of their cultural characteristics and the system applied by each institution; such work plays a major role in the flow of users, as well as the classification. Hospital care units and emergencies integrate hospital care system component. The purpose of the work of health teams in the emergency room is to serve patients coming in critical condition, accept non-urgent cases and proceed to direct them to basic outpatient or existing specialized network of health care (Gil-Montes & Garcia, 2008). Recently, it has been debate the ability of hospitals to provide timely care to patients with emergency medical conditions. Although overcrowding has often been the subject of discussion among emergency physicians, few studies have investigated and documented this phenomenon nationwide. Lately, overcrowding documentation has been using photographs of overcrowded emergency rooms and anecdotes rather than empirical data (Hwang, Richardson, Livote, Harris, Spencer & Morrison, 2008). The shortage of nurses is a structural problem, due in large part to the relentless commodification of medical services and hospital care. Factors such as mergers of hospitals, staff layoffs, wage stagnation and overwork have created, over several years, the shortage of nurses, which in recent years has reached crisis levels (Arkansas State University, 2016).
The Overcrowding is a problem of saturation of emergency services common in many countries in the world. Patients must endure long hours waiting to be evaluated or transferred to another unit which leads to poor result in the care, adverse effects on safety, comfort and user satisfaction. Also, overcrowding limits resources, nurse performance, and health team. It means less time to attend to patients waiting rooms or ambulances. The nurse of the emergency unit responsible for coordinating the nursing team needs to find ways to manage nursing care, visualizing holistic patient needs, reconciling the objectives of the organization with the aims of the nursing team (Garlet, Da Silva Guedes & Quintana, 2009). On the other hand, in various areas of the hospital including the emergency room requires one nurse to six patients. Nurses associations have struggled to achieve an improvement in this fundamental aspect of their work. The problem has even led to resignations work by nurses with work overload. Hospitals require nurses to use exhausting days to compensate for the lack of sufficient staff (Arkansas State University, 2016).
Measurement systems workload managers have responded to purely economic strategies in the allocation of staff and the provision of templates, placing emphasis on quantitative meas
urement of nursing work (Calvo, 2008). On the other hand, the workload is a set of activities, tasks, and interventions performed by a nurse, about the number of patients who depend on her care. Thus, the workload is a set of psychophysical requirements that the worker is responsible for throughout their working period (Rueda, 2009). When the load is, excessive fatigue appears, which is the decline in the physical and mental capacity of the individual having done work for a period, this may be physical, mental or psycho (Calvo, 2008).
Theoretical framework:
As a frame of reference the model adaptation Callista Roy (2003) supports the importance of human adaptation to cope with sudden changes, in this case, represents the changes that overcrowding causes in nurses. The objectives of the model Callista Roy seek that the individual reaches a maximum level of adaptation and evolution, focusing on the adaptation of man, and the concepts of person, health, nursing, and environment are linked globally (Heather Andrews, 1999). Roy’s model is a theory of systems with a meaningful analysis of the interactions. The philosophical framework of Callista Roy establishes among its main concepts and definitions that adjustment problems are “broad areas of interest that are related to adaptation, they describe the difficulties presented indicators of positive adaptation.
The focal stimulus is the immediate internal or external stimulus that faces the human system. Contextual stimuli are other stimuli that are present in the situation and contribute to the effect that causes the focal stimulus; residual stimuli are environmental factors that are within or outside the human system that causes a limited impact about the moment ” (Roy & Andrews, 1999: p65). Roy also talks about the processes that human beings face. One of them is coping processes that are innate or acquired ways to react to changes in an environment. Roy postulates the following philosophical values and beliefs about nursing. Human beings are holistic and transcendent. The person searches self-realization, a reason for its existence. Self-determination, people, make decisions and therefore are autonomous and responsible for the processes of interaction and creativity.
‘ People and the world have common patterns and integral relationships, which identify them as unique beings. The transformation of individuals and the environment is created in human consciousness, the ability of each to interpret the common internal and external environment. Adaptation is “the process and result through which people with thoughts and feelings, either individually or in groups, using awareness and choose to create a human and environmental integration. The integrated process refers to the level of adaptation in which the structures and functions of the whole life process to meet human needs work. Acquired coping mechanisms originate through methods such as learning. The experiences throughout life contribute to common reactions to stimuli (Roy & Andrews, 1999). The model also serves to identify relevant concepts behaviors health promotion and to integrate research findings to make easier recommendations aimed at improving the quality of service offered by the nursing staff.
Research
Cubero (2014) enhanced a research project, focused on analyzing the effectiveness of care systems. He reviewed evidence published over the past 15 years, including staff observation that applies to, types of system, and waiting time before administrating health care. The search strategy was used to identify clinical trials in different databases such as Pubmed, Cochrane Library, EBSCO and Google Scholar.
Result. Among the most significant results, emergency room saturation is a problem that creates an increase in demand for such services worldwide, with results of poor service provided and an increase in mortality timeouts. The random arrival attention and structured systems could not match up.
Hwang, Richardson, Livote, Harris, Spencer & Morrison (2008) conducted a study to evaluate the association of factors of overcrowded emergency department (ED) with the quality of pain care. A retrospective observational study of all adult patients (‘ 18 years) with conditions that warrant pain attention in an academic, urban, tertiary ED performed on July 1 and July 31, 2005, and December 1 to December 31, 2005. The inclusion of patients happened if they presented with a chief complaint of pain. The predictor variables studied were ED overcrowding 1) census, 2) number of patients in hospital beds waiting (pensioners), and 3) the number of pensioners divided by census ED (shipping charge). The outcomes of interest were measured process pain care: documentation of clinical pain assessment ordered medications, and activity times (e.g., arrival, evaluation, authorization of medicines). Thus, a total of 1068 patients had reviewed visits. Fewer patients were medicated when census was high (> 50th percentile; parameter estimate = -0.47; 95% confidence interval [CI] = -0.80 to -0.07). There was a direct correlation with the total census of erectile dysfunction and increased time for pain evaluation (Spearman r = 0.33, p <0.0001), time of analgesic medication orders (r = 0.22, p <0.0001), and the time to administrate pain medicine (r = 0.25, p <0.0001). Delays were significant (> 1 hour) for pain assessment and the management and administration of pain medicine administrated in periods of high emergency department census and the number of pensioners, but not the shipping charge. ED overcrowding, as determined by the volume of patients has a negative impact on patient care. Also, a greater number of patients in the emergency department if census or the number of pensioners associated with worse pain care.
Bernstein, Ronsky, Duseja, Estein, Handel, Hwang, et., Al. (2009) Conducted a study aim to review the literature addressing the effects of overcrowding on the results of clinical orientation. Literature was examined in the English language for years 1989-2007 for case series, cohort studies and clinical trials investigating the effects of overcrowding. An amount of 369 articles identified, of which 41 were for inclusion, and there were no randomized controlled trials. According to the articles, overcrowding correlates with an increment risk of hospital mortality. Longer waiting times for treatment of patients with pneumonia or acute pain was present, and the items revealed that patients were more likely to leave the emergency department against medical advice. The effects of overcrowding and its relationship with patient satisfaction conducted in the articles showed that clinical objectives, such as mortality, clinically relevant processes of care, treatment time for patients with painful diseases such as pneumonia were directly related to overcrowded conditions. Two domains of quality of care safety and punctuality, are compromised because of overcrowding. Recently there has been a growing debate regarding the ability to provide timely care to patients with emergency medical conditions.
Garlet, Da Silva Guedes & Quintana (2009) conducted a qualitative study, type case study, which aimed to analyze the conceptions of professional health team about the purpose of working in emergencies care unit. The study took place in a hospital care unit emergency from the state of the Rio Grande del Sur. The techniques for data collection were observation and a semi-structured interview. The results point to the divergence between the needs of health that lead users to seek unity and purpose of work highlighted by local professionals. The team shows dissatisfaction with the excessive pursuit of service for patients and overcrowding, whose needs cannot be classified as an emergency, underlining the sum of attendances as a justification for resistance to doing the job and lack of commitment care production.
Belancieri, Beluci, Silva & Gasparelo (2010), conducted a study to investigate the level of resilience of nursing when working in overcrowded cond
itions. Aiming to the knowledge, strengths, and weaknesses of the professional facing adversity to which they are subject. They showed excessive impulse control and difficulties in regulating emotions, which brings them great expenditure of energy because they do not externalize their feelings, especially in the working environment. The study concluded that professional health care offering could be a fundamental strategy because giving an excellent service to users depends mainly on the safe work environment.
A study Van Bogaert (2010) suggests that the nurse has constant working pressure, facing pain, suffering, despair, death, helplessness, and anguish; moreover, the lack of workers who can cover the requirements of an overcrowded health institutions fully makes double their workday. The emotional exhaustion that brings their work and the imbalance of relationships with colleagues, organization, patients and the workload, causes deterioration in the quality of care.
Summary
The review of literature related to the subject presented confirms that pain management in an overcrowded emergency room has consequences on patients as well as on the health care worker. Some authors who have addressed the concept of pain management are White (2010); Bravo, (2010); International Association for the Study of Pain (2011). Few studies directly measured the ratio of an emergency room overcrowded with the patient and its effect on the quality of pain management giving greater relevance to the proposed study. The next chapter presents the project method.
SECTION III
APPROACH
Introduction
This chapter describes the study design, in which a detailed description related to the population, sample and inclusion criteria of the subjects presented to complete the research. Furthermore, details on the way to collect and analyze data, and details of the rights of the participants follows ahead.
Project Design / Method
The research is quantitative descriptive transversal. It breaks down the core strategies that the researcher adopts to explore the phenomenon. The designs are strategies to try to get answers to questions (Beck, 2011). To investigate the relations between variables the Pearson Product Moment Correlation (PPMC) will be employed. To obtain the relation between two sets of data. Furthermore, to the determine the strength or weakness of association and best fit.
Population and sampling
The population refers to a set of individuals or elements that we can observe, measure a characteristic or attribute (Polit, & Hungler, 2011). The study population will consist of nurses from the emergency room of the practicum site.
The sample is a meaningful representation of the characteristics of a population. The sample consists of ten (10) nurses from a population of twenty (20) nurses that work in the emergency room of a Puerto Rican hospital. A random sample using the fish bowl draw method is employed to select the participants out of a small population.
Inclusion Criteria
‘ BSN, MSN, Ph.D. Nurses
‘ Work in an emergency room
‘ Over 21 years’ old
‘ Of both sexes
‘ The focus is voluntary participation in the study
Exclusion criteria
‘ Under 21
‘ Not interested in participating in the study
Instrument
To obtain data, the researcher will construct a questionnaire using the study variables. The questionnaire focuses two areas of interest: the first part collects socio-demographic data, the second part is related to indicators on the subject under study, configured as claims with a value of three points with a range of responses ranging from agreeing, undecided (a) or disagree.
Validity and reliability of the instrument
As part of the validation, a panel of three experts evaluates the instrument and will determine if it meets the objectives of the study. The researcher will meet with experts and will invite them to the formal part of the document panel. The information provided will explain the study, as well as the risks and benefits, guaranteeing the confidentiality of the participant. Experts will use a form validation to determine the clarity and relevance of the premises within the questionnaire. The researcher acknowledges the expert recommendation.
Data Collection
To carry out this procedure the recommendations made by Polit & Hungler (2011) and the Committee of Walden University IRB usually employed in this type of research. Walden University IRB will receive the proposal for approval. Authorization also will be requested in writing to the hospital administration where the study will be carried out. There will be a presentation of the purpose of the research and the need for it as part of an academic project.
Once approval of the IRB is received, a meeting with the floor supervisor will be held to identify subjects who meet the inclusion criteria. At the meeting, it will be explained to the institution the need for research as part of an academic project, which dates available for research, as well as details relating to the procedure used to collect the data. There is an explanation of the method of study and the information contained in the fact sheet. Selection of participants happens every three shifts randomly.
Once the identification of participants takes place, the researcher will be presented before them, and explain their participation in the study. During this first interview, it will explain the purpose and the type of instrument to collect data and practical benefits of participating in it. The researcher then will deliver the newsletter to participants who agree in writing to participate voluntarily. The researcher will hand out the instrument. This process will be conducted in strict confidentiality and privacy, respecting the subject’s decision to join or not to the study.
Human Rights Protection
The researcher took IRB and HIPAA certifications related to federal confidentiality laws and protection of human rights to supports and be part of an ethical and correct process during the research study. To ensure the protection of individuals, the principles of confidentiality, identity protection will be observed. They will explain that participation in the research was free and voluntary and that the risk of completing the instrument was considered minimal.
Currently, the physical, psychological, social, legal or other real risk is minimal. The only potential risk of the participants is to feel slightly tired and bored to complete the instrument. The researcher during recruitment will provide participants the information needed to ensure the free and voluntary participation. Informed consent describes the purpose of the study, in which involve the instrument and the type of questions.
The approval of the study will be made by the Human Rights Committee of Walden University (IRB) and will wait for authorization from the Hospital where the study and the administration of the questionnaire will be carried out. Participants who agree to be part of the free study and may voluntarily withdraw at the time they want, without being held by the researcher. They will explain in advance the potential benefit of being part of academic research. Participants do not receive financial compensation for their participation. The researcher will be available always to answer questions or concerns about the study. Once participants responded to the instrument, it gets delivered to the researcher for tabulation and analysis.
Participants understand, that if their rights get violated, they can utilize the card given to them with the phone number of the Human Rights Office of Walden University (IRB) and Grade Mentor Project to communicate whenever they want it. The researcher will provide a phone number for any questions arising from any participant, after having been part of the study and completed the process of data collection in the hospital under study. Once a collection of
the questionnaires takes place, these will be kept by the researcher. The fact sheet will be saved on separate instruments to ensure objectivity and purity of the sealing process. There is no connection with the information provided in the consent such as dates and signatures with the information given by participants in the questionnaire during and after the investigation. Both documents will be locked away in a drawer in the researcher’s home for five years, and then must be destroyed with a shredder. The study is warranted by what participants in advance will ensure the periodic review of appropriate measures to protect their rights, welfare, and dignity as human beings who participate in a research study measures.
Precautions to minimize risks
The researcher will use a simple vocabulary, not offensive, to connect with the participants, who will be allowed to take the time to fill out the questionnaire in full and self-removal from participation in the study whenever they want without penalty. The researcher also is available to answer questions during the administration of the instruments.
Data analysis
The data will be measured using descriptive statistics adding the frequencies of the answers averaging and obtaining the percentage of each of the data. The results will be achieved and summed to get the percentage of the answers. Excel will be the program used for the tabulation of results. To find the relation between variables the Pearson Product Moment Correlation (PPMC) will be used to express the degree of relationship between variables (1) nursing pain management (2) an emergency room with hallway overflow.
Project Evaluation Plan
The researcher will submit a research proposal to the Human Rights Office of Walden University (IRB) for analyzing the content thereof, to determine that it meets the study variables. The researcher then processes the data collection analyze all the information collected and compared with the literature presented in this research proposal, to answer the questions of the study, and to provide conclusions and recommendations. During and after completion process, the researcher will use the standard mechanisms to protect the identity and confidentiality of all material addressed in this research.
Summary
The chapter explains the research design, which is guided by Polit and Hungler (2011). As part of the study method, study variables, information about the instrument and its validity will be an exhibit. Also, the process of collecting the necessary data described to complete the study and protection of human rights of potential research participants will be ensured, in line with the criteria for inclusion and exclusion of potential participants.
References
Arkansas State University .(2016). Falta de enfermeras arriesga la salud hospitalaria.
Disponible en: http://www.ellatinoarkansas.com/content.cfm?ArticleID=17.
Bartholomew, L. K., Parcel, G.s., Kok, G. & Gottleib, N. H. (2006). Intervention Mapping: Designing Theory- and evidence-base health promotion programs (2nd ed.) Mountain View, CA: Mayfield.5.
Beck, C. (2011). Nursing Research: Generating and Assessing Evidence for Nursing Practice (9th ed.). Philadelphia: Lippincott.
Belancieri MF, Beluci ML, Silva DVR, Gasparelo EA. (2010). A resili”ncia em
trabalhadores da ”rea da enfermagem. Estud Psicol. 2010;27(2):227-33.
Bernstein SL, Verghese V Leung W, et al. Development and validation of a new index to measure emergency department crowding. Acad Emerg Med. 2003;10:938-942.
Bravo, A. (2010). Cuidados de enfermer”a en el paciente con dolor. Disponible en:
Calvo E. (2008). Does Working Longer Make People Healthier and Happier? Work Opportunity
Briefs, Center for Retirement Research at Boston College
.
Castillo, G”lvez & Garc”a. (2012). Gu”a manejo del dolor agudo en urgencias. Disponible
en: http://es.slideshare.net/garciaj.cesar/guia-manejo-del-dolor-agudo-en-urgencias
Castillo, I., Torres, N., Ahumada, A., C”rdenas, K. & Licona C. (2011). Estr”s laboral en
enfermer”a factores asociados. Cartagena (Colombia). Disponible en: http://rcientificas.uninorte.edu.co/index.php/salud/article/viewArticle/5333/5590
Collins. (2017). English Dictionary. Retrieved from https://www.collinsdictionary.com/us/dictionary/english/overcrowding
Cubero-Alpizar, C. (2014). Los sistemas de triage: respuesta a la saturaci”n en las salas de urgencias. Rev. Enfermeria Actual en Costa Rica, 27, 1-12. DOI: http://dx.doi.org/10.15517/revenf.v0i27.16145
De Cassia, R., Almedia, L., Oliverira, A. & Do Campo, M. (2014). Carga horaria de
trabajo de los enfermeros y su relaci”n con las reacciones fisiol”gicas de estr”s. Rev. Latino-Am. Enfermagem. Nov.-dic. 2014;22(6):959-65. Disponible en: http://www.scielo.br/pdf/rlae/v22n6/es_0104-1169-rlae-22-06-00959.pdf
Fayol, H. (1930). Industrial and General Administration. Sir l Pitman & Sons, limited 1930
Garlet, E., Da Silva, M., Guedes, J. & Quintana, G. (2009). La finalidad del trabajo en
urgencias y emergencias bajo la perspectiva de los profesionales. Disponible en: http://www.scielo.br/pdf/rlae/v17n4/es_16.pdf
Gil-Monte PR. (2002). Influencia del g”nero sobre el proceso de desarrollo del s”ndrome
de quemarse por el trabajo (Burnout) en profesionales de enfermer”a. Psicolog”a en Estudio2002; 7 (1): 3-10.
Hern”ndez, E., Cerezo, S. & L”pez, M. (2007). Estrategias de afronta-miento ante el
estr”s laboral en enfermeras. RevEnfermInstMex Seguro Soc 2007; 15 (3):161-166.
Hwang U., Richardson L., Livote E., Harris B., Spencer N., Sean Morrison R. (2008). Emergency department crowding and decreased quality of pain care. Academic Emergency Medicine, 15(12), 1248-1255.
IASP. (2011). Asociaci”n Internacional para el Estudio del Dolor Pain | IASP Taxonomy,
2011. (Accessed May 2, 2011, available in: http://www.iasp-pain.org/AM/Template.cfm?Section=Pain_Defi’isplay.cfm&ContentID=1728).
Kelly, D. L .(2011). Applying Quality Management in Health Care, (3rd ed). AUPHA Chicago, Illinois
Moustaka E, (2010). Constantinidis TC. Sources and effects of Work-related stress in
nursing. Health Sci J. 2010;4(4):210-6.
Newhouse, R. P., Dearholt, S. L., Poe, S. S., pugy L. C., & White, K. (2005). Evidence Base Practice: A practical approach to implementation, The Journal of nursing administration, 35(1), 35-40.
Organizaci”n Mundial de la Salud (2015). Enfermer”a. Disponible en:
http://www.who.int/topics/nursing/es/
Polit, D. and Hungler, B.: Nursing Research: Principle and Method. 6th ed.: Philadelphia:Lippincott Company. (2011). P.P. 416-417.
Robazzi MLCC, Mauro MYC, Secco IAO, Dalri RCMB, Freitas FCT, Terra FS, et al.
(2012). Altera”es na sa”de decorrentes do excesso de trabalho entre trabalhadores da ”rea de sa”de. Rev Enferm UERJ. 2012;20(4):526-32
Roy, C. (2003). Reflections on nursing research and the Roy adaptation model. Japanese
Journal of Nursing Rsearch, 36(1),7-11.
Roy, C., & Andrews, H. A. (1999). The Roy adaptation model (2nd ed.). Stamford, CT: Appleton
& Lange.
Rueda, A (2009). Administraci”n y gesti”n de servicios de enfermar”a.
Rev. Difusi”n de cuidados de enfermer”a. 2009; 978-84-95626-94-3.
Van Bogaert P. Commentary on Kowalski C, Ommen O, Driller E, Ernstmann N, Wirtz
M, Kohler T, et al. (2011). Burnout in nurses-the relationship between social capital in hospitals and emotional exhaustion. J Clin Nurs 19, 1654-1663. J
Clin Nurs. 2011; 20(5-6): 913-4.
White E. L. (2002). Specificity of Cortical Synaptic Connectivity: enphasis on perspectives gained from quantitative electron microscopy J neurocytol 2002 mar-Jun:(3-5):195-202
Zambrano, M. (2012). Salas de emergencia. Disponible en: https://es.scribd.com/doc/
61394287/Salas-de-emergencia-2