Interpersonal Paradigms in the Emergency Department

¶ … Range Nursing Theories

As a profession, nursing presents many challenges. Indeed, it is one of the most stress inducing jobs in the world, not only in terms of the physical toll and long hours, but also because of the emotionally exhausting nature of the work. For this reason, personnel turnover tends to be high and there is a general shortage of nursing personnel at hospitals. Because of the vital nature of the profession to the healthcare field and to humanity in general, many researchers have addressed the problem of high personnel turnover in the nursing profession, as well as factors like leadership, work efficiency and interpersonal relationships.

Of all the work environments within the nursing profession, the Emergency Room is probably the most stressful, which also leads to high personnel turnover. One approach towards a resolution is to find ways of enhancing nursing staff satisfaction. Increased satisfaction at work would lead to greater commitment and a lower tendency to leave the workplace for greener pastures. As such, two middle range theories will be evaluated for their applicability to the quest of improving nursing staff satisfaction in the emergency department.

Description of Clinical Practice Problem

Burn-out is one of the most common problems faced by nurses today. This is a particular challenge in the emergence department, where overcrowding of patients, leadership challenges, logistical problems and a basic lack of satisfaction among both personnel and patients tend to be part and parcel of the work day. For this reason, leadership is one of the most important components in the medical profession, and particularly in high-stress environments like the emergency room.

According to Lin et al. (2011, p. 239), leadership has an effect on every aspect of nursing, including work attendance, productivity, performance, and work satisfaction. Good leadership would lead to good nursing outcomes, whereas poor leadership would necessarily lead to an increase of stress factors, such as poor job satisfaction. Indeed, the authors go as far as mentioning that leadership could affect not only the performance, but the very survival of the organization. As such, a leader in such a role needs to recognize that his or her function is no longer a solely medical one, but that it entails all the components of leadership in the organization, including ensuring that personnel are satisfied and committed to their work.

A particular challenge in the emergency department is that the nature of the work is not only continuously changing; it also entails a high velocity of actions during critical care in an environment that is a complex mixture of relationships among staff members, leadership, and patients receiving care. Effective leadership is therefore vital in order to ensure the smooth operation of such an often volatile environment.

As such, a good emergency department would be the result of not only the experience and technical skills of the leader, but also of his or her behavior and interpersonal skills. Without the effective management of relationships, leaders in the emergency environment cannot operate in an effective way.

As mentioned, effective leadership would affect the commitment employees display in the workplace. Without a committed workforce, the emergency department would battle to maintain a consistent level of excellence in their care. Myer and Maltin (2010, p. 334) emphasize the importance of commitment among employees and the benefits that this has not only for employers, but also for the workforce itself. According to the authors, a high level of commitment among employees has been shown to correlate well with employee satisfaction. This applies particularly to the emergency environment, since a high level of commitment would also relate to lower stress levels and a greater sense of meaning in the workplace.

One particular factor that leads to stress among emergency department employees is patient overcrowding. This leads to a sense of rush as employees struggle to meet the needs of all the patients coming into the emergency room. The stress created by this detracts from effective employee-employer relationships as well as the effectiveness of patient care provided. Rowe et al. (2011) suggest that operational processes could be used to remedy this problem. Again, it comes down to effective relationships among team members and employers to implement and manage such logistical changes effectively.

Hwang, Younsuk, and Hojung (2011) place the same emphasis on physical structure and process management in order to improve the quality of healthcare. They suggest that critical pathways play a vital role in ensuring the effective functioning of multidisciplinary teams within healthcare.

In short, the basis of staff satisfaction should begin with effective interpersonal relationships, which would affect behavioral paradigms. There are many relationships among emergency department staff members. These include the leader-follower relationship, relationships among colleagues, those among team members, and those among team members and team leaders. These should be managed effectively, with communication skills set up in such a way that concerns can be openly discussed, suggestions made, and changes implemented as necessary.

When effective communication and relationships are in place, more practical concerns like process issues and the flow of patients can be handled effectively as well. Two particular middle range theories that can be evaluated in order to apply to the enhancement of staff satisfaction in the emergency department include Harry Stack Sullivan's interpersonal theory and Carl Rogers' person-centered theory.

Interpersonal Theory

Harry Stack Sullivan's theory was positioned in terms of developmental theory. His central premise was that every person exists as part of a relationship network with other people (Penckofer et al., 2011). It is impossible to exist without at least some influence from these. When an individual is a young child, for example, there is a particular dependence upon interpersonal relationships. This dependence upon others continues throughout the human lifetime.

In terms of nursing theory, the application of this theory has resulted in Pelau's nursing theory, where she took Sullivan's idea of degree of anxiety in terms of interpersonal relationships further by describing four levels of such anxiety. These include mild, moderate, severe, and panic levels (Penckofer et al., 2011). Nurses then use these levels as a means of assessing anxiety among patients. Once the anxiety level has been assessed, it is the task of the nurse to assist patients to manage the anxiety by turning it into constructive action. The nurse then functions as an effective component within the interpersonal relationships experienced by the patient at the time. This relationship is then used in terms of creating a supportive environment for the patient.

Evaluation

By naming it, both Sullivan and Peplau have created an explicit middle range theory. The social significance of the theory relates to the condition of anxiety experienced by a large number of patients when entering the emergency department. Most such patients have experienced an unforeseen trauma and the anxiety level will tend to be high. Its theoretical significance relates to the precise explanation of the psychological condition of patients and how this can be managed by nursing staff. Concepts such as interpersonal relationships, dynamism, and anxiety are clearly defined and explained, ensuring the internal validity of the theory, with consistency in terms of the definitions and terms.

The reasoning related to the theory is appropriate. Deductive reasoning is used to arrive at a theory of interpersonal relationships. Observing that people are continually dependent upon each other and influenced by this dependency throughout the lifespan, Peplau deduced that this dependency could be used to reduce anxiety and other negative experiences within the clinical setting. Various studies have been applied to support this theory, making it empirically viable, particularly in the field of psychology. As such, the idea of participant-observer indicates that patients must participate in their healing process. This is a vital part of ensuring that negative emotions such as anxiety and fear can be eliminated and turned to good use to speed up the healing process.

Applicability

While the interpersonal theory traditionally applies to the nurse-patient relationship, it can also be used to apply to the clinical setting in the emergency department and interpersonal relationships among staff. First, the theory applies to the ideal of effectiveness. When a nurse interacts effectively with a patient, he or she experiences the satisfaction of effectively alleviating anxiety and helping the patient cope better with the stress-inducing injury. The same is true of family members who have entered the facility.

A second component of this is the leader-follower relationship. In this case, the participant-observer paradigm is applicable. While leaders identify the actions and logistics within the department, nurses must be part of the process by actively participating in suggestions and improvements. There should be an open communication channel among nursing staff and their leaders.

Finally, team work applies in terms of both anxiety reduction and the participant-observer paradigm. Anxiety can be significantly reduced when nursing staff work in teams, since this means a lighter workload, while also including team members who work together on similar problems. The psychological sense of support is important to reduce stress among nursing staff and to increase satisfaction. This relates closely to the participant-observer paradigm, where nursing staff are part of a creative team offering solutions to handling a high volume of patients in a very stressful environment.

In these ways, effective work with individual patients, good leadership, and interactive teamwork all conform to the principles of the interpersonal theory in order to enhance nursing staff satisfaction in the emergency department.

Person-Centered Theory

Like Sullivan's theory, Carl Rogers developed his person-centered theory around concepts found within psychology. According to Rogers, each person is unique and has a certain actualizing tendency (Rogers, 2012). Whereas Sullivan's interpersonal theory therefore focuses on the necessity of relationships, Rogers' view focus more on the specific individual an his or her ability to activate an inherent actualizing property.

For Rogers, there are two central important concepts, including the organism and the self. Organism includes experience, which can be regarded in terms of three components: Frame of reference; behavior; and conscious and unconscious experiences. The self includes the self-concept and the ideal self (Rogers, 2012).

According to Rogers, both organism and self are strongly influenced by the environment, and particularly from the social environment. This is parallel with Sullivan's idea that no person functions without the influence of interpersonal relationships. In Rogers' paradigm, this generally occurs by means of evaluation by others, where positive evaluations result in a tendency towards positive self-regard, and negative evaluations have the opposite effect (Rogers,

2012).

When it comes to nursing practice, Rogers' ideas are used to apply to the regard that nurses hold for their clients. This is done with the understanding that all patients are inherently good and can engage in self-actualization (Rogers, 2012). As such, nursing is to approach each individual as unique in his or her own right. A nurse is therefore expected to collaborate with each individual in creating a care plan, rather than impose a generic care plan that is universally applicable. This is parallel to the idea in Sullivan's theory that the nurse is to regard the patient as a type of partner in the healing process in terms of the participant-observer role. The collaboration is vital in terms of giving patients a sense of control over their own healing process. Further components of this process include the fact that nurses need to offer unconditional positive regard, a sense of understanding that is entirely empathic, and a genuine concern for the well-being of their patients.

Evaluation

By naming it, Rogers created an explicit middle range theory. The social significance of the theory relates to the nature of patients in terms of being unique. Each human being is unique in his or her own right. This applies to all patients and should be used to affect a paradigm of control and healing. Its theoretical significance relates to the premise that patients have a specific psychological need when they enter the clinical care setting. Rogers' theory implies that each patient has the need for acknowledgement in terms of his or her uniqueness. Concepts such as organism, self, self-actualization, and self-regard are clearly and delineated and explained.

The reasoning related to the theory is appropriate. Deductive reasoning is used to arrive at a theory of person-centered paradigms. Observing that each person is entirely unique in his or her own right, Rogers' deduces that each individual also has the ability towards unique self-actualization. Various studies have been applied to support this theory, making it empirically viable, particularly in the field of psychology. Person-centered theory has been a long-accepted paradigm of psychological counseling. By providing patients with the tools to become partners rather than mere recipients of their treatment, nurses ensure that these patients are able to self-actualize in terms of their healing process.

Applicability

Like Sullivan's paradigm, Rogers' theory traditionally applies to the nurse-patient relationship or indeed to the counselor-client relationship. It can, however, also apply significantly to the professional relationships within the clinical setting. In terms of the leader-follower relationship, for example, leaders should acknowledge the uniqueness of each nurse and his or her ability to use self-actualization as a means to contribute to the clinical care setting.

One challenge in this, however, is that a large number of staff would make it somewhat difficult to truly establish the means by which each individual is acknowledged and led towards self-actualization. The same challenge applies to nursing within the emergency department, which is often a rushed affair with many patients to assist. The emergency department does not truly lend itself to building the long-term relationship required for a nurse to truly lead each patient to self-actualization as would, for example, an oncology ward.

It is somewhat more viable, however, to exhibit unconditional positive regard across the board towards both employees and patients, regardless of the number of persons in one's care.

In terms of staff relationships, unconditional positive regard is also somewhat more than encouraging self-actualization in others. However, if a leader were to emphasize the importance of self-actualization, nurses can themselves ensure that self-actualization is a goal. This might entail some staff training, which in turn could present challenges in terms of scheduling and time.