Thriving despite adversity: Job engagement and self-care among community nurses
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Background: Community nursing in Norway has become an increasingly stressful occupation and many nurses who experience symptoms of burnout leave the profession. Yet others manage to cope with the adversity of nursing. This study addressed the question ‘how and why do nurses in community health care experience job engagement and stay healthy – and what can we learn from those who succeed?’ The assumption underlying this study was that job engagement is health promoting, and the intention was to study how and why community nurses can thrive despite the burdens of nursing. The idea was that if we could better understand nurses’ job engagement, we might be able to suggest ways in which to help all community nurses to thrive. Objective: The main objective of this study was to explore, in-depth, the nature of job engagement among thriving community health nurses and to investigate how job engagement may be maintained and promoted. Job engagement was understood to consist of three basic phenomena: “calling”, “zest for work” and “vitality,” all of which required in-depth exploration. This was done by conducting one empirical in-depth interview study and qualitative content analysis addressing the questions and aims of the study. Design: The study used an explorative qualitative design, positioned as phenomenological research in relation to its philosophical approach of being concerned with the nurses’ lifeworlds, while methodologically it also drew on hermeneutics. The data were collected through 15 tape-recorded interviews that took between forty-five minuets to two hours, and were conducted in the interviewees’ workplaces or homes. A thematic interview guide was modified from interview to interview, but the opening question was always: “Can you please tell your work-life story?” Fourteen interviews were transcribed verbatim and the nurses read and approved the transcriptions. The fifteenth interview was recorded, but could not be transcribed due to an equipment failure. The data from this interview were recaptured as well as possible from notes taken after the interview. A qualitative content analysis was conducted with both descriptive and interpretive approaches. The analytic tool evolved throughout the project. Five analytical steps were undertaken: 1) Gaining a general impression of the interview; 2) Dividing the text into fragments of meaning (meaning units); 3) Transforming the meaning units; 4) Meaning condensation and the creation of codes and categories and; 5) Searching for themes, understood as the expression of latent content. The analysis consisted of analysing each participant’s story and each issue and theme across participants and was conducted with a combination of case-focused, cross-case and issue-focused analysis. Further, the analysis proved to be a spiral-like process where I repeatedly and cyclically moved between steps and between cases, and between working with the transcribed interviews and reading literature on topics related to the phenomena being studied. Findings: In addressing research question 1: ‘How do thriving nurses experience job engagement?’, I explored job engagement among community nurses who were thriving at the time they participated in the study, and the processes that promoted job engagement among these nurses (presented in paper 1). The analysis revealed that the nurses had high level of ethical standards and that a sense of calling was a core aspect in all the nurses’ lives, something which they expressed through their nursing practice. The analysis also revealed a relatively enduring pattern of introspection and reflection, including deep attention to meaning, meaningfulness, and values connected to challenges at work, their experience of job engagement and their attempts to promote and maintain it. The concept of ‘meaning’ in and of life emerged as highly essential in the nurses’ experience of job engagement, and that helped to crystallise the job engagement construct, in which the search for meaning, the experience of meaning, and holding on to meaning has the force of a drive. The analysis thus revealed that job engagement was experienced by these nurses as a process driven by the search for meaning, the experience of meaning and the holding on to meaning. Job engagements’ motivational factor was a sense of calling and the calling/vocation match. Its fundament was the talent and habit of introspection and reflection. The findings indicate that to promote job engagement, acknowledgment of the importance of values and possible value conflict between the person and the workplace is vital, both before a choice of profession is made and on a relatively continuing basis during one’s work life. The data illustrated that it is possible to make introspection and reflection about values and the meaning of work an integral part of working life. On the basis of the entire analysis and interpretation, it is concluded that staff development and vocational guidance work should include explicit recognition of, and attention to, the importance of a nurse’s awareness of values, ethical issues, and the meaning of work, as vital to the experience of job engagement. In addressing research question 2: ‘What is the role of job engagement in community nurse burnout?’ I explored whether job engagement may contribute to exhaustion and burnout and not only health and well-being, and the processes that might inhibit job engagement among community nurses (presented in paper 2). Nine of the nurses had experienced stress bringing them close to burnout, and one of them to burnout, yet they had all regained enthusiastic engagement in nursing at the time of the interviews. Their stories revealed a negative process, in which job engagement played a perverse role which brought them to the brink of burnout. Choosing nursing as a profession helped the nurses to respond to an existential issue: finding meaning in life. The nurses expressed that a sense of calling was an underlying guide to their choice of profession. The need to experience and hold on to meaning tended to overshadow the importance of manageability of one’s professional responsibilities. High job engagement, which followed from the nurses’ sense of calling to the nursing profession and the nurses’ devotion to work, contributed to a strong sense of duty and heavy self-demand regarding own and other’s levels of performance. This got them into trouble. The study illustrated that moral distress and overload leading to near burnout may be exacerbated by a high level of job engagement and frustration about not living up to one’s high ethical standards. Thus, job engagement appears to play a paradoxical role in nurse burnout. Further, the study also suggests that job engagement may not only promote thriving on the job, but may also contribute to a negative process leading to poor functioning. The motivational factor of this negative process also appeared to be the sense of calling and the calling/vocation match, where highly diligent dutifulness resulted in experiences of moral distress, overload, fatigue and even burnout. In addressing research question 3: ‘How do thriving nurses maintain and enhance their job engagement?, I explored the role of self-care in maintaining and enhancing job engagement among thriving community nurses, and I aimed at summarising the salutogenic and pathogenic processes in which job engagement plays a central role (presented in paper 3). In nine cases, the perceived failure to live up to one’s own performance demands contributed to the process of burning out. This triggered introspection, sensibility and reflection, leading to coping, avoidance of burnout, and the enhancement of job engagement. The nurses showed alertness, appraisal and the ability to act to preserve job engagement. This pattern brought to mind the construct ‘sensibility’ which is theorized in paper 3 and argued to be of vital importance to maintain and enhance job engagement. To enhance job engagement, the nurses worked to lower the too-rigorous standards they had set for themselves and for others, and/or they changed jobs or modified their working conditions. This self-care happened on a philosophical level and on a practical level and often combined actions played out in the following way: the nurses’ abiding existential curiosity about the surrounding world and about self, stimulated self-monitoring and self-tuning in their search for coherence. ‘Existential curiosity’ and ‘monitoring and self-tuning’ were thus the forerunners to action. The data revealed six main active coping strategies which provided the direct means to regain job engagement; ‘striving to be a realistic idealist’; ‘engaging in meaningful activities alongside nursing’; ‘ensuring a place for silence and withdrawn peace’; ‘solving emotional problems’; ‘learning from experience’ and;’ ability and willingness to undertake major change’. The ‘Self-tuning Model of Self-care’ was developed to summarise these processes graphically. The Model shows three parallel processes, one of which is characterised as salutogenic and another as pathogenic, both driven by the same motivational factor—a sense of calling and the calling/vocation match. These two processes are mediated by a third process involving introspection, sensibility, reflection and active coping. This is a sensing/reacting process that is adaptive in that it can result in changes leading to regaining job engagement. Thus, the promotion and maintaining of job engagement appears to be dependent on the nurses’ self-care. Conclusion: Job engagement plays a seemingly paradoxical role in nurse work-life. A nurse’s sense of calling and his/her experience of calling/vocation match stimulate two processes leading simultaneously to high job engagement and to highly diligent dutifulness. The salutogenic process, in which job engagement plays a central role, can be stimulated, and meaning, zest for work and vitality can be protected if the nurse engages in an ongoing mediating self-care process described in this study as ‘self-tuning’. This self-care process is teachable and has as its fundament the talent and habits of introspection, sensibility, reflection and active coping. Self-tuning also depends on the willingness to learn from experience and on being able to take action to improve one’s situation. The findings of this study, informed by the experience of nurses, may have relevance to persons in stressful professions who wish to stimulate their job engagement or who find themselves on the path to burnout.