Difficulties Experienced in Trauma Nursing Practice by Expert Emergency Nurses in Japan

The objective of this study was to determine the difficulties experienced in trauma nursing practice by expert emergency nurses in Japan. Ten nurses who worked at emergency and critical care centers in Japan were directly involved in nursing patients were selected by purposive sampling and under-went semi-structured interviews regarding the difficulties they experienced in trauma nursing. The nurses were specialists in critical care nursing or were certified emergency nurses. The interview responses were analyzed by the qualitative descriptive method. The following six categories of difficulties associated with the direct care of trauma patients and their family members encountered in trauma nursing practice were identified: [Initial handling of highly urgent trauma patients], [Understanding and observing the condition of patients who are in the treatment stage], [Judging when to transition to end-stage care for patients difficult to save], [Mitigating suffering and expanding safe activities of daily living for trauma patients], [Transitional care with a long-term perspective for trauma patients], and [Relationships with the family members of patients who died]. Three categories of difficulties related to the role of the expert nurse in trauma nursing practice were identified: [Person-to-person coordination and cooperation for a trauma patient], [Playing an educational role for the nursing staff], and [Pursuing expertise in trauma nursing and gaining empirical knowledge]. The findings suggested a need to establish systems for training and consultative support and opportunities to create meaning by reflecting on fulfillment and nursing practice.


Introduction
The number of deaths from physical trauma such as traffic accidents is decreasing from year to year in Japan. Accidents such as traffic accidents are the main cause of death in children and adolescents [1]. To prevent such deaths from external causes, the Japan Nursing for Trauma Evaluation and Care (JNTEC TM ) guidelines intended for nurses have been promulgated in Japan, and many nurses involved in emergency nursing have learned trauma nursing.
Several studies of trauma nursing in Japan have been reported. For example, a study employing participant observations and interviews of critically injured patients found that such patients are overwhelmed by sudden shock during recovery, fear having relationships severed, are intent on escaping from their extreme situation, and make efforts to understand the event that occurred [2]. A study that focused on the needs of relatives of head trauma patients found that the family members' needs included information and emotional support [3]. Additionally, a case report [4] and a study [5] about the educational effect of trauma nursing are reported. However, few studies have examined what constitutes trauma nursing practice in Japan. Investigators, therefore, conducted interviews of emergency nurses, with a focus on trauma nursing practice. They reported that emergency nurses see the trauma nursing practice according to a timeline from the initial trauma to the patient's reintegration into society and that the nursing can be classified into three categories: nursing care for the trauma patient, nursing care for the members of the trauma patient's family, and nursing care as a trauma care team [6]. The study results showed that emergency nurses required a broad range of knowledge and skills for trauma nursing practice and that such practice is wide-ranging.
Emergency nurses experience vast difficulties. In addition to providing direct care to patients and relatives of patients whose status is complicated and highly urgent and patients in critical condition, they must coordinate across disciplines.
It is surmised that trauma care nursing in particular is difficult even for expert nurses with years of experience, due to factors such as the diversity and complexity of the care and time pressures. A survey of previous studies of the difficulties encountered by emergency nurses in Japan found that the topics examined included the relationships between patients in critical condition and their family members [7], end-stage care [8] [9], support for decision-making by patient representatives [10], and matters related to family members [11]. Focusing on the difficulties associated with trauma nursing, the feelings nurses have experienced in caring for trauma patients include fear and discouragement [12].
In a survey of nurses working in emergency outpatient care regarding initial emergency responses, 46.8% responded that they "somehow managed" to care for trauma patients, and 4.7% said they were "unable to care for such patients well". The most common response was that a problem they encountered in dealing with such patients was that they "lacked the necessary knowledge and skills" [13]. and experience to reexamine one's own emotions and behaviors objectively and giving meaning to nursing care have been found to be important [14]. Consequently, determining the substance of the difficulties that emergency nurses experience in trauma nursing practice and the background of such difficulties may make it possible to integrate trauma nursing knowledge and experience and give meaning to such nursing. Moreover, it may provide basic data needed to build a training program in trauma nursing.
Therefore, the objective of this study was to identify the difficulties experienced in trauma nursing practice by expert emergency nurses in Japan.

1) Trauma nursing practice
Nursing whose main duties consist of acting directly and indirectly on patients and their family members, from resuscitation to rehabilitation, to facilitate recovery with regard to existing or potential health problems resulting from trauma.

2) Expert nurse
A nurse who is certified by the Japanese Nursing Association and implements superior, advanced nursing practice. The nurses in this study were certified as Certified Nurse Specialists in critical care nursing or as Certified Nurses in emergency nursing by the Japanese Nursing Association.

3) Difficulties
Difficulties are described as experiences of aggravation, unpleasantness, anxiety, or distress encountered by expert emergency nurses during the course of nursing practice for trauma patients and their family members.

Design
A qualitative descriptive design was used in this study to identify the difficulties experienced in trauma nursing practice by expert emergency nurses in Japan.
Qualitative descriptive designs are used in qualitative research for studies that are descriptive in nature, particularly for examining health care and nursing-related phenomena.

Requirements for Selection as a Subject
The 10 nurses selected as subjects met all of the following requirements: 1) working as a nurse and directly involved in nursing patients at the time of selection; 2) working at an emergency and critical care center certified by the Japan

Data Collection
The data were collected from March 2017 to July 2017.
After being selected through a purposive sampling method using the Japanese Nursing Association website, the subjects were given a written explanation of aspects of the study, such as its purpose and the ethical considerations involved, and were asked whether they wanted to participate in the study. This correspondence was carried out by postal mail. If the subject wished to participate in the study, consent was obtained from the nursing supervisor of their institution following the same method. Semi-structured interviews were conducted at a location where privacy could be ensured. Each subject was interviewed only once by an investigator and the interview took approximately 45 to 60 minutes. The topics covered in the interview were basic attributes (sex, years of nursing experience, years of emergency nursing experience, department with which subject was currently affiliated) and the difficulties experienced by the subject in trauma nursing practice. The interview was recorded with the consent of the subject.

Data Analysis
The data were analyzed by qualitative descriptive analysis, which comprised an analysis by subject and an overall analysis. First, a verbatim transcript was prepared from the data, and the transcript was read repeatedly and carefully to gain an overview of the content. Next, contextual units were extracted from the verbatim transcript for inclusion in the analysis by subject, focusing on the difficulties experienced by the subject in trauma nursing practice. An initial summary was prepared in a manner that preserved the semantic content of the individual contextual units. The level of abstraction of the expressions that reflected that description was then increased to prepare a secondary summary. In the overall analysis, the secondary summaries obtained for all of the subjects were classified based on their similarities and commonalities, and subcategories and categories were formulated and labeled.

Reliability Assurance
To examine the rigor and accuracy of the analysis results, a trial interview was conducted with one expert nurse who met the inclusion requirements. This re-N. Makino et al. Open Journal of Nursing sulted in improvements in the interviewer's interviewing skills and the accuracy of the interview guide. In addition, member checking was performed, and a determination of whether the interpretation of the data was valid was requested.
Throughout the process, the investigators consulted with one another regarding data extraction and the formulation and labeling of categories. In addition, an investigator who specialized in emergency nursing and was experienced in qualitative research provided supervision with regard to the analysis results.

Ethical Considerations
This study was conducted with approval from the Ethics Committee of Sapporo Medical University (Approval No. 28-2-61). The participating institution and subjects were given written and oral explanations of aspects of the study such as the following: the intent and purpose of the study; that study participation was voluntary; that they could decline to participate; that anonymity and confidentiality would be maintained; that rigorous methods of data handling, retention, and disposal would be employed; the psychological burden associated with recalling past experiences and how to cope with it; and how the results would be published. Written informed consent to participate was obtained from all subjects.

Overview of the Subjects
There were 10 subjects (three men and seven women) ( Table 1) with a mean nursing experience of 19.7 ± 6.0 years, a mean working experience in an emergency and critical care center of 15.2 ± 5.5 years, and a mean involvement in trauma nursing of 15.2 ± 5.5 years. All subjects met the inclusion criteria as described above.

Difficulties Experienced in Trauma Nursing Practice by Expert Emergency Nurses in Japan
The following nine categories were extracted for the difficulties experienced in The categories are explained below. Categories, subcategories, and typical

1) [Initial handling of highly urgent trauma patients]
This category indicates the difficulty of the initial handling of trauma patients when they are first brought to the hospital. The difficulty of the initial response, which affects whether the patient lives or dies and their prognosis, was indicated by subcategories such as the following: (I understand that the response that the patient receives when they are brought to the hospital will affect their prognosis, and this makes it difficult to handle highly urgent treatments) and (Responding is difficult because we are pressed to quickly make decisions for trauma patients in life-or-death situations). In addition, the subjects felt it was difficult to provide the wide range of responses required, such when a sudden change occurs during treatment of a trauma patient (It is difficult to switch responses due to differences in the patient's condition as a result of a sudden change) or when observing extensive sites of trauma (Responding to extensive injuries requires knowledge and observational ability, and I feel this is difficult). Moreover, the subjects said that nurses are assigned multiple duties when a trauma patient is brought to the hospital and that responding is difficult under those circumstances (Handling multiple duties is difficult when a trauma patient is brought to the hospital). Open Journal of Nursing

Difficulties Related to the Direct Care of Trauma Patients and Their Family Members Encountered in Trauma Nursing Practice
Of the nine categories described above, the first six are specific to those that arise early has been shown to play a role in the improvement in the patient's subsequent functional prognosis. Pain has been reported to be the stressor most commonly experienced by trauma patients [16], and the pain was a typical source of suffering in the present study. With traumatic injuries, it is difficult to treat conditions such as progression of the inflammation and necrosis that frequently occur, despite treatment, as a result of latent infection or bruising, and this prolongs the patient's suffering [2]. While mitigating the suffering of the patients, the subjects must make arrangements so that support for recovery is continued, and these responsibilities make assessments difficult.
Lastly, [Transitional care with a long-term perspective for trauma patients] is discussed. The patients with which the subjects in the present study were in-

Difficulties Concerning the Role of the Expert Nurse in Trauma Nursing Practice
The The role of the emergency nurse in trauma nursing practice has been found to be not only to provide care for the patient and their family but also to coordinate across disciplines as a member of the trauma care team [6]. Subjects in the present study mentioned [Person-to-person coordination and cooperation for a trauma patient] as a category of difficulty. In the emergency medicine setting, there is very little discussion among coworkers regarding their understanding of phenomena that occur or the actions to be taken, and care is carried out under an assumption of mutual understanding [17]. For trauma patients, initial trauma care that adheres to a systematic treatment strategy is recommended, and multiple treatments are administered at the same time. This likely requires the emergency nurse to exhibit an ability to coordinate combined with foresight.
Although the subjects in the present study were experienced and skilled, they still experienced difficulty in coordinating across disciplines. This indicates that the diversity of trauma in terms of mechanisms of injury, severity, and disease types likely played a role in this difficulty. It is also related to the subcategory.   [19], and the results were similar to those of the present study. To resolve these difficulties, it may be necessary to take measures such as establishing a consultative support system for difficult cases or consulting with a nurse who specializes in family nursing.

Implications for Nursing Practice
In addition, the subjects in this study were required to fulfill a variety of roles, as indicated by the categories [Playing an educational role for the nursing staff] and [Person-to-person coordination and cooperation for a trauma patient]. Although the subjects were qualified and therefore fulfilled these roles, the results indicated that this was a source of difficulty. Introspection and reflection by nurses fosters a conceptual ability for nursing practice [20], which indicates that creating opportunities to make nursing meaningful is a way of resolving such difficulties.
Lastly, we discuss difficulties in taking a long-term perspective, as indicated by the category [Transitional care with a long-term perspective for trauma pa-N. Makino et al. Open Journal of Nursing tients]. In Japan, comprehensive community care is well developed, and this requires nursing development that anticipates the transition from the acute phase to reintegration into society. For trauma patients, the functional disability that remains after the injury makes reintegration into society difficult. Moreover, many trauma patients are young, which creates major challenges to their reintegration into society. Expert nurses like the subjects of this study can bring about a resolution of these difficulties by maintaining a long-term perspective, assuming responsibility for the patient's condition, and encouraging utilization of the patients' family members, those close to the patients, and the societal resources of the community.

Study Limitations
The subjects in this study were limited to expert emergency nurses who filled the selection criteria. Moreover, there were only 10 subjects in the study. Consequently, the results obtained represented the subjects' portion of a wide range of difficulties experienced. Moreover, the departments with which the subjects were affiliated covered a broad range from initial trauma care to care subsequent to the initial trauma. Therefore, differences in their trauma nursing experience cannot be ruled out. Challenges for the future will be to increase the sample size, identify the variety of difficulties that take into account the backgrounds of the subjects, and construct a system for resolving the difficulties experienced in trauma nursing practice.