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A narrative approach to understanding the nursing work environment in Canada
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Social Science & Medicine 61 (2005) 2482–2491 www.elsevier.com/locate/socscimed
A narrative approach to understanding the nursing work environment in Canada Linda McGillis Hall, Diana Kiesners CIHR New Investigator, University of Toronto, Faculty of Nursing, 50 St. George Street, Toronto, Ont., Canada M5S 3H4 Available online 20 June 2005
Abstract Narrative 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. Seigrist’s ((1996) Journal of Occupational Health Psychology, 1, 27–41, (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) effort–reward 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 today’s health care system and the associated workload, the widespread shortage of nurses, and the imbalance this creates for nursing work. A crucial finding 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; Effort–reward imbalance; Canada
Introduction A number of recent reports and research studies have identified 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, & Corresponding author. Tel.: +1 416 978 2869;
fax: +1 416 978 8222. E-mail address: [email protected] (L. McGillis Hall).
Davis, 1996). Warnings that an ageing population of nurses combined with a lack of new graduates signifies 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 difficulty of recruiting new ones are at least partially due to a stressful and undesirable work environment. Many 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
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professional status, difficult relations in the workplace, difficulty 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 (O’Brien-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 significant and consistent predictor of stress among nurses in hospitals being downsized was workload. ‘‘The greater the nurse’s workload as a result of changes in the hospital,’’ the authors found, ‘‘the greater the impact of restructuring and the greater the nurse’s emotional exhaustion, cynicism, depression, and anxiety’’ (p. 104). Decreased job satisfaction, professional efficacy, 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 finding 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 (ZborilBenson, 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 staffing 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 fluctuate. Some nurses have tended to advocate for themselves by leaving an undesirable work environment. Nurses often migrate to other countries where signing bonuses, educational
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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 identified as major nursing workplace issues such as patient acuity and the staffing levels available to meet patient workload needs.
Theoretical framework The nursing work environment includes a number of dimensions (e.g., physical and psycho-social) that can be influenced by organizational management practices (Koehoorn, Lowe, Rondeau, Schellenberg, & Wagar, 2002). Many of the issues that were identified in the nursing work in this study include areas related to the field of psychosocial work environments. Thus, the theoretical model for effort–reward 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).
Extrinsic (situation)
Demands Obligations
Money Esteem Security Career opportunities
High effort
Intrinsic (person)
Low reward
Imbalance (Overcommitment)
Fig. 1. Effort–reward imbalance model (Seigrist, 1996).
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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 lives—‘‘what it’s like to be a nurse in today’s 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 change—to acquire, in effect, a snapshot of a health care system in transformation from the perspective 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 organizations located in different geographical regions of Ontario, 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 identified 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 employed 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 parttime, a situation that suited her lifestyle. Six were Registered Nurses while one subject was a Registered Practical Nurse.
The interviews were approximately 1 h long. Marrow (1996) suggested that research findings 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 it’s like to be a nurse in today’s work environment.’’ Specific areas of interest were derived from a substantive review of the literature. Some of the concepts and categories were therefore preestablished, 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 difficult 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 specific. 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 superficial. 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 questions—those concerned with beliefs, values and feelings—the 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 satisfied 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
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following the interviews they should not hesitate to call the interviewer to discuss them, and that if there was any part of the discussion they wanted excluded from the study their wishes would be honoured. Analysis All of the interviews were transcribed verbatim, and the transcriptions checked to ensure accuracy. The data analysis was guided by a methodology for identifying and interpreting narratives (Lieblich, Tuval-Mashiach, & Zilber, 1998). Each of the transcribed interviews was read closely to identify a particular participant’s story, the narrative theme underlying it. Portions of these narrative themes were highlighted and these segments of the transcripts were reread to capture the essence of the individual story, and summaries created. These were then analysed with reference to the topic areas established before the interviews and new categories that arose in the course of interviewing. Care was taken to maintain the nurses’ viewpoints and the balance of their narratives to maintain their emphasis, and their words.
Results Description of the sample The eight participants were employed in either Medical or Surgical units in their respective institutions and 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 situation 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 understaffing; and adequacy of patient care. Workload and understaffing 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 implications for health policy and management decisions are presented.
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Extrinsic dimension: The situation Effort Extrinsic factors in the work situation of nurses lead to the efforts they put forth in their work. These can include time pressures, interruptions, responsibility, the pressure to work overtime, physical demands, and increasing demands from work overall (Seigrist, 1996, 2002). Patient acuity. The primary area reported by all of the nurse participants as a major cause of stress in their working lives was patient acuity, which is consistent with the ‘‘effort’’ dimension of the theoretical model. The effort dimension explores whether a job has become more and more demanding (Seigrist, 1996, 2002; Seigrist et al., 2004). In this study, nurses identified that patients were sicker; often presenting with multiple conditions rather than just one: I think the major source of stress for nurses is that patients are sicker nowadays. Patients are not coming in with just Chronic Obstructive Pulmonary Disease (COPD), for example. They’re coming in with COPD and congestive heart failure and kidney failure—you know, every body system is going. So that’s a lot for a nurse because you’re not just focussing on one area. You’re focussing on every area and acuity has gone way up. And there are that many more procedures and paperwork involved with them. (Nurse 2). Another aspect of ‘‘effort’’ relates to employees having a lot of responsibility in their work. Nurses in this study described escalating work responsibility in their everyday work. Whereas a nurse might once have been required to care for three very sick patients out of six in a shift, now all six could be critically ill or fresh post-operative patients. Less critically ill patients who would once have been hospitalized are often dealt with on an out-patient basis, raising the average acuity of those patients remaining in hospital. In addition, the patient population is ageing as patients are getting older. As well as their medical problems, now they are recovering from surgery so their other problems are compounded. Issues of acuity are connected with workload, which is itself influenced by the nurse–patient ratio and staff mix. However, it is striking that of all the factors considered in the interviews, increased patient acuity was the one agreed upon as major by all respondents. In general, the patients are sicker, the nurses are fewer, and the result is increased stress for the nurse. Although acuity is agreed to have been on the rise for some time, nurse–patient ratios often have not reflected this increase: The acuity is high, very high. You have very ill patients. We are the only active Medical floor in the
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hospital. It’s a sort of almost step-down from ICU or a step-up to ICU. So you do have very ill patients. The acuity has been increasing over the years with no additional staff provided to the unit. (Nurse 8). We have a lot of really sick patients right now but our nurse–patient ratio doesn’t change. If you have four patients, you might have two that are really sick and two that are less sick. They’re all sick, but their acuity levels will be different. A four-patient workload with varied levels might not be as difficult as a four-patient workload where the acuity for all four is at the highest level. In general, the acuity is increasing. (Nurse 1). They come in and they’re really, really sick. It’s hard because if you’ve got four patients and they’re all really acute then you’re running around trying to make sure everything is done whereas if you’ve got at least one patient who can manage a little bit on their own or do something for themselves, then it’s not so bad. (Nurse 4). Workload and understaffing. The constant time pressures associated with a heavy workload are part of the demands and obligations included in the ‘‘effort’’ dimension of the EFI model (Seigrist, 1996). Workload was reported to be extremely high and appeared, even to the minimally experienced, to be increasing: I haven’t been a nurse for that long, but a lot of people seem to be saying the same things—that it’s too hard or that people are staying later at work because they didn’t have time to finish everything during the day. (Nurse 1). A nurse with 21 years of work experience felt that the increase in workload was accelerating: It’s amazing but I just don’t think anything has been as bad as it has been in the last five years. I’m trying to think of why that is and all I can think of is just that people are getting older; they need more help with activities of daily living, like just washing, dressing and walking because of physical infirmities. We have so many more machines attached to people nowadays. I really do think that we had better staffing in the past. (Nurse 5). Nurses were frustrated at being denied a sense of completion with regard to patient care or, indeed, to any given task. For some it was simply a question of feeling they had done a good job, had completed their care according to their own standards. A nurse who came to hospital nursing after working in Community Health compared the care: In the community you’re one on one and in the hospital it’s like 50 to one. You can never finish a
task. In the community you went in and you did what you had to do and you really didn’t leave until it was completed or the patients were set for that moment. You did everything you needed to do. Here at the hospital, you never feel like you ever finish a task. You just prioritize and finish what you have to at that moment. Actually sometimes I’m embarrassed that hospital patients are not getting the care they should. My workload is so extreme that after a shift I kind of pray that I’ve done everything, because I’m flying constantly all day long. (Nurse 7). Sometimes patients felt apologetic about asking for help from nurses they know are already overburdened. At other times they appeared to see first hand how overwhelmed their nurses were: They read the papers, they know what’s going on. The first thing they’ll say, a lot of them, is, ‘‘I’m so sorry for bothering you. I know you’re busy.’’ So then you have to say, ‘‘No, I’m here for you. I’m your nurse. So what can I do for you?’’ (Nurse 2). They feel really badly because their nurse is running around like a chicken with her head cut off. ‘‘Oh, poor so and so. She was really running yesterday.’’ They don’t want to ring the buzzer and that’s not what it’s all about. ‘‘You know, if you need help,’’ I tell them, ‘‘push the buzzer, because it’s the squeaky wheel that gets the grease here. If you don’t buzz for me, I won’t know.’’ (Nurse 5). Reward Extrinsic factors in the work situation of nurses include the rewards received for work. These can include salary, respect, adequate support and treatment, esteem, recognition, job security, promotion prospects, undesirable change, and career opportunities (Seigrist, 1996, 2002). Esteem and recognition: Adequacy of patient care. One of the components of ‘‘reward’’ relates to the adequacy of the recognition and esteem that the employee receives from their superiors and colleagues (Seigrist, 1996, 2002). This is considered an important dimension of worklife balance. Individuals who are perceived to be overcommitted to their work have a strong desire for esteem (Tsutsumi et al., 2002). Nurses in this study clearly demonstrate overcommitment to their work, yet recognition of their work is not described. Rather, nurses articulate how the level of patient care they were able to provide was a significant work life issue for many of them. Nurses were unhappy about being unable to provide the level of care that they considered adequate, which in turn impacts on their perception of
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esteem. There was little time to communicate with patients: You know, what’s rewarding about nursing is talking to people and helping them. That’s how you find out things that maybe you weren’t aware of, that will help with the care you’re giving them. I think that’s a big part of it. But it’s so busy now you can’t always give all the care that you would want to give. (Nurse 1). I wish I were allowed to work at a more relaxed pace, that I had more time to go in and chat with my patients rather than being so task-oriented all the time. Because I really do think that emotional bond is important with patients. I would just like to have more time to do teaching and to be able to have that chat with them. (Nurse 5). Nurses traditionally gain recognition and esteem from patients through their experiences involving teaching. Patient education was regarded by nurses in this study as a crucial aspect of patient care and one nearly impossible to find time for. Let’s say the patient is a new diabetic. You have to make sure that you get the doctor’s order to the Diabetic Educator and that the patient knows what the supplies are and that they practice giving themselves the injection. You have to make sure that they’re able to do it at home on their own, when you’re not doing it anymore and that they’re ready to function independently outside of the hospital, that they’re not leaving the hospital unprepared. (Nurse 6). The pressures of time and workload meant that nurses were constantly multitasking, doubling and tripling up on activities, performing diagnostic functions while carrying out routine tasks: You have to start asking questions right off the bat. While you’re bathing them you’re asking them who they live with, where they live, how they are getting home. You have to. You don’t have time to say, ‘‘Okay, now we’ll discuss your ileostomy.’’ While you’re making the bed you’re saying ‘‘Oh, the ostomy nurse—do you know if she’s booked to come in on Tuesday to discuss the types of prosthetics that you’re going to need and give you the forms for the doctor to sign to have it paid for?’’ (Nurse 6). Some nurses reported that basic hygiene and housekeeping—‘‘beds and baths’’, were becoming compromised because of lack of time and overwhelming nursing workload. The nurses’ time was completely taken up with more critical issues. Making patients comfortable and relaxed by cleaning them up is considered by nurses’
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to be an important precondition to their successful therapy and healing that nurses were not able to carry out in this work climate: One man was very sick and, even though he’d had a post-operative wash, he had a bit of blood here and there, and a little bit of urine here and there. I couldn’t not wash him and then ask him to get up for a walk and do the deep breathing, the coughing and all the exercises that I wanted him to do in order to get better. I had to make him feel good first. (Nurse 5). Intrinsic dimension: The person Intrinsic factors in the work situation of nurses lead to the coping mechanisms used to deal with work, primarily in the form of overcommitment. This can include a need for approval, disproportionate irrationality and the inability to withdraw from work (Seigrist, 1996, 2002). Overcommitment Seigrist (2002) suggests that employee response to demands is an excessive work-related overcommitment, which may be characterized through the inability to withdraw from work obligations. This was evident with the nurses in this study. No matter how hard or how long nurses worked, there did not seem to be enough hours in the day to handle the workload. Some nurses reported missing breaks and meals on a frequent basis. The lack of respite could be extreme: Lots of times we don’t take an afternoon break— that’s almost non-existent—and a supper break. We don’t take care of ourselves break-wise because we want to get out on time. Quite often I work shifts with very little break. I have even worked twelvehour shifts with no break, especially on the night shift. You could not leave the floor. I sit there and eat my sandwich while I’m charting and hardly have time to go to the washroom. (Nurse 5). Nurses said they knew that if they took breaks they would have to work overtime in order to get their work done. This is consistent with the EFI model, where the demands or obligations of the job can pressure employees to work overtime (Seigrist et al., 2004). Nurses felt, however, that it was better to work the overtime, as they would feel better if they went and took 20 min to sit down. Some thought their health was being affected by this workload. I think that nursing is affecting everybody’s health with the length of the shifts, the stress, and the physical demand of night shifts. It has to take a toll on someone’s life. I have a nurse’s back and am
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emotionally exhausted every day. I come home and I think, ‘‘Now tomorrow when I go back I will be positive,’’ but it takes me five minutes on the floor and I’m back in the same boat I was before because situations do not change. (Nurse 8). Depending on the nurse and the institution, workload might be rated from somewhat stressful to so crushingly high that interviewees were considering leaving their institutions or jobs because of it. This represents the excessive work-related commitment, or overcommitment experienced by employees who cannot let go of work, and it stays with them after they have left work (Seigrist, 2002). One nurse repeatedly used the word ‘‘frantic’’ to describe her work situation. To an interviewee who had been a nurse for 40 years, the effects of current nursing workload on the profession were overwhelming: You go home every day knowing you haven’t completed your job. There is no way that you can finish your workload. You have to decide on what is most important and hopefully what is left isn’t and wasn’t that important because there is just too much for the workload, for the amount of nurses. The hospitals have cut and cut. You are portering and you are lifting, you are taking on the job of the orderly. You are everything. (Nurse 8). The majority of nurses reported extreme physical exhaustion at the end of shift and the sense of having been on the run throughout. This behaviour is characteristic of the imbalance that is created when employees are overcommitted to their work (Seigrist, 1996). Because of increases in patient acuity, nurse–patient ratio was not necessarily an accurate predictor of workload. As one nurse explained, I used to be able to handle four or five patients, even six, quite nicely because usually several of them were going home or they weren’t that sick, but now you have six that are sick! (Nurse 3). The imbalance between effort and reward in nursing work The model of ERI suggests that when there is a lack of reciprocity between the work expended and the reward or gains to the employee, a negative outcome results (Seigrist, 1996, 2002). In this study, the stress and burnout of excessive workload was accompanied by high levels of absenteeism. Because it was often difficult to replace staff on short notice and because some institutions had the practice of replacing the second sick call on a shift but not the first, absenteeism further increased the workload for the remaining nurses and, in a circular manner, contributed to their stress and potential absenteeism. When acuity was high and
workload was at a critical level, the practice of not replacing the first sick call placed a burden on the nurses who were present. If there was a second sick call, if two nurses were absent, the unit would begin calling around to try to find a replacement nurse. However, this was not always possible; casual and part-time pools might be already over-used and replacement staff simply not available. Even if a replacement could be found, there was sometimes a lengthy period of time during which nurses had to deal with an inadequate nurse–patient ratio. Nurses might end up staying at work for extra hours, even though they had already worked a full 12-h shift. For one nurse, a contentious issue was trying to balance her duties as Charge Nurse with her patient load, a balance that was easier to achieve on some days than on others: On some days it doesn’t work at all, because I still have a patient assignment even though I’m the Charge Nurse. I have three patients. Sometimes that’s hard if there’s stuff going on because you’re striving to look after your patients and there’s other stuff going on and you feel like you’re being torn between everything that needs doing. (Nurse 2). High workload and the resultant stress were also linked in some nurses’ minds with both nurse and patient safety. When nurses were rushing around, accidents were more likely to occur and nurses were more likely to injure themselves. The ongoing disparity of effort and rewards is prevalent in nurse’s work. Seigrist (2002) suggests that an imbalance is maintained when an alternative choice is unavailable, when the condition is accepted for strategic reasons, or as a personal coping style of the individual. It is evident that workload has fostered the level of imbalance reported by nurses in this study. Workload as an issue is affected by acuity, absenteeism and understaffing. It in turn affects stress levels, perceived quality of patient care, absenteeism and possible risk of injury to nurses. Often understaffing is a budgetary issue, but some institutions are finding it difficult to recruit nurses even when they actively seek them. It is impossible to overestimate the importance of workload as a factor causing an imbalance in the working lives of nurses. Some felt that even talking about other worklife concerns served to obscure the importance of this central issue: The workload is getting to everybody these days. It’s the sheer mental stress that is involved. You come home and you bring it home with you and you’re just exhausted because of the workload. You bring the tiredness home, the stress levels home. (Nurse 8). I think workload is everything. Work environment is everything. I’ve stuck with it as long as I have because of the people and the work environment I
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used to have. This is very stressful, the way things are here now. You’d always have a day where you had a stressful day, that’s part of nursing, but you shouldn’t have to work 150% every day. It gets to the point where you can’t even say hello to a patient. You should be able to breathe. You should be able to work at a natural pace instead of always being pressured and pushed. That’s what’s happening here now. (Nurse 3). The absence or insufficiency of non-nursing staff such as porters interacted with and created other problems for nursing staff. With porters in short supply, in some institutions volunteers are helping with transport. However, their participation is limited as the nurse still has to get the patient onto the stretcher as volunteers are not allowed to provide direct patient care. It is obvious that the patient care requirements of the unit were not necessarily reflected in the staff mix: On weekends we’re still doing X-rays, we’re still sending patients up to the OR, just like from Monday to Friday, but we’re down one nurse and we don’t have a desk clerk after 3:00 pm. So when a new patient comes in, the nurse is putting the chart together, which has got a lot of documentation, completing the requisitions, phoning for the electrocardiogram (ECG) because the patient is going to the OR. Then you’ve got to phone the respiratory technologist (RT) to do the ECG because there’s no ECG technician on during the weekend. The nurse is now answering the phone to the relatives, putting the charts together, making all of these arrangements while trying to look after her own set of patients. Weekends are not fun! (Nurse 6). It was often reported that technology had actually increased nurses’ workload. Nurses’ suspected that most technologies presented to them as labour-saving devices actually increased workload and were used as an excuse to reduce staffing or to introduce other organizational economies. These perceptions highlight the dualism that seems to occur between management and staff, each with competing priorities and values (Traynor, 1999): We have morphine pumps, epidural lines, femoral lines, so you’re doing vital signs frequently. For postoperative patients on a patient controlled-anesthesia (PCA) pump, you have to do vitals every hour for twelve hours. For five years we’ve had PCA pumps. To change the rate of the cartridge now takes two nurses. There are so many problems with the pumps that for accountability—holy smokes! They haven’t saved us any time. (Nurse 6). Now we have very expensive monitors because you have to be doing vital signs every 15 min for a couple
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of hours. So you’re in there all the time, it’s almost one-on-one nursing care. But you don’t have one-onone staffing to support this. (Nurse 6). One nurse said that she knew extra staffing was the solution but also knew that funds did not exist to implement it, causing her to feel hopeless about the whole situation. This tendency for nurses to discuss the financial state of their workplace demonstrates how the language of fiscal rationing has permeated the nursing workplace (Traynor, 1999). Another nurse who logged 24 patient care hours in a single shift wondered if anyone noticed, again underscoring the dualism between management and the nursing staff (Traynor, 1999): But if I were to say what the solution is, once again it comes down to more staffing. And I know that’s not going to happen because, the way it is now, we don’t even have the funding for current staffing needs. (Nurse 8). I often wonder why we’re doing these things. Does anyone ever look at that and say, ‘Wow, better not let that happen again!’ (Nurse 3).
Discussion The nurses who participated in this study varied in age and years of experience in nursing, yet all had a similar story to tell about their work environment. The findings from this study illustrate the degree to which factors such as patient acuity, workload and understaffing shape the work environment for nurses and create imbalance. The nurses’ narratives explored here suggest that multiple factors constitute the nurses’ work environment and their experiences and perceptions of the work environment. Nursing work environments: High effort and low reward These work environment factors demonstrate a higheffort workplace with little or no evidence of reward conditions in place for nurses. Seigrist (2002) suggests that the lack of balance between high effort and low reward in work situations affects health. Preliminary evidence of this is apparent in these narratives from nurses with descriptions of absenteeism, taking home feelings of guilt and excessive stress. The EFI model is based on the notion of reciprocity, whereby the efforts of the employee at work are reinforced through rewards that are socially defined (Seigrist, 2004). A failure to achieve reciprocity results in an imbalance with high effort and low rewards. This results in decreased self esteem and long-term stress for employees (Seigrist, 1996, 2004). Several studies have identified these
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concerns in nursing work environments (Aiken et al., 2001; Baumann et al., 2001; Kluska, Spence Laschinger, & Kerr, 2004; McGillis Hall, 2003; O’Brien-Pallas et al., 2004; Page, 2003).
Implications for policy makers and administrators Several predictable issues surfaced repeatedly in the interviews related to the changing needs of hospitalized patients in today’s health care system, and the widespread shortage of nurses. A crucial finding in this study is the extent to which the nurse is impacted by the adequacy of care they are able to provide. Nursing practice is a profession, and nurses have an inherent sense of caring in their work and a sensitivity to the needs of their patients. These narratives outline the tremendous burden of guilt that nurses bear when factors in the work environment prevent them from providing complete, quality care. As well, nurses identified the key role they play in health care teaching and preparing patients for their discharge back into their homes and the community. From the nurses’ perspective, the care they are providing in today’s hospital health care environment is inadequate. The perceptions that nurses have of access to resources has been found to impact the amount of ERI they experience (Kluska et al., 2004). Nurses are experiencing frustration and stress that is impacting their worklife, family and home life, as well as their personal health. In telling their stories, these nurses have provided an opportunity from which health care policy makers and administrators can develop an understanding of these experiences, and how these experiences are shaping the practice of hospital nursing today. These narratives about the nursing work environment will inform interventions that can be tailored to improve the quality of patient care that nurses are able to provide. Nurses’ awareness of the impact of their own personal behaviours on patients was evident. These narratives may also serve to provide a mechanism by which nurses can reflect on their practice in the work environment, and how it impacts patient outcomes. This in turn could have long-term implications on patient and system outcomes. The ERI model provides a useful tool for studying the worklife of nurses. Government funding cutbacks in the past decade have forced health care settings to restructure and downsize nursing positions (McGillis Hall, 2005). The result is a work environment that lacks balance and is contributing to adverse outcomes for the system (e.g., absenteeism) and the nurse (e.g., stress). Using the information from these narratives, health care administrators can re-examine the nursing work environment and the work of nurses within it. Tangible efforts to redesign nursing work that involve nurses in
the process should lead to a better understanding of the staffing required to maintain a safe and healthy patient care work environment. The importance of placing an emphasis on workplace health is underscored in this study. Nurses are a fundamental component of patient care delivery systems. Their work may not always be quantifiable in strict fiscal terms. Nurses in this study demonstrated patterns of coping with job demands that reflect overcommitment to their work. It is apparent from this study that stress-reduction approaches should be implemented in nursing workplaces. These provide a tremendous potential for intervention approaches that can promote the esteem and recognition rewards that nurses need to achieve balance in their work. Interventions can be designed to provide direct support for nurses dealing with real-life issues in the workplace. The importance of listening to nurses’ stories about the challenges they undergo in their workplaces can only help to inform us of the key issues in the workplace that need to be addressed for the successful retention of nurses in the profession.
Acknowledgements Funded by the Ministry of Health and Long Term Care, Ontario, Canada.
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ARTICLE IN PRESS L. McGillis Hall, D. Kiesners / Social Science & Medicine 61 (2005) 2482–2491 Cohen, L., & Manion, L. (1994). Research methods in education (3rd ed.). New York, London: Routledge. Greenglass, E. R., & Burke, R. J. (2001). Stress and the effects of hospital restructuring on nurses. Canadian Journal of Nursing Research, 33(2), 93–108. Health Canada. (2001). Healthy nurses, healthy workplaces. Ottawa, Canada: The Office of Nursing Policy: Health Policy & Communications Branch, Health Canada. Heitlinger, A. (2003). The paradoxical impact of health care restructuring in Canada on nursing as a profession. International Journal of Health Services, 33(1), 37–54. Keddy, B., Gregor, F., Foster, S., & Denney, D. (1998). Theorizing about nurses’ work lives: The personal and professional aftermath of living with healthcare ‘reform’. Nursing Inquiry, 6, 58–64. Kluska, K. M., Spence Laschinger, H. K., & Kerr, M. S. (2004). Staff nurse empowerment and effort–reward imbalance. Canadian Journal of Nursing Leadership, 17(1), 112–127. Koehoorn, M., Lowe, G.S., Rondeau, K.V., Schellenberg, G., & Wagar, T.H., (2002). Creating high-quality health care workplaces. (CPRN Discussion Paper No. W|14). Retrieved January 24, 2005, from the Canadian Health Services Research Foundation Web site: http://www.chsrf.ca/final_ research/commissioned_research/programs/pdf/cr-cprn_e.pdf. Lieblich, A., Tuval-Mashiach, R., & Zilber, T. (1998). Narrative research: Reading, analysis and interpretation. Thousand Oaks, CA: Sage. Marrow, C. (1996). Using qualitative research methods in nursing. Nursing Standard, 11(7), 43–45. McGillis Hall, L. (2003). Nursing staff mix models and outcomes. Journal of Advanced Nursing, 44(2), 217–226. McGillis Hall, L. (2005). Strategies used to rebuild nursing following restructuring. Canadian perspectives. Journal of Research in Nursing, 10(1). Nicklin, W., & McVeety, J. E. (2002). Canadian nurses’ perceptions of patient safety in hospitals. Canadian Journal of Nursing Leadership, 15(3), 11–21. Nursing Task Force. (1999). Good nursing, good health: An investment for the 21st century. Ontario Ministry of Health. O’Brien-Pallas, L., Thomson, D., McGillis Hall, L., Pink, G., Kerr, M., Wang, S., Li, X., et al. (2004). Evidence-based
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standards for measuring nurse staffing and performance. Final report. Toronto, ON: Canadian Health Services Research Foundation. Page, A. (2003). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press. Price, B. (2002). Laddered questions and qualitative data research interviews. Journal of Advanced Nursing, 37(3), 273–281. Sandelowski, M. (1991). Telling stories: Narrative approaches in qualitative research. Image: Journal of Nursing Scholarship, 23, 161–166. Seigrist, J. (1996). Adverse health effects of high effort-low reward conditions. Journal of Occupational Health Psychology, 1, 27–41. Seigrist, J. (2002). Effort–reward imbalance at work and health. In P. L. Perrewe, & D. G. Ganster (Eds.), Historical and current perspectives on stress and health. Research in occupational stress and well being, vol. 2. Boston, MA: Jai Press. Seigrist, J. (2004). Adverse health effects of effort-reward imbalance—applying the model to Eastern Europe. Retrieved January 27, 2005, from http://www.magtud.sote.hu/ siegrist.htm. Seigrist, J., Starke, D., Chandola, T., Godin, I., Marmot, M., Niedhammer, I., & Peter, R. (2004). The measurement of effort–reward imbalance at work: European comparisons. Social Science & Medicine, 58, 1483–1499. Traynor, M. (1999). Managerialism and nursing: Beyond oppression and profession. London: Routledge. Tsutsumi, A., Kayaba, K., Nagami, M., Miki, A., Kawano, Y., Ohya, Y., Odagiri, Y., & Shimomitsu, T. (2002). The effort-reward imbalance model: experience in Japanese working population. Journal of Occupational Health, 44, 398–407. Wunderlich, G. S., Sloan, F. S., & Davis, C. K. (1996). Nursing staff in hospitals and nursing homes: Is it adequate?. Washington, DC: National Academy Press. Zboril-Benson, L. R. (2002). Why nurses are calling in sick: The impact of health-care restructuring. Canadian Journal of Nursing Research, 33(4), 89–107.
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A narrative approach to understanding the nursing work environment in Canada Linda McGillis Hall, Diana Kiesners CIHR New Investigator, University of Toronto, Faculty of Nursing, 50 St. George Street, Toronto, Ont., Canada M5S 3H4 Available online 20 June 2005
Abstract Narrative 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. Seigrist’s ((1996) Journal of Occupational Health Psychology, 1, 27–41, (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) effort–reward 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 today’s health care system and the associated workload, the widespread shortage of nurses, and the imbalance this creates for nursing work. A crucial finding 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; Effort–reward imbalance; Canada
Introduction A number of recent reports and research studies have identified 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, & Corresponding author. Tel.: +1 416 978 2869;
fax: +1 416 978 8222. E-mail address: [email protected] (L. McGillis Hall).
Davis, 1996). Warnings that an ageing population of nurses combined with a lack of new graduates signifies 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 difficulty of recruiting new ones are at least partially due to a stressful and undesirable work environment. Many 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
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professional status, difficult relations in the workplace, difficulty 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 (O’Brien-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 significant and consistent predictor of stress among nurses in hospitals being downsized was workload. ‘‘The greater the nurse’s workload as a result of changes in the hospital,’’ the authors found, ‘‘the greater the impact of restructuring and the greater the nurse’s emotional exhaustion, cynicism, depression, and anxiety’’ (p. 104). Decreased job satisfaction, professional efficacy, 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 finding 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 (ZborilBenson, 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 staffing 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 fluctuate. Some nurses have tended to advocate for themselves by leaving an undesirable work environment. Nurses often migrate to other countries where signing bonuses, educational
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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 identified as major nursing workplace issues such as patient acuity and the staffing levels available to meet patient workload needs.
Theoretical framework The nursing work environment includes a number of dimensions (e.g., physical and psycho-social) that can be influenced by organizational management practices (Koehoorn, Lowe, Rondeau, Schellenberg, & Wagar, 2002). Many of the issues that were identified in the nursing work in this study include areas related to the field of psychosocial work environments. Thus, the theoretical model for effort–reward 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).
Extrinsic (situation)
Demands Obligations
Money Esteem Security Career opportunities
High effort
Intrinsic (person)
Low reward
Imbalance (Overcommitment)
Fig. 1. Effort–reward imbalance model (Seigrist, 1996).
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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 lives—‘‘what it’s like to be a nurse in today’s 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 change—to acquire, in effect, a snapshot of a health care system in transformation from the perspective 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 organizations located in different geographical regions of Ontario, 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 identified 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 employed 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 parttime, a situation that suited her lifestyle. Six were Registered Nurses while one subject was a Registered Practical Nurse.
The interviews were approximately 1 h long. Marrow (1996) suggested that research findings 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 it’s like to be a nurse in today’s work environment.’’ Specific areas of interest were derived from a substantive review of the literature. Some of the concepts and categories were therefore preestablished, 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 difficult 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 specific. 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 superficial. 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 questions—those concerned with beliefs, values and feelings—the 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 satisfied 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
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following the interviews they should not hesitate to call the interviewer to discuss them, and that if there was any part of the discussion they wanted excluded from the study their wishes would be honoured. Analysis All of the interviews were transcribed verbatim, and the transcriptions checked to ensure accuracy. The data analysis was guided by a methodology for identifying and interpreting narratives (Lieblich, Tuval-Mashiach, & Zilber, 1998). Each of the transcribed interviews was read closely to identify a particular participant’s story, the narrative theme underlying it. Portions of these narrative themes were highlighted and these segments of the transcripts were reread to capture the essence of the individual story, and summaries created. These were then analysed with reference to the topic areas established before the interviews and new categories that arose in the course of interviewing. Care was taken to maintain the nurses’ viewpoints and the balance of their narratives to maintain their emphasis, and their words.
Results Description of the sample The eight participants were employed in either Medical or Surgical units in their respective institutions and 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 situation 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 understaffing; and adequacy of patient care. Workload and understaffing 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 implications for health policy and management decisions are presented.
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Extrinsic dimension: The situation Effort Extrinsic factors in the work situation of nurses lead to the efforts they put forth in their work. These can include time pressures, interruptions, responsibility, the pressure to work overtime, physical demands, and increasing demands from work overall (Seigrist, 1996, 2002). Patient acuity. The primary area reported by all of the nurse participants as a major cause of stress in their working lives was patient acuity, which is consistent with the ‘‘effort’’ dimension of the theoretical model. The effort dimension explores whether a job has become more and more demanding (Seigrist, 1996, 2002; Seigrist et al., 2004). In this study, nurses identified that patients were sicker; often presenting with multiple conditions rather than just one: I think the major source of stress for nurses is that patients are sicker nowadays. Patients are not coming in with just Chronic Obstructive Pulmonary Disease (COPD), for example. They’re coming in with COPD and congestive heart failure and kidney failure—you know, every body system is going. So that’s a lot for a nurse because you’re not just focussing on one area. You’re focussing on every area and acuity has gone way up. And there are that many more procedures and paperwork involved with them. (Nurse 2). Another aspect of ‘‘effort’’ relates to employees having a lot of responsibility in their work. Nurses in this study described escalating work responsibility in their everyday work. Whereas a nurse might once have been required to care for three very sick patients out of six in a shift, now all six could be critically ill or fresh post-operative patients. Less critically ill patients who would once have been hospitalized are often dealt with on an out-patient basis, raising the average acuity of those patients remaining in hospital. In addition, the patient population is ageing as patients are getting older. As well as their medical problems, now they are recovering from surgery so their other problems are compounded. Issues of acuity are connected with workload, which is itself influenced by the nurse–patient ratio and staff mix. However, it is striking that of all the factors considered in the interviews, increased patient acuity was the one agreed upon as major by all respondents. In general, the patients are sicker, the nurses are fewer, and the result is increased stress for the nurse. Although acuity is agreed to have been on the rise for some time, nurse–patient ratios often have not reflected this increase: The acuity is high, very high. You have very ill patients. We are the only active Medical floor in the
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hospital. It’s a sort of almost step-down from ICU or a step-up to ICU. So you do have very ill patients. The acuity has been increasing over the years with no additional staff provided to the unit. (Nurse 8). We have a lot of really sick patients right now but our nurse–patient ratio doesn’t change. If you have four patients, you might have two that are really sick and two that are less sick. They’re all sick, but their acuity levels will be different. A four-patient workload with varied levels might not be as difficult as a four-patient workload where the acuity for all four is at the highest level. In general, the acuity is increasing. (Nurse 1). They come in and they’re really, really sick. It’s hard because if you’ve got four patients and they’re all really acute then you’re running around trying to make sure everything is done whereas if you’ve got at least one patient who can manage a little bit on their own or do something for themselves, then it’s not so bad. (Nurse 4). Workload and understaffing. The constant time pressures associated with a heavy workload are part of the demands and obligations included in the ‘‘effort’’ dimension of the EFI model (Seigrist, 1996). Workload was reported to be extremely high and appeared, even to the minimally experienced, to be increasing: I haven’t been a nurse for that long, but a lot of people seem to be saying the same things—that it’s too hard or that people are staying later at work because they didn’t have time to finish everything during the day. (Nurse 1). A nurse with 21 years of work experience felt that the increase in workload was accelerating: It’s amazing but I just don’t think anything has been as bad as it has been in the last five years. I’m trying to think of why that is and all I can think of is just that people are getting older; they need more help with activities of daily living, like just washing, dressing and walking because of physical infirmities. We have so many more machines attached to people nowadays. I really do think that we had better staffing in the past. (Nurse 5). Nurses were frustrated at being denied a sense of completion with regard to patient care or, indeed, to any given task. For some it was simply a question of feeling they had done a good job, had completed their care according to their own standards. A nurse who came to hospital nursing after working in Community Health compared the care: In the community you’re one on one and in the hospital it’s like 50 to one. You can never finish a
task. In the community you went in and you did what you had to do and you really didn’t leave until it was completed or the patients were set for that moment. You did everything you needed to do. Here at the hospital, you never feel like you ever finish a task. You just prioritize and finish what you have to at that moment. Actually sometimes I’m embarrassed that hospital patients are not getting the care they should. My workload is so extreme that after a shift I kind of pray that I’ve done everything, because I’m flying constantly all day long. (Nurse 7). Sometimes patients felt apologetic about asking for help from nurses they know are already overburdened. At other times they appeared to see first hand how overwhelmed their nurses were: They read the papers, they know what’s going on. The first thing they’ll say, a lot of them, is, ‘‘I’m so sorry for bothering you. I know you’re busy.’’ So then you have to say, ‘‘No, I’m here for you. I’m your nurse. So what can I do for you?’’ (Nurse 2). They feel really badly because their nurse is running around like a chicken with her head cut off. ‘‘Oh, poor so and so. She was really running yesterday.’’ They don’t want to ring the buzzer and that’s not what it’s all about. ‘‘You know, if you need help,’’ I tell them, ‘‘push the buzzer, because it’s the squeaky wheel that gets the grease here. If you don’t buzz for me, I won’t know.’’ (Nurse 5). Reward Extrinsic factors in the work situation of nurses include the rewards received for work. These can include salary, respect, adequate support and treatment, esteem, recognition, job security, promotion prospects, undesirable change, and career opportunities (Seigrist, 1996, 2002). Esteem and recognition: Adequacy of patient care. One of the components of ‘‘reward’’ relates to the adequacy of the recognition and esteem that the employee receives from their superiors and colleagues (Seigrist, 1996, 2002). This is considered an important dimension of worklife balance. Individuals who are perceived to be overcommitted to their work have a strong desire for esteem (Tsutsumi et al., 2002). Nurses in this study clearly demonstrate overcommitment to their work, yet recognition of their work is not described. Rather, nurses articulate how the level of patient care they were able to provide was a significant work life issue for many of them. Nurses were unhappy about being unable to provide the level of care that they considered adequate, which in turn impacts on their perception of
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esteem. There was little time to communicate with patients: You know, what’s rewarding about nursing is talking to people and helping them. That’s how you find out things that maybe you weren’t aware of, that will help with the care you’re giving them. I think that’s a big part of it. But it’s so busy now you can’t always give all the care that you would want to give. (Nurse 1). I wish I were allowed to work at a more relaxed pace, that I had more time to go in and chat with my patients rather than being so task-oriented all the time. Because I really do think that emotional bond is important with patients. I would just like to have more time to do teaching and to be able to have that chat with them. (Nurse 5). Nurses traditionally gain recognition and esteem from patients through their experiences involving teaching. Patient education was regarded by nurses in this study as a crucial aspect of patient care and one nearly impossible to find time for. Let’s say the patient is a new diabetic. You have to make sure that you get the doctor’s order to the Diabetic Educator and that the patient knows what the supplies are and that they practice giving themselves the injection. You have to make sure that they’re able to do it at home on their own, when you’re not doing it anymore and that they’re ready to function independently outside of the hospital, that they’re not leaving the hospital unprepared. (Nurse 6). The pressures of time and workload meant that nurses were constantly multitasking, doubling and tripling up on activities, performing diagnostic functions while carrying out routine tasks: You have to start asking questions right off the bat. While you’re bathing them you’re asking them who they live with, where they live, how they are getting home. You have to. You don’t have time to say, ‘‘Okay, now we’ll discuss your ileostomy.’’ While you’re making the bed you’re saying ‘‘Oh, the ostomy nurse—do you know if she’s booked to come in on Tuesday to discuss the types of prosthetics that you’re going to need and give you the forms for the doctor to sign to have it paid for?’’ (Nurse 6). Some nurses reported that basic hygiene and housekeeping—‘‘beds and baths’’, were becoming compromised because of lack of time and overwhelming nursing workload. The nurses’ time was completely taken up with more critical issues. Making patients comfortable and relaxed by cleaning them up is considered by nurses’
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to be an important precondition to their successful therapy and healing that nurses were not able to carry out in this work climate: One man was very sick and, even though he’d had a post-operative wash, he had a bit of blood here and there, and a little bit of urine here and there. I couldn’t not wash him and then ask him to get up for a walk and do the deep breathing, the coughing and all the exercises that I wanted him to do in order to get better. I had to make him feel good first. (Nurse 5). Intrinsic dimension: The person Intrinsic factors in the work situation of nurses lead to the coping mechanisms used to deal with work, primarily in the form of overcommitment. This can include a need for approval, disproportionate irrationality and the inability to withdraw from work (Seigrist, 1996, 2002). Overcommitment Seigrist (2002) suggests that employee response to demands is an excessive work-related overcommitment, which may be characterized through the inability to withdraw from work obligations. This was evident with the nurses in this study. No matter how hard or how long nurses worked, there did not seem to be enough hours in the day to handle the workload. Some nurses reported missing breaks and meals on a frequent basis. The lack of respite could be extreme: Lots of times we don’t take an afternoon break— that’s almost non-existent—and a supper break. We don’t take care of ourselves break-wise because we want to get out on time. Quite often I work shifts with very little break. I have even worked twelvehour shifts with no break, especially on the night shift. You could not leave the floor. I sit there and eat my sandwich while I’m charting and hardly have time to go to the washroom. (Nurse 5). Nurses said they knew that if they took breaks they would have to work overtime in order to get their work done. This is consistent with the EFI model, where the demands or obligations of the job can pressure employees to work overtime (Seigrist et al., 2004). Nurses felt, however, that it was better to work the overtime, as they would feel better if they went and took 20 min to sit down. Some thought their health was being affected by this workload. I think that nursing is affecting everybody’s health with the length of the shifts, the stress, and the physical demand of night shifts. It has to take a toll on someone’s life. I have a nurse’s back and am
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emotionally exhausted every day. I come home and I think, ‘‘Now tomorrow when I go back I will be positive,’’ but it takes me five minutes on the floor and I’m back in the same boat I was before because situations do not change. (Nurse 8). Depending on the nurse and the institution, workload might be rated from somewhat stressful to so crushingly high that interviewees were considering leaving their institutions or jobs because of it. This represents the excessive work-related commitment, or overcommitment experienced by employees who cannot let go of work, and it stays with them after they have left work (Seigrist, 2002). One nurse repeatedly used the word ‘‘frantic’’ to describe her work situation. To an interviewee who had been a nurse for 40 years, the effects of current nursing workload on the profession were overwhelming: You go home every day knowing you haven’t completed your job. There is no way that you can finish your workload. You have to decide on what is most important and hopefully what is left isn’t and wasn’t that important because there is just too much for the workload, for the amount of nurses. The hospitals have cut and cut. You are portering and you are lifting, you are taking on the job of the orderly. You are everything. (Nurse 8). The majority of nurses reported extreme physical exhaustion at the end of shift and the sense of having been on the run throughout. This behaviour is characteristic of the imbalance that is created when employees are overcommitted to their work (Seigrist, 1996). Because of increases in patient acuity, nurse–patient ratio was not necessarily an accurate predictor of workload. As one nurse explained, I used to be able to handle four or five patients, even six, quite nicely because usually several of them were going home or they weren’t that sick, but now you have six that are sick! (Nurse 3). The imbalance between effort and reward in nursing work The model of ERI suggests that when there is a lack of reciprocity between the work expended and the reward or gains to the employee, a negative outcome results (Seigrist, 1996, 2002). In this study, the stress and burnout of excessive workload was accompanied by high levels of absenteeism. Because it was often difficult to replace staff on short notice and because some institutions had the practice of replacing the second sick call on a shift but not the first, absenteeism further increased the workload for the remaining nurses and, in a circular manner, contributed to their stress and potential absenteeism. When acuity was high and
workload was at a critical level, the practice of not replacing the first sick call placed a burden on the nurses who were present. If there was a second sick call, if two nurses were absent, the unit would begin calling around to try to find a replacement nurse. However, this was not always possible; casual and part-time pools might be already over-used and replacement staff simply not available. Even if a replacement could be found, there was sometimes a lengthy period of time during which nurses had to deal with an inadequate nurse–patient ratio. Nurses might end up staying at work for extra hours, even though they had already worked a full 12-h shift. For one nurse, a contentious issue was trying to balance her duties as Charge Nurse with her patient load, a balance that was easier to achieve on some days than on others: On some days it doesn’t work at all, because I still have a patient assignment even though I’m the Charge Nurse. I have three patients. Sometimes that’s hard if there’s stuff going on because you’re striving to look after your patients and there’s other stuff going on and you feel like you’re being torn between everything that needs doing. (Nurse 2). High workload and the resultant stress were also linked in some nurses’ minds with both nurse and patient safety. When nurses were rushing around, accidents were more likely to occur and nurses were more likely to injure themselves. The ongoing disparity of effort and rewards is prevalent in nurse’s work. Seigrist (2002) suggests that an imbalance is maintained when an alternative choice is unavailable, when the condition is accepted for strategic reasons, or as a personal coping style of the individual. It is evident that workload has fostered the level of imbalance reported by nurses in this study. Workload as an issue is affected by acuity, absenteeism and understaffing. It in turn affects stress levels, perceived quality of patient care, absenteeism and possible risk of injury to nurses. Often understaffing is a budgetary issue, but some institutions are finding it difficult to recruit nurses even when they actively seek them. It is impossible to overestimate the importance of workload as a factor causing an imbalance in the working lives of nurses. Some felt that even talking about other worklife concerns served to obscure the importance of this central issue: The workload is getting to everybody these days. It’s the sheer mental stress that is involved. You come home and you bring it home with you and you’re just exhausted because of the workload. You bring the tiredness home, the stress levels home. (Nurse 8). I think workload is everything. Work environment is everything. I’ve stuck with it as long as I have because of the people and the work environment I
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used to have. This is very stressful, the way things are here now. You’d always have a day where you had a stressful day, that’s part of nursing, but you shouldn’t have to work 150% every day. It gets to the point where you can’t even say hello to a patient. You should be able to breathe. You should be able to work at a natural pace instead of always being pressured and pushed. That’s what’s happening here now. (Nurse 3). The absence or insufficiency of non-nursing staff such as porters interacted with and created other problems for nursing staff. With porters in short supply, in some institutions volunteers are helping with transport. However, their participation is limited as the nurse still has to get the patient onto the stretcher as volunteers are not allowed to provide direct patient care. It is obvious that the patient care requirements of the unit were not necessarily reflected in the staff mix: On weekends we’re still doing X-rays, we’re still sending patients up to the OR, just like from Monday to Friday, but we’re down one nurse and we don’t have a desk clerk after 3:00 pm. So when a new patient comes in, the nurse is putting the chart together, which has got a lot of documentation, completing the requisitions, phoning for the electrocardiogram (ECG) because the patient is going to the OR. Then you’ve got to phone the respiratory technologist (RT) to do the ECG because there’s no ECG technician on during the weekend. The nurse is now answering the phone to the relatives, putting the charts together, making all of these arrangements while trying to look after her own set of patients. Weekends are not fun! (Nurse 6). It was often reported that technology had actually increased nurses’ workload. Nurses’ suspected that most technologies presented to them as labour-saving devices actually increased workload and were used as an excuse to reduce staffing or to introduce other organizational economies. These perceptions highlight the dualism that seems to occur between management and staff, each with competing priorities and values (Traynor, 1999): We have morphine pumps, epidural lines, femoral lines, so you’re doing vital signs frequently. For postoperative patients on a patient controlled-anesthesia (PCA) pump, you have to do vitals every hour for twelve hours. For five years we’ve had PCA pumps. To change the rate of the cartridge now takes two nurses. There are so many problems with the pumps that for accountability—holy smokes! They haven’t saved us any time. (Nurse 6). Now we have very expensive monitors because you have to be doing vital signs every 15 min for a couple
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of hours. So you’re in there all the time, it’s almost one-on-one nursing care. But you don’t have one-onone staffing to support this. (Nurse 6). One nurse said that she knew extra staffing was the solution but also knew that funds did not exist to implement it, causing her to feel hopeless about the whole situation. This tendency for nurses to discuss the financial state of their workplace demonstrates how the language of fiscal rationing has permeated the nursing workplace (Traynor, 1999). Another nurse who logged 24 patient care hours in a single shift wondered if anyone noticed, again underscoring the dualism between management and the nursing staff (Traynor, 1999): But if I were to say what the solution is, once again it comes down to more staffing. And I know that’s not going to happen because, the way it is now, we don’t even have the funding for current staffing needs. (Nurse 8). I often wonder why we’re doing these things. Does anyone ever look at that and say, ‘Wow, better not let that happen again!’ (Nurse 3).
Discussion The nurses who participated in this study varied in age and years of experience in nursing, yet all had a similar story to tell about their work environment. The findings from this study illustrate the degree to which factors such as patient acuity, workload and understaffing shape the work environment for nurses and create imbalance. The nurses’ narratives explored here suggest that multiple factors constitute the nurses’ work environment and their experiences and perceptions of the work environment. Nursing work environments: High effort and low reward These work environment factors demonstrate a higheffort workplace with little or no evidence of reward conditions in place for nurses. Seigrist (2002) suggests that the lack of balance between high effort and low reward in work situations affects health. Preliminary evidence of this is apparent in these narratives from nurses with descriptions of absenteeism, taking home feelings of guilt and excessive stress. The EFI model is based on the notion of reciprocity, whereby the efforts of the employee at work are reinforced through rewards that are socially defined (Seigrist, 2004). A failure to achieve reciprocity results in an imbalance with high effort and low rewards. This results in decreased self esteem and long-term stress for employees (Seigrist, 1996, 2004). Several studies have identified these
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concerns in nursing work environments (Aiken et al., 2001; Baumann et al., 2001; Kluska, Spence Laschinger, & Kerr, 2004; McGillis Hall, 2003; O’Brien-Pallas et al., 2004; Page, 2003).
Implications for policy makers and administrators Several predictable issues surfaced repeatedly in the interviews related to the changing needs of hospitalized patients in today’s health care system, and the widespread shortage of nurses. A crucial finding in this study is the extent to which the nurse is impacted by the adequacy of care they are able to provide. Nursing practice is a profession, and nurses have an inherent sense of caring in their work and a sensitivity to the needs of their patients. These narratives outline the tremendous burden of guilt that nurses bear when factors in the work environment prevent them from providing complete, quality care. As well, nurses identified the key role they play in health care teaching and preparing patients for their discharge back into their homes and the community. From the nurses’ perspective, the care they are providing in today’s hospital health care environment is inadequate. The perceptions that nurses have of access to resources has been found to impact the amount of ERI they experience (Kluska et al., 2004). Nurses are experiencing frustration and stress that is impacting their worklife, family and home life, as well as their personal health. In telling their stories, these nurses have provided an opportunity from which health care policy makers and administrators can develop an understanding of these experiences, and how these experiences are shaping the practice of hospital nursing today. These narratives about the nursing work environment will inform interventions that can be tailored to improve the quality of patient care that nurses are able to provide. Nurses’ awareness of the impact of their own personal behaviours on patients was evident. These narratives may also serve to provide a mechanism by which nurses can reflect on their practice in the work environment, and how it impacts patient outcomes. This in turn could have long-term implications on patient and system outcomes. The ERI model provides a useful tool for studying the worklife of nurses. Government funding cutbacks in the past decade have forced health care settings to restructure and downsize nursing positions (McGillis Hall, 2005). The result is a work environment that lacks balance and is contributing to adverse outcomes for the system (e.g., absenteeism) and the nurse (e.g., stress). Using the information from these narratives, health care administrators can re-examine the nursing work environment and the work of nurses within it. Tangible efforts to redesign nursing work that involve nurses in
the process should lead to a better understanding of the staffing required to maintain a safe and healthy patient care work environment. The importance of placing an emphasis on workplace health is underscored in this study. Nurses are a fundamental component of patient care delivery systems. Their work may not always be quantifiable in strict fiscal terms. Nurses in this study demonstrated patterns of coping with job demands that reflect overcommitment to their work. It is apparent from this study that stress-reduction approaches should be implemented in nursing workplaces. These provide a tremendous potential for intervention approaches that can promote the esteem and recognition rewards that nurses need to achieve balance in their work. Interventions can be designed to provide direct support for nurses dealing with real-life issues in the workplace. The importance of listening to nurses’ stories about the challenges they undergo in their workplaces can only help to inform us of the key issues in the workplace that need to be addressed for the successful retention of nurses in the profession.
Acknowledgements Funded by the Ministry of Health and Long Term Care, Ontario, Canada.
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