Registered Nurses' perceptions of their work and professional development

AIM: This paper is a report of a study to elucidate Registered Nurses' perceptions of their work and professional development 6 years after graduation. BACKGROUND: Nursing education and health care has rapidly changed in the last two decades. Education and experience are important components in Registered Nurses' ability to promote a high quality of care, but a great deal depends on their work circumstances. This study emphasizes Registered Nurses' view of their work in health care, at a time in their career when they have several years of experience. METHOD: Data were collected in 2003 from in-depth interviews with 15 Registered Nurses 6 years after their graduation. The interviews were semi-structured and analysed with interpretive content analysis. FINDINGS: The findings revealed two themes and five sub-themes. The first theme, An appropriate but demanding profession, consisted of two sub-themes: 'having found one's niche' and 'growing old in nursing may be difficult'. The second theme, A profession with opportunities and obstacles, consisted of three sub-themes: 'being aware of Registered Nurses' potential', 'having knowledge that is seldom made use of' and 'attaining professional growth is no matter of course'. CONCLUSION: Keeping Registered Nurses' satisfied and avoiding their dissatisfaction is crucial for both educators and employers. It is essential that employers give priority to Registered Nurses' time with patients and to motivate and support them in professional development. Further intervention studies regarding a change of the balance between obstacles and opportunities are needed.     

Client-centred empowering partnering in nursing

AIM: This paper explores nurses' experiences 1 year after an organization's commitment to providing a client-centred and client-empowering partnering approach to care. BACKGROUND: Historically, nurses' approach to providing care in all nursing contexts has been one of doing for clients, and previous studies have focused more on in-hospital care than on home care. However, the isolation inherent in in-home nursing and nurses' limited professional autonomy and power associated with physician control over patients in home care have been reported, as has their difficulty in finding the meaning and satisfaction of human connectedness and mutuality in nurse-client relationships. Overall, research to date does not inform us about how nurses might make a change toward a more client-centred and client-empowering approach to nursing. METHODS: An interpretive phenomenological design was used to elicit in-depth understanding about Registered Nurses' experiences of providing care using this innovative empowerment model. A purposefully selected sample of eight Registered Nurses participated in in-depth interviews. Data were generated during 2002. Hermeneutic analysis was used to elicit themes and patterns emerging from the data. FINDINGS: Caring, client-centredness and the context of in-home care were important in implementing the new partnering approach. Barriers encountered at system, organizational and personal levels distracted nurses from fully comprehending and enacting the approach. After a year, they had begun to contemplate potential strategies for partnering with clients, but had not yet explored the power of their professional autonomy. CONCLUSION: Nurses are inclined to practise within the expert model of service delivery. They need to work through issues of professional autonomy and rise to the challenge of exercising their autonomy within the current healthcare context if they are to attend more consistently to client-centred empowering partnering. The home care setting offers an excellent environment for achieving these aims.     

Nurses' moral strength: a hermeneutic inquiry in nursing practice

Title.  Nurses' moral strength: a hermeneutic inquiry in nursing practice.
Aim.  This paper is a report of a study to interpret nurses' experiences of moral strength in practice.
Background.  Moral strength is said to be beneficial in providing nursing care for patients, thereby contributing to high qualitative care. However, few studies focus on the meaning of nurses' moral strength.
Methods.  This study included eight Registered Nurses working in different aspects of health care in southern Sweden. Individual interviews were conducted in 2006 and 2007. We recorded, transcribed verbatim, and interpreted the interviews by a method grounded in hermeneutics.
Findings.  Three themes were interpreted on three different levels: the action level as 'having courage to act on one's convictions', the relational level as 'being attentive and recognizing vulnerability', and the existential level as 'facing the unpredictable' . Overall, moral strength was understood as a driving force to be someone special in the care of patients, i.e. someone who makes a difference.
Conclusion.  The value of nurses' moral strength in patient care should be recognized. Attention must be given to aspects outside the individual, e.g. professional and institutional processes that influence the work environment. Clinical team supervision can help make such processes visible and supportive.     

A comparative analysis of contemporary nurses' discontents

AIM: This paper reports a study to evaluate and increase understanding of contemporary Registered Nurses' discontents, and to compare these discontents and their effects with those of nurses 20 years ago. BACKGROUND: In 1986, Turner argued that nurses' discontents were reflected in a discourse or 'vocabulary of complaint' that provided a sense of solidarity amongst practising nurses, and defused their frustrations rather than channelling them into demands for workplace reform. In this paper, we revisit Turner's notion of a vocabulary of complaint in the context of a study of nurse retention in the contemporary Australian healthcare workplace. METHODS: This paper draws on the qualitative data from a larger project (completed in 2001) exploring the relationship between job satisfaction and self-concept in both recently graduated and experienced nurses. Here, we elaborate on thematic analyses of the comments of 146 Australian Registered Nurses with more than 5 years' nursing experience. FINDINGS: There is still a high level of discontent amongst contemporary practising nurses, although the focus of their complaints and their responses to them have changed since Turner's study. Conflicting expectations of nurses and managers and lack of opportunity to provide comprehensive care emerged as the most important issues for experienced nurses today. Rather than contributing to a sense of solidarity as in Turner's study, contemporary nurses' discontents reflect intense personal frustration and underpin individual nurses' decisions to leave, or plan to leave, the workforce. CONCLUSION: There is an urgent need for increasing health service management and community awareness about the relationship between providing comprehensive nursing care and nurses' job satisfaction. Addressing nurses' discontents, wider nursing involvement in the international policy arena, and the politicization of nurses worldwide may contribute to alleviating the current global nursing shortage.     

A unit-based protocol to enhance Jordanian nurses' autonomous decision making

AIM: To develop a unit-based protocol to enhance Jordanian nurses' autonomous decision making. BACKGROUND: Many escalating changes are influencing health care organizations, which require the enhancement of nurses' autonomy to manage these frequent changes. Autonomy is addressed in the context of accountability, authority and responsibility. Nurses' involvement in patient care and unit operation decisions is a part of their autonomy. Autonomy will influence nurses' job satisfaction and retention, patients' satisfaction and the quality of nursing care. METHODS: This protocol was developed based on a personal experience, nurses and senior nursing students' feedback, a review of the literature, and consultation with a group of 26 nurses in a teaching hospital. The nurses were asked on the comprehensiveness and applicability of the protocol to health care settings. Nurses' suggestions regarding the protocol were taken into consideration during the development and revision stages. RESULTS AND CONCLUSIONS: A unit-based protocol was developed to enhance nurses' autonomous decision making through activities that support the process of autonomy and work environment. This protocol will have positive short, intermediate and long-term outcomes for patients, nurses and organizations.     

Nurses' lived experience of being a preceptor.

Registered nurses' lived experience of preceptorship was studied in this phenomenological study. To illuminate the meaning of registered nurses' experience of being a preceptor for student nurses, individual tape-recorded interviews were conducted with 17 registered nurses. They narrated their experience of being a personal preceptor for student nurses during practical training on a hospital unit, and the interviews transcribed verbatim were analyzed phenomenological-hermeneutically. The analysis revealed two main themes (1) including the student in their daily work and (2) increasing awareness of the process of learning, as well as six other themes, which contributed to a new comprehension of the meaning of being a preceptor. All the themes were related to the ongoing preceptor-preceptee relationship. The preceptors' thinking on past experiences and their ideas of nursing care in the future were present simultaneously. Nurses acting as preceptors were perceived as conscious individuals, demanding a balance of their daily work responsibility with increased awareness of the professional demands of nursing care. Preceptors gained increased awareness of and a desire to fulfill the student nurses' varied learning needs and increased awareness of their own learning process.     

Predictors of career commitment and job performance of Jordanian nurses

BACKGROUND AND AIMS: Few studies focused on nurses' career commitment and nurses' job performance. This research aimed at studying variables of nurses' career commitment and job performance, and assessing the relationship between the two concepts as well as their predictors. METHODS: A survey was used to collect data from a convenient sample of 640 Registered Nurses employed in 24 hospitals. RESULTS: Nurses 'agreed' to be committed to their careers and they were performing their jobs 'well'. As a part of career commitment, nurses were willing to be involved, in their own time, in projects that would benefit patient care. The highest and lowest means of nurses' job performance were reported for the following aspects: leadership, critical care, teaching/collaboration, planning/evaluation, interpersonal relations/communications and professional development. Correlating of total scores of nurses' career commitment and job performance revealed the presence of a significant and positive relationship between the two concepts. Stepwise regression models revealed that the explained variance in nurses' career commitment was 23.9% and that in nurses' job performance was 29.9%. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers should promote nursing as a career and they should develop and implement various strategies to increase nurses' career commitment and nurses' job performance. These strategies should focus on nurse retention, staff development and quality of care. CONCLUSIONS: Nurses' career commitment and job performance are inter-related complex concepts that require further studies to understand, promote and maintain these positive factors in work environments.     

Experiencing a nurse identity: the meaning of identity to Swedish registered nurses 2 years after graduation

RATIONALE: The professional identity and experiences of nurses have been focused upon in different studies AIM: This is a longitudinal study whose aim was to understand how nurses experience the meaning of their identity as nurses, when they are students and nurses 2 years after graduation. DESIGN: Data were collected through interviews once a year during education and two years after graduation, and were analysed using a phenomenological hermeneutic method, inspired by the philosophy of Paul Ricoeur. FINDINGS: The analyses of the narratives resulted in four perspectives: 'Having the patient in focus', 'Being a team leader', 'Preceptorship' and 'Task orientation'. The nurses did not change perspectives but the perspective showed a transition over time. CONCLUSION: The nurses' not changing perspective over time is understood as being a life paradigm, remaining throughout the years.     

Prerequisites for quality improvement in nursing

AIM: This study examines how the characteristics of nurses, working communities and leadership affect the prerequisites for quality improvement in nursing. BACKGROUND: Knowledge of the phenomena affecting nurses' action is needed, since quality of care is seen as a result of an individual carer's professional skills, work motivation and commitment to work. METHODS: Material for the study was collected using a questionnaire. The respondents were 723 nursing practitioners from two special level hospitals. The main instrument used was the Managerial Abilities instrument developed by the researchers. FINDINGS: The results of the statistical analyses showed that exhaustion experienced by the nurses is the most important obstacle to quality improvement in nursing. The education of nurses, good team work and the ward sister's managerial abilities have a positive influence on quality improvement in nursing. CONCLUSION: Nurses' exhaustion should be reduced in order to improve quality of care.     

Developing a mid-range theory of patient advocacy through concept analysis

AIM: The aim of this paper is to clarify and refine the concept of patient advocacy through synthesizing the advocacy literature in nursing and to establish a theoretical basis for future studies on patient advocacy in nursing. BACKGROUND: Patient advocacy is an essential component of the Registered Nurse professional role. During the past 30 years, the patient advocacy role has become more important, but the concept of patient advocacy lacks a consistent definition and research into nurses' patient advocacy roles is limited. There have been few quantitative empirical studies on patient advocacy in nursing. METHOD: Walker and Avant's method of concept analysis was used as a guideline in examining the concept of patient advocacy through synthesizing the advocacy literature in English (1974-2006). FINDINGS: A mid-range theory of patient advocacy emerges during the process of synthesizing and analysing the advocacy literature. Three core attributes of the concept of patient advocacy are identified: (1) safeguarding patients' autonomy; (2) acting on behalf of patients; and (3) championing social justice in the provision of health care. They reflect nurses' patient advocacy roles at both macro- and micro-social levels. Antecedents of patient advocacy occur at both macro- and micro-social levels and call for nurses' advocacy roles in the healthcare system. Consequences produced by nurses' patient advocacy behaviours are contextual. Nurses' patient advocacy behaviours not only can positively influence the patients, other nurses and the nursing profession, but also can cause negative consequences for nurses who take action to advocate for patients. CONCLUSION: The proposed mid-range theory may be useful in guiding advocacy practice in nursing and in guiding research in the advocacy area. The proposed theory needs to be furthered refined and tested in the future.     

Gender and professional identity in psychiatric nursing practice in Alberta, Canada, 1930-75

This paper examines gender-specific transformations of nursing practice in institutional mental health-care in Alberta, Canada, based on archival records on two psychiatric hospitals, Alberta Hospital Ponoka and Alberta Hospital Edmonton, and on oral histories with psychiatric mental health nurses in Alberta. The paper explores class and gender as interrelated influences shaping the work and professional identity of psychiatric mental health nurses from the 1930s until the mid-1970s. Training schools for nurses in psychiatric hospitals emerged in Alberta in the 1930s under the influence of the mental hygiene movement, evolving quite differently for female nurses compared to untrained aides and male attendants. The latter group resisted their exclusion from the title 'nurse' and successfully helped to organize a separate association of psychiatric nurses in the 1950s. Post-World War II, reconstruction of health-care and a de-institutionalization policy further transformed nurses' practice in the institutions. Using social history methods of analysis, the paper demonstrates how nurses responded to their circumstances in complex ways, actively participating in the reconstruction of their practice and finding new ways of professional organization that fit the local context. After the Second World War more sophisticated therapeutic roles emerged and nurses engaged in new rehabilitative practices and group therapies, reconstructing their professional identities and transgressing gender boundaries. Nurses' own stories help us to understand the striving toward psychiatric nursing professionalism in the broader context of changing gender identities and work relationships, as well as shifting perspectives on psychiatric care.     

The positive face of resistance: nurses relate their stories

OBJECTIVE: To relate nurses' stories of their experiences of acts of resistance. BACKGROUND: Although resistance is often characterized as negative, it can be seen as a way that the less powerful speak up about workplace concerns. By studying how nurses resist, new perspectives about how some groups exercise power may be understood. METHODS: For this qualitative study, 19 nurses were interviewed. They were asked to describe an act of resistance in their professional life. The interviews were tape recorded, transcribed, and then analyzed using narrative methods. RESULTS: Four major categories emerged from the narratives: definitions of resistance, relationships, core narratives, and creating meaning. This article focuses on 2 of these for space constraints and relevance to this journal: relationships and creating meaning. CONCLUSION: The nurses interviewed described situations in their work lives, where they felt that they performed an act of resistance because of unfair treatment, abuse of power, or ethical concerns. It often took courage to do so, but the acts had mainly positive effects on them and their institutions. It is theorized that resistance may actually be positive for both the staff nurse and the organization.     

Work related predictors for "satisfaction with dementia care" among nurses working in nursing homes

In German nursing homes dementia care is gaining increasing relevance. Dementia care is known to bear the high risk of a substantial occupational burden among nursing staff. Within this context, the "nurses' satisfaction with the care for residents with dementia" is investigated. Secondary data of the German 3q-study is used to assess degrees of nurses' satisfaction with the care for residents with dementia and potential work related predictors. Data from 813 nurses and nursing aides working in 53 nursing homes were included. 42% of all nursing staff was dissatisfied with the care for residents with dementia in their institution, however, pronounced differences were found between the institutions. Registered nurses and nurses in leading positions were more dissatisfied. A multiple regression analysis indicates that high "quantitative demands", low "leadership quality" and "social interaction with other professions" are strong predictors for nurses' satisfaction with the care for residents with dementia. No association was found for "emotional demands" and "possibilities for development". The results indicate that the "nurses" satisfaction with the care for residents with dementia" may be a highly relevant work factor for nursing staff in nursing homes which deserves additional attention in practice and research. The high predictive power of several work organisational factors implies that preventive action should also include work organisational factors.     

Increasing the impact of the clinical nurse specialist through activity in a shared governance organization.

For the CNS frustrated by traditional placement in an organization, participation in a shared governance organization increases opportunities to improve nursing practice and staff satisfaction. CNSs provide nursing expertise and leadership skills for specific committees as they assist staff nurses in meeting committee objectives. The authors also propose the use of a shared governance organization committee structure as a mechanism for CNSs to increase meaningful interaction with staff nurses and influence their professional development. Their model displays four pathways for CNS-staff nurse interaction through shared governance organization activities: examination of the goals of the profession, evaluation of personal needs and goals, assessment of the characteristics of one's work, and transmission of information. The support provided by the CNS in dealing with these issues increases the staff nurses' sense of a "professional self" and, it is postulated, enhances job satisfaction, decision making, and commitment to the organization's goals.     

Registered Nurses' views on their professional role

Aim The aim is to study Registered Nurses’ opinions and reflections about their work tasks, competence and organization in acute hospital care. Background The definition of the role of nurses has changed over time and it is often discussed whether Registered Nurses have a professional status or not. Method A qualitative research design was used. Data were derived from written reflections on diaries and from focus group interviews. Results All respondents had difficulties in identifying the essence of their work. It can be argued that being ‘a spider in the web’ is an important aspect of the nursing profession. Conclusion Registered Nurses tend to regard their professional role as vague. Managers must be considered key persons in defining the professional role of Registered Nurses. Implications for nursing management This study contributes to an understanding of the managers’ and the importance of nursing education in Registered Nurses professional development.     

Rural nurses' safeguarding work: reembodying patient safety

Practice-based evidence includes research that is grounded in the everyshift experiences of rural nurses. This study utilized institutional ethnography to reembody the work of rural nurses and to explore how nurses' work experiences are socially organized. Registered nurses who work in small acute care hospitals were observed and interviewed about their work with the focus on their experiences of providing maternity care. The safeguarding work of rural nurses included anticipating problems and emergencies and being prepared; careful watching, surveillance, and vigilance; negotiating safety; being able to act in emergency situations; and mobilizing emergency transport systems. Increased attention to inquiry about safeguarding as an embodied nursing practice and the textual organization of the work of rural nurses is warranted.     

Job satisfaction in a Norwegian population of nurses: a questionnaire survey

BACKGROUND: Although job satisfaction is a factor that influences retention, turnover and quality of nursing care globally, there are few studies exploring these factors in European countries. OBJECTIVES: To describe job satisfaction among hospital nurses in Norway, to explore the relationship between nurses' job satisfaction and participation in a clinical ladder program and to explore relationships between several variables and intent to stay. A secondary purpose was to investigate the use of a job satisfaction instrument in a different culture than its origin. DESIGN: In a survey, 2095 nurses in four different hospitals answered a questionnaire that included demographic data, intent to stay and a job satisfaction instrument covering the importance of and actual satisfaction with different job factors. RESULTS: Interaction, followed by pay and autonomy were the most important job factors for Norwegian nurses. Actual job satisfaction was similar to nurses in other countries. There was no significant difference in job satisfaction between participants and non-participants in a clinical ladder. Nurses intending to stay more than a year were significantly more satisfied in their job. Further education and 1 day or more scheduled for professional development were factors that were positively related to intent to stay in the hospital. CONCLUSIONS: Norwegian nurses' views on the importance of different job factors mirrored views of the importance ascribed to working milieu in the Norwegian society. As such, the instrument used seemed sensitive to cultural differences. Nurses' actual satisfaction with their job was similar to respondents in many other countries and may imply that structures and content defining nurses' working situation are similar in many parts of the world. Participation in a clinical ladder did not increase nurses' overall job satisfaction. However, further education and the opportunity for professional development increased nurses' intention to stay in the organization.     

The 1999 Irish nurses' strike: nursing versions of the strike and self-identity in a general hospital

AIM: The aim of this paper is to report findings from a study investigating nurses' experiences of strike in one public general hospital in the Republic of Ireland. BACKGROUND: October 1999 heralded the first nationwide nurses strike in the Republic of Ireland. The strike reflected an international shift towards industrial action in a profession which had previously viewed such action as the antithesis of professional behaviour. METHODS: A focused ethnographic approach studied a group of striking Registered Nurses, not as a culture per se, but as a collection of individuals sharing a common human experience. A purposive sampling approach identified eight information-rich cases from a modified quota structure. Semi-structured interviews were carried out immediately prior to, during and at the end of the 1999 strike. The participants also maintained journals which were explored during the interviews. Data were analysed using a constant comparative approach, seeking to achieve category saturation. FINDINGS: Four strike versions were identified. The anticipatory version is constructed as an inevitable protest, the orientation version as history-making solidarity and the performing version as a job of work. The withdrawal version is constructed as a conspiracy from which nurses are excluded. These versions portray ongoing tension that is experienced between conflicting self-identities of Registered Nurses as nurses and as strikers. The analysis revealed strategies adopted to resolve tensions between these identities within the dimensions of carer, patient advocate, multidisciplinary team member and professional. CONCLUSIONS: Debate on such potentially contentious issues by individual nurses, hospital managers and union leaders may facilitate awareness and preparation in advance of any future industrial action. Strategies that may be helpful in the event of a strike include a prestrike orientation programme for the entire organization, a support system for staff during the strike and informal de-briefing among all staff in the context of a social gathering when the strike is over.     

Care as a matter of courage: vulnerability, suffering and ethical formation in nursing care

The aim of the study was to explore nurses' experience of how their own vulnerability and suffering influence their ethical formation and their capacity to provide professional care when they are confronted with the patient's vulnerability and suffering. Care is shaped in the meeting between human beings. Professional care is informed by the patient's appeal for help as it is expressed in the meeting. Ethical formation is understood as a personal ethical and existential process, resulting in the capacity to provide professional care. A nurse must have the sense of being a complete human being with own personal attributes and sensitivity in order to be able to relate to other people. The study is based on qualitative interviews with 23 experienced nurses from Sweden, Finland and Denmark. The analyses and interpretation were carried out in line with Steinar Kvale's three levels of interpretation. The study clarifies that ethical formation is a union of the nurse's personal attributes and professional qualifications and that ethical formation is developed over time. Moreover, it also demonstrates that the nurse's personal and professional life experiences of vulnerability and suffering influence ethical formation. Vulnerability and suffering have proven to be sensitive issues for nurses, like a sore point that either serve as an eye-opener or cause the development of blind spots. Furthermore, vulnerability, suffering and the sore points are seen to shape the nurse's courage in relation to care. Courage appears to be a significant unifying phenomenon that manifests itself as the courage to help patients face their own vulnerability and suffering, to bear witness to patients' vulnerability and suffering and to have faith in oneself in arguing for and providing professional care. Courage thus seems to play a significant role in nurses' ability to engage in care. Nurses' own vulnerability, suffering and sore points seem to shape their courage.