RESEARCH
EMERGENCY NURSES’ PERSPECTIVES: FACTORS
AFFECTING CARING
Authors: Carol L. Enns, MN, RN, and Jo-Ann V. Sawatzky, PhD, RN, Winnipeg, Manitoba, Canada
Earn Up to 9.5 CE Hours. See page 291.
Introduction: Caring is a universal phenomenon. However, as
a result of higher patient acuity and staff shortages within the
chaotic ED environment, caring behaviors may be in peril. The
purpose of this study was to gain insight into the meaning of
caring from the perspective of emergency nurses. Exploring
nurses’ perspectives of caring is central to improving staffing
and retention issues in this unique work environment.
Methods: As part of a larger study, a subsample of emergency
nurses who work in public hospitals in Manitoba, Canada (n =
17) were interviewed. A qualitative descriptive design was
used to gain insight into the caring perspectives of nurses by
asking them, “What does caring meaning to you?” and “What
affects caring in your practice in the emergency department?”
Emerging themes were extracted through analysis of audio
tapes and transcripts.
aring is a universal nursing phenomenon. It is
C understood and accepted as a fundamental value in
nursing as both a discipline of knowledge and as a
professional practice. 1 Nursing scholars contend that caring
is the essence of nursing practice. Theorists agree that
caring is central to the nursing role and have defined caring
as a characteristic of nursing. 2–4 Certainly, nurses in
practice view caring as relevant to their role. However,
despite the vast amount of research and theoretical
development with regard to caring, the meaning of caring
Carol L. Enns is Senior Instructor, Faculty of Health Sciences–College of
Nursing, University of Manitoba, Winnipeg, Manitoba, Canada.
Jo-Ann V. Sawatzky is Associate Professor, Faculty of Health Sciences–
College of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada.
Funded by the Dr. Paul H.T. Thorlakson Foundation Fund, Winnipeg,
Manitoba, Canada.
For correspondence, write: Carol L. Enns, MN, RN, 277 Helen Glass
Centre for Nursing, University of Manitoba, Winnipeg, MB, Canada R3T
2N2; E-mail: carol.enns@umanitoba.ca.
J Emerg Nurs 2016;42:240-5.
Available online 10 February 2016
0099-1767
Copyright © 2016 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2015.12.003
240 JOURNAL OF EMERGENCY NURSING
Results: Advocacy and holistic care emerged as major themes
in the meaning of caring for emergency nurses. Caring was
affected by a number of factors, including workload, lack of
time, staffing issues, shift work, and lack of self-care. However,
lack of management support was the most consistent hindrance
to caring identified by study participants.
Discussion: Caring continues to be a unifying concept in
nursing; however, influencing factors continue to undermine
caring for emergency nurses. Caring is not subsidiary to nursing;
it is the central core of nursing. Therefore, fostering a caring
working environment is essential for nurses to practice holistic
nursing care. It is also imperative to job satisfaction and the
retention of emergency nurses.
Key words: Caring; Emergency nurses; Work environment
has not been clearly established. Moreover, caring is
inferred to be context specific. 5
The emergency department is a unique nursing work
environment. Factors such as the unpredictable nature of the
department, increasing patient-to-nurse ratios, overcrowd-
ing, and high staff turnover rates contribute to this highly
stressful contemporary work environment. 6 These factors
may also influence ED nurses’ perception of caring and the
ability to care. Although the meaning of caring has been
explored in many areas of nursing, there is a dearth of
literature specifically related to the perspectives of emergency
nurses with regard to caring. Therefore, it was imperative to
investigate the meaning of caring and the factors that affect
caring from the emergency nurse’s point of view.
Diverse theories of caring have fueled an ongoing
debate among nursing theorists and researchers regarding its
definition. As well, despite use of a variety of empirical
methods to quantify the concept of caring, the results have
been inconsistent. 7,8 However, the instruments used in
these studies have attempted to define and measure different
aspects of caring through the use of predetermined
assessment scales. Whereas quantitative research has
contributed to the body of evidence related to caring,
qualitative research has also provided important contribu-
tions to our understanding of this concept. For example, in
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a study that explored the meaning of caring among hospital
night nurses in Sweden, advocacy for patients and their
relatives emerged as a major theme. 9 In another study,
based on the content analysis of videotaped episodes in an
emergency department, the researchers described the caring
nurse as open and perceptive, morally responsible, truly
present, and genuinely concerned for the patient. 10
However, instrumental behavior, defined as emotionally
detached but not insensitive care, predominated among the
participants. Finally, Burhans and Alligood 11 used a
phenomenological approach to explore the perceptions of
medical and surgical nurses in the United States. Their
essential themes revealed that human needs must be met
through caring, empathy, and respectful interactions
between nurses and patients.
Factors affecting the ability to care have also been
explored. In a qualitative study of surgical nurses, Enns and
Gregory 12 found that factors affecting caring included lack
of time, lack of caring support, tasking, increased acuity,
increased workload, lack of resources, lack of continuity of
care, emotional divestment, not caring for each other, and a
lack of peer support. Qualitative descriptive studies have
been conducted to explore caring within specialized areas of
nursing practice, including intensive care and psychiatric
units. 13,14 However, few studies have explored caring in the
emergency department. 10,15
To date, the issue of discontent related to the inability
to enact caring in the workplace persists because of staff
shortages, lack of time, and workload issues. 8,12,16,17 As a
result of the higher acuity of patients and nursing shortages
and the chaotic work environment of the emergency
department, caring behaviors may be in peril. The ability of
the nurses to “care” may affect how they view their work
environment and their own personal expressions of caring.
Therefore, exploring the meaning of caring and the factors
that affect caring for emergency nurses will facilitate the
development of strategies to uphold the essence of caring in
this work environment.
Methods
As part of a larger study described elsewhere, 18 a qualitative
descriptive design was used to gain insight into the caring
perspectives of emergency nurses.
PROTECTION OF HUMAN SUBJECTS
Ethical approval for this research was granted through a
university-based research ethical review board. The regula-
tory body mailed written descriptions of the study, a copy of
the quantitative survey, and invitations to participate in
face-to-face interviews to all ED nurses within the province.
May 2016 VOLUME 42 • ISSUE 3
Enns and Sawatzky/RESEARCH
Procedures included the assurance of participant confiden-
tiality, including the use of assigned numbers. Specific
interview consent forms were signed by participants prior to
the interviews.
SAMPLE
Invitations to participate in this study were mailed to all ED
nurses in the province of Manitoba, Canada, by the
provincial nurses’ regulatory body. A convenience sample of
registered nurses (n = 17) was selected from an overwhelm-
ingly positive response to the request for volunteers to
participate in the interviews (44%; n = 114). The sample
included emergency nurses and educators who worked in
urban (n = 11) and rural (n = 6) facilities. Saturation was
achieved after completion of the 17 interviews.
DATA COLLECTION
Data were collected through tape-recorded face-to-face
interviews with individual participants; each interview was
approximately 60 to 90 minutes in duration. Interviews
were conducted between January and April 2010. The
principle researcher conducted each interview using the
person-centered interview approach. Participants were
asked to respond, in their own words, to the following
questions:
1.What does caring mean to you?
2.What affects caring in your practice in the emergency
department?
DATA ANALYSIS
The tape-recorded interviews were transcribed verbatim.
Based on the work of Lincoln and Guba, 19 credibility,
dependability, confirmability, and transferability were
established to discern rigor and accurately represent
participants’ experiences. Listening to the audio tapes
(confirmability) assisted in validating the content of the
interviews and corrected any discursive speech. Confirm-
ability was also enhanced by recording notes during and
after the interviews to identify essential structures to support
the findings, which helped enlighten the researchers with
regard to the topic of interest as each interview was
conducted and analyzed. Dependability was supported
through examination of the context of the findings, as well
as how each interview contributed to the overall findings.
Finally, transferability was established with rich descriptions
that could be applied in other contexts by other researchers.
Data collection and content analysis were performed
concurrently. The primary researcher listened to the tape
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recordings and reviewed the notes after the interview. The
researcher (CE) conducted the interviews and initial data
analysis to maintain the credibility of the study. Each
transcript was read several times by both researchers, and
notes were formulated. Through discussion, themes and
subthemes about the perspectives of caring and factors that
affect caring in the emergency department were established.
Results
The study participants (n = 17) ranged in age from 26 to 61
years, with a mean age of 40 years. Work experience ranged
from 3 to 37 years in the nursing profession and from 2 to
36 years in the emergency department. Ten participants had
earned a diploma, and 7 had completed a baccalaureate
degree; 12 were female and 5 were male. Data from the
interviews revealed several themes related to expressions of
caring and factors affecting ability to care. No differences in
the thematic analysis were noted based on the demographic
or educational background of the participants.
THEMES
The Meaning of Caring: Emergency Nurses’ Perspectives
Two major themes emerged from the nurses’ stories: patient
advocacy and holistic care, including care for the patient and
family. Although the meaning of “caring” is often described
in the literature as an indefinable concept, the participants
shared what caring meant to them:
“…caring is being an advocate right now for patients
because they are getting so lost in the system. It is
helping them to get organized as they see so many
different specialists all the time and they don’t have
anyone that is their home person….”
“Caring as a nurse…is taking care of my clients
physically, emotionally, while maintaining the best care
possible—being their advocate and being very holis-
tic….”
In the emergency department, patients are assessed and
cared for by nurses for a brief snapshot in time. Within this
contemporary health care environment, the nurses
expressed concern that patients were “lost in the system.”
The participants expressed the importance of attempting to
provide “whole” care for patients and their families, looking
after all their needs within a specific time frame and in an
often chaotic work environment. These nurses also
242 JOURNAL OF EMERGENCY NURSING
lamented how important it was for them to feel as though
they had provided “good” care.
Nursing Work Environment: Factors Affecting Caring
Participants identified factors affecting caring, including the
workload, lack of time, staffing issues, lack of management
support, shift work, and lack of self-care. The nurses shared the
following elements that contributed to their inability to provide
care for patients and their families in the emergency department.
The Workload. All participants painted a vivid picture of
the work environment. They described a chaotic, fast-paced
arena where they frequently endured difficult situations in
which a heavy workload affected their “caring” capacity:
“Definitely it’s the workload, the assignments, the nurse
to patient ratio…it’s the constant battle of priorities.”
“…a lot of days you are there…you might be in the
middle of triaging a patient who needs some education
but then some traumas come in….”
The unique culture and context of the workload in the
emergency department was shared by all the participants.
These emergency nurses conveyed feelings of displeasure in an
environment where they are constantly being “pulled” in
many directions.
Lack of Time. Participants described the lack of time
spent with patients in the emergency department. They
voiced concern that there was never enough time to address
patients’ needs adequately, particularly during busy times:
“Sometimes you can just provide very minimal care and
sometimes not even that. That’s really hard to deal with
because of the volume…that’s huge in caring for the
new patients coming in.”
“There is not proper follow-up for patients…they’re
discharged so quickly, they don’t get patient education….”
Participants noted that within the context of the
emergency environment, patients are “revolving” through
the doors of the department at an ever faster pace. They felt
that the norm was “minimal” care for patients in their
department. The participants expressed feelings of guilt
because they did not have the time to provide quality care.
Staffing Issues. Participants commented on staffing
issues, which included staff shortages and concern about
VOLUME 42 • ISSUE 3 May 2016

working with an increasing number of inexperienced
junior staff. They shared examples of how these factors
affected their ability to provide optimal nursing care, as
well as their own self-care:
“It’s a time factor; they (junior staff) don’t want to put
in the time. I am finding the younger generation, they
want to work part time, make enough to live their
lifestyle…they see it as more of a job, it’s not something
that you work towards…there are no more emergency
nurses. When I started in emergency, you developed as
an emergency nurse. Now it’s like a stepping stone to
go somewhere.”
Participants from both urban and rural institutions
agreed that staff shortages were common. All participants
reportedly worked overtime and extra shifts as a result of
theses shortages. The more senior nurses noted that an
increasing number of junior staff were working in the
emergency department and that the generational differences
were creating feelings of discontent among the staff. The
senior nurses resented the younger generation for not being
interested in working full time or developing professionally
as emergency nurses. Many of the participants felt strongly
that the unpredictable nature of the emergency department
and the skills required to work there make it a poor work
environment for newly graduated nurses.
Lack of Management Support. In order to care, all
participants overwhelmingly described the need to feel
supported and listened to by management. This under-
lying theme was the most pervasive among the partici-
pants.
“Currently our manager has been very supportive of
nursing, which helps because it makes us feel
validated…we have not felt validated for a long time.”
“I’m not saying we have bad managers…sometimes I
think the focus is so far removed from what we do that
it’s hard for them to see. Our statistics are amazing…
but we’re trying to tell our managers that we’re not
providing the best care.”
The participants articulated at length about the lack of
support received from management and how this affected
their ability to care for their patients. It was clear that the
nurses wanted a manager who would listen to their
work-related issues and ideas. They yearned for a manager
who “validated” their concerns. Participants also believed
May 2016 VOLUME 42 • ISSUE 3
Enns and Sawatzky/RESEARCH
that it was important for a manager to be visible on the unit
and to assist with patient care decisions.
Shift Work. Although shift work is the norm in
nursing, the participants shared the uniqueness of the
emergency department in relation to caring and shift
work. The “mandated overtime,” which requires nurses to
work hours beyond their scheduled shifts and occurs as a
result of staff shortages, was clearly articulated by the
participants as a barrier to care:
“It might be your third or fourth 12-hour day…you
have had some busy shifts and you have been working
overtime…let’s say someone comes in you are just
doing the basics for them…you’re trying to be friendly,
considerate, but you are so tired…you have nothing left
to give…you just kind of go through the motions.”
The nurses all believed that given the context of the
environment, “mandatory overtime” is unrealistic and
unhealthy. Although the participants were mixed in their
preference of either 8- or 12-hour work days, their major
issue was being forced to work beyond scheduled shift times.
Lack of Self-Care. Participants described the impor-
tance of staying healthy and acknowledged that self-care is
required in order to care effectively for others. Many of the
participants expressed concern for their own health, as
well as the general health and well-being of their peers:
“…you feel like you can’t even take care of yourself; you
know, like making sure you eat and you drink
properly.”
“…you don’t feel like you’ve done a good job for your
patient physically, mentally, emotionally and even for
yourself…this is not the nurse that you wanted to be.”
In order for these nurses to care for others, they realized
the importance of caring for themselves. The increase in
patient acuity, high patient turnover, and staffing issues
were directly affecting their ability to provide optimal care
for patients and their families.
Discussion
The emergency nurses who participated in this study were
very grateful for the opportunity to share their insights
about caring in the work environment. The information
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RESEARCH/Enns and Sawatzky
elicited from this qualitative inquiry offers a distinct lens
into the personal perspectives of nurses. Although findings
from person-centered interviews are subject to various
interpretations, the central themes were easily identified and
extracted. These themes were congruent among the
participants interviewed, as well as with previous research.
The major elements relating to the meaning of caring
for the participants included advocacy and holism. These
findings are consistent with a previous study of emergency
nurses. 10 However, the nurses in our study also spoke of the
challenges in the work environment that affected their
ability to provide care. The nurses shared their interpreta-
tions of the meaning of caring, which included caring for
the “whole” patient and acting as an advocate. Although the
participants embraced the concept of caring in their
practice, they expressed displeasure and discontent between
the ideal and the reality in their workplaces.
Several key factors hindered the participants’ ability to
provide optimal care in the emergency department. Our
findings are consistent with a study in which surgical nurses
reported similar factors (ie, lack of time, lack of caring
support, tasking, increased acuity, lack of continuity of care,
emotional divestment, and not caring for each other) that
impeded their ability to care. 12 However, in our study, the
participants repeatedly stressed that the lack of support from
managers was a major hindrance in their ability to care for
patients. As well, the nurses discussed validation within the
context of “not being listened to” by management.
Participants felt disconnected from managers within the
work environment. Consequently, the participants were
unable to truly care for their patients.
The overwhelming response rate of volunteers for the
interview was congruent with a similar study 12 and affirms
that these nurses want and need to be heard. Emergency
nurses need to have the opportunity to voice concerns about
their inability to provide “good care” in the chaotic ED work
environment. Their voices lend support for previous research
evidence that the high patient ratios and high acuity in the
emergency department, as well as the increase in junior and
inexperienced staff, contribute to poor job satisfaction, higher
levels of burnout, and higher turnover rates. 20
The persistent theme of heavy workload/lack of time to
provide optimal care is also supported by previous
research. 15,21 A Canadian study of nurses on medical and
surgical units found that discontent was present among
nurses because of an imbalance between effort and reward in
their work. 21 Similar to our study, workload and
understaffing dominated the narratives, linking high patient
acuity to the inadequacy of patient care. Although the
nurses in our study enjoyed the challenge of the unique
workplace, including the drama and excitement of the
244 JOURNAL OF EMERGENCY NURSING
emergency department, they were frustrated by the
perceived deficiencies in their ability to care.
In summary, the 6 subthemes of heavy workload, lack
of time, staffing issues, lack of management support, shift
work, and lack of self-care were identified as factors affecting
caring. These findings may be used to inform practice and
improve the work milieu for emergency nurses. The lack of
management support was particularly evident in this study.
Managers must be encouraged to develop strategies to create a
supportive work environment that facilitates nurses’ caring
perspective. As well, it is important for managers to increase
their visibility and engagement with their staff. Although the
nurses we interviewed lamented a loss of caring, most did not
intend to leave their positions. Therefore, frontline nurses need
to be supported to ensure they can perform their roles to the
very best of their ability. Creating a culture of caring that is
supported by the organizational and management perspective
will truly enhance the nursing work experience. Moreover,
further research is needed to explore the relationship between
organizational factors and perceptions of caring.
Limitations
The findings are limited to the participants interviewed and
to their personal experiences. Nonetheless, the rich
descriptions of caring and the factors affecting caring that
emerged from the interviews provided insight into the
meaning of caring for emergency nurses.
Implications for Emergency Nurses
There is a need for ED managers to develop innovative
strategies that will support an environment where nurses are
able to truly care for their patients. Emergency nurses must
also be supported in their need for “a voice.” Management
that validates the expressions of concern from nurses will
foster a positive working environment. Nurse managers
need to develop strategies to support a work environment
that supports nurses’ caring perspectives while also
increasing their visibility and engagement with staff.
Although the participants lamented a loss of caring, most
did not intend to leave their positions in the emergency
department. Therefore, frontline nurses need support in
order to ensure they can perform their roles to the very best
of their ability. It is also important for clinical nurses to
continue to advocate for strategies that will have a positive
impact on their ability to care. Creating a culture of caring
that is supported by an organizational and management
perspective will truly enhance the work experience. It will
VOLUME 42 • ISSUE 3 May 2016

reduce physical and emotional burnout and increase job
satisfaction, which in turn will have an overall favorable
impact on the retention of emergency nurses.
Conclusion
Nurse scholars continue to endorse the elusive concept of
caring as universal and integral to nursing practice. When
asked, “What does caring mean to you?” participants
described their own perceptions and personal meanings of
caring. Advocacy and holistic care were central themes in
their descriptions of caring. The factors that affected their
ability to care undermined their nursing practice and
affected their job satisfaction. Because of the increase in
acuity and complexity of our patients, the nursing shortage,
and an aging population of nurses, it is particularly critical
today to acknowledge the importance of caring perspectives
and identify factors that enhance or deter nurses’ ability to
care. Caring is central to nursing, and nurses still believe it is
integral to their work.
Acknowledgments
We thank the participants for their willingness to share
their experiences in the interviews, as well the College of
Registered Nurses of Manitoba for administrative support
in this study.
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