A narrative approach to understanding the nursing work environment in Canada

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  • Social Science & Medicine 61 (2

    det

    all

    ursin

    line 2

    of recruiting new ones are at least partially due to a

    stressful and undesirable work environment. Many

    ARTICLE IN PRESS

    Corresponding author. Tel.: +1416 978 2869;fax: +1416 978 8222.factors combine to create stressful work conditions for

    nurses, among them: heavy workloads, long hours, low

    0277-9536/$ - see front matter r 2005 Elsevier Ltd. All rights reserved.

    doi:10.1016/j.socscimed.2005.05.002

    E-mail address: l.mcgillishall@utoronto.ca

    (L. McGillis Hall).Introduction

    A number of recent reports and research studies have

    identied an urgent need to improve the working

    conditions of nurses (Advisory Committee on Healthy

    Human Resources (ACHHR), 2002; Aiken et al., 2001;

    Baumann et al., 2001; Health Canada, 2001; Nursing

    Task Force, 1999; Page, 2003; Wunderlich, Sloan, &

    Davis, 1996). Warnings that an ageing population of

    nurses combined with a lack of new graduates signies a

    major nursing shortage is of serious concern for a health

    care system in which nurses constitute a substantial

    proportion of the workforce. The quality of nursing

    work life affects not only the recruitment and retention

    of nurses but also outcomes for patients, the system and

    families.

    The burnout of experienced nurses and the difcultyNarrative interviews were conducted with hospital nurses participating in a research study designed to provide

    support and assistance to hospitals as they addressed work life issues for nurses in an attempt to create quality work

    environments. The eight interviews were conducted in a sample of Canadian hospitals and generated themes relating to

    an imbalance between the effort that nurses put into their work and rewards attained from it. Seigrists ((1996) Journal

    of Occupational Health Psychology, 1, 2741, (2002) In: P.L. Perrewe & D.G. Ganster (Eds.), Historical perspectives on

    stress and health. Research in Occupational Stress and Well Being (vol. 2). Boston, MA: Jai Press) effortreward

    imbalance model was used to frame this study. The nurses narratives suggest that multiple factors constitute the nurses

    work environment and their experiences and perceptions of it. Issues which surfaced repeatedly in the interviews related

    to changing needs of hospitalized patients in todays health care system and the associated workload, the widespread

    shortage of nurses, and the imbalance this creates for nursing work. A crucial nding is the extent to which the nurse is

    impacted by the adequacy of care they are able to provide. These narratives outline the tremendous burden of guilt and

    the overcommitment that nurses bear when factors in the work environment prevent them from providing complete,

    quality care. Nurses are experiencing frustration and stress that is impacting their worklife, family and home life,

    personal health, and possibly patient outcomes.

    r 2005 Elsevier Ltd. All rights reserved.

    Keywords: Nurses work environment; Effortreward imbalance; CanadaAbstractA narrative approach to unenvironmen

    Linda McGillis H

    CIHR New Investigator, University of Toronto, Faculty of N

    Available on005) 24822491

    rstanding the nursing workin Canada

    , Diana Kiesners

    g, 50 St. George Street, Toronto, Ont., Canada M5S 3H4

    0 June 2005

    www.elsevier.com/locate/socscimed

  • support and full-time work are all incentives that can

    create a drain of nurses going abroad (Heitlinger, 2003).

    Publications to date have directed limited attention to

    the work environment in which nurses work and its

    impact on the nurse and subsequently the patient. This

    study is based on the nurses experience in the work

    environment using a qualitative approach involving

    interviews. The interviews highlighted areas identied as

    major nursing workplace issues such as patient acuity

    and the stafng levels available to meet patient work-

    load needs.

    Theoretical framework

    ARTICLE IN PRESS

    DemandsEsteemSecurity

    L. McGillis Hall, D. Kiesners / Social Science & Medicine 61 (2005) 24822491 2483professional status, difcult relations in the workplace,

    difculty in carrying out professional roles, and a variety

    of workplace hazards (Baumann et al., 2001, p. 1).

    Work life factors are interrelated in complex and

    intricate ways. In a recent study of 720 Canadian nurses

    the likelihood of emotional exhaustion was found to

    increase when nurses were at risk of an effort and reward

    imbalance (OBrien-Pallas et al., 2004). Increased acuity,

    complexity and intensity of patient care combined with

    downsized nursing leadership have led to increased

    workload, while this in turn has resulted in decreased

    satisfaction and nursing morale, increased absenteeism

    and reduced quality of patient care (ACHHR, 2002).

    Greenglass and Burke (2001) investigated the effects

    of hospital restructuring on nurses and found that the

    most signicant and consistent predictor of stress among

    nurses in hospitals being downsized was workload. The

    greater the nurses workload as a result of changes in the

    hospital, the authors found, the greater the impact of

    restructuring and the greater the nurses emotional

    exhaustion, cynicism, depression, and anxiety (p.

    104). Decreased job satisfaction, professional efcacy,

    and job security were also related to increased workload.

    Restructuring has also been found to have a greater,

    more negative effect on younger nurses, a nding with

    severe potential implications for both retention and

    recruitment (Burke & Greenglass, 2000).

    Nurses believe that patients well-being and safety are

    increasingly jeopardized by deterioration of nurses

    working conditions (Aiken et al., 2001; Keddy, Gregor,

    Foster, & Denney, 1998; Nicklin & McVeety, 2002).

    When patient care must be compromised because nurses

    do not have enough time to achieve quality outcomes,

    job satisfaction and morale also suffer. These may be

    connected with high levels of absenteeism (Zboril-

    Benson, 2002).

    Restructuring and increased workload are also related

    to high levels of absenteeism among nurses. In one

    study, nearly 25% of 2000 respondents reported that

    they had seriously considered leaving nursing; of these,

    half cited overwork and stress as their main reasons

    (Zboril-Benson, 2002). Another 15.6% cited disillusion

    with nursing, while high job dissatisfaction, full-time

    work, 12-h shifts and working in an acute care setting

    were also predictors of absence. This suggests that 12-h

    shifts may not be practicable in the present health care

    work environment, particularly for older nurses. When

    nurses were asked for a solution to the problem of

    absenteeism, provision of adequate stafng levels was

    the most common response (Zboril-Benson, 2002).

    While a nursing shortage may result in short-term

    bargaining opportunities for nurses, this is highly

    market dependent and likely to uctuate. Some nurses

    have tended to advocate for themselves by leaving an

    undesirable work environment. Nurses often migrate to

    other countries where signing bonuses, educationalIntrinsic(person)

    Extrinsic(situation)

    Imbalance(Overcommitment)

    High effortLow reward

    Obligations Career opportunities

    Fig. 1. Effortreward imbalance model (Seigrist, 1996).The nursing work environment includes a number of

    dimensions (e.g., physical and psycho-social) that can be

    inuenced by organizational management practices

    (Koehoorn, Lowe, Rondeau, Schellenberg, & Wagar,

    2002). Many of the issues that were identied in the

    nursing work in this study include areas related to the

    eld of psychosocial work environments. Thus, the

    theoretical model for effortreward imbalance at work

    (ERI) (Seigrist, 1996, 2002) as outlined in Fig. 1 was

    used to frame this research. Emerging from social

    reciprocity theory, ERI asserts that ongoing high effort

    at work in combination with low reward leads to distress

    reactions that result in adverse long-term effects on the

    physical and mental health of employees (Seigrist, 2002,

    2004). Effort refers to the demands of work. Rewards

    are transmitted to employees as scarce resources

    including money, esteem, and career opportunities.

    There are two dimensions to the model: an extrinsic

    situational dimension of work-related demands and

    rewards, and an intrinsic personal dimension of ways

    of coping with demanding situations and of eliciting

    extrinsic rewards, as measured by the construct of

    overcommitment (Seigrist, 2002).

    Money

  • zations located in different geographical regions of

    ARTICLE IN PRESSL. McGillis Hall, D. Kiesners / Social Science & Medicine 61 (2005) 248224912484Ontario, which enhances the representativeness of the

    sample.

    Names of possible interviewees were provided to the

    principal investigator of the study by on-site contact

    persons for each institution. These potential interviewees

    were nurses who identied an interest in participating in

    the study. Purposive sampling was used to select

    individuals from each site who were contacted by

    telephone, informed of the purpose of the interviews

    and asked if they were still willing to be interviewed. All

    of the nurses who expressed willingness to participate in

    these interviews were female. The subjects were em-

    ployed in either Medical or Surgical units in their

    respective institutions and presented a wide range of

    nursing experience from 9 months to 40 years. Seven of

    the nurses interviewed were employed full-time,

    although most had worked part-time at one point or

    another in their careers. One currently worked part-

    time, a situation that suited her lifestyle. Six were

    Registered Nurses while one subject was a Registered

    Practical Nurse.Method

    A narrative inquiry approach was employed in this

    study as it allows individuals to tell stories about

    experiences from their daily lives (Sandelowski, 1991).

    Interviews were conducted with eight hospital nurses,

    one from each of the eight hospital settings participating

    in the research. The study was developed out of concern

    for the effects of the reorganization of health care on the

    nursing work environment. The nurses were asked to

    describe in their own words issues of importance to them

    in their working liveswhat its like to be a nurse in

    todays work environment. The intent was to provide

    an opportunity for nurses to speak out about work life

    issues; to obtain their understanding of designated

    working life issues; to discover other areas of developing

    concern; and to listen to their recommendations for

    needed changeto acquire, in effect, a snapshot of a

    health care system in transformation from the perspec-

    tive of the nurse.

    Sample and data collection process

    The study received approval from the university ethics

    review board as well as the ethics boards of all eight of

    the hospitals involved in the study. Interviews were

    conducted with a sample of eight nurses from the study

    hospitals who had indicated willingness to discuss the

    work environment of nurses with an interviewer. The

    hospitals involved were acute care, publicly funded

    hospitals that were randomly selected from across the

    province of Ontario, Canada. The eight hospitals

    represent teaching, community, and small rural organi-The interviews were approximately 1 h long. Marrow

    (1996) suggested that research ndings can take on an

    unreal character when that research is conducted away

    from the clinical setting, thus, it was felt that proximity

    to the work environment might make it easier for

    subjects to connect with and discuss work life issues even

    when they were not on duty. Whenever possible,

    interviews were conducted at the health care institution

    where the subject worked, both for the convenience of

    the nurses and to put them at ease by being interviewed

    in a familiar setting. Interview rooms were booked at

    their institutions so that the interviews would take place

    in privacy and the nurses would not be interrupted by

    work matters.

    Structure of interviews

    Interviews were such that the interviewer to some

    extent guided the interview by asking open-ended

    questions related to the topics of interest (Bowling,

    1997). Nurses were asked to talk about any issues related

    to their work lives that were important to them and that

    would help to illuminate what its like to be a nurse in

    todays work environment. Specic areas of interest

    were derived from a substantive review of the literature.

    Some of the concepts and categories were therefore pre-

    established, while others emerged from the interviews.

    Various techniques have been recommended for

    conducting qualitative research interviews. According

    to Britten (2000), the interviewer should begin with

    questions that are easy for the interviewee to answer and

    move towards difcult or sensitive issues in the course of

    the interview. Cohen and Manion (1994) found a

    funnel approach to be useful, in which the interview

    begins with a wide focus and gradually becomes more

    specic. Price (2002) stated that, although it is important

    not to force data or shape it according to research or

    other paradigms, entirely undirected interviews often

    produced results that were relatively supercial. He

    suggested that probes be structured at three levels of

    inquiry: action, knowledge and philosophy. Questions

    should be formed according to their level of anticipated

    intrusion, descriptions of action being assumed within

    this framework to be the least invasive and philosophical

    questionsthose concerned with beliefs, values and

    feelingsthe most invasive. Knowledge-based questions

    are best asked in the middle of the interview. This

    laddered technique was used when possible and when

    probes appeared necessary.

    Following the interview, subjects were asked whether

    they wished any details or portions of the interview

    deleted. Every attempt was made to ensure that the

    subjects were satised with the outcome and course of

    the interviews, and to ascertain that they had no

    reservations about what had been discussed. They were

    told that if any such reservations arose at any time

  • The eight participants were employed in either

    Medical or Surgical units in their respective institutions

    ARTICLE IN PRESSL. McGillis Hall, D. Kiesners / Social Science & Medicine 61 (2005) 24822491 2485and presented a wide range of nursing experience, from

    9 months to 40 years. The range of experience was a

    fortuitous artefact that helped demonstrate how the

    concerns of nurses might develop throughout their

    careers. The majority of the nurses interviewed were

    registered nurses who were employed full-time, although

    most had worked part-time at one point or another in

    their careers. One currently worked part-time, a situa-

    tion that suited her lifestyle, and one participant was a

    licensed practical nurse.

    Themes

    Detailed analysis of the transcripts revealed three key

    themes communicated by the nurses: patient acuity,

    workload and understafng; and adequacy of patient

    care. Workload and understafng dominated the

    narratives, although this was strongly linked to patient

    acuity and the adequacy of patient care provided. These

    key nursing work environment issues are now described

    and discussed in the context of the ERI model, as they

    were revealed in the nurses narratives, and implicati...

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