Uncovering a health and wellbeing gap among professional nurses: situated experiences of direct care nurses in two Canadian cities

https://doi.org/10.1016/j.socscimed.2019.112568Get rights and content

Highlights

  • Direct care practice enhanced nurses' intellectual and occupational wellbeing.

  • Direct care practice worsened nurses' physical, emotional, and social wellbeing.

  • A health gap was found between white and ethnic minorities in direct care practice.

  • Institutional, social and emotional support systems are key health coping strategies.

  • An equitable work environment promotes nurses' wellbeing and patient quality care.

Abstract

Understanding the drivers of nurses' poor health and the implications for quality of care are important in sustaining a healthy workforce, stimulating professional nursing practice, and ensuring healthy lives while promoting the wellbeing of nurses of all ages. Previous scholarship has identified factors influencing nurses' wellbeing, but have neglected to take a comprehensive approach to assessing the multiple dimensions of nurses' wellbeing and their collective, syndemic effects. Neither have these studies explored the context within which these experiences occur, or how these experiences differ for nurses with multiple marginalized identities in spite of an increasingly diverse workforce. Using the six dimensions of wellness framework, we examined the distinct and interrelated dimensions of nurses' wellbeing that were either enhanced or aggravated by professional practice and how it changed by nurses' race and ethnicity using their situated experiences. The study was conducted using a qualitative research design, which drew on phenomenology and in-depth interviews with Registered and Practical Nurses (n = 70) in two Canadian cities. Of the six dimensions of wellbeing identified, direct care practice enhanced nurses' occupational, intellectual, and spiritual wellbeing, but worsened their physical, emotional and social health. A health gap was found along racial lines, as ethnic minority nurses reported more detrimental effects of direct care nursing on their physical, emotional, occupational, and social wellbeing than their white counterparts. Nurses resorted to institutional structures, social and emotional support from supervisors, coworkers and family members, and engaged in spiritual activities to cope with these adverse health effects. These findings highlight the utility of an adaptable framework in identifying the multiple dimensions and gaps in nurses' wellbeing. Furthermore, our findings echo the urgent need for workplace and safety policies that address issues of diversity and make the work environment safe, equitable and promote nurse productivity and quality care.

Introduction

Understanding the drivers of nurses' poor health and the implications for quality of care are important in sustaining a healthy workforce and promoting professional nursing practice. A range of individual-level factors in the workplace have been identified as influencing nurses' wellbeing (Caruso, 2014; Gates et al., 2011; Roche et al., 2010). Physical violence against registered nurses has been associated with increased conflicts, delayed tasks such as the administration of patient medications, an increase in medication errors, decreased job satisfaction, and turnover intentions (Gates et al., 2011; Roche et al., 2010). Exposure to verbal aggression, emotional abuse, and long hours of work have been found to diminish productivity in the areas of neurocognitive functioning and performance, support and communication demands (Boateng and Adams, 2016; Caruso, 2014). Furthermore, narratives suggest that nurses in specific specializations and of minority ethnic identity may be experiencing more frequent and severe health consequences than their white counterparts (Flynn, 2011). However, no study to the best of our knowledge has examined if this gap indeed exists and what dimensions of nurses' health may be affected in spite of the growing interest of nursing administrators to implement policies and practice that promote equity in nurses' health and quality patient care (Brunetto et al., 2013a,b).

Workplace environment-level factors that affect nurses' wellbeing include the flexibility of role and hours, staffing, fiscal policies, supportive leadership and supervision and are well-documented (Brunetto et al., 2013a,b; McGilton et al., 2014; Roche et al., 2015; Seago and Spetz, 2008). Targeted research has generated recommendations to promote workplace wellness through specific strategies such as the implementation of procedures to prevent musculoskeletal strain and the use of sleep support strategies. There have also been attempts to promote mental health, and foster an open culture that discusses the challenges faced by nurses (Perry et al., 2015).

However, these studies have implicitly assumed equal experiences for nurses of different social identities. The findings in these studies, either through a positivist lens or through narratives, have been viewed objectively, ignoring the situated experiences of multiple marginalized positions that have the capacity to produce unfettered knowledge. Consequently, interventions and workplace policies put in place are not target specific and do little to improve the wellbeing of ethnic minorities in such professional settings (CUPE, 2018; Ministry of Labour, 2019). While a plethora of studies have disparately examined and theorized the individual health consequences of nursing practice and the experiences of ethnic minorities (Neiterman and Bourgeault, 2015; Schilgen et al., 2017; Wheeler et al., 2014), there is currently no study that identifies, compares, and integrates the multiple dimensions of nurses' health experiences and how they change by racial and ethnic status even as the workforce has grown increasingly diverse (Kawi and Xu, 2009; Van Herk et al., 2011).

Therefore, in this study we holistically explore how direct care nursing affects multiple facets of nurses' wellbeing and how this differs by ethnicity through the situated experiences of nurses in two Canadian cities. We focus on answering the questions:

  • 1.

    What aspects of nurses' wellbeing are enhanced or exacerbated by the practice of direct care nursing?

  • 2.

    What differences exist between the situated health experiences of white nurses and ethnic minorities in direct care practice?

  • 3.

    What coping mechanisms do nurses use in managing the detrimental effects of direct care practice?

We employ Hettler's six dimensions of wellness framework, which examines wellness from distinct and interrelated dimensions (Hettler, 1976), to guide the organization of our analysis and interpretation of findings.

The concept of health and wellness has evolved over the past two centuries from its starting place as merely the absence of disease or infirmity. From there it progressed to a state of physical, mental, and (increasingly) social wellbeing; now the current architype of subjective wellness encompasses the former and the attainment of self-actualization and a commitment to socially shared goals (Miller, 2005). While wellness has been defined in as few as three and as many as 17 dimensions (Hattie et al., 2004; Miller, 2005), we find the six dimensions of wellness developed by Hettler (1976) to be the most concise, inclusive of the context and environment within which nurses work; therefore it is an appropriate lens through which nurses' wellbeing can be explored.

Hettler (1976) posits that a person's physical, social, emotional, occupational, intellectual, and spiritual dimensions of health synergize to contribute to a more successful existence (Fig. 1). The six dimensions of wellness has been used in various health contexts including ageing (Strout and Howard, 2012; Waites et al., 2014), rehabilitation (Nathenson et al., 2014), nursing care among aging adults (Strout and Howard, 2012), physical activity in the community (Sanders et al., 2012), and sexual health (Daugherty et al., 2017). However, it has yet to be explored in the context of healthcare professionals (Bart et al., 2018).

We apply the six dimensions of wellness framework as a lens in characterizing the multiple dimensions of nurses' wellbeing and illuminating the coping strategies that nurses employ in the conduct of their work. We find this framework particularly relevant to nurses' wellbeing because these six dimensions reflect a range of roles and experiences that nurses embody on a daily basis, as well as, the corresponding pressures these roles exert on nurses' own wellbeing. While the literature has examined most of these dimensions disparately (Brunetto et al., 2013a,b; Karasek, 1979; Leiter and Laschinger, 2006; Spence Laschinger, 2008), comprehensive integration of the dimensions for a truly holistic view of nurse wellbeing is lacking. This study is the first to examine the multiple dimensions of nurse wellbeing simultaneously and identify the differences in experiences by race and ethnicity. Each dimension in this study is operationalized following the original interpretation and modified to fit the study context.

Physical wellbeing is defined as one's commitment to self-care through physical activity, nutritious dietary patterns, and regular utilization of healthcare (Hettler, 1980; Strout and Howard, 2012). This has been expanded for purposes of this study to include practices that either cause or prevent injury and preserve wellbeing at the workplace.

Emotional wellness is the ability to manage, accept, and take responsibility for feelings and outcomes, and it manifests in managing one's life in a fulfilling way and includes the ability to recognize limitations and seek support when necessary to manage challenges (Hettler, 1980; Strout and Howard, 2012). We extend emotional wellness in this study to examine the interactions between patients and colleagues as well as emotions associated with co-worker interactions.

Occupational wellness refers to one's ability to contribute skills and talents to work that one finds meaningful, rewarding and beneficial to the community (Hettler, 1980; Strout and Howard, 2012). We expand the occupational wellness in the context of nursing to include the organizational structure that nurses operate within and the pressure that organizational structure and systems exert back on nurses' job satisfaction.

Intellectual wellness is the embodiment of lifelong learning, where one is committed to acquiring and applying knowledge and skills (Hettler, 1980; Strout and Howard, 2012). In the context of nursing, this includes opportunities to develop desired skills for new job duties and promotion.

Social wellness is the ability to form and maintain positive interpersonal and community relationships, characterized by effective communication and mutual respect (Hettler, 1980; Strout and Howard, 2012). We include interpersonal interactions and relationships as well as organizational culture in these social dynamics.

Spiritual wellness is operationalized as pursuing, acquiring, and nurturing a value system and meaning in one's life (Hettler, 1980; Strout and Howard, 2012). Spirituality in the context of nursing is often focused on providing holistic care to patients (Lewinson et al., 2015) and less so as a critical dimension of nurses' own spiritual wellbeing (Narayanasamy, 2014). However, nurses can consider both their work and themselves to be spiritual, independent of organized religion (Grant et al., 2004).

These six dimensions of wellness provide a comprehensive framework and parallel how the workplace situations that nurses encounter may similarly impact the multiple dimensions of their wellbeing. It also reflects the interrelatedness of nurses' wellbeing, as a disruption in one dimension may affect other dimensions of wellness. For example, conflict with colleagues, which fosters poor social wellness, can negatively influence emotional and occupational wellness (Boateng and Adams, 2016) and - more important to some healthcare models – may ultimately negatively impact the quality of care provided to patients.

By using this framework, we are able to identify key dimensions of nurses' wellbeing that require attention by nursing management, for which other existing theories are limited (Cook et al., 2013; Leiter and Laschinger, 2006; Spence Laschinger, 2008). Furthermore, we distinguish between aspects of wellbeing that either improve or worsen for direct care nursing practitioners and how such experiences differ by social location (e.g., ethnicity).

Section snippets

Methods

The research presented here is part of a larger qualitative study that explored the career pathways, professional integration, and lived experiences of regulated nurses in Canada.

Results

Nurses' experiences of their wellbeing were thematically grouped into six dimensions: physical, emotional, occupational, intellectual, social and spiritual wellness. We also explored wellbeing variation by ethnicity and coping strategies. To situate nurses' words in context, we included the nurses' professional designation, years of professional experience, area of specialization, and ethnicity.

Discussion

This study characterized the impact of nursing practice on the wellbeing of direct-care nurses in two Canadian cities, examined differences in experiences by race and the coping mechanisms used to manage the consequences. Using the six dimensions of wellness framework, we found that direct care practice to a large extent created problems for or exacerbated nurses' physical, emotional, and social wellness; which may create a situation for detrimental risk for quality of patient care. A further

Conclusion

In summary, this study categorizes the six dimensions of nurses' wellbeing that are positively and negatively impacted due to their situated experiences in nursing practice in two Canadian cities. The study showed that direct care practice enhanced the occupational, intellectual and spiritual wellbeing of nurses, but had negative physical, emotional, and social health impacts. We also identified a health and wellbeing gap by racial status, with nursing practice bringing about more intense

Acknowledgments

We wish to acknowledge Prof. Tracey Adams of Western University for her review and previous comments of an earlier draft of this paper, as well as the anonymous reviewers whose comments enriched the paper. We are also grateful to all the nurses in the multiple healthcare facilities in London and Toronto whose participation in the research has made this contribution to knowledge on health disparities.

References (50)

  • J. Baxter et al.

    Evaluating qualitative research in social geography: establishing ‘Rigour’ in interview analysis

    Trans. Inst. Br. Geogr.

    (1997)
  • G.O. Boateng

    Exploring the Career Pathways, Professional Integration and Lived Experiences of Regulated Nurses in Ontario, Canada (Doctoral dissertation)

    (2015)
  • Y. Brunetto et al.

    The importance of supervisor–nurse relationships, teamwork, wellbeing, affective commitment and retention of North American nurses

    J. Nurs. Manag.

    (2013)
  • Y. Brunetto et al.

    The impact of workplace relationships on engagement, well-being, commitment and turnover for nurses in Australia and the USA

    J. Adv. Nurs.

    (2013)
  • Canadian Institute for Health Information

    Regulated Nurses, 2015

    (2016)
  • C.C. Caruso

    Negative impacts of shiftwork and long work hours

    Rehabil. Nurs.: Off. J. Assoc. Rehabilit. Nurses

    (2014)
  • K.S. Cook et al.

    Social exchange theory

  • CUPE

    Preventing Violence and Harassment in the Workplace

    (2018)
  • T.K. Daugherty et al.

    Beyond the absence of disease or infirmity: the case for sexual wellness

    Coll. Stud. J.

    (2017)
  • J. Etowa

    Spirituality and self-reclamation: a response to nursing on the margins of the profession

    GSTF J. Nurs. Health Care

    (2015)
  • K.C. Flynn

    Moving beyond Borders: A History of Black Canadian and Caribbean Women in the Diaspora

    (2011)
  • D.M. Gates et al.

    Violence against nurses and its impact on stress and productivity

    Nurs. Econ. Pitman

    (2011)
  • D. Grant et al.

    Spirituality in the workplace: new empirical directions in the study of the sacred

    Sociol. Relig.

    (2004)
  • D.S. Hall

    The relationship between supervisor support and registered

    Nurs. Admin. Q.

    (2007)
  • J.A. Hattie et al.

    A factor structure of wellness: theory, assessment, analysis, and practice

    J. Couns. Dev.

    (2004)
  • Cited by (0)

    View full text