Collegian
Volume 16, Issue 4 , Pages 185-192, December 2009

An investigation of emotional wellbeing and its relationship to contemporary nursing practice

  • Jayln Rose, RN, BNurs, BNurs(Hons), PhD, MRCNA

      Affiliations

    • Department of Nursing & Midwifery Fraser Coast Campus, University of Southern Queensland, PO Box 910, Hervey Bay, QLD 4655, Australia
    • Corresponding Author InformationCorresponding author. Tel.: +61 7 4194 3133; fax: +61 7 4194 3173.
    • ,
  • Nel Glass, RN, BA, MHPEd, PhD, FRCNA, FCN

      Affiliations

    • CU National/St Vincents & Mercy Private Hospital, 71 Victoria Parade, Fitzroy, VIC 3065, Australia
    • Tel.: +61 39 411 7389; fax: +61 39 411 7754.

Received 13 October 2008; received in revised form 8 June 2009; accepted 4 August 2009.

Article Outline

Summary 

This paper is an investigation of emotional wellbeing and its relationship to contemporary nursing practice for women community health nurses (CHNs) who are providing palliative care. Palliative care provision has been acknowledged as a source of job satisfaction for many nurses however emotional interactions place increasing strain on nurses’ wellbeing. Psychosocial aspects of care are reported as having a personal as well as a professional impact. Work related stress places nurses at increased risk of harm and impaired wellbeing. An emancipatory methodology was chosen for this study. Semi-structured interviews and reflective journaling were the methods used. The data was collected over a 16-month period during 2006–2007. There were fifteen participants. This qualitative study explored Australian rural and urban community nurses’ experiences with wellbeing, emotional work and their professional practice. The findings revealed opposing social forces, an inner ‘dialectical’ tension between the nurses’ expectations of their professional practices and what is valued in their practice settings. In terms of emotional wellbeing, two overarching themes will be discussed: feeling balanced and feeling out of balance. Workplace environments that were not always conducive to healing increased the emotional strain on nurses. Nurses’ work promotes the healing of others therefore to deny the healing of nurses’ is to deny others of healing. The need for further qualitative research investigating the emotional wellbeing and professional practice of community nurses who provide palliative care is necessary.

Keywords: Emotional wellbeing, Community nurses, Palliative care, Emancipatory research, Contemporary nursing

 

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Introduction 

The relationship between emotional wellbeing and nurses’ professional practice remains an under researched area internationally yet recent Australian studies have emerged that make valuable contributions to this developing area (Chang et al., 2006, Gabrielle et al., 2008a, Gabrielle et al., 2008b). Plausible reasons could be that the emotional demands of patient/client care are considered all part of the job (de Castro, 2004) and equally, that research funding in both Australia and the United Kingdom (UK) is focused on disease prevention, diagnosis and treatment (National Health and Medical Research Council, 2007, National Institute for Health Research, 2008). Yet, there is “a direct and critical relationship between nursing work, nursing work environments and the patient experience, particularly patient outcomes” (Lawless & Moss, 2007, p. 230). Therefore, if what nurses do and their work environment influences patient outcomes, arguably further research on nurses wellbeing and their professional practice needs to be undertaken.

This notwithstanding, the practice environment for nurses worldwide is characterised by a, work more for less phenomena where limited human and material resources are common place (Glass, 2007). Nurses’ conversations are often related to the stressful nature of their work responsibilities (Chang et al., 2006, Gabrielle et al., 2008a) and the emotional labour inherent within nurse/patient interactions (Bolton, 2001, Martínez-Iñigo et al., 2007, Theodosius, 2008, Zapf et al., 2003).

For nurses caring for and caring about people with a life limiting illness, the stress can be considerable due to the emotional challenges. Managing the emotional challenges involves emotional work, subsequently intensifying the emotional labour required to perform nursing care. As a consequence, nurses need to protect themselves against stress at work by utilising emotional intelligent strategies (Codier et al., 2008, Glass, 2007, Glass, 2009, McQueen, 2004). McQueen (2004, p. 106) strongly asserted that the “emotional work calls upon some of the skills that fall within emotional intelligence … [and] management of emotions is required in successful interactions”. Emotional intelligence involves awareness of self; awareness of others; and empathy (Reeves, 2005). Nurses who intervene with emotional intelligence act efficiently whilst remaining focused on the emotional needs of patients.

It is clear that the emotional demands of nursing are minimalised to the point of being “commonly overlooked” (de Castro, 2004, p. 120) yet as Chang et al. (2006, p. 36) asserted, “better provision of support within the workplace and reducing associated stress could enhance [nurses] mental health”. In addition, the nursing profession must remain mindful of the strong affiliations between nursing stress and the impact on client care (McNeely, 2005, Salmond and Ropis, 2005).

When the lens is narrowed to focus specifically on nurses’ caring for clients with cancer or a life limiting illness, the effects of the emotional challenges on nurses are considerable (Burt, Shipman Addington-Hall, & White, 2008; Wallerstedt & Andershed, 2007). Kenny, Endacott, Botti, & Watts (2007) highlighted the impact on nurses’ emotional wellbeing in this type of nursing practice. Research by Wilkes et al. (1998), Wilkes and Beale (2001) and Dunne, Sullivan, and Kernohan (2005) revealed the stress community nurses experienced when caring for palliative patients in their own homes. The sources of stress related to several factors including family dynamics and relationships; role conflict; nursing workloads, communication and nursing environments.

Therefore, not only it is critical to listen to and acknowledge nurses’ experiences of their professional practice, but also it is necessary to conduct further research into what can be regarded as the emotional ‘package’ of workplace demands, stresses and its effects on wellbeing. With limited research undertaken in Australia to explore the relationship between emotional wellbeing and professional practice related to community nurses (Rose and Glass, 2006, Rose and Glass, 2008) it is important to bridge the gap in order to advance nursing knowledge.

This paper is developed from the findings of a doctoral study entitled: ‘Emotional work, emotional wellbeing and professional practice: the lived experiences of women community health nurses providing palliative care in the home environment in Australia’ (Rose, 2008). The study was undertaken with rural and urban community health nurses (CHNs) who practice within New South Wales, Australia. This paper will explore emotional wellbeing and reveal the important relationship it holds to contemporary nursing practice. As this study was undertaken within NSW, Australia, the title of community health nurse (CHN) will be primarily used in this paper.

When over-viewing the results it was found that the CHNs emotional wellbeing was multifaceted and immersed in the unique subjective experiences related to their personal and professional worlds. The CHNs identified the interconnectedness between their emotional, physical and spiritual selves, accentuating their need to feel balanced in their nursing practice. Four sub-themes emerged: being self-aware; coping; feeling spiritually enriched and seeking boundaries.

In this paper a discussion will explore the CHNs experiences of emotional wellbeing, and also their experiences of feeling emotionally unwell, identified thematically as feeling ‘out of balance’. Whilst this paper is developed from research with community nurses, the authors believe the results have national and international relevance for all nurses irrespective of specialty and practice arenas. What now follows is a review of current literature relevant to community health nurses and palliative care provision.

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Background 

For the purpose of this review the authors wish to acknowledge that whilst palliative care is not the substantive role for generalist CHNs working in NSW, Australia, a core component of their clinical practice involves the holistic care of clients, their families and significant others who are living with a life limiting illness. The international discourse has identified nurses working in a generalist community role as either community nurses (CHNs); district nurses (DNs) or public health nurses (PHNs) depending on the designation assigned by the health organisation.

The literature related directly to CHN palliative care limited, the review incorporates related palliative care scholarship. The discussion is divided into two sections and will begin with the palliative care nursing literature.

Palliative care nursing 

Palliative care was identified as a discipline that places a variety of demands and stresses upon nurses particularly as clients “seek to share their fears, hopes and expectations with nurses … [placing] upon the receptive nurses many emotional and physical demands” (Barnard, Hollingum, & Hartfiel, 2006, p. 6). However, the study by Webster and Kristjanson (2002) highlighted that palliative care engendered a spirit of vitality amongst nurses, dispelling any notion that the role was depressing. Providing psychosocial care to clients and their families, particularly emotional support, has been identified as challenging for many nurses (Costello, 2001, Payne, 2001) having an impact on their emotional wellbeing (Graham et al., 2005, Kenny et al., 2007).

The therapeutic relationships that develop between nurses, clients and families were highly valued (Barnard et al., 2006, Graham et al., 2005) however distancing (Ablett & Jones, 2007; Barnard et al., 2006, Costello, 2001) or focusing on clinical tasks (Costello, 2001, Kenny et al., 2007) were strategies used to avoid “being drawn into intense and emotionally draining experiences” (Barnard et al., 2006, p. 11).

Community nursing palliative care 

The role of CHNs was identified as becoming increasingly complex even to the point where the nurses “could almost be categorised as social workers with the added benefit of expert nursing skills over and above that” (Davy, 2007, p. 19). There were many CHNs who believed that there involvement in palliative care was valued and visible (Goodman, Knight, Machen, & Hunt, 1998), however nurses also spoke of the invisibility they perceived related to the emotional work undertaken in the home environment (Luker, Austin, Caress, & Hallett, 2000). Psychosocial aspects of care were recognised in the scholarship as having a personal impact on CHNs emotional state (Begat and Severinsson, 2006, Dunne et al., 2005).

The hidden aspects of community nursing such as the complex relationships that Annells and Koch (2001, p. 811) refer to as ‘automatic and unconscious, fitted in when possible, usually not documented’ can impact on nurses stress levels and ultimately job satisfaction. Many CHNs found their role rewarding despite the emotional challenges (Andrew and Whyte, 2004, Dunne et al., 2005, Goodman et al., 1998). Scholars have warned of under-appreciating stress related harms for nurses as they can lead to complacency or tolerance and have been directly linked to personal and professional performance (Hawksley, 2007, McNeely, 2005).

The study 

The study aimed to explore the CHNs subjective and unique experiences of providing palliative care with the central focus on the CHNs emotional wellbeing and its relationship to professional practice.

Methodology 

The methodology was qualitative in design and emancipatory in approach. The emancipatory methodology applied to this study has been explained in detail elsewhere (Rose & Glass, 2008). The author's concurred with other scholars that the silencing of women as a phenomenon that perpetuates women's oppression (Fine, 1992, Glass and Davis, 1998) and women's voices are “central to feminist qualitative research enterprise” (Kitzinger, 2004, p.126). Whilst participation in feminist research is not exclusive to women, the participants in this study were all women. This study provided an opportunity for women CHNs to ‘de-silence’ and reclaim their voices (Glass, 1998) enabling them to speak freely about the unique workplace experiences that could otherwise remain hidden from public view. Mooney and Nolan (2006, p. 245) believed that “critical engagement is a means to knowledge development and emancipation of nursing”.

Participants 

Applying a purposive sampling technique direct contact was made with community health centres and relevant information and consent forms were distributed. Fifteen women CHNs from rural and urban New South Wales participated. All CHNs were over the age of 18 years and actively involved in the provision of palliative care.

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Methods 

Two methods were developed that were congruent and consistent with the research methodology and philosophical underpinnings of the research. The two methods, interviews/storytelling and reflective journaling, were chosen to encourage information rich stories (Eddy and Mellalieu, 2003, Patton, 2002).

Interviews/storytelling 

The interviews were semi-structured incorporating open-ended questions. This method aimed to validate the unique experiences of the women participants and was considered congruent with feminist inquiry and “resembled a conversation between friends” (Davis & Taylor, 2006, p. 201) however the researcher remained mindful at all times of her responsibility not to influence the storytelling process. The interview questions explored the concept of emotional work, the meaning of emotional wellbeing and the relationship it held to the participant's palliative care practice and self-care. All interviews took place in mutually chosen venues that were deemed emotionally safe by the women. The interviews were recorded on an iPod digital recorder following signed consent. Interviews were 1–2h in duration.

Reflective journaling 

Reflective journaling enabled documentation of the researcher's thoughts and feelings related to the study. Reflective journaling has been advocated as a notable strategy for scholars and clinicians to promote reflexivity (Manias and Street, 2001, Taylor, 2004).

Due to the sensitive nature of the research, there were occasions where the participants expressed deep emotional feelings. Journaling provided the researcher with an opportunity to express her emotions following the interviews and thus act as a tool for therapeutic conversation (Glass, 2001) and a useful strategy for reflection and self-healing.

Rigour 

The interviews were conducted in mutually agreed locations that were deemed emotionally safe to the participants. Locations varied between the privacy of participant's homes, public cafés and private offices in their workplace. During each interview the audio recorder was paused at any time upon request. This occurred on two occasions when a dialectical tension arose between the participants’ desire to speak and their simultaneous fear of speaking out about sensitive workplace issues. With anonymity being paramount, all identifying characteristics were changed and at times there was no pseudonym used with some data excerpts.

Cultural safety and ethical considerations 

One of the prime considerations with sensitive topic research is cultural safety. Qualitative researchers aim to protect the participants when there is potential to cause emotional harm. The harm can occur as the researcher seeks to uncover intimate details related to the participant's life (Roberts, 2002). Participants in this study were at risk of emotional harm due to the sensitive nature of the inquiry. Emotional support was provided during the interview process by the researcher. Details of counselling services were available should additional support be required.

Ethical considerations were of equal importance in this study. Following University Human Ethics approval and subsequent site approval, information and consent sheets were distributed. Direct contact with all interested CHNs took place. Following informed and signed consent face-to-face interviews were arranged. To ensure anonymity, pseudonyms have replaced participants’ names and any identifying data removed.

Data analysis 

The interviews were digitally uploaded and converted from WAV to MP3 files, copied to CD and returned to each participant for member checking. Participants were aware of their option to clarify, make changes or exclude data should they chose. That process ensured that credibility and authenticity were attained. A critical analysis of the data was conducted with the researcher immersing herself in the information rich stories (Eddy and Mellalieu, 2003, Patton, 2002), reviewing reflective journal notations and critical conversations with the research supervisor. Themes that arose through the analysis were subsequently used to represent the findings.

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Findings 

In answer to the question ‘What does emotional wellbeing mean to you?’ the initial reservations by the CHNs demonstrated that wellbeing was a concept usually reserved for clients. To overcome the difficulty, the researcher posed a second question that explored the CHNs experiences of feeling emotionally unwell. It was anticipated that if the nurses could explain feeling emotionally unwell, a raised consciousness of their wellbeing would be realised. The CHNs stories were directly and/or indirectly related to the notion of balance therefore the theme ‘feeling balanced’ was used to depict nurses’ experiences of wellbeing whilst the theme ‘out of balance’ best captured that complexity of feeling emotionally unwell. The two key themes will now be discussed.

Feeling balanced 

The work/life balance (Ablett and Jones, 2006, Barnard et al., 2006, Hawksley, 2007) has been a subject of interest for many scholars, however for the CHNs in this study, balance was intrinsically linked to their wellbeing and their emotional, physical and spiritual health. Four key aspects were evident and subsequently placed into sub-themes. The sub-themes to be discussed are:

•Being self-aware;

•Coping;

•Feeling spiritually enriched;

•Settling boundaries.

Being self-aware 

Self-awareness has been long associated with reflective practice. A strong degree of self-awareness enabled the CHNs to respond to situations and challenges they encountered. Participants revealed that increased self-awareness was integrally linked to their emotional wellbeing and equally they needed to be aware of their emotional wellbeing. Awareness of the personal/professional nexus was evident as the CHNs spoke of their need to spend time with family and friends, remain objective in clinical practice and work with empathy rather than sympathy to reduce the emotional drain.Rosemary was a strong advocate for reflective practice. Working with oppressive management in addition to mentoring less experienced CHNs, Rosemary identified the need to remain aware of her own emotional wellbeing. To achieve wellbeing, Rosemary believed that she had to:

[k]eep things in balance… sometimes I go home feeling very sad but I think its probably better that I feel a bit sad [rather] than just walk out the door and not think anything. Then I should give it away!

For Dee, self-awareness was critically linked to her ability to recognise her emotional state and to create change as needed. She reflected:

Being aware more than anything. Being aware of what state you are in and recognise what you need and what you do need to do about it. And it's not what anyone else can do for you, you have to do it yourself.

Coping 

Researchers have reported that the emotional demands of palliative care placed nurses at risk of stress and distress impairing their ability to cope (Wilkes and Beale, 2001, Wilkes et al., 1998). A few nurses in this study raised coping as a strategy to address the challenges of palliative care. The relationship between coping and the CHNs emotional wellbeing were highlighted in comments such as “when I feel like I can cope” and “the way I cope”. The ability to cope was also dependent on the socio-political context in which the nurses were positioned, for example, CHNs casually employed had less opportunity to know the clients well and at times found themselves in emotionally challenging situations. Rita shared the emotional challenges she faced when caring for two clients with a diagnosis similar to a close relative. When asked what emotional wellbeing meant to her Rita began by stating it was:

[h]ow I cope with different situations. I suppose and every situation is different as well, and if there are things that you can relate to more. Like at the moment because [my relative] is not well then [coping] is an important issue for me.

The link between Rita's personal ordeal and her clinical practice made evident the challenge she faced when working with palliative clients. Rita believed that as a casual CHN it was her responsibility to ‘fill in’ where needed regardless of the emotional demands. To counter balance the emotional impact, Rita took a philosophical approach stating that she:

[a]lways had a very supportive family and [has] always been of a very happy disposition. And I think it's what you put into life as opposed to the cards that life deals you, I think that it's how you deal with things.

Feeling spiritually enriched 

Several of the participants drew strong links between their emotional wellbeing and their spirituality. Spirituality can have differing meanings depending on the individual's life view and values (Barnett, 2006). However, spirituality for the participants was associated with their way of being in the world. Nurses’ expressed the need to feel happy, energetic and joyful whilst some nurses sought solitude, needing to feel peaceful and being able to enjoy their day.

Feeling spiritually enriched was also incorporated feeling grounded and balanced. Relationships with family, friends, animals and music were all identified as important to the CHNs wellbeing. Sarah remarked that her emotional wellbeing was when she had:

[a] lot of energy (pause) I feel like engaging with people, I feel positive and enthusiastic about life and feel just generally healthy and well.

Setting boundaries 

Scholars have identified professional boundaries as a way for nurses to negotiate the challenges associated with palliative care provision (McNeely, 1996; Wilkes & Beale, 2001) however, boundaries are negotiated in context with nurses unique circumstances (Lillibridge, Axford, & Rowey, 2000). The CHNs in this study identified boundaries as a way of valuing themselves and a strategy for self-care. Taylor put it well when she said, “its about saying that it's okay to look after me”.

Amelia encapsulated the thoughts of many CHNs when she remarked:

I think that palliative care is one of those things that you could go home and worry about things all night and for me it's making sure that I go home and leave my work at work. Sometimes it's not that easy.

At times the boundaries were associated with leaving personal issues at home not wanting to let them affect work. Lee reflected:

The thing is how you actually try and maintain the boundaries. If you’re having a bad time in life, not to be bringing that to work. Although we are human, we have our frailties, we can’t all do that all of the time.

Out of balance 

The nurses drew strongly on the interconnectedness between their emotional, physical and spiritual selves to describe feeling out of balance. Physical tension, distress, sadness, restlessness and irritability were reported. Mind racing, sleeplessness and worrying caused ongoing effects leaving some nurses depleted of energy. The CHNs relayed stories of how their impaired emotional wellbeing impacted on their personal and professional worlds and on their collegial relationships. Amelia said:

I usually get physical tense … I might jump to conclusions at something, my mind tends to race a bit if I’m upset, so I can find myself drawing conclusions before I’ve heard all the information.

Anna associated being out of balance with stress, and like Amelia, recognised the impact that it had on her professional/personal interface. Anna described feeling:

Stressed, restless, angry. Not content, not happy not all the things that you wish you were. Very short tempered.. I don’t sleep well, I lay awake at night looking at the ceiling and worrying … I am unhappy and very restless.

Like Anna, Shae's impaired emotional wellbeing also had an impact that affected others. Shae recalled:

If I’m unbalanced everybody knows it. I talk about [the issue] a lot. I can’t let it go. I’m teary, I’m emotional, I’m impulsive. I say and make rash decisions that I wouldn’t do if I felt balanced which ends me up in more strife … I put myself in the firing line sometimes unnecessarily. I don’t sleep well, I’m anxious. I’m looking for the next thing to go wrong. I come from a real negative base. I am expecting the worst instead of expecting the best. I act like I am a victim when I am unbalanced … it's a real negative thing.

Organisational issues and system failures were other contributing factors to the CHNs impaired wellbeing. Lee's frustration and irritability with organisational issues had impacted on her job satisfaction and also her workplace environment. Lee argued that it was not:

a user friendly service, not when its under resourced because there is nothing to give [the clients], so I get frustrated with the systems and maybe I get frustrated with my co-workers … but I think they know I’m frustrated with the fact that I can’t give the care that I would like to give.

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Discussion 

The community nurses’ emotional wellbeing was multifaceted and complex. Part of the issue is that nurses’ workplace environments are not conducive to promoting emotional health and healing, and that results in nurses not feeling adequately supported (Glass, 2007, Hutchinson et al., 2006, Jackson, 2004). Inherent within this, is the issue of nurses’ feeling unheard. It was evident that nurses did not always discuss their emotional wellbeing with their colleagues yet brief corridor encounters between the researcher and community nurses affirmed the nurses’ need and desire to speak out. The researcher noted on one occasion when outlining the study to potential participants that ‘the nurses were quiet, and silence filled the room’ yet as the researcher traversed the corridors on departure ‘nurses whispered unexpected and at times complex disclosures related to the challenges they faced’.

It is evident from the findings that community nurses encounter many challenges in professional practice and that feeling unheard impacted considerably on their wellbeing. That coupled with the emotional strains associated with palliative care provision can expose nurses’ emotional vulnerability and accentuate the need for emotional wellbeing. It is evident that a dialectical tension prevails between community nurses’ expectations of their professional practice, and what is valued in their practice environments, thus having implications on community nurse retention.

Nursing registration/certification demands that nurses comply with professional competency standards. Inherent within such professional standards is the incorporation of reflective practice (ANMC, 2006, Taylor, 2004) a key skill and strategy for all nurses’ to manage their own responses to workplace environments. The findings raise awareness of the critical relationship between the notion of ‘balance’ and nurses’ emotional wellbeing. The importance of organisations to work collaboratively with community nurses to achieve wellbeing must not be underestimated. This could be attained by introducing a model of clinical supervision that would incorporate strategies to promote emotional intelligence, foster self-care and focus on balance as a critical factor to enhance emotional wellbeing and improve professional practice. Once developed, clinical supervision should be accessible to all community nurses providing palliative care.

The authors would therefore argue that research funding needs to be directed toward studies on nurses’ emotional health, healing and wellbeing as previous research studies have demonstrated a strong relationship between personal/professional wellbeing and professional satisfaction/integration (Glass, 2007, Glass, 2008).

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Conclusion 

This study explored emotional wellbeing in context to community nurses who provided palliative care in the community setting. A significant relationship between the community nurses’ emotional, physical and spiritual health and quality client care existed. The community nurses’ positions were juxtaposed in that they valued their palliative role bringing about a sense of job satisfaction whilst simultaneously feeling at times stressed, frustrated and not heard.

According to Theodosius (2008, p. 135), when ‘emotions are felt, experienced and expressed; they make things real to us’. The importance of valuing nurses experiences associated with palliative care provision is therefore critical. Embracing an emancipatory methodology in nursing research provides opportunities for healing and enhancing nurses emotional wellbeing and professional practice.

The authors concur with Jackson (2004, p. 199) who stated that “it is sadly ironic that the seeds of healing may be denied in environments that are supposed to be dedicated to the healing of others”. Therefore, to deny the healing of nurses’ is to deny others of healing.

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Acknowledgements 


•The authors would like to acknowledge the participants’ openness and generosity of spirit in sharing their meaningful stories.

•Southern Cross University for awarding an Australian Postgraduate Scholarship to the first author.

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PII: S1322-7696(09)00064-X

doi:10.1016/j.colegn.2009.08.001

Collegian
Volume 16, Issue 4 , Pages 185-192, December 2009

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