Experiences of and actions towards worries among ambulance nurses in their professional life: A critical incident study

International Emergency Nursing (2008) 16, 35–42

www.elsevierhealth.com/journals/aaen

Experiences of and actions towards worries amongambulance nurses in their professional life: Acritical incident study

Anders Svensson RNPEN, MNSc (Lecturer) a,b,*, Bengt Fridlund RNAN,RNT, PhD (Professor) a

a Centre for Acute and Critical Care, School of Health Sciences and Social Work, Vaxjo University,SE-351 95 Vaxjo, Swedenb Department of Emergency Care, Central Hospital, Vaxjo, Sweden

Received 20 March 2007; received in revised form 26 September 2007; accepted 14 October 2007

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KEYWORDSAmbulance nurse;Worry;Qualitative method;Ambulance service

55-599X/$ - see front mattei:10.1016/j.ienj.2007.10.00

* Corresponding author. Addre, School of Health Sciencty, SE-351 95 Vaxjo, SwedenE-mail address: anders.sve

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ress: Cenes and S. Tel.: +nsson@v

Abstract Nurses working in the ambulance service are frequently exposed to situ-ations in which they have to take sole responsibility for sick or injured patients,many of which can be emotionally trying. The purpose of this study was thereforeto describe critical incidents in which ambulance nurses experience worry in theirprofessional life and the actions they take in order to prevent and cope with it.The sample consisted of 13 male and 12 female nurses working in ambulance ser-vices in three small to medium-sized counties in the south of Sweden. The data werecollected by means of interviews and analysed according to Critical Incident Tech-nique (CIT). The result showed that nurses worried about specific emergency situa-tions as well as situations related to their working environment. Worry wasalleviated by their own actions or with help from others. It was also shown that,with increasing experience, came a responsibility to be able to cope with all kindsof situations. This responsibility was experienced as worrying. However, if the nursefelt confident in their colleague, the worry could ease. It was concluded that theworry experienced by ambulance nurses in specific emergency situations requiresflexibility on the part of the ambulance service. Nurses must be given the opportu-nity to address their worries in the way that is most appropriate for each individual.

�c 2008 Elsevier Ltd. All rights reserved.

8 Elsevier Ltd. All rights rese

tre for Acute and Criticalocial Work, Vaxjo Univer-46 470 708379.xu.se (A. Svensson).

Background

Ambulance personnel are frequently faced withsituations in which they have to take sole

rved.

mailto:[email protected]

Table 1 Socio-demographic and professional char-acteristics of the ambulance nurses (N = 25)

SexMale 13Female 12

Number of years in the profession1–4 85–9 410–14 615–19 420– 3

Specialist educationPrehospital emergency nurse 12Anaesthetic nurse 3

36 A. Svensson, B. Fridlund

responsibility for seriously sick or injured patientsas well as those in shock; a reality in which the cir-cumstances vary from one situation to another. Pa-tients with life threatening symptoms are treatedunder conditions complicated by emotional, cul-tural and social factors (Suserud, 2002). Some situ-ations are perceived as more overwhelming,resulting in the ambulance personnel experiencinga higher level of worry (Alexander and Klein,2001). It has been found that a person with a ten-dency to worry about problems that occur in his/her everyday life runs the risk of developing anxi-ety and depression (Boehnke et al., 1998). Intenseworry undermines the active measures he/she nor-mally takes in complex and possibly problematicsituations. Further, such difficulties tend to esca-late; the more worried and anxious the person is,the more threatening the potential problem ap-pears to be (Boehnke et al., 1998). The pressurethe ambulance personnel frequently have to en-dure can lead to post-traumatic stress syndrome(Jonsson et al., 2003; Jonsson and Segesten,2004). Ambulance personnel, independent of theirlevel of education (Suserud and Haljamae, 1997),are seldom distressed by major accidents or gravepersonal injuries but rather by situations in whichthey feel compassion for the patients and their rel-atives. Such situations can be related to accidentsinvolving children or suicide (Regehr et al., 2002).There is a connection between this work relatedworry and physical and psychological symptomslike stomachache, headache and sleeping disor-ders, when studying both female and male ambu-lance personnel. It has been shown that 25% offemale and 20% of male ambulance personnelexperienced two or more of the above-mentionedsymptoms as a result of their professional life (Assaet al., 2005). Therefore, worry as a risk factor forambulance personnel should not be ignored. In or-der to identify active measures to prevent worryingthere is a need for a more detailed mapping ofemergency situations that cause ambulance per-sonnel to worry. Therefore, the purpose of thisstudy was to describe critical incidents in whichambulance nurses experience worry in their profes-sional life and the actions they take in order to pre-vent and cope with it.

Prehospital emergency and Anaesthetic nurse 2No specialist education 8

Number of years in ambulance service1–4 65–9 710–14 615–19 520– 1

Method

Study design and method

The study had a descriptive qualitative design andwas analysed according to Flanagan’s CriticalIncident Technique (CIT) (Flanagan, 1954). The

objective of this method is to gather observationsof human behaviour by means of descriptions ofreal, well-defined and meaningful incidents. Theincidents can be collected through observations,interviews, questionnaires or self-reports (Flana-gan, 1954). It is of great importance that the sub-ject under investigation has a well-definedpurpose and that the respondents are given theopportunity to describe both positive and negativecritical incidents that they perceive as important.The number of incidents can vary, depending onthe complexity of the purpose, but more than 100is usually recommended in order to achieve an ade-quate analysis (Andersson and Nilsson, 1964).

Ambulance nurses

In line with qualitative designs the respondentswere selected strategically; i.e. with regard tosocio-demographic and professional characteristicssuch as age, education level, sex and years in theprofession (Fridlund, 2006). The group of respon-dents were collected from three ambulance ser-vices in small to medium-sized counties in thesouth of Sweden and consisted of 13 male and 12female ambulance nurses. Their work experiencein the ambulance profession varied between 1and 20 years and some had specialist educationwithin different fields of nursing (see Table 1).

Extract descriptions of critical incidents of

importance to the activity under investigation

Label and classify the incidents with similar

behavior into: SUB-CATEGORIES

Label and classify the sub categories after content into:

CATEGORIES

Label and classify the

Experiences of and actions towards worries among ambulance nurses 37

Ethical considerations

The study adhered to the principles outlined in theDeclaration of Helsinki (World Medical AssociationDeclaration of Helsinki, 2005). In Sweden there isno need for consent to be obtained from an ethicalboard if written consent has been obtained fromthe respondents and if the study does not involvea physical intervention affecting a person. Themanagers of the ambulance service involved gaveapproval for the study to be conducted in theirdepartment. Ambulance nurses, suggested by themanagers, were sent a letter containing informa-tion about the purpose of the study, that participa-tion was voluntary and that they were free towithdraw from the study at any time without hav-ing to provide an explanation. The respondentsgave their written consent to take part in thestudy. They were also assured that the data wouldbe treated confidentially. The interviews were con-ducted at a location chosen by the nurses. Threeinterviews took place over the phone, since it sui-ted those respondents best (Swedish NationalBoard of Health and Welfare, SPS 2003:460).

categories after the comprehensive structure of

the data into: MAIN AREAS

Box 1 Framework summery on how the data wascategorized according to the Critical Incident Technique(Flanagan, 1954).

Data collection

Data were collected by means of semi-structuredinterviews, which were recorded on an MP3 playerand later transcribed verbatim. The interviewsstarted with an open question about critical inci-dents; i.e. emergency situations in which thenurses experienced worry and the actions he/shetook in order to deal with it. This question was fol-lowed by more in-depth questions such as ‘‘How doyou mean? Explain how you felt!’’ in order toobtain a clear picture of how the nurses hadexperienced the situation. The interviews lastedbetween 12 and 25 min.

Data analysis

The data analysis started by carefully readingthrough the interviews on several occasions in or-der to become familiar with the content. Incidentsrelated to the aim were delimited and subjected toa structural analysis in line with the CIT-tradition(see Box 1). A total of 262 critical incidents wereidentified. Comparison of the incidents was thenmade in order to find similarities and differencesand with the aim of grouping them together. Theseincidents were categorized by experiences and ac-tions, in 12 and 13 sub-categories, respectively.Some of the behaviours fitted into more than oneof the sub-categories, thus the sub-category that

best accorded with the behaviour described waschosen. The sub-categories were then divided in asimilar way into 5 and 6 categories as well as 2and 2 main areas, respectively. The purpose of acategory is to describe the general character ofthe sub-categories, while that of the main area isto describe the overall theme contained in the data(Andersson and Nilsson, 1966).

Results

Worry related to specific emergencysituations (Table 2)

Worrying about feeling inadequate

The nurses worried about situations in which he/she felt inadequate. The worry derived from notknowing how to manage the assignment whenmeeting a patient. ‘‘The worry comes from notbeing able to help the patient in a satisfactoryway’’. Unusual calls could lead to insecurity:

Table 2 Summary of the main areas, categories and sub-categories of emergency situations that worry nurses

Main area Category Sub-category

Worry related tospecific emergencysituations

Worrying aboutfeeling inadequate

The nurse feels worried in situationswhere he/she cannot managethe assignment (8)The nurse feels worried insituations for which he/she isunprepared (7)The nurse feels worried insituations where he/she lacksexperience (6)

Worrying about emergencysituations in which thenurse may be personallyinvolved

The nurse feels worried in situationswhere he/she knows the patient (11)The nurse feels worried in situationshe/she can associate withhis/her personal life (9)

Worrying about specific calls The nurse feels worried in situationsinvolving children (14)The nurse feels worried insituations involving child birth (4)

Worry relatedto the workingenvironment

Worrying about emergencysituations which thereis a lack of control

The nurse feels worried insituations where he/she risks his/her own safety (20)The nurse feels worried insituations that he/she cannotcontrol (11)The nurse feels worried insituations where the technicalequipment fails (7)

Worrying relatedto lack of trust

The nurse feels worried insituations where he/she lacksconfidence in his/ her colleague (9)The nurse feels worried in situationswhere he/she experiences a lack oftrust from management (8)

Number of incidents in brackets.


‘‘. . . lack of experience makes you a beginner everytime’’.

It was considered important to be prepared forall possible scenarios: ‘‘. . . if you do not get a lotof information on the way out, you do not knowwhat to expect’’.

Worrying about emergency situations in whichthe nurse may be personally involvedThe nurses worried when a situation could be asso-ciated with their personal life. They worried aboutgoing to addresses or places where relatives orfriends might be: ‘‘. . .the worry you feel whenyou leave is that it might be one of your own’’.They sometimes experienced situations that werevery similar to their own private life: ‘‘I went outon a call pertaining to sudden infant death . . . itconcerned twins, and I have twins myself’’. The

nurses could relate to how they would have reactedthemselves if they had been personally involved: ‘‘Icould see myself in the parents’ situation’’. Itseemed that their own family situation governedtheir emotions: ‘‘. . . I have children myself, so Icould see myself in their situation’’.

Worrying about specific callsThe nurses worried in situations involving childrenor childbirth. In many cases the worry was due tothe feeling that everything they did had to be right:‘‘Because they have their whole life ahead ofthem, so to speak. Older people have lived theirlives, more or less’’. They also felt the pressurefrom the parents: ‘‘. . .what a disaster for the par-ents if something were to happen’’. A feeling ofhelplessness in situations where the children wereunable to express themselves could also be identi-


fied: ‘‘. . . so it is difficult to get a correct anamne-sis of what is wrong’’.

Worry related to the working environment(Table 2)

Worrying about emergency situations in whichthere is a lack of controlThe nurses were worried about situations in whichthey lacked control: ‘‘That you cannot control thesituation//you want to be in control when you areat the scene of an accident or in someone’s home’’.They were also faced with threats and violence:‘‘. . .the feeling of discomfort when someone getsreally mad and you can see it in their eyes that theymay explode at any moment and you cannot es-cape’’. Colleagues exposed nurses to situations thatthey could not control: ‘‘. . .the driver of the emer-gency vehicle was not capable of doing his job//I donot really feel that I can trust the colleague I amtravelling with’’. Some worried when the technicalequipment failed: ‘‘. . .you try to transmit an ECGfrom a heart patient and it does not work and youcan see for yourself that the patient has sufferedan infarction.’’

Worrying related to lack of trustThe nurses were worried in situations in which theylacked confidence in their colleague: ‘‘. . . if I lack

Table 3 Summary of the main areas, categories and sub-calleviate and cope with their worry

Main area Category Sub-c

Alleviating worry byone’s own actions

Reflecting on worry TheTheThe

Experience has aninfluence on worry

TheThe

Alleviating worry bytheoretical means

ThefromThe

Alleviating worry bypractical means

TheexerThepract

Worry is alleviatedby healthcareprofessionals andnext-of-kin’s actions

Seeking support afterthe emergency situation

Theto soThedebr

Seeking support in theemergency situation

TheconfiThe

Number of incidents in brackets.

confidence in my colleague I worry about bothhim/her and myself, that we will not manageit’’. Lack of trust on the part of the managementteam was also a reason: ‘‘Our managers do notprovide us with a sense of security’’.

Alleviating worry by one’s own actions(Table 3)

Reflecting on worryThe nurses reflected on their worry: ‘‘I think it is ahealthy kind of worry in a way. A certain amountof stress and worry is good so to speak, becauseit makes you more alert’’. Worry was analysed onthe way to a patient: ‘‘You have to prepare your-self as much as possible when you are on yourway to the patient. Think about different scenar-ios, the kind of equipment you have, the kind ofmeasures you might have to take’’. Sometimesthe nurses tried to ignore the worry, in order notto be influenced by it: ‘‘I cannot say that I goaround worrying, because if I did, I don’t think Icould cope with this job’’.

Experience has an influence on worryProfessional experience influenced worry: ‘‘. . .thelonger you have worked and the more you haveexperienced, the calmer you are, because youknow you can manage//I think that experience is

ategories describing what actions nurses take in order to

ategory

nurse ignores his/her worry (12)nurse’s worry decreases with mental preparation (12)nurse’s worry results in focused energy (8)

nurse’s worry decreases with increasing experience (25)nurse’s worry changes over the years (6)

nurse’s worry decreases by gleaning knowledgeliterature (14)nurse’s worry decreases with increasing education (8)

nurse’s worry decreases by means of trainingcises (11)nurse’s worry decreases with the help of clinicalice in other departments (9)

nurse’s worry decreases when he/she talksmeone he/she considers trustworthy (17)nurse’s worry decreases/increases by means ofiefing (7)

nurse’s worry decreases if he/she feelsdence in his/her colleague (10)nurse’s worry decreases if back-up is called in (9)


the most important thing in this job’’. However,worry about some situations increased with experi-ence: ‘‘. . .the more you have learnt through theyears, the more you can do, and the more respon-sibility you take in the ambulance, the more rea-son you have to worry’’. The worry changed overthe years: ‘‘. . .you get more familiar with somethings, but you also realise that you are not goodat everything. Perhaps you were more naive be-fore and thought that everything would work outin one way or the other.’’

Alleviating worry by theoretical meansThe nurses tried to alleviate worry through the-oretical studies: ‘‘. . . I have done the specialisteducation now//education provides knowledgeand knowledge provides security’’. The nursesreflected on how to fill gaps in their knowledgeby means of education: ‘‘. . .you wish that youhad more training in the area of children’’.

Literature studies led to in-depth knowledge:‘‘. . . If you feel insecure you should study the guid-ing principles of this workplace, and if I thinkabout something at home, then I look it up inbooks.’’

Alleviating worry by practical meansThe nurses tried to alleviate worry by improvingtheir clinical practice: ‘‘. . .you take part in asmany exercises and training sessions as possible’’.It was seen as important to do exercises togetherwith other professions: ‘‘. . .practise together withthe fire brigade and so on’’. The nurses practicedat different departments in order to fill gaps intheir knowledge ‘‘. . . I try to go to the deliveryward sometimes//then you are prepared for thatand you gain experience too’’.

Worry is alleviated by healthcareprofessionals and next-of-kin’s actions(Table 3)

Seeking support after the emergency situationThe nurses coped with worry by seeking supportafter a difficult situation: ‘‘. . .you talk about itwith a colleague you have confidence in and feelsecure with’’. They also spoke to persons from out-side the ambulance service: ‘‘We have a lot of con-tact with the hospital chaplains’’ and with next-of-kin: ‘‘my partner works within medicine too, andshe knows what it is like to meet patients . . . itfeels good to talk to someone about it some-times’’. This was not always a positive experience:‘‘It can be difficult to get other people to under-stand. If you tell different people, they find other

aspects more distressing than the ones I findunpleasant’’.

Seeking support in the emergency situationWorry could disappear if the colleague was consid-ered trustworthy: ‘‘If I work together with thesame people as usual, then we know each otherwell. Then you work more as a team. You knoweach other well and know what the other personcan and cannot do.’’ Knowing that one had a com-petent colleague could relieve worry: ‘‘. . .my col-league is a good communicator, so he would haveto deal with that aspect’’. In some situations,back-up was called in to relieve worry: ‘‘I havesent for a midwife in some situations in which Ifelt insecure’’. Contact could also be made byphone: ‘‘. . .you can dial the emergency servicecentre’’.

Discussion

Methodological issues

According to Fridlund (2006), the researcher of aqualitative study needs to reflect on the applicabil-ity, concordance, security and accuracy of thematerial, in order to safeguard the security of thedata collection. Applicability describes how wellthe sample conforms to the purpose of the study.Respondents from three organisations were se-lected from a broad base of age group, specialisteducation and number of years in the profession,in order to obtain a clear picture of the conceptof worry from an ambulance nurse’s perspective.Interviews were chosen as the data collectionmethod, which allowed the respondents to de-scribe their thoughts in more detail with the helpof follow-up questions. The CIT method also makesit possible to collect data via observations, ques-tionnaires and self-reports (Flanagan, 1954). How-ever, these methods would probably not result inthe same breadth of data, since the possibility forreflection would not be available. However, theycould have been used as a complement to theinterviews, thus enhancing the researchers’ under-standing. Concordance describes the validity of thedesign in relation to the purpose. The design wasseen as highly applicable in this kind of study, sincethe purpose was to describe situations the nursesfound meaningful and decisive for their experienceand behaviour. As both the researchers and thenurses were familiar with the environment in whichthe study was conducted, the risk of misunder-standing during the interviews was minimised.


The interviews and transcriptions were carried outby the same person in order to safeguard the secu-rity of the study. The interviews were also readthrough several times before categorizing theminto sub-categories, in order to further improvesecurity. The incidents were analysed accordingto character and content. This step was repeatedseveral times before the end result emerged. Thecategorizing of incidents into sub-categories wasconducted in cooperation with the second re-searcher, experienced both in theory and practice,which minimised the risk of subjectivity (Anderssonand Nilsson, 1964). Direct quotes from the inter-views strengthened the accuracy of the study.

Results issues

Worry related to specific emergency situationsThe nurses worried about specific situations thatcould arise in their profession. Situations thatevoked worry were related to children. Alexanderand Klein (2001) and Regehr et al. (2002) also foundthat situations involving children were a source ofworry for ambulance personnel. The nurses foundit difficult to describe why such calls distressedthem, but a certain amount of external influencewas evident. It could arise from the demandsplaced on the nurses by the parents of the sick orinjured child or from the father in situations involv-ing childbirth. The nurses worried about becomingpersonally involved in situations where they knewthe patient or could associate the case with some-thing in their personal life. According to Alexanderand Klein (2001), this can be very emotionally try-ing. Since most of the nurses in the study workedand lived in the same area, they ran the risk ofbeing exposed to such situations quite frequently.The nurses found the feeling of inadequacy to bea source of worry. It could arise from the insecuritythey experienced at seeing the sick or injured pa-tient with their own eyes. According to Jonssonand Segesten (2004), ambulance personnel can di-vert this type of worry by engaging in an inner dia-logue with themselves by which they preparementally for what they are about to see. The nursesfelt that their worry eased, the more they were ex-posed to emergency situations.

Worry related to the working environmentThe nurses worried in situations where they felt alack of confidence in their colleague or lack of trustfrom their managers. Similar results were obtainedin a study by Van der Ploeg and Kleber (2003). Lackof confidence in close colleagues arose from situa-tions in which the nurse had felt little or no support

when working with that particular person. Notbeing able to trust a colleague is seen as very trying(Alexander and Klein, 2001). The nurses also wor-ried about situations they could not control, themost characteristic being violence or threatsagainst them. The worry in such situations camefrom the fear of being hurt. According to Suserudet al. (2002), threats against ambulance personnelare increasing. They point out that managers needto see the importance of providing self-defencetraining and equipping their personnel withalarms.

Worry is alleviated by one’s own actionsThe nurses believed that worry could be alleviatedthrough more training exercises as well as clinicalpractice in other departments at the hospital.According to Alexander and Klein (2001), it is ofgreat importance that ambulance personnel aregiven the opportunity to do clinical exercises in or-der to prepare themselves for the emotional andexhausting calls that they may have to face. Thenurses reflected on their worry in specific situa-tions and considered it to result in focused energyand a strong ability to take action. Reflection onprevious experiences is a tool for ambulance per-sonnel to mentally prepare for future scenarios(Jonsson and Segesten, 2004). The nurses felt thattheir worry changed over the years. The worryevoked by certain types of situation decreased inline with increasing experience. However, theopposite could also be seen. Situations that werenot worrying initially could become a source ofworry with increasing experience, which was alsopointed out by Alexander and Klein (2001). Theambulance nurses felt that, with increasing experi-ence, came a responsibility to be able to cope withall kinds of situations. This responsibility led toworry in some situations.

Worry is alleviated by healthcare professionalsand next-of-kin’s actionsThe nurses sought support in emergency situationsby calling in back-up, thus reducing their worry.They used trustworthy persons as sparring partnersin order to ventilate their worry. This could takeplace during or after the situation. In order to leavetrying situations behind and move on, it is impor-tant to talk about thoughts, emotions and experi-ences with a trusted person (Jonsson andSegesten, 2004). Most of the time, the ambulancenurses consulted a colleague. Some found debrief-ing a good method for reducing worry. Others,however, claimed that this only served to increasetheir worry.


Conclusions and implications

The study has shown that worry among ambulancenurses can both be related to specific nursing situ-ations and to the working environment. Since worryis a subjective term, experienced in various waysby different people, it is complex and demandsan ambulance service that can offer a broad rangeof methods of support in order to help the nurses todeal with their worry. The study has also revealedthat worry is handled individually or with help fromothers. Nurses need to verbalise practical ways oflearning to tackle their worry and to obtain supportfrom the ambulance organisation in order to do so.There is a need for more in-depth studies of ambu-lance nurses’ experiences of worry. Such studiesshould be based on the actions the nurses find effi-cient for minimising their individual worry. Theseactions should then be included in educationalinterventions and follow-up training for ambulancenurses. One way to facilitate the nurses is to pro-vide them with an opportunity to practise thingsthat are important for reducing their worry in spe-cific situations. Furthermore, ambulance nursespoint out the importance of working with a skilledcolleague. The cooperation with the colleague canboth increase and decrease the worry in some situ-ations. This phenomenon should be studied morein-depth in order to map how the interaction withcolleagues influences the worry among ambulancenurses.

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Experiences of and actions towards worries among ambulance nurses in their professional life: A critical incident study