International Journal of Nursing Studies 51 (2014) 761–767
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Registered nurses’ perceptions of their professional work in nursing homes and home-based care: A focus group study Elisabeth Carlson *, Margareta Ra¨mga˚rd, Ingrid Bolmsjo¨, Mariette Bengtsson Department of Care Science, Faculty of Health and Society, Malmo¨ University, Jan Waldenstro¨ms Gata 25, SE-20506 Malmo¨, Sweden
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 April 2013 Received in revised form 1 October 2013 Accepted 2 October 2013
Background: In Sweden, as well as in most industrialised countries, an increasing older population is expected to create a growing demand for health care staff. Previous studies have pointed to lack of proficient medical and nursing staff specialised in geriatric care, which poses serious threats to the care of a vulnerable population. At the same time, there are studies describing elderly care as a low-status career choice, attracting neither nurses nor student nurses. Judging from previous research it was deemed important to explore how nurses in elderly care perceive their work, thus possibly provide vital knowledge that can guide nurse educators and unit managers as a means to promote a career in elderly care. Objective: The aim of the present study was to illuminate how nurses, working in nursing homes and home-based care, perceived their professional work. Method: This was a qualitative study using focus groups. 30 registered nurses in seven focus groups were interviewed. The participants worked in nursing homes and homebased care for the elderly in rural areas and in a larger city in southern Sweden. The interviews were analysed in line with the tradition of naturalistic inquiry. Results: Our findings illustrate how nurses working in elderly care perceived their professional work as holistic and respectful nursing. Three categories of professional work emerged during analysis: (1) establishing long-term relationships, (2) nursing beyond technical skills, and (3) balancing independence and a sense of loneliness. Conclusions: The findings are important as they represent positive alternatives to the somewhat prevailing view on elderly care as depressing and undemanding. Nurse educators might use the key aspects as good examples, thus influencing student nurses’ attitudes towards elderly care in a positive way. Elderly care agencies might find them helpful when recruiting and retaining nurses to a much needed area. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Elderly care Focus groups Long term relationship Professional work Registered nurses
What is already known about the topic? Previous research has described elderly care as undemanding and depressing, not usually considered as a career choice by student nurses and newly graduated nurses. Job satisfaction is a strong predictor for nurse recruitment and retention.
* Corresponding author. Tel.: +46 406657451. E-mail address: [email protected] (E. Carlson). 0020-7489/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2013.10.002
Professional identity can be conceptualised in terms of what it means to be and act as a nurse in everyday nursing practice. What this paper adds Professional work in elderly care is complex, requiring advanced nursing skills and several years of previous experience in acute-care settings. Three key aspects of registered nurses’ perception of their professional work emerged: establishing long-term relationships, nursing beyond technical skills, and
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balancing independence with a sense of loneliness, indicating a strong professional identity. The findings provide nurse educators and unit managers with positive examples when attracting and recruiting to an area in need of qualified and engaged registered nurses. 1. Introduction In Sweden, as well as in most industrialised countries, an ageing population is expected to create a growing demand for health care staff, in particular specialist nurses in geriatric care. It is not unusual that high age is followed by the risk to develop a number of different chronic diseases leading to an increased group of patients with long-term caring needs. Hence, it is most likely that a major part of nursing and medical care for this population will be redirected from hospitals to home-health care teams or assisted living, intensifying the need for highly qualified geriatric care. It is therefore alarming when student nurses and newly graduated nurses describe elderly care as boring, undemanding and depressing, and not an option for a future career (Kloster et al., 2007; Stevens, 2011). The reported findings are in part contradicted by findings in a recent study by Carlson (2013). Student nurses valued the independent and person-centred nature of nursing they had experienced during clinical placements in elderly care. This was put forward by the students as a reason to consider a career in elderly care. On the other hand, some students described elderly care as hopeless in a stressful and depressing work environment, and explained that elderly care was not a career choice they would consider after graduation. In Sweden, recent reports (Statistics Sweden, 2011; National Board of Health and Welfare, 2012) point to the risk that lack of proficient medical and nursing staff specialised in geriatric care and gerontology poses serious threats to care and patient safety for a vulnerable population. Adding to this picture is the anticipated worldwide shortage of health and social care staff (WHO, 2006). Conclusively, with the current global demographic change, an increased demand for nurses working in geriatric care will be imminent. 1.1. Job satisfaction Job satisfaction, including intrinsic factors such as: autonomy, freedom to use personal knowledge and judgement, and relationships with patients, as well as extrinsic factors i.e. working conditions, benefits and salaries, is a strong predictor for nurse retention (Ellenbecker, 2004; Karsh et al., 2005). Vlachos (2012) reported that continuous relationships with patients and families, and being able to make a difference were rewarding components significant for positive job satisfaction in nursing homes. On a similar note, Prentice and Black (2007) concluded that sufficient resources allowing nurses to care for, and make a difference to the residents’ lives were important factors for nurse retention. In a survey by Ellenbecker (2001), professional autonomy, relationships with peers and patients and sensing that the work is important and worthwhile were indicators positively
related to job satisfaction. Factors influencing job satisfaction negatively were related to relationship to administration and the power to change organisational policies. In a later study by Ellenbecker et al. (2008), job satisfaction and tenure were presented as the strongest predictors of nurse retention. However, job satisfaction is probably not only of vital importance to nurses. Ellenbecker and Cushman (2012) proposed in an extended theoretical model, including patient outcomes that the qualities of patient care will be affected by how satisfied nurses are in their jobs. Cowin et al. (2008) investigated the relationships between nurses’ professional identity or selfconcept, job satisfaction and retention plans. Their findings suggested that nurses’ self-concept had a stronger relationship to retention than to job satisfaction. However, the study did not focus exclusively on nurses in elderly care. Therefore, to facilitate the recruitment and retention of nurses it is important to further explore nurses’ perceptions of their professional work in nursing homes and home based care. 1.2. Professional identity Professional identity as a concept is not well described in nursing literature, and has been addressed in terms of similar and related concepts, for example, professionalism or professional self. Johnson et al. (2012) explained that formation of professional identity involves a sense of values, practices and purposes associated with the nursing role, acquired through socialisation, commencing at the start of nursing education and extending during a life-long career. In an earlier study by Fagermoen (1997) professional identity could be conceptualised in terms of what it meant to be and act as a nurse directly linked to everyday nursing practice. Ska˚r (2009) conceptualised professional autonomy on a similar note by illustrating how experienced registered nurses defined autonomy in terms of being knowledgeable, confident, and having the personal courage to act. Ellenbecker (2001) discussed nurses’ professional autonomy in terms of meeting professional standards and providing care beneficial to patients. However, formation of professional identity does not take place in a void. It is socially constructed and evolves in interaction with significant and generalised others (Shaffir and Pawluch, 2003), in a process of actively gaining skills and knowledge, values and attitudes of a group that the individual seeks to become a member of. Professional identity evolves through education (Levett-Jones et al., 2007), and through professional experience gained over time in interaction with colleagues and patients (Fagermoen, 1997). In the light of the expected nursing shortage in elderly care, it was deemed important to explore how elderly care nurses perceived their work, and thereby contribute to the existing knowledge of factors for attracting and retaining nurses to a much needed area. 1.3. Aim of the study The aim of the present study was to illuminate how nurses, working in nursing homes and home based care, perceived their professional work.
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2. Methods A qualitative design, utilising focus group interviews as data collection method was employed. Focus groups are ideal in capturing the interaction between participants who share experience and perspectives, and in exploring beliefs and attitudes (Freeman, 2006). The chosen method was therefore deemed relevant as a means to illuminate the social reality of being a nurse in elderly care as described by the participants. 2.1. Participants and setting In Sweden, social welfare and health care for older people is the responsibility of local municipalities, usually organised as home-based care or long-term care in nursing homes. For this paper, we use elderly care as the common term. The needs of the patients range from complex medical conditions to dementia and end of life care. For the current study the researchers contacted unit managers in four different municipalities in the southwest of Sweden. The nursing homes and the organisation for home-based care within these municipalities provide clinical placements for the undergraduate nursing programme at the affiliated university where the researcher work. The unit managers were provided with written information describing the study, the inclusion criteria, and for the first author. During a regular weekly meeting, eligible nurses were informed about the study by their respective unit manager. They had the opportunity to read the written information in order to make an informed decision whether to participate or not. Registered nurses (RNs) with at least one year of work experience in nursing homes or home-based care for the elderly met the inclusion criteria for this study. 30 nurses volunteered by sending an e-mail to the first author (Table 1). It was possible to form seven focus groups, with three to seven participants in each group (5 + 4 + 3 + 4 + 3 + 7 + 4). Five of the groups represented RNs working in rural areas, and two groups were made up of RNs representing six out of ten boroughs in a larger city. Correspondence with participants included an information letter briefly describing the aim of the study, the interview process, telephone number and to the first author as well as ethical considerations. 2.2. Ethical considerations The study was conducted in accordance with the Helsinki Declaration (WMA, 2008) and approved by the local Ethical Advisory Board at the university where Table 1 Focus Group participants (n = 30). Gender (female/male)
25/5
Age, mean (range) Years of professional experience mean (range) Specialist nursea Yes/no/missing
46 (25–64) 20 (1½–42) 17/11/2
a Midwifery = 1; Primary health care = 10; Palliative care = 1; Elderly care = 1; Anaesthesiology and intensive care = 2; Surgical and medical care = 2.
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the authors hold their positions. It was assured, by the first author prior to the interviews, that participants fully understood the issue of confidentiality, and that they had the right to withdraw from the study at any time without further explanation. Informed consent was obtained, and none of the nurses declined or terminated participation in the focus group interviews. 2.3. Data collection The interviews were held during spring 2012, either at the different workplaces or at the university where the authors work, subject to participant convenience. Interviews were conducted by using a digital voice-recorder and lasted between 57 and 96 min (mean 75 min). During interviews, participants were encouraged to elaborate on their thoughts of being a nurse in elderly care, and the discussions started with the first author asking ‘How would you like to describe nursing in elderly care?’. The researcher allowed the discussion to evolve, and only interrupted when the discussions raised any questions that needed clarification. Such follow-up questions were typically phrased as: Can you please explain what you mean or can you please tell me a bit more? Seven interviews were considered sufficient with this specific population (McLafferty, 2004), even though the groups comprising three participants each are small (Kitzinger, 1994). However, as emerging data were continuously compared it was deemed reasonable to include the smaller groups. 2.4. Data analysis and rigour The interviews were transcribed verbatim and read repeatedly by the first author (EC). No software for coding of data was used, but hand coded as a means to gain a deeper understanding of the data (Polit and Beck, 2006). The first author started the inductive process of analysing (Lincoln and Guba, 1985) by identifying meaning units illustrating patterns of how nurses perceived their work in elderly care. Meaning units were then sorted into coded subcategories, and the meaning of each subcategory was explained and clarified. Hence, a model for continuing analysis as well as the transcripts was presented to the three co-authors who independently critically reviewed the material. The next step involved peer review (Creswell and Miller, 2000) when the emerging findings were discussed with a group of fellow researchers at the university where the authors work. This process provided the researchers with valuable feedback for the continued analysis. The final abstractions of meaning units and subcategories into categories were discussed and agreed by all four authors (Table 2). The authors are experienced qualitative researchers as well as lecturers in research methodology. In an effort to obtain credibility, data are presented by verbatim quotes and explained by the authors’ interpretation. The quotes represent discussions from all seven focus groups to illustrate the richness of the data. Moreover, as discussed by Malterud (2001) and Tong et al. (2007) the researchers’ background and personal experience will affect not only what to investigate or how to analyse, but
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also the interaction with participants during data collection. The researchers in the presented study hold positions as either senior lecturers (EC, MR, MB) or professor (IB) at the affiliated university. However, at the time of the study the researchers were neither involved in clinical work nor collaborative initiatives between the university and the studied settings. Thus, none of the researchers had any personal or professional knowledge of the participants. 3. Findings Registered nurses working in elderly care perceived their professional work as holistic and respectful nursing. We illustrate this by elaborating the following categories: establishing long-term relationships, nursing beyond technical skills, and balancing independence and a sense of loneliness. Our findings are illustrated by excerpts from the focus groups. P ¼ Participant; Fg ¼ Focus group
3.1. Establishing long-term relationships All nursed described how they valued the possibility to establish long-term relationships with patients and their families, contrary to the short and superficial relationships they had experienced in acute-care settings. One of the nurses told the focus group of some of her patients that she had taken care of for more than ten years, and this was something she appreciated: ‘‘Well, you know your relationship with the patients is completely different when you see them for years, and that is something that has become more and more important to me’’ (P 17, Fg 5). Long-term relationships with patients were described as entirely positive, and a major reason why the nurses perceived elderly care as a preferred field of nursing. It was interesting to note how the nurses often compared their current work situation to previous work experience, favouring the former: You don’t meet the same patients from one shift to another working in acute-care; you don’t have the continuity and get to know the people you care for. I think it is worth a lot when you are able to follow up all the nursing interventions you actually start’’ (P 23, Fg 6).
‘‘There are so many things I like with home-based care; you get a totally different view on your patients as you are the guest in their homes.’’ When you meet the patients and their families, you get to see the full picture, not only a single symptom or a diagnosis’’. (P 8, Fg 2) ‘‘Yes, and I appreciate all my home visits, meeting them [the patients] in their own environment, on their terms, and with families and pets around them.’’ (P 9, Fg 2). 3.2. Nursing beyond technical skills The nurses argued that their choice of elderly care as a preferred field of nursing was choosing a nursing career stretching beyond technical skills. They considered their work to be more complex than in acute-care settings as they worked closer together with patients and families. They emphasised the necessity of a holistic approach to nursing care, acknowledging all aspects of their patients’ needs. This was explained as: ‘‘Nothing is ever black or white, what we do is much harder, more assessments to be done, and you need some experience to see the full picture. I mean you have to see your patient in a holistic way.’’ (P 7, Fg 2). Therefore, the decision to practice in elderly care had usually been taken by the nurses after they had worked some years in acute-care settings. The nurses agreed that over time as you gained professional experience, your thoughts on the nature of nursing changed. As expressed by one of the participants: ‘‘I remember as a new grad I absolutely loved being busy administrating i.v. drips, cannulas and meds, but in the long run, it doesn’t give you any real satisfaction. However, meeting an old person though, who will tell you all about his life and who you get to meet day after day is something I have come to appreciate.’’ (P 28, Fg 7). Furthermore, the nurses shared the experience of being preceptors to undergraduate student nurses. Although, acutely aware of the need for qualified nursing staff, the nurses usually recommended their students to gain some experience in acute-care settings before commencing a career in elderly care. The reason, given by the nurses, was that caring for older people was an advanced and complex nursing skill requiring experience from a variety of nursing specialities:
The nurses experienced professional pride when they were able to follow the recovery processes of their patients and described continuity of nursing care as a professional benefit:
‘‘I think that you need some years under your belt, you need all sorts of skills which I think you learn by working in different hospital wards, especially since you have more colleagues around you to turn to for support’’ (P 19, Fg 5).
‘‘It is such a great feeling when you have struggled with a problem for several months, trying to heal a venous ulcer and then suddenly you actually get to see the result’’ (P 1, Fg 1).
The nurses also pointed to the multi-facetted aspects of their work when they accounted for elderly care as being not only of a palliative, but also curative and preventive nature. One nurse explained:
Further, several of the nurses valued the individualised and person-centred care they were able to provide. This was something they considered much harder to achieve in acute-care settings:
’’We do a lot of preventive work trying to prevent pressure ulcers or malnutrition, but prevention is probably not what you think of at first’’ (P 13, Fg 3).
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Table 2 Examples from the analysis process reflecting nurses’ perception of their work in elderly care. Meaning unit
Sub category
Category
Being able to follow your patients, some of them I met for the first time ten years ago and that is something I appreciate (P 22, F G 6)a The feeling you get when you have struggled with a problem for several months, like trying to heal a venous ulcer and then suddenly you see the result (P 1, F G 1)
Caring for patients during long periods of time
Establishing long-term relationships
When you are new as a nurse your focus is on medicaltechnical skills, it is so important during your training but after some years/elderly care is so much more (P 17, F G 5) Nothing is ever black or white, what we do is much harder, more assessments to be done and you need some experience to see the full picture, I mean you have to see your patient in a holistic way (P 7, F G 2)
A professional journey
You have to enjoy independent work and responsibility, you can’t be a person that needs reassurance all the time (P 14, F G 4) When you work in a hospital you are never really left on your own, you have all that equipment and staff and doctors, but here you are on your own, it is your decision that counts and that is hard, very hard (P 27, F G 7) a
Continuity in nursing care
Nursing beyond technical skills
Providing holistic care
Independent work sense of loneliness
Balancing independence with a
Nursing as solitary work
P indicates participant and F G stands for Focus Group i.e. P 22, F G 6 = participant number 22 in focus group number six.
In their experience, nurses lacking experience of elderly care might not understand or recognise all the different opportunities to practice advanced nursing. They assumed this was a reason that elderly care has a reputation of being tedious, slow-paced, and not providing enough of medicaltechnical challenges for nurses.
‘‘In a way, you are left to the wolves when you work in a nursing home, you are left to your own knowledge and skills, and you have to be quite confident, you can’t just open a door and call for a colleague or a doctor’’ (P 10, Fg 3).
3.3. Balancing independence with a sense of loneliness
4. Discussion
In all focus groups, the nurses discussed how much they appreciated the autonomous nature of nursing. The advantage of independent work was put forward by some of the nurses why they had chosen a career in elderly care:
Our study is unique as it presents a truly positive picture of nurses’ professional work in nursing homes and home-based care. Based on the findings in the present study, we argue that nursing in elderly care is a complex and advanced professional role, requiring several years of previous experience in acute-care settings. The nurses in this study were attracted to work in elderly care related to the autonomous and person-centred nature of nursing. Their decision to practice elderly care was a conscious career choice, thus supporting Ellenbecker et al. (2008) suggesting that nurses in elderly care are highly committed to their jobs. The nurses could clearly describe their everyday nursing practice with a sense of professional pride. This suggests that these elderly care nurses had developed a strong professional identity closely related to what it meant to be and act as a nurse in everyday nursing practice (Fagermoen, 1997). The nurses’ work in elderly care was multifaceted and based on long lasting relationships with patients, thus substantiating the study by Vlachos (2012) where longterm relationships were perceived as beneficial for job satisfaction. With regard to future recruitment it is interesting to note that independent and person-centred care was put forward by student nurses as a reason to choose elderly care (Carlson, 2013). Nursing homes and home-based care are therefore probably most valuable as clinical placements. These placements can provide a
‘‘I think you develop professionally, it is quite empowering when you realise you have the necessary knowledge to take a decision. (P 13, Fg 4) ‘‘Yes, you have to enjoy independent work and the responsibility; you can’t be a person that needs reassurance all the time. (P 14 Fg 4). Although independent work was highly valued, it was also seen as problematic as the nurses experienced a sense of loneliness during their daily work. The nurses discussed several reasons for this. First, each nurse had a greater number of patients to care for during a shift, at some nursing homes as many as forty to fifty patients, creating a stressful working environment. Second, the ratio of registered nurses to patients in nursing homes was lower than in acute-care settings. The nurses were acting as group leaders and administrators of care rather than participating in basic patient care, which was usually done by nurse assistants. The nurses pointed to how this affected professional feedback. They felt it was harder for them to find someone to discuss with or ask for advice on a daily basis. The nurses explained how they had to rely solely on their personal experience and competence when assessing a patient. As articulated by one respondent:
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learning environment where the essence of caring and nursing can be explicit helping student nurses shaping and developing professional identity (Carlson and Bengtsson, 2013). The nurses’ desire to establish long-term relationships can be seen as a reaction to what has been discussed by Heaslip and Boarde (2012) as a strategy among nurses to focus on the technological aspects of care to protect them from feeling vulnerable. They concluded that nursing involves emotional, intellectual and physical commitment to patients. This is concordant with our findings when nurses pointed to the relational aspect of their work, and the continuity of the nursing care they provided in collaboration with patients and families. The significance of meaningful relationships with patients and families is further substantiated in a phenomenological study by de Guzman et al. (2009). They proposed that nurses in geriatric care develop a special kind of relationships with elderly patients based on holistic care that is caring for the physical, mental, emotional and spiritual wellbeing of the older person. Dewar and Nolan (2013) presented a promising model to promote what is referred to as ‘appreciative caring conversation’ (p.4) required to realise relationship centred care in practice. This is a model we find interesting to test and implement in the Swedish context where our study took place as a means of illuminating the meaning of holistic and relational nursing in elderly care. Balancing independence and loneliness is a unique feature of elderly care. The ability to handle that balance requires several years of experience, and is one part of being professional. Professional identity is reshaped and evolves throughout a nurse’s professional life (Johnson et al., 2012). In the current study, the evolution of professional identity can be exemplified by nurses describing how their thoughts on nursing had changed from a technical to a relational and holistic aspect, or in the ¨ hle´n and Segesten (1998) from working as a words of O nurse to being a nurse. Nurses in our study described how confident and knowledgeable they felt in relation to the decisions they had to make without the immediate support from physicians. This suggests that elderly care nurses, due to maturity and tenure, have developed a strong sense of professional autonomy encompassing confidence, knowledge and personal courage to act as conceptualised by Ska˚r (2009). However, it needs to be noted that nurses in the current study expressed a sense of loneliness in daily work despite their appreciation of having professional autonomy. This implies that collaboration with peers and coworkers might be as important as building relationships with patients. Ellenbecker (2001) as well as Prentice and Black (2007) pointed to how respectful professional relationships between nursing colleagues and physicians influenced positively on job satisfaction and retention. On the other hand, Choi et al. (2011) reported that the relationship between nurse and physician was not significantly associated to higher RN job satisfaction, and it was suggested that the collaboration with physicians was a less critical issue in nursing homes than in acute-care settings. Why this should be the case is not explained, rather based on our findings, we would argue that collaboration with physicians and being able to share
the burden of complex decisions are as important in nursing homes as in acute-care settings. Therefore, building on the current study, the aspect of a sense of loneliness needs to be elaborated upon. We propose further research on emotional stress and the psychosocial aspects of lonely work, and how these factors might influence job satisfaction. In addition, we recommend that models for clinical supervision (CS) are discussed and possibly implemented in elderly care practice. Be´gat et al. (2005) described CS as a structured model for reflection and problem solving where nurses can become clear about why they think and act in certain ways. Improved patient care, stress reduction, and enhanced job satisfaction were presented as perceived benefits of CS. We suggest that CS most likely hold the potential to support not only personal but also professional development thus strengthening the professional identity. 4.1. Limitations Our study was situated in Southern Sweden, and the organisation of elderly care which might have impacted the findings is thus restricted to a Swedish context, and cannot be widely generalised. Another limitation is the possibility that participants might have withheld vital information to avoid conflict or voicing critical views. However, the first author (EC) started the interviews by explaining that no data could be traced to any individual and that participants would remain anonymous. In addition, the focus groups were characterised by lively discussions, and participants seemed comfortable and open when sharing their thoughts. Moreover, the interviews started with informal small talk in an effort to create a respectful and friendly atmosphere. However, it can be argued that we present an overly positive view on nurses’ professional work in elderly care. This can be attributed to the question of purposive sampling and respondent bias. One reason might be that the participants who volunteered were those who had made a conscious and rational career choice, and thus developed a strong professional identity as nurses in elderly care. Note that the mean age of the participants was 46 years and most of them had worked for more than 20 years. This implies a group of confident and autonomous nurses with no intention to leave. Age and tenure have previously been described as variables related to intention to stay and job satisfaction (Ellenbecker, 2004; Ellenbecker et al., 2008). In addition, as we did not find any differences according to demographic variables or type of care settings no comparisons were conducted. On the contrary, the participants discussed professional work in terms related to their relationships to patients and their relatives, not in terms of how that work was organised or whether it took place in rural or urban settings. We would therefore interpret this as strength of the study contributing to the unique character of the positive picture of elderly care we have presented. We also need to acknowledge the fact that no formal member checking was performed as we did not want to add to the nurses’ work load. However, we achieved what Sandelowski (1993) refers to as informal member checking, by raising follow-up questions during the interviews as a means to seek clarification or elaboration of meaning and intention.
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5. Conclusion Our study shows that the opportunity to develop longterm relationships, execute professional autonomy, and provide holistic care are all central to registered nurses’ professional work in elderly care. The findings are important as they represent positive alternatives to the somewhat prevailing view on elderly care as depressing and undemanding. Nurse educators might use the key aspects as good examples, thus influencing student nurses’ attitudes towards elderly care in a positive way. Elderly care agencies might find them helpful when recruiting and retaining nurses to a much needed area. Conflict of interest: No conflict of interest has been declared by the authors. Ethical approval: The study was approved by the local Ethical Advisory Board at the university where the authors hold their positions. Funding: This research was made possible by generous grants funded by the Postdoctoral Programme for Quality Development in Higher Education at Malmo¨ University, Sweden. Acknowledgements The authors also wish to extend their gratitude to all the registered nurses participating in the study for sharing their time and experience. References Be´gat, I., Ellefsen, B., Severinsson, E., 2005. Nurses’ satisfaction with their work environment and the outcomes of clinical nursing supervision on nurses’ experiences of well-being—a Norwegian study. Journal of Nursing Management 13, 221–230. Carlson, E., 2013. Meaningful and enjoyable or boring and depressing? The reasons student nurses give for and against a career in aged care. Journal of Clinical Nursing (in press). Carlson, E., Bengtsson, M., 2013. The uniqueness of elderly care: registered nurses’ experience as preceptors during clinical practice in nursing homes and home-based care. Nurse Education Today, http://dx.doi.org/10.1016/j.nedt.2013.07.017. Choi, J.S., Flynn, L., Aiken, L.H., 2011. Nursing practice environment and registered nurses’ job satisfaction in nursing homes. Gerontologist 52 (4) 484–492. Cowin, L.S., Johnson, M., Craven, R.G., Marsh, H.W., 2008. Casual modeling of self-concept, job satisfaction and retention of nurses. International Journal of Nursing Studies 45, 1449–1459. Creswell, J.W., Miller, D.L., 2000. Determining validity in qualitative inquiry. Theory into Practice 39 (3) 124–130. de Guzman, A.B., Dangoy, R-J., David, K.C., de Claro, K.A., de Guzman, G., de Jesus, G.I., 2009. How many sides does a coin have? A phenomenology of Filipino nurses’ motivation and attitudes toward geriatric care. Educational Gerontology 35, 260–276. Dewar, B., Nolan, M., 2013. Caring about caring: developing a model to implement compassionate relationship centered care in an older people care setting. International Journal of Nursing Studies, http:// dx.doi.org/10.1016/j-ijnurstu.2013.01.008. Ellenbecker, C.H., 2001. Home health care nurses’ job satisfaction: a system indicator. Home Health Care Management & Practice 13 (6) 462–467.
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Ellenbecker, C.H., 2004. A theoretical model of job retention for home health care nurses. Journal of Advanced Nursing 47 (3) 303–310. Ellenbecker, C.H., Porell, F.W., Samia, L., Byleckie, J.J., Milburn, M., 2008. Predictors of home healthcare nurse retention. Journal of Nursing Scholarship 40 (2) 151–160. Ellenbecker, C.H., Cushman, M., 2012. Home health care nurse retention and patient outcome model: discussion and development model. Journal of Advanced Nursing 68 (8) 1881–1893. Fagermoen, M.S., 1997. Professional identity: values embedded in a meaningful nursing practice. Journal of Advanced Nursing 25, 434–441. Freeman, T., 2006. ‘Best practice’ in focus groups: making sense of different views. Journal of Advanced Nursing 56 (5) 491–497. Heaslip, V., Boarde, M., 2012. Does nurses’ vulnerability affect their ability to care? British Journal of Nursing 21 (15) 912–916. Johnson, M., Cowin, L.S., Wilson, I., Young, H., 2012. Professional identity and nursing: contemporary theoretical developments and future research challenges. International Nursing Review 59, 562– 569. Karsh, B., Booske, B.C., Sainfort, F., 2005. Job and organizational determinants of nursing home employee commitment, job satisfaction and intent to turnover. Ergonomics 48 (10) 1260–1281. Kitzinger, J., 1994. The methodology of focus groups: the importance of interaction between research participants. Sociology of Health and Illness 16, 103–121. Kloster, T., Høie, M., Ska˚r, R., 2007. Nursing students’ career preferences: a Norwegian study. Journal of Advanced Nursing 59, 155–162. Levett-Jones, T., Lethlean, J., McMillan, M., Higgins, I., 2007. Belongingness: a montage of nursing students’ stories of their clinical placement experiences. Contemporary Nurse 24, 162–174. Lincoln, Y.S., Guba, E.G., 1985. Naturalistic Inquiry. SAGE Publications, Beverley Hills, CA, pp. 332–356. Malterud, K., 2001. Qualitative research: standards, challenges and guidelines. Lancet 358, 483–488. McLafferty, I., 2004. Focus group interviews as a data collecting strategy. Journal of Advanced Nursing 48 (2) 187–194. National Board of Health and Welfare, 2012. Competence in Geriatrics and Gerontology-suggestions for design and implementation of edu¨ kad kompetens inom geriatrik och gerontologi cational resources.(O fo¨rslag till utformning och genomfo¨rande av satsning). (In Swedish). Polit, D.F., Beck, C.T., 2006. Essentials of nursing research: methods, appraisal, and utilization, 6th ed. Lippincott, Williams and Wilkins, Philadelphia. Prentice, D., Black, M., 2007. Coming and staying: a qualitative exploration of registered nurses’ experiences working in nursing homes. International Journal of Older People Nursing 2, 198–203. Sandelowski, M., 1993. Rigor or rigor mortis: the problem of rigor in qualitative research revisited. Advances in Nursing Science 16 (2) 1–8. Shaffir, W., Pawluch, D., 2003. Occupations and professions. In: Reynolds, L., Herman-Kinney, N. (Eds.), Handbook of Symbolic Interactionism. AltaMira Press, Walnut Creek, CA, pp. 893–913. Ska˚r, R., 2009. The meaning of autonomy in nursing practice. Journal of Clinical Nursing 19, 2226–2234. Statistics Sweden, 2011. Trends and forecast for education and labour market—revised 2012-11-09.(Trender och prognoser om utbildning och arbetsmarknad). (In Swedish)http://www.scb.se/2013-02-01. Stevens, J.A., 2011. Student nurses’ career preferences for working with older people: a replicated longitudinal survey. International Journal of Nursing Studies 48, 944–951. Tong, A., Sainsbury, P., Craig, J., 2007. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care 19 (6) 349–357. Vlachos, S., 2012. Nurse Satisfaction in Caring for Elders. Paper 20. (Honors Theses)http://scholars.unh.edu/honors/20. World Health Organization, 2006. World Health Report 2006: Working Together for Health. World Health Organization, Geneva. WMA. 2008. www.wma.net/en/30publications/10policies/b3/index.html (01.10.13). ¨ hle´n, J., Segesten, K., 1998. The professional identity of the nurse: O concept analysis and development. Journal of Advanced Nursing 28 (4) 720–727.
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Registered nurses’ perceptions of their professional work in nursing homes and home-based care: A focus group study Elisabeth Carlson *, Margareta Ra¨mga˚rd, Ingrid Bolmsjo¨, Mariette Bengtsson Department of Care Science, Faculty of Health and Society, Malmo¨ University, Jan Waldenstro¨ms Gata 25, SE-20506 Malmo¨, Sweden
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 April 2013 Received in revised form 1 October 2013 Accepted 2 October 2013
Background: In Sweden, as well as in most industrialised countries, an increasing older population is expected to create a growing demand for health care staff. Previous studies have pointed to lack of proficient medical and nursing staff specialised in geriatric care, which poses serious threats to the care of a vulnerable population. At the same time, there are studies describing elderly care as a low-status career choice, attracting neither nurses nor student nurses. Judging from previous research it was deemed important to explore how nurses in elderly care perceive their work, thus possibly provide vital knowledge that can guide nurse educators and unit managers as a means to promote a career in elderly care. Objective: The aim of the present study was to illuminate how nurses, working in nursing homes and home-based care, perceived their professional work. Method: This was a qualitative study using focus groups. 30 registered nurses in seven focus groups were interviewed. The participants worked in nursing homes and homebased care for the elderly in rural areas and in a larger city in southern Sweden. The interviews were analysed in line with the tradition of naturalistic inquiry. Results: Our findings illustrate how nurses working in elderly care perceived their professional work as holistic and respectful nursing. Three categories of professional work emerged during analysis: (1) establishing long-term relationships, (2) nursing beyond technical skills, and (3) balancing independence and a sense of loneliness. Conclusions: The findings are important as they represent positive alternatives to the somewhat prevailing view on elderly care as depressing and undemanding. Nurse educators might use the key aspects as good examples, thus influencing student nurses’ attitudes towards elderly care in a positive way. Elderly care agencies might find them helpful when recruiting and retaining nurses to a much needed area. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Elderly care Focus groups Long term relationship Professional work Registered nurses
What is already known about the topic? Previous research has described elderly care as undemanding and depressing, not usually considered as a career choice by student nurses and newly graduated nurses. Job satisfaction is a strong predictor for nurse recruitment and retention.
* Corresponding author. Tel.: +46 406657451. E-mail address: [email protected] (E. Carlson). 0020-7489/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2013.10.002
Professional identity can be conceptualised in terms of what it means to be and act as a nurse in everyday nursing practice. What this paper adds Professional work in elderly care is complex, requiring advanced nursing skills and several years of previous experience in acute-care settings. Three key aspects of registered nurses’ perception of their professional work emerged: establishing long-term relationships, nursing beyond technical skills, and
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balancing independence with a sense of loneliness, indicating a strong professional identity. The findings provide nurse educators and unit managers with positive examples when attracting and recruiting to an area in need of qualified and engaged registered nurses. 1. Introduction In Sweden, as well as in most industrialised countries, an ageing population is expected to create a growing demand for health care staff, in particular specialist nurses in geriatric care. It is not unusual that high age is followed by the risk to develop a number of different chronic diseases leading to an increased group of patients with long-term caring needs. Hence, it is most likely that a major part of nursing and medical care for this population will be redirected from hospitals to home-health care teams or assisted living, intensifying the need for highly qualified geriatric care. It is therefore alarming when student nurses and newly graduated nurses describe elderly care as boring, undemanding and depressing, and not an option for a future career (Kloster et al., 2007; Stevens, 2011). The reported findings are in part contradicted by findings in a recent study by Carlson (2013). Student nurses valued the independent and person-centred nature of nursing they had experienced during clinical placements in elderly care. This was put forward by the students as a reason to consider a career in elderly care. On the other hand, some students described elderly care as hopeless in a stressful and depressing work environment, and explained that elderly care was not a career choice they would consider after graduation. In Sweden, recent reports (Statistics Sweden, 2011; National Board of Health and Welfare, 2012) point to the risk that lack of proficient medical and nursing staff specialised in geriatric care and gerontology poses serious threats to care and patient safety for a vulnerable population. Adding to this picture is the anticipated worldwide shortage of health and social care staff (WHO, 2006). Conclusively, with the current global demographic change, an increased demand for nurses working in geriatric care will be imminent. 1.1. Job satisfaction Job satisfaction, including intrinsic factors such as: autonomy, freedom to use personal knowledge and judgement, and relationships with patients, as well as extrinsic factors i.e. working conditions, benefits and salaries, is a strong predictor for nurse retention (Ellenbecker, 2004; Karsh et al., 2005). Vlachos (2012) reported that continuous relationships with patients and families, and being able to make a difference were rewarding components significant for positive job satisfaction in nursing homes. On a similar note, Prentice and Black (2007) concluded that sufficient resources allowing nurses to care for, and make a difference to the residents’ lives were important factors for nurse retention. In a survey by Ellenbecker (2001), professional autonomy, relationships with peers and patients and sensing that the work is important and worthwhile were indicators positively
related to job satisfaction. Factors influencing job satisfaction negatively were related to relationship to administration and the power to change organisational policies. In a later study by Ellenbecker et al. (2008), job satisfaction and tenure were presented as the strongest predictors of nurse retention. However, job satisfaction is probably not only of vital importance to nurses. Ellenbecker and Cushman (2012) proposed in an extended theoretical model, including patient outcomes that the qualities of patient care will be affected by how satisfied nurses are in their jobs. Cowin et al. (2008) investigated the relationships between nurses’ professional identity or selfconcept, job satisfaction and retention plans. Their findings suggested that nurses’ self-concept had a stronger relationship to retention than to job satisfaction. However, the study did not focus exclusively on nurses in elderly care. Therefore, to facilitate the recruitment and retention of nurses it is important to further explore nurses’ perceptions of their professional work in nursing homes and home based care. 1.2. Professional identity Professional identity as a concept is not well described in nursing literature, and has been addressed in terms of similar and related concepts, for example, professionalism or professional self. Johnson et al. (2012) explained that formation of professional identity involves a sense of values, practices and purposes associated with the nursing role, acquired through socialisation, commencing at the start of nursing education and extending during a life-long career. In an earlier study by Fagermoen (1997) professional identity could be conceptualised in terms of what it meant to be and act as a nurse directly linked to everyday nursing practice. Ska˚r (2009) conceptualised professional autonomy on a similar note by illustrating how experienced registered nurses defined autonomy in terms of being knowledgeable, confident, and having the personal courage to act. Ellenbecker (2001) discussed nurses’ professional autonomy in terms of meeting professional standards and providing care beneficial to patients. However, formation of professional identity does not take place in a void. It is socially constructed and evolves in interaction with significant and generalised others (Shaffir and Pawluch, 2003), in a process of actively gaining skills and knowledge, values and attitudes of a group that the individual seeks to become a member of. Professional identity evolves through education (Levett-Jones et al., 2007), and through professional experience gained over time in interaction with colleagues and patients (Fagermoen, 1997). In the light of the expected nursing shortage in elderly care, it was deemed important to explore how elderly care nurses perceived their work, and thereby contribute to the existing knowledge of factors for attracting and retaining nurses to a much needed area. 1.3. Aim of the study The aim of the present study was to illuminate how nurses, working in nursing homes and home based care, perceived their professional work.
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2. Methods A qualitative design, utilising focus group interviews as data collection method was employed. Focus groups are ideal in capturing the interaction between participants who share experience and perspectives, and in exploring beliefs and attitudes (Freeman, 2006). The chosen method was therefore deemed relevant as a means to illuminate the social reality of being a nurse in elderly care as described by the participants. 2.1. Participants and setting In Sweden, social welfare and health care for older people is the responsibility of local municipalities, usually organised as home-based care or long-term care in nursing homes. For this paper, we use elderly care as the common term. The needs of the patients range from complex medical conditions to dementia and end of life care. For the current study the researchers contacted unit managers in four different municipalities in the southwest of Sweden. The nursing homes and the organisation for home-based care within these municipalities provide clinical placements for the undergraduate nursing programme at the affiliated university where the researcher work. The unit managers were provided with written information describing the study, the inclusion criteria, and for the first author. During a regular weekly meeting, eligible nurses were informed about the study by their respective unit manager. They had the opportunity to read the written information in order to make an informed decision whether to participate or not. Registered nurses (RNs) with at least one year of work experience in nursing homes or home-based care for the elderly met the inclusion criteria for this study. 30 nurses volunteered by sending an e-mail to the first author (Table 1). It was possible to form seven focus groups, with three to seven participants in each group (5 + 4 + 3 + 4 + 3 + 7 + 4). Five of the groups represented RNs working in rural areas, and two groups were made up of RNs representing six out of ten boroughs in a larger city. Correspondence with participants included an information letter briefly describing the aim of the study, the interview process, telephone number and to the first author as well as ethical considerations. 2.2. Ethical considerations The study was conducted in accordance with the Helsinki Declaration (WMA, 2008) and approved by the local Ethical Advisory Board at the university where Table 1 Focus Group participants (n = 30). Gender (female/male)
25/5
Age, mean (range) Years of professional experience mean (range) Specialist nursea Yes/no/missing
46 (25–64) 20 (1½–42) 17/11/2
a Midwifery = 1; Primary health care = 10; Palliative care = 1; Elderly care = 1; Anaesthesiology and intensive care = 2; Surgical and medical care = 2.
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the authors hold their positions. It was assured, by the first author prior to the interviews, that participants fully understood the issue of confidentiality, and that they had the right to withdraw from the study at any time without further explanation. Informed consent was obtained, and none of the nurses declined or terminated participation in the focus group interviews. 2.3. Data collection The interviews were held during spring 2012, either at the different workplaces or at the university where the authors work, subject to participant convenience. Interviews were conducted by using a digital voice-recorder and lasted between 57 and 96 min (mean 75 min). During interviews, participants were encouraged to elaborate on their thoughts of being a nurse in elderly care, and the discussions started with the first author asking ‘How would you like to describe nursing in elderly care?’. The researcher allowed the discussion to evolve, and only interrupted when the discussions raised any questions that needed clarification. Such follow-up questions were typically phrased as: Can you please explain what you mean or can you please tell me a bit more? Seven interviews were considered sufficient with this specific population (McLafferty, 2004), even though the groups comprising three participants each are small (Kitzinger, 1994). However, as emerging data were continuously compared it was deemed reasonable to include the smaller groups. 2.4. Data analysis and rigour The interviews were transcribed verbatim and read repeatedly by the first author (EC). No software for coding of data was used, but hand coded as a means to gain a deeper understanding of the data (Polit and Beck, 2006). The first author started the inductive process of analysing (Lincoln and Guba, 1985) by identifying meaning units illustrating patterns of how nurses perceived their work in elderly care. Meaning units were then sorted into coded subcategories, and the meaning of each subcategory was explained and clarified. Hence, a model for continuing analysis as well as the transcripts was presented to the three co-authors who independently critically reviewed the material. The next step involved peer review (Creswell and Miller, 2000) when the emerging findings were discussed with a group of fellow researchers at the university where the authors work. This process provided the researchers with valuable feedback for the continued analysis. The final abstractions of meaning units and subcategories into categories were discussed and agreed by all four authors (Table 2). The authors are experienced qualitative researchers as well as lecturers in research methodology. In an effort to obtain credibility, data are presented by verbatim quotes and explained by the authors’ interpretation. The quotes represent discussions from all seven focus groups to illustrate the richness of the data. Moreover, as discussed by Malterud (2001) and Tong et al. (2007) the researchers’ background and personal experience will affect not only what to investigate or how to analyse, but
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also the interaction with participants during data collection. The researchers in the presented study hold positions as either senior lecturers (EC, MR, MB) or professor (IB) at the affiliated university. However, at the time of the study the researchers were neither involved in clinical work nor collaborative initiatives between the university and the studied settings. Thus, none of the researchers had any personal or professional knowledge of the participants. 3. Findings Registered nurses working in elderly care perceived their professional work as holistic and respectful nursing. We illustrate this by elaborating the following categories: establishing long-term relationships, nursing beyond technical skills, and balancing independence and a sense of loneliness. Our findings are illustrated by excerpts from the focus groups. P ¼ Participant; Fg ¼ Focus group
3.1. Establishing long-term relationships All nursed described how they valued the possibility to establish long-term relationships with patients and their families, contrary to the short and superficial relationships they had experienced in acute-care settings. One of the nurses told the focus group of some of her patients that she had taken care of for more than ten years, and this was something she appreciated: ‘‘Well, you know your relationship with the patients is completely different when you see them for years, and that is something that has become more and more important to me’’ (P 17, Fg 5). Long-term relationships with patients were described as entirely positive, and a major reason why the nurses perceived elderly care as a preferred field of nursing. It was interesting to note how the nurses often compared their current work situation to previous work experience, favouring the former: You don’t meet the same patients from one shift to another working in acute-care; you don’t have the continuity and get to know the people you care for. I think it is worth a lot when you are able to follow up all the nursing interventions you actually start’’ (P 23, Fg 6).
‘‘There are so many things I like with home-based care; you get a totally different view on your patients as you are the guest in their homes.’’ When you meet the patients and their families, you get to see the full picture, not only a single symptom or a diagnosis’’. (P 8, Fg 2) ‘‘Yes, and I appreciate all my home visits, meeting them [the patients] in their own environment, on their terms, and with families and pets around them.’’ (P 9, Fg 2). 3.2. Nursing beyond technical skills The nurses argued that their choice of elderly care as a preferred field of nursing was choosing a nursing career stretching beyond technical skills. They considered their work to be more complex than in acute-care settings as they worked closer together with patients and families. They emphasised the necessity of a holistic approach to nursing care, acknowledging all aspects of their patients’ needs. This was explained as: ‘‘Nothing is ever black or white, what we do is much harder, more assessments to be done, and you need some experience to see the full picture. I mean you have to see your patient in a holistic way.’’ (P 7, Fg 2). Therefore, the decision to practice in elderly care had usually been taken by the nurses after they had worked some years in acute-care settings. The nurses agreed that over time as you gained professional experience, your thoughts on the nature of nursing changed. As expressed by one of the participants: ‘‘I remember as a new grad I absolutely loved being busy administrating i.v. drips, cannulas and meds, but in the long run, it doesn’t give you any real satisfaction. However, meeting an old person though, who will tell you all about his life and who you get to meet day after day is something I have come to appreciate.’’ (P 28, Fg 7). Furthermore, the nurses shared the experience of being preceptors to undergraduate student nurses. Although, acutely aware of the need for qualified nursing staff, the nurses usually recommended their students to gain some experience in acute-care settings before commencing a career in elderly care. The reason, given by the nurses, was that caring for older people was an advanced and complex nursing skill requiring experience from a variety of nursing specialities:
The nurses experienced professional pride when they were able to follow the recovery processes of their patients and described continuity of nursing care as a professional benefit:
‘‘I think that you need some years under your belt, you need all sorts of skills which I think you learn by working in different hospital wards, especially since you have more colleagues around you to turn to for support’’ (P 19, Fg 5).
‘‘It is such a great feeling when you have struggled with a problem for several months, trying to heal a venous ulcer and then suddenly you actually get to see the result’’ (P 1, Fg 1).
The nurses also pointed to the multi-facetted aspects of their work when they accounted for elderly care as being not only of a palliative, but also curative and preventive nature. One nurse explained:
Further, several of the nurses valued the individualised and person-centred care they were able to provide. This was something they considered much harder to achieve in acute-care settings:
’’We do a lot of preventive work trying to prevent pressure ulcers or malnutrition, but prevention is probably not what you think of at first’’ (P 13, Fg 3).
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Table 2 Examples from the analysis process reflecting nurses’ perception of their work in elderly care. Meaning unit
Sub category
Category
Being able to follow your patients, some of them I met for the first time ten years ago and that is something I appreciate (P 22, F G 6)a The feeling you get when you have struggled with a problem for several months, like trying to heal a venous ulcer and then suddenly you see the result (P 1, F G 1)
Caring for patients during long periods of time
Establishing long-term relationships
When you are new as a nurse your focus is on medicaltechnical skills, it is so important during your training but after some years/elderly care is so much more (P 17, F G 5) Nothing is ever black or white, what we do is much harder, more assessments to be done and you need some experience to see the full picture, I mean you have to see your patient in a holistic way (P 7, F G 2)
A professional journey
You have to enjoy independent work and responsibility, you can’t be a person that needs reassurance all the time (P 14, F G 4) When you work in a hospital you are never really left on your own, you have all that equipment and staff and doctors, but here you are on your own, it is your decision that counts and that is hard, very hard (P 27, F G 7) a
Continuity in nursing care
Nursing beyond technical skills
Providing holistic care
Independent work sense of loneliness
Balancing independence with a
Nursing as solitary work
P indicates participant and F G stands for Focus Group i.e. P 22, F G 6 = participant number 22 in focus group number six.
In their experience, nurses lacking experience of elderly care might not understand or recognise all the different opportunities to practice advanced nursing. They assumed this was a reason that elderly care has a reputation of being tedious, slow-paced, and not providing enough of medicaltechnical challenges for nurses.
‘‘In a way, you are left to the wolves when you work in a nursing home, you are left to your own knowledge and skills, and you have to be quite confident, you can’t just open a door and call for a colleague or a doctor’’ (P 10, Fg 3).
3.3. Balancing independence with a sense of loneliness
4. Discussion
In all focus groups, the nurses discussed how much they appreciated the autonomous nature of nursing. The advantage of independent work was put forward by some of the nurses why they had chosen a career in elderly care:
Our study is unique as it presents a truly positive picture of nurses’ professional work in nursing homes and home-based care. Based on the findings in the present study, we argue that nursing in elderly care is a complex and advanced professional role, requiring several years of previous experience in acute-care settings. The nurses in this study were attracted to work in elderly care related to the autonomous and person-centred nature of nursing. Their decision to practice elderly care was a conscious career choice, thus supporting Ellenbecker et al. (2008) suggesting that nurses in elderly care are highly committed to their jobs. The nurses could clearly describe their everyday nursing practice with a sense of professional pride. This suggests that these elderly care nurses had developed a strong professional identity closely related to what it meant to be and act as a nurse in everyday nursing practice (Fagermoen, 1997). The nurses’ work in elderly care was multifaceted and based on long lasting relationships with patients, thus substantiating the study by Vlachos (2012) where longterm relationships were perceived as beneficial for job satisfaction. With regard to future recruitment it is interesting to note that independent and person-centred care was put forward by student nurses as a reason to choose elderly care (Carlson, 2013). Nursing homes and home-based care are therefore probably most valuable as clinical placements. These placements can provide a
‘‘I think you develop professionally, it is quite empowering when you realise you have the necessary knowledge to take a decision. (P 13, Fg 4) ‘‘Yes, you have to enjoy independent work and the responsibility; you can’t be a person that needs reassurance all the time. (P 14 Fg 4). Although independent work was highly valued, it was also seen as problematic as the nurses experienced a sense of loneliness during their daily work. The nurses discussed several reasons for this. First, each nurse had a greater number of patients to care for during a shift, at some nursing homes as many as forty to fifty patients, creating a stressful working environment. Second, the ratio of registered nurses to patients in nursing homes was lower than in acute-care settings. The nurses were acting as group leaders and administrators of care rather than participating in basic patient care, which was usually done by nurse assistants. The nurses pointed to how this affected professional feedback. They felt it was harder for them to find someone to discuss with or ask for advice on a daily basis. The nurses explained how they had to rely solely on their personal experience and competence when assessing a patient. As articulated by one respondent:
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learning environment where the essence of caring and nursing can be explicit helping student nurses shaping and developing professional identity (Carlson and Bengtsson, 2013). The nurses’ desire to establish long-term relationships can be seen as a reaction to what has been discussed by Heaslip and Boarde (2012) as a strategy among nurses to focus on the technological aspects of care to protect them from feeling vulnerable. They concluded that nursing involves emotional, intellectual and physical commitment to patients. This is concordant with our findings when nurses pointed to the relational aspect of their work, and the continuity of the nursing care they provided in collaboration with patients and families. The significance of meaningful relationships with patients and families is further substantiated in a phenomenological study by de Guzman et al. (2009). They proposed that nurses in geriatric care develop a special kind of relationships with elderly patients based on holistic care that is caring for the physical, mental, emotional and spiritual wellbeing of the older person. Dewar and Nolan (2013) presented a promising model to promote what is referred to as ‘appreciative caring conversation’ (p.4) required to realise relationship centred care in practice. This is a model we find interesting to test and implement in the Swedish context where our study took place as a means of illuminating the meaning of holistic and relational nursing in elderly care. Balancing independence and loneliness is a unique feature of elderly care. The ability to handle that balance requires several years of experience, and is one part of being professional. Professional identity is reshaped and evolves throughout a nurse’s professional life (Johnson et al., 2012). In the current study, the evolution of professional identity can be exemplified by nurses describing how their thoughts on nursing had changed from a technical to a relational and holistic aspect, or in the ¨ hle´n and Segesten (1998) from working as a words of O nurse to being a nurse. Nurses in our study described how confident and knowledgeable they felt in relation to the decisions they had to make without the immediate support from physicians. This suggests that elderly care nurses, due to maturity and tenure, have developed a strong sense of professional autonomy encompassing confidence, knowledge and personal courage to act as conceptualised by Ska˚r (2009). However, it needs to be noted that nurses in the current study expressed a sense of loneliness in daily work despite their appreciation of having professional autonomy. This implies that collaboration with peers and coworkers might be as important as building relationships with patients. Ellenbecker (2001) as well as Prentice and Black (2007) pointed to how respectful professional relationships between nursing colleagues and physicians influenced positively on job satisfaction and retention. On the other hand, Choi et al. (2011) reported that the relationship between nurse and physician was not significantly associated to higher RN job satisfaction, and it was suggested that the collaboration with physicians was a less critical issue in nursing homes than in acute-care settings. Why this should be the case is not explained, rather based on our findings, we would argue that collaboration with physicians and being able to share
the burden of complex decisions are as important in nursing homes as in acute-care settings. Therefore, building on the current study, the aspect of a sense of loneliness needs to be elaborated upon. We propose further research on emotional stress and the psychosocial aspects of lonely work, and how these factors might influence job satisfaction. In addition, we recommend that models for clinical supervision (CS) are discussed and possibly implemented in elderly care practice. Be´gat et al. (2005) described CS as a structured model for reflection and problem solving where nurses can become clear about why they think and act in certain ways. Improved patient care, stress reduction, and enhanced job satisfaction were presented as perceived benefits of CS. We suggest that CS most likely hold the potential to support not only personal but also professional development thus strengthening the professional identity. 4.1. Limitations Our study was situated in Southern Sweden, and the organisation of elderly care which might have impacted the findings is thus restricted to a Swedish context, and cannot be widely generalised. Another limitation is the possibility that participants might have withheld vital information to avoid conflict or voicing critical views. However, the first author (EC) started the interviews by explaining that no data could be traced to any individual and that participants would remain anonymous. In addition, the focus groups were characterised by lively discussions, and participants seemed comfortable and open when sharing their thoughts. Moreover, the interviews started with informal small talk in an effort to create a respectful and friendly atmosphere. However, it can be argued that we present an overly positive view on nurses’ professional work in elderly care. This can be attributed to the question of purposive sampling and respondent bias. One reason might be that the participants who volunteered were those who had made a conscious and rational career choice, and thus developed a strong professional identity as nurses in elderly care. Note that the mean age of the participants was 46 years and most of them had worked for more than 20 years. This implies a group of confident and autonomous nurses with no intention to leave. Age and tenure have previously been described as variables related to intention to stay and job satisfaction (Ellenbecker, 2004; Ellenbecker et al., 2008). In addition, as we did not find any differences according to demographic variables or type of care settings no comparisons were conducted. On the contrary, the participants discussed professional work in terms related to their relationships to patients and their relatives, not in terms of how that work was organised or whether it took place in rural or urban settings. We would therefore interpret this as strength of the study contributing to the unique character of the positive picture of elderly care we have presented. We also need to acknowledge the fact that no formal member checking was performed as we did not want to add to the nurses’ work load. However, we achieved what Sandelowski (1993) refers to as informal member checking, by raising follow-up questions during the interviews as a means to seek clarification or elaboration of meaning and intention.
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5. Conclusion Our study shows that the opportunity to develop longterm relationships, execute professional autonomy, and provide holistic care are all central to registered nurses’ professional work in elderly care. The findings are important as they represent positive alternatives to the somewhat prevailing view on elderly care as depressing and undemanding. Nurse educators might use the key aspects as good examples, thus influencing student nurses’ attitudes towards elderly care in a positive way. Elderly care agencies might find them helpful when recruiting and retaining nurses to a much needed area. Conflict of interest: No conflict of interest has been declared by the authors. Ethical approval: The study was approved by the local Ethical Advisory Board at the university where the authors hold their positions. Funding: This research was made possible by generous grants funded by the Postdoctoral Programme for Quality Development in Higher Education at Malmo¨ University, Sweden. Acknowledgements The authors also wish to extend their gratitude to all the registered nurses participating in the study for sharing their time and experience. References Be´gat, I., Ellefsen, B., Severinsson, E., 2005. Nurses’ satisfaction with their work environment and the outcomes of clinical nursing supervision on nurses’ experiences of well-being—a Norwegian study. Journal of Nursing Management 13, 221–230. Carlson, E., 2013. Meaningful and enjoyable or boring and depressing? The reasons student nurses give for and against a career in aged care. Journal of Clinical Nursing (in press). Carlson, E., Bengtsson, M., 2013. The uniqueness of elderly care: registered nurses’ experience as preceptors during clinical practice in nursing homes and home-based care. Nurse Education Today, http://dx.doi.org/10.1016/j.nedt.2013.07.017. Choi, J.S., Flynn, L., Aiken, L.H., 2011. Nursing practice environment and registered nurses’ job satisfaction in nursing homes. Gerontologist 52 (4) 484–492. Cowin, L.S., Johnson, M., Craven, R.G., Marsh, H.W., 2008. Casual modeling of self-concept, job satisfaction and retention of nurses. International Journal of Nursing Studies 45, 1449–1459. Creswell, J.W., Miller, D.L., 2000. Determining validity in qualitative inquiry. Theory into Practice 39 (3) 124–130. de Guzman, A.B., Dangoy, R-J., David, K.C., de Claro, K.A., de Guzman, G., de Jesus, G.I., 2009. How many sides does a coin have? A phenomenology of Filipino nurses’ motivation and attitudes toward geriatric care. Educational Gerontology 35, 260–276. Dewar, B., Nolan, M., 2013. Caring about caring: developing a model to implement compassionate relationship centered care in an older people care setting. International Journal of Nursing Studies, http:// dx.doi.org/10.1016/j-ijnurstu.2013.01.008. Ellenbecker, C.H., 2001. Home health care nurses’ job satisfaction: a system indicator. Home Health Care Management & Practice 13 (6) 462–467.
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