Nurses’ coping with patients’ relatives: Attachment style, burnout, and intentions to leave nursing

Abstract Background Conflictual interactions with patients’ relatives are prevalent in the work of hospital nurses. These situations may increase burnout and result in intentions to leave the nursing profession and high rates of turnover. It is important to understand the coping mechanisms and behaviours that nurses employ in such conflicts, to help them develop more adequate strategies that could prevent these outcomes. This study aimed at revealing how nurses’ attachment styles colour their behavioural coping mechanisms when dealing with such interactions with patients’ relatives, and how they are related to burnout and intentions to leave the profession. Methods An online survey was completed by 140 hospital nurses that included three scenarios of typical conflicts with patients’ relatives. Each scenario was followed by questions that assess stress and inadequacy when handling such situations, and behaviours: problem-solving responses, emotional support seeking, avoidance, and escalating responses. The survey also included self-reports of attachment styles, burnout, and intentions to leave nursing. Data were analysed using SEM (Amos 23). Results The model shows an acceptable fit (χ2(24) = 39.33, p = .025; CFI = .963; RMSEA = .068). Higher anxious attachment was associated with higher stress and feelings of inadequacy in handling the situation, which in turn were associated with more emotional support seeking, avoidance, and escalating responses. Escalating responses were indirectly associated with intentions to leave the nursing profession via higher burnout. Higher avoidant attachment was associated with fewer problem-solving responses. Conclusions Evaluating nurses’ attachment style, cognitions, and behaviours in conflicts with patients’ relatives is imperative for understanding burnout and intentions to leave nursing. Nursing training should include simulations of conflictual interactions with patients’ relatives to help modify maladaptive coping. Key messages • Evaluating nurses’ attachment style, cognitions, and behaviours in conflicts with patients’ relatives is imperative for understanding burnout and intentions to leave nursing. • Training for nursing staff should consider nurses’ awareness of their attachment style to modify maladaptive cognitions and behaviours in conflicts with patients’ relatives.


Background:
This study analyses how healthcare workers (HCWs) perceived risks, protection and preventive measures during the COVID-19 pandemic in relation to medically approved risks and organisational measures. We aim to explore 'blind spots' of pandemic protection and identify mental health needs.

Methods:
A German multi-method hospital study at Hannover Medical School serves as an 'optimal-case' scenario of a high-income country, well-resourced hospital sector and an organisation with low HCW infection rate serves to explore governance gaps in HCW protection. Document analysis, expert information and survey data (n = 1163) were collected as part of a clinical study into SARS-CoV-2 serology testing during the second wave of the pandemic (November 2020-February 2021). Selected survey items included perceptions of risks, protection and preventive measures. Descriptive statistical analysis and regression were undertaken for gender, profession and COVID-19 patient care.

Results:
Our study reveals a low risk of 1% medically approved infections among participants, but a much higher mean personal risk estimate of 15%. The majority (68.4%) expressed 'some' to 'very strong' fear of acquiring infection at the workplace. Individual protective behaviour and compliance with protective workplace measures were estimated as very high. Yet only about half of the respondents felt strongly protected by the employer; 12% even perceived 'no' or 'little' protection. Gender and contact with COVID-19 patients had no significant effect on the estimations of infection risks and protective workplace behaviour, but nursing was correlated with higher levels of personal risk estimations and fear of infection.

Conclusions:
A strong mismatch between low medically approved risk and personal risk perceptions of HCWs brings stressors and threats into view, that may be preventable through improved information, risk communication and inclusion of mental health support in pandemic preparedness. Key messages: Healthcare workers' perceptions of COVID-19 infection risks are much higher than medically approved infection risk. Pandemic preparedness and protection plans must pay greater attention to information, risk communication and mental health needs.

Background:
Conflictual interactions with patients' relatives are prevalent in the work of hospital nurses. These situations may increase burnout and result in intentions to leave the nursing profession and high rates of turnover. It is important to understand the coping mechanisms and behaviours that nurses employ in such conflicts, to help them develop more adequate strategies that could prevent these outcomes. This study aimed at revealing how nurses' attachment styles colour their behavioural coping mechanisms when dealing with such interactions with patients' relatives, and how they are related to burnout and intentions to leave the profession.

Methods:
An online survey was completed by 140 hospital nurses that included three scenarios of typical conflicts with patients' relatives. Each scenario was followed by questions that assess stress and inadequacy when handling such situations, and behaviours: problem-solving responses, emotional support seeking, avoidance, and escalating responses. The survey also included self-reports of attachment styles, burnout, and intentions to leave nursing. Data were analysed using SEM (Amos 23).

Results:
The model shows an acceptable fit (2(24) = 39.33, p = .025; CFI = .963; RMSEA = .068). Higher anxious attachment was associated with higher stress and feelings of inadequacy in handling the situation, which in turn were associated with more emotional support seeking, avoidance, and escalating responses. Escalating responses were indirectly associated with intentions to leave the nursing profession via higher burnout. Higher avoidant attachment was associated with fewer problem-solving responses.

Conclusions:
Evaluating nurses' attachment style, cognitions, and behaviours in conflicts with patients' relatives is imperative for Background: D/deaf and hard of hearing (D&HoH) populations are disproportionally affected by physical and mental health problems while facing barriers to accessing health services. These barriers stem from communication challenges with healthcare providers, who are often unprepared to meet their specific needs. This study aimed to develop and evaluate an intervention to improve healthcare providers' skills to communicate with these patients.

Methods:
This study featured a participative action research design. Consistently, the intervention was developed through iterative phases together with the target populations and key stakeholders. The finale version was tested in healthcare workers in Canton of Vaud in Switzerland. Participants completed a questionnaire before (T0) and 6 months after (T1) the intervention, assessing perceived knowledge of deafness and hard of hearing and tools to improve communication, selfefficacy on how to communicate with D&HoH patients and institutional benefits (application frequency of communication rules and tools).

Results:
The final intervention aimed to increase participants' 1) awareness of D&HoH experience and communication needs, 2) knowledge of the tools and basic rules to improve communication. Two D&HoH trainers led one half-day intervention among 28 healthcare providers (e.g., nurses, pharmacists; mean age = 43.6). Paired-sample t-tests revealed significant increases in knowledge between T0 and T1, t (23) = -7.81, p < .001 and in self-efficacy, t (24) = -10.23, p < .001, whereas there was no significant difference between institutional benefits at T0 and T1.

Conclusions:
Although findings suggest the intervention is a promising means to increase perceived knowledge and self-efficacy on how communicating with D&HoH patients, complementary approaches, such as a resource person within the institutions providing day-to-day support to the teams besides the intervention, may be necessary to induce institutional changes.
Key messages: Future research should implement the intervention more broadly within inpatient and outpatient settings in Switzerland to increase knowledge on how communicating with D&HoH patients. Intervention implementation should be complemented by an additional structural approach to induce sustainable changes in practice and evaluated over 12 months to ensure sustainability. Background: Determining and maintaining optimal staffing level in hospitals is crucial, as understaffing may have serious consequences and even increase mortality risk among patients. There is no consensus, however, on the optimal way to determine staffing requirements in hospitals as patients' care needs vary between wards and days. Nurse work experience may also affect quality of care and ultimately patients' survival but research on this topic is scarce.

Methods:
Administrative register data on patients (N = 254,308) and employees of 40 hospital units was used in one hospital district in Finland from years 2013-2019. Both nurse understaffing and nurse work experience were measured with two different indicators in each unit-day. Mixed-effects survival models were used to analyse the associations of these exposures with mortality at patient-level, when adjusted for patients' characteristics, such as age, sex and comorbidities.

Results:
Preliminary results showed that every one percent increase in the cumulative proportion of understaffed days -measured as low nursing hours relative to planned -was associated with 1.002-fold mortality risk among patients (95% CI, 1.000-1.004, p-value = 0.044). Short work experience was not associated with increased risk of death.

Conclusions:
This study supports previous findings on the associations between nurse understaffing and increased mortality risk among patients in Finland although no association with mortality was found for the other three staffing characteristics. However, the average daily shares of actualized nursing hours relative to planned hours were quite high in hospital units. An indicator based on actualized relative to planned working hours in routine administrative data could be useful in evaluating understaffing in hospitals.

Key messages:
Adequate level of nursing professional in hospitals is related to patient survival. It is also crucial of develop efficient ways to evaluate understaffing in hospitals.