Emergency Department (ED) provides immediate care and life support to patients with acute conditions, often with life-threatening situations. Admission to ED can be a traumatic experience for both, the patient as well as accompanying attendants, leading to additional mental and physical stress. ED surroundings can generate certain practices and emotions such as-uncomfortable procedures, inadequate communication between clinicians and patients, uncertainty, confusion, perceived defencelessness, lack of control, dejection, and nervousness. Witnessing aggression, violence, death, or suffering of near and dear ones can be emotionally and physically demanding for the caregivers and emergency staff. Such stressors can lead to overwhelmed emotions in oneself and poor self-regulation. There are increasing incidences of aggressive behavior and violence in ED's.
Studies addressing stress levels among doctors, nurses, and health-care workers posted in the ED are available, but there is a paucity of information regarding stress levels, stressors, and their correlates among attendants accompanying the patients. We report a study on caregivers' attitudes and their response to stress in ED settings and useful suggestions for stress management. Early identification of any unusual behavioral patterns among caregivers can help to take measures in preventing incidents of violence.
This is a prospective, cross-sectional, observational study conducted at the ED of a tertiary care hospital from April to June 2019. A total of 256 participants were selected by block randomization of 10; each meeting the following inclusion criteria was enrolled in the study – (1) adult attendant aged a18 years, (2) duration of stay of at least 2 h in the emergency department, (3) if accompanied by more than one attendant, closest of consanguinity, or affinity included.
Attendants who were visually impaired or were under the influence of alcohol or any other psychotropic substance were excluded from the study.
Approval from institutional ethics committee was taken. For the study, obvious signs of stress and predictors of violence using STAMP method were recorded at the initial encounter in the ED by a single trained interviewer physician. Further information was collected using structured and prevalidated questionnaire which included case number, age, sex, level of education, marital status, relationship to patient, previous ED experience, waiting time, mode of payment, level of information provided, and improvement in patient condition. Stress levels were assessed using the Perceived Stress Scale (PSS 10) and the Stress Visual Analog Scale (VAS) at the end of 2 h of stay in the ED.
The average stress level and 95% confidence interval assuming Gaussian distribution were obtained. In addition, the factors associated with stress level were studied by running a linear regression analysis. The value of P ≤ 0.05 was considered as statistically significant.
PSS-10 is a 10-item scale, measuring degree to which situations in one's life are appraised as stressful during the past month. There are six negative and four positive questions on which the subjects are required to choose from a scale of five alternatives: “Never (0),” “Almost never (1),” “Sometimes (2),” “Fairly often (3),” or “Very often (4)” relating to their feeling of being stressed. This scale has been found to have adequate reliability and validity. The scale was introduced to the subject during the interview at the end of 2 h and requested to fill up the questionnaire.
STRESS VAS is a rapid quantitative tool used to highlight any significant increase or decrease in their subjective stress levels. The participants are asked to “Indicate how stressed you feel on the small ruler” on arrival and now at the end of 2 h. It yielded a single subjective stress score between 0 and 10, highlighting significant level of change in stress levels during the 2 h stay in ED. Several studies have indicated satisfactory stability, high inter-rater reliability and were validated by Lesage et al. as comparable to PSS scores.
STAMP is an objective assessment of stress and imminent violence by observing obvious signs of stress. It has five distinctive elements conceptualized as a potential violence assessment framework and described through the acronym STAMP – “Staring and eye contact, Tone and volume of voice, Anxiety, Mumbling and Pacing.” Recording of behavior is instantaneous, focal and are recorded as and when occurred. The results of the causal factor comparison indicate that the reliability and validity (degree of overlap of causal factors identified from the same method, i.e., inter-analyst overlap) of STAMP (65%) are higher.
Majority of the participants were in the age group of 31–50 years and were married with a slight male preponderance. Most of them were spouses of the patient, with education up to graduation and had previous experience of visiting an ED. Many of them were covered under some form of health insurance or government health benefit schemes [Table 1].
Mean of PSS score was found to be 15.09 ± 0.454 with a 95% confidence interval (CI) of 14.2–15.98. As per the PSS score, 150 (58.6%) of participants exhibited mild level of stress, 67 (26.2%) had moderate stress, 36 (14.1%) had severe stress, whereas 3 (1.2%) had no demonstrable stress [Figure 1].
The mean of VAS score at time zero in the emergency department was 6.46 ± 0.13 (CI-6.21–6.71) and at the end of 2 h was 6.45 ± 0.15 (CI: 6.15–6.74). The differences in the mean VAS at time zero and at 2 h was found to be statistically insignificant (P = 0.938)
Maximum severe stress was found among attendants of critical patients, categorized as red as per triage category, constituting 21 (32.81%), followed by yellow category 9 (10.98%) and minimum from green category 6 (6.38%). Maximum mild form of stress was observed in white category comprising 13 (81.25%), followed by 63 (67.02%) from green category, 35 (54.69%) from red category, and 39 (47.56%) from yellow category. The association of PSS score with Triage Categories was found statistically significant (P < 0.05).
Association of perceived stress scale with demographic characteristics and other variables [Table 2]
All attendants reported some form of stress. Younger population < 40 years had higher levels of severe stress (68.29%) compared to participants more than 40 years of age (37.86%). Age was found to be a statistically significant factor affecting stress (P = 0.01).
Severe stress was reported more in females (23.14%) as compared to males (5.93%). Mild form of stress was reported more in males (65.19%) than females (51.24%). Gender was found to be statistically significant factor (P = 0).
Maximum attendants 7 (21.21%) who reported severe form of stress were educated up to primary levels. 59 (33.91%) reported moderate stress were graduates. Higher educational status was found statistically significant factor in stress (P < 0.001). Among graduates and above, 46.28% exhibited moderate to severe stress while similar stress levels were observed in 34.82% of participants who studied up to secondary level.
Relation with patient
Most of daughters (33.33%) reported severe stress, followed by father (17.65%), spouse (15.22%), and mothers (12%). Closeness of relationship was found to be significant factor affecting stress levels (P = 0).
All attendants (100%) who were unmarried showed moderate to severe form of stress while 37.3% of married exhibited similar stress levels (P = 0).
First encounter with emergency department
Attendants who had no previous experience to ED showed higher stress levels (32.2%) as compared to those with experience (8.63%) (P = 0.00).
Waiting time for physician
Longer waiting time had significant stress increasing PSS-10 score and shorter waiting time generated least stress. Among those who reported “Longer than expected” for consultation, 15% reported severe form of stress, 37.5% moderate stress, and 47.5% mild stress. All 6 who reported “Much too long” were found having severe stress.
Waiting time for nurse
Similarly, all those who reported “Much too long” presented with severe stress, while 15.38% of who reported “Longer than expected” had severe stress.
Waiting time for general duty assistant
14.11% of those reported “About right” time had severe stress while 74.75% who had time longer than expected had severe stress. All these longer waiting times had significant association.
Moderate-to-severe stress was reported by 45.65% attendants whose patients did not show any improvement in condition following treatment initiation. Similar stress was observed in 30.37% attendants whose patients' showed improvement. Perception about patient condition was found to be a significant factor associated with stress in attendants.
Types of violent behavior
It was found that 64.1% attendants had anxiety, 27% had only verbal aggression, and 5.9% showed both verbal and passive aggression. 1.2% attendants showed verbal, passive, and physical aggression [Figure 2].
Association of aggression with variables [Table 3]
Verbal aggression was the most common form of violence observed in all triage categories. Majority of verbal aggression was noted among 62.5% attendants of white category patients followed by 44.68% in green category and 18.75% in red category of patients' attendants. A small number of attendants 3.66% with patients belonging to yellow category exhibited physical violence).
First encounter with emergency room
Majority of attendants who had no previous experience of ED were found to be verbally aggressive (35.59%) while 5.08% of them exhibited physical violence. 26.9% of attendants having previous experience of ED showed some form of aggression, while 73.1% showed no aggression.(P = 0.00).
Attendants belonging to both genders were aggressive. 34.82% of males and 35% of females showed aggression higher than anxiety.
Attendants who were graduates showed higher verbal and passive aggression (39.65%) than those of primary (27.27%) and secondary (18.09%) level of education. Whereas relatives educated up to primary levels indulged in greater physical violence (9.09%).
Relationship with patient
Spouses (8.69%) and daughters (33.33%) exhibited higher verbal, passive, and physical aggression.
Verbal form of aggression was seen across all age groups. Maximum physical violence was observed in age group between 51 and 60 years (7.89%). Verbal and passive form of aggression was observed in all 3 (100%) participants from age group of 61–70 years, followed by 3 (8.82%) from age group of 21–30 years.
Although both single and married attendants had anxiety, physical violence was reported in only married attendants. Verbal aggression was seen in 34.43% married and 33.33 single attendants.
Waiting time for physician
Majority of attendants who reported “Longer than expected” wait time exhibited only verbal aggression (77.5%) and both verbal and passive aggression (7.5%).
Waiting time for nurses
78.46% of attendants perceiving “Longer than expected” time for ED nurse demonstrated aggression higher than anxiety.
Waiting time for general duty assistant
All attendants who waited “much too long” for a general duty assistant showed higher levels of aggression, while 74% of those who reported “longer than expected” showed higher aggression.
Attendants whose patient's condition did not improve after treatment showed verbal aggression in 52.17%, verbal and passive form of aggression in 7.61%, and 3.26% showed physical violence.
Admission of a patient in the emergency department and the recovery process is stressful for family members. Patients' attendants must deal with the unfamiliarity of the environment, treatment procedures, and uncertainty in outcome. Family members may experience high levels of fear, denial, anger, and guilt while facing risk of losing their loved ones. Perception of not being treated early coupled with their socioeconomic and educational background leads to incidences of assault and vandalism in the ED.
The study demonstrated that 98.2% of the attendants reported some form of stress, with moderate stress in 26.2% and severe stress in 14.1%. Other studies, mainly done in ICU patients, have also reported that caretakers undergo high burden and stress. Karale et al. reported mild stress in 23.3%, moderate stress in 73%, and severe stress in 3.33% relatives of patients.
Similar findings were recorded by Patil et al. who assessed stress level among the relatives of patients admitted in intensive care unit. They found 8% relatives with severe stress, 44% with moderate stress, and 48% with low stress. Kulkarni et al. found that among care givers of patients suffering from cancer, nearly 62% were ready to ask for professional help from nurses, medical social workers, and counselors to cope up with their stress. High levels of anxiety and stress have been found to be associated with moderate to major risk of posttraumatic stress disorders among family members. Understanding the stress of attendants and addressing their concerns by the staff in ED may help reduce anxiety levels and reduce incidence of violence and improve satisfaction levels.
The results of the study demonstrated a significant association of higher stress levels with factors such as red category patients' attendants with no prior ED experience, marital status being single, perceived longer waiting time to avail services, dissatisfaction with treatment, middle age groups, first degree relation, female gender, and lower educational status. All these factors are likely to produce higher anxiety and stress levels. In a study by Hiremath et al., in relatives of oral cancer patients, PSS-10 was found to be highly associated with age, marital status of caregiver, type of family, relationship with patient, government health policies, and education status of the caregiver. Other studies have also reported higher incidence of stress and depression, which affected Quality of life among caregivers.
Anxiety was observed in almost more than half of sample population, i.e., 64%. Verbal aggression was the most common type of violence (27.0%) exhibited by attendants. Verbal and passive aggression was observed in 5.9% and physical aggression in 1.2% of the patient attendants. Ori et al., in a study on prevalence and attitude of workplace violence among postgraduate students in a tertiary hospital in Manipur observed that verbal threats (56.11%) were the commonest form. Abbas and Selim also found verbal abuse as the most common type of violence (98.7%), followed by threatening behavior (46.7%) and physical assault (38.7%). Chen et al. found 65.8% prevalence of workplace violence occurring primarily in emergency and pediatric departments.
Kumar et al., in their study found long waiting periods (73.5%), delayed medical attention (45.6%), violation of visiting hours, patients' dissatisfaction with nursing care (41%), psychological stress (38.4%), and denial of hospital admission due to limited availability of beds in wards (31.1%) as prominent causes of violence. In another study by T Carmi-Iluz et al., most common causes of violence reported were long waiting time (46.2%), dissatisfaction with treatment (15.4%), and disagreement with physician (10.3%). Violation of visiting hour (88.8%), long waiting time (86.4%), visitors' psychological problems (83.2%), and smoking in waiting areas (82.4%) were observed as important precipitating factors by Koukia et al. Jung Kyoon and Sonneveld reported anxiety mainly due to distrust between the patient and family members with hospital staff, patients' consistent focus on their status, and uncertainty about waiting time.
Strategies should be devised to minimize the level of stress experienced by caregivers of patients admitted to ED. These include but are not limited to:
- Involving mental health teams for sensitization training
- Social workers to be assigned to strengthen communication between health-care staff and patient attendants.
Understanding the factors associated with stress and aggressive behavior will help in planning interventions to prevent violence and improve satisfaction levels, especially in emergency departments. This will help caretakers to cope with stress, increase family re-sources, and maintain the strengths for supporting the patient.
Almost all attendants coming to ED undergo stress. Attendants accompanying critically ill patients, with no previous ED experience, unmarried, in middle age group, female gender, first degree relatives, perceiving long waiting time, and dissatisfied with treatment were at significant risk of developing high stress. Verbal aggression was the most and physical aggression was least common but with timely intervention, it is easier to prevent situation from becoming worse. Attendants of nonemergent patients, no previous experience at EDs, middle age group, undue long waiting time, and poor response of patient to treatment are more likely to resort to violence. Hospitals need to devise strategies to prevent ED visits of nonemergent patients, reduce overcrowding, and identify needs of attendants. ED staff should be trained for better communications with attendants, methods of identification of impending violence, and developing coping mechanisms.
Research quality and ethics statement
This study was approved by the Institutional Ethics Committee (EM/IEC/18–63). The authors followed applicable EQUATOR network guidelines during the conduct of this research project.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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