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Staff nurses' appraisals and coping strategies in a critical incident Appleton, Leanne Andrea 1993

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STAFF NURSES'APPRAISALS AND COPING STRATEGIES IN ACRITICAL INCIDENTbyLEANNE ANDREA APPLETONB .Sc .N ., The University of Alberta, 1989A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCE IN NURSINGinTHE FACULTY OF GRADUATE STUDIES(The School of Nursing)We accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAApril, 1993© Leanne Andrea Appleton, 1993In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study . I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives . It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission .(Signature)	 111	 ~chor~I of!q uo/9The University of British ColumbiaVancouver, CanadaDate	(Ii 'ZO) 	 I61 6( 3DE-6 (2/88)iiABSTRACTAlthough there was extensive literature pertaining tohow nurses reacted to and coped with stressful encounters,there was little information about a specific kind ofstress : critical incident stress (CIS) . The purpose of thisstudy was to describe how medical/surgical general dutynurses appraised, reacted to, and coped with criticalincidents (CI)s.Lazarus and Folkman's (1984) theoretical framework wasused to guide this study. A descriptive research design wasused to gain knowledge related to the following fourresearch questions : 1) What events did medical/surgicalstaff nurses appraise as CIs? 2) What were the nurses'reactions to CIs? 3) How did the nurses cope with the CIs?4) How had the CIs impacted on the nurses' professional andpersonal lives?The investigator recruited 50 nurses and eachparticipant completed four instruments. Quantitative datawere coded and descriptive statistics were calculated.Open-ended questions were subjected to content analysis.The staff nurses did experience CIs within their dailypractice . Using content analysis the nurses' CIs wereassigned to one of six categories : moral distress, lack ofresponsiveness by a health care professional, violencetoward nurses, emergency situations, death, and contactiiiwith infectious disease (hepatitis, acquired immuno-deficiency syndrome) . The majority of the nurses recalledCIs that occurred early in their nursing careers and someincluded student experiences . In addition, a large majorityof nurses reported that the CIs occurred on evening andnight shifts.Nurses primarily reported negative emotions one to twodays following experiencing the CIs (fear, anxiety, worry,anger, disappointment, frustration, and disgust) . Nursesalso used a variety of strategies to cope with the CIs.However, four coping strategies were used most often:seeking out social support, self-controlling, positivereappraisal, and planful problem-solving . Despite nursesuse of a variety of coping strategies, a large majority ofnurses identified debriefing as one resource that would havebeen helpful following the CIs . Lastly, at least 18% of thenurses reported that CIs did have an impact on theirprofessional or personal lives . The implications of thefindings for nursing education, administration, and researchare discussed .ivTABLE OF CONTENTSABSTRACT	 iiTABLE OF CONTENTS	 ivLIST OF TABLES	 viiACKNOWLEDGMENTS	 viiiCHAPTER ONE : INTRODUCTION	 1Background to the Problem 	 1Statement of the Problem 	 4Purpose of the Study	 5Theoretical Framework	 5The Appraisal Process	 5Coping	 9Outcomes of Coping	 10Significance of the Study	 11Research Questions	 12Definition of Terms	 12Medical/Surgical Staff Nurse	 12Critical Incident	 12Critical Incident Stress 	 13Assumptions	 13Limitations	 13Organization of the Thesis	 14CHAPTER TWO : REVIEW OF THE LITERATURE 	 15Staff Nurses' Appraisal of and Coping with Stress	 15Appraisal of and Coping with Critical Incidents	 30vSummary	 34CHAPTER THREE : METHODOLOGY	 38Instruments	 38Participant Information Sheet	 38Critical Incident Information Form	 38Emotional Appraisal Scale	 39Ways of Coping Scale (Revised)	 41Protection of Human Rights 	 44Sample Selection	 44Subject Recruitment 	 45Data Collection	 45Data Analysis	 46CHAPTER FOUR : PRESENTATION AND DISCUSSION OF FINDINGS	 49Response Rate	 49Demographic Characteristics of the Sample	 50Research Question 1 : What Events Do Medical/SurgicalStaff Nurses Appraise as CIs? 	 53Moral Distress	 58Lack of Responsiveness From a Health CareProfessional	 64Violence Toward Nurses	 68Emergency Situations	 72Death	 74Contact with Infectious Body Fluids 	 76viResearch Question 2 : What are Medical/Surgical StaffNurses' Reactions to an Event Appraised a CI?	 78Research Question 3 : How do Medical/Surgical StaffNurses Cope with a CI?	 82Additional Findings	 87Research Question 4 : How Have CIs Impacted on Medical/Surgical Nurses' Professional and Personal Lives? . . . .90CHAPTER FIVE : SUMMARY, CONCLUSIONS, AND IMPLICATIONS 	 93Summary	 93Conclusions	 95Implications	 96Nursing Education	 96Nursing Administration	 97Nursing Research	 100REFERENCES	 102APPENDICES	 110Appendix A : Participant Information Sheet 	 110Appendix B : Critical Incident Information Form	 112Appendix C : Emotional Appraisal Scale	 117Appendix D : Ways of Coping Scale (Revised) 	 119Appendix E : Participant Resource Information	 124Appendix F : Participant Introductory Letter	 127Appendix G : Participant Information Letter	 130ViiLIST OF TABLESTable 1 : Ages of the Subjects	 51Table 2 : Years of Experience as a R .N	 52Table 3 : Number of Years in Present Position	 53Table 4 : Categorization of Critical Incidents	 57Table 5 : Physical Reactions to a CI	 79Table 6 : Scores on Emotional Appraisal Scale	 80Table 7 : Scores on Ways of Coping Scale	 83viiiACKNOWLEDGEMENTSTo accomplish this important goal within my nursing career Iowe gratitude to many individuals . To my husband, Rob, whobelieved in me, supported and encouraged me to keep strivingto achieve one of my dreams . I am especially appreciative toeach of the 50 medical/surgical staff nurses who sharedtheir critical incident experiences . To my committeemembers, Professor Judith Lynam, Dr . Marilyn Willman, andDr . Sally Thorne, all of whom supported my effortsthroughout this process . I especially thank ProfessorJudith Lynam for her positive remarks and words ofencouragement when I was doubtful, and Dr . Marilyn Willmanfor her editorial contributions . I would like to thank myfamily : Mom, Dad, Cameron, Gina, and Nana for theircontinuous support . I am also grateful to my colleagueswithin this program, especially to Flo, Elisabeth, and Mary.To my friends Laurie, Christine, Patty, Carla, Lori, Cheryl,and Beth for allowing me to gain perspective during thischallenging process .1CHAPTER ONEINTRODUCTIONMedical/surgical general duty nurses experience stresswithin their daily practice . However, it is not known ifthey experience the specific type of stress, known ascritical incident stress . This study describes howmedical/surgical nurses' appraise, react to, and cope withcritical incidents.Background to the ProblemStress is part of our daily lives and it has beendefined in a variety of ways . Several authors haveidentified that when an individual experiences a stressfulevent, there are automatic physiological responses withinthe body, primarily involving the neurological, theneuroendocrine, and the endocrine body systems (Everly,1981 ; Everly & Rosenfeld, 1981 ; Everly & Sobelman, 1987;Selye, 1956) . Prolonged or repeated exposure to stress isthought to cause a wide range of mild to severe mental orphysical health problems (Cox, 1978 ; Selye, 1956, 1973).Numerous authors also agree that what is perceived asstressful by an individual depends on several personal andenvironmental factors (Antonovsky, 1979 ; French, Rodgers, &Cobb, 1974 ; Lazarus & Folkman, 1984 ; Payne & Firth-Cozens,1987) . Individual appraisal of an event determines whetherthe event will be viewed as stressful and enables the2individual to decide the appropriate means to control orresolve stress through coping (Lazarus & Folkman, 1984) . Anindividual copes with a stressful encounter by drawing uponseveral resources : positive beliefs, health and energy,problem solving skills, social skills, and social supportnetworks (Lazarus & Folkman, 1984) . It is clear that evenif two individuals experience the same event, such as movingto a new city and beginning a new job, one may experiencethe event as stressful and the other may experience it as achallenge . In addition, even though two individuals mayappraise the same event as being stressful, they each drawupon unique resources to cope with that event.It is evident in the stress literature that anindividual's workplace or occupation can be a source ofstress (French, Rodgers & Cobb, 1974 ; Payne & Firth-Cozens,1987 ; Vachon, 1987) . Nurses are constantly subjected tostress in their daily practice . Numerous studies and thetheoretical literature have examined how general duty nursesappraise and cope with stress (Dewe, 1987 ; Gribbins &Marshall, 1982 ; Huckabay & Jagla, 1979 ; Kelly & Cross, 1985;Robinson & Lewis, 1990 ; Yu, Mansfield, Packard, Vicary, &McCool, 1989) . Despite an abundance of studies examininggeneral duty nurse stress in acute care settings, thisauthor did not locate any studies that investigated hownurses appraise and cope with a specific kind of stress,3critical incident stress (CIS).Critical incident stress is defined as the emotional,physical, cognitive, and behavioral reactions to a criticalincident (CI) ; these reactions may be acute or delayed(Mitchell, 1983 ; Snelgrove, 1989) . A CI is a traumaticevent or situation that causes unusually strong or extremeemotional responses in a person making usual coping skillsineffective. The reaction may interfere with the person'sability to function immediately or later (Back, 1992;Bergmann & Queen, 1986a ; Mitchell, 1983, 1986 ; Snelgrove,1988a) . All nurses have the potential to experience CIS;however, staff nurses who work in complex environments suchas acute care hospitals are particularly at risk.There is extensive literature pertaining to CIS amongrescue personnel such as firemen, policemen, and paramedics.The majority of this literature describes their reactions tocaring for victims of disasters, is anecdotal in nature, andemphasizes the need for critical incident stress debriefing(CISD) programs (Bell, 1991 ; Graham, 1981a, 1981b ; Heber &Hunsinger, 1991 ; Kelly, 1984 ; Melton, 1985 ; Mitchell, 1982,1983, 1985, 1986, 1988a, 1988b ; Pierson, 1989 ; Snelgrove,1988a, 1988b).The literature concerning CIS in relation to nurses isanecdotal in nature, rather than research-based, and focuseson the need for CISD programs to assist nurses to cope with4CIS (Back, 1992 ; Bergmann & Queen, 1986a, 1986b, 1986c,1986d ; Brown, 1990 ; Jimmerson, 1988 ; Johnston, 1987 ; RoyalInland Hospital, 1991 ; Rubin, 1990) . No studies have beenfound that examine how general duty nurses experience CIS intheir daily practice . Further, there is little informationconcerning what situations or events general duty nursesappraise as being CIs, their emotional responses, theircoping strategies in relation to this type of stress, andthe role others play in assisting them to manage it.Several authors speculate that individuals who experienceCIS may suffer serious consequences ; that is, nurses maydisplay dysfunctional behaviors in both their professionaland personal lives, and some may even consider leaving theirpositions (Bergmann & Queen, 1986a ; Graham, 1981a, 1981b;Mitchell, 1983) . Several authors also postulate that anindividual experiencing a CI, and the subsequent stressreactions, may develop the more serious post-traumaticstress disorder (PTSD) (Bergmann & Queen, 1986a ; Mitchell,1983, 1986 ; Snelgrove, 1989).Statement of the ProblemThere is little information about CIS in nursing.Staff nurses who practice within hospitals are one group whomay experience CIs . The nature of these experiences, howthey are appraised, and the coping strategies used by staffnurses in relation to them are unknown .5Purpose of the StudyThe purpose of this study is to describe how generalduty nurses appraise, react to, and cope with a CI.Theoretical FrameworkThe theoretical framework that will be used in thisstudy is Lazarus and Folkman's (1984) model of stressappraisal and coping . These authors propose that, in orderto understand why there are variations between individualswho experience comparable conditions, one must consider thecognitive processes that occur after experiencing an eventand before the individual reacts to the event.The Appraisal ProcessAccording to Lazarus and Folkman (1984), cognitiveappraisal is an evaluative process that determines what issignificant to an individual in terms of his or her well-being . This, in turn, shapes an individual's behavioral andemotional responses . This cognitive process in essencedraws out what is meaningful to an individual or what is atstake for that individual.Lazarus and Folkman (1984) emphasize that this model isa transactional model, in which there is a relationshipbetween the person and the environment . "Psychologicalstress is a particular relationship between the person andthe environment that is appraised by the person as taxing orexceeding his or her resources and endangering his or her6well-being" (Lazarus & Folkman, 1984, p . 19) . Theenvironment is referred to as either or both of the externaland internal demands that exceed an individual's resources(Folkman, Lazarus, Dunkel-Schetter, Delongis, & Gruen,1986) . The cognitive appraisal process is influenced bynumerous personal and situational factors . The personalfactors include an individual's beliefs and commitments.Examples of situational factors are novelty, uncertainty,predictability, and timing . The authors have identifiedthree kinds of cognitive appraisal : primary appraisal,secondary appraisal, and reappraisal.Primary appraisal involves an individual'sdetermination that an event is irrelevant, benign-positive,or stressful . An event in the environment is appraised asbeing irrelevant when there is no implication for anindividual's well-being . When a benign-positive appraisaloccurs, there is an enhancement of an individual's well-being or it is a positive encounter . There are three kindsof stressful appraisals : harm/loss, threat and challenge.Within a harm/loss situation, an individual has alreadysustained damage, as in a traumatic injury, recognition of aloss of self-esteem, or loss of a valued person . The mostdamaging situations are those in which there are majorlosses . In threat, the individual anticipates harm orlosses that may occur . Within a situation viewed as a7challenge, the individual recognizes that there is potentialfor gain . Although there are distinctions among the threetypes of stressful appraisals, there are instances in whichthey may not be mutually exclusive . For example, a jobpromotion may be appraised as both a challenge and a threat.An individual may recognize not only the potential gains,such as increased financial rewards and responsibility, butalso the risk of not performing as well as expected.Secondary appraisal is the process used by individualsto determine what resources and options are available tocope with a stressful event . This is another example of anevaluative process as the individual considers whatresources are available, the probability that a certainstrategy will be effective, and the consequences ofimplementing such a strategy . Examples of individual copingresources include health and energy, existential beliefs(about God) or general beliefs (about control), commitments,problem-solving skills, social skills, social support andmaterial resources (Lazarus & Folkman, 1984) . Lazarus andFolkman (1984) also emphasize that there may be specificconstraints that prevent the use of these resources incertain situational contexts . Coping options aredistinguished from coping resources . Coping options aresuch actions as changing the situation, accepting it,seeking more information, or holding back from acting8impulsively . Coping resources, on the other hand, refer tothe specific personal and environmental resources anindividual draws on in order to cope.Lazarus and Folkman (1984) emphasize that primary andsecondary appraisal are interdependent . An individual isonly able to classify an event as being either harmful,challenging, or threatening based on a convergence ofinformation from both the primary and the secondaryappraisals . For example, an individual who appraises anevent as a threat and identifies adequate resources mayappraise the threat as minimal . On the other hand, anindividual may appraise a situation as a challenge, butdetermine that insufficient resources are available to cope.The event may then be appraised as threatening.Reappraisal is the individual's modified appraisal of asituation through more information from the environmentand/or new interpretations of the event . The onlydistinction between appraisal and reappraisal is that thelatter occurs after the initial appraisal . For example, athreat may be reappraised as irrelevant, or a benign-positive appraisal may be reappraised as a threat . Thesemodifications will influence a change in consequentindividual emotions, coping strategies, and adaptationaloutcomes .9CopinqAccording to Lazarus and Folkman (1984), coping isdetermined by the primary and secondary appraisals . Copingis defined as " . . . constantly changing cognitive andbehavioral efforts to manage specific external and/orinternal demands that are appraised as taxing or exceedingthe resources or the person" (Lazarus & Folkman, 1984, p.141) . It is process-oriented in that when the individualappraises and reappraises the event, he or she will modifythe coping strategies needed to meet the demands . Theindividual also draws on a multitude of personal andenvironmental resources in order to cope.Coping includes all the efforts an individual usesregardless of the outcome . Based on the primary andsecondary appraisal, the individual will either change themeaning of a situation or modify the environment . Lazarusand Folkman (1984) outline two types of coping: problem-focused coping and emotion-focused coping . The former issimilar to problem-solving and is utilized to alter ormanage the environment which caused the distress (orthreat) . The latter refers to a group of cognitiveprocesses aimed at reducing the emotional distress:distancing, self-controlling, seeking social support,escape-avoidance, accepting responsibility, and positivereappraisal . Lazarus and Folkman (1984) state that these10two functions are also interdependent and may facilitate orimpede one another.Outcomes of CopinqLazarus and Folkman (1984) state that the primeimportance of appraisal and coping processes is that theyaffect three adaptational outcomes : social functioning,morale, and somatic health . Social functioning refers to anindividual's degree of satisfaction with interpersonalrelationships or degree of fulfillment in various roles, forexample, as a parent, a spouse, and a friend . Morale refersto how individuals feel about themselves . An individual'semotional reactions and coping strategies are also seen tohave an effect on health and illness ; this is referred to assomatic health (Lazarus & Folkman, 1984) . These threeoutcomes are also closely interrelated . Good functioning inone outcome may be directly linked to poor functioning inanother and good functioning in one area does not mean thatan individual is functioning well in all areas . Forexample, a nurse may be satisfied with the closerelationships maintained with friends and family . However,this nurse also encounters stress or more specifically CISat work and this may lead to dissatisfaction and/or lowmorale with relation to his or her role as a nurse.After an individual appraises and copes with aspecific event, a judgement is made on the extent to which11the encounter was resolved effectively (Folkman et al .,1986) . This is based on consideration of an individual'svalues, goals, commitments, beliefs and expectationsconcerning the stressful event. For example, even though anindividual may not be able to resolve the stressful event,there may be positive adaptational outcomes (positivemorale, and effective interpersonal reactions) . In such aninstance the individual may feel that the demands of theevent were managed as well as could be expected . On theother hand, an individual may recognize that even when astressful event is resolved, there may be negative outcomes.This may occur when the resolution of a stressful encounteris inconsistent with an individual's values, beliefs, andexpectations ; an inconsistency may create additionalconflicts for the individual (interpersonal difficulties,low morale, and health problems) (Folkman et al ., 1986).As CIS is one specific kind of stress, thisinvestigator believes that Lazarus and Folkman's 1984theoretical framework will assist in understanding hownurses appraise and cope wtih CIs, and how this particulartype of stress affects their social functioning.Significance of the StudyThis study will add to the body of knowledge inrelation to nursing and CIs . It will identify what eventsor situations medical/surgical staff nurses appraise as CIs,12and how they react and cope . As there is ever-increasingclient acuity within hospitals, nursing administrators andeducators may recognize CIS as an important issue . They mayhave to consider providing supportive programs for nurseswho experience CIs or change care delivery methods . Inaddition, this study may stimulate further related researchregarding nurses and CIs.Research QuestionsThe following questions will guide this study:1. What events do medical/surgical staff nurses appraise asCIs?2. What are medical/surgical staff nurses' reactions to anevent appraised as a CI?3. How do medical/surgical staff nurses cope with a CI?4. What impact have CIs had on medical/surgical nurses'professional and personal lives?Definition of TermsMedical/Surgical Staff Nurse - A registered nurse (RN),working in a medical or surgical area in an acute carehospital.Critical Incident (CI) - Any situation defined by the nurseas being a traumatic event, causing the nurse to experienceunusually strong emotional reactions, making the usual13coping skills ineffective (Back, 1992 ; Bergmann & Queen,1986a ; Mitchell, 1983).Critical Incident Stress (CIS)- Recognition of theemotional, physical, cognitive, and behavioral reactions toa critical incident . These reactions can be either acute ordelayed (Back, 1992 ; Bergmann & Queen, 1986a ; Mitchell,1983, 1986) .AssumptionsIt is assumed that general duty nurses experience CIsin the context of their everyday practice and that thenurses will be honest in completing the study instruments.LimitationsThe findings of this study will not be generalizable toother medical/surgical nurses because of the conveniencesampling technique used nor to nurses in other contexts andclinical settings . The study will only examine how nursesreact and cope with a CI at one point in time (the first fewdays and evenings following the event) . Participants willbe recalling these CIs retrospectively, and the quality ofdata gathered will depend on the participants' memory of theevents .14Organization of the ThesisThis thesis is comprised of five chapters . Thischapter has outlined the following: background to theproblem, statement of the problem, purpose of the study,Lazarus and Folkman's (1984) theoretical framework,significance, research questions, definition of terms,assumptions, and limitations . Chapter Two presents a reviewof the literature . The third chapter describes themethodological approach. Chapter Four presents the resultsof the data analysis and a discussion of the findings . Thefinal chapter presents the summary, conclusions,implications for nursing, and recommendations for futureresearch .15CHAPTER TWOREVIEW OF THE LITERATUREThe literature is reviewed under the following twomajor headings : staff nurses' appraisal of and coping withstress, and appraisal of and coping with critical incidents.In addition, other related literature is presented.Staff Nurses' Appraisal of and Coping with StressIn a descriptive study of approximately 1800 nurses,Baily, Steffen, and Grout (1980) identified stressors ofintensive care unit (ICU) nurses . Nurses reported thatpatient care and interpersonal relationships caused the moststress . Paradoxically, these same nurses also reported thegreatest challenge and benefit from these two sources.Yu et al . (1989) conducted a survey of 952 nurses inmany specialized areas to examine their perceptions ofoccupational stress in hospital settings . In this study,occupational stress was categorized as general work pressureand uncertainty and routinization of tasks . Nurses whoappraised their area of work as most stressful were those inadministration, cardiology, medical/surgical settings, theemergency room, and the ICU.In a descriptive study with 85 nurses, Burns,Kirilloff, and Close (1983) investigated the specificsources of stress and satisfaction of nurses working in anemergency department using the Lazarus and Folkman (1984)16categories . The top two categories that nurses appraised asbeing most stressful (threat and harm/loss stress appraisal)were unit management issues such as inadequate staffing,apathetic, inexperienced staff (physicians and nurses), andpatient care issues such as critical emergencies, cardiacarrests, fatalities, serious injury or death of children,uncooperative, abusive or demanding patients or families,triage, and decision making . The greatest source ofsatisfaction (a benefit) was appraised as patientimprovement and progress.In another descriptive study of 46 ICU nurses, Huckabayand Jagla (1979) investigated stress factors in ICU . It wasreported that these nurses appraised events or situationswithin the environment as more stressful (threatening orharmful) than internal stressors relating to the person.For example, the top five events appraised as stressful wereworkload and amount of physical work, death of a patient,communication problems between staff and nursing office,communication problems between staff and physicians, andmeeting the needs of the family . These authors reportedthat, as the degree of control over a situation decreased,the appraised threat increased.Huckabay and Jagla (1979) also concluded thatexperienced nurses were able to cope with stress moreeffectively because they were able to draw upon resources17such as acquired knowledge and proficiency . Younger, lessexperienced nurses reported a higher level of stress.In a descriptive study of 182 full-time ICU nurses,Anderson and Basteyns (1981) reported the situations nursesidentified as most stressful . These nurses rated thefollowing five situations as most stressful : death of ayoung adult, inability to obtain help when the unit wasshort staffed, unavailability of the doctor when anemergency arose, medication errors, and situations in whichadequate help was not available to properly care forpatients.In an exploratory study, Spoth and Konewko (1987)examined the frequency and severity of stress experienced bynurses within the context of several different ICU nursingunits (three general ICUs, two neurologic, and one cardiacICU) . Overall, across all ICUs, the stressors that nursesdescribed most frequently were too many interruptions, lackof respect or consideration from physicians, and the rapiddecision making involved with patient care . The factorsthat were rated by these nurses as most severe were too manyinterruptions, lack of respect from physicians, and thephysician not arriving quickly enough in a time of crisis.Nurses who worked in the neurologic ICU reported the highestfrequency and severity of stress.These investigators also explored the relationship18between potentially stressful life events, (those eventsoccurring outside the ICU) and critical care stressors(Spoth & Konewko, 1987) . Although there was no relationshipbetween these two variables, insight was gained regardingwhich life events nurses perceived as most stressful . Thetop five stressful life events were change in work hours andconditions, change in financial status, vacation, Christmasseason, and change in work responsibilities.Robinson and Lewis (1990) reported that ICU nursesdescribed lack of reward, the crisis atmosphere, and theexperience level of medical residents as the three mainwork-related stressors . Fatigue, anxiety, frustration,irritability and forgetfulness were rated as the top fivereactions to such events . These investigators also reportedthat ICU nurses used the following top five copingstrategies to deal with stress : discussed problems with co-workers, used caffeine, watched t .v ./read, problem-solved,and discussed problems with family.In a descriptive study of 24 neonatal ICU staff nurses,Gribbins and Marshall (1982) identified personal (reactiveand proactive) and management coping strategies . Personalreactive strategies included talking to people outside theunit and talking with fellow nurses . Personal proactivestrategies included setting priorities, humour, andconfrontation . Management strategies included attending19psychotherapy sessions and participation in meetings.Nurses with one year of experience, as compared to nurseswith three to four years of experience, used fewer copingstrategies and experienced different stresses . They did nottalk to fellow nurses, attend psychotherapy sessions,participate in meetings, or use humour and confrontation.These investigators acknowledged that it was difficultto present conclusions because of the small sample.Nevertheless, this finding raises questions about whetherutilization of more effective coping strategies were relatedto the level of nursing experience . As a result of thefindings, changes were implemented to assist both new andmore experienced nurses in coping with stresses within theNICU . For example, nurses in orientation are encouraged tobring family and friends to visit the NICU in hope of theirincreased understanding of the nurse's stress experiences.Bene and Foxall (1991) investigated the relationshipbetween death anxiety and job stress in 30 hospice and 40medical-surgical nurses . These investigators identifieddeath as one experience nurses frequently encountered andwere interested in its effect on their overall stress.Overall, both hospice and medical-surgical nursesreported high levels of job stress within the same threestress categories : relationships with physicians, emotionaldemands/uncertainty, and overload/staffing . However,20medical-surgical nurses reported an increased amount ofstress in terms of severity within the emotional demands/uncertainty, patient aggression, death and dying, andfloating categories . In addition, the medical-surgicalnurses more frequently reported overload/staffing, patientaggression, communication within the unit, and floatingsituations as causing them stress . These findings mayassist in understanding which events or situationsmedical/surgical staff nurses appraise as stressful incomparison to other nurses.Death anxiety was not correlated with job stress forthe hospice nurses (Bene & Foxall, 1991) . This findingraises questions as to whether nurses who work exclusivelywith the terminally ill in fact exhibit higher deathanxiety . The medical-surgical nurses' death anxiety wasfound to correlate with the amount of job stress . Theseinvestigators believed that even though medical/surgicalnurses experienced patient deaths less often than hospicenurses, their higher scores might be related to theadditional overall stress within their workplace.In a comparable study, Foxall, Zimmerman, Standley, andBene (1990) investigated differences between frequency andsources of stress perceived by ICU, hospice and medical-surgical nurses . These authors reported no difference amongthe nurses in relation to the overall total scores on the2144-item 4-point Nursing Stress Scale . However, three maindifferences were reported after further data analysis . TheICU and hospice nurses experienced more stress than medical-surgical nurses in relation to death and dying . Medical-surgical nurses had a greater amount of stress than theother two groups with workload/staffing . ICU and medical-surgical nurses experienced greater stress than the hospicenurses in reference to floating . These differences suggestthat nurses practicing in different specialties withdifferent types of patients and levels of acuity, and uniqueresources, may appraise different types of events as beingstressful . Furthermore, in terms of this study, a questioncan be raised as to whether general duty nurses in differentmedical/surgical settings will describe quite differentevents as being Cis.Maloney (1982) studied the differences of stress levelsand consequences between 30 ICU and non-ICU nurses . Thenon-ICU nurses scored higher on the state anxiety scale thanthe ICU nurses . State anxiety referred to anxiety producingsituations within the work environment . In addition, thenon-ICU nurses experienced higher levels of trait anxietythan the ICU nurses . Trait anxiety is referred to asemotional/physical uneasiness . Both of these findings areinconsistent with previous findings . Maloney postulatedthat since nurses choose the area in which they wish to22work, ICU nurses may have higher stress tolerance than non-ICU nurses . In addition, this investigator suggested thatnurses within the ICU environment may support one anothermore than non-ICU nurses (nurses utilized each other as acoping resource) . However, it can be argued that perhapsthe ICU nurses possessed more resources in terms of howtheir environment was structured than the non-ICU nurses.If this were true, nurses would then be responding andreacting to stress depending on how their work environmentwas set up.Maloney (1982) also reported that even though the non-ICU nurses scored higher with state and trait anxiety thanICU nurses, there were no differences between the two groupsin terms of their overall job satisfaction/dissatisfaction(Maloney, 1982) . However, the non-ICU nurses experiencedhigher levels of workload dissatisfaction . Finally, thenon-ICU nurses reporting higher levels of anxietyexperienced greater personal difficulties with friends andfamily than did ICU nurses.Walcott-McQuigg and Ervin (1992) studied 67 communityhealth nurses in regards to seven categories of stressfulsituations : knowledge and technical skills, managementdynamics, direct patient care, interpersonal relations,physical work environment, life events, and administrativeawards . The top five most stressful encounters were : lack23of time to complete work during scheduled hours, theirschedule did not permit adequate time to organize work,uncooperative family members, inability to reach aphysician, and unfamiliar situations . These investigatorsalso reported that older and more experienced nursesexperienced less stress than did younger nurses.Kelly and Cross (1985) compared 31 ICU nurses and 61ward nurses in terms of appraisal of, and coping with,certain stressful events . The events included were avariety of environmental, interpersonal, patient care,knowledge and skill, and workload situations . Both groupsused a variety of coping strategies, some examples included:" . . .drawing upon past experiences, talking over the problemwith others, and basing an action on understanding of asituation" (Kelly & Cross, 1985, p . 326).However, Kelly and Cross (1985) reported that the wardnurses experienced more stress in relation to environmentalfactors, such as actual work space, than did the ICU nurses.Although the medical/surgical nurses primarily used adaptivecoping strategies, these nurses were reported to eat more,sleep less, and cry more in comparison to the ICU nurses.These findings raise questions as to whether the ICU is themost stressful place for nurses to work . Theseinvestigators recommend that medical/surgical nurses receivethe same support and resources as ICU nurses and that24changes be made to decrease the environment-related stressfactors.Schaefer and Peterson (1992) compared the effectivenessof coping strategies of 209 critical care nurses and non-critical care nurses . These investigators reported thatthere was no difference in the coping strategies used ortheir effectiveness between these two groups . Critical careand non-critical care staff nurses reported thatconfrontational, optimistic, self reliant coping strategieswere most effective in the management of job stress.Evasive and palliative coping strategies were leasteffective.Vachon (1987) examined the perceived stress of 600health care professionals in caring for the critically ill,the dying, and bereaved . The younger group of healthprofessionals (under 30 and 31 to 45 years) appraised workenvironment situations such as communication problems withcolleagues and inadequate staffing as being mostproblematic . The oldest group (over 45 years) reported themost stress from their occupational role with patients andfamilies . It was reported that the two older groups copedby developing a sense of team support, and team buildingwhereas the younger group was more likely to seek outspecific colleagues at an individual level . What isparticularly interesting about this study is that the older25participants in similar situations experienced less stressby making use of an increased number and variety of copingstrategies . Females represented the majority (71%) of thesubjects and 49% were nurses . Of the males studied, 65%were physicians . The investigators reported that femaleswere twice as likely to report difficulty coping withdisfiguring illnesses (23% versus 12%) . Males reporteddifficulty coping with unpredictable situations (35% versus13%) .In a descriptive study of approximately 1300 nurses,Dewe (1987) reported several principal coping strategiesused by nurses in stressful situations, "problem-orientedbehaviour, trying to unwind and put things into perspective,expressing your feelings or frustrations, keeping theproblem to yourself, accepting the job as it is and tryingnot to let it get to you" (p . 496).Ethical distress can be linked to another concept,moral distress, another type of stress . Considering thatnursing practice has become more complex within the last tenyears with technological advances, increased patient acuity,increasing financial restraint, and increase in consumerism,it is not surprising to find empirical research thatsupports nurses as experiencing moral distress . Moraldistress occurs when moral choices cannot be translated intomoral action (Jameton, 1984) . Typically an individual who26experiences moral distress has feelings of guilt, anger,frustration, and powerlessness (Jameton, 1984) . Mostimportant, however, several authors believe that moraldistress is associated with nurses' stress and burnout(Cameron, 1986 ; Rodney & Starzomski, 1992).Rodney (1987) examined in a qualitative study theexperiences of critical care nurses' ethical decision-makingwith prolongation of life . She found that moral distresswas a part of the nurses' experiences . "Nurses [were] boundby constraints that meant nurses were unable to implementchoices . . . [and] moral distress was associated with somesignificant feelings for nurses, including resentment,frustration, and sorrow" (Rodney, 1988, p . 10) .	Theconcept of moral distress is helpful in understanding thecomplexities of ethical situations and also important inthat it should be considered as one type of situation thatnurses may consider to be a CI.Ehrenfeld and Cheifetz (1990) conducted a one-dayworkshop to address the issue of coping with stress for 264cardiac nurses . This workshop was not intended to meet thecriteria of a research project, but rather to encouragegroup work and sharing of experiences and ideas relating tostress . It was discovered through each of the group leadersthat the following five events were reported as the moststressful : dealing with an inexperienced physician or lack27of physician's presence when needed, lack of adequatelyskilled nursing staff or lack of nursing staff, coping withpatients and families, coping with sudden death, and lack ofcommunication or inadequate communication with physiciansand with staff.Through the same data collection procedure, Ehrenfeldand Cheifetz (1990) reported that of these 264 cardiacnurses, 32 .6% used active coping skills towards solving aproblem, 11 .7% sought out other resources to facilitateproblem-solving, 37% were passive, and 18 .6% participated inactivity that was not directed to the solution.Norbeck (1985) reported that 180 critical care nurseswho experienced high levels of job stress had low jobsatisfaction and high levels of psychological symptoms.Nurses who were inexperienced and worked nights reported lowjob satisfaction . Those nurses who were inexperiencedreported low job satisfaction . This investigator alsoidentified the specific stressful events that were relatedto decreased job satisfaction and increased psychologicalsymptoms . Workload, communication difficulties with nurses,and physical set-up of the critical care unit contributed toperceived low job satisfaction . Four environmental factors(physical set-up, noise level, numerous pieces of equipmentand its failure, and injury to a nurse), and two emotionallystressful factors (dealing with the psychological needs of28the patients, and communication difficulties with nurses)were related to increased psychological symptoms.In another study, Gray-Toft and Anderson (1981)examined the relationship between stress, job satisfaction,and turnover in staff nurses . The sample included 122nurses from five different nursing areas ; medical, surgical,cardiovascular, oncology, and hospice . Across all of thesefive nursing units the three most stressfulevents/situations were workload, feelings associated withinadequate preparation to meet the emotional demands ofpatients, and death and dying . These investigators alsoreported that the nurses who scored the highest in relationto stress were less satisfied with their jobs and had higherturnover rates . For example, the nurses working on themedical unit experienced the most stress and, within a five-month period, had a 30% turnover rate . This raisesquestions as to whether nurses who experience CIs may bemore vulnerable to lower job satisfaction and possiblyhigher job turnover.In a descriptive study of 76 ICU nurses, Stone, Jebsen,Walk, and Belsham (1984) reported that nurses whoexperienced burnout were more dissatisfied, and perceivedevents occurring within the critical care environment asthreatening . Nurses who held a positive sense ofaccomplishment viewed their work environment as innovative29and supportive . Nurses who utilized an increased number ofeffective coping skills experienced less burnout . Further,nurses who were more experienced and/or had more educationwere less likely to perceive events within the critical carecontext as stressful (threatening) . Again, this studyraises questions as to whether nurses who experience CIs aresusceptible to higher levels of burnout.Boyle, Grap, Younger, and Thornby (1991) examined therelationship between personality hardiness, ways of coping,and social support in the development of burnout within 103critical care nurses . According to Kobasa, Maddi, and Kahn(1982), hardiness refers to a personality disposition thatfacilitates the use of effective coping strategies and, as aresult, resolution of a stressful situation . Boyle et al.reported that nurses who scored low in hardiness scored highon the burnout scale . In addition, Boyle et al . reportedthat nurses who primarily utilized emotion-focused copingstrategies also had higher burnout scores . Finally, nurseswho scored high in relation to social support scored low inburnout.Keane, Ducette, and Adler (1985) examined thedifferences between ICU and non-ICU nurses in relation toburnout . These investigators reported that there were nodifferences between these two groups . Both of these nursinggroups scored high in burnout when they felt powerless,30alienated, and had an external locus of control . The nurseswho felt challenged, in control, had an internal locus ofcontrol, and commitment towards their jobs scored lower onthe burnout scale . In relation to coping, these nurses wereessentially coping more effectively within their workingenvironments.Appraisal of and Coping with Critical IncidentsOnly within the last ten years has CIS beenacknowledged as a serious problem for rescue personnelassisting victims in tragic circumstances and witnessinghuman tragedy (Mitchell, 1988a) . Several authors state thatfiremen, policemen, and paramedics experience the followingevents as CIs : death of a child, death or injury of a co-worker in the line of duty, multi-casualty incident (couldinclude a disaster), incidents resulting in death whererescue attempts took place over an extended period, or wheredeath was sudden and unexpected, incidents where the victimis known to the emergency worker, and any event that hassignificant emotional power to overwhelm usual copingmechanisms (Bell, 1991 ; Bergmann & Queen, 1986a ; Mitchell,1983, 1988b ; Snelgrove, 1988a) . Two authors report thatemergency service workers' CIS emotional reactions mayinclude fear, anger, irritability, frustration, anxiety,guilt, grief, and sadness (Mitchell, 1982, 1983 ; Snelgrove,1989) . All of these reactions correspond to Lazarus and31Folkman's (1984) harm/loss and threat stress appraisalcategories . Fear, anxiety, worry, and anger correspond tothreat appraisal as there is a potential for harm or loss.Anger, sadness, guilt, and disgust are consistent with theharm/loss stress appraisal . Common physical reactionsinclude headaches, nausea, vomiting, diarrhea, and fatigue(Mitchell, 1983 ; Snelgrove, 1989).Several authors report that, in coping with a CI,emergency rescue workers may display a variety ofbehavioural and cognitive responses : impaired thinking anddecision making, depression, confusion, sleep disturbances,possible interpersonal difficulties at work and at home, andsubstance abuse (Mitchell, 1982, 1983 ; Snelgrove, 1988b,1989) .There have been attempts to assist rescue personnel incoping with CIS through the development of critical incidentstress debriefing (CISD) programs . CISD is thepsychological and educational group process aimed atsoftening the impact of CIS through "talking it out"(Snelgrove, 1989) . The primary purpose of these programs isto assist groups of individuals with their subsequentemotional reactions and to provide a resource to assist themin coping with CIS . The majority of the CIS literaturefocuses on information pertaining to CISD : the purposes, thebenefits, and how to implement a CISD program (Bell, 1991 ;32Mitchell, 1983, 1986, 1988a, 1988b ; Snelgrove, 1988a,1988b) . The latter authors provide anecdotal descriptionsof those who have been involved in the debriefing process,and describe it as being helpful in assisting them in copingwith their CI experiences.The author has located two descriptive studies thatexamined the need for and the benefits of CISD programs.The first study addressed the effectiveness of the programs(Alberta Public Safety Services, 1985b) . Based on 42debriefing sessions per year with an average of 14 rescuepersonnel in attendance, the authors estimated a saving of$320,000 a year . This money was saved by decreasing theincidence of sick leave and workers leaving the occupationof emergency services.The second study used a comparative descriptive methodto assess the need for on-site counselling following a traindisaster (Alberta Public Safety Services, 1985a) . Seventyrescue personnel directly involved in the rail disaster werethe study group, while 100 emergency workers not involved inthe disaster acted as the control group . Through a 30-itemhealth questionnaire, participants indicated whether thespecific behaviours, emotions, and cognitive abilitiesoccurred more, the same, less, or much more . It was foundthat the study group was constantly under more stress, lesssatisfied with job performance, feeling more nervous and33strung out, and feeling less hopeful about the future . Inaddition, 78 .6% of the study group rated post-disastercounselling as being important/very important.Only within the last several years have authorsacknowledged that nurses are vulnerable to experiencing CISwithin acute care settings, even though this phenomenon hadexisted previously (Back, 1992 ; Bergmann & Queen, 1986a;Jimmerson, 1988 ; McCall & Bebb, 1990) . Bergmann & Queen(1986a) state that the following situations may be appraisedas CIs by nurses:The death of a child, especially when due to criminalactivity or parental negligence ; the serious injury ordeath of a patient resulting from routine or emergencyservice operations ; almost any case which is chargedwith emotion for that particular nurse such as thesudden death of an infant under particularly tragiccircumstances ; any loss of life which followsextraordinary and prolonged expenditures of physicaland emotional energy during treatment ; any incidentwhich can be considered a serious physical orpsychological threat or a sudden loss to the nurse,(i .e ., working on a patient who is a friend or familymember) ; almost any incident in which the circumstancesare so unusual or the sights and sounds so distressingas to produce a high level of immediate or delayed34emotional reaction that surpasses the normal copingmechanisms of the nurse (p . 35).Again, the descriptions of nurses' emotional and physicalresponses are identical to those reported within theemergency rescue personnel literature.There is no information regarding how nurses cope withCIs . However, in other situations when nurses' copingstrategies are inadequate in managing their stress, theremay be negative consequences : low job satisfaction,substance abuse, increased turnover, and higher burnout.There is a focus on the provision of CISD programs to assistnurses in coping with the resultant emotional, physical,behavioral and cognitive reactions (Back, 1992 ; Bergmann &Queen, 1986b, 1986c ; Brown, 1990 ; Jimmerson, 1988 ; Rubin,1990) .SummaryThere were numerous studies that examined which eventsand situations staff nurses considered to be stressful andthe strategies used to cope . These studies were conductedwithin different contexts (both non-ICU and ICUenvironments), and investigators used different theoreticalframeworks pertaining to stress . It was revealed thatnurses who practiced within medical-surgical nursing unitswere no less stressed than those nurses who worked withincritical care environments . Furthermore, some of these35studies reported that medical-surgical nurses experiencedmore stress in some circumstances than did critical carenurses, especially related to lack of resources available.Moral distress was also examined as one possible type ofstress nurses may encounter in relation to ethicalsituations.It was reported that medical-surgical nurses andcritical care nurses used similar coping strategies tomanage their stress . It was revealed that nurses used avariety of coping strategies, and these were not identifiedexplicitly by the investigators as being either emotion- orproblem-focused as in Lazarus and Folkman's (1984)theoretical framework . However, the numerous copingstrategies reported correspond to Lazarus and Folkman's(1984) emotion- and problem-focused categories . Inaddition, data revealed that nurses who had more experienceused more effective coping strategies.Although these studies identified the events generalduty nurses considered to be stressful, there is lack ofunderstanding as to which events may have been considered asCIs . As a result of this omission, there is a lack ofunderstanding of how nurses react and also cope with thesetraumatic and overwhelming events (CIs).Literature was reviewed that linked job stress and jobsatisfaction, high turnover, and burnout among staff nurses .36Several investigators found that nurses who had increasedstress were less satisfied and consequently scored higher inregards to burnout . There was inconclusive evidence relatedto whether medical/surgical nurses experienced higherburnout and turnover than did ICU nurses . This raisedquestions as to whether nurses who experience CIs may bevulnerable in developing lower job satisfaction, higherturnover, and burnout.There was an abundance of literature pertaining to CISamong rescue personnel ; however, the majority of theinformation was anecdotal, emphasized the importance of CISDprograms, and was speculative . Two studies described howrescue personnel reacted as a result of a disaster andreported the cost-benefit of CISD programs . Still, there isclearly a lack of research investigating how rescuepersonnel react and cope in situations appraised as CIs.There is some literature reporting that nurses alsoexperience CIS ; however, there have been no studiesinvestigating nurses and CIS. The literature is anecdotal,speculative, and advocates the implementation of CISDprograms . Still, this raises the question of whether CIshave been imbedded in the context of some of these numerousstress studies without the traumatic experiences havingbeen taken out and examined . It is therefore warranted toinvestigate and describe nurses' critical incident37experiences as it is important to know what situationsnurses appraise as being CIs, how they react to a CI, howthey cope with a CI, and the impact of the events upon theirpersonal and professional lives .38CHAPTER THREEMETHODOLOGYA descriptive design was used as it allows fordescription of phenomena about which very little is known.InstrumentsParticipant Information SheetA general information sheet was developed by theinvestigator to record demographic information ; gender, age,number of years of experience, and number of years inpresent position (Appendix A).Critical Incident Information FormThis instrument was developed by the investigator andrequired that participants respond to a variety of yes/noand open ended questions concerning appraisals of andreactions to CIs and their impact on the nurses' lives.The instrument was tested through a pilot project andappropriate changes were incorporated.Minor revisions related to grammar and sentencestructure were implemented, as well as a suggestion to boldthe definition of a CI on the instrument . Question number3, which related to the time the CI occurred was changed toinclude both 8-hour and 12-hour shifts . Question number 5was changed slightly to offer an option for the respondentsto elaborate further about how the CI challenged theirpersonal beliefs . One question (number 7) was changed from39an open-ended question to a closed-ended format . Onequestion, which was pertinent to the appraisal of the CI wasadded to this instrument (number 10) . Changes were alsoincorporated in question number 11, providing an option forrespondents to elaborate and include any other physicalreactions that they experienced as a result of the CI . Inaddition, it was necessary to be specific about reference tothe time of these reactions after the CI . It was decided tomeasure reactions within the first few days and eveningsfollowing the CI . Lastly, a sentence was added to clarifythe definition of debriefing (Appendix B).Emotional Appraisal ScaleThis instrument (Appendix C) was chosen because one ofthe study's questions was to measure medical/surgical staffnurses' reactions to CIs . A decision was made to useFolkman and Lazarus's (1986) 16-item Emotional AppraisalScale rather than the 1985 version (Dr . S . Folkman, personalcommunication, October 26, 1992) . The most recent studyincorporated a factor analysis which was based on a muchbroader community sample and variety of stressfulencounters . The instrument is a 16-item checklist with a 5-point Likert scale (0 = not at all ; 4 = a great deal) . The16 items are categorized into 4 emotional scales : threatemotions, challenge emotions, harm emotions, and benefitemotions . Threat emotions include fear, anxiety and worry .40Challenge emotions include confidence, security, andcontrol . Anger, disappointment, frustration, and disgustrefer to harm emotions; and exhilaration, happiness, relief,pleasure, eagerness, and hopefulness correspond to benefitemotions.Scores range from 0 to 12 for threat emotions, 0 to 12for challenge emotions, 0 to 16 for harm emotions, and 0 to24 for benefit emotions . The maximum score is 64 and thehigher the scores for each of the categories, the higher theintensity of emotion.The instrument was developed from the cognitive-phenomenological theory of emotion (Lazarus, Kanner, &Folkman, 1980) . This theory has gained increasingacceptance as a result of empirical research withindifferent populations and in different contexts . Thequality and intensity of emotions (including both positiveand negative emotions) such as anxiety, disgust, relief,happiness, and anger are dependent upon the appraisalprocess . According to these authors " . . .the relationsbetween cognition and emotion are, no doubt, exceedinglycomplex two way streets, with emotion often redirecting orinterfering with cognitive activity, as well as vice versa"(Lazarus, Kanner, & Folkman, 1980, p . 191) . The authorsemphasize that several of these positive and negativeemotions occur concurrently (challenge, benefit, harm/loss,41and threat) and, over time, these emotions will intensify orweaken over the course of cognitive appraisals and re-appraisals . There is also evidence of construct validity.Folkman and Lazarus (1985) reported that studentsexperienced both threat and challenge emotions concurrently,and this supports one component within their (1984)theoretical framework.Within this same study, there was evidence of internalconsistency as reliability alpha coefficients were .80 forthe threat emotions ; .59 for the challenge emotions ; .84 forthe harm emotions, and .78 for the benefit emotions.In another study, 75 husbands and wives wereinterviewed once a month for six months regarding the moststressful encounter that they had experienced each previousweek (Folkman & Lazarus, 1986) . Internal consistency datawere as follows ; .87 for harm emotions, .80 for benefitemotions, .81 for threat emotions, and .82 for challengeemotions (Folkman & Lazarus, 1986).Ways of Coping Scale (Revised)This tool was developed from Lazarus and Folkman's(1984) theoretical framework and chosen as one of theinstruments for the study as it would measure how nursescoped with CIs . This framework emphasizes that throughoutthe changing person-environment interaction, a person copeswith stressful events through the use of both problem-42focused and emotion-focused coping.The Ways of Coping Scale (Appendix D) is a 66-item 4-point Likert scale (0 = not used to 3 = used a great deal)which measures the behavioral and cognitive copingstrategies used to deal with a stressful situation (Folkmanet al ., 1986) . There is evidence of content validity aschanges were made to the instrument as a result of ongoingtesting with different populations . For example, the 1985version differs from the 1980 version as unclear andredundant items were deleted or reworded, and several newitems were added (Folkman et al ., 1986).The 66 items are categorized as being either emotion-focused or problem-focused . The minimum score for allemotion- and problem-focused coping categories is zero withmaximum scores of 18 for confrontive-coping, 18 fordistancing, 21 for self-controlling, 18 for seeking socialsupport, 12 for accepting responsibility, 24 for escape-avoidance, 18 for planful problem-solving, and 21 forpositive reappraisal . The maximum score is 150 and thehigher the scores for each of the categories, the greaterthe degree of use of a specific coping strategy.Several research studies provide evidence ofconstruct validity . For example, one study reported that98% of all participants (men and women) used both emotion-and problem-focused coping strategies (Folkman & Lazarus,431980) . In another study Folkman and Lazarus (1985) reportedthat 94% of all college students used both types of copingduring an examination . It was also reported that students'coping methods did change throughout different points intime throughout the examination . This finding supportsLazarus and Folkman's (1984) framework in relation to theconstant changes that occur when an individual appraises,reappraises an event and tries to cope.In the 1985 Folkman and Lazarus study, reliabilityalpha coefficients were : .85 for problem-focused coping, .84for wishful thinking, .71 for distancing, .81 for seekingsocial support, .65 for emphasizing the positive, .75 forself-blame, .56 for tension reduction, and .65 for self-isolation . Further evidence of internal consistency isprovided by another study conducted by Folkman, et al .,(1986) . In this study, the sample consisted of 75 husbandsand wives, and they reported the most stressful encounterthat they had experienced during the previous week . Theparticipants were interviewed once a month for six months.Reliability alpha coefficients were .70 for the confrontivecoping scale, .61 for the distancing, .70 for selfcontrolling, .76 for seeking social support, .66 foraccepting responsibility, .72 for escape avoidance, .68 forplanful problem-solving, and .79 for positive reappraisal .44Protection of Human RightsTo ensure that the human rights of the participantswere protected, the study met the criteria set forth by theUniversity of British Columbia Behavioral Sciences ScreeningCommittee for Research and Other Studies Involving HumanSubjects and all three hospital research committees . Onehospital committee expressed concern for the participants'psychological well-being, as they might become upset and/ordisturbed by recalling an event that had been traumatic.Thus, arrangements were made for assistance with possibleeffects with several resource people in the community whohad been educated about CIS and its effects . Participantswithin the two teaching hospitals were advised of theiravailability if required . Anonymity was maintained byinstructing participants to separate their completedquestionnaires from their request for resource information(Appendix E) . Participants who were employed at thecommunity hospital were simply instructed to contact thenewly-developed CISD team within the hospital.Participants were informed in the introductory letterand information letter of measures taken to ensure anonymityand confidentiality (see Appendix F & G).Sample SelectionA convenience sample of 50 medical/surgical generalduty nurses was selected from three hospitals within the45British Columbia Lower Mainland . Two facilities were majortertiary teaching hospitals, and one was an acute carecommunity hospital . This investigator chose to include thisnumber of participants and three different hospital sites toenhance the reliability of the findings (Woods & Catanzaro,1988) .Criteria for participation in the study were thefollowing : a) registered nurse with at least 6 months ofexperience and employed on a medical/surgical nursing unit,b) has experienced a CI, c) has volunteered to participatein the study .Subject RecruitmentFollowing the approval of the University of BritishColumbia Behavioral Sciences Screening Committee forResearch and Other Studies Involving Human Subjects, andeach of the hospital research committees, sample recruitmentcommenced . The investigator chose 5-6 medical/surgicalunits within each of the three hospitals and contacted eachhead nurse by telephone to explain the study and the requestfor participants . Brief meetings were then scheduled withthe general duty nurses . The purpose of the meetings was toexplain the study, emphasize the benefits in participating,answer questions, and request participation.Data CollectionIntroductory letters (Appendix F) were left with some46of the head nurses upon request, and others communicatedinformation about the study through the staff communicationbook and/or bulletin board . The investigator discussed thestudy with nurses individually, or in small groups of two orthree. Nurses who met the inclusion criteria andvolunteered received a package which included anintroductory letter and consent form, the instruments and,for the two tertiary teaching hospitals, a separate sheetthat outlined resources and/or resource people to seek outfor support if required, and a return envelope . Nurses whowere employed at the community hospital were informedverbally who to contact as a resource, as this hospital hadits own CISD team . Participants were asked to returncompleted instruments in the sealed envelope to a boxprovided on each of the medical/surgical nursing units . Theinvestigator picked up the envelopes on a weekly basis.Data AnalysisQuantitative data from the instruments were coded usingthe Lotus 1-2-3 statistical package and descriptivestatistics such as means, ranges, frequency distributions,and standard deviations were calculated.Open-ended questions in the Critical IncidentInformation Form were subjected to content analysis andcategories were established for the CI responses . Theinvestigator reviewed all 50 CIs two to three times and47conceptualized mutually exclusive categories that wouldcapture them . Criteria for the six categories wereestablished . One category, moral distress, involvedsituations in which nurses had been confronted with choices,but for a variety of reasons were unable to implement theirchoices . Key individuals involved were doctors, nurses,administrators, and families . Lack of responsiveness from ahealth care professional was identified as a second categoryand encompassed CIs in which nurses did not receive adequateassistance during a serious or crisis situation . Oftenthese CIs could have been prevented if the nurses hadreceived such assistance.Violence towards nurses was another category andcriteria for selection of the CIs included both verbal andphysical abuse from a patient or other member of the healthcare team . In addition, exercising of overt power over anurse was considered to fit within this category.Death was a CI category for nurses who describedincidents involving caring for patients near death and forgrieving family members . Emergency situations wasconceptualized as another category in which nurses wereoften trying to save a patient's life, as in cardiac orrespiratory arrest, or nurses believed the risk for such anoccurrence was high . Finally, a category labelled ascontact with infectious body fluids (Hepatitis B /H .I .V .)48was identified . The main criterion for this type of CI wasdirect exposure to a life-threatening disease.The CI responses were reviewed by the investigator atotal of three times to ensure consistency in grouping theCIs . In addition, two other individuals were asked tocategorize the CI responses (25 each) in accordance with thecriteria . Inter-rater reliabilities were 88% and 84%respectively.The investigator then reviewed the seven CIs that werecategorized differently by the raters and a decision wasmade to place six of the seven CIs in the categories chosenby the raters . The remaining CI was reviewed by a thirdrater who was an expert in the area of moral distress and itwas placed accordingly .49CHAPTER FOURPRESENTATION AND DISCUSSION OF THE FINDINGSThis chapter is organized into two sections . The firstsection presents the response rate, the demographic data,and years of experience for nurses in the sample . Thesecond section includes the findings and discussion relatedto the four research questions.Response RateQuestionnaires were distributed only to those R .N .'swho could recall having a CI . A total of 50 out of 140questionnaires was returned, yelding a response rate of35 .7% . The relatively low response rate may be related toseveral factors . As a convenience sample was used, onlythose nurses who were interested in the study andvolunteered their time participated . Most of the data werecollected during the Christmas season . Several nurses chosenot to participate feeling that the questionnaire was toolengthy . Some of the respondents took between 40 minutes to1 hour to complete the questionnaire . In addition, eventhough the investigator reviewed the definition of a CI witheach prospective participant, there was no assurance thatthey indeed could recall or identify with a CI experience.Conversely, the investigator questioned whether there werenurses who could identify CI experiences, but because of thesensitive nature decided not to participate . During one of50the scheduled meetings with a small group of nurses, onenurse stated "I have thought about participating, but Ijust cannot handle going over the traumatic incident again,I just want to forget it ." Furthermore, despite theassurance that the questionnaire was anonymous, it may havebeen easier for the nurses to discuss their CIs with theinvestigator informally rather than recording theirexperiences on such a sensitive concept . The investigatoralso observed that, during some of the meetings with thestaff, those nurses who initially thought that they hadnever experienced a CI were convinced otherwise by some oftheir peers . This was done by nurses questioning each otherabout certain traumatic events that had occurred in thepast . It was then observed that some of the nurses whooriginally thought that they could not relate to this typeof stress, could identify an event that was a CI for them.Lastly, the investigator did not keep track of individualnurses, so only general reminder notices were posted on eachof the nursing units to prompt return of the questionnaire.This strategy did not prove to be effective.Demographic Characteristics of the SampleThe sample consisted of 50 medical/surgical generalduty nurses, of whom 47 were female (94%) and 3 were male(6%) . Ages ranged from 20 to 58, with the majority betweenthe ages of 20 and 31 (see Table 1) .51Table 1Ages of the SubjectsAge Frequency Percent (%)20-23 6 12 .024-27 20 40 .029-31 10 20 .032-35 2 4 .036-39 3 6 .040-43 4 8 .044-47 1 2 .048-50 0 0 .051-54 3 6 .055-58 1 2 .0Total 50 100 .0With the use of a convenience sampling technique, thedemographic findings related to gender were representativeof the population of nurses in British Columbia (B .C .).Approximately 97% of the nurses in B .C . were female and2.48% were male (University of British Columbia Health HumanResources Unit, 1992) . However, there were differences interms of age when compared to provincial and nationalstatistics . Seventy-two percent of the sample were agedbetween 20 and 31 and 18% between 32 and 43 . In 1991, 28%of B .C . nurses were in the <25 to 34 age group and 35% werein the 35 to 44 age group (University of British ColumbiaHealth Human Resources Unit, 1992). In addition, accordingto Statistics Canada (1991), 35% of nurses were aged <25 to34, and 35% were aged 35 to 44. Thus, there were largernumbers of young nurses (20 to 31) in the sample than in the52general nursing population . Explanations may be related toseveral factors . It may be that younger nurses couldreadily identify with CIS or that they were more willing toparticipate . Also, medical/surgical units are often thefirst place of employment for younger, less experiencednurses.As shown in Table 2, the majority of nurses within thissample had between one and six years of experience, with asmaller proportion of nurses having more than seven years ofexperience . None of the nurses had less than one year ofexperience.Table 2Years of Experience as a R .N.Years Frequency Percent (%)< 1 0 0 .01-3 21 42 .04-6 12 24 .07-9 7 14 .0>10 10 20 .0Total 50 100 .0The majority of nurses had been in their presentpositions from one to six years, with a smaller numberhaving been in their positions for less than one year (seeTable 3) . In addition, some of the CIs occurred whenrespondents were students.53Table 3Number of Years in Present PositionYears	Frequency	Percent (%)< 1	6	12 .01-3	26	52 .04-6	14	28 .07-9	2	4 .0> 10	2	4 .0Total	50	100 .0Research Question 1 : What Events Do Medical/Surgical StaffNurses Appraise as Cis?Prior to presenting the findings relating to appraisalsof CIs, additional findings within the Critical IncidentInformation Form (Appleton, 1992) are provided that may helpto explain why certain events were appraised as CIs . Forexample, 44% of the respondents reported that the incidentchallenged their personal beliefs . Some nurses commentedthat the incident caused them to question how much their ownwell-being should be jeopardized at work . Others reportedthat they wanted to carry out a set of specific actions, butwere unable to because of certain constraints : doctors,other nurses, families, or policies within the institution.Furthermore, 82% of the nurses reported that their CIsoccurred suddenly (without warning) . The majority of thesample (65%) reported that their CIs involved dealing withsomething new . Among these experiences were : using new54equipment, implementing new nursing interventions, being ina life-threatening position (dealing with aggressive andviolent behaviour, HIV exposure), communicating death tofamily members, code situations, death of a young adult andchild, new patient with life-threatening condition andfighting for patient's rights with administrators.A majority of the nurses (72%) also reported that therewere elements of uncertainty within their CI experiences.It should be emphasized that some of the nurses who statedthat the CIs involved something new also reported that therewere elements of uncertainty . Therefore, the elements ofnovelty and uncertainty are not mutually exclusive . Inaddition, nurses who were confronted with uncertainty andnew situations also reported that 80% of the time they feltcomfortable with the decisions made during the CIexperiences.The type of uncertainty experienced was varied but itpotentially had a significant impact . For example, onenurse who recalled a CI that was categorized under moraldistress wrote that she was uncertain that the patient wouldreceive any of the care he needed before dying, anduncertain if her reputation would be damaged or if herlicense would be revoked.Within the violent CI category, nurses were uncertainof their own and other patients' safety . Within the context55of emergency situations, nurses were uncertain of patientoutcome, that is survival or death . Regarding exposure toHIV, nurses were uncertain if they had contracted the life-threatening virus . Nurses who reported CIs that pertainedto lack of responsiveness of a member of the health careteam expressed uncertainty related to what was done for thepatient . Finally, nurses who experienced a CI involving apatient death were uncertain as to whether everything wasdone to try to save the patient's life.Sixty-one percent of the sample stated that they didnot recall having any other stresses in their lives at thesame time as the CI . Of the 39% who reported havingadditional stresses, 58% described them as personal andprofessional.Nurses recalled CIs that had occurred from three daysto 30 years previously (M=2 .9 years) . Sixty percent of therespondents were recalling events that occurred within oneyear previously . The reason for this is not clear . Whilethe investigator did not construct any definitive timecriteria for the CI experiences, 66 .6% of the nursesrecalled CIs that occurred early in their careers (between 1to 3 years), including some student experiences . When theinvestigator recruited these participants and explained thedefinition of a CI, several nurses in each of the threehospitals stated the following : "Oh, I can relate, I56remember the worst thing that happened to me was when I wasa new grad . . ." This finding may be related to the fact thatnurses who experienced such traumatic events early in theircareers were unable to draw upon resources such as pastexperience, knowledge, and a variety of coping strategies.Lazarus and Folkman's (1984) theoretical framework supportsthis reasoning as an event may be appraised as stressful dueto many factors : lack of resources, novelty, uncertainty,and lack of development of a variety of coping strategies.It was also reported in several stress studies that older,more experienced nurses were less stressed than youngernurses because of their ability to draw upon pastknowledge/experience, and a larger repertoire of copingstrategies (Gribbins & Marshall, 1982 ; Huckabay & Jagla,1979 ; Vachon, 1987 ; Walcott-McQuigg & Ervin, 1992).Twenty-nine percent of the sample reported the CIsoccurring on an extended 12-hour night shift (1900 to 0700),22% on evening shift (1500 to 2300), and 22% from 2300 to0700 . Eighteen percent of the nurses reported CIs occurringduring day shift (0700 to 1500) and 16% from 0700 to 1900.In total, 65% of the CIs occurred during evening andnight shifts . This finding is consistent with Lazarus andFolkman's (1984) framework . Individuals who are confrontedwith inadequate resources such as on evening and nightshifts, may experience stress . This finding is especially57important to consider at the time when budget decisions arebeing made . Furthermore, nursing unit managers, cliniciansand physicians (persons with more experience and seen ashaving expertise) are not as accessible during this timeperiod. The investigator believes that some of these eventswould not have been classified as CIs by the participants ifthey had occurred during the day.Using content analysis, the medical/surgical staffnurses' CIs were categorized within the following sixcategories : moral distress, emergency situations, death ofa patient, violence against nurses, lack of responsivenessby a health care professional, and actual/potential contactwith infectious body fluids (Hepatitis B, and Human Immuno-deficiency Virus (H .I .V .)) . The moral distress categoryoccurred most frequently (see Table 4), with the leastfrequent category being contact with life threateningTable 4Categorization of Critical IncidentsCategory Frequency Percent(%)Moral distress 14 28 .0Lack of responsiveness 11 22 .0Violence toward nurses 10 20 .0Emergency situations 6 12 .0Death 6 12 .0Contact with HIV, Hep B	3 6 .0Total 50 100 .0infectious diseases . For each of the categories, examples58have been extracted to illustrate the different types of CIsexperienced by the staff nurses . As some of the respondentsjotted down their CI experiences in a point form format,the investigator has made some minor editing of thenarratives to enhance the "readability ."Moral DistressThis category captured the events in which nurses wereconfronted with moral dilemmas . A total of 14 CIs weregrouped within this category . As a result of being involvedwith these dilemmas, the nurses described feelings that areconsistent with moral distress . Moral distress is definedfor the purposes of this study as : " . . .the psychologicaldisequilibrium and negative feeling state experienced when aperson makes a moral decision but does not follow through byperforming the moral behavior indicated by that decision"(Wilkinson, 1987/1988, p . 16) . Nurses within this samplewere confronted with choices, but were unable to act onthose choices . Key players who prevented moral action wereoften families and members of the health care team (doctors,nurses, supervisors, and administrators).The following example involved a nurse who experiencedmoral distress as a result of acting as a patient advocate.She was torn between risking her job security and protectionof a patient's rights:The patient involved was a 31-year-old male on a59medical floor in a large 1000-bed hospital . Despitehaving a diagnosis of metastatic cancer, he was notreceiving any analgesics or sedatives, nor had he beenreferred to pastoral care . His physician orderedsaline injections and a continuous infusion of salineand ordered nurses to deceive the patient and tell himhe was getting analgesics and sedatives . This went onfor weeks and patient was in moderate to severediscomfort . I found this patient as a float nurse onthe unit and refused to take part in the deception andreported to my night supervisor, two assistantdirectors, and the head director as well as myprovincial association. They all threatened me withthe loss of my license. Guided by my ethics I pursuedthe matter for several weeks . I was very much afraidfor the loss of my livelihood, and all for a patientwhom I did not know personally, and for whom I hadacted as a patient advocate . Between pastoral care andmy union lawyers this patient did receive the care towhich he was entitled.Within the category of moral distress nurses expressedfeelings of helplessness in relation to performing certainnursing procedures and interventions that were contrary topatients' beliefs . One nurse recalled the following event:The patient was a 12-year-old Jehovah's Witness . Her60hemoglobin was extremely low, therefore requiring herto receive a blood transfusion in order to extend herlife as she was battling leukemia . Her parents refusedto have her receive the blood transfusion due to theirreligious beliefs . The patient also refused to receivethe transfusion for the same reason . Her attendingdoctor received a court order to go ahead with thetransfusion as the patient was a minor . At the time Iwas a student nurse assigned to this patient . My RNthought it would be a good experience for me to hangthe blood on this girl, not taking into considerationmy confused emotions and ethical uncertainty at this.I was devastated as I had to cover the blood tubingwith cloths so the girl could not see that we wereactually giving her the transfusion . I could not lieto the girl, I had to tell her that it was indeed theblood transfusion . I felt helpless, confused and mostof all angry for having to deal with this situationwith little support from the other staff members whowere working at the time.Nurses also reported feelings of senselessness andguilt associated with unnecessary or pointless interventionsfor patients . One nurse described the following situation:A young male who was diagnosed with rheumatic arthritisat age 13, lived for years with excruciating pain .61Gradually he developed horrific bed sores over everybony prominence . The bed sores were also covered withpseudomonas . Living and breathing for him wasexcruciatingly painful . He had daily dressing changesthat took at least two hours . For me, as a student ittook at least three hours . . . . Gloved, masked, gowned,I was encased . It was a hot hot day and the hospital'sair conditioning had failed . With every twitch orturn, with every dressing removal or application hewould scream . He would tip back his head and screamuntil I was finished each portion . Then he would lapseinto unconsciousness for a few minutes . I did theentire thing with sweat and tears rolling down my face.I even sobbed out loud once when I made him roll to oneside . This boy was very terminal . He died one weeklater . We all knew he was on his way out . I recallfeeling horrified that he was forced to endure torturefor no valid reason . Wound healing was not a validreason, as he was dying.Within this category nurses also described theirfeelings associated with being caught between what thefamily wished and identifying what would really be best interms of the patient . One nurse described the followingsituation as a CI:A nineteen-year-old trauma patient whose father was62killed in the same car accident was admitted to thenursing unit . She arrived during a night shift and Iwas working days . The patient's family had notinformed her of the death of her father . The familydid not want to tell her for a few days . They felt shewas not strong enough emotionally . The patient wouldbe asking how her father was and I was not able totell her . I was fearful that she might hear it fromsomeone other than her family . She was a universitystudent and of East Indian descent . She was eventuallytold two days later by her family, after numerous phonecalls and discussions with the family and myself.Jameton (1984) noted that there is often overlap/blurring between the concepts of ethics and morality.Ketefian (1989) also acknowledged that there is confusionbetween moral reasoning and ethical practice . Therefore,for the purposes of this study, morality refers to a set ofvalues or principles to which one is personally committed(Jameton, 1984) . Jameton stated that within nursing thesevalues are often guided by the formal set of rules, as inthe Canadian Nurses' Association (CNA) Code of Ethics(1991) . Again, moral distress is referred to as a situationin which a nurse knows what ought to be done (moral choice)but there are contextual constraints preventing moral action(Rodney & Starzomski, 1992) .63Twenty-eight percent of the participants described CIsthat were consistent with moral distress . Some authorssuggest there are links between moral distress and stressand burnout (Cameron, 1986 ; Rodney & Starzomski, 1992).There are no reports of moral distress as a CI and thisstudy is the first to identify it . One explanation is thatnurses could have identified moral distress CI experiencespreviously, but the experiences were not separated from theresearch relating to stress . However, there was evidencewithin the current research in the area of ethics that therewere nurses who left their jobs in part as a result of theirinability to cope with moral distress (Wilkinson, 1987/1988) . The investigator speculated that the nurses inWilkinson's study might have identified their moral distressas a CI since the effects were quite serious (they lefttheir positions).Nursing practice has become more complex within thelast ten years . There have been numerous technologicaladvances and patient acuity and financial restraint haveincreased as has consumerism. Nursing decisions have becomemore complex and perhaps there are more situations in whichthe rules are unclear . It was not surprising, therefore, toobtain empirical evidence that nurses were experiencingmoral distress CIs.The nurses within this study expressed heightened64feelings of helplessness, senselessness, anger, andfrustration . This finding is consistent with two studiesinvolving moral distress (Erlen & Frost, 1991 ; Rodney,1987) . One investigator explained that the strength ofnurses' feelings was dependent on how closely they relatedto a patient situation and their role in trying to deal withthe situation (Wilkinson, 1987/1988) . Lazarus & Folkman's(1984) framework also supported this ; individuals who holdstrong beliefs and values surrounding an event will havestronger reactions (because the events are important andhave meaning to them).Lack of Responsiveness from a Health Care ProfessionalEleven out of the 50 CIs were grouped within thissecond category . Situations within this category occurredwithin the context of not receiving adequate response and/orinterventions from members of the health care team during aserious or critical situation . Such situations wereassociated with nurses feeling frustrated and angry . Thefollowing two examples illustrate this . One nurse reported:I was working nights and I had finished handing out theevening medications half an hour previously, when Iheard a patient yelling . He was usually very mildmannered, but was now throwing items in the room andbeing verbally abusive . Although he was unable towalk, I feared for my own safety as well as the safety65of the other two patients in the room . The doctorwas called and he ordered blood gases "STAT ." Iexplained that I could not get near the patient letalone take blood gases . He said "Do the best you can"and hung up . Two more times the doctor was notifiedbefore he would order sedation . Ultimately thesecurity was called, four nurses from the hospital andtwo R .C .M .P . officers were used to hold the patientdown to give the sedation.The following example occurred on a night shift andinvolved a patient who was experiencing delirium tremens.He was not given any sedation during the day shift, and wasbecoming progressively more agitated . The nurse wrote:He had pulled out his intravenous, was hallucinatingand was very diaphoretic . I called the doctor then,and received an order for an oral medication as thepatient refused to have an intravenous started . I thengave him the oral dose stat . From then on thesituation was awful . Security was called as he becamephysically and verbally aggressive and was going intoall the patients' rooms and going through theirbelongings . He continued to hallucinate and becameextremely paranoid . Again the doctor was called forfurther orders . The doctor voiced annoyance at beingcalled but reluctantly gave an order for Haldol66intramuscular . This was given with no effect . After30 minutes I called the doctor again to be asked "Whattime is it now?" and "Do you need anything else?" Thedoctor was politely told of the patient's severelyescalating condition . Again Haldol was ordered andagain after 30 minutes it was ineffective . All of thiswas given with no effect, as well as patient beingrestrained with leather wrist and ankle restraints.Each time the doctor was called she expressed annoyanceand was then asked to come to the hospital to assesspatient . This was refused as well as a request for aninternist . For at least nine hours this patientscreamed obscenities and was physically abusive . . . . Iwas very concerned for the safety and life of thispatient as well as the safety and well-being of theother 19 patients and the staff.Although the two previous examples involved violencetowards a nurse, the stressful situation evolved into a CIbecause of the lack of responsiveness on the part of thephysician . These escalating situations could have beenprevented if the nurses had received adequate support fromthe physician.This next example involved lack of responsiveness onthe part of colleagues during a crisis situation . The nursewrote :67I was a new grad at the time (< 4 months) and it was myfirst shift working without a preceptor in a veryspecialized acute medical floor . My patient wasconsidered a fairly light assignment . At approximately0500 hours the patient passed approximately 2 litres offresh melena . I called the doctor to come in andreceived some orders . I informed my co-workers that mypatient was bleeding but received no help or support.It wasn't until I grabbed one co-worker and looked herin the eye and stated I need help now, that I didactually receive help . The patient continued toactively bleed . A crisis situation evolved . Thedoctor who arrived to "help" was very condescending andangry . I felt people (doctor and nurses) were ignoringme when I said my patient was bleeding . I felt theywere saying to themselves, "Oh, she is new, she hasnever seen a major bleed ."In this sample, 22% of the CIs reported were related tolack of responsiveness from a health care professional.Previous investigators may have alluded to this lack ofresponsiveness by reporting nurses who considered lack of aphysician's presence during an emergency/crisis as beingstressful (Anderson & Basteyns, 1981 ; Spoth & Konewko,1987) .Lazarus and Folkman's (1984) theoretical framework also68assists in understanding why this kind of event wasappraised as a CI . A nurse who had less than adequateresources in a serious patient situation experienceduncertainty and fear as how to cope with the event.Huckabay and Jagla (1979) reported that communicationdifficulties amongst staff were considered to be stressful.The context of these communication difficulties is not known(whether they were related to patients, staff, physicians,or family members).There was no previous evidence within the current CIliterature that identifies this type of CI . Explanation asto why nurses appraised this lack of responsiveness as a CImay be related to situations that nurses assessed as seriousthat became more severe and could have been easilyprevented.Violence Toward NursesViolence toward nurses was another category that nursesdescribed as being a CI . Ten out of 50 CIs were groupedwithin this category . Violence encompassed verbal abuse,verbal threats, and physical abuse toward a nurse by apatient or another member of the health care team . Exertingpower over another person was also considered to fit withinthis category . Nurses described feelings that wereassociated with vulnerability . For example, nurses werefearful of their safety when they were the targets of verbal69threats . The CI for one nurse relates to a post-operativepatient being verbally and emotionally abusive:This patient was using foul, vulgar, abusive languagein a very loud and threatening manner . The patientalso used arm motions in an attempt to threaten me.Attempts were made to calm the patient down but wereunsuccessful . The patient frightened all of thepatients on the floor.In other circumstances nurses were the target ofphysical threats with associated risk of physical injury andpossible death . The following two examples illustrate this.One nurse described how a 19-year-old male patient withencephalitis became very disoriented and agitated:He was physically very strong and had broken out ofleather wrist restraints . At the time of the incidenthe ran down to the nurses station and saw me . Hemistook me for his ex-girlfriend and proceeded to swingthe leather restraints with large metal buckles at myhead . A resident doctor in the next room heard theincident and tackled the patient by his feet, droppinghim to the floor . I feared for my life . If I had beenhit with the whirling buckle, I would have surelysuffered a serious head injury.A second nurse recalled:Suddenly I heard a call for help down the hall . I70walked into a private room where the call hadoriginated from . In that room I saw three nursesattempting to clamp a very violent man's chest tube, hewas trying to kick or hit one of the nurses . I yelled,"get out of here," and they all came to their sensesand started to get out of the room. When the patientcracked his chest tube bottle and was waving a brokenbottle at the nurses everyone ran out of the room . Itwas very scary to see how close these nurses were tobeing wounded with a broken bottle by a crazy man.Violence was not restricted to nurse-patientinteractions ; in some instances it was between a physicianand a nurse . The nurse expressed feelings of anger andbelittlement associated with lack of respect as aprofessional . The physician was exercising overt power overthe nurse . She described a situation in which her patientwas on telemetry:The key persons involved were : chief ofgeneral surgery, patient (who was a doctor), andmyself . The ICU reported to me that the patient'smonitor was reading as a "straightline ." I went in theroom to check on the patient . The chief surgeon wassitting in chair taking a history and physical . Iexcused myself and checked the patient's leads . Thesurgeon burst out with abusive language toward me for71interrupting his history and physical . He told me towait outside . Words were exchanged between the surgeonand myself . The situation got totally out of control.I told the surgeon never to call me down in front ofa patient . The surgeon flew into a rage . . . . What gotto me was that the patient, even though he agreed I wascorrect to check on him said, "I have to take thedoctor's side because I am also a doctor ."In this study, 20% of the sample described CIs thatinvolved violence . There was literature describing violenceas a stressful occupational hazard for nurses (Anderson,Ghali & Bansil, 1989 ; Cox, 1987, 1991; Lipscomb & Love,1992) . Violence was only implicitly referred to by CISauthors (Bergmann & Queen, 1986a) . This finding issignificant as there was evidence of physical assault,verbal threats by patients, families, and a physician asbeing components of violence in this study.Explanations as to why nurses identified violent eventsas CIs vary. Some nurses were afraid for their own lives,the safety of other patients, or the potential for somethingserious happening . Nurses valued their own safety and anevent that was perceived as a threat to this safety wasappraised as stressful, which is consistent with Lazarus andFolkman's (1984) reasoning . Another possibility that isconsistent with Lazarus and Folkman's framework is related72to the lack of resources available . Several of theseviolent events occurred during night shift, when there wereless staff to respond to an urgent situation . In addition,nurses may have reported these violent CIs because violencewithin acute care settings is on the rise (British ColumbiaMinistry of Health, 1992a) . Nurses may also not be willingto accept violence as "part of the job," and are thereforereporting violent incidents.It is not surprising to find studies that provideevidence that health care workers have lost much time due toworkplace violence and some have even left their positions.In 1987 and 1991, Cox reported that 18% and 24 .3% of theannual staff turnover was related to verbal abuse . Inaddition, Carmel and Hunter (1989) reported that 121 staffmembers sustained 135 injuries over a one year period in amaximum security forensic hospital, with 43% of the injuriesresulting in lost time at work.Emergency SituationsWithin this sample six of the CIs fit within thiscategory . All of the incidents involved patients whosestatus was deteriorating . In some situations the patientsexperienced a cardiac or respiratory arrest while, inothers, the nurses perceived this as highly likely . Thenurses were caring for patients who were near death, andwere implementing measures to try to prevent death . One73nurse described the following:I was working with a practical nurse, the others wereon coffee break . The ward was very busy, andalmost every call bell was on . I found one patient whohad a tracheostomy a few days back lying on thefloor . The patient had pulled the trach out . There wasblood all over the floor . I checked the patient andfound him unconscious, with his skull split open at theback . I was unable to assist the patient back to bed.There was no one to make a phone call so I called,"arrest ." I did get help but it sure took long time,the patient ended up in ICU.A second nurse wrote:Shortly after coming on shift at 1930, an arrest wascalled while I was receiving report . The patient hadsurgery the day before and was up and about . Thepractical nurse (PN) found the patient lying in bed ina pool of blood, in a full arrest . I started cardio-pulmonary resuscitation (CPR), the arrest teamarrived . . . . I was playing "gofer" and the PN was doingcompressions . All other staff for the shift weretrying to continue with other duties . Approximately 15minutes into the arrest, another patient complained offeeling dampness around his dressing (same surgery andsame day) . When the RN looked under the bed linen, the74blood was spurting . She yelled and another PN came tohelp . It took two to put pressure on the site so itwasn't spurting . . . . Within 15 minutes we had thesecond patient in the operating room . However, he wasnear arrest . Meanwhile the arrest team continued towork on patient number one, but was unsuccessful after1 hour and 15 minutes . Basically in an hour and a halfinto my shift--one arrest caused by an arterial bleed,and a second with an arterial bleed and just 10 .5 hoursleft to work!DeathThis category involved nurses who cared directly forpatients who were near death and/or their grieving families.A total of six CIs were grouped in this category . Severalnurses' CIs involved the death of a young patient . Thefollowing is a situation one nurse faced:During my shift in the neurological intensive care unitmy patient deteriorated rapidly . She was a 23-year-oldnew mother who had suffered a subarachnoidhemorrhage, and because of the position of her aneurysmshe was not a candidate for surgery . She subsequentlywent into vasospasm and infarcted half her brain andhad a cerebral herniation while I was caring for her.She died the next day.Common characteristics associated with this category75included nurses' feelings of helplessness, sadness andgrief . For example one nurse recalled caring for a "28 yearold leukemic patient who died . He had an eleven-month-oldchild and a newborn . His wife took the death very hard--difficult to console ."Numerous investigators have reported that nursesappraised death and emergency situations as stressful(Anderson & Basteyns, 1981 ; Burns et al ., 1983 ; Foxall etal ., 1990 ; Huckabay & Jagla, 1979) . In this sample, nurses(six in each category) reported death and emergencysituations as CIs . These findings are consistent withLazarus and Folkman's (1984) theoretical framework.Identification of death as a CI could be explained bythe degree of loss surrounding the death . Some of the CIsinvolved deaths of young children, a young mother andfather, and a death witnessed by a young child.In relation to emergency situations, one possibleexplanation as to why nurses appraised these events as CIsis that they were confronted with the events within amedical/surgical nursing unit . Emergency situations may nothave occurred on a daily basis . In combination with theirheightened level of fear and uncertainty related to patientoutcomes, their perceptions of a CI may also be explained bythe lack of resources available at the time . For example,in comparison to an ICU, resources are less readily76available.Contact With Infectious Body FluidsThree of the 50 CIS experiences fit into this category.It included the CIs that nurses described related to directcontact with potentially life-threatening infectiousdiseases, such as Hepatitis B/HIV, as the following examplesillustrate . One nurse wrote:I poked myself with a needle used on an HIV positivepatient . I had to go to occupational health, and beadmitted through emergency and seen by the ChiefExecutive Officer . I had a blood test done and then Iwas offered the option of receiving A .Z .T .(medicationtreatment for individuals testing positive for HIV).This option of taking A .Z .T . was done over thetelephone . I had to complete numerous forms and thewhole process took more than two hours . I wasterrified and did not return back to work that day orfor about one and a half weeks for stress leave(fearing I had contracted HIV and having no controlover this).A second nurse reported:A 27-year-old long term patient died half an hourbefore I arrived on the ward after I had been off sickfor a number of days . Her mother met me in thecorridor and told me of her death and we cried77together . Then I started my shift . Later thatafternoon a high risk HIV patient was returning fromthe O .R . and during the transfer his davol snappedapart spraying my face, eyes, and mouth . I had a freshcold sore on my lip and I was concerned that it mayhave been a possible entry site . Hospital proceduredictated a wash and to be seen in emergency . The wardwas busy and could not afford my prolongedabsenteeism twice during the shift . I had to returnagain after my shift and wait about one hour to beattended to.Again, there was no direct referral to direct exposureto a life-threatening disease as incidents in the CIliterature . Bergmann and Queen (1986a) implicitly statedthat a CI may involve an event that causes a seriousphysical risk.The British Columbia Ministry of Health (1992b)reported 1,411 HIV cases in B .C . . Across Canada there were7,282 cases of HIV (Health and Welfare Canada, 1992).Nurses care for these individuals during various stages oftheir disease processes, and in different contexts (acutecare settings, clinics, home care, and hospice programs).Explanations as to why nurses appraised their exposureto this potentially life-threatening disease were possiblyrelated to having no control of the situation, uncertainty,78and fear of testing positive for HIV . The process oftesting takes at least six months for accurate results andthis could possibly make things even worse . In addition,nurses described the steps that had to be taken asimperfect . Two out of the three nurses had to wait one totwo hours in the emergency of their respective agencies tohave necessary blood work and paper work completed . Afterall procedures were final, nurses returned to work to resumetheir duties (each of the nursing units would have had towork short staffed while they were absent) . The stress ofpotential harm was augmented by competing pressures,responsibility to self versus responsibility to thecolleagues and patients on the unit.One of the nurses did receive one initial visit with apsychologist, but she said that this was not useful, asthere was not much discussion about the event . This findingraised a question as to whether hospitals could provideimproved protocols/procedures, as well as accessible andmeaningful resources to nurses with this specific kind ofCI.Research Question 2 : What are Medical/Surgical Staff Nurses'Reactions to an Event Appraised as a CI?Using the Critical Incident Information Form(Appleton, 1992), information was gained about the physicalreactions that nurses experienced one to two days following79the Cis . They reported a variety of physical reactionsrelated to experiencing CIs (see Table 5).Table 5Physical Reactions to a CIPhysical Reaction	N=43	Frequency	Percent(%)Nausea	7	16 .0Diarrhea	2	5 .0Headache	10	23 .0Fatigue	35	81 .0Insomnia	20	47 .0Others	14	33 .0In addition to these, 33% of the nurses reported severalothers, such as, nervousness, crying, anxiety, fear,decreased concentration, agitation, preoccupation with theevent (thinking about it all the time), tense stomach, andshaking of the knees.Other emotional reactions to CI experiences weremeasured using Folkman and Lazarus's (1986) EmotionalAppraisal Scale . Nurses reported using a variety of suchreactions (see Table 6) . During the first few days andevenings following a CI, nurses reported using harm emotions(anger, disappointment, frustration, disgust) with scoresranging from 0 to 16 (M=9 .86), threat emotions (fear,anxiety, worry) with scores from 0 to 12 (M=6 .36), challengeemotions (confidence, security, control) ranging from 0 to10 (M=3 .48), and benefit emotions (exhilaration, happiness,80relief, pleasure, eagerness, hopefulness) with scoresranging from 0 to 15 (M=3 .22) . Overall, nurses' totalscores ranged from 6-44 (M=22 .40).Table 6Scores on Emotional Appraisal ScaleScore Frequency Percent (%)Threat Appraisal	(M=6 .36,	S .D .=3 .37)0-2 9 18 .03-5 13 26 .06-8 11 22 .09-12 17 34 .0Total 50 100 .0Harm Appraisal (M=9 .86, S .D .=3 .80)0-2 3 6 .03-5 3 6 .06-8 12 24 .09-12 17 34 .013-16 15 30 .0Total 50 100 .0Challenge Appraisal (M=3 .48, S .D .=2 .95)0-2 20 40 .03-5 15 30 .06-8 11 22 .09-12 4 8 .0Total 50 100 .0Benefit Appraisal (M=3 .22,	S .D .=4 .03)0-3 33 66 .04-7 8 16 .08-11 6 12 .012-15 3 6 .016-20 0 0 .021-24 0 0 .0Total 50 100 .081With reference to Folkman and Lazarus's (1986) study,overall scores were comparable (M=20 .06) to the nurses'total scores in this study (M=22 .40) . However, nurses whoexperienced CIs reported a higher intensity of negative(harm/loss and threat) emotions than did participants in theFolkman and Lazarus study who were lay people . The findingcan be explained by the fact that nurses who experienced CIswere frequently in situations where the stakes were high.For example, in numerous instances, nurses perceived threatsto their safety or a patient's safety, as was the case interms of the violence and lack of responsiveness categories.In other words, the investigator believes that nurses usedthese harm and threat emotions more frequently because theywere often dealing with difficult situations in which theycould in some cases become victims themselves (as in thecase of violence).The above finding relative to harm and threat emotionsis consistent with the anecdotal CIS literature in otheroccupations (emergency rescue personnel) (Mitchell, 1982,1983 ; Snelgrove, 1989).Still, there was a small number of nurses who reportedusing the benefit and challenge emotions after CIs . Thisfinding is consistent with Lazarus and Folkman's theoreticalframework in that individuals will use a variety of emotionsduring a stressful encounter . The finding is also82consistent with stress literature . For example, severalauthors reported that nurses often experienced stressreactions in relation to patient care and interpersonalrelations but also reported the greatest amount of challengefrom these same two situations (Bailey et al ., 1980) . Inrelation to this sample, nurses may have been worried,fearful, and anxious, but at the same time experiencedemotions such as relief, hope, and confidence . There werestressful events encountered by individuals in which thefour types of stressful appraisals were also not mutuallyexclusive (Lazarus & Folkman, 1984).Research Question 3 : How do Medical/Surgical Staff NursesCope with a CI?Using the Ways of Coping Scale (Folkman et al ., 1986),nurses' coping strategies following a CI were measured . Itwas reported that during the first few days and eveningsfollowing a critical incident nurses used a variety ofemotion- and problem-focused coping strategies (see Table7) .Emotion-focused coping strategies included distancing,self-controlling, accepting responsibility, escape-avoidance, and positive reappraisal . Problem-focused copingstrategies included seeking social support, confrontivecoping, and planful problem-solving. The top four copingstrategies, in descending order, used by the nurses were83seeking out social support, with scores ranging from 0 to 15(M=8 .00), self-controlling with scores from 0 to 14(M=5 .96), positive reappraisal with scores from 0 to 18 (M=5 .14), and planful problem-solving with scores ranging fromTable 7Scores on Ways of Coping ScaleWay of Coping	Score	Frequency	Percent(%)Confrontive (M=3 .78, S .D .=3 .13)0-34-78-1112-1516-19291542058 .030 .08 .04 .00 .0Total 50 100 .0Distancing (M=3 .90,	S .D .=3 .03)29 58 .00-34-7 14 28 .08-11 6 12 .012-15 1 2 .016-19 0 0 .0Total 50 100 .0Self-Controlling	(M=5 .96,	S .D .=3 .82)0-3 15 30 .04-7 20 40 .08-11 8 16 .012-15 7 14 .016-19 0 0 .0Total 50 100 .0Social Support	(M=8 .00,	S .D .=3 .46)0-3 6 12 .04-7 14 28 .08-11 24 48 .012-15 6 12 .016-19 0 0 .0Total 50 100 .0840 to 12 (M=4 .70) . The confrontive coping strategies scoresranged from 0 to 15 (M=3 .78), distancing from 0 to 12(M=3 .90), accepting responsibility from 0 to 7 (M=2 .08), andTable 7 (Continued)Way of Coping	Score Frequency Percent(%)Accepting Responsibility (M=2 .08,	S .D .=2 .01)0-3 37 74 .04-7 13 26 .08-11 0 0 .012-15 0 0 .016-19 0 0 .0Total 50 100 .0Escape-Avoidance (M=3 .60,	S .D .=3 .30)0-3 29 58 .04-7 14 28 .08-11 5 10 .012-15 2 4 .016-19 0 0 .0Total 50 100 .0Problem-Solving (M=4 .70,	S .D .=3 .28)0-3 20 40 .04-7 23 46 .08-11 3 6 .012-15 4 8 .016-19 0 0 .0Total 50 100 .0Positive Reappraisal (M=5 .14, S .D .=4 .14)0-3 20 40 .04-7 19 38 .08-11 7 14 .012-15 2 4 .016-19 2 4 .0Total 50 100 .085escape avoidance from 0 to 13 (M=3 .60) . Overall, thenurses' scores ranged from 2 to 74 (M=37 .16) . The nurses'total score was higher (M=37 .16), than that for Folkman andLazarus's 1986 sample (M=30 .08) . Both of these samplesutilized a variety of both problem- and emotion-focusedcoping strategies . The nurses' higher total score was aresult of their using primarily two problem- and emotion-focused coping strategies (seeking social support, planfulproblem-solving, self-controlling, and positivereappraisal) . The use of a variety of coping strategies isconsistent with Lazarus and Folkman's (1984) theoreticalframework and research suggests that effective copingincludes the use of an average of six to seven differenttypes of coping strategies (Folkman & Lazarus, 1985) . Inaddition, these same investigators determined that there wasan association between problem-focused coping and one typeof emotion-focused coping, emphasizing the positive.Therefore, it can be suggested that nurses who used positivereappraisal (emotion-focused coping) may have utilizedproblem-focused coping more readily.There is additional support for these findings withinthe nursing stress literature, with several investigatorsreporting that nurses used a variety of the followingstrategies : talking to people about their experiences (bothat home and at work), use of humour, confrontation, drawing86upon past experiences, trying to base action onunderstanding of the situation, setting priorities, tryingto put things into perspective, expressing feelings orfrustrations, keeping the problem to self, using caffeine,trying to keep a positive perspective, and accepting the jobas it was (Dewe, 1987 ; Gribbins & Marshall, 1982 ; Kelly &Cross, 1985 ; Robinson & Lewis, 1990 ; Schaefer & Peterson,1992) .There was no evidence within the CI literature on hownurses tried to cope with CIs . It seemed that, althoughthese nurses experienced a more traumatic event, they wereusing coping strategies similar to those used by nurses instressful situations . However, this study did not measurethe effects of and coping strategies that nurses used as aresult of these CIs in the long term . Perhaps some of thenurses were coping with the CI weeks or months after theevent .Although this sample was 97% female, andgeneralizations cannot be made as to whether women in thissample coped differently than the men, there are severalpertinent studies . For example, Long (1989) reported thatwithin our society there is an underlying assumption thatwomen do not cope with stress as effectively as men.However, in a study of 100 middle-aged adult men and women(aged 45 to 64), Folkman and Lazarus (1980) reported that8798% of the subjects used emotion- and problem-focused copingin dealing with stressful events of daily living . What isparticularly interesting is that men used more problem-focused coping at work than did women . It was reportedthat, in similar contexts of daily living, women and men didnot differ in their use of emotion-focused coping . In a1986 study involving 75 married couples, Folkman et al.reported that men and women consistently used emotion- andproblem-focused coping in dealing with stressful events insimilar contexts.Dunkel-Schetter, Folkman and Lazarus, (1987) reportedthat women were using reappraisal as a coping strategy morethan men in similar working contexts . These investigatorspostulate that this strategy reflects a more optimisticoutlook and need to use an inner-focused strategy to copewith a given stressor.Additional FindingsDebriefing has been recognized as one strategy toassist nurses to cope with CI experiences . When thesubjects were asked if they had participated in a debriefingsession following their CI, a large majority (84%) responded"no ." The nurses who responded "yes" described their mainsupport coming from their head nurse or a person frompastoral care . They talked to these individuals about thesituation and received support by being able to express88their feelings about the incident . Other nurses describedinformal talks with their peers as being beneficial (oftennurses were told that they had done all that was possible).Furthermore, the nurses who did not participate in adebriefing wished that they had had the opportunity to doso .Debriefing for the purposes of this study was definedas "a formal psychological and educational group processaimed at softening the impact of stress as a result ofexperiencing a CI, through 'talking it out'" (Snelgrove,1989) . This is an important finding as nurses recognizedthat such an approach may have assisted them in coping withthe CI.Only a few studies have attempted to measure theeffectiveness of these debriefings (Alberta Public SafetyServices, 1985a, 1985b) . Robinson (1992) reported thathospital personnel found them helpful through talking withothers about the incident (42%), talking about the incident(17%), understanding of self (12%), understanding of thesituation (9%), and 9% stated that they gained solutions,support, and direction . The author also recognized the lackof research findings related to debriefings as they areconfidential groups, and it is therefore difficult tomeasure their effectiveness (Dr . R . Robinson, personalcommunication, November 5, 1992) .89Although the investigator provided the nurses adefinition related to the debriefing option, there are otherforms of intervention that may be more beneficial to nurses.For example, defusings may be another means of assistingnurses in coping with their CIs . Defusings are similar todebriefings except that they are shorter in length (20 to 45minutes) and may only involve two to three people . Withinthe air traffic industry, Logie (1992) reported that many ofher interventions incorporated one-to-one defusings . Thereare similarities between both of these interventionmodalities . The most important is that both interventionsinvolve skilled individuals . A mental health professionalis an essential part of the team . However, Robinson andMurdoch (1991) emphasized that peers who are educated in thedebriefing process are the main thrust of the program . "Inmany instances peers have been in the same or similarsituation as the troubled employee, peers can thereforeoften readily understand the plight of their colleagues andthey are generally perceived by their colleagues 'tounderstand'" (Robinson & Murdoch, 1991, p . 1).Through attendance at a recent workshop theinvestigator learned that CISD programs should have a strongconnection to an employee assistance program and mentalhealth support . Mental health professionals are availablefor referrals, consultation, and participation in90debriefings as necessary . Within acute care settings,nurses who volunteer to become peer debriefers must berespected by their colleagues, educated about CISDinterventions, and be committed to these interventions.In terms of costs to implement such programs, someemergency services departments have been able to start theprogram with $10,000 .00 (Richmond Fire-Rescue Department,1990) . Some hospitals have also developed a team on atotally volunteer basis (Lawrence, 1992) . Costs are animportant factor for setting up necessary programs.However, administrators must consider the savings in thereduction in sick calls, stress leave, and possiblyincreased retention.Research Question 4 : How Have CIs Impacted onMedical/Surgical Nurses' Professional and Personal Lives?Nurses responded to several questions that related tothe impact of these specific CI experiences within theirprofessional and personal lives . Twenty-nine percent ofthis sample reported that the CIs did have a negative impacton interpersonal relationships with their colleagues atwork, while 71% did not report a negative effect.Furthermore, 18% reported that the CI did affect theirrelations with family and/or friends, with 82% reporting noeffects on relationships.The majority (70%) of this sample were recalling CIs91that occurred during their present position and, of this70%, 11% considered leaving their positions . Of the 30% ofnurses recalling events that occurred in previous positions,27% had considered leaving their positions because of theCIs .One of the reasons why there is concern about stressand CIs is that there are negative effects within nurses'lives at work and at home . The investigator believed that alarge number of these nurses would consider that their CIshad a negative affect on their personal and professionallives, but this was not the case.There could be several reasons for this finding.First, the questions developed by the investigator were verybroad . Secondly, nurses may not have considered whether theCIs affected such aspects of their lives as communicationdifficulties with their families, illness, and tensionbetween colleagues at work . Thirdly, nurses within thisstudy may not have been conscious or aware that their liveswere indeed affected by the CI . Some of the nurses who hadexperienced such effects may have already left theprofession.Within this chapter the major findings were discussedin relation to previous research studies, Lazarus &Folkman's (1984) theoretical framework, and pertinentliterature . Through the use of content analysis, six CI92categories were identified : moral distress, lack ofresponsiveness, violence, emergency situations, death, anddirect exposure to a life-threatening disease . The majorityof the nurses recalled CIs that occurred earlier in theircareers, and on evening or night shifts . Nurses recalled avariety of physical and emotional reactions, and primarilyused four different types of strategies to cope with theCIs . A large majority of the respondents identifieddebriefing as being an option that might have been helpfulin coping with the CIs .93CHAPTER FIVESUMMARY, CONCLUSIONS, AND IMPLICATIONSThis chapter includes a summary of the study andconclusions based on the findings . Implications for nursingeducation, administration, and future research are outlined.SummaryDespite numerous studies that investigated how staffnurses appraised and coped with stress in their dailypractice, there were no studies located that related tostaff nurses and a specific kind of stress : criticalincident stress (CIS) . Literature pertaining to CIS amongnurses was anecdotal and emphasized the need for programs toassist nurses in coping with CIs . The purpose of this studywas to describe how nurses appraised, reacted to, and copedwith a CI.The investigator selected a descriptive design andrecruited 50 medical/surgical staff nurses within threedifferent hospitals to comprise the sample . Allparticipants completed four instruments : ParticipantInformation Sheet, Critical Incident Information Form(Appleton, 1992), Emotional Appraisal Scale (Folkman &Lazarus, 1986), and Ways of Coping Scale (revised) (Folkmanet al ., 1986) . These instruments were used to answer thefour questions that guided this study : 1) What events didmedical/surgical staff nurses appraise as CIs? 2) What were94medical/surgical staff nurses' reactions to an eventappraised as a CI? 3) How did medical/surgical staff nursescope with a CI? 4) What impact have CIs had onmedical/surgical nurses' professional and personal lives?Participants ages ranged from 20 to 58, with themajority between the ages of 20 and 31 . The majority of theCIs that these nurses recalled occurred early in theirnursing careers, with some occurring while they were nursingstudents.Through content analysis it was determined that the CIsfell into the following six categories : moral distress (14),lack of responsiveness from a health care team member (11),violence (10), emergency situations (6), death (6), andexposure to a life-threatening disease (3).Nurses reported a variety of physical reactions withinthe first few days and evenings following the CIs, with themajority experiencing fatigue and a moderate proportionexperiencing insomnia .	The largest number of nursesexperienced emotions that corresponded to Lazarus andFolkman's (1984) harm/loss and threat emotions . Nurses alsoreported using the challenge and benefit emotions, but to alesser degree.Responses on the Ways of Coping Scale (revised)(Folkman et al ., 1986) indicated that nurses utilized avariety of emotion- and problem-focused coping strategies to95cope with their CIs . The four most commonly used copingstrategies were : seeking out social support, self-controlling, positive reappraisal, and planful problem-solving . The use of a variety of coping strategies isconsistent with Lazarus and Folkman's (1984) theoreticalframework . At least 18% of the nurses also reported thatthe CIs did have an impact on their professional or personallives . Eighty-four percent of the nurses identified theneed for more formal assistance in coping with their CIs.ConclusionsThe conclusions extracted from this study are thefollowing :1. Medical/surgical staff nurses do experience CIswithin their daily practice.2. The majority of medical/surgical staff nursesrecalled CIs that occurred early in their nursing careers.3. The majority of the CIs reported occurred onnights/evening shifts.4. The nurses primarily experienced harm/loss andthreat emotions one to two days following the CIs.5. The nurses primarily used four different types ofstrategies to cope with the CIs : seeking out social support,self-controlling, positive reappraisal, and planful problem-solving .966. Debriefing was identified by the majority of thenurses as one resource that would have been helpfulfollowing the CIs.7. A small percentage of the nurses reported that theCI experiences did have an impact on their personal orprofessional lives .ImplicationsA number of implications can be identified for nursingeducation, administration, and research.Nursing EducationEducational programs within acute care hospitals shouldeducate nurses about critical incident stress and inserviceeducators should advocate the development and implementationof programs to assist nurses following CIs . Debriefing anddefusing are two such programs.Nursing educators may find it useful to know that somenurses recalled CIs that occurred early in their careers orwhen they were students . Recognizing the potential for suchoccurrences among students will help to ensure thatappropriate resources are available to assist them in copingwith this kind of stress . In addition, within nursingcurricula, a course in ethics should be incorporated inorder to assist students to recognize moral dilemmas inpractice . In addition, such a course will provide studentsthe opportunity to identify how they might cope with such97moral dilemmas as beginning practitioners.Nursing AdministrationNursing administrators may find it useful to know thatthe term CI does not mean that this kind of stress occursonly within a critical care context . Other studies haveshown that nurses working within a medical/surgical contextexperience just as much stress as critical care nurses andsometimes even more . The findings of this study provideevidence that nurses experience different types of CIs.Some of those described offer new perspectives such as moraldistress, lack of responsiveness, violence, and exposure toa life-threatening disease . The implementation ofdebriefing and/or defusing programs will only be effectiveif planners and organizers are aware of the kinds of CIsnurses experience.Administrators should be aware that a large number ofnurses reported CIs that fell within the category of moraldistress . As patient acuity levels increase within themedical/surgical context and financial constraint continues,this specific type of CI may be even more prevalent.Therefore, the investigator suggests that acute carehospitals establish ethical committees with staff nurserepresentation . The committees should be accessible tostaff nurses confronted with moral dilemmas.Nursing administrators should also be aware that nurses98described CIs that were categorized as a lack ofresponsiveness from a health care team member (most of theseCIs involved the physician) . Policies should be implementedthat provide clear direction for staff nurses when they areconfronted with this situation . For example, a nurse who isnot receiving adequate support from a physician should haverecourse to a mechanism for addressing the problem . Nursesshould also receive inservice education in assertiveness andconflict resolution . Physicians should also participate inseminars regarding effective communication skills.Nursing administrators and inservice educators shouldbe aware that violence was identified as one category of CIwithin this sample . Management must provide all staffnurses with inservice education about the management ofpatient aggression and strategies to prevent, manage, andresolve violence against nurses . With this finding,questions are raised concerning the structures withinhospitals to assist nurses in coping with violence . Forexample, several hospitals have implemented emergencyresponse teams and educational programs to assist nurses indealing with violence (Burke, 1992) . In addition, theBritish Columbia Hospital Association is planning toimplement a new educational program entitled "Drawing theLine" for the specific purpose of providing guidance tohospitals in managing violence within the workplace (B .99Goodall, personal communication, February 8, 1993).Given that a few of the nurses' CIs involved exposureto a life-threatening disease, policies and proceduresshould be in place to ensure that quick and thoroughmeasures are implemented.Nursing administrators should also be aware that mostof these medical/surgical staff nurses' CIs occurred onnights or evenings . It has always been true that fewernursing staff are scheduled on nights and evenings . Thisinvestigator questions whether this can continue, especiallyas the level of patient acuity continues to rise.Lastly, the findings raise questions about theemployers' responsibility for the well-being of theiremployees . The British Columbia Nurses Union and theRegistered Nurses Association of British Columbia haveadvocated changes to the existing structures . Nurses arethe largest group of health professionals within acute caresettings . It is important to have adequate resources forthem to draw upon . Examples of these resources may includedebriefing teams, defusing teams, peer support groups, andcounselling, changes in care delivery methods, and moreresources available on evening and night shifts . Suchinterventions may serve to reduce time lost in turnover andillness, resulting in substantial budgetary savings .100Nursing ResearchAs this investigator used a convenience sample torecruit the medical/surgical staff nurses it would bebeneficial to repeat this study, but choose a probabilitysampling technique to increase the generalizability offindings . This study described how medical/surgical staffnurses appraised, reacted to, and coped with Cis . Studiesdescribing and comparing how nurses in other contexts (e .g .,paediatrics, obstetrics, critical care, community health)and of both sexes experience CIs would be beneficial inincreasing the understanding of CIS among nurses.This study was descriptive in nature and nurses wereonly asked to describe one CI . It would be beneficial todesign a study measuring the prevalence of CIs among nurses.This type of study might indicate whether some specialtynursing groups experience more CIs than others . A studydesigned to measure the relationship between nurses' CISexperiences and job satisfaction and burnout would add tothe knowledge about quality of worklife.This study focused on obtaining data on the nurses'reactions and coping strategies at one point in time . 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American Association of OccupationalHealth Nurses, 37(4), 121-128 .110Appendix A : Participant Information Sheet111PART ONEPARTICIPANT INFORMATION SHEETGENDER : FemaleMaleYEARS OF EXPERIENCE AS A R .N . :	YEARS IN PRESENTPOSITION:< 1 Year	 	 < 1 Year1-3	1-34-6	4-67-9	7-9> 10	> 10AGE :20-2324-2728-3132-3536-3940-4344-4747-5051-5455-5859-62> 62112Appendix B : Critical Incident Information Form113Appleton (1992)CRITICAL INCIDENT INFORMATION FORMPART TWOPlease read the following definition, and then proceed.A critical incident is an event or situation that youconsider as being traumatic and causes you to have unusuallystrong emotional responses, and may also make your usualcoping skills ineffective.1 . Describe in 50-75 words a critical incident that youhave experienced (Please include in this description who wasinvolved, a brief description of what happened and what roleyou played in the situation).2 . How long ago did this critical incident occur?3 . When did this critical incident occur? (circle one)a) Day Shift (07-15)b) Evening Shift (15-23)c) Night Shift (23-07)d) Days (07-19)e) Nights (19-07)4 . What was the worst part of this critical incident?1145 . Do you recall this incident as challenging your personalbeliefs?a) yes	 b) noElaborate if you wish:6 . Do you recall this situation occurring suddenly (withoutwarning)?a) yes	 b) no	7 . Do you recall having any other stresses in your life atthe same time as this critical incident?a) yes	 b) noIf yes please specify:a) personal stressb) professional stressc) other8 . Did this incident involve dealing with something new?a) yes	 b) no	If yes please explain:9 . Do you recall that there was an element of uncertaintywith this incident?a) yes	 b) noIf yes please explain:10 . Were you comfortable with the decisions that you madeduring the incident?a) yes	 	 b) noElaborate if you wish :11511 . After the critical incident (within the first few daysand evenings following this event) do you recallexperiencing any of the following physical reactions?(circle the relevant reactions)a) nausea	e) insomniab) diarrhea	f) if others, please specify:c) headached) fatigue12 . Do you recall the critical incident having a negativeimpact on your interpersonal relationships with yourcolleagues at work?a) yes	 b) no	with your friends and/or family?a) yes	 b) no13 . Did this incident occur while you were working at yourpresent position?a) yes	 b) noIf yes please answer question 15 . If no go to question 14.14 . Did you consider leaving your position because of thisincident?a) yes	 b) no	15 . Have you considered leaving your present positionbecause of this incident?a) yes	 b) no	16 . Please read the following (prior to answering thisquestion):Debriefing is defined as a formal psychological andeducational group process aimed at softening the impactof stress as a result of experiencing a CI, through"talking it out ." This is different than informaltalking to a colleague about the event .116Did you participate in a debriefing session followingthe critical incident that you have just described?a) yes	 b) noIf you answered yes, go to question 18 . If you answered no,go to question 17.17. Would you have liked a debriefing session followingyour CI?a) yes	 b) no18. If there is anything you wish to add regarding thiscritical incident, please do so in the space provided :117Appendix C : Emotional Appraisal Scale118Folkman and Lazarus (1986)EMOTIONAL APPRAISAL SCALEPART THREEAs best you can, describe how you felt after experiencingthis critical incident (within the first few days andevenings following this event) . To do this, it is importantthat for each item you circle the number that best describesthe extent of that feeling.Not atallAlittleSome-whatQuitea bitAGreatdeala . angry 0 1 2 3 4b . worried 0 1 2 3 4c . exhilarated 0 1 2 3 4d . disappointed 0 1 2 3 4e . secure 0 1 2 3 4f . confident 0 1 2 3 4g . in control 0 1 2 3 4h . fearful 0 1 2 3 4i . pleased 0 1 2 3 4i . hopeful 0 1 2 3 4k . disgusted 0 1 2 3 41 . eager 0 1 2 3 4m . frustrated 0 1 2 3 4n . anxious 0 1 2 3 4o . happy 0 1 2 3 4p . relieved 0 1 2 3 4q . other (please 0 1 2 3 4specify) :119Appendix D : Ways of Coping Scale (Revised)120Folkman et al . (1986)WAYS OF COPING (REVISED)PART FOURPlease read each item below and indicate, by circling theappropriate category, to what extent you used it afterexperiencing the critical incident (the first few days, andevenings following the event) . Simply circle the "not used"column if an item is not applicable .Notused1. Just concentrate on what I had to 0do next -- the next step.2. I tried to analyze the problem in 0order to understand it better.3. Turned to work or substitute acti- 0vity to take my mind off things.4. I felt that time would make a dif- 0erence -- the only thing to do wasto wait.5. Bargained or compromised to get	0something positive from thesituation.6. I did something which I didn't	0think would work, but at least Iwas doing something.7. Tried to get the person responsible 0to change his or her mind.8. Talked to someone to find out	0more about the situation.9 .	Criticized or lectured myself .	010 . Tried not to burn my bridges, but	0leave things open somewhat.11 . Hoped a miracle would happen .	012 . Went along with fate ; sometimes I	0just have bad luck.13 . Went on as if nothing had happened . 014 . I tried to keep my feelings to	0myself.15 . Looked for the silver lining, so	0to speak ; tried to look on thebright side of things .Usedsome-whatUsedquiteabitUsedagreatdeal1 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 3Usedsome-whatUsedquiteabit121Usedagreatdeal1 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 3Notused16. Slept more than usual.17. I expressed anger to the person(s)who caused the problem.18. Accepted sympathy andunderstanding from someone.19. I told myself things that helpedme to feel better.20. I was inspired to do somethingcreative.21. Tried to forget the whole thing.22. I got professional help.23. Changed or grew as a person in agood way.24. I waited to see what would happenbefore doing anything.25. I apologized or did something tomake up.26. I made a plan of action andfollowed it.27. I accepted the next best thing towhat I wanted.28. I let my feelings out somehow.29. Realized I brought the problem onmyself.30. I came out of the experience better 0than when I went in.31 . Talked to someone who could do	0something concrete about theproblem.32. Got away from it for a while ; tried 0to rest or take a vacation.33. Tried to make myself feel better by 0eating, drinking, smoking, usingdrugs or medication, etc.34. Took a big chance or did something 0very risky.35. I tried not to act too hastily or 0follow my first hunch.36. Found new faith.37. Maintained my pride and kept astiff upper lip.38. Rediscovered what is importantin life .00000000000000000122Usedsome-whatUsedquiteabitUsedagreatdeal1 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 3Notused39 . Changed something so things would 0turn out all right.40 . Avoided being with people in	0general.41. Didn't let it get to me ; refusedto think too much about it.42. I asked a relative or friend Irespected for advice.43 . Kept others from knowing how bad	0things were.44. Made light of the situation;refused to get too serious aboutit.45. Talked to someone about how I wasfeeling.46. Stood my ground and foughtfor what I wanted.47. Took it out on other people.48. Drew on my past experiences ; Iwas in a similar situationbefore.49. I knew what had to be done, soI doubled my efforts to makethings work.50. Refused to believe that it hadhappened.51. I made a promise to myself thatthings would be different nexttime.52. Came up with a couple of different 0solutions to the problem.53. Accepted it, since nothing could be 0done.54. I tried to keep my feelings frominterfering with other thingstoo much.55. Wished that I could change whathad happened or how I felt.56. I changed something about myself.57. I daydreamed or imagined a bettertime or place than the one I wasin.58. Wished that the situation would goaway or somehow be over with .000000000000000Notused59. Had fantasies or wishes about howthings might turn out.60. I prayed.61. I prepared myself for the worst.62. I went over in my mind what Iwould say or do.63. I thought about how a person Iadmire would handle thissituation and used that as a model.64. I tried to see things from theother person's point of view.65. I reminded myself how much worsethings could be.66. I jogged or exercised .123Usedsome-whatUsedquiteabitUsedagreatdeal0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3124Appendix E : Resource Information125If you found participation in this research has raisedissues about your experience with a critical incident, andyou would like more information regarding resources and/orresource people, please fill in the information below . Ican provide you with a list of possible resource people thatmay be beneficial to you . Ensure that you separate thisinformation from you completed questionnaire and leave it onyour nursing unit for me, phone me, or send it to me c/o theU .B .C . School of Nursing.PLEASE DETACH THIS INFORMATION, DO NOT INCLUDE WITH YOURCOMPLETED QUESTIONNAIRE.REQUEST FOR RESOURCES/RESOURCE PEOPLENameAddressAND/ORPhone Number126If you found participation in this research has raisedissues about your experience with a critical incident, andyou wish to seek out assistance that may be beneficial toyou, please contact the following resource :127Appendix F : Participant Introductory Letter128PARTICIPANT INTRODUCTORY LETTERSTUDY TITLE :	Acute care medical/surgical general dutynurses' appraisal of, reactions to, andcoping with critical incidents : Adescriptive study.INVESTIGATOR :	Leanne AppletonMaster's nursing student, School ofNursingUniversity of British ColumbiaTHESIS SUPERVISOR Professor Judith LynamSchool of NursingUniversity of British ColumbiaPhone number : 822-7476Dear Potential Participant,My name is Leanne Appleton and I am in the M .S .N.program at the University of British Columbia . My thesis isa study of how medical/surgical staff nurses describe, reactto, and cope with critical incidents.Despite numerous studies investigating how nurses reactand cope with stress in acute care settings, there is a lackof knowledge concerning nurses' descriptions, reactions, andcoping abilities in relation to a specific stressful event,a critical incident . A critical incident refers to an eventor situation that a nurse defines as being traumatic,causing unusually strong emotional reactions, and making hisor her usual coping skills ineffective . The purpose of thisstudy is to obtain medical/surgical nurses' descriptions ofcritical incidents and how they react to, and cope with suchevents.I invite you to participate in this study if you havehad a critical incident experience, and have at least 6months experience as a R .N . Participation in this study isvoluntary, and you may withdraw at any time withoutjeopardizing your present position .129If you choose to participate in this study, you will berequired to complete a set of instruments, that containinformation about your description, reactions, and copingstrategies in relation to a critical incident . This willtake approximately 35-45 minutes to complete.Your completion of the instruments will be taken asevidence of your willingness to participate . It also servesas your consent to have the information used for the purposeof the study . To ensure confidentiality you will never beidentified by name, as the instrument will be coded with anumber . Data collected will be kept in a locked filingcabinet . Only the investigator and thesis committee memberswill have access to the information .Sincerely,Leanne Appleton R .N .,B .Sc .N.c/o School of Nursing130Appendix G : Participant Information Letter131PARTICIPANT INFORMATION LETTERAcute care medical/surgical general dutynurses' appraisal of, reactions to, andcoping with critical incidents : Adescriptive study.Leanne AppletonMaster's nursing student, School ofNursingUniversity of British ColumbiaTHESIS SUPERVISOR Professor Judith LynamSchool of NursingUniversity of British ColumbiaPhone number : 822-7476Dear Participant,Thank you for participating in this study . The purposeof this study is to obtain medical/surgical nurses'descriptions of critical incidents and how they react to,and cope with such events.Although participating in this study will not be ofimmediate benefit to you, the findings of this study mayhave implications in nursing education and practice.Your participation in this study is voluntary and youmay withdraw from the study at any time without jeopardizingyour present position . Your completion of the instrumentswill be taken as evidence of your willingness toparticipate . It also serves as your consent to have theinformation used for the purpose of the study.STUDY TITLE:INVESTIGATOR132Please find enclosed in this package four separateinstruments: The Participant Information Sheet, the CriticalIncident Information Form (Appleton, 1992), the EmotionalAppraisal Scale (Folkman & Lazarus, 1986), and the Ways ofCoping Scale (Folkman et al ., 1986).Please answer all questions in the order that they arepresented here . In addition, please read the directions foreach tool carefully, as there are specific instructions foreach of the four instruments . It is estimated thatcompletion of all instruments will take approximately 45minutes.To ensure confidentiality you will never be identifiedby name, as the instrument will be coded with a number.Data collected will be kept in a locked filing cabinet.Only the investigator and thesis committee members will haveaccess to the information .Sincerely,Leanne Appleton R .N .,B .Sc .N.c/o School of Nursing


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