PERSPECTIVES OF CRITICAL CARE NURSES ON REFUGEES HEALTHCARE IN LEBANON: RELATIONSHIP OF WORK-ENVIRONMENT AND NURSES’ EMOTIONAL EXHAUSTION AND PATIENT QUALITY OF CARE

Abstract

The Syrian war has resulted in a humanitarian crisis since 2011 that forced a significant displacement of over 13 million Syrians, with an estimated 6.6 million displaced internally and 5.5 million fleeing to the neighboring countries namely Lebanon, Jordan, Iraq, and Turkey. The United Nations High Commissioner for Refugees (UNHCR) estimated that Lebanon was a host of 927,638 Syrian refugees by the early 2014, of which 879,907 officially registered within the UNHCR, which counted for 21% of the total population in the country. By the end of 2015, the number of Syrian refugees had reached 1.5 million representing a 30% increase in the Lebanon’s pre-crisis population and ranking as the highest per capita concentration refugees worldwide since 1980. This unprecedented inflow in the number of Syrian refugees with multiple health needs associated with the already severe nursing shortage in their living areas increased demand on the Lebanese healthcare system that threatened the continuity of service delivery without knowing its impact on the perspective of nurses’ delivering the care Purpose: The purpose of this study is to explore the relationship between the psychosocial work environment factors and their impact on nurses’ related outcomes (emotional health) and patient outcomes (implicit rationing of care) among critical care nurses serving Syrian refugees. Sample: In the original study, a convenience sample of 3,300 nurses who worked in acute care hospitals and primary healthcare centers was used. The inclusion criteria included full time registered nurses who were involved in direct patient care in hosting communities for at least one full year. Exclusion criteria included registered nurses who were in academia and other industries, other professionals working in healthcare (nutritionists, physiotherapists, social workers) nursing students, nursing instructors, and volunteers and registered nurses who assumed managerial and administrative positions and those involved in indirect service. For the purpose of this study, only Lebanese nurses working in critical care areas were selected. The sample consisted of 372 critical care nurses serving in private and public hospitals. Ethical Considerations: Before conducting the original study, the researchers obtained approval from the AUB Social and Behavioral Sciences Institutional Review Board (IRB). Prior to distributing the questionnaires to the nurses of the participating hospitals and primary healthcare centers, the approval to conduct the study was granted from the ethical committees or administration of the participating hospitals and the Primary Healthcare Department of the Lebanese Ministry of Public Health. Instruments: In addition to the nurses’ socio-demographic and work-related questions, six other instruments were used to determine and measure the various work environment factors among critical care nurses and its effect on emotional exhaustion as a nurse-related outcome, and implicit rationing of care as a patient-related outcome. The questionnaires used are Health Professions Stress Inventory (HPSI), NASA Task Load Index (NASA-TLX) scale, Practice Environment Scale of the Nursing Work Index (PES-NWI) questionnaire, the 14-item Resilience Scale, Maslach Burnout Inventory, and the BERNCA scale. Methods: Descriptive statistics were used to determine the characteristics of the study sample along with perceived psychosocial work environment factors (means, standard deviations, frequency, and percentage tables). All questions with a Likert scale were presented as categories as well as average scores. Total scores were then calculated based on each domain. We used Kendal Tau-B correlations and linear regression to explore associations between emotional exhaustion (nurses-related outcome) and the psychosocial work-environment variables. Logistic regression was used to explore associations between implicit rationing of care with the different work environment factors such as workload, work stressors, nursing resources, leadership, and resilience. Results: The results revealed that the critical care Nurses in Lebanese private and public hospitals experienced an above-average workload and average work stressors level. The critical care Nurses reported adequate leadership support from their managers during hectic shifts while suffering from shortage in nursing staff. Moreover, nurses reported high resilience and emotional exhaustion scores. The Kendal Tau-B showed a positive significant correlation between emotional exhaustion, workload, and work stressors, and a negative significant correlation between emotional exhaustion, leadership, teamwork, and resilience scores. Moreover, the multiple logistics regression showed that the higher the emotional exhaustion the more critical care nurses rationed care specifically preparing the nursing care plans and the paperwork. Conclusion: We conclude that critical care nurses experienced shortage of staff, high workload, and work stressors levels that are significantly associated with high emotional exhaustion and rationing of care levels in Lebanese private and public hospitals serving Syrian Refugees during the economic crisis. It was controversial how the critical care nurses reported adequate leadership while their administrators were not able to recruit enough staff. In addition, one of the controversial results is the critical nurses high resilience levels at the same time reporting high emotional exhaustion levels, which can be due to a cultural interpretation of nurses’ accepting workload or a misconception about resilience.