Accepted: 24 July 2017 DOI: 10.1111/jan.13411
ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUALITATIVE
Nursing lives in the blogosphere: A thematic analysis of anonymous online nursing narratives Aimee Castro1
| Gavin Andrews2
1 Ingram School of Nursing, McGill University, Montreal, Quebec, Canada 2
Department of Health, Aging & Society, McMaster University, Hamilton, Ontario, Canada
Abstract Aim: The aim of this study was to explore the work-life narratives of nurses through a thematic analysis of the nursing accounts they post in their publicly accessible, anonymous blogs.
Correspondence Aimee Castro, Ingram School of Nursing, McGill University, Montreal, Quebec, Canada. Email: [email protected].
Background: Many nurses participate on social media. Blogs have been advocated as a self-reflective tool in nursing practice, yet as far as the authors are aware, no previous studies have explored nurses’ individual blogs for their potential to reveal nurses’ perceptions of nursing work.
Funding information This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors
Design: The research design was qualitative description. Methods: Between May–August 2015, Internet search engines were used to discover lists of nursing blogs recommended by organizations representing nurses’ interests. Recommended blogs were purposively sampled. Four anonymous blogs written by nurses from different nursing specialties met the sampling criteria. All 520 of their entries from 2014 were read and copied into NVivo 10, where an inductive coding process was followed. Findings: Three major themes arose in these nurses’ online discussions of their work lives: they truly care about and value their nursing work, but they are feeling stressed and burnt out and they are using their anonymous blogs to share factors that frustrate them in their nursing work. Three main areas of frustration were revealed: teamwork problems, challenging patients and families, and management issues. Conclusion: Anonymous nursing blogs offer valuable, longitudinal insights into nurses’ perceptions of their work lives. Nursing blogs should be further explored for ongoing insights into nurses’ experiences of nursing work, as well as nurses’ recommendations for addressing issues causing them to feel frustrated in their work environments. KEYWORDS
healthcare management, midwives, nurses, nursing, nursing blogs, nursing narratives, nursing work, social media, thematic analysis, web logs
1 | INTRODUCTION
the rise of such blogs, opportunities to study these online nursing narratives have emerged.
Many nurses participate in the blogosphere—the online community
Compared with other forms of online data sources, blogs are
and space centred on blogs. According to Kung and Oh (2014),
unique in that they create in-depth research opportunities written
almost a third (32%) of nurses read or write on blog websites. With
from the perspective of one main writer, over time, in dialogue with
J Adv Nurs. 2017;1–10.
wileyonlinelibrary.com/journal/jan
© 2017 John Wiley & Sons Ltd
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their readers (Heilferty, 2009) and free from the influence of an interviewer (Eastham, 2011). Micro-blogging websites like Twitter create ongoing dialogue but can inhibit narration due to character
Why is this research or review needed?
restrictions for posts (Grajales, Sheps, Ho, Novak-Lauscher, & Eysen-
•
bach, 2014). Public online forums like message boards and wikis cre-
longitudinal data in real-time of nurses’ and their blog
ate opportunities for longer posts (Grajales et al., 2014), but they are
readers’ frustrations, ideas and recommendations regard-
not typically author-centric. Blogs offer substantive volumes of immediately accessible, longitudinally transcribed data (Hookway, 2008). Anonymous online narratives give writers opportunities for
ing nursing and healthcare practice.
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Blogs can also help to transcend the limitations of time and space:
ing blogs are addressed.
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tions (Keim-Malpass et al., 2014).
What are the key findings?
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Nurse bloggers care about their patients and believe in the value of nursing work, but they are feeling stressed
1.1 | Background Researchers have paid attention to how nurses write online but not
Yet, nursing blogs have not been researched for their insights into nurses’ perceptions of their work.
blogs written in real-time by authors from around the world can be easily accessed within minutes or years after their original publica-
Nurses’ job satisfaction and patient safety may both improve when concerns that resonate across these nurs-
honest self-disclosure relating to stigmatized topics, creating new avenues for support (Keim-Malpass, Steeves, & Kennedy, 2014).
Anonymous nursing blogs can offer massive amounts of
and burnt out.
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Nurse bloggers, under the protection of anonymity, share
to what nurses are saying there. In previous studies of healthcare
frustrations that typically fall into three key categories:
blogs, researchers have focused on studying the relationship
teamwork difficulties, challenging patients and families
between authors’ credentials and the quality of blogs’ contents (Buis & Carpenter, 2009; Guardiola-Wanden-Berghe, Sanz-Valero, &
and healthcare management problems.
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This research illustrates how public, anonymous nursing
Wanden-Berghe, 2010). One quantitative content analysis of health-
blogs offer rich, longitudinal and easily accessible data
related blogs found that the language used in physicians’ writings
for gaining insights into nurses’ and their blog readers’
were more technical when compared with nurses’ more “affective”
perceptions of nursing practice and healthcare policies.
narrative vocabularies (Denecke & Nejdl, 2009, p. 1875). A study of nursing blogs included descriptive statistics for Spanish nurses’ posts, but this work did not deeply describe these nurses’ experiences (Brito-Brito et al., 2015). Blomberg (2016) described the content of blog entries written by different nurses on a Swedish healthcare
How should the findings be used to influence policy/practice/research/education?
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explore more nursing blogs written by nurses from dif-
union magazine’s website. A common recommendation in nursing education literature was the idea of using blogs as a learning tool in nursing education for self-reflection and collaboration (Anderson, 2010; Casella, Mills, & Usher, 2014; Garrity, Jones, Vanderzwan, De
Further research should build off this study’s example to ferent specialties and nationalities.
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Healthcare managers may find research on anonymous nursing blogs useful in addressing nursing staff burnout and/or turnover.
La Rocha, & Epstein, 2014; Grassley & Bartoletti, 2009; Lin & Shen, 2013; Papastavrou, Hamari, Fuster, Istomina, & Salminen, 2016; Watson, 2012). Several of these studies illustrate how nursing blogs are an international phenomenon, appearing in Spain (Brito-Brito
desirable responding (Fang, Wen, & Prybutok, 2014). However,
et al., 2015), Sweden (Blomberg, 2016) and Taiwan (Lin & Shen,
discussion boards are less author-centric than blogs; one writer may
2013), among other countries. However, none of these studies
post on many different forums, so there may be fewer opportunities
explored personal nursing blogs written by nurses anonymously.
for an in-depth understanding of individual writers’ ongoing
The online source that may be most like blogs is the online dis-
experiences.
cussion forum, as both offer opportunities for longer narrative
Nursing blogs are a unique form of in-depth, public nursing
responses, public discussions and longitudinal analyses. Some online
reflection that occurs internationally and virtually, outside the con-
forums where nurses participate have been studied in relation to
straints of borders and time zones and without an interviewer effect.
knowledge sharing and educational needs (Brooks & Scott, 2006;
Yet, despite traits like these which may make researching nurses’
Curran & Sibte Raza Abidi, 2007). Discussion boards have also been
experiences easier than traditional interviewing methods, personal
used to facilitate dialogue between healthcare professionals and
nursing blogs have not been the focus of any qualitative study thus
patients (Jones & Ashurst, 2013). For the study of both discussion
far. Nurses make up the highest proportion of the professional
forums and blogs, while the interviewer effect may be avoided, the
healthcare workforce (American Association of Colleges of Nurses,
social nature of these spaces may lead contributors to share narra-
2011). When nurses’ voices and reflections go unheard, patient
tives that are more likely to please their readers—a form of socially
safety can be put at risk (Garon, 2012). Considering that nurses are
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key players in providing safe healthcare services, their blogged sto-
automatically included if the recommending website was affiliated
ries need to be heard.
with a college nursing programme. The criteria for an organization being in existence for 10 years or having 500 social media followers
2 | THE STUDY 2.1 | Aim
were arbitrary metrics, but our rationale was that if an organization met these criteria, then it was probably well-established in nursing circles since it has existed for 10 years and/or is popular enough to have 500 followers. As a well-established organization, then, it was
The purpose of this study was to explore the work-life narratives of
more likely to be recommending blogs that would be popular and/or
nurses through a thematic analysis of the nursing accounts they post
read by more nurses than blogs on lists shared by any one relatively
in their public blogs. The overall research question was, “when
unknown individual would be. From these lists, blogs were then cho-
nurses who work in traditional healthcare settings have the protec-
sen to be included in the study if they met the criteria listed in
tion of online anonymity, how do they describe their nursing insights
Table 1.
and experiences on blog platforms?”
The initial Google and Yahoo searches resulted in lists of nursing blogs which when combined had 100 unique recommendations. Of
2.2 | Design
those 100, only four met our blog-selection criteria (Table 1). Ultimately, all four authors were female and American and they repre-
The structure of our study can be considered a kind of qualitative
sented four different specialties. As the fifth criterion in Table 1
description, as defined by Sandelowski (2000). Qualitative descrip-
notes, blog writers had to be nurses working at least part-time in a
tion offers “a comprehensive summary of an event in the everyday
traditional healthcare setting (ie, either a hospital or outpatient clinic;
terms of those events” (Sandelowski, 2000, p. 336). This design
not school nursing, public health, consulting, etc.). Three of the four
involves analyses that stay close to the surface of the data—an
bloggers worked in a hospital. The fourth (a Certified Nurse Midwife)
appropriate methodology for answering our research question which
worked some days in the hospital performing deliveries and other
focuses on describing what nurses are saying in their online narra-
days in a women’s health outpatient clinic. While four blogs is too
tives.
small of a sample for generalizations to be made, generalization is not necessarily a goal of qualitative research (Polit & Beck, 2012).
2.3 | Sample
Instead, transferability is more of a priority (Polit & Beck, 2012).
The sampling strategy was purposive. A common strategy for researchers studying blogs is to sample blogs from blog lists shared online by others (Li & Walejko, 2008). A limitation of this strategy for studies seeking to generalize results is that found lists may consistently overlook certain blogs (particularly those that are less connected with other blogs in the list) (Li & Walejko, 2008); however, this factor also suggests that blogs that are more connected to each other and the topic of interest (and thus, are being viewed more often among blog readers of that topic) are more likely to be found by sampling from such lists. Since personal nursing blogs have not been explored, we decided that a reasonable first step in researching this domain would be to sample blogs that are likely to be among the most read. To find such blogs, we used a list-sampling strategy. Using first Google and then Yahoo search engines, we searched for lists of nursing blogs recommended by at least two established groups representing nurses’ interests. The search engine key words used were “top nursing blogs,” “nursing magazine favourite blogs”, “nursing blogs 2015,” “‘nursing magazine’ AND ‘blog’,” and “best blogs for nurses.” The lists considered were found on the first page of the results returned by each search engine. Websites sharing nursing blog recommendations were considered organizations representing nurses’ interests if they met the following criteria: the organization existed for more than 10 years (as of May 2015) or the organization had more than 500 social media followers and its mission statement centred on supporting nurses and/or other healthcare professionals. A blog-recommending website’s suggestions were
T A B L E 1 Criteria for blogs to be included in the final study Criteria: Each blog had to: 1. Be recommended by at least two different, established nursing organizations found through Google and Yahoo. 2. Be written in English. 3. Be very accessible to the public, indicating that the nurse bloggers want their stories shared publicly. Therefore, to be included in this study, the blog could not require a password or member sign-up to view present or past blog posts. 4. Be written by one nurse about his or her nursing work-life experiences. There could not be multiple authors of the same blog website. 5. Be written by a nurse working at least part-time in a traditional healthcare setting (eg, a hospital or outpatient clinic; not school nursing, public health, consulting, etc.). This criterion was applied to ensure that reasonable comparisons on nurses’ work environment reflections could be made. 6. Be recently updated and active between January 1st 2014 and December 31st 2014. This timeframe was chosen to obtain a recent, yet still longitudinal, set of blog entries from each source. 7. Have more than 10 entries available between January 1st 2014 and December 31st 2014. 8. Be anonymous, to learn what nurses want to share about their nursing experiences without fear of reprisal. Therefore, neither the author’s full name nor the hospital where the author worked could be mentioned in the blog’s home page, “About Me” page, and/or in their entries posted throughout 2014.
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Providing context to a study can aid in transferability (Polit & Beck,
reviewing themes that may fit together as sub-themes, defining and
2012), so Table 2 presents key characteristics from this sample.
naming final major themes and writing up the themes to report the overall “story” of the data (p. 19). The coding process of these four blogs started with a reading of every entry from 2014 to appreciate
2.4 | Data collection
each nurse’s year-long narrative—as a whole—(phase 1 of the pro-
The data embedded in the four bloggers’ typed posts were collected
cess of thematic analysis). Following these readings, the primary
and analysed between May–August of 2015. For each website, every
investigator began an inductive coding process of each blog entry
entry from January 2014–December 2014 was copied into a docu-
copied into NVivo 10. After open-coding each transcript’s entries
ment that was then uploaded to NVivo 10 software for analysis.
and comments into units of meaning (ie, nodes) (phase 2), the nodes were re-organized into sub-themes until three major themes coded across all four blogs were identified as best fitting the data’s story
2.5 | Ethical considerations
(phases 3 through 5).
The Canadian Tri-Council Policy Statement 2 Article 2.2 states that publicly accessible data research is exempted from Research Ethics Board review when “there is no reasonable expectation of privacy”
2.7 | Rigour
(TCPS 2, 2014). At the time the data were collected, the blogs
The use of computer software to systematize coding can improve
were publicly accessible without membership requirements. Some
the rigour of thematic analysis (Tai & Ajjawi, 2016). Providing verba-
blogs had over 1,000 followers. These blog data were found
tim quotes supports the validity of data generation (Whittemore
research material written by adults and intended for public online
et al., 2001). The principal investigator kept a reflective journal
discussion.
throughout the research process to keep track of any biases,
We are aware that anonymous online blogs are spaces where
assumptions and impressions (Houghton, Casey, Shaw, & Murphy,
nurses are congregating because they feel they can have their voices
2013; Keim-Malpass et al., 2013) she may have had. This journal
safely heard there. If nursing blogs are to remain a safe space for
and the NVivo files are available for auditing.
nurses sharing their narratives, researchers must be careful to represent the authors as their blogged words were intended. To accomplish this, we quoted the blogs as often as possible and we studied
3 | FINDINGS
their stories chronologically (starting from their January 2014 posts and finishing with their December 2014 entries) to gain a deeper
This project explored the online narratives of four female American
context for understanding each blog entry (Whittemore, Chase, &
nurse bloggers whose websites were anonymous, were regularly
Mandle, 2001).
updated in 2014 and came recommended by nursing-related groups. The following self-explanatory pseudonyms are used in this report: Nurse-Midwife (2014) (a Certified Nurse Midwife), Nurse-NeuroICU
2.6 | Data analysis
(2014) (a neuro critical care unit nurse), Nurse-ER (2014) (an emer-
All 520 blog posts between 1 January 2014–31 December 2014
gency room (ER) nurse) and Nurse-Recovery (2014) (a rehabilitation
were thematically analysed. Using a set time-period, we could com-
nurse). Throughout this paper, “n” represents the number of times a
pare nurses’ experiences in the same timeline. Comments by readers
concept was found in the data; Table 3 lists these frequencies for
on nurses’ blogs were also analysed. Although many commenters
each major theme. Out of the data immersion and analysis process,
were not nurses, their comments were still included since such inter-
three major themes were identified: these bloggers care about nurs-
actions are inherent to the nature of blogging.
ing (range: N = 139–717); but they are feeling stressed and burnt
The process of thematic analysis followed the six steps recom-
out (range: N = 23–589); so, under the protection of online anonym-
mended by Braun and Clarke (2006): familiarization with the data,
ity, they share the key factors contributing to their work frustrations
initial coding, searching for themes among the initial codes,
(range: N = 130–1122).
T A B L E 2 Sample characteristics Pseudonym
Nurse-Midwife
Nurse-Recovery
Nurse-NeuroICU
Nurse-ER
Type of nurse
Certified Nurse Midwife (CNM)
Rehabilitation nurse
Neuro critical care unit nurse
Emergency room nurse
Region
U.S.A.
Mid-Western U.S.A
Texas, U.S.A.
U.S.A.
Blog statistics (June 14th, 2015)
1024 followers. Ranked #49 of babble.com’s 50 best pregnancy blogs of 2011
91 members/followers
1406 blog members/ followers
Home page had 1,395,549 visits
Blogging Since
2009
2007
2004
2011
# Entries in 2014 (Total: 520)
17 (longer entries)
187 (shorter entries)
26 (longer entries)
290 (shorter entries)
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T A B L E 3 Major theme frequencies (n) per blog
Nurses care about nursing work Feeling stressed and burnt out Areas of frustration
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times it meant comfortingly touching a patient, like Nurse-NeuroICU (2014) insisted on doing every shift.
NurseMidwife
NurseRecovery
NurseNeuroICU
206
139
241
717
23
37
218
589
142
130
445
1122
Nurse-ER
These bloggers also concerned themselves with patients’ rights and advocacy. For non-communicative patients, bloggers described reaching out to various team members and family to get the best care possible for the patient, even if those conversations were difficult. Nurse-Recovery (2014) reminded readers that patients have the right to refuse treatments: “Don’t force someone to do something they refuse to consent to do, like take a bath. Do the words assault and battery mean anything to you?. . . Patient says no, you document
3.1 | Nurses care about nursing work Nurses explicitly and implicitly shared their strong belief in the value of nurses’ work. They used their online platforms to describe what real-life nursing can look like. Four sub-themes were noted.
to CYA [cover your ass]” (December).
3.1.4 | Describing sympathizing with patients Sometimes all nurses could do for their patients was cry with them. Nurse-ER (2014) worried about how little empathy homeless
3.1.1 | Describing “real life” nursing tasks
patients received. Nurse-Midwife (2014) recalled how she always
These nurses wrote many entries that described their workday tasks
heartbeat was lost. Nurse-NeuroICU (2014) vented about a glioblas-
(range: N = 39–343). The tasks the bloggers outlined varied some-
toma case where the patient “finally had to be four-point restrained
cried with her patients when she had to tell them that a foetal
what according to their specialty. Nurse-Midwife (2014) wrote about
because the tumour had hit the pain centres in their brain. . . [yet] [t]
how “I seem to have a special on shoulder dystocias lately. I would
he family didn’t want continuous pain control because they felt the
love for that black cloud to just go away, please, thankyouvery-
patient was still able to communicate” (November). She said such
much!” (March). Nurse-NeuroICU (2014) described nursing patients
cases “haunted” her. These ethically intense situations read as the
with brain injuries, while Nurse-ER (2014) chronicled frontline ER
most painful narratives for nurse bloggers to share.
conditions like dealing with gunshot wounds and patients addicted to opioids. Still, while the details of their days differed, all four were also sharing entries illustrating nursing practices that transcend spe-
3.2 | Feeling stressed and burnt out
cialties. This is exemplified in one of Nurse-Recovery’s (2014) posts:
All four nurses discussed feeling stressed and/or burnt out. Symp-
“I saw one of our patients today who was put on C-diff[icile] isola-
toms of burnout include feelings of job dissatisfaction, insensitivity
tion. Felt like old times. . . I did a little patient education for this
towards patients or families and depressive symptoms (Browning,
sweet 80 something year old guy and complimented him on using
Ryan, Thomas, Greenberg, & Rolniak, 2007; Khamisa, Peltzer, &
his moisturizer on his hands (which is really a part of his rehab, too)”
Oldenburg, 2013). Three of the four nurses described being so
(January). Many nursing tasks (like patient education and skin care)
stressed at work that at times they were debating finding a new
are appropriate in all nursing settings.
position; Nurse-Midwife (2014) did not express such intentions. Nurse-ER (2014) wrote one post in March 2014 entitled “I’m just
3.1.2 | Expressing pride in nursing
about done” which complained about a lack of adequate staffing and feeling like she had “had enough” of work. Another one of her posts,
The narratives often exuded a sense of pride in nursing work.
“How I Became A Bitch” (September), described becoming meaner as
Nurse-Midwife (2014) raved about the benefits that evidence-based
a result of the physical, mental and emotional demands of emer-
midwifery could provide women with. Nurse-ER (2014) defended
gency room nursing. It received over 100 comments, with readers
nursing, exclaiming “We are the backbone of the medical profession.
debating whether the post was unprofessional, accurate and/or justi-
Without us, it would collapse” (February). In total, there was a range
fied.
of between 9-113 nodes where nurses and commenters shared anecdotes specifically praising nursing.
While it was Nurse-ER (2014) who wrote such sentiments most frequently, it was Nurse-NeuroICU (2014) whose blog entries in 2014 showed her stressors growing over time. Early in 2014, she
3.1.3 | Describing caring about and advocating for patients
discussed how she was feeling optimistic about work. Yet, by August, she was so frustrated with her work environment that she was interviewing for a new job. She wrote that a reason she was
Each blog made between 28-107 references to nurses describing
seeking a new position was because her current environment (with
how they cared and advocated for their patients. Caring for patients
staff cuts and increasing acuity) was causing her to “dread” work and
often involved taking time to chat and develop a relationship with
to use Benadryl and alcohol to recover from shifts; these feelings
them, as Nurse-ER (2014) did with elderly ladies in the ER. Other
were in spite of her beloved nurse co-workers’ presence. Nurse-
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could give orders which nurses might think were inappropriate, but
use medication or alcohol to cope with their work stressors, either.
nurses believed that questioning such orders could put a nurse’s job
When Nurse-ER (2014) described the turmoil of the ER, she joked
at risk.
that a consequence of the chaos was that “When the staff feels out of control, they go home and drink” (January). Nurse-NeuroICU (2014) did not feel she could explain any of this
3.3.2 | Challenging patients and families
to the job interviewer. All four blogs and several commenters had
As much as nurses care about their patients, patients and families
references to nurses who had been fired for criticizing their institu-
may also contribute to nursing frustrations. Nurses described
tions’ practices. In the end, Nurse-NeuroICU (2014) only told the
demanding patients who appeared to use the call-bell unnecessarily.
interviewer that she wanted to branch out in nursing.
Nurse-Recovery (2014) recalled that “Sometimes, when I was on the
Based on their individual numbers of references relating to
floor, I would have those moments with those super-needy patients
burnout and frustration, Nurse-Midwife (2014) was experiencing
where I felt as if every ounce of caring was sucked out of me”
the fewest stressors (N = 23), followed by Nurse-Recovery (2014)
(November). More worrisome to the bloggers, however, were the
(N = 37), Nurse-NeuroICU (2014) (N = 218) and Nurse-ER (2014)
patients whose inappropriate behaviours sometimes took the nurses
(N = 589). Nurse-ER’s (2014) blog had the most blog entries in
away from more acute patients’ bedsides.
2014 (290), the most references relating to caring about nursing
Nurses blogged that patients’ families could also become barriers
work (N = 717) and the most references to nursing frustrations and
to providing nursing care. It was claimed that some family members
burnout (N = 589).
yelled at nurses directly, taking nurses away from other patients. The families that seemed to discourage nurses the most, though,
3.3 | Areas of frustration
were the families who needed ethics committees to come in and discuss the patient’s treatment (like painful life support technologies).
Three key factors correlated with these negative descriptions: team-
As Nurse-NeuroICU (2014) noted on her blog, such cases were men-
work issues, challenging patients and families and “manglement.”
tally and physically exhausting for nursing staff.
“Manglement” was a term found in a few of the nursing blogs. It is a combination of the words “management” and “mangled.” Nurse bloggers used this term to describe higher ranking, anonymous health-
3.3.3 | “Manglement” issues
care administrators who the bloggers felt were out-of-touch with
The concept of “manglement issues” heavily contributed to nursing
frontline nursing work.
frustrations. There were many references (range: N = 34–637) relating to healthcare administration problems in nursing work. Four main
3.3.1 | Teamwork issues These blogs suggested that co-worker cooperation issues are an
frustrations were revealed: charting time; patient satisfaction scores and hospital accreditations; understaffing; and unsafe work environments.
ongoing challenge in nursing. An impression given throughout the
A common nursing complaint across all four blogs was that too
posts was that due to a combination of understaffing, healthcare
much time was spent on charting which did not contribute to patient
hierarchies and unprofessionalism, units often failed to cooperate as
care. The first item on Nurse-Midwife’s (2014) entry listing things
a team.
she wished she had learnt more about in school was billing. Nurse-
While nurse bloggers said that sometimes the only reason they
ER (2014) called charting the “bain (sic) of our existence” (February).
remained in their current positions was because of their close bonds
When they weighed its annoyances with its benefits, nurse bloggers
with co-workers, they also admitted that lateral nurse aggressions
decided that the level of required charting was too high, given their
were an ongoing challenge. The suggestion that “nurses eat their
time constraints.
young” (meaning that older nurses bully new nurses) arose several times.
Nurses were also frustrated by management’s apparent prioritization of “patient satisfaction” (where patients are given opportunities
Non-nursing co-worker challenges were also described in all four
to rate the services they receive at a hospital). Nurse-NeuroICU
nurses’ blogs. Healthcare hierarchy frustrations where bloggers
(2014) complained about how she felt her unit was being turned into
believed that nurses were at the bottom of the pyramid were often
a place for “Very Important Patients” only (August). Nurse-ER (2014)
discussed. For instance, Nurse-NeuroICU’s (2014) hospital adminis-
and her blog commenters debated her sarcastic suggestion that she
tration appeared to take credit for a big nursing award that her unit
create a website which would help patients decide which ER serves
won and the poster advertising the award did not represent a single
patients best, with notes about whether cars could be valet parked
person working as a bedside nurse. Yet, administrators, a doctor and
on arrival.
a researcher were portrayed.
These satisfaction scores were linked, in bloggers’ minds, to hos-
Nurse bloggers’ interactions with doctors were usually amicable.
pital accreditations that are used for quality control. Nurse-ER
Their only major frustration with physician colleagues seemed to be
(2014) recommended using duct tape to hold such surveyors off.
the greater issue of the healthcare hierarchy, where they felt doctors
Nurse-NeuroICU (2014) stated, “Joint Commission surveys are
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generally held to be bullshit” (January). For hospitals constantly
often felt under significant stress at work. External research on
implementing budget cuts, surveys were thought to be needless and
nursing burnout in relation to nursing specialty matched the pat-
expensive activities.
terns in these blogs. In the blogs, there was a clear spectrum of
Understaffing complaints were prevalent throughout the blogs
burnout and it appeared to roughly correlate with the acuity of
(although they were not in Nurse-Midwife’s (2014) posts). Nurse-
each nursing specialty: Nurse-Midwife (2014) and Nurse-Recovery
Recovery (2014) argued, “Get us what we ask for. . .not c$%p we
(2014) made fewer references to stress or career burnout, while
don’t want. Like enough nursing staff. You know. . .those 24/7 folks
Nurse-NeuroICU (2014) and Nurse-ER (2014) made a lot more.
who make the place run” (February). When Nurse-ER (2014) vented
While some of the differences in number of references for this
about being short-staffed in the ER, she received empathetic com-
theme may be explained by the differences in blog post numbers
ments like this one: “Acuity and age are increasing while staffing is
(Nurse-ER (2014) had the most entries and so response frequencies
decreasing. When your median age of patients is 85 and you have
are skewed towards her), the spectrum noted does align with
no tech support, it makes it impossible to accomplish all tasks. . . we
Browning et al.’s (2007) results comparing nurses’ specialties to the
are getting our butts kicked” (May).
probability of nurse burnout. In a comparison of nurse practitioners,
Nurse bloggers believed that understaffing situations were con-
managers and ER nurses in the USA, ER nurses were burning out
tributing to unsafe work environments. Patients who physically
most and felt least in control of their work, while nurse practition-
abused nurses were featured several times. Nurse-NeuroICU (2014)
ers had the fewest symptoms of burnout and felt most in control
shared that work might be improving because “Nobody’s tried to
(Browning et al., 2007). Like the nurse practitioners, Nurse-Midwife
punch me lately. (Well, they tried, but they didn’t connect. Much.)”
(2014) and Nurse-Recovery (2014) described calmer (and often less
(May). The physical abuse nurses recorded in these blogs appeared
acute) working environments and had fewer references to frustra-
to be restricted to Nurse-NeuroICU’s (2014) critical care unit and
tions and burnout. Nurse-NeuroICU (2014) and Nurse-ER (2014),
Nurse-ER’s (2014) inner city unit. Nurse-Midwife (2014) and Nurse-
on the other hand, described the most acute patient cases, frustra-
Recovery (2014) had patients who became antagonistic but not
tions and burnout symptoms (Browning et al., 2007; Khamisa et al.,
physically aggressive.
2013).
Reports of unsafe work conditions were not only restricted to
The moral and ethical dilemmas surrounding quality patient care
punching and verbal abuse, though. In 2014, nurse bloggers did not
which Nurse-NeuroICU (2014) and Nurse-ER (2014) narrated about
feel they received adequate protection from the infections they
are common contributors to professional fatigue and burnout (McS-
faced at work. Two commenters shared that their hospitals had poli-
teen & Peden-McAlpine, 2006). In a study of intensive care unit
cies which penalized workers for calling in sick.
nurses, moral distress surrounding medical procedures perceived as € futile were linked to increased job dissatisfaction (Ozden, Kar-
During 2014’s ebola crisis, three of these bloggers (all but NurseMidwife, 2014) were also sharing their beliefs about hospitals being
€ zog lu, & Yıldırım, 2013). Based on these bloggers’ descriptions of ago
unprepared for epidemics. Nurse-ER (2014) described her worries
the stressors surrounding ethical nursing care, these nurses under-
regarding ER nurses’ lack of ebola training. Nurse-NeuroICU (2014)
stand how difficult it can be to care for acutely ill patients when
wrote, “If I had to care for a patient with Ebola tomorrow, I would
other patients’ and family members’ actions prevent nurses from
have no appropriate protective gear. I would also have no way to
doing their work well.
refuse the assignment (not that I would; I’d pull up my big-girl pan-
Finally, dissonance between management’s goals and nurses’
ties and pray like hell)” (October). So, another source of frustration
needs appeared to add to these nurses’ frustrations. These blog-
at work for these nurses included perceptions of biologically unsafe
gers’ sentiments regarding charting time have been reiterated in
work environments.
nursing research. Sassen (2009) explains how too often, electronic health records (EHRs) do not take nurses’ needs into consideration before EHRs are implemented. As a result, nurses are frustrated
4 | DISCUSSION
when the programmes do not complement their work-flows. Understaffing was another issue commonly given by bloggers as a
Four popular, anonymous, American female nurses’ blog entries and
reason for feeling depressed or wanting to find a new job. These
comments from 2014 were thematically analysed. The project was
understaffing situations can contribute to unsafe work conditions
exploratory: what were nurses saying in their anonymous blogs
for patients and staff, alike (Stone et al., 2007). Yet, too often
about their experiences of nursing in traditional healthcare settings?
when nurses report situations they believe are inappropriate,
Three major themes were revealed: (1) Nurses care about their nurs-
nurses are disciplined (Jackson et al., 2014). Therefore, it is perhaps
ing work; but (2) nurses are feeling stressed and burnt out; and (3)
understandable that when nurses choose to blog anonymously,
these nurses use their anonymous blogs to share areas of frustration
they use that protection to share their honest impressions of their
in nursing work.
professional lives. Anonymous blogs where neither the nurse nor
The fact that these nurses care about and are proud of nursing
their hospital or patients are specifically identified provide nurses
their patients should not be surprising: patients are at the centre of
with opportunities to share their frustrations and potential ideas
their profession (Walker et al., 2015). However, these nurses also
for solutions, allowing nurses’ voices to be heard without risking
8
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the loss of their jobs. These ideas can be expressed in real-time over blogs, as healthcare policies or conditions change (like the unfolding of the ebola crisis of 2014).
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AUTHOR CONTRIBUTIONS All authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE (http://www.ic mje.org/recommendations/):
4.1 | Limitations In terms of limitations, since all four nurses were American bloggers, the overall picture of nurses’ blogged experiences drawn by this research may be biased towards the American, female nurse demographic. Furthermore, although four different specialties were repre-
•
substantial contributions to conception and design, acquisition of
•
drafting the article or revising it critically for important intellectual
data, or analysis and interpretation of data; content.
sented, more nursing blogs in these specialties as well as in others need to be studied to gain a deeper understanding of different nurses’ blogging practices and nursing narratives. While node frequencies (n) were included to help support the
ORCID Aimee Castro
http://orcid.org/0000-0002-6461-0866
presence of each theme, there is some limitation to comparing frequencies between the blogs for each theme, as some blogs were
REFERENCES
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5 | CONCLUSION This qualitative study of four popular, anonymous American nursing blogs revealed that these nurses care about their nursing work, but they have many frustrations that they are sharing and discussing on their websites. Such platforms offer readers, healthcare managers and researchers access to many nurses’ typed, longitudinal narratives. As long as nurse bloggers remain anonymous and do not name the institution or network they work for, then nurses, researchers and managers can all learn from online nursing narratives without specific institutions being publicly criticized, fairly or unfairly, for policies their nurses disagree with. If the concerns described frequently and anonymously on nursing blogs by frontline healthcare providers could be analysed further by researchers and then addressed in healthcare policies, patient care might improve and nurses’ symptoms of burnout might also be reduced. The research suggests that blogs can help academics and healthcare managers understand how nurses describe their work lives when they have the protection of anonymity. Nursing blogs (at least, popular, anonymous ones like these four) appear to be accessible, cheap and reliable sources of longitudinal data on nurses’ lived experiences. Most of their accounts corresponded with external research’s conclusions regarding aspects like patient advocacy, burn out symptoms and management frustrations. Considering that as far as this study’s literature review revealed, nurses’ personal blog narratives had not previously been researched indepth, this project is a first step in helping nurses’ online narratives be better understood.
CONFLICT OF INTEREST No conflict of interest has been declared by the author(s).
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How to cite this article: Castro A, Andrews G. Nursing lives in the blogosphere: A thematic analysis of anonymous online nursing narratives. J Adv Nurs. 2017;00:1–10. https://doi.org/ 10.1111/jan.13411
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ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUALITATIVE
Nursing lives in the blogosphere: A thematic analysis of anonymous online nursing narratives Aimee Castro1
| Gavin Andrews2
1 Ingram School of Nursing, McGill University, Montreal, Quebec, Canada 2
Department of Health, Aging & Society, McMaster University, Hamilton, Ontario, Canada
Abstract Aim: The aim of this study was to explore the work-life narratives of nurses through a thematic analysis of the nursing accounts they post in their publicly accessible, anonymous blogs.
Correspondence Aimee Castro, Ingram School of Nursing, McGill University, Montreal, Quebec, Canada. Email: [email protected].
Background: Many nurses participate on social media. Blogs have been advocated as a self-reflective tool in nursing practice, yet as far as the authors are aware, no previous studies have explored nurses’ individual blogs for their potential to reveal nurses’ perceptions of nursing work.
Funding information This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors
Design: The research design was qualitative description. Methods: Between May–August 2015, Internet search engines were used to discover lists of nursing blogs recommended by organizations representing nurses’ interests. Recommended blogs were purposively sampled. Four anonymous blogs written by nurses from different nursing specialties met the sampling criteria. All 520 of their entries from 2014 were read and copied into NVivo 10, where an inductive coding process was followed. Findings: Three major themes arose in these nurses’ online discussions of their work lives: they truly care about and value their nursing work, but they are feeling stressed and burnt out and they are using their anonymous blogs to share factors that frustrate them in their nursing work. Three main areas of frustration were revealed: teamwork problems, challenging patients and families, and management issues. Conclusion: Anonymous nursing blogs offer valuable, longitudinal insights into nurses’ perceptions of their work lives. Nursing blogs should be further explored for ongoing insights into nurses’ experiences of nursing work, as well as nurses’ recommendations for addressing issues causing them to feel frustrated in their work environments. KEYWORDS
healthcare management, midwives, nurses, nursing, nursing blogs, nursing narratives, nursing work, social media, thematic analysis, web logs
1 | INTRODUCTION
the rise of such blogs, opportunities to study these online nursing narratives have emerged.
Many nurses participate in the blogosphere—the online community
Compared with other forms of online data sources, blogs are
and space centred on blogs. According to Kung and Oh (2014),
unique in that they create in-depth research opportunities written
almost a third (32%) of nurses read or write on blog websites. With
from the perspective of one main writer, over time, in dialogue with
J Adv Nurs. 2017;1–10.
wileyonlinelibrary.com/journal/jan
© 2017 John Wiley & Sons Ltd
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their readers (Heilferty, 2009) and free from the influence of an interviewer (Eastham, 2011). Micro-blogging websites like Twitter create ongoing dialogue but can inhibit narration due to character
Why is this research or review needed?
restrictions for posts (Grajales, Sheps, Ho, Novak-Lauscher, & Eysen-
•
bach, 2014). Public online forums like message boards and wikis cre-
longitudinal data in real-time of nurses’ and their blog
ate opportunities for longer posts (Grajales et al., 2014), but they are
readers’ frustrations, ideas and recommendations regard-
not typically author-centric. Blogs offer substantive volumes of immediately accessible, longitudinally transcribed data (Hookway, 2008). Anonymous online narratives give writers opportunities for
ing nursing and healthcare practice.
•
Blogs can also help to transcend the limitations of time and space:
ing blogs are addressed.
•
tions (Keim-Malpass et al., 2014).
What are the key findings?
•
Nurse bloggers care about their patients and believe in the value of nursing work, but they are feeling stressed
1.1 | Background Researchers have paid attention to how nurses write online but not
Yet, nursing blogs have not been researched for their insights into nurses’ perceptions of their work.
blogs written in real-time by authors from around the world can be easily accessed within minutes or years after their original publica-
Nurses’ job satisfaction and patient safety may both improve when concerns that resonate across these nurs-
honest self-disclosure relating to stigmatized topics, creating new avenues for support (Keim-Malpass, Steeves, & Kennedy, 2014).
Anonymous nursing blogs can offer massive amounts of
and burnt out.
•
Nurse bloggers, under the protection of anonymity, share
to what nurses are saying there. In previous studies of healthcare
frustrations that typically fall into three key categories:
blogs, researchers have focused on studying the relationship
teamwork difficulties, challenging patients and families
between authors’ credentials and the quality of blogs’ contents (Buis & Carpenter, 2009; Guardiola-Wanden-Berghe, Sanz-Valero, &
and healthcare management problems.
•
This research illustrates how public, anonymous nursing
Wanden-Berghe, 2010). One quantitative content analysis of health-
blogs offer rich, longitudinal and easily accessible data
related blogs found that the language used in physicians’ writings
for gaining insights into nurses’ and their blog readers’
were more technical when compared with nurses’ more “affective”
perceptions of nursing practice and healthcare policies.
narrative vocabularies (Denecke & Nejdl, 2009, p. 1875). A study of nursing blogs included descriptive statistics for Spanish nurses’ posts, but this work did not deeply describe these nurses’ experiences (Brito-Brito et al., 2015). Blomberg (2016) described the content of blog entries written by different nurses on a Swedish healthcare
How should the findings be used to influence policy/practice/research/education?
•
explore more nursing blogs written by nurses from dif-
union magazine’s website. A common recommendation in nursing education literature was the idea of using blogs as a learning tool in nursing education for self-reflection and collaboration (Anderson, 2010; Casella, Mills, & Usher, 2014; Garrity, Jones, Vanderzwan, De
Further research should build off this study’s example to ferent specialties and nationalities.
•
Healthcare managers may find research on anonymous nursing blogs useful in addressing nursing staff burnout and/or turnover.
La Rocha, & Epstein, 2014; Grassley & Bartoletti, 2009; Lin & Shen, 2013; Papastavrou, Hamari, Fuster, Istomina, & Salminen, 2016; Watson, 2012). Several of these studies illustrate how nursing blogs are an international phenomenon, appearing in Spain (Brito-Brito
desirable responding (Fang, Wen, & Prybutok, 2014). However,
et al., 2015), Sweden (Blomberg, 2016) and Taiwan (Lin & Shen,
discussion boards are less author-centric than blogs; one writer may
2013), among other countries. However, none of these studies
post on many different forums, so there may be fewer opportunities
explored personal nursing blogs written by nurses anonymously.
for an in-depth understanding of individual writers’ ongoing
The online source that may be most like blogs is the online dis-
experiences.
cussion forum, as both offer opportunities for longer narrative
Nursing blogs are a unique form of in-depth, public nursing
responses, public discussions and longitudinal analyses. Some online
reflection that occurs internationally and virtually, outside the con-
forums where nurses participate have been studied in relation to
straints of borders and time zones and without an interviewer effect.
knowledge sharing and educational needs (Brooks & Scott, 2006;
Yet, despite traits like these which may make researching nurses’
Curran & Sibte Raza Abidi, 2007). Discussion boards have also been
experiences easier than traditional interviewing methods, personal
used to facilitate dialogue between healthcare professionals and
nursing blogs have not been the focus of any qualitative study thus
patients (Jones & Ashurst, 2013). For the study of both discussion
far. Nurses make up the highest proportion of the professional
forums and blogs, while the interviewer effect may be avoided, the
healthcare workforce (American Association of Colleges of Nurses,
social nature of these spaces may lead contributors to share narra-
2011). When nurses’ voices and reflections go unheard, patient
tives that are more likely to please their readers—a form of socially
safety can be put at risk (Garon, 2012). Considering that nurses are
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3
key players in providing safe healthcare services, their blogged sto-
automatically included if the recommending website was affiliated
ries need to be heard.
with a college nursing programme. The criteria for an organization being in existence for 10 years or having 500 social media followers
2 | THE STUDY 2.1 | Aim
were arbitrary metrics, but our rationale was that if an organization met these criteria, then it was probably well-established in nursing circles since it has existed for 10 years and/or is popular enough to have 500 followers. As a well-established organization, then, it was
The purpose of this study was to explore the work-life narratives of
more likely to be recommending blogs that would be popular and/or
nurses through a thematic analysis of the nursing accounts they post
read by more nurses than blogs on lists shared by any one relatively
in their public blogs. The overall research question was, “when
unknown individual would be. From these lists, blogs were then cho-
nurses who work in traditional healthcare settings have the protec-
sen to be included in the study if they met the criteria listed in
tion of online anonymity, how do they describe their nursing insights
Table 1.
and experiences on blog platforms?”
The initial Google and Yahoo searches resulted in lists of nursing blogs which when combined had 100 unique recommendations. Of
2.2 | Design
those 100, only four met our blog-selection criteria (Table 1). Ultimately, all four authors were female and American and they repre-
The structure of our study can be considered a kind of qualitative
sented four different specialties. As the fifth criterion in Table 1
description, as defined by Sandelowski (2000). Qualitative descrip-
notes, blog writers had to be nurses working at least part-time in a
tion offers “a comprehensive summary of an event in the everyday
traditional healthcare setting (ie, either a hospital or outpatient clinic;
terms of those events” (Sandelowski, 2000, p. 336). This design
not school nursing, public health, consulting, etc.). Three of the four
involves analyses that stay close to the surface of the data—an
bloggers worked in a hospital. The fourth (a Certified Nurse Midwife)
appropriate methodology for answering our research question which
worked some days in the hospital performing deliveries and other
focuses on describing what nurses are saying in their online narra-
days in a women’s health outpatient clinic. While four blogs is too
tives.
small of a sample for generalizations to be made, generalization is not necessarily a goal of qualitative research (Polit & Beck, 2012).
2.3 | Sample
Instead, transferability is more of a priority (Polit & Beck, 2012).
The sampling strategy was purposive. A common strategy for researchers studying blogs is to sample blogs from blog lists shared online by others (Li & Walejko, 2008). A limitation of this strategy for studies seeking to generalize results is that found lists may consistently overlook certain blogs (particularly those that are less connected with other blogs in the list) (Li & Walejko, 2008); however, this factor also suggests that blogs that are more connected to each other and the topic of interest (and thus, are being viewed more often among blog readers of that topic) are more likely to be found by sampling from such lists. Since personal nursing blogs have not been explored, we decided that a reasonable first step in researching this domain would be to sample blogs that are likely to be among the most read. To find such blogs, we used a list-sampling strategy. Using first Google and then Yahoo search engines, we searched for lists of nursing blogs recommended by at least two established groups representing nurses’ interests. The search engine key words used were “top nursing blogs,” “nursing magazine favourite blogs”, “nursing blogs 2015,” “‘nursing magazine’ AND ‘blog’,” and “best blogs for nurses.” The lists considered were found on the first page of the results returned by each search engine. Websites sharing nursing blog recommendations were considered organizations representing nurses’ interests if they met the following criteria: the organization existed for more than 10 years (as of May 2015) or the organization had more than 500 social media followers and its mission statement centred on supporting nurses and/or other healthcare professionals. A blog-recommending website’s suggestions were
T A B L E 1 Criteria for blogs to be included in the final study Criteria: Each blog had to: 1. Be recommended by at least two different, established nursing organizations found through Google and Yahoo. 2. Be written in English. 3. Be very accessible to the public, indicating that the nurse bloggers want their stories shared publicly. Therefore, to be included in this study, the blog could not require a password or member sign-up to view present or past blog posts. 4. Be written by one nurse about his or her nursing work-life experiences. There could not be multiple authors of the same blog website. 5. Be written by a nurse working at least part-time in a traditional healthcare setting (eg, a hospital or outpatient clinic; not school nursing, public health, consulting, etc.). This criterion was applied to ensure that reasonable comparisons on nurses’ work environment reflections could be made. 6. Be recently updated and active between January 1st 2014 and December 31st 2014. This timeframe was chosen to obtain a recent, yet still longitudinal, set of blog entries from each source. 7. Have more than 10 entries available between January 1st 2014 and December 31st 2014. 8. Be anonymous, to learn what nurses want to share about their nursing experiences without fear of reprisal. Therefore, neither the author’s full name nor the hospital where the author worked could be mentioned in the blog’s home page, “About Me” page, and/or in their entries posted throughout 2014.
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Providing context to a study can aid in transferability (Polit & Beck,
reviewing themes that may fit together as sub-themes, defining and
2012), so Table 2 presents key characteristics from this sample.
naming final major themes and writing up the themes to report the overall “story” of the data (p. 19). The coding process of these four blogs started with a reading of every entry from 2014 to appreciate
2.4 | Data collection
each nurse’s year-long narrative—as a whole—(phase 1 of the pro-
The data embedded in the four bloggers’ typed posts were collected
cess of thematic analysis). Following these readings, the primary
and analysed between May–August of 2015. For each website, every
investigator began an inductive coding process of each blog entry
entry from January 2014–December 2014 was copied into a docu-
copied into NVivo 10. After open-coding each transcript’s entries
ment that was then uploaded to NVivo 10 software for analysis.
and comments into units of meaning (ie, nodes) (phase 2), the nodes were re-organized into sub-themes until three major themes coded across all four blogs were identified as best fitting the data’s story
2.5 | Ethical considerations
(phases 3 through 5).
The Canadian Tri-Council Policy Statement 2 Article 2.2 states that publicly accessible data research is exempted from Research Ethics Board review when “there is no reasonable expectation of privacy”
2.7 | Rigour
(TCPS 2, 2014). At the time the data were collected, the blogs
The use of computer software to systematize coding can improve
were publicly accessible without membership requirements. Some
the rigour of thematic analysis (Tai & Ajjawi, 2016). Providing verba-
blogs had over 1,000 followers. These blog data were found
tim quotes supports the validity of data generation (Whittemore
research material written by adults and intended for public online
et al., 2001). The principal investigator kept a reflective journal
discussion.
throughout the research process to keep track of any biases,
We are aware that anonymous online blogs are spaces where
assumptions and impressions (Houghton, Casey, Shaw, & Murphy,
nurses are congregating because they feel they can have their voices
2013; Keim-Malpass et al., 2013) she may have had. This journal
safely heard there. If nursing blogs are to remain a safe space for
and the NVivo files are available for auditing.
nurses sharing their narratives, researchers must be careful to represent the authors as their blogged words were intended. To accomplish this, we quoted the blogs as often as possible and we studied
3 | FINDINGS
their stories chronologically (starting from their January 2014 posts and finishing with their December 2014 entries) to gain a deeper
This project explored the online narratives of four female American
context for understanding each blog entry (Whittemore, Chase, &
nurse bloggers whose websites were anonymous, were regularly
Mandle, 2001).
updated in 2014 and came recommended by nursing-related groups. The following self-explanatory pseudonyms are used in this report: Nurse-Midwife (2014) (a Certified Nurse Midwife), Nurse-NeuroICU
2.6 | Data analysis
(2014) (a neuro critical care unit nurse), Nurse-ER (2014) (an emer-
All 520 blog posts between 1 January 2014–31 December 2014
gency room (ER) nurse) and Nurse-Recovery (2014) (a rehabilitation
were thematically analysed. Using a set time-period, we could com-
nurse). Throughout this paper, “n” represents the number of times a
pare nurses’ experiences in the same timeline. Comments by readers
concept was found in the data; Table 3 lists these frequencies for
on nurses’ blogs were also analysed. Although many commenters
each major theme. Out of the data immersion and analysis process,
were not nurses, their comments were still included since such inter-
three major themes were identified: these bloggers care about nurs-
actions are inherent to the nature of blogging.
ing (range: N = 139–717); but they are feeling stressed and burnt
The process of thematic analysis followed the six steps recom-
out (range: N = 23–589); so, under the protection of online anonym-
mended by Braun and Clarke (2006): familiarization with the data,
ity, they share the key factors contributing to their work frustrations
initial coding, searching for themes among the initial codes,
(range: N = 130–1122).
T A B L E 2 Sample characteristics Pseudonym
Nurse-Midwife
Nurse-Recovery
Nurse-NeuroICU
Nurse-ER
Type of nurse
Certified Nurse Midwife (CNM)
Rehabilitation nurse
Neuro critical care unit nurse
Emergency room nurse
Region
U.S.A.
Mid-Western U.S.A
Texas, U.S.A.
U.S.A.
Blog statistics (June 14th, 2015)
1024 followers. Ranked #49 of babble.com’s 50 best pregnancy blogs of 2011
91 members/followers
1406 blog members/ followers
Home page had 1,395,549 visits
Blogging Since
2009
2007
2004
2011
# Entries in 2014 (Total: 520)
17 (longer entries)
187 (shorter entries)
26 (longer entries)
290 (shorter entries)
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T A B L E 3 Major theme frequencies (n) per blog
Nurses care about nursing work Feeling stressed and burnt out Areas of frustration
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times it meant comfortingly touching a patient, like Nurse-NeuroICU (2014) insisted on doing every shift.
NurseMidwife
NurseRecovery
NurseNeuroICU
206
139
241
717
23
37
218
589
142
130
445
1122
Nurse-ER
These bloggers also concerned themselves with patients’ rights and advocacy. For non-communicative patients, bloggers described reaching out to various team members and family to get the best care possible for the patient, even if those conversations were difficult. Nurse-Recovery (2014) reminded readers that patients have the right to refuse treatments: “Don’t force someone to do something they refuse to consent to do, like take a bath. Do the words assault and battery mean anything to you?. . . Patient says no, you document
3.1 | Nurses care about nursing work Nurses explicitly and implicitly shared their strong belief in the value of nurses’ work. They used their online platforms to describe what real-life nursing can look like. Four sub-themes were noted.
to CYA [cover your ass]” (December).
3.1.4 | Describing sympathizing with patients Sometimes all nurses could do for their patients was cry with them. Nurse-ER (2014) worried about how little empathy homeless
3.1.1 | Describing “real life” nursing tasks
patients received. Nurse-Midwife (2014) recalled how she always
These nurses wrote many entries that described their workday tasks
heartbeat was lost. Nurse-NeuroICU (2014) vented about a glioblas-
(range: N = 39–343). The tasks the bloggers outlined varied some-
toma case where the patient “finally had to be four-point restrained
cried with her patients when she had to tell them that a foetal
what according to their specialty. Nurse-Midwife (2014) wrote about
because the tumour had hit the pain centres in their brain. . . [yet] [t]
how “I seem to have a special on shoulder dystocias lately. I would
he family didn’t want continuous pain control because they felt the
love for that black cloud to just go away, please, thankyouvery-
patient was still able to communicate” (November). She said such
much!” (March). Nurse-NeuroICU (2014) described nursing patients
cases “haunted” her. These ethically intense situations read as the
with brain injuries, while Nurse-ER (2014) chronicled frontline ER
most painful narratives for nurse bloggers to share.
conditions like dealing with gunshot wounds and patients addicted to opioids. Still, while the details of their days differed, all four were also sharing entries illustrating nursing practices that transcend spe-
3.2 | Feeling stressed and burnt out
cialties. This is exemplified in one of Nurse-Recovery’s (2014) posts:
All four nurses discussed feeling stressed and/or burnt out. Symp-
“I saw one of our patients today who was put on C-diff[icile] isola-
toms of burnout include feelings of job dissatisfaction, insensitivity
tion. Felt like old times. . . I did a little patient education for this
towards patients or families and depressive symptoms (Browning,
sweet 80 something year old guy and complimented him on using
Ryan, Thomas, Greenberg, & Rolniak, 2007; Khamisa, Peltzer, &
his moisturizer on his hands (which is really a part of his rehab, too)”
Oldenburg, 2013). Three of the four nurses described being so
(January). Many nursing tasks (like patient education and skin care)
stressed at work that at times they were debating finding a new
are appropriate in all nursing settings.
position; Nurse-Midwife (2014) did not express such intentions. Nurse-ER (2014) wrote one post in March 2014 entitled “I’m just
3.1.2 | Expressing pride in nursing
about done” which complained about a lack of adequate staffing and feeling like she had “had enough” of work. Another one of her posts,
The narratives often exuded a sense of pride in nursing work.
“How I Became A Bitch” (September), described becoming meaner as
Nurse-Midwife (2014) raved about the benefits that evidence-based
a result of the physical, mental and emotional demands of emer-
midwifery could provide women with. Nurse-ER (2014) defended
gency room nursing. It received over 100 comments, with readers
nursing, exclaiming “We are the backbone of the medical profession.
debating whether the post was unprofessional, accurate and/or justi-
Without us, it would collapse” (February). In total, there was a range
fied.
of between 9-113 nodes where nurses and commenters shared anecdotes specifically praising nursing.
While it was Nurse-ER (2014) who wrote such sentiments most frequently, it was Nurse-NeuroICU (2014) whose blog entries in 2014 showed her stressors growing over time. Early in 2014, she
3.1.3 | Describing caring about and advocating for patients
discussed how she was feeling optimistic about work. Yet, by August, she was so frustrated with her work environment that she was interviewing for a new job. She wrote that a reason she was
Each blog made between 28-107 references to nurses describing
seeking a new position was because her current environment (with
how they cared and advocated for their patients. Caring for patients
staff cuts and increasing acuity) was causing her to “dread” work and
often involved taking time to chat and develop a relationship with
to use Benadryl and alcohol to recover from shifts; these feelings
them, as Nurse-ER (2014) did with elderly ladies in the ER. Other
were in spite of her beloved nurse co-workers’ presence. Nurse-
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NeuroICU (2014) was not the only nurse to suggest nurses might
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could give orders which nurses might think were inappropriate, but
use medication or alcohol to cope with their work stressors, either.
nurses believed that questioning such orders could put a nurse’s job
When Nurse-ER (2014) described the turmoil of the ER, she joked
at risk.
that a consequence of the chaos was that “When the staff feels out of control, they go home and drink” (January). Nurse-NeuroICU (2014) did not feel she could explain any of this
3.3.2 | Challenging patients and families
to the job interviewer. All four blogs and several commenters had
As much as nurses care about their patients, patients and families
references to nurses who had been fired for criticizing their institu-
may also contribute to nursing frustrations. Nurses described
tions’ practices. In the end, Nurse-NeuroICU (2014) only told the
demanding patients who appeared to use the call-bell unnecessarily.
interviewer that she wanted to branch out in nursing.
Nurse-Recovery (2014) recalled that “Sometimes, when I was on the
Based on their individual numbers of references relating to
floor, I would have those moments with those super-needy patients
burnout and frustration, Nurse-Midwife (2014) was experiencing
where I felt as if every ounce of caring was sucked out of me”
the fewest stressors (N = 23), followed by Nurse-Recovery (2014)
(November). More worrisome to the bloggers, however, were the
(N = 37), Nurse-NeuroICU (2014) (N = 218) and Nurse-ER (2014)
patients whose inappropriate behaviours sometimes took the nurses
(N = 589). Nurse-ER’s (2014) blog had the most blog entries in
away from more acute patients’ bedsides.
2014 (290), the most references relating to caring about nursing
Nurses blogged that patients’ families could also become barriers
work (N = 717) and the most references to nursing frustrations and
to providing nursing care. It was claimed that some family members
burnout (N = 589).
yelled at nurses directly, taking nurses away from other patients. The families that seemed to discourage nurses the most, though,
3.3 | Areas of frustration
were the families who needed ethics committees to come in and discuss the patient’s treatment (like painful life support technologies).
Three key factors correlated with these negative descriptions: team-
As Nurse-NeuroICU (2014) noted on her blog, such cases were men-
work issues, challenging patients and families and “manglement.”
tally and physically exhausting for nursing staff.
“Manglement” was a term found in a few of the nursing blogs. It is a combination of the words “management” and “mangled.” Nurse bloggers used this term to describe higher ranking, anonymous health-
3.3.3 | “Manglement” issues
care administrators who the bloggers felt were out-of-touch with
The concept of “manglement issues” heavily contributed to nursing
frontline nursing work.
frustrations. There were many references (range: N = 34–637) relating to healthcare administration problems in nursing work. Four main
3.3.1 | Teamwork issues These blogs suggested that co-worker cooperation issues are an
frustrations were revealed: charting time; patient satisfaction scores and hospital accreditations; understaffing; and unsafe work environments.
ongoing challenge in nursing. An impression given throughout the
A common nursing complaint across all four blogs was that too
posts was that due to a combination of understaffing, healthcare
much time was spent on charting which did not contribute to patient
hierarchies and unprofessionalism, units often failed to cooperate as
care. The first item on Nurse-Midwife’s (2014) entry listing things
a team.
she wished she had learnt more about in school was billing. Nurse-
While nurse bloggers said that sometimes the only reason they
ER (2014) called charting the “bain (sic) of our existence” (February).
remained in their current positions was because of their close bonds
When they weighed its annoyances with its benefits, nurse bloggers
with co-workers, they also admitted that lateral nurse aggressions
decided that the level of required charting was too high, given their
were an ongoing challenge. The suggestion that “nurses eat their
time constraints.
young” (meaning that older nurses bully new nurses) arose several times.
Nurses were also frustrated by management’s apparent prioritization of “patient satisfaction” (where patients are given opportunities
Non-nursing co-worker challenges were also described in all four
to rate the services they receive at a hospital). Nurse-NeuroICU
nurses’ blogs. Healthcare hierarchy frustrations where bloggers
(2014) complained about how she felt her unit was being turned into
believed that nurses were at the bottom of the pyramid were often
a place for “Very Important Patients” only (August). Nurse-ER (2014)
discussed. For instance, Nurse-NeuroICU’s (2014) hospital adminis-
and her blog commenters debated her sarcastic suggestion that she
tration appeared to take credit for a big nursing award that her unit
create a website which would help patients decide which ER serves
won and the poster advertising the award did not represent a single
patients best, with notes about whether cars could be valet parked
person working as a bedside nurse. Yet, administrators, a doctor and
on arrival.
a researcher were portrayed.
These satisfaction scores were linked, in bloggers’ minds, to hos-
Nurse bloggers’ interactions with doctors were usually amicable.
pital accreditations that are used for quality control. Nurse-ER
Their only major frustration with physician colleagues seemed to be
(2014) recommended using duct tape to hold such surveyors off.
the greater issue of the healthcare hierarchy, where they felt doctors
Nurse-NeuroICU (2014) stated, “Joint Commission surveys are
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7
generally held to be bullshit” (January). For hospitals constantly
often felt under significant stress at work. External research on
implementing budget cuts, surveys were thought to be needless and
nursing burnout in relation to nursing specialty matched the pat-
expensive activities.
terns in these blogs. In the blogs, there was a clear spectrum of
Understaffing complaints were prevalent throughout the blogs
burnout and it appeared to roughly correlate with the acuity of
(although they were not in Nurse-Midwife’s (2014) posts). Nurse-
each nursing specialty: Nurse-Midwife (2014) and Nurse-Recovery
Recovery (2014) argued, “Get us what we ask for. . .not c$%p we
(2014) made fewer references to stress or career burnout, while
don’t want. Like enough nursing staff. You know. . .those 24/7 folks
Nurse-NeuroICU (2014) and Nurse-ER (2014) made a lot more.
who make the place run” (February). When Nurse-ER (2014) vented
While some of the differences in number of references for this
about being short-staffed in the ER, she received empathetic com-
theme may be explained by the differences in blog post numbers
ments like this one: “Acuity and age are increasing while staffing is
(Nurse-ER (2014) had the most entries and so response frequencies
decreasing. When your median age of patients is 85 and you have
are skewed towards her), the spectrum noted does align with
no tech support, it makes it impossible to accomplish all tasks. . . we
Browning et al.’s (2007) results comparing nurses’ specialties to the
are getting our butts kicked” (May).
probability of nurse burnout. In a comparison of nurse practitioners,
Nurse bloggers believed that understaffing situations were con-
managers and ER nurses in the USA, ER nurses were burning out
tributing to unsafe work environments. Patients who physically
most and felt least in control of their work, while nurse practition-
abused nurses were featured several times. Nurse-NeuroICU (2014)
ers had the fewest symptoms of burnout and felt most in control
shared that work might be improving because “Nobody’s tried to
(Browning et al., 2007). Like the nurse practitioners, Nurse-Midwife
punch me lately. (Well, they tried, but they didn’t connect. Much.)”
(2014) and Nurse-Recovery (2014) described calmer (and often less
(May). The physical abuse nurses recorded in these blogs appeared
acute) working environments and had fewer references to frustra-
to be restricted to Nurse-NeuroICU’s (2014) critical care unit and
tions and burnout. Nurse-NeuroICU (2014) and Nurse-ER (2014),
Nurse-ER’s (2014) inner city unit. Nurse-Midwife (2014) and Nurse-
on the other hand, described the most acute patient cases, frustra-
Recovery (2014) had patients who became antagonistic but not
tions and burnout symptoms (Browning et al., 2007; Khamisa et al.,
physically aggressive.
2013).
Reports of unsafe work conditions were not only restricted to
The moral and ethical dilemmas surrounding quality patient care
punching and verbal abuse, though. In 2014, nurse bloggers did not
which Nurse-NeuroICU (2014) and Nurse-ER (2014) narrated about
feel they received adequate protection from the infections they
are common contributors to professional fatigue and burnout (McS-
faced at work. Two commenters shared that their hospitals had poli-
teen & Peden-McAlpine, 2006). In a study of intensive care unit
cies which penalized workers for calling in sick.
nurses, moral distress surrounding medical procedures perceived as € futile were linked to increased job dissatisfaction (Ozden, Kar-
During 2014’s ebola crisis, three of these bloggers (all but NurseMidwife, 2014) were also sharing their beliefs about hospitals being
€ zog lu, & Yıldırım, 2013). Based on these bloggers’ descriptions of ago
unprepared for epidemics. Nurse-ER (2014) described her worries
the stressors surrounding ethical nursing care, these nurses under-
regarding ER nurses’ lack of ebola training. Nurse-NeuroICU (2014)
stand how difficult it can be to care for acutely ill patients when
wrote, “If I had to care for a patient with Ebola tomorrow, I would
other patients’ and family members’ actions prevent nurses from
have no appropriate protective gear. I would also have no way to
doing their work well.
refuse the assignment (not that I would; I’d pull up my big-girl pan-
Finally, dissonance between management’s goals and nurses’
ties and pray like hell)” (October). So, another source of frustration
needs appeared to add to these nurses’ frustrations. These blog-
at work for these nurses included perceptions of biologically unsafe
gers’ sentiments regarding charting time have been reiterated in
work environments.
nursing research. Sassen (2009) explains how too often, electronic health records (EHRs) do not take nurses’ needs into consideration before EHRs are implemented. As a result, nurses are frustrated
4 | DISCUSSION
when the programmes do not complement their work-flows. Understaffing was another issue commonly given by bloggers as a
Four popular, anonymous, American female nurses’ blog entries and
reason for feeling depressed or wanting to find a new job. These
comments from 2014 were thematically analysed. The project was
understaffing situations can contribute to unsafe work conditions
exploratory: what were nurses saying in their anonymous blogs
for patients and staff, alike (Stone et al., 2007). Yet, too often
about their experiences of nursing in traditional healthcare settings?
when nurses report situations they believe are inappropriate,
Three major themes were revealed: (1) Nurses care about their nurs-
nurses are disciplined (Jackson et al., 2014). Therefore, it is perhaps
ing work; but (2) nurses are feeling stressed and burnt out; and (3)
understandable that when nurses choose to blog anonymously,
these nurses use their anonymous blogs to share areas of frustration
they use that protection to share their honest impressions of their
in nursing work.
professional lives. Anonymous blogs where neither the nurse nor
The fact that these nurses care about and are proud of nursing
their hospital or patients are specifically identified provide nurses
their patients should not be surprising: patients are at the centre of
with opportunities to share their frustrations and potential ideas
their profession (Walker et al., 2015). However, these nurses also
for solutions, allowing nurses’ voices to be heard without risking
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the loss of their jobs. These ideas can be expressed in real-time over blogs, as healthcare policies or conditions change (like the unfolding of the ebola crisis of 2014).
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AUTHOR CONTRIBUTIONS All authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE (http://www.ic mje.org/recommendations/):
4.1 | Limitations In terms of limitations, since all four nurses were American bloggers, the overall picture of nurses’ blogged experiences drawn by this research may be biased towards the American, female nurse demographic. Furthermore, although four different specialties were repre-
•
substantial contributions to conception and design, acquisition of
•
drafting the article or revising it critically for important intellectual
data, or analysis and interpretation of data; content.
sented, more nursing blogs in these specialties as well as in others need to be studied to gain a deeper understanding of different nurses’ blogging practices and nursing narratives. While node frequencies (n) were included to help support the
ORCID Aimee Castro
http://orcid.org/0000-0002-6461-0866
presence of each theme, there is some limitation to comparing frequencies between the blogs for each theme, as some blogs were
REFERENCES
posting more often in 2016 than others and therefore provided more data for analysis overall.
5 | CONCLUSION This qualitative study of four popular, anonymous American nursing blogs revealed that these nurses care about their nursing work, but they have many frustrations that they are sharing and discussing on their websites. Such platforms offer readers, healthcare managers and researchers access to many nurses’ typed, longitudinal narratives. As long as nurse bloggers remain anonymous and do not name the institution or network they work for, then nurses, researchers and managers can all learn from online nursing narratives without specific institutions being publicly criticized, fairly or unfairly, for policies their nurses disagree with. If the concerns described frequently and anonymously on nursing blogs by frontline healthcare providers could be analysed further by researchers and then addressed in healthcare policies, patient care might improve and nurses’ symptoms of burnout might also be reduced. The research suggests that blogs can help academics and healthcare managers understand how nurses describe their work lives when they have the protection of anonymity. Nursing blogs (at least, popular, anonymous ones like these four) appear to be accessible, cheap and reliable sources of longitudinal data on nurses’ lived experiences. Most of their accounts corresponded with external research’s conclusions regarding aspects like patient advocacy, burn out symptoms and management frustrations. Considering that as far as this study’s literature review revealed, nurses’ personal blog narratives had not previously been researched indepth, this project is a first step in helping nurses’ online narratives be better understood.
CONFLICT OF INTEREST No conflict of interest has been declared by the author(s).
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How to cite this article: Castro A, Andrews G. Nursing lives in the blogosphere: A thematic analysis of anonymous online nursing narratives. J Adv Nurs. 2017;00:1–10. https://doi.org/ 10.1111/jan.13411
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