Articulating Uncertainty: Opportunities for Nursing Practice within the Ontology of Anxiety

1. RCN International Research Conference Edinburgh 2016 Articulating Uncertainty: Opportunities for Nursing Practice within the Ontology of Anxiety John McKinnon University of Lincoln UK

2. Defining Anxiety A future focused emotion associated with anticipatory hyper-vigilance in the face of uncertainty. McKinnon (2016:108)

3. Distinguishing Anxiety from Fear(Sylvers et al,2011; Meeton et al, 2012) • Temporal Focus • Hyper-vigilance in place of “Flight or Fight”. • Increased perfusion of left rather than right frontal lobe • Faciliated by stria terminalis rather than amygdaloid process. • Increased rather than reduced sensitivity to external stimuli

4. Research Questions • What are the dynamics of anxiety within nursing ontology? • What is the value of anxiety to nursing practice?

5. Methodology • Part of a larger study into the commonality of emotion in nursing practice • A purposive sample of 33 nurses talked exhaustively about the emotions they experienced in practice and the roots of those emotions. • Interviews audio-taped, transcribed verbatim and anonymised • Data was analysed using a grounded theory approach until saturation was reached • Study undertaken at the time immediately followingpublication of the Francis Report

6. The Sample by Specialism 6 District Nurses 4 Health Visitors 2 School Nurses 5 Nurses in an Acute Adult Surgical Ward 3 Mental Health Nurses 10 Paediatric Hospital Nurses 3 Neonatal Intensive Care Nurses

8. Fear and Anxiety “a bit of fear and dread if I know that a patient is particularly disturbed; anxiety about whether there will be physical implications ..you might have to restrain somebody” Senior Sister in a Secure Mental Health Unit

9. Catastrophising- ‘What if?’ “I was very worried this morning about that boy because I thought any minute now he’s just going to arrest on us, and you feel anxious that the doctors aren’t taking you seriously enough and that you’re going back to them, then you feel anxious that PICU team aren’t going to get here quick enough.” A Children’s Nurse

10. Catastrophising

11. Anxiety- A Ward Sister’s Narrative “ In my case it is time constraints and the workload is just too massive and the time is running out….It does make me anxious, once it’s done it’s done, so it is during it, when I am in the moment and everyone is calling my name” “Something is going to go wrong and I am ultimately responsible or I will be held responsible…. Sometimes it feels a bit like you are spinning plates, you are just trying to keep them all up, and that can lead to anxiety because you never know when one is going to fall.”

12. Anxiety – The Root Factors • Awareness that the likelihood of achieving the required outcomes of care and management reduces with time. • Multitasking to keep pace with events leads to the possibility that “something is going to go wrong”. • The time and nature of what is “going to go wrong” is uncertain and “because you never know when”, hyper-vigilance is required but proactive responses are therefore very limited. So powerlessness in the face of a nebulous threat also generates anxiety. • The nurse’s awareness that she is “ultimately responsible” and “will be held responsible” accompanies awareness of factors 1-3.

13. Anxiety- Leverage for Accountability “ …anxiety but in a controlled way, I’m not saying that that impacts detrimentally on practice, I think its quite a healthy thing because if you’re feeling quite anxious and feeling and yeah anxious and worried about things I would hope that would stop me becoming complacent about my role which I would never want to feel like that’s good enough, I always want to feel like I’ve done the most I can I guess to limit then me feeling anxious because I know I’ve done everything I should and then I will stay later come in early to make sure I have done everything I can so I’m not so worried about any repercussions.” A Health Visitor

14. Trait and State Anxiety “Do they do different things to me? Yes, I think they do, they must do because the acute worry would stop me sleeping and make it harder for me to switch off so I would be on overdrive, whereas the chronic worry, well worryingly it becomes a bit normal, so … it is part of you.” Mental Health Nurse Consultant

15. Anxiety with Hindsight “…when you’ve made a clinical decision or when you’ve seen a patient in their home and you’re driving away it’s whether you’ve done your best for that patient and whether you’ve made the right decisions. Or whether, you know that, you’ve missed something that you haven’t dealt with. So it’s the omissions as well as the actions that you worry about.” A District Nurse

16. Anxiety with Hindsight I often go home from a shift and think, ‘oh I’m not happy with that patient and just something is not right’, and I have to try to remove myself from it at home but I often replay the day from the start so I often feel worried about patients even though I’m not even here, so I sometimes think, ‘I’ve told that nurse this but is she really going to pick up on it and do something, or I hand over, like I’ve been practicing being in charge of the night shifts, and I’ve handed over the ward and then I go home and think, ‘oh God have I forgotten something?’ Recently Qualified Children’s Nurse

17. Panic – The Point of Realisation “you could probably say that , probably anxiety first and then it is followed by panic that is hasn’t been done and I need to do it now. Staff Nurse in Surgical Ward

18. Anxiety and Measuring Risk “the clinical decision making more … worry would come into it if you are having to leave someone and walk away. The other difference is that you leave them in that environment having seen that environment and wondering how they are going to continue to cope when you are not there. So it’s either getting services in but if they refuse additional services then you are leaving with them managing in a poor situation. Whereas if you’ve not seen that poor situation its not there to worry you. That’s been an issue at times. You feel like ‘can I leave this person?.... ….I think the more you know, the more things are not right and the more problems there are that could do with solving but there are not enough resources to solve those problems so you have to manage them with the resources we have. A Cardio- Respiratory Nurse

19. Concern “You are holding it in your head, different risks to different people so you would hold in your head, risks involved in a person absconding, somebody who is at risk of self-harming, somebody who perhaps has a history of violence, somebody who was violent the day before, and so you would have that in your head.” Nurse in Charge of Mental Health Unit

20. Anxiety Continuum “You worry that ultimately the person is going to be ok and nothing bad is going to happen to them, that is your biggest worry: that they are not going to kill themselves. And then you worry, a bit down the scale from that is that even if they don’t do something as drastic as kill themselves you worry that their life is going to turn out alright and that it, it’s not going to be sort of too bad, their quality of life.” Mental Health Nurse Consultant

21. Points on the Anxiety Continuum “Well, the worry about them killing themselves is almost the ultimate worry, but it’s a worry that doesn’t come along every day but when it does it is bad. That is specific about that whereas the worry about whether things are going to turn out ok for them comes along every day but it isn’t as big. So, they are angled in different ways if that makes sense. And with colleagues, it’s a little bit of a mix of both, so sometimes it can be really quite acute and a bit more like, I am not saying a colleague is going to kill themselves but it can more in the field of, this doesn’t happen very often but sometimes people are really on the edge and then there are other times when every day you get more of a low key kind of level of concern…I just mean that one is more acute and one is more pervasive, so one is, it doesn’t happen very often but when it does it shoots up the graph if you like, whereas the other it’s just there constantly somewhere between the middle and the end.” A Mental Health Nurse

22. Anxiety Continuum Panic Anxiety Concern Preoccupation Imminent High Risk Medium Risk Low Risk Danger A Point of Realisation Practice Omissions (Including Drug Errors) Not Coping Plurality of Crises Accountability implications Unusual Infrequent Regular Daily Suicidal Behaviour Deteriorating Patient Status Heavy Workload Rapidly Changing Multi-factorial Demands Multitasking Rapidly Reducing Time Window Associated Accountability Welfare of Chronically ill Clinical Decision Making in Indeterminate Situations Significant Changes in Patient Health Patterns Concern about Individual Colleagues Associated Accountability Vulnerable Patient Status Team Health Team Organisation Care Management and Planning Staffing Maintenance Equipment Maintenance Stock Maintenance Awareness of Accountability

23. Anxiety as a Reflection Point- Children’s Nurse Narrative “ a degree of anxiety in relation to what I was doing and sort of you know, the nature of it, like I've been doing a lot more on the plasma exchange machine which is actually quite a complex machine to be dealing with, and that did make me anxious but it wasn't like it, you know it was more anxious about the technique rather than actually what I was doing in my job.” “I was able to verbalise better like, 'look I need help with this thing and I need help with that thing', and with doing that and by saying that ; actually highlighting that I ended up reducing my anxiety which meant you know that I felt I was doing better again and with more satisfaction that I had done it and I'd completed it well, and then the next time round, although I was still a bit anxious, I definitely reduced that anxiety and I was like, 'No I'll troubleshoot this one myself but I know I can just ask‘”

24. Conclusion • Anxiety provides leverage for accountability. • Anxiety provides opportunities for intuitive evaluation, deciphering the nebulous and setting priorities. • Anxiety as a reflection point identifies areas of uncertainty and aids articulation.

25. Anxiety Satisfaction Anger Joy Sadness Frustration Fear

26. Emotional Intelligence Sadness Fear Joy Satisfaction Anxiety Anger Frustration Emotional Labour Present Danger and Threat Loss without source of blame Success out of uncertainty Uncertainty Making a Positive Difference and being Valued Loss with a source of blame Obstructions to Good Practice