A narrative approach to understanding the nursing work environment in Canada

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  • Social Science & Medicine 61 (2

    det

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    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 implications

    for health policy and management decisions are

    presented.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 participants 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 sampleExtrinsic 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 identied 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. Theyre coming in with COPD

    and congestive heart failure and kidney failureyou

    know, every body system is going. So thats a lot for

    a nurse because youre not just focussing on one area.

    Youre 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 inuenced by the nursepatient

    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, nursepatient ratios often have not

    reected this increase:

    The acuity is high, very high. You have very ill

    patients. We are the only active Medical oor in the

  • overwhelmed their nurses were:

    They feel really badly because their nurse is running

    ARTICLE IN PRESSL. McGillis Hall, D. Kiesners / Social Science & Medicine 61 (2005) 248224912486hospital. Its 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

    nursepatient ratio doesnt change. If you have four

    patients, you might have two that are really sick and

    two that are less sick. Theyre all sick, but their acuity

    levels will be different. A four-patient workload with

    varied levels might not be as difcult 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 theyre really, really sick. Its hard

    because if youve got four patients and theyre all

    really acute then youre running around trying to

    make sure everything is done whereas if youve got at

    least one patient who can manage a little bit on their

    own or do something for themselves, then its not so

    bad. (Nurse 4).

    Workload and understaffing. The constant time pres-

    sures 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 havent been a nurse for that long, but a lot of

    people seem to be saying the same thingsthat its

    too hard or that people are staying later at work

    because they didnt have time to nish everything

    during the day. (Nurse 1).

    A nurse with 21 years of work experience felt that the

    increase in workload was accelerating:

    Its amazing but I just dont think anything has been

    as bad as it has been in the last ve years. Im 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 inrmities.

    We have so many more machines attached to people

    nowadays. I really do think that we had better

    stafng 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 youre one on one and in the

    hospital its like 50 to one. You can never nish aaround like a chicken with her head cut off. Oh,

    poor so and so. She was really running yesterday.

    They dont want to ring the buzzer and thats not

    what its all about. You know, if you need help, I

    tell them, push the buzzer, because its the squeaky

    wheel that gets the grease here. If you dont buzz for

    me, I wont 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, undesir-

    able 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 signicant 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 ofThey read the papers, they know whats going on.

    The rst thing theyll say, a lot of them, is, Im so

    sorry for bothering you. I know youre busy. So

    then you have to say, No, Im here for you. Im your

    nurse. So what can I do for you? (Nurse 2).task. In the community you went in and you did what

    you had to do and you really didnt 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 nish a task.

    You just prioritize and nish what you have to at

    that moment. Actually sometimes Im 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 Ive done everything, because Im

    ying 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 rst hand how

  • ARTICLE IN PRESSL. McGillis Hall, D. Kiesners / Social Science & Medicine 61 (2005) 24822491 2487esteem. There was little time to communicate with

    patients:

    You know, whats rewarding about nursing is talking

    to people and helping them. Thats how you nd out

    things that maybe you werent aware of, that will

    help with the care youre giving them. I think thats a

    big part of it. But its so busy now you cant

    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 nd time for.

    Lets say the patient is a new diabetic. You have to

    make sure that you get the doctors 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

    theyre able to do it at home on their own, when

    youre not doing it anymore and that theyre ready to

    function independently outside of the hospital,

    that theyre 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 youre bathing them youre asking them who

    they live with, where they live, how they are getting

    home. You have to. You dont have time to say,

    Okay, now well discuss your ileostomy. While

    youre making the bed youre saying Oh, the ostomy

    nursedo you know if shes booked to come in on

    Tuesday to discuss the types of prosthetics that

    youre 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 house-

    keepingbeds and baths, were becoming compro-

    mised 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 nursesto 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 hed had a

    post-operative wash, he had a bit of blood here and

    there, and a little bit of urine here and there. I

    couldnt 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 rst.

    (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 irration-

    ality 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 dont take an afternoon break

    thats almost non-existentand a supper break. We

    dont 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 twelve-

    hour shifts with no break, especially on the night

    shift. You could not leave the oor. I sit there and eat

    my sandwich while Im 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 employ-

    ees 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 20min to sit

    down. Some thought their health was being affected by

    this workload.

    I think that nursing is affecting everybodys health

    with the length of the shifts, the stress, and the

    physical demand of night shifts. It has to take a toll

    on someones life. I have a nurses back and am

  • ARTICLE IN PRESSL. McGillis Hall, D. Kiesners / Social Science & Medicine 61 (2005) 248224912488emotionally exhausted every day. I come home and I

    think, Now tomorrow when I go back I will be

    positive, but it takes me ve minutes on the oor

    and Im 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 overcommit-

    ment 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 havent

    completed your job. There is no way that you can

    nish your workload. You have to decide on what is

    most important and hopefully what is left isnt and

    wasnt 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, nursepa-

    tient ratio was not necessarily an accurate predictor of

    workload. As one nurse explained,

    I used to be able to handle four or ve patients, even

    six, quite nicely because usually several of them were

    going home or they werent 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 difcult

    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 rst, 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 andworkload was at a critical level, the practice of not

    replacing the rst 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 nd 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 nursepatient

    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 doesnt work at all, because I still

    have a patient assignment even though Im the

    Charge Nurse. I have three patients. Sometimes

    thats hard if theres stuff going on because youre

    striving to look after your patients and theres other

    stuff going on and you feel like youre 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 nurses work.

    Seigrist (2002) suggests that an imbalance is main-

    tained 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 understafng. It in turn affects

    stress levels, perceived quality of patient care, absentee-

    ism and possible risk of injury to nurses. Often under-

    stafng is a budgetary issue, but some institutions are

    nding it difcult 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. Its

    the sheer mental stress that is involved. You come

    home and you bring it home with you and youre 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. Ive stuck with it as long as I have

    because of the people and the work environment I

  • story to tell about their work environment. The ndings

    from this study illustrate the degree to which factors

    ARTICLE IN PRESSL. McGillis Hall, D. Kiesners / Social Science & Medicine 61 (2005) 24822491 2489used to have. This is very stressful, the way things are

    here now. Youd always have a day where you had a

    stressful day, thats part of nursing, but you

    shouldnt have to work 150% every day. It gets to

    the point where you cant 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. Thats whats happening here

    now. (Nurse 3).

    The absence or insufciency 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 reected in the staff mix:

    On weekends were still doing X-rays, were still

    sending patients up to the OR, just like fromMonday

    to Friday, but were down one nurse and we dont

    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 electro-

    cardiogram (ECG) because the patient is going to the

    OR. Then youve got to phone the respiratory

    technologist (RT) to do the ECG because theres

    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 stafng 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 youre doing vital signs frequently. For post-

    operative patients on a patient controlled-anesthesia

    (PCA) pump, you have to do vitals every hour for

    twelve hours. For ve years weve had PCA pumps.

    To change the rate of the cartridge now takes two

    nurses. There are so many problems with the pumps

    that for accountabilityholy smokes! They havent

    saved us any time. (Nurse 6).

    Now we have very expensive monitors because you

    have to be doing vital signs every 15min for a couplesuch as patient acuity, workload and understafng

    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 high-

    effort 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 dened (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 identied theseof hours. So youre in there all the time, its almost

    one-on-one nursing care. But you dont have one-on-

    one stafng to support this. (Nurse 6).

    One nurse said that she knew extra stafng 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

    nancial state of their workplace demonstrates how the

    language of scal 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 man-

    agement and the nursing staff (Traynor, 1999):

    But if I were to say what the solution is, once again it

    comes down to more stafng. And I know thats not

    going to happen because, the way it is now, we dont

    even have the funding for current stafng needs.

    (Nurse 8).

    I often wonder why were 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

  • balance and is contributing to adverse outcomes for the

    Acknowledgements

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    interviews related to the changing needs of hospitalized

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    A narrative approach to understanding the nursing work environment in CanadaIntroductionTheoretical frameworkMethodSample and data collection processStructure of interviewsAnalysis

    ResultsDescription of the sampleThemesExtrinsic dimension: The situationEffortPatient acuityWorkload and understaffing

    RewardEsteem and recognition: Adequacy of patient care

    Intrinsic dimension: The personOvercommitment

    The imbalance between effort and reward in nursing work

    DiscussionNursing work environments: High effort and low reward

    Implications for policy makers and administratorsAcknowledgementsReferences

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