Challenges Faced by Nurses Working in Emergency Unit of BP

Introduction : A challenge is regarded as a very difficult situation with a variety of conditions at a given time. Nurses are the major human resources in health care services of the world and are the backbone of the hospital but still they are facing various challenges. The objective of the study was to assess the challenges faced by nurses working in the emergency unit of BPKIHS. Methods : A descriptive cross-sectional study design was used to conduct the study. Fifty nurses who met the eligibility criteria were selected by total enumerative sampling technique. For data collection, self-prepared semi-structured, self-administered questionnaires were used. Collected data was analyzed by using descriptive and inferential statistical tests. Results: The mean age of the respondents was 25.72. Among the challenges, two-thirds (66.0%) of the respondents have faced physical violence. Majority (84.0%) of the respondents have faced psychological violence at least once. More than half (54.0%) of the respondents have faced more stress. More than half (58.0%) of the respondents have faced more workload, nearly two-thirds of the respondents (60.0%) have more salary and employment benefits. Marital status and education level had a significant association with workload domain (p<0.05). Conclusion : Among the challenges, majority of the respondents had faced psychological violence, more than half of the respondents had faced more workload whereas nearly two-thirds of the respondents had more salary and employment benefits.


INTRODUCTION
A challenge is regarded as a very difficult situation with a variety of conditions or circumstances at a given time. 1 Nurses are the major manpower in health care services of the world and called as backbone or nucleus of the hospital but still they are facing various challenges. 2 Nurse leaders face innumerable challenges in the 21st century such as nursing workforce shortages, negative affectivity, generation workforce concerns, changing delivery systems, and increasing clinical practice complexity. 3spite urbanization and globalization in India, nurses faced challenges such as workplace violence, workplace place health hazards, long working hours, non-nursing roles, overcrowding, stress and these challenges arise due to issues at the organizational, state and national levels. 4sides brain drain, inappropriate staffing, educated consumer, the changing technology, workplace violence, rising public expectation are challenges faced in nursing in Nepal. 5ough nurse's career is broadening with lots of opportunity but nurses are coping with a multitude of challenging and unpredictable cases while working.Such routine stressful conditions can have a dangerous effect on the physical and mental health, functioning and coping skills of nurses.Ineffective coping mechanisms can lead to burn-out, decreased focus and decision-making skills, further affecting the quality of care shown by decreased compassion, increased errors and increased adverse reactions. 6he different challenges faced by nurses also lead them to change their profession and move to other countries for remuneration and for better respect.Catering to the needs of nurses and combating their challenges can make nurses empowered, encouraged, challenged and affirmed to continue doing what they do best without any barriers.It is of the utmost importance, first, to consider and understand each and every potential challenge faced by nurses in order to deal with them effectively, not only to identify and understand them, but also to find solutions to alleviate them. 4erefore, the objectives of the study were to assess the challenges faced by nurses working in emergency unit of BPKIHS and to find out the association between the challenges faced by nurses and selected demographic variables.

METHODS
Descriptive cross-sectional study design was adopted to assess the challenges faced by nurses working in emergency unit of BPKIHS and to find out association between the challenges faced by nurses and selected demographic variables.The study was conducted in emergency unit of BPKIHS, Dharan, Nepal and all the nurses working in the emergency unit of BPKIHS was the population of the study.Total enumeration sampling method was used to select the subject.
For data collection, a pretested self-administered semi-structured questionnaire based on the objectives of the study by extensive literature search, consultation with experts and feedback from peer was used.The data collection was done on June 2021.The tool has two components.The items of workplace violence, overcrowding and occupational hazards were followed by interrogative questions whereas items of stress, workload and salary and employment benefits were followed by statements to assess their challenges in working unit by using Likert scale.
For content validity, consultation with the concerned advisor, subject teachers, guides, experts and peer review was done.Based on their feedbacks, certain items were added and modified in Section B. Nepali version of the tool was prepared and validated by consulting with expert in Nepali language.The Nepali tool was back translated into English for accuracy.Instrument was pretested among 10% of the sample (5 samples) from same emergency unit before actual data collection period started.The subjects included in the pretest were excluded from the main study.
Data was collected after getting the ethical clearance from the Institutional Ethical Review Committee of BPKIHS.Then, permission from hospital Matron and respective ward in-charge was obtained.After that nurses who were willing to participate in study and with minimum of six months of work experience were enrolled in the study.Written consent was obtained from each respondent after explaining the details of the research.Data was collected by selfadministered pretested tool.
After completion of data collection, questionnaires were checked for completeness.Data was entered, stored and coded in Excel 2010 and SPSS version 16 for further analysis.Serial numbers were given for each questionnaire.The collected data were checked on the same day of data collection for its completeness to find out errors and missing information.Descriptive statistics like percentage, frequency, range, mean and standard deviation were applied to describe the independent and dependent variables.For inferential statistics, Pearson's Chi-Square test, and Fisher's exact test and for nonparametric data Mann-Whitney U test were used to find association between challenges faced and sociodemographic variables.The confidence interval was taken as 95% and the level of significance of 0.05.

DISCUSSION
This study revealed that more than half (58.0%) of the respondents belongs to age group of 20-25years, followed by 26-30 years (i.e.36.0%).All the respondents were female.More than two third of the respondents (72.0%) had education of PCL nursing, followed by BSc.Nursing (18.0%) and Bachelor of nursing (10%).Majority (82.0%) had total nursing work experience of 1-5 years with mean experience 4.18 and standard deviation ± 3.503, minimum experience 1year and maximum of 23 years.Likewise, almost all (94.0%) of them had total work experience at emergency unit of 1-5 years.
Nearly three-fourth of the respondents (72.0%) was unmarried.Majority (98.0%) of the respondents were posted as staff nurse.
The study revealed that out of 50 respondents, two third of them (66.0%) have faced physical violence at least once.Among those who faced physical violence (n=33), majority (87.9%) faced physical violence in form of pushing.Findings were inconsistent with study conducted by Fuaad in which nearly half (44.7%) were physically violated and nearly two third (65.6%) faced pushing as form of violence. 13Three fourth (75.8%) perpetrators of the violence were patient and the relatives of patients.Findings were consistent with study by Pandey which showed that nearly two third (65.0%) perpetrators of the violence were patient and the relatives of patients. 7More than half (57.6%) of the respondents were attacked in evening shift (60.6%).
The findings were inconsistent with study conducted by Ijaz which showed that one third (38.10%) of the respondents were attacked in resuscitation area and in morning shifts 42.86%. 8Nearly two third (63.6%) of the respondents reported the incident of violence and among them (85.7%) reported it to incharge.Among those who didn't report the incident more than two third (66.7%) reported it was not important.Similar findings were reported in study by Fuaad which showed that more than half (57.1%) of the respondents reported incident and among those who didn't report the incident nearly two third (63.1%) responded that they didn't felt it was important.showed that two third (67.0%) of the respondents faced psychological violence in the form of threat (50.0%) and nearly two-third (65.0%) relatives of patients were perpetrators whereas nearly two third (60.0%) of the respondents reported incident to in charge among those who didn't report the incident more than half (55.0%) responded that they didn't felt it was important. 14The finding of current study was similar to study conducted by Fuaad which revealed that majority (87.9%) perpetrators violated due to unsatisfied with services. 13e finding of the current study showed that almost all (92.0%) of the respondents experienced overcrowding very often while working.Majority (86.0%) of the nurses perceived inadequate personnel/staffs as major cause of overcrowding.The finding was similar in qualitative study conducted by Clark that revealed inadequate personnel/staffs as major cause of overcrowding. 15The findings were inconsistent with qualitative study conducted by Atakro which showed that lack of space as major cause of overcrowding. 16Regarding effects of overcrowding, majority (88.0%) of the respondents reported increased delay in clinical assessment.The finding of current study is inconsistent to systematic review by Morley which showed that poor patient outcomes and inability of nurses to adhere in recommended guideline treatment were effects of overcrowding. 17e findings of the current study showed that near to half (46.0%) of the respondents faced physical hazards very often while working.Almost all (92.0%) of the respondents faced noise as physical hazards and near to half (47%) faced tiredness as health problem caused by physical hazards.The findings were inconsistent in the study by Kilic where more than half (54.1%) encountered noise as mostly faced physical hazards but consistent with finding that tiredness near to half (45.9%) as associated with health problems due to physical hazards. 11Similar findings were reported in study by Joshua which showed majority experienced tiredness as associated health problem. 18The findings of the current study also revealed that more than half (58.0%) of the respondents faced biological hazards sometimes while working and two-third (68.0%) of the respondents got viral infections and cut injury while working.Findings were inconsistent in the study by Kilic were near to half (48.6%) of the respondents faced viral infections and the majority (83.8%) experienced needle-stuck injury as associated health problem. 11nding of the current study showed that more than half (56.0%) of the respondents faced chemical hazards sometimes while working.Almost all (92.0%) of the respondents got encountered with disinfectants and almost all (90.0%) faced allergies.The findings were inconsistent with the study by kilic were two third (64.0%) of the respondents encountered disinfectants mostly and more than one third (36.9%) faced allergies as associated health problem. 11e finding of current study showed that more than half (58.0%) of the respondents faced psychological hazards sometimes while working.The majority (89.9%) of the respondents was violated by patient and patient's relatives and almost all (92.0%) felt stress and anxiety.Similar findings were reported in study by Kilic which showed majority (81.0%) of the respondents was violated by patient and their relatives and mostly (86.6%) faced stress and anxiety as associated health problem. 11Similar findings were reported in study by Joshua were stress and anxiety as major associated health problem. 18e finding of current study showed that one third (34%) of the respondents experienced stress very often because of demanding nature of patient.Similar findings were reported in study by Johan which showed near to half (43.5%) experienced stress very often because of demanding nature of patient. 19Near to half (44%) of the respondents felt stress sometimes due to presence of patient family at work.Similar findings were reported in study by Johan were near to half (49.5%) of the respondents felt stress sometimes due to presence of patient family at work. 19whereas more than two third (68%) of the respondents felt stress very often due to heavy workload.Similar findings were reported in study by Johan were two third (65.0%) felt stress very often due to workload. 19ne third (34%) of the respondents felt stress sometimes due to poor cooperation in emergency unit.Findings were contradictory with the study done by Johan were half (50.0%) felt stress sometimes due to poor cooperation in emergency unit. 19Near to half (44.0%) of the respondents felt stress very often due to impolite behavior of patient.Similar findings were reported in study by Johan were half (50.0%) felt stress very often due to impolite behavior of patient. 19ore than two third (70.0%) of the respondents felt stress very often due to lack of resources while working.Findings were contradictory with the study done by Johan which revealed near to half (47.1%) felt stress very often due to lack of resources while working. 19Similar findings were reported in study by Adzakpah that revealed demanding nature of patients, poor cooperation while working, lack of resources, impolite behavior of patient, workload are the major causes of stress. 20ndings of current study revealed that three fourth of the respondents (76%) strongly agree that their workload increase due to inadequate nurses during staff shortage.Similar findings were reported in study by Leong which showed nearly two third (63.3%) of the respondents strongly agree that their workload increase due to inadequate nurses during staff shortage. 10Majority (82%) of the respondents strongly agree that their workload increases due to unfixed nurse patient ratio.Similar findings were reported in study by Leong were almost all (95.7%) strongly agreed that their workload increases due to unfixed nurse patient ratio. 10More than half (54%) of the respondents strongly agree that they suffered from weak health due to heavy workload.Findings were contradictory with the study conducted by Leong which revealed majorities (87.5%) strongly agree that they suffered from weak health due to heavy workload. 10Whereas more than one third (44%) of the respondents agree that they are easily exhausted by workload.Findings were contradictory with the study conducted by Leong were almost all (91.0%) agree that they are easily exhausted by workload. 10Similar findings were reported in study by Mersin that revealed strong agreement on staff shortage, unfixed nurse patient ratio are causes of workload and weak health, frustration and easy exhausted are effects from workload. 21e finding of current study showed that half of the respondents (50%) strongly agree that they are dissatisfied as their salary doesn't reflect their education qualification.Findings were contradictory with the study conducted by Leong which showed majority (89.3%) strongly agree that they are dissatisfied as their salary doesn't reflect their education qualification. 10Near to half (48%) agree that respondent's salary doesn't reflect their seniority.Findings were contradictory with the study conducted by Leong which revealed more than two third (73.0%) agree that respondent's salary doesn't reflect their seniority. 10More than one third (40%) agree that respondent's salary and benefits don't keep up with inflation.Findings were contradictory with the study conducted by Leong which showed almost all (92.9%) agree that respondent's salary and benefits don't keep up with inflation. 10Near to half of the respondents (46%) strongly agree that they aren't provided with financial incentives while on training.Findings were contradictory with the study conducted by Leong were almost all (96.1%) strongly agreed that they aren't provided with financial incentives while on training. 10Similar findings were reported in study by Poudel that revealed nurses were dissatisfied with their salary and benefits. 22Similar findings were reported in study by Shah that revealed nurses were dissatisfied with their salary and employment benefits. 23e finding of study revealed that more than half of the respondents (54%) had total stress score more than mean of total stress score i.e. they had more stress.Similarly, more than half of the respondents (58%) had total workload score more than mean of total workload score i.e. they had more workload.Likewise, nearly two third of the respondents (60%) had total salary and employment benefits score more There was no significant (p>0.05)association between psychological violence and age, gender, marital status, education level, total nursing work experience and total work experience at emergency unit.However, Pandey contradicts the present finding as it showed age group and working shift had statistically significant association with psychological violence (p-value < 0.05). 7ere was no significant (p>0.05)association between stress domain and age, gender, marital status, education level, total nursing work experience and total work experience at emergency unit.The finding was similar to study conducted by Paudel which showed that stress was not significant to education level, age group, marital status. 24e current findings of study showed that workload was significant (p<0.05) with marital status and educational level but not significant (p>0.05) with age, total nursing work experience and total work experience at emergency unit.The findings were consistent to study by Shakya that showed statistically significant (p<0.05) with marital status and educational level. 6ere was no significant (p>0.05)association between salary and employment benefits domain and age, gender, marital status, education level, total nursing work experience and total work experience at emergency unit.

CONCLUSION
Among the challenges, more than half of the respondents had total stress score more than mean of total stress score i.e. they had faced more stress.Similarly, more than half of the respondents had total workload score more than mean of total workload score i.e. they had faced more workload.Likewise, nearly two third of the respondents had total salary and employment benefits score more than mean of total salary and employment benefits score.i.e. they had more salary and employment benefits.These challenges are affecting the nurses and they were not able to provide quality care to patients.
total 7 items: age, sex, marital status, educational level, total nursing work, total work experience at emergency unit and designation.Part II: Questionnaire Related to Challenges It includes of 6 domains which are made based on literature.The questionnaires for different domains were used after obtaining permission from the authors.

Table 4 : Association between Stress Domain and Socio-demographic Variable of the Respondents (n= 50) Characteristics Categories Stress Domain pvalue Mean ± SD Mean rank
*Mann-Whitney Test

and Employment Benefits Domain and Socio-demographic Variable of the Respondents
* Mann-Whitney U Test

Challenges Faced by Nurses Working in Emergency Unit of BP Koirala Institute of Health... than
20an of total salary and employment benefits score.i.e. they had more salary and employment benefits.Similar findings were reported in study by Adzakpah which showed occupation stress was above mean score.20