The Beat Goes On: Emergency Nurses' Song of Resilience.

Since the beginning of the COVID-19 pandemic, emergency nurses have been on the frontlines. Not only were emergency nurses caring for patients with physical symptoms, they were also confronted by anxiety, depression, stress, and uncertainty in patients, peers, and themselves. Even as nurses cared for patients seeking their help, they were dealing with their own struggles as members of the larger community and the organization. The purpose of this study was to examine emergency nurses' resiliency and to provide nurse leaders a different lens for viewing resilience. Five interconnected elements surfaced through direct observations with live environmental music therapy, focus groups, and essays with emergency room nurses. Fostering the elements of emergency nurses' song of resilience: harmony, melody, rhythm, silence/rest, and beingness may enhance individual, team, and organizational performance. Nurse leaders can support resiliency and promote healthy work environments by perceiving resilience creatively and through reflection. 2022 by Elsevier Inc. All rights reserved.

There are 5 interconnected elements of resiliency: harmony, melody, rhythm, silence/rest, and beingness.

Emergency nurses’ song of resilience may support the work environment, organization, and patients seeking care.

Nurse leaders can build on their understanding of resiliency and cultivate healthy work environments.

To understand emergency nurses’ song of resilience, it is necessary to understand the unique nature of nurses’ experience. Emergency departments are inherently stressful, and emergency nurses are likely to experience the kind of stress that erodes resilience. Emergency nurses’ work is emotional labor, oversaturated with chaos, drama, and trauma in the best of times. In the context of the COVID-19 pandemic, the question of how emergency nurses found and held onto their resilience was a priority for nurse leaders because resilience is a significant protection against stress. ,

Background, Problem, and Purpose

Nurse leaders are constantly trying to ensure safe patient care even when resources are scarce. If not done well, efforts can leave nurses to feel emotionally and cognitively exploited. , Resilience becomes an essential pursuit because if it is missing, nurses can become overwhelmed, and cascading failures in patient care can follow.

This study provides nurse leaders with a different lens in which to view resilience. The purpose of this project was to listen to emergency nurses, to learn more about their lived experiences, and to discover what elements of resilience are important and necessary for them. Nurses in the emergency department experience and are exposed to chaos, drama, and trauma. Nurse leaders can support staff by strengthening, not hindering, the different elements of resiliency. By shifting focus to supporting the interrelated elements of resiliency presented here, nurse leaders can empower emergency nurses to be aware of their own song of resilience.

Literature Synthesis

Even before the COVID-19 pandemic, it was recognized that nurses provide the best care to patients when they are working at the peak of their own wellness. Yet, the literature suggests the workplace generates many stressors and worries for emergency nurses via heavy workloads, increased patient acuity, time pressures, and poor allocation of resources. , These stressors and worries must be mitigated, because nurses’ wellbeing directly impacts patients’ experience and health. , Both of which can impact the financial sustainability of health care organizations by way of value-based purchasing, recruitment, retention, and engagement of nurses. , , Despite this realization, there is little research on emergency nurses’ resiliency during a pandemic, a time during which stressors and worries are heightened.

Scholarly literature offers correlations between resiliency and both negative and positive outcomes for patients, team members, and organizations. , 4, 5, 6 Resilience is supported or hindered by individuals and organizations, with hindrances typically compounded by stressors and worries. Some authors have gone so far to position the pursuit of resilience as an ethical obligation.

Project Summary

Methods

Researchers used a qualitative research methodology to explore and understand the unique nature of emergency nurses’ experience. Prior to conducting the study, institutional review board approval was obtained from the organization. Ten emergency nurses were active participants, recruited through an e-mail invitation that explained the purpose of the study. Once participants responded through email, they were informed about the date, time, and location of focus groups and facilitated essays. Twelve 1-hour direct observations with live environmental music therapy were conducted across the shifts in an emergency department, located within an inner-city not-for-profit hospital, averaging more than 30,000 emergency visits annually. Data were collected from these methods over the course of 3 months, during a COVID-19 surge. Direct observations included emergency nurses as they interacted, communicated, and cared for patients. Researchers completed reflective journal entries during observations. These entries were analyzed along with the focus group transcription and essays, using Paul Ricoeur’s hermeneutic interpretive circle. This work resulted in an Excel spreadsheet where the text was divided, redivided, aligned, and realigned via a dialectal and iterative process. This process led to the emergence of patterns, subthemes, and main themes that eventually resulted in the categorizing of elements that compose emergency nurses’ resilience.

The patterns that surfaced from the data analysis of reflective observations of live environmental music therapy, focus groups, and essays allowed researchers to witness emergency nurses’ complex and varying processes of their work and resilience as a musical composition. Life in the emergency room is like a concert, a constant “show time,” being there are no rehearsals or re-dos. Every action or inaction is part of the performance in this high-stakes environment. Every person’s voice and part must come together to render high-quality care. As emergency nurses engaged in live environmental music therapy, focus groups, and essays, it became clear that these activities were actions supporting elements of resiliency by allowing nurses the opportunity to affirm each other, share experiences, be heard, and reflect on how they found and sustained resilience.

Analysis of these methods revealed tools of resilience that emergency nurses utilized during the pandemic. It was revealed that these tools impacted the quality of the elements of resilience. Researchers discovered that these tools related to a reflection of the themes within Christine Stevens’ Hoop of Harmony model and process. Stevens’ model is a “picture of wholeness and a path to personal healing.” (p.16) The Hoop of Harmony and data analysis inspired a new perception of emergency nurses’ resilience, that the researchers coined, Nurses’ Song of Resilience (Figure 1 ).

Figure 1

The Song of Resilience

Elements of Emergency Nurses’ Song of Resilience

Ricoeur’s analysis included critical interpretation and discussion, eventually leading researchers to explore the integration of music theory and philosophy with the nurses responses. Five interconnected elements for resilience emerged from the data: harmony, melody, rhythm, silence/rest, and beingness. Each element theme corresponded with an inventory of specific tools of resilience for nurses. The quality of the 5 elements hindered or nourished emergency room nurses’ experiences of resiliency and are described below.

Harmony—the successful combining of the internal and external world, and was supported or hindered by factors outside of the individual nurse. That is, harmony developed or ebbed and flowed in response to the organization’s communication, allocation of resources, and information bombardment from the external world. At the core, harmony was sense-making. “I would make sure I stayed aware. I watched the numbers. I looked at numbers at different places and tried to put it into perspective. Our more is less than it was in New York. They had 1000s and 1000s a day coming in, and we were having hundreds…I just had to put it into perspective and put it in an overall picture.”

Melody—spoke to pleasant succession, and rose up from socialization and emotions. Melody was derived from shared stories and experiences, as well as emotional and social engagement among emergency room team members. Emergency nurses’ possessed a unique social culture and dynamic, at times feeling or being misunderstood by others. Often things came up that only ‘they could understand’. Emotional engagement and honest communications with self and team members was important. When emergency nurses faced challenges, they used laughter, humor, and offloading to colleagues as essential coping strategies. These activities proved an essential component of resiliency, as conveyed in statements like “…it is easier for us as a group to get by. We are all going through the same thing together. We know how it is. I have stuff to work out, you have stuff to work out in your personal and professional life. Here, we all know exactly what it is like. So, it is easier to talk about it and laugh about it. We can relate better to each other…”

Rhythm—surfaced from acquired experience, systematic arrangement of policies and procedures, and the comfort of consistent routine. Rhythm came into existence with practice, adaptive anticipation, time awareness, and knowing what to expect. Beginnings and change proved challenging. Experience contributed to flexibility and practice when the standard processes and procedures were absent or incomplete. Often, the word rhythm was cited by nurses as an important element in their perception of their work. “In the beginning, it was so unorganized. The policy kept changing every day or every couple of hours. It was so confusing. Every day you are asking, is this what we are doing? No, we don’t do that anymore. So now, we are in the rhythm. We know everybody is on the same page. It’s way better now. In the beginning, it was just pandemonium. You didn’t know what to wear…you didn’t know what mask. Are we re-using them or are we not? So, now it is like, now this is how we are doing it. It comes down to practice and then just…and kind of setting the policy in stone….and then everybody being aware of the policy.”

Silence/Rest—was reflection, and emerged from breaks, respite, self-talk, and reflective practices. Emergency nurses demonstrated that clear and insightful thinking often happened in response to silence/rest. “I do think about what I could do differently to kind of prepare myself for the next PUI [patient under investigation]. Now we know what to get. I thought about that on my way home…. When you come out of the room, you are just going on to the next person, but then later on, you might kind of reflect and think differently about how it's going…it can make things go smoother next time. It’s just a PUI now and it is not as big of a deal as it used to be.”

Beingness—the place where the elements merge or the zone. Nurses are a whole being, not only a nurse. But identifying as an ER nurse was found important in meaning-making and purpose building in life. It was summarized best by “I am an ER nurse” or “We are ER nurses.”

How Did Emergency Nurses Discover Their Resiliency?

Harmony refers to how messages were perceived, same or different, complementary, or contradictory. Communication and allocation of resources were crucial components, grounded in the need for “everyone in the ensemble to sing off the same sheet of music.” Nurses continued to move in and out of society and were exposed to contradictory perceptions about what was happening or what was going to happen from the organization, community, nation, and across the world. When messages from the external world and the organization were dissimilar, uncertainty was heightened, and what nurses experienced as nonsensical hindered resiliency. Discord accentuated fears, as emergency nurses were faced with staffing issues and scarce resources (i.e., personal protective equipment [PPE] and time). Conversely when the words, actions, and behaviors of senior leaders aligned with expectations, nurses could attach meaning and pursue goals without hesitancy. Harmony was achieved when emergency nurses were able to make sense out of the information coming to them.

In an emergency nurses’ life, as in music, melody surfaced to be an essential component. In songs, the melody relays emotional narratives to the listeners while sharing the story of the writer. Melodies are the catchy tunes that can stick with a person for a lifetime. Melody was disrupted when emergency nurses felt isolated. Yet, feeling isolation was prevalent during the COVID-19 pandemic. For example, nurses carried out care tasks covered in PPE in exam rooms without the aid of fellow team members, due to fear of unnecessary exposure. Melody became disjointed in the context of worry, concern, uncertainty, unsettled disagreements, and most notably heightened concern for peers and family. The essence of melody was created when emergency nurses were in harmony with peers and completing tasks together, though the crux was found in social/emotional expressions, speaking their needs, and honest communication with themselves and each other. Melody rose up from socialization among peers. Social support, shared stories, and emotional experiences acted as connectors.

The emergency department is a fast-paced environment, and rhythm was a word that stood out from both the focus groups and essays from the beginning. Emergency nurses frequently shared that they were trying “to find” or had “recently re-discovered” their rhythm. The pursuit of rhythm was disrupted by constantly changing policies and procedures, and exacerbated by fears of staffing issues and scarce resources, real and anticipated. Whether off-beat or in the “groove,” within the emergency department, “the beat goes on.” At times, it surfaced that nurses looked to their peers to help them get back on track with the tempo. When nurses felt they miss-stepped they looked to others. Rhythm was conveyed as a contagious and connective element. This rhythm, as emergency nurses described it, seemed to center on the desire to reasonably anticipate what was needed. To achieve rhythm, emergency nurses had to experiment with new ways of doing things and practice, or repeat the pattern, until they felt comfortable.

When emergency nurses took time to reflect, they were able to make comparisons and find the ‘good’ in their situation. Silence/rest surfaced as a significant element of resiliency. As in music, silence/rest is necessary to create patterns, it gives balance and aesthetics to the sounds. Without silence, music would be noise. Nurses often shared about their self-talk, such as “it’s going to work out fine” or “we are going to make it through.” Emergency nurses made evident through the varied methods of this research project, that they found practical insights regarding their lived experience through silence/rest practices. Silence during and after a song can create a profound impact by giving a moment of integration of the experience of the music. Emergency nurses practiced silence/rest in a variety of ways: a few breaths between patient encounters, reflective thought on the way home, and/or retreating to the safety and support of family.

Beingness is the awareness of the person. The awareness of who is doing the creating or working. Some call it “the zone.” It’s the state of existence and inspires purpose and meaning-making. It fuels the ability to listen or play music, and to work in the emergency department. Because beingness is in part, self-awareness, to feel connection to this can strengthen and support the sense of wellness and belonging to life and work. And in turn, their resilience. At the same time, beingness is not a destination, but is fluid, allowing movement for change and adaptation of the facets that compose a person. It is the place where emergency nurses seemed to accept all parts of themselves and find balance in their experience. Beingness is summarized best by nurses’ assertions “I am an ER nurse” or “We are ER nurses.” When they identify with this part of their beingness in an accepting, positive, and proud way, it connects them to a group, to a purpose, and it is meaningful to them.

Application of the Findings to Practice

Broadly, this study aimed to yield generalizable knowledge about the resiliency of emergency nurses during crisis. Insight was gained from the voices of nurses and contributes to the body of evidence on resilience. Additionally, the outcomes validate much of the scholarly literature today and adds the benefit of a new practical and philosophical lens for viewing how nurse leaders might make a difference. Understanding and reflecting on the nurses’ song of resilience may support the work environment, organization, and patients seeking care.

This study revealed that the song of resiliency for each person is unique. At the same time, there are elements that emergency nurses share. Respect for the individual’s voice, while supporting the group collective voice, can enhance the production of emergency nursing.

Researchers recognize the generalizability of this study’s outcomes may be limited to the single-site study and the small sample size (N = 10). It’s hoped that the results of this study may inspire continued advancement in the area of resiliency for nurses.

Implications for Nursing Leaders

Nurse leaders can use this model to perceive emergency nurses’ resilience and build on their understanding of resiliency and cultivate healthy work environments. This understanding may be useful in problem-solving scenarios. If nurse leaders are aware of emergency nurses’ song of resiliency elements, they have a creative way to view, discuss, and listen.

Nurse leaders may also use this model to perceive their own lives and work. To be able to care for others is reflective of the care we give ourselves. Although it is more common for caregivers to see outside of themselves and try to help others, understanding this model on a personal level may help nurse leaders make their own song audible, as well as deepen the understanding and compassion for the emergency nurses’ that leaders lead.

When leaders and team members are aware of their own songs and listen to others, the relationship can be strengthened by sharing more harmonious and enjoyable moments together. Every person holds some responsibility to be aware of and explore their own unique journey of resilience. This Song of Resilience model may assist uncovering the beautiful and inspiring music of life and work.