Adjusting to personal and organisational change: Views and experiences of female nurses aged 40–60 years
Article Outline
- Summary
- Introduction and background to the study
- Methodology
- Findings
- Discussion
- Conclusion
- References
- Copyright
Summary
The Australian nursing workforce is ageing and there is a well-documented shortage of nurses. This global phenomenon means that retaining nurses in the workforce is gaining in importance as older nurses retire and leave nursing. The existing literature reveals deficiencies in knowledge about older nurses as they adapt to ageing often within stressful work environments. The aim of this narrative-based study, informed by feminist principles, was to explore the views and experiences of female registered nurses aged 40–60 years, in acute hospital and community health care settings. In-depth semi-structured interviews of approximately 1
h duration were gathered during late 2004. The transcribed narratives were subjected to thematic analysis. Two major themes were identified. The first theme: “Feeling uncared for” contained three sub-themes—Unsupportive work relationships: “We should be helping each other”; Workplace bullying: “It hurts me and I feel really bad”; and, Stress and burnout: “It's just like being in a pressure cooker all the time”. The second major theme identified was “Adapting to ageing: my nursing career”.
Findings of this research suggest some unmet support needs for older nurses in the workforce which could discourage them from remaining in nursing. The findings highlight a need for further research into the support needs of older nurses.
Keywords: Ageing, Older, Female nurses, Qualitative, Feminist
Introduction and background to the study
Australia has an ageing nursing workforce, which combined with the shortage of nurses occurring across most areas of healthcare means that the retention of nurses has gained higher levels of importance than previously (Preston, 2006; Wickett, McCutcheon, & Long, 2003). The ageing nursing workforce is a global concern (Buchan, 1999, Hatcher et al., 2006; Shields & Wilkins, 2006). One major retention strategy posited is to keep practising nurses working, however reports suggest this involves rethinking retention strategies, and placing higher value on older workers than previously (Hatcher et al., 2006; Naegele & Walker, 2006; Preston, 2006). The average, predominately female, Australian nurse is aged 43.3 years, and workforce levels of nurses aged over 50 has risen from 21.5% in 1999 to 29.8% in 2004 (Australian Institute of Health & Welfare, 2006). This means that ageing nurses, perhaps expecting to retire soon, may need to be encouraged to continue working at a time of rapid change within the health care system (Preston, 2006, Stanton, 2002).
Ageing worker generally means the time when individuals begin noticing health problems or decreasing work-related capabilities (Ilmarinen, 2001). This mainly physical deterioration usually occurs after age 45, but can occur earlier for workers in physically demanding jobs (Ilmarinen, 2001). Nurses commonly retire around 55 years (Heath, 2002), or move to less demanding jobs, a practice believed related to work injuries, especially back injuries (Smedley, Inskip, Cooper, & Coggon, 1998; Yip, 2001), or health-related problems. It is well reported that nursing is a mentally, emotionally and physically challenging profession and nurses consistently report high levels of stress (Chang et al., 2006; Cheng, Kawachi, Coakley, Schwartz, & Colditz, 2000; Healy & McKay, 2000; McVicar, 2003). Middle age is associated with increasing risk of chronic disease, for example, hypertension, diabetes and heart disease (He et al., 2004, Ulstad, 2004). Studies suggest ageist beliefs are prevalent in nursing, perhaps reflecting common societal views (e.g., inflexibility, inability to keep pace with changing technology, less value than others) which can result in older workers being bullied in the workplace (Bernard, 1998, Buchan, 1999; Dychtwald, Erickson, & Morison, 2006; Letvak, 2002). Many studies suggest workplace support; especially managerial support helps protect nurses from physical and mental decline (Cheng et al., 2000, Chang et al., 2006; Spence Laschinger, Finegan, Shamian, & Almost, 2001). Despite evidence that the average age of nurses is increasing, with many now aged over 50, the literature review revealed little knowledge regarding older nurses’ views and experiences as they adapt to ageing often within stressful working environments.
This paper is drawn from a larger study that had two major aims, these being to explore: (1) the health and ageing concerns and self-care strategies of older female registered nurses, and (2) the views and experiences of those same older registered nurses working in acute hospital and health care settings. Findings related to aim (1), the health and ageing concerns and self-care strategies have been previously reported (Gabrielle, Jackson, & Mannix, 2008). This current paper focuses on the views and workplace experiences of female registered nurses aged 40–60 years, in acute hospital and community health care settings.
Methodology
This narrative-based study was informed by feminist principles which meant conducting research that focused on women, and which valued and respected the women's views and contribution as they shared their life stories (Hall & Stevens, 1991; Webb, 1993). Further feminists believe conducting research which aims to deepen understanding and improve women's experiences has transformative and empowerment potential for participants and researchers (Jackson, Clare, & Mannix, 2003; Taylor, 2002, Webb, 1993). Being a catalyst for change can occur when the researcher with critical reflection and awareness of issues of power (the women's well-being uppermost throughout entire process) conducts research that transmits caring to another person (Jackson, Clare et al., 2003; Taylor, 2002). Sandelowski (1991) maintains that listening to another person's story deepens their understanding of their own life process facilitating the change process. Encouraging ordinary nurses to have a voice has special relevance for all those nurses who tend not to identify as a group and who can feel alone and isolated in their daily struggles (Cheek & Rudge, 1995).
Recruitment and sample size
Purposive participant enlistment occurred through publicity in a state wide nurse's magazine containing essential inclusion criteria. Recruitment continued until data saturation occurred (Jackson, Daly, & Chang, 2003) and resulted in participation of 12 female registered nurses aged 40–60 years, from metropolitan Sydney and country NSW hospitals and community services.
Data collection
Conversational-style semi-structured in-depth interviews (60–90min) were conducted during 2004. Interviews included questions such as: What are your feelings about being an older nurse? And, how would you describe your relationship with your workmates? A feminist interview approach meant reflecting on preconceptions, awareness of subjective and reciprocal nature of interview process, and listening deeply and respectfully to participants (Anderson & Jack, 1991).
Ethical considerations
Full ethics approval was granted for this study from relevant University Human Research Ethics Panel. Prior to interview participants completed consent forms, demography profile and nominated pseudonyms. Informed consent included voluntary nature of participation, anonymity and confidentiality concerns. Participants had access to free counselling services. Positive feedback was received at post-interview contact.
Data analysis
The first author transcribed interviews verbatim and thematic analysis of data occurred.
A slow developmental process was adopted using self-transcription, repeated listening to interviews, and multiple readings of individual interviews before collating data as a whole. The feminist approach acknowledged the dynamic and subjective nature of data interpretation (Anderson & Jack, 1991; Graneheim & Lundman, 2004) and premature conclusions misrepresenting participants’ true meaning (Sandelowski, 1995).
The thematic process of reducing data into meaningful themes included first searching for obvious, manifest ideas within the narratives, grouping these into categories before reducing the text into smaller coded units. This process repeated many times led towards further abstraction and resulted in two major themes and sub-themes (Graneheim & Lundman, 2004).
Rigour
To address rigour, and in keeping with feminist principles, careful thought was given to possible biases and prejudices regarding older women and women generally (Anderson & Jack, 1991). The study's credibility was enhanced by using an appropriate methodology, information-rich participants and themes reflecting the data (Graneheim & Lundman, 2004; Hall & Stevens, 1991). This last issue was addressed by using participant quotes to reflect the themes. To further help address rigor, reflection and self-critique combined with regular ongoing dialogue and consensus between research team members helped promote a truthful and integrated study (Graneheim & Lundman, 2004; Hall & Stevens, 1991). Koch and Harrington's (1998) assertion that these reflective processes make qualitative research more rigorous strengthened this position.
Findings
Participants
Participants were aged between 40 and 60 years (average 47 years). Their extensive nursing experience in Australia spanned 6–44 years (average 27 years). One participant trained in New Zealand. Eight participants worked in general or midwifery hospitals and four were community nurses. Eight participants worked part-time and four had full-time employment.
Themes
Two major themes emerged: feeling uncared for and adapting to ageing: my nursing career.
Feeling uncared forParticipants related many occasions where they felt unappreciated within their workplace. Participants described experiencing work conditions and work practises not conducive to remaining in nursing. They described instances of bullying, lack of support and frequently described themselves as burnt-out. Many worried about the constant stress associated with nursing resulting in illness or injury and subsequent loss of their career. Sub-themes identified were: unsupportive work relationships; workplace bullying; and, stress and burnout.
Unsupportive work relationships “We should be helping each other”
Participants reported often feeling disheartened and exploited in their workplace. This suggests participants lacked autonomy; a situation compounded by insufficient resources and perceived unsupportive managers. This perception of lack of support from all levels of management was a significant issue for participants and contributed towards diminished trust in their organisation. Some participants attributed this lack of support to ageist beliefs in management which suggested lack of valuing of older nurses.
Sally: I was devastated that there was no loyalty from the administration … I started to realise, nobody really cares about you … Just another injury, too bad… pick yourself up … It's very hard, and I’ve been one of those people that have had minimal sick leave, in the 24 years that I’ve been nursing. … You know, you’re an older nurse you should know better, there was that type of attitude.
Paula: I think probably because we’re the senior staff we cop it more than the new grads [graduates] and the younger ones…because they want to keep them so they try not to pressure them too much.
For Mollie an uncaring attitude from her employer compounded feelings of powerlessness and feeling devalued in her workplace in spite of her dedication to nursing. Though Mollie's narrative revealed that she felt uncared for and disappointed in the lack of support she received, she demonstrated her professional approach to nursing.
Mollie: I feel angry about it [her work injury] … My boss has never actually asked me how it was … But…I’ll always turn up for work and always look after my patients, and…really, I’m lucky to have a job at 60, aren’t I?
When the interviewer suggested her employer was lucky to have her Mollie expressed her pride in her nursing skills, and her ability to do her job well.
Mollie: It's very specialised… I have a good relationship with all my patients, and I think I’ve got quite a few brownie points within the company for the way that I do manage the patients.
Workplace bullying. “It hurts me, and I feel really bad”
Bullying behaviour took many forms and included subtle negative behaviours such as withholding necessary support. Participants reported work instances where support or co-operation from other nurses was withheld. The following excerpt of narrative describes a negative workplace culture and its effect on Heidi.
Heidi: [Some nurses], they’re not understanding towards other nurses, and… they don’t help them, and…that does have an impact on your health… The usual response, from most [nurses]…not everyone…is that they see you [needing help] and they just pretend they don’t see you.
Heidi disclosed occasions in which she became so distraught that she hid herself in the bathroom and wept.
Heidi: I went to the toilet and I just cried, and cried, and cried, because I had no support… And, then I had to sort of get myself together.
Francesca held the perception that her workplace was based on a bullying culture in which there were nurses in favour and nurses who were not favoured. Because of this, Francesca felt that there was little support and collegiality in her workplace, resulting in a low trust-working environment for her.
Francesca: Our manager … She's a bit of a bully… bullies usually have their little hierarchy … It shouldn’t happen that way. We’re supposed to be colleagues and some [nurses] act like [other nurses]…are subordinate.
Participants described being bullied themselves or witnessing the bullying of others. Ann expressed distress and humiliation when she witnessed nursing colleagues behaving badly towards patients and visitors. Such acts impacted negatively and created a workplace environment that was often experienced as toxic and unfriendly. While Ann was concerned that stress among her colleagues was revealed in acts of bullying or rudeness, she felt unable to do anything to help the situation.
Ann: [Bullying] reflects on the whole place… it's like everyone is bad and we’re not bad, and they’re nice people [other nurses]. It's just that they get stressed out and don’t know how to deal with it … We are supposed to be this caring profession and yet quite often you see signs of not very caring behaviour. I’m not assertive enough to be able to say something to them [nurses]… I feel something has to be done.
Stress and burnout: “It's just like being in a pressure cooker all the time”
Participants described busy workplaces and constant work pressure from a position of seniority at ward level. They reported high stress levels and frequently described themselves as burnt out. They described many work occasions where the skill mix required them to be responsible for running the ward, oversee junior nurses and carry a patient load as well. Work overload often resulted in missed meal breaks, had detrimental health effects and led participants to consider or make workplace changes. Paula confessed there was little opportunity to feel a sense of achievement.
Paula: You’ve been hassled from [casualty], and the ADON [Assistant Director of Nursing] to move patients out and you’re getting abused from patients … It's just one crisis to another, been pulled from your own work to help with the new grads [graduate nurses] and enrolled nurses … and doing all of this extra stuff so that your patients get neglected because you’re filling up the other gap.
Participants felt that their needs and their status as older women were unrecognised, or ignored, within the workplace. They reported being placed under frequent pressure to work overtime, and often having intrusive phone calls on their days off to work extra shifts. Nicole described feeling under constant pressure to work overtime. This led to her exhaustion, and ultimately to her decision to reassess her lifestyle.
Nicole: I had a really bad headache, nausea, and I think I was just really overtired and I ended up in [hospital …and I thought] “Why kill myself doing this sort of job … I’ve got to look after myself.”
Adapting to change: my nursing careerThis theme, adapting to change, captured participants at a time when they were questioning many aspects of their lives including their working lives. They worried about ageing and described witnessing older nurses where nursing activities were taking a health toll. The narratives revealed it was usually a combination of events which motivated participants to review and instigate change in their lives. Chronic pain, poor nursing conditions, ageing and personal issues played a large role in future career decisions. However a core issue for participants was recognising that as they aged they needed to care more for themselves than they had previously.
Paula: It's just more the awareness now [with ageing] that you do have to take care.
Francesca: I was so sore… even though I love hospital nursing I can’t [do it any more].
Sara: I’m tired, it would be nice to have someone care for me, but that's probably not going to happen, so it's up to me to change things.
This increased awareness of physical and emotional changes which the participants connected with the ageing process, often meant making life changes and actively revising work strategies. These changes were designed to help them survive in nursing and improve their quality of life. Some strategies included limiting exposure to hard, physical work; reducing working hours or moving to physically lighter nursing; refusing to work double shifts or overtime; and, deliberate rest and relaxation to recuperate off-duty.
Ruth: I can’t see any end to it [the working conditions]… I can only work two days a week because I couldn’t cope with longer, I give very good service for the eight hours I’m there…and then I go home and I forget about it.
Suzy: I would not say personal suffering was the sole reason, [for leaving hospital nursing for the community], it contributed, but I was getting very, very tired of shiftwork… Nursing has changed a lot over the years, and the demands on you change too.
However in spite of the need for change there were benefits participants associated with ageing. Woven throughout narratives was the participants’ love of nursing and the pleasure they derived from nursing. They believed their developing maturity and nursing experience gave them perspective, improved their nursing ability and helped them as mentors for younger nurses. They spoke of themselves as good nurses who contributed to others.
Lauren: [Nurses] are all in it together, we should be there for each other all the time…. I’d like to think I affected [other nurses] so much that they’d say… “I’d like to be like that.”
Ruth: I am a good nurse and I can make a difference in those eight hours and they need me and so I keep doing it.
Marie: I love looking after the patients and just talking to them and just caring for them.
These participants described themselves as facing significant levels of workplace stress.
They described poor working conditions, workplace conflict, lack of support and some participants demonstrated high levels of emotional and physical distress which could encourage them to leave nursing. These workplace issues, often combined with ageing concerns, influenced them to make workplace changes necessary to protect their health.
Discussion
While it is acknowledged that these factors impact on the working lives of most nurses the effects are more significant on older nurses for a number of reasons. Reduced musculoskeletal and cardiorespiratory capacity occurs with ageing and ageing workers generally require a corresponding reduction in workload to remain healthy (Ilmarinen, 2001). Nurses report high levels of musculoskeletal injuries (Cyr, 2005; O’Brien-Pallas, Sharmian, & Thomson, 2004). Older workers are significantly more likely than younger workers to have musculoskeletal problems which negatively impact sleeping patterns (Edéll-Gustafsson, Kritz, & Bogren, 2002), resulting in high stress levels and subsequent health risks (Cheng et al., 2000; Deane, Chummun, & Prashad, 2002; Kawachi et al., 1995). Many studies point to increased risk of cardiovascular disease, hypertension and other chronic diseases in nurses associated with ageing (He et al., 2004, Kawachi et al., 1995). Chang's et al. (2006) survey of Australian nurses found age predicted reduced physical health levels, a major influence on the retirement decisions of older nurses (Cyr, 2005).
Bullying is believed common in nursing and can affect all nurses (Hutchinson, Vickers, Jackson, & Wilkes, 2005). However, there are suggestions that nurses most at risk are the newest (Heath, 2002, Randle, 2003) and the oldest, the latter perhaps due to ageist attitudes in the nursing population (Bernard, 1998, Dychtwald et al., 2006, Letvak, 2002). Letvak (2002) found older nurses least likely to be offered retraining programs despite the job opportunities and empowerment potential such opportunities present (Kuokkanen & Leino-Kilpi, 2000). Feelings of disempowerment are associated with increased susceptibility to burnout (Janssen, de Jonge, & Bakker, 1999) and ill-health (Hochwalder & Bergsten Brucefors, 2005). There are conflicting reports about the mental health of older nurses. Gillespie and Melby (2003) found older nurses had a lower sense of personal achievement than younger nurses suggesting vulnerability to burnout, while Letvak (2005) found superior mental health levels in older nurses. Chang's et al. (2006) found significant correlation between workplace stress (including conflict) and diminished mental health although many years nursing in one unit was a protective factor. They found nurses’ coping strategies also predict mental health highlighting the importance of workplace support.
On a human level all nurses deserve fair working conditions and a healthy workplace (World Health Organisation, 1999) and on a practical level a satisfied nurse is likely to remain in nursing. These participants, with years of experience, loved nursing and if conditions were right, wanted to stay. However, narratives suggested that the key value of caring, a basic tenet of nursing, needs to extend between nurses themselves (Heath, 2002). There are physical and mental changes associated with ageing. However, although mental speed and precision slows with ageing this is often compensated for by other attributes, such as increased wisdom and a strong motivation to learn, which suggests older nurses could benefit organisations in other capacities (Ilmarinen, 2001). Appreciating the contribution of older nurses and viewing them as a valuable resource may require an attitudinal change within nursing management and the workplace (Andrews, Manthorpe, & Watson, 2005; Dychtwald et al., 2006, Norman et al., 2005).
Conclusion
There is an acute nursing shortage in Australia and the mainly female workforce is ageing. These older, experienced nurses are needed in nursing however little knowledge exists about their workplace experiences, especially in relation to their health and well-being. Limitations of this study included the self-selected nature and small sample size, and generalisability to the nursing population was not intended. Nonetheless, narratives suggested nursing conditions that could discourage older nurses remaining in the workforce. Significant areas of concern were workplace conflict or bullying; poor working conditions resulting in high stress levels; and, lack of managerial support especially in relation to their changing needs. Issues raised in this study point to the need for further research in this important area. A larger national study investigating the clinical experiences and health needs of the ageing nursing workforce is warranted.
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PII: S1322-7696(08)00025-5
doi:10.1016/j.colegn.2007.09.001
© 2008 Royal College of Nursing, Australia. Published by Elsevier Inc. All rights reserved.
