Dissertation Proposal on the Stress Problem Among the ER Physicians

Chapter 2: Literature Review

Introduction: Literature Review

This research seeks to explore the stress problem among the ER physicians and how it is associated with SOC as the basis for coping with the problem. The current literature establishes the relevance of the problem by presenting the notion that ER physicians are vulnerable to stressful situations and that their SOC levels determine their ability to cope with stress. According to Carlton, Holsinger, and Anunobi, (2016), SOC involves three key elements: comprehensibility, manageability and meaningfulness. SOC as the independent variable is closely related to the ER physicians ability to cope with stress. Different studies such as Benz, et al, (2013) and , Binder et al. (2006) have been done on the topic to demonstrate how the two variables related. However, gaps still exist in the available research since the majority of researchers fail to explore the key constructs that promote the individual physicians ability to cope with stress. According to Benz, Angst, Lehmann & Aeschlimann (2013), existing studies on the topic present the notion that SOC can be applied as a predictor to the physicians coping abilities with stress in which SOC influences the coping abilities.

This chapter will explore different studies that have been done on the topic as well as explore the stress prevalence among the ER physicians. Furthermore, the research will adopt a theoretical perspective aligned with salutogenic theory to demonstrate the relationship between SOC and ER physicians ability to cope with stress. The beginning of Chapter Two focuses on literature review and will include the literature search strategy section, which provides the basis for understanding how the research was conducted on the topic. The second section of this chapter involves the theoretical perspective that forms the basis for this research. The third section explores the stress prevalence among the ER physicians while the fifth section explores the SOC concept in details. Other key sections include the relationship between SOC and coping with stress as well as the related literature to the key variables or concepts. The last section of the chapter presents a summary of the major themes in the literature as well as a conclusion of the chapter.

Literature Search Strategy

This research will make use of previous studies that have been done on the topic. Some of the key databases that will be used to search previous studies will include Ebsco, Proquest, Medline as well as CINAHL plus. The primary search strategy that is being utilized is the use of keywords due to the high chances of helping get appropriate articles for the study. Some of the keywords are: Sense of Coherence (SOC), stress, Emergency Room, physicians, coping with stress, salutogenic theory, manageability, comprehensibility and meaningfulness. The search phrases were effective in getting the related articles from the accessed library databases and search engines. The scope of the literature review also involves studies done in the last 5 years, peer reviewed articles, seminal literature and scholarly books, which explores the research topic in details. The justification for adopting latest studies is based on the idea of addressing the existing problems within ER settings and demonstrating how physicians can use this research as the basis for improving their coping abilities. Based on the idea that SOC is not a relatively new term and has been adopted in other studies promoting health and well-being, the depth of this research will be profound and the availability of current research is also high thus promoting easier understanding of the topic.

Theoretical Perspective

In this study, the theoretical perspective, which will be adopted, will include the Salutogenic theory, which emphasizes on how positive attributes of an individual are linked to the individual's ability to adapt to life stressors (Ezeamama, Elkins, Simpson, Smith, Allegra, and Miles, 2016). Salutogenic theory was first established by Antonovsky (1987) as the basis for exploring health in terms of personal attributes or emphasizing on resilience. Antonovsky (1987) further presented the salutogenic orientation as a "movement away from traditional pathogenic perspectives which focus on illness, towards an alternative way to better understand factors that keep people healthy." The salutogenic theory was based on exploring the reason why some people manage to stay healthy while others fail despite stressful situations (Goldberg, 2015). According to Binder, Mesenholl-Strehler, Pass, and Endler, (2006), the key goal of the Salutogenesis Theory is to promote the role of health-promoting and protective factors in stress or disease situations. The theory further presented the notion that personal attributes are linked to the successful adaptation to life stressors which leads to salutogenic outcome. Hence, the theory can be closely associated with ER physicians ability to cope with stressful situations while others fail to cope based on their SOC levels. The theory argues that there exists a variety of factors that influence stress, health and coping; however, how the threats are perceived by individuals determines their response and success (Benz, Angst, Lehmann & Aeschlimann, 2013).

Research done by Silver (2013), presents the notion that stressors are common in ER situations making the physicians vulnerable and may create a variety of consequences based on the way they manage the stressors. According to Richardson and Ratner (2005), the salutogenic theory makes major propositions and hypothesizes that SOC improves the individual coping abilities, which promotes health. The theory guides in understanding the relationship between SOC and the ER physicians ability to cope with stress based on the assumption that high SOC levels lead to improved coping abilities. Research done by Tartas et al. (2014) also confirms this theory and emphasizes the impact of individuals positive attributes as outlined in the salutogenic theory suggesting that SOC enhances the chances of coping with stress among the physicians in context. According to Tartas et al., (2014), the salutogenic theory presents the notion that SOC is associated with individuals well-being and life satisfaction. Higher levels of SOC empower the physicians to manage stressful situations in the ER. The salutogenic theory further emphasizes health-promoting attributes as well as resilience thus enhancing the chances of the physicians managing their external and internal environment better. (Andruszkiewicz, Basinska, Felsmann, Banaszkiewicz, Marzec, and Kedziora-Kornatowska (2017). In addition, Silver (2013) notes that the theory differs from the traditional pathogenic theory, which identified the risk factors of the condition affecting individuals. A study done by Kamwendo, Hansson, and Hjerpe (1998) suggests that the salutogenic theory focuses on the role of the protective and health promoting aspects that reduces the impact of stress. The salutogenic theory adopted further presents the argument that physicians who perceive stress as threats have higher chances of experiencing negative outcomes compared to those who perceive stress as non-threatening (Langeland et al., 2013). The theoretical perspective adopted makes key assumptions of which this research seeks to prove.

It suggests that individuals manage stress based on how they perceive stress which further relates to the comprehensibility construct of SOC.

The theory suggests that high SOC levels increases the chances of managing stress among the ER physicians.

ER physicians have the capability to regulate their reactions to stressors by engaging in positive thoughts.

ER physicians with adequate resources have improved chances of managing stressors.

The extent to which individual physicians in ER assign emotional value to stress impacts their commitment and engagement.

SOC further provides both internal and external resources as a means through which ER physicians can identify stress, understand and cope in effective ways.

The salutogenic theory is selected as the main theoretical perspective to guide this research since it emphasizes on the individual ability to manage stress, which also relates to the concept of SOC. Hence, it is critical in establishing recommendations or empowering ER physicians to manage their conditions. The SOC constructs as presented through the theory also promotes knowledge or understanding on ways in which the ER physicians can enhance their ability to cope with the stressful situations that are common in their settings. According to Faresjo, Karalis, Prinsback, Kroon, and Lionis, (2009), salutogenic theory focuses on the key resources that help in improving or maintaining health thus providing the basis for how individuals cope despite stressful situations and hardships. The ability to implement the salutogenic way of living defines how individuals perceive stressful situations and provides coping tools for an improved quality of life, as well as mental well-being (Hart, Wilson, & Hittner, 2006). Antonovsky (1987) sought after exploring why some individuals stay healthy despite stress and hardships. He found they were able to do so by possessing and focusing on thought patterns that foster health and well-being rather than focusing on the determinants of disease; this finding provides the philosophy behind the salutogenic theory. SOC determines the ability to resist stress in salutogenic theory to enhance better quality of life and coping with stress (Tei, Becker, Sugihara, Kawada, Fujino, Sozu, Murai, Takahashi, 2015). According to Langeland et al. (2013), salutogenic theory links SOC as an effective aspect that enhances the individuals ability to comprehend a situation, as well as adopt problem-solving solutions. In this regard, it enhances the chances of physicians understanding their working environments, the associated challenges, and how they perceive the challenges as meaningful, comprehensible and manageable. Salutogenic theory as the theoretical perspective for this research argues that SOC is critical in shaping the individuals view of life, as well as the ability to respond to stressful situations (Langeland et al., 2013).

The salutogenic theory also makes the assumptions that SOC is exemplified through attitude, behaviors and emotional levels to promote wellbeing, which accounts for the strong relationship between SOC and coping abilities (Yeh, Huang, & Chou, (2008). Antonovsky (1987) argues how individuals perceive stimuli as threatening or non-threatening determines their ability to effectively address the situation. In this regard, a review of salutogenic model demonstrates that it emphasizes positive attributes, which enable individuals such as the ER physicians' in the context of a stressful work environment to successfully adapt to the stressors in the workplace (Langeland et al., 2013). Hence, the salutogenic theory tends to promote physicians ability to cope with stress by adopting protective and health-promoting factors rather than solving the risk factors. The salutogenic theory further links the individual coping abilities with improved self-esteem, preventive health orientation, social support and intelligence, which suggests that the ER physicians with such resources have better chances of dealing with stressful situations (Xiao, Wang, Chen, Wu, Cai, Weng, Li, Zhang, 2014). Crane and NC DOCKS (2007) affirm that the salutogenic theory is based on the assumption that strong SOC levels stimulate or promote the individuals adaptation to stress and ensure active engagement in life. Similarly, Adriaenssens, De, and Maes (2015) point out that the ability to have positive and active engagement in life helps in shaping stress perception, as well as predict the individual physicians coping abilities with stress.

The salutogenic theory relates...