Define the topic in general terms

Abstract:

The emergency department (ER) is one of the most important and sensitive parts of the hospitals, where
nurses play many different roles related to patient care. Hence, the nature of demanding of this field
associates with creating stress, anxiety, and depression (SAD) for nurses. In addition to the burnout, which
was described, that considering one of the most frequent problems in ER. It is characterized by low self-
esteem, emotional exhaustion, and lack of empathy. In addition, it has been associated with many factors
such as; poor work performance, unsuitable contact with patients, overthrowing ethics.

The Emergency Department (ER) is considering a high-stress environment for both health care employees
and patients. The nurses who are working in ER department play many different roles which are mainly
focused on providing specialized medical care for the patients. Where dealing with those patients is
considered a serious worrying and stressful condition to all health care nurses there, the thing that led to
making emotional stress; which is one of the professional hazards for the ER department employees. As a
result, elongated stress influence psychosomatic disorders; somatic manifestation, personality disorder,
psychiatric syndrome, and chronic fatigue were also noticed.

Problem statement: Many different factors are associating with developing stress, anxiety, and depression,
which in turn reflected on the nurse’s psyche, job satisfaction, and nurse’s work performance,
consequently affect the service provided for the patients, which may lead to a serious problem that needs
a study and find a solution.

Aims: The main aim of this study is to determine the level of stress, anxiety, depression, and burnout
among ER nurses in Palestine.

Methodology: A cross-sectional, self-administered questionnaire will be used to determine the level of

stress, anxiety, depression, and burnout among ER nurses in Palestine. The sample will be recruited from
three types of hospitals government, private, and educational (twelve hospitals). Data will be collected via
a questionnaire consisting of four parts to assess socio-demographic factors, work factors, SAD, and
burnout of emergency nurses. All analyses will perform by SPSS, by extracting the numbers, the
percentages, the averages, and the standard deviations.

Clearly state the research problem

Problem statement:

The stress, anxiety, depression (SAD), and burnout that nurse’s staff may face in ER department are
all considered an emotional strain that is associated with a certain occurrence that the nurse suffers
at a point in time. Since the nurses are considering a backbone of ER department system, it is
important to investigate the stress frequency in those individuals. Many different reasons may
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 associate with the creation of the mentioned emotional efforts which in turn reflected on the nurse’s
psyche, job satisfaction, and nurse’s work performance, consequently affect the service provided for
the patients, which may lead to a serious problem that needs a study and find a solution.

Define the objectives of the study

Main objective:
- This study aims to assess the level of stress, anxiety, depression (SAD), and burnout among ER
nurses in Palestine.
Specific objectives:
- To assess the association between SAD and burnout among ER nurses in Palestine.
- To assess the association between SAD and burnout among ER nurses and the types of hospitals in
Palestine.
- To assess the association between SAD and burnout and demographic factors among ER nurses in
Palestine.
- To assess the association between SAD and burnout and work factors among ER nurses in Palestine.

Describe the method to be used:

A cross-sectional study design will be used in this study, which will be used to assess the levels of stress,
anxiety, depression (SAD), and its association with burnout among ER nurses in Palestine.

A convenient sampling method will be used to conduct the study in three types of hospitals (government,
private, and educational hospitals) in West Bank / Palestine.

Using self-administered questionnaires (demographic factors, work factors, depression, anxiety, stress
scale, and burnout scale) to collect the data.

Describe the expected outcomes

- The level of stress, anxiety, depression (SAD), and burnout is high among ER nurses in Palestine.
- Will be an association between SAD and burnout among ER nurses in Palestine.
- Will be an association between SAD and burnout among ER nurses and the types of hospitals in
Palestine.
- Will be an association between SAD and burnout and demographic factors among ER nurses in
Palestine.
- Will be an association between SAD and burnout and work factors among ER nurses in Palestine.

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State the significance of the study

Study significance:

The nursing profession is a very important one since it has a critical and sensitive role for individuals. A self-
esteem health care job focused on therapeutic care of the individual, families, and communities so that
they can recover and improve optimum health. It works on disease and injury inhibition, the help of
healing, optimization of health and abilities, provides protection, upgrading, easing of suffering through the
diagnosis and treatment of human response. The nursing profession takes care of all people regarding the
patient’s age, sex, culture, religion, etc. For those reasons, it is important to follow up with nurse’s
requirements, problems that may face especially in the ER department and the environmental workplace
which may affect their job and work performance. Hence, it is important to stand in this issue and consider
it to make a study regarding the issue and figure out the problem that nurses staff face in ER department in
Palestinian hospitals, to find solutions and improve the work performance in the hospitals and other health
care in our country.

CONCEPTUAL &OPERATIONAL DEFINITIONS:

Stress:

Define as emotional distress, which rises according to the individual’s estimation of the experienced
situation as a threat, challenge, or harm (Apóstolo, Mendes, & Azeredo, 2006). In this study, stress will
evaluate by using a questionnaire: DASS-21, within the subscale stress (DASS-S), which has seven items for
stress evaluation.

anxiety :

Define as emotional distress, which is the personal response to a threat when the individual is confronted
with uncertainty and/or with an existential threat (Apóstolo et al., 2006). In this study, anxiety will assess
by DASS-21, within subscale anxiety (DASS-A), which has seven items for anxiety evaluation.

Depression:

Define as emotional distress but has no specific emotions. It may combine emotions such as guilt, shame,
anger, and anxiety. Depression can be provoked by the experience of a great loss, which may result from
hopeless feelings or that life is not worth living (Apóstolo et al., 2006). In this study, depression will
estimate by DASS-21, by subscale depression (DASS-D) which has seven items for depression evaluation.

Burnout:

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 is a syndrome of emotional exhaustion, de-personalisation, and reduced personal accomplishment that can occur
among individuals who do ‘people work’ of some kind. In this study, Burnout will assess by using the Copenhagen
Burnout Inventory (CBI) tool, which measures burnout in three different areas: personal, work, and with clients,
which has 19 items.

1.THE TOPIC / LITERATURE REVIEW

Define the research topic and research and how your research topic is related to existing literature and
current trends in the research topic.

Briefly describe the research topic:

The stress, anxiety, depression, and burnout among ER nurses are considering some of the most common
psychiatric problems worldwide. Therefore, many studies have been done regarding this issue. An
American cross-sectional study design was done that aims to explore the frequency of compassion
burnout, fatigue, and satisfaction among ER nurses and other particular inpatient specialties nurses. The
results showed that almost 82% of ER nurses were suffering from moderate to high burnout levels, and
about 86% were suffering from moderate to high fatigue levels. The difference between ER nurses and
other ones who are working in ICU, nephrology, and oncology departments is that they didn’t reach the
statistical significance level compared to ER nurses on subscales of burnout and fatigue. However, ER
nurses showed a risk for less compassion satisfaction compared to other selected nurses (Hooper et al.,
2010).

Another study conducted in Australia, which was a cross-section survey was done that aims to investigate
compassion fatigue and satisfaction with the causative factors of depression, anxiety, and stress. Finding
that, burnout and stress were significantly associated with higher depression and anxiety levels. These
higher levels were correlated mainly with young nurses and full-time nurses (Hegney et al., 2014). While a
Canadian study has been done that aims to figure out the relationship between the factors of workplace
stress and posttraumatic stress disorder symptoms. Finding that there are three sets of factors associated
with ER nurse's stress including; patients care, hospital characteristics, and the interpersonal
environment. Significantly, interpersonal conflict was associated with the symptoms of posttraumatic
stress disorder. Sixty-seven percent believed that they got insufficient support from hospital managers
following the traumatic occurrence, 20% used to change their career as a result of the trauma. And 18%
only attended incident stress and none required outside help for their pain (Laposa et al., 2003).

State the key ideas, theories. Concepts and findings in the current literature related to your research
topic; especially those linked with the research problem under investigation
A cross-sectional study conducted in China was done that aims to figure out the association between
nurses, self-efficacy, work burnout, and stress. Finding that the total consequence of job stress on burnout
was huge. Both work stress and the nurses are directly moderately affected by burnout. Work stress
influenced directly the nurses and self-efficacy. Nurses have directly affected self-efficacy. However, self-
efficacy is not influenced burnout directly (Liu & Aungsuroch, 2019). Another systematic study was done in
the same country that aimed to measure the three dimensions of burnout in ER nurses and assess the
nurses’ proportion who used to experience a very high level of burnout. The results showed that emotional
exhaustion was moderate among nurses, while the absence of personal accomplishment and
depersonalization showed higher levels of burnout. The proportion of ER nurses who are suffering from
high depersonalization, high emotional exhaustion, and low personal accomplishment was 44.3%, 40.5%,
and 42.7%, respectively (Li et al., 2018). In Ireland, a cross-section study design was done that aims to
measure the ER department nurse’s self-report traumatic stress levels. The results indicated that 82% of ER
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nurses were suffering from traumatic stress. Hence, the study applied some suggestions that associate
with decreasing the stress such as creating new systems to support ER nurses in the country (Duffy et al.,
2015).

Define the knowledge gap in the literature that is linked with the research
There were few studies in the previous lecture in the middle east, and the majority of them did not study
the ER in specific. A systematic review was done in the Middle East that works in collecting the searched
results that are found in certified websites regarding the quantitative measure of burnout among health
care providers including nurses. Finding that burnout is the most common one with incidence estimates
mainly varying between 40-60%. This burnout in the Middle East is referred to the emotional distress,
work environments, violence and terror exposure, and low social support (Chemali et al., 2019).

However, there were a few studies in ER in Palestine, while, those studies did not examine stress, anxiety
and depression, and burnout together, and the associations between them. A cross-sectional study
conducted in Palestine aimed to evaluate the levels of burnout and the risk factors which are associated
with nurse’s health in ER departments in Palestinian hospitals. It was also to examine the career turnover
and the relationship between workplace violence and burnout. They found that 64% were suffering from
emotional exhausting, followed by 38.1% suffering from depersonalization, and 34.6% suffering from low
personal achievement. Also, they found that burnout was significantly related to nurse’s intention to leave
their job at ER departments (Hamdan, 2017).

Describe how your research will add and contribute to the existing body of knowledge of the subject matter
and why it is interesting and relevant to your field of study

This study will be one of few studies worldwide that will determine the level of stress, anxiety, depression
(SAD), and burnout. In addition, this study will assess the associations between SAD and burnout.
Furthermore, this study will be conducted in ER, while the previous studies are usually conducted on all
hospital departments. The link between SAD and burnout are concepts that have sustained the interest of
nurses and researchers for several decades. These concepts are highly relevant to the workforce in general
and nursing in particular. Despite this interest and relevance, the effects of SAD and burnout on patient
outcomes, patient safety, and quality care are not well defined by evidence. There is a great need for
comprehensive studies that will examine these dynamics in a way that will yield more solid evidence on
which to base practice.

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2.RESEARCH QUESTIONS AND HYPOTHESES
List the main research question(s) you want to answer.

Research Hypothesis: formulate the hypotheses of your research, which are to be tested by the research
project; please clearly state the research sub-questions of your research:

Questions of the study:

- What is the level of stress, anxiety, depression (SAD), and burnout among ER nurses in Palestine?
- Is there an association between SAD and burnout among ER nurses in Palestine?
- Is there an association between SAD and burnout among ER nurses and the types of hospitals in
Palestine?
- Is there an association between SAD and burnout and demographic factors among ER nurses in
Palestine?
- Is there an association between SAD and burnout and work factors among ER nurses in
Palestine?
Study hypothesis:
- Null hypothesis 1: there is no association between SAD and burnout among ER nurses in
Palestine?
- Null hypothesis 2: there is no association between SAD and burnout among ER nurses and the
types of hospitals in Palestine?
- Null hypothesis 3: there is no association between SAD and burnout and demographic factors
among ER nurses in Palestine?
- Null hypothesis 4: there is no association between SAD and burnout and work factors among ER
nurses in Palestine?

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3.METHODOLOGY
In this section, you need to give details about how you will answer the research questions formulated
above.

Indicate what kind of research methodology you will follow; whether it is quantitative, qualitative, or
both

A cross-sectional study design will be used to assess the level of stress, anxiety, depression, and its
association with burnout among ER nurses in Palestine. For this study, the research paradigm the
quantitative approach to support the research with objective and statistical data.

Describe the methods that you will be using to achieve the study objectives:

Population and sampling

The study population consisted of E.R nurses from twelve different hospitals government, private and
educational. These hospitals are located in the West Bank- Palestine. Were chosen since they have a
large number of emergency nurses and are readily accessible to the researchers.

Sampling method

A cross-sectional research design was adopted to assess the Level of Stress, Anxiety, Depression, and its
association with Burnout among ER Nurses. The sample will take from twelve hospitals (governmental,
private, and educational). The convenient sample will be used to recruit the participants of nurses from
the E.R department.

Sample size

Sample size will be calculated using an online sample size calculator, depending on previous studies,
using the calculation was done using (OpenEpi/version 3.0) the sample size calculator website (OpenEpi,
2013).

Inclusion Criteria and Exclusion Criteria

- Inclusion Criteria: ER nurses who have than one year of work experience in the west bank.

- Exclusion Criteria:-

*Emergency department nurses from Gaza due to difficult access to hospitals.

Study measurements

Study tool: A self-administer questionnaire will be used to collect the data from the participants.

The tool used in this study has four categories:

Category I: deals with the socio-demographic variables: age, gender, marital status, area of living

Category II: work factors: years of experience, educational level, job description number of night duties
done in a month.

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Category III: DASS-21 scoring:

Depression Anxiety Stress Scale‐21 (DASS‐21) was developed by Lovibond (1995). The DASS 21 measures
symptoms of depression, anxiety, and stress. It comprises three subscales that each has seven items:
depression (DASS 21-D), anxiety (DASS 21-A), and stress (DASS 21-S). Each item is scored on a 4-
point Likert scale ranging from 0 (“did not apply to me at all”) to 3 (“applied to me very much”). The
scores for the total DASS 21 and each subscale are summed. Examples for items in each subscale; DASS‐
D: “I couldn't seem to experience any positive feeling at all”, DASS‐A: “I was aware of dryness of my
mouth”, and DASS‐S: “I found it hard to wind down”.

The DASS‐21 scores for each subscale of depression, anxiety, and stress have a different cut‐off point for
the classification of severity. The subscale scores “after being multiplied by two” are classified into
“normal, mild, moderate, severe and extremely severe symptoms” according to the DASS‐21 manual
(Lovibond, S.H. & Lovibond, P.F, 1995)

Category IV: Burnout scale: The Copenhagen Burnout Inventory (CBI): A new tool for the assessment of burnout
(Kristensen, 2005).

I will use the Measurement Tool (CBI), which measures burnout in three different areas: personal, work,
and with clients, which has 19 items.

Describe the research population and the sampling method you will be targeting:

Data collection

After obtaining permission from RIP of AAUP University, we contact the Ministry of Health - Hospital
Administration Department to obtain approval and then communicate with nursing directors and head
nurses in the targeted hospitals, followed by conduct with Committee: Medical Superintendent and
Nursing superintendent to distribute and collect data. Then explain the Nature and purpose of the study
oral and written. In addition to Inform consent, obtain from the nurses.

The study data will be taken through a questionnaire which will be distributed to the selected nurses in
big twelve different hospitals in different cities in the country, including governmental, private, and
educational hospitals. These hospitals:

*Alia Governmental Hospital – Hebron.

*AL-Ahli hospital-Hebron.

*Beit-Jala Governmental Hospital- Bethlehem.

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*Palestine Medical Complex-Ramallah.

*Istishari Arab Hospital- Ramallah.

*AL-Najah National Hospital – Nablus.

* Rafidia Governmental Hospital- Nablus.

*Jericho hospital- Jericho.

*Dr. Thabet Thabet Government Hospital- Tulkarm.

*Jenin Government Hospital -Jenin.

* Alrazi hospital- jenin..

Then the data collected and become ready for analysis.

Pilot study:

I am using the questionnaire technique for a research study. I will conduct a pilot study on 10% of
respondents. Moreover, I will exclude results from my findings and conclusion.

Explain how you will analyze your results and answer the research question

-Data analysis

After the data collection, it will be organized and analyzed. For the analysis of closed-ended questions, a
computer program (SPSS) will be used. Data will be analyzed by using descriptive statistics, which will
include means and standard deviations analysis, tables and figures will be drawn and from these, the
data will be presented in pie diagrams and bar graphs.

What specific provisions have been made to protect the confidentiality of sensitive information about
individuals participating in the research?

The confidentiality of the participants will be ensured as the questionnaires will be anonymous. The
participant's names will not be entered on the questionnaire. This provision of anonymity is explained in
the consent form to participants.

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4. POTENTIAL OBSTACLES

In this section, you need to mention any potential limitations that might hinder your study. Include the
following;

Is there any practical limitation that might hinder?

It might be because of the COVID-19 pandemic, which may affect the result of this study, as it may
increase the level of SAD and Burnout.

How will you attempt to control for potential confusing variables and errors:

Me and my supervisors.

If your methodology may lead to problems you can anticipate, state this openly and show why pursuing
this methodology outweighs the risk of these problems:

There are no problems with the methodology.

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5. TENTATIVE THESIS OUTLINE

What is the planned outline of your thesis? Please explain what sections your thesis will have, and what
will be addressed in those sections.

List of contents:
-introduction
Background
Problem statement
Study significance
Study objectives
* Main objective
* Specific objective
Questions of the study
Study hypothesis

- Literature review

- Methodology
Study design
Target population
Data collection
Data analysis

Conclusion

References

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6. RESEARCH PLAN / TIMETABLE / budget

The research plan, the timetable is your plan of action. It can be formatted as a list or a table of concrete
tasks, activities, and deadlines:

Task Time

Prepare proposal 4 weeks

Collection data 4-5 weeks

Data analysis 4 weeks

Result & discussion 3 weeks

(If applicable) The research budget. It can be formatted as a list or a table of equipment/ consumables

Budget items Number of items Cost per item Total cash cost Notes

It depends on the ease

transportation
30 20 nis 600 nis of transportation and
between cities
its availability

Paper and copied 500-700 0.5 nis 250-350 nis

Total 850-950 nis

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 7. BIBLIOGRAPHY

Please list the literature and sources you have used for producing this thesis proposal.

Chemali, Z., Ezzeddine, F., Gelaye, B., Dossett, M., Salameh, J., Bizri, M., Dubale, B., & Fricchione, G. (2019). Burnout
among healthcare providers in the complex environment of the Middle East: a systematic review. BMC
public health, 19(1), 1-21.
Duffy, E., Avalos, G., & Dowling, M. (2015). Secondary traumatic stress among emergency nurses: a cross-sectional
study. International emergency nursing, 23(2), 53-58.
Hamdan, M. (2017). Burnout among workers in emergency Departments in Palestinian hospitals: prevalence and
associated factors. BMC health services research, 17(1), 1-7.
Hegney, D. G., Craigie, M., Hemsworth, D., Osseiran‐Moisson, R., Aoun, S., Francis, K., & Drury, V. (2014).
Compassion satisfaction, compassion fatigue, anxiety, depression and stress in registered nurses in A
ustralia: study 1 results. Journal of nursing management, 22(4), 506-518.
Hooper, C., Craig, J., Janvrin, D. R., Wetsel, M. A., & Reimels, E. (2010). Compassion satisfaction, burnout, and
compassion fatigue among emergency nurses compared with nurses in other selected inpatient specialties.
Journal of emergency nursing, 36(5), 420-427.
Laposa, J. M., Alden, L. E., & Fullerton, L. M. (2003). Work stress and posttraumatic stress disorder in ED
nurses/personnel (CE). Journal of emergency nursing, 29(1), 23-28.
Li, H., Cheng, B., & Zhu, X. P. (2018). Quantification of burnout in emergency nurses: A systematic review and meta-
analysis. International emergency nursing, 39, 46-54.
Liu, Y., & Aungsuroch, Y. (2019). Work stress, perceived social support, self‐efficacy and burnout among Chinese
registered nurses. Journal of nursing management, 27(7), 1445-1453.

Kristensen T.S., Borritz M., Villadsen E., Christensen K.B. The Copenhagen Burnout Inventory: A new tool for the
assessment of burnout. Work Stress.  2005;19:192–207.

Lovibond, S.H. & Lovibond, P.F. (1995).

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 1. APPENDICES

(If applicable) Instructions: Data collection instruments, data collection form, elaboration on methods and
procedures to be used, etc.) (Please attach the related documents)

- https://www.bristol.ac.uk/media-library/sites/sps/documents/c-change/dass.pdf

- https://www.researchgate.net/publication/
247511197_The_Copenhagen_Burnout_Inventory_A_new_tool_for_the_assessment_of_burnout.

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