Abstract
Background
Saudi Arabia has in the last couple of decades experienced high nurse turnover in both public and private institutions. Indeed, several reasons have been given as to why the turnover rates are so high. One such reason is burnout. It is noteworthy that just like other regions in the world, Saudi Arabia suffers from small numbers of health personnel. Due to the shortage, many nurses and other health professionals are overworked.
In turn, the affected nurses suffer from physical fatigue. On the same note, the RNs suffer from mental fatigue brought on by working in a highly stressful environment. The proposed research study tries to determine the ways in which burnout can be lowered among nurses in Saudi Arabia. To be more specific, the study aims at determining whether reflective learning can be used to reduce the chances of burnout experienced by nurses.
Objectives
The study will determine whether reflective learning can improve burnout among nurses managing cardiac patients in the coronary care unit of King Fahad Medical City in the Kingdom of Saudi Arabia.
Methods
The research will employ a cross-sectional qualitative research methodology. The sample will consist of 15 nurses, who will be grouped into three focus groups, from King Fahad Medical City in the Kingdom of Saudi Arabia.
Significance
The study is significant as it focuses on the core/root of the problem that causes burnout. In turn, it offers solutions for high health facility employee turnover and encourages better service delivery in hospitals.
Introduction/Background
The work pressures related to the daily Frontline role of staff nurses make them prone to stress and burnout. For this reason, reflective learning is increasingly becoming an effective intervention for enhancing resilience and understanding of professional practice for improved nurse and patient outcomes (Jack, 2017).
The purpose of this evidence-based project is to evaluate the impact of the adaptation of reflective learning on nursing burnout in managing cardiac patients in a coronary care unit of King Fahad Medical City (KFMC) in the Kingdom of Saudi Arabia. Anecdotal evidence based on the statements of nurses providing clinical care at the unit formed the basis for this project. The staff nurses often complained of stress and burnout after their shifts at the KFMC’s coronary care unit. High levels of stress and burnout can affect the nurses’ performance and wellbeing.
The genesis of nursing fatigue or burnout in nursing practice is ascribed to occupational stress, heavy workloads, low staffing ratios, and exposure to trauma/suffering (Khater, Akhu-Zaheya, & Shaban, 2014). Emotional/physical fatigue may arise due to heavy workloads. Burnout manifestations may be high in a coronary care unit because of the high exposure to trauma that causes emotional exhaustion (Khater et al., 2014). Therefore, the intensification of burnout among the staff nurses in KFMC’s coronary unit may be related to adverse survival prognosis, exposure to patient pain/mortality, and age (Jack, 2017). Burnout manifestations among the nurses included detachment and sadness.
It is crucial for RNs to work in a positive clinical environment for their wellbeing and quality patient care delivery. A strong relationship has been established between nurse wellbeing and clinical outcomes (Romano, Trotta, & Rich, 2013). This implies that occupational burnout or fatigue has adverse impacts not only for nurses but also for patients. Jenkins and Warren (2012) indicate that, in clinical settings, staff nurses experience of trauma/suffering and heavy workloads reduce their performance and patient safety outcomes. Interventions that promote self-care have the potential of reducing nursing stress and burnout.
Reflective learning, where nurses gain “new insights of the self and practice” from clinical experiences can ensure better preparation for similar situations (Henderson, Cooke, Creedy, & Walker, 2012, p. 302). As such, engagement in reflective learning could offer some protection to burnout, leading to improved nurse wellbeing and patient outcomes.
For nurses, reflection on clinical experiences with cardiac patients is critical; however, cardiovascular nursing can be demanding emotionally and physically. Reflective learning, i.e., meditating and analysing individual clinical experiences, can promote emotional resilience and professional development (Foureur, Besley, Burton, Yu, & Crisp, 2013). Nurses working with cardiac patients are exposed to trauma or distress on a daily basis related to poor survival prognoses. Further, in addition to attending to the patient’s clinical needs, they also provide family/patient emotional support – professional demands that often cause anxiety (Gomez-Urquiza et al., 2016).
Reflective learning is the key to better workplace resilience and coping with a stressful and intellectually demanding coronary care environment. In this paper, a critical review of relevant scholarly literature will be performed to establish the relationship between reflective learning and nursing burnout in a coronary care unit.
Critical Review of Literature
Studies Worldwide
Nurses can improve their practice by engaging in reflective learning. Pipe, FitzPatrick, Doucette, Cotton, and Arnow (2016) evaluated a programme that sought to improve mindfulness and compassion among American nurses. In this study, the interviewees (nurses from diverse practices) reflected on individual video stories through a shared platform. The aim was to strengthen reflection on mindfulness and compassion in practice through video stories. The strategy was found to enhance objectivity, high time sensitivity, and stress coping patterns, resulting in improved focus on patient needs because of its replenishing effect on nurses (Pipe et al., 2016).
A disconnect exists between the pedagogical approaches for building the capacity to deal with stress/emotional fatigue and actual practice experiences. An integrative review by Dwyer and Hunter (2015) found that although reflection was a widely adopted tool for improving the affective domain, the concept is rarely utilised in the American practice context. Thus, there is a need for interventions that support pedagogical and clinical preparation for demanding practice to build emotional and physical resilience in nurses.
Analytical and critical thinking skills are emphasised in nursing practice. The compilation of a portfolio of evidence (PoE) based on clinical experiences is one way of enhancing reflective learning (Ticha & Fakude, 2015). A qualitative study examined the perceptions of nurses on reflective learning based on PoE compilation (Ticha & Fakude, 2015). The results indicated that reflections captured in PoEs allowed the nurses to identify practice challenges and benefit from clinical learning experiences. In addition, through the reflective learning strategy, the subjects were able to develop the self-confidence and critical thinking skills required in nursing practice. Reflective practice also led to improved self-directed clinical learning. Therefore, the adaptation of reflective learning based on clinical experiences can motivate nurses to become critical thinkers and self-directed learners.
Besides critical thinking, self-care is considered to give adequate protection against stressors in practice contexts. Therefore, guiding nurses and learners through a journey towards self-care can enable them to manage nursing stress and burnout and enhance their efficacy. Blum (2014) evaluated a nursing program initiative that involved self-care activities for staff nurses. The self-care practice activities involved mindfulness meditation and reflective journaling in enabling the participants to learn from their experiences.
The study found that self-care activities inspired and challenged nurses to deal with the stresses in their practices, be empathetic to others, and gain clarity on their professional goals (Blum, 2014). Further, through shared interactive experiences, the participants were able to identify self-care activities they can apply in practice.
Reflective practice is not self-criticism, but rather a source of psychological support for improved performance in the future. One way nurses can be motivated to engage in reflective practice is through clinical supervision groups. McAvey and Jones (2013) explored the views of clinical supervision groups in a London hospital on reflective learning as a tool for dealing with stressful and emotional issues in critical care environments. Participation in clinical supervision groups was shown to decrease burnout resulting from physical and emotional exhaustion. In addition, the groups provided a platform for nurses to compare practice with their peers, receive psychological support, and acquire practice skills required in critical care (McAvey & Jones, 2013).
Reflection is an important emotion-focused tool for reducing burnout to achieve improved wellbeing of nurses. Reducing nursing burnout contributes to improved patient care. Stewart and Terry (2014) explored educational interventions that could decrease nursing burnout in clinical environments through a systematic review. Their findings were consistent with those reported by McAvey and Jones (2013).
Clinical supervision and training on stress management methods were found to contribute to lower burnout levels in nurses. Therefore, supportive relationships can enable staff nurses to deal with stress and burnout. In addition, professional/personal growth achieved through reflective learning can offer protection against burnout in critical care environments.
Studies in the Middle East
Studies carried out in Middle Eastern countries establish that engagement in reflective learning ameliorates stress and burnout by staff nurses. These findings are consistent with those of similar studies performed elsewhere in the globe. Further, burnout is associated with low productivity if the nurses lack the emotional resiliency to cope with demanding tasks. Farsi, Habibi, and Lashkari (2014) investigated the impact of burnout on the productivity of nurses working in a Tehran hospital and the contributing factors.
The nurses’ burnout levels, as measured with the Maslach Burnout Inventory, ranged between moderate and high (>60%) in two dimensions: “emotional exhaustion, personal accomplishment, and depersonalisation” (Farsi et al., 2014, p. 173). They recommend adaptive coping strategies, including reflective practice training and prophylactic measures, to reduce burnout and improve productivity.
A comparable study Adib-Hjbaghery, Khamechain, and Alavi (2012) investigated the impact of nurses’ experiences on stress and burnout. The results indicated that lack of experience, improper logistics, lack of coordination, and heavy workloads increased the risk of professional stress and burnout (Adib-Hjbaghery et al., 2012).
In addition, lack of emotional resilience and work pressure affected the nurses’ ability to establish a work-life balance. Lack of experience meant that the nurses did not engage in reflective learning to strengthen their emotional resources. The authors concluded that hospital support and improved logistics and collaboration would enable the nurses to cope with the pressure and result in low burnout levels.
A comparable study explored the clinical decision-making patterns of critical care nurses in a Jordanian hospital (Maharmeh, Alasad, Salami, Saleh, & Darawad, 2016). The study’s aim was to assess the use of reflective learning in routine patient care decisions. ICU cases require complex decisions that emotionally, intellectually, and physically draining. In this study, autonomy, collaborative decisions, and experience were found to reduce stress/fatigue in ICU environments. The ICU nurses exhibited great sensitivity and empathy to the patients under their care. Further, the authors concluded that reflective practice and experience increase the efficacy and confidence of ICU nurses in managing complex cases.
The risk of burnout and emotional fatigue is high in nursing practice. Social support systems that promote reflective learning can reduce the prevalence of fatigue/burnout among staff nurses. Ariapooran (2014) evaluated the prevalence of fatigue/burnout in 173 Iranian nurses and how they correlated with clinical support. The study found out that lack of social support contributes to compassion fatigue among nurses. In addition, a lack of engagement in support systems that promote reflective practice and collaboration increased the risk of nurse burnout. Thus, support systems that promote collaborative practice can help decrease the prevalence of burnout/fatigue in clinical settings.
Studies in Saudi Arabia
The prevalence of burnout in critical care and its impact on nurse outcomes has also been investigated in locally. Alharbi, Wilson, Woods, and Usher (2016) explored the impact of burnout/fatigue on job satisfaction among ICU nurses in a cross-sectional survey. The study found that burnout levels among Saudi nurses range between moderate to high in domains related to “emotional exhaustion and de-personalisation” (Alharbi et al., 2016, p. 715). Further, burnout was strongly correlated with low job satisfaction. Therefore, strategies, such as reflective learning, should be adopted in clinical settings to help nurses cope with stress and burnout.
On their part, Al-Sareari, Al-Khalidi, Mostafa, and Abdel-Fattah (2013) sought to determine the factors that contributed to fatigue among clinicians in Saudi healthcare centres. The qualitative survey found higher levels of emotional exhaustion among younger clinicians than older ones. This implies that experience and reflective learning can ameliorate the effect of stress in busy clinical settings. In addition, high levels of depersonalisation were seen in the younger nurse, implying that emotional intelligence develops with practice experience. Further, longer vacations were associated with low emotional exhaustion scores (Al-Sareari et al., 2013). Thus, vacations and experience can reduce the prevalence of job-related burnout among Saudi clinicians.
Job-related demands can adversely affect nurse performance. Al-Homayan, Shamsudin, Subramaniam, and Islam (2013) surveyed nurses working in busy Saudi public hospitals to identify the physical and emotional demands that cause poor performance. The main response to the heavy work demands was stress. The nurses also suffered from sleep deprivation due to the demanding nature of the public hospital environment.
The stress was ameliorated by organisational support for the nurses and care coordination. In addition, interpersonal support through staff motivation, consultation/collaboration, empathy, and share experiences was associated with reduced stress (Al-Homayan et al., 2013). This shows that collective reflections on shared experiences enhance resiliency among nurses working in a demanding clinical environment. Collective reflective learning also offers protection against emotional and physical stress inherent in critical care settings such as cardiac care units.
Research Aim
The aim of this research is to determine whether reflective learning can improve burnout in nurses. In particular, the study will focus on nurses managing cardiac patients in the coronary care unit in a chosen health facility.
Research Question
Does adaptation of reflective learning improve nursing burnout for managing cardiac patients in the coronary care unit of King Fahad Medical City in the Kingdom of Saudi Arabia?
Significance of the Study
Burnout and fatigue are some of the challenges that nurses face on a daily basis. Many countries, and health facilities, rarely have enough nurses during a shift. This is particularly the case for the coronary care unit. Long working hours, working in a stressful environment, dealing with loss and pain, and having the needs of others first, have all contributed to the high numbers of nurses suffering from burnout. One result of the exhaustion and fatigue is turnover, where nurses leave their work stations for other alternatives.
On the same note, there are many nurses who do their work due to passion. However, statistics show that nurses who do their job based on passion are most likely to be affected by burnout. The premise is pegged on the idea that motivation is crucial for any passionate endeavour. The stated factors that contribute to burnout, also profoundly affect motivation.
The study is significant as it focuses on the core/root of the problem that causes burnout. In turn, it tries to offer solutions for high health facility employee turnover. The purpose of the study is to determine whether reflective learning can help lower burnouts. Thus, the study and report generated will highlight some of the factors that can be used to resolve stated problems.
Research Design and Methods
Design of the Study
A cross-sectional qualitative research design will be employed. The descriptive nature of the study will allow the collection of data from the nurses in the said unit easily. In justification of the choice of the design mentioned, it is important to state that the design is cost effective. Due to budget restrictions (a budget is provided in the Appendix section of the report), the chosen design was more suitable. In the same breath, the design was also chosen due to its descriptive nature. The primary data is based on opinions and experiences of nurses in managing cardiac patients in a coronary care unit of King Fahad Medical City (KFMC) in the Kingdom of Saudi Arabia.
Strengths and Weakness of Research Design
Grove, Burns and Gray (2014) explain that one of the strengths of a cross-sectional study is that the study is easier to conduct. The research does not need long periods for follow-up after the study. A second strength that can be highlighted is that the design is best for descriptive studies (Grove, Burns & Gray, 2014). Also, a cross-sectional study allows for the measurement of several outcomes in one study. The advantage allows for the researcher to customise the study accordingly.
In the same breath, one of the major disadvantages of the study design is that it is highly susceptible to bias. To resolve the shortcoming, the researcher involved different and highly trained research assistants to help in the analysis of the data collected.
Conceptual Framework
The study has both independent and dependent variables. The independent variable that will be tested is the level of burnout in the nurses who will participate in the study. The dependent variable is reflective learning. Whereas the independent variable might change, the dependent variable will not. Therefore, any customisation and changes will be applied to the independent variable and not the dependent variable.
Setting and Sample Size
The research study will be conducted in King Fahad Medical City (KFMC) in the Kingdom of Saudi Arabia. The hospital was chosen as it has a well-established coronary care unit. A total of 15 nurses will be used for the study.
Sample Selection Criteria and Description
Sample selection and procedures for recruitment were based on the number of nurses in the coronary care unit. The unit has 15 nurses, and all of them were included in the study. All nurses joined the research study on a voluntary basis. The participants were made up of 12 men and three women. The researcher expected few women due to the socio-cultural elements of the region. The participants were, therefore, not analysed using their age. On the same breath, the researcher categorised the study group according to the number of years they had worked in the unit, and also according to the number of times they had experienced a form of fatigue or burnout.
Data Collection
The sample size was divided into three groups of five members each. Data was then collected through the focus groups. The focus groups were guided by a set of questions that were developed by the researcher before the study. The questions were also pre-tested to ensure they were well understood and captured the intended elements. The questions that were used as a guide for the focus group discussions are presented below.
- Number and structure of shifts
- Reflective learning
- Meditation/Reflecting on individual experiences
- Comparison with other team members’ experiences
- Feelings after interaction and reflection
- Conclusions
Gantt Chart
The following is a Gantt chart showing the timelines of the study.
Limitations of the Study
Several limitations of the study can be pointed out. The first limitation is the unequal gender balance. As mentioned, the study included only three female nurses and 12 male nurses. The main reason behind the choice was that the hospital did not have enough female nurses. It can be argued that the socio-cultural elements in the Kingdom of Saudi Arabia resulted in the fewer numbers of female nurses. Due to cultural constraints, women in the region are not allowed to work. In fact, those who work are considered rebellious. The limitation had, therefore, nothing to do with the shortcoming of the research design or the tools of data collection, but with the environment in which the research was done.
Another limitation of the study was the limited number of participants. The researcher did not have the choice of random selection of the participants as the numbers were too low. It is debatable that the low numbers of nurses in the unit are due to the level of specialisation required to work in the coronary care unit.
Data Analysis
After the data collection, the researcher will analyse the collected data. Being a scientific research, statistical analysis will be done (Suresh, Suresh, & Thomas, 2012). An analysis tool will be developed by the researcher to help in the initial analysis of the data that was collected. The focus groups will be tasked to rate the questions and discussions they have on a scale of 0 to 10, with 0 being the lowest score and ten being the highest.
The researcher will take several actions to make sure that the data is valid and reliable. The first step, as mentioned, is the pre-test of the guidelines that will be used by the focus groups. The said guidelines are important as they form the topics of discussion and also give a way forward on the meditation part. The pre-test will not be administered to nurses in the same hospital. A nearby health facility will be used for the purpose of the pre-test. After the pre-test, feedback will be shared, and possible recommendations and amendments will be done to the guidelines.
Secondly, the researcher can also make the data collected more accurate by removing bias. As mentioned, a limitation of the research design selected is that it encourages bias in the collection and analysis of data. One of the factors that make it easier for the researcher to avoid bias is the fact that all nurses in the unit will participate in the study. In the same breath, internal validity is enhanced by the fact that the researcher will not be present during the focus groups. A team leader will be appointed in each group to record the data and present to the team so that no external factors interfere with the collection. In turn, chances of bias in the analysis of the data will be lowered.
Ethical Considerations
The researcher will adhere to research guidelines that are provided by the Human Research Ethics Committee of the University. It is important to note that the researcher will seek approval from the said Committee before doing the research to ensure that all ethical considerations are/have been observed. Ethical considerations will also be guided by the Ministry of Health of the Kingdom of Saudi Arabia and the Human Resource department of King Fahad Medical City. The researcher will be in a position to ensure that the study is conducted ethically by understanding the stand of the said entities regarding ethics.
As stated, several ethical considerations that were noticed in the planning and conducting of the survey can be pinpointed. The first ethical consideration is the willing participation of the identified sample size. Because all the nurses in the hospital will be included in the study, ‘willingness to participate’ might be jeopardized. It is expected that some of the identified nurses will opt out of the survey.
To ensure that no ethical concerns are raised, the researcher has to speak to the management of the health facility and then speak to the individual nurses to convince them to participate in the study. In the unfortunate event that some of the participants refuse to take part in the study, the researcher will have to rethink the viability of the survey based on the number of participants. The number should not be less than 10% of the total population.
Important to mention, the researcher has to make sure that all participants are aware of the voluntary nature of the study. Therefore, if a participant agrees to do the study but declines before the research is done, the researcher has no right to force the participant to finish the study. One of the biggest challenges of this ethical consideration is that it might affect the number of participants in the study. As stated, if the participants are too few, the research study will not be eligible.
Another important ethical consideration to observe is culture. The socio-cultural scene in the Kingdom of Saudi Arabia is very pronounced. It is for this reason, as stated that few women hold any form of job titles in the hospital.
The researcher has to consider that the women who are working in the hospital might be stigmatised, especially if they are natives. Discussion groups should, therefore, not encourage more stigmatisation. The three focus panels will have one female nurse each. This puts the female nurses in a unique position to explain their experiences openly. The researcher has to bear this in mind and look for ways to make the said gender comfortable throughout the study.
Last but not least, the researcher has to ensure that the research assistants are also aware of the ethical considerations and guidelines followed. The research assistants form an integral part of the process. They not only help the researcher but also make sure that the research is done accordingly. Based on the said premise, it is important for the researcher to train all research assistants, despite their role in the project, thoroughly. To ensure that the research is viable and the data collected is accurate, the researcher can present the research assistants to the Human Research Ethics Committee members of the University for their approval in regards to their knowledge of research ethics.
Dissemination of Findings
The report on findings that will be generated by the study will be disseminated in various platforms. The first platform is the university. The report will be shared with other students in both digital and hardcopy formats. The hard copy forms will be placed in the school library. Crucial to point out, the information that will be provided through the report will be critical in developing theses and discussions for future research. A second platform that will be used is the King Fahad Medical City hospital library. The report can also be placed on the hospital website so that it is accessible to the public. The document will also be shared with all necessary lines of ministries of the government of the Kingdom of Saudi Arabia.
The report will also be submitted to a peer-reviewed journal publication with the hope of future release. It is expected that the publication will take some time due to the logistics of such an activity. However, it is believed that the necessity of the study will ensure review and publication of the same. After the peer-reviewing exercise, the report, which will be in the form of an article in the journal, will be disseminated in digital format online. Also important to mention, the findings realised will be presented and discussed in nursing conferences at both local and international levels. All the said venues and platforms will help the public understand more about reflective learning, in turn, help generate discussions on how to best solve issues of burnout and fatigue among nurses.
Project Funding
To adequately conduct the research, the researcher has to look for funding. The expense of the research is too high for the researcher to bear alone. One of the potential sponsors/ funders of the project is the University. The researcher intends to apply for the research funds through the Department of Medicine and Nursing. The researcher will also apply for funds for the research through the Ministry of Education and the Ministry of Health.
Additionally, the researcher will seek for private sponsors of the study. Numerous research institutions and organisations that help students with financial aid for research studies they deem necessary can be approached. The researcher will develop proposals and send them out to the identified organisations. Suffices to state, the private funding will not in any way affect the outcome of the study. The researcher can also approach the King Fahad Medical City hospital management for the financing of the research. The management will, however, be informed that their sponsorship of the research will in no way affect the outcome of the study. Find below the budget of the study.
Table 1: Budget of the research study.
Justification of Budget
The different items that have been highlighted in the budget are critical in ensuring the completion of the study. Three project assistants will be hired for the survey. The project assistants will help the researcher create and improve the guidelines that will be used during the focus group discussions. Also, they will be helpful in the collection of data. The researcher will always have a research assistant during any advocacy meetings on the study, especially those on funding.
The incentives are meant for the nurses who will take part in the survey. The unit number is 15, which is the intended number of participants. Crucial to note, the incentives are not a form of payment, but rather a form of appreciation for the time used. As stated, the coronary care unit of King Fahad Medical City is very busy. Due to the few staff employed in the unit, it is expected that the participants will be very busy. The researcher feels obliged to appreciate the time that the participants will have spared amidst their busy schedule.
The telephone charges and logistics go hand in hand. The researcher will need talk time to communicate with all necessary parties who might affect the study. These parties include the management of the hospital, the school through the supervisor, and the research assistants. In regards to logistics, the researcher will need money for advocacy activities that are intended to raise funds to conduct the research. Several supplies will be needed to facilitate the study, and they are also included in the logistics.
These supplies include paper to print out the proposals, internet connectivity, and even cab fare to cater for any traveling needs within the city. The last item on the budget is the miscellaneous and contingency costs. The funds are necessary to ensure that any unexpected turn of events that requires funding is resolved without negatively affecting the study.
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