How help-seeking behaviors help reduce emergency nurses' stress?

1. Introduction

Unpredictable and challenging circumstances make the nursing profession extremely demanding and stressful [1], [2]. A survey conducted just before the COVID-19 pandemic showed that job pressure, leading to stress and poor mental health, is the main reason nurses leave the profession [3]. The pandemic exacerbates the nurse retention problem in the global healthcare system, as higher psychological pressure is placed on nurses [4], [5]. The concept of stress in nursing may refer to the physiological state resulting from the lack of proper experience and knowledge in uncertain situations [6]. Such stress is harmful to nurses and patients [7]. Nurses' emotional and psychological state is a critical factor affecting their performance, risk of errors, healthcare delivery quality, patient care, recovery, and death [8], Roussillon-Soyer et al., 2021; [9]. Hospitals worldwide allocate funds to address stress-related issues among nurses to identify and adopt stress-alleviating measures [10].

In hospitals, emergency departments (ED) serve as a crucial entry point for patients with acute illnesses and injuries that require immediate attention and life-saving measures. ED nurses should act differently from how they operate in other wards or departments [11],Shamir & Howell, 2018). Working in ED requires precision and swift and prompt responses to various situations [12], [13]. Highly complex, unpredictable, traumatic, severe, and fast-changing clinical emergencies require nurses to possess enough knowledge, comprehension, and experience to understand the standard of care needed [14]. It is a high-pressure job because trauma patients require immediate attention, necessitating the need for quick action. There is very little time for reflection, but ED nurses cannot afford to act recklessly. The risk is very high, and it may result in loss of human life.

More precisely, ED nurses have to cope with many job stressors [14], namely, overcrowding [11], frequent workflow interruptions, poor teamwork [15], encountering multiple requests for immediate response simultaneously or time pressure, mainly at the triage phase [9], unavailability of doctors, high workloads, high short-term absenteeism, unsupportive management, and many interpersonal challenges [16] such as dealing with violent patients and handling their relatives' anger [17], [18]. In such context, nurses who lack the necessary knowledge and experience find emergencies more challenging and experience high job stress levels, resulting in lower job satisfaction and performance and increased burnout, absenteeism, and turnover intentions [19], [20]. Burnout has been reported by 26% of ED nurses [21], and it is always a current issue in research in ED [22].

However, in ED, cases abound where nurses are confronted with a lack of knowledge or experience [6], [23], [24]). They also often face work situations where they perceive there is no ready solution to pursue [11]. They then need to formulate interpretations and choose what to do while being held accountable for their actions (Santana, 2019; Weigl, 2016). Consequently, it is critical to understand the variance in nurses' approaches. We need to know more about how they cope in these uncertain situations and seek informal or formal support.

This study innovates in using the concept of “individual action propensity,” defined as “an individual orientation towards taking immediate action and using trial-and-error in situations where [people] lack knowledge or experience, as opposed to having a propensity to think and then act” [25]. ED nurses who approach a problem by first thinking have low individual action propensity, and nurses who prefer acting before thinking show high action propensity. According to Santos Alves et al. [26], nurses with high assessment orientation always try first to analyze and understand an uncertain situation before executing their action plan. Those with high locomotor exposure are more likely to make spontaneous judgments. In doing so, this study answers the need to investigate the relationship between individual action propensity and job stress in a hospital environment [27]. Its purpose is to understand better how ED nurses' help-seeking behaviors moderate the relationship between their action propensity and stress (see Fig. 1 ).

Fig. 1.

Model of the moderating impact of emergency department nurses’ help-seeking behaviors on the relationship between their action propensity and their job

Vera et al. [25] argue that it is crucial to increase awareness among individuals about developing both modes of action propensity. If habits and routines are in place, the tendency of acting before thinking is likely to be efficient. However, when individuals recognize they do not have the necessary knowledge or experience, a higher propensity for thinking might alleviate their stress. Hence, ED nurses with higher “acting before thinking” tendencies are more likely to feel higher job stress levels when faced with these situations. In contrast, those showing a higher “thinking before acting” inclination should experience lower stress levels.

Moreover, in uncertain situations in which individuals lack knowledge or experience, they tend to use proactive help-seeking behaviors and turn to other people for input, assistance, and advice to solve specific problems [28]; Salvato & Rerup, 2011). Hofmann et al. [29] confirm that when nurses feel a lack of experience, they are likely to require social support and assistance to handle stressful situations. The nursing staff should be inclined to think and seek help to assist patients [30], [31]. Support from colleagues, supervisors, and organizations reduces stress among nursing staff [31], [32]. Vera et al. [25] state that help-seeking behaviors are negatively related to high action propensity (or locomotion) when individuals lack knowledge or experience. However, their help-seeking behaviors are expected to be beneficial regardless of their action propensity (action-oriented or reflective-oriented).

2. Methods

This study aims to understanding how ED nurses' help-seeking behaviors moderate the relationship between their type of action propensity (either “thinking before acting” or “acting before thinking”) and their stress. We adopted a questionnaire design to undertake this research.

2.1. Design and sample

We developed a questionnaire to test hypotheses. Based on the number of items in the questionnaire (25) and the rule of item ratio (10:1), the sample size should reach 250 (Bryman, 2016; Randall & Gibson, 2013). After being pretested, the questionnaire was distributed among 400 nursing staff from August 2019 to October 2019. The list of the ED nursing staff of three tertiary care hospitals of Lahore in Pakistan (Jinnah Hospital, Mayo Hospital, and Services Hospital) has been used to identify a convenient sample of nurses. We complied with the medical Helsinki declaration and obtained approval from hospital higher authorities. A letter attached to each questionnaire explained the research objectives and that all information collected would be kept confidential and anonymous. 350 ED nurses (response rate of 87%) completed the questionnaire, and we discarded 29 incomplete ones. The resulting sample size of 321 ED nurses allows us to avoid non-responsiveness, generalize issues, and reduce sample error.

2.2. Variables measures

The structured self-administered questionnaire asked for brief demographic information and measured our research variables. First, we measured job stress with the 16-item scale developed by Sheu et al. [33], proposing 11 items related to job stress (with answers ranging from 1 “often” to 5 “almost never”) and five items related to work environment stress (responses ranging from 1 “strongly agree” to 5 “strongly disagree”). Second, we measured each of the two individual action propensity modes (i.e., “acting before thinking” and “thinking before acting”) with three items developed by Vera et al. [25] on a scale ranging from 1 “rarely” to 5 “several times daily.” One item example reads: “How frequently do you solve tasks where you had insufficient knowledge by immediately starting to solve the task and discover a solution through trial and error?” Third, we measured the help-seeking behavior variable with the 3-item scale of Lee [28], asking participants to indicate the extent to which they approached a different source (e.g., colleagues, other departments, supervisors) for help when problems arose on a scale ranging from 1 “rarely” to 5 “several times daily”.

2.3. Sample of ED participating nurses

Table 1 shows that the participant sample includes 321 emergency nurses, 68% of whom are women, which is in keeping with the gender segregation found in care jobs. More than half of the participants (56%) are between 18 and 25 years. Regarding qualification, 51% have a B. Sc degree, and 49% have a local high school education diploma (F. Sc) plus a nursing diploma.

Table 1.

Profile of emergency department (ED) participating nurses.

Description	Frequency	(%)
Gender
Male	102	31.8
Female	219	68.2
Age (years)
18–25	178	55.5
26–33	117	36.4
34–41	24	7.5
41–48	2	0.6
Qualification
F. Sc (HSSC)	156	48.6
B. Sc (Bachelor’s degree)	165	51.4
Total	321	100.0

2.4. Reliability and validity of measures and correlation among variables

The data was entered and analyzed using the Statistical Package for the Social Sciences (SPSS 22) and Analysis of Moment Structures (AMOS 22) software. We did not include incomplete questionnaires in the analysis. Following the Podsakoff et al. [34] guidelines, all scale items were loaded onto a single latent variable, which yielded 12% of total variance, well below the 30% threshold for common method bias [35]. Table 2 shows the Pearson correlation analysis among all research variables. There is no multicollinearity issue, as the correlation among study variables is<0.70 [36]. It shows that average variance extracted (AVE) values are ˃0.5 in each case, and the Cronbach's Alpha composite reliability (CR) of each construct is ˃0.7 [37], [38]. Hence, convergent validity is confirmed. As the square root of AVE for each construct is higher than squared correlations, the discriminant validity is also confirmed [39]. As expected, there is a positive correlation between nurses' “acting before thinking” propensity and their job stress (r = 0.178, p < 0.01) and a negative relationship between nurses' “thinking before acting” predisposition and their job stress (r = -0.184, p < 0.01).

Table 2.

Descriptive statistics, Pearson correlation, validities, and reliability estimates.

	Variables	Mean	SD	CR	AVE	1	2	3	4
1	Help-seeking behavior	3.17	0.95	0.80	0.566	0.75
2	“Acting-Thinking” propensity	3.84	1.17	0.75	0.502	-0.358**	0.71
3	“Thinking-Acting” propensity	2.91	1.03	0.79	0.572	0.313**	-0.135*	0.76
4	Job stress	2.21	0.37	0.77	0.521	-0.009	0.178**	-0.184**	0.72

SD: Standard deviation; CR: Cronbach's Alpha composite reliability; AVE: Average variance extracted.

**p < 0.01 and *p < 0.05.

2.5. Analytic strategy

A structural model was developed using structural equation modeling (SEM) to test the influence of emergency nurses' propensity for action on their job stress. The model has a good fit with χ2/df < 0.30, CFI & NNFI > 0.90, and RMSEA < 0.08 [40], [41]. We then applied two structural models [42] to test the moderating effect of emergency nurses' help-seeking behaviors on the relationship between their propensity for action and their job stress.

3. Results

Table 3 results confirm that nurses' type of individual action propensity has a significant statistical impact on their job stress. Nurses with a higher “acting before thinking” tendency are more likely to express job stress (β = 0.135, p < 0.05), whereas those with a higher “thinking before acting” propensity feel less job stress (β = -0.136, p < 0.05).

Table 3.

Relationship between ED nurses' types of individual action propensity and their job stress (SEM analysis results).

Types of individual action propensity	(β)	t	p
“Acting before Thinking”	0.135*	2.916	0.004
“Thinking before Acting”	−0.136*	−2.098	0.036

*p < 0.05.

Table 4 results confirm that help-seeking behaviors are negatively related to “acting before thinking” propensity (r = -0.36**) and positively linked to “thinking before acting” propensity (r = 0.31**). Furthermore, in situations where they lack knowledge or experience, nurses' help-seeking behaviors negatively moderate the positive relationship of the propensity “acting before thinking” and job stress (β = -0.101, p < 0.05). Hence, adopting help-seeking behaviors reduces the negative link between individuals' action propensity and job stress. Results also confirm that nurses' help-seeking behaviors negatively moderate the negative relationship between the “thinking before acting” propensity and job stress (β = -0.208, p < 0.05). Hence, help-seeking behaviors can also reduce the job stress of nurses showing an individual penchant for thinking. Fig. 2 illustrates the moderating role of ED nurses' help-seeking behaviors between their action propensity (acting before thinking & thinking before acting) and their job stress.

Table 4.

Moderating impacts of ED nurses' help-seeking behavior on the relationship between their type of action propensity and their job stress.

Paths- SEM analysis			β	t	p
Acting-Thinking propensity	→	Job stress	0.127*	1.989	0.047
Help-seeking behavior	→	Job stress	-0.305**	4.951	0.000
Interaction	→	Job stress	-0.101**	5.10	0.000
Thinking-Acting propensity	→	Job stress	-0.350*	2.559	0.010
Help-seeking behavior	→	Job stress	-0.212**	4.356	0.000
Interaction	→	Job stress	-0.208*	2.378	0.017

**p < 0.01, *p < 0.05.

Fig. 2.

The moderating role of ED nurses' help-seeking behaviors between their action propensity (acting before thinking & thinking before acting) and their job stress.

4. Discussion

This study innovates by using the concept of individual action propensity [25] to examine ED nurses' approach towards solving situations for which they lack knowledge or experience about what to do, likely to be frequent in their work life. In such uncertain cases, we found that the “acting before thinking” propensity is positively associated with nurses' stress, whereas “thinking before acting” negatively correlates with their stress. We also confirmed that ED nurses' help-seeking behaviors help reduce stress, regardless of their action propensity. Such findings invite researchers to adopt Conservation Of Resources (COR) theory [43] to investigate how help-seeking behaviors might be used to gain resources that enable ED nurses to better deal with work stressors. The findings are consistent with prior research suggesting that help-seeking behaviors lead to increased resiliency and decreased stigma [44].

5. Implications for nursing managers

This study has several important implications for nursing managers. The nursing organizational culture has a crucial role in coping with job stress (Choi & Kim, 2020). Managers and supervisors should train and help ED nurses be less action-oriented in uncertain situations and seek help to reduce stress. Improving the “thinking propensity” could also be done through mindfulness interventions involving the self-regulation of attention and thinking, bringing various benefits to the health care staff, such as psychosocial health, reduced stress, and job satisfaction [45]; et al., 2019).

Bringing nurses to seek help might require training to reduce some potential false beliefs about seeking help, such as staff members being afraid of being seen as incompetent, inadequate, and dependent, losing power or independence, or wasting their time [46], [28]. In professions with a culture of strength and resilience, employees tend to perceive such behaviors as a threat to self-esteem [44]. Nursing managers should normalize help-seeking behaviors because self-stigmatization remains widespread [47], [48]. Managers also need to communicate the benefits for nurses of seeking help when they lack knowledge or experience, namely: a broader range of expertise, built-in variability, greater capability for reorganizing their activities, ability to work in parallel, innovation, and developing interpersonal alliances or networks [49], [28], [50].

Studies have also shown that adverse contextual conditions and insufficient support from colleagues and managers might lead to disappointment, higher stress, and decreased trust within ED teams [51], [52], [53], [13]. Considering that high-quality working relationships contribute to helping behaviors [46], the hospital administration should proactively promote a collectivist culture rather than an individualistic one [28]. Managers should also be aware that the higher the task demand, the lower the helping opportunities [54]. They should help ED nurses deal with uncertain situations and stress through more formalized discussion opportunities to share their collective experiences with patients [55]. They might also look at if simulated practices can be helpful to reduce nurses' stress in unfamiliar situations [56], [57].

6. Limitations and future research

The current study is not free from limitations. First, the participating nurses belonged to the Lahore region of Pakistan only; hence, the results might not be generalized to other areas. Second, as this study is based on a cross-sectional research design, experimental or longitudinal studies are needed to confirm the meaning of the relationships between the research variables. Third, it would be worth investigating the effectiveness of various approaches to incite ED nurses who face situations where they lack knowledge or experience to think and look for help from their colleagues and supervisors. Fourth, this study has explored specific determinants of ED nurses' stress at an individual level. They are, however, confronted with multilevel sources of stressors (individual, interpersonal, organizational, etc.) over which they have little or no control [58]. Future studies could investigate ways of intervening simultaneously at various levels (personal, job, managerial, technological, physical layout, etc.) in the wake of recent investigations [13], [9].

7. Conclusion

This study innovates in using the concept of “individual action propensity” [25] to examine ED nurses' approach to solve situations for which they lack knowledge or experience by either “thinking before acting” or “acting before thinking.” It also investigates the impact of the type of action propensity on their stress level and how help-seeking behaviors might be beneficial. Results confirm that when ED nurses lack knowledge or experience, a propensity for acting relates positively to their stress but negatively to their help-seeking behaviors. In contrast, a propensity for thinking reduces stress and is positively associated with their help-seeking behaviors. Finally, help-seeking behaviors are likely to reduce ED nurses' stress, regardless of the type of action propensity. Managers should help ED nurses be less action-oriented in uncertain situations and seek help to reduce their stress. Changing these nurses' behaviors requires reducing barriers and adopting facilitators at multiple levels, whether individual, interpersonal, organizational, or environmental.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.