Nurses’ work, work psychology, and the evolution & devolution of care provision in nursing homes: A scoping review

Abstract

Background

Societal aging is exerting profound impacts on providers of long-term care. Nurses provide much of the direct care in the long-term care sector, and they increasingly provide unit- and facility-level leadership and fill top administrative and clinical roles.The work health and quality of work life of long-term care nurses are emergent concerns and the foci of research across multiple disciplines.

Objectives

To enhance our understanding of factors influencing long-term care nurses’ work health and quality of work life, we summarize the findings of disparate studies across diverse disciplines, time, and jurisdictions.

Eligibility criteria

No restrictions were placed on study date, design, or country. Searches were restricted to English language only or translated studies. Included studies reported associations and relationships between/amongst nurses’ work (role and work design), work environments, work attitudes, and work outcomes. Published peer-reviewed studies and reviews were included, as were reports. Editorials and opinion pieces were excluded. The search included publications up to March 2022.

Sources of evidence

Medline, CINAHL, PsychINFO, EMBASE, Scopus, PSNet

Charting methods

Data abstraction from full-text articles.

Results

The evolution of long-term care nurses’ work to include both medical and administrative responsibilities has generally not been managed well, resulting in persistent role ambiguity, job dissatisfaction, and burnout. Nurses are concerned about their capacity to provide resident care and the adequacy of their preparation. Their work environments are under-resourced, and they are at high risk for workplace injury or violence. Supervisory and organizational support can be protective of negative aspects of nurses’ work environments. Supervisory support can improve the immediate work environment, assist nurses in fulfilling their roles, and afford greater role clarity, and supervisors can influence their nursing staff's perceptions of the work safety and the value that their organization places on them. Organizational support can reduce work stress, enhance feelings of self-worth, and mitigate some of the self-stigmatization that influences long-term care nurses’ attitudes toward themselves and their work, which influences work outcomes, including job performance and quality of resident care.

Conclusions

Work stress, burnout, increased turnover, decreased morale and work motivation, increased health and safety concerns, and decreases in job satisfaction accompanied by self-stigmatization are all indicators of a system that has failed nurses, other long-term care staff, and nursing home residents. We consider the implications of our findings for enhancing the work health and quality of life of nurses working in long-term care and identify gaps in knowledge about their psychological health that merit future study.

Tweetable Abstract

The long-term care sector is failing nurses globally. This review is a step toward understanding how we can improve the work psychology, including work-related psychological health, of nurses in long-term care.

What is already known.

Societal aging is exerting profound impacts on members of the health human services sector who provide long-term care.

Nurses provide a substantial proportion of the direct care in the long-term care sector, and they increasingly provide unit- and facility-level leadership in nursing homes.

Nurses’ poor work-related psychological health (work health) and quality of work life in the long-term care sector are emergent concerns and the foci of research across multiple disciplines.

What this paper adds

This scoping review synthesized and summarized research focusing on the work, work psychology, and work-related psychological health of nurses in the long-term care sector.

We identified what is known about associations amongst the work environment, work psychology, and nurses’ work outcomes, including care quality.

We discussed the implications of our findings for enhancing the work-related psychological health and quality of life of nurses and identified gaps in knowledge that merit future study.

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1. Introduction

Societal aging is exerting profound impacts on the health human services sector. Globally, as early as 2030, one in six people will be over 60 (World Health Organization (WHO), 2021) and demand for workers in the long-term care sector is expected to increase 60% by 2040 (Organisation for Economic Co-operation and Development (OECD), 2020). While these are projections, there are early indications of their accuracy. Increasing demand for institutional long-term care (i.e., care provided in nursing homes, long-term care homes, aged care homes, or care homes) appears to be overburdening the sector, as evidenced by shortages of health, human, and services-related resources (OECD, 2020). Researchers and practitioners alike have voiced concerns about the impacts of these pressures on the quality of care and quality of life for nursing home residents and on the quality of work life for care staff (Alzheimer's Disease International 2013; WHO, 2015; Alzheimer's Disease International 2020; OECD, 2020). A considerable volume of research has focused on identifying factors that influence older persons’ quality of care and quality of life in aging societies, while comparatively less research has examined factors that impact the work-related psychological health (work health) and quality of work life of workers who provide their care (OECD, 2020).

2. Background

In general, care workers in the long-term care sector are acknowledged as experiencing high levels of burnout, higher rates of workplace injury than workers in other health sectors, and an increasingly high incidence of workplace violence (OECD, 2020). They are also considered to be undercompensated, they work in environments that are chronically understaffed, their work is the subject of stigmatization, and they experience a general lack of job mobility (OECD, 2020). These issues – some enduring and some emergent – highlight the importance of focusing on understanding relationships between the work and work psychology of care workers, in the interest of improving their work lives and in acknowledgement of potential links between their well-being and their capacity to provide care.

Nurses’ roles in the long-term care sector have undergone changes over the past three decades in response to increasing demands for long-term care, greater acuity amongst residents, and persistent and pervasive sector under-funding. There is a growing reliance on other types of workers, like health care aides, for direct care provision in nursing homes. While nurses are still responsible for direct care, some members of the profession have been increasingly engaged in coordination and administration activities at the unit and facility levels that relate to the provision of resources critical to care but that are outside of direct care provision (Castle and Lin, 2010; Siegel and Young, 2021; Orellana et al., 2017; Prentice and Black, 2007).

This scoping review summarized research focusing on the work and work psychology of nurses in the long-term care sector, including their work-related psychological health. We identified what was known about associations amongst the work environment, worker health, and work outcomes and highlighted gaps in knowledge that merit future study.

3. Methods

We undertook a scoping review to address the question ‘What is known about the work, work health, and work psychology of nurses in the long-term care sector and their associations with the long-term care work environment?’ We knew that studies relevant to our interests were published in diverse literatures that have historically been somewhat disconnected (e.g., management sciences and nursing sciences); therefore, we chose to complete a scoping review as a means of gaining a broad understanding of the topic in the interest of synthesizing findings across discrete literatures.

3.1. Search strategy and selection criteria

A primary search strategy for this scoping review was first developed for Medline in March 2021 in consultation with a research librarian. The search strategy was then translated and adapted to the features of other major health-, management-, and psychology- related databases: CINAHL, PsychINFO, EMBASE, Scopus, and PSNet. This search was completed by July 2021, and an update applying the same search strategies to the same databases was completed in March 2022. No restrictions were placed on publication date (i.e., articles were considered from the time that each database was introduced), study design, or country. We did restrict our search to English language and English-translated articles available from journals publishing in languages other than English.

We included studies that reported outcomes exploring associations and relationships amongst nurses’ work (role and work design), work environments, work attitudes, and work outcomes and reports developed by international entities (e.g., produced by the WHO) that synthesized and summarized the findings of similar articles. While published peer-reviewed studies and reviews were included, editorials and opinion pieces were excluded in an effort to avoid any biases that might be present in the latter.

All of the co-authors are themselves conversant with long-term care and aging research; in addition, we consulted closely with one co-author who is a health sciences expert with particular knowledge and experience in the nursing field (AB) to ensure that our list of related terms was exhaustive for “nurses”, as well as for the setting of interest; i.e., “long-term care homes”. We took into account regional and historic variations of these terms. No geographic limitations were set. Included studies featured settings (i) providing long-term care to residents in institutional settings and (ii) employing registered nurses, licensed practical nurses, or equivalent licensed nursing staff. Studies were excluded that (i) did not feature settings providing long-term care to residents in institutional settings or (ii) did not feature registered nurses, licensed practical nurses, or equivalent licensed nursing staff. Work psychology concepts of interest, including “work attitudes”, “work environments”, “work design”, and “work outcomes'' were searched, in addition to relevant synonyms and related concepts, including “attitudes of healthcare personnel”.

3.2. Appraisal and data collection

The combined search results from both Medline and CINAHL databases yielded 779 results. Two members of our team (CS and WB) independently applied inclusion criteria to the first 20 citations, met to discuss their application and ensure the criteria were uniformly applied, and then applied the criteria to 20 more citations, meeting again to discuss the selection process and to ensure the eligibility criteria were applied in a methodical way. Additional searches were then conducted using PsychINFO, EMBASE, PSNet, and Scopus that yielded a total of 1070 results when combined with searches from CINAHL and Medline. Once duplicates were removed, 686 citations remained to be screened. Inclusion criteria (see sub-Section 3.1) were applied to the titles and abstracts from the combined searches, leaving 312 citations. Articles focused exclusively on types of care staff other than nurses were removed (n = 79). Studies whose participants were exclusively nurses were retained (n = 59), as were those that considered nursing staff along with other types of care staff (n = 150). Of those articles considering nurses and other types of staff, 103 were retained following a scan of the methods and findings sections to confirm that nurse-specific findings were distinguishable from findings relating to other types of staff. Three reports prepared by international entities that were relevant to our review's focus were included for full-text review.

Full texts of the 186 articles and three reports were reviewed. Seventy-four articles were removed as they did not meet the inclusion criteria. Over September to November 2021, data were extracted for the remaining 112 articles and three reports. In March 2022, the database searches were rerun from July 2021 to ensure currency, and 62 additional articles were identified for full-text review. Of these, 14 articles that met our inclusion criteria were included, their full-texts reviewed, and data added to the existing data extraction form. Finally, we skimmed the reference sections of all articles and reports included in our full-text review (112+3 + 14), which led to the inclusion of 15 additional articles in our full-text review, for a total of 144 articles. The PRISMA Flow Diagram associated with our review is provided in Fig. 1.

Fig. 1.

PRISMA flow diagram.

Source: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/

3.3. Data extraction

Data from the 144 full-text articles were extracted into a table prepared as an Excel spreadsheet. Prior to completing the data extraction, two authors (CS and WB) independently extracted data from a subset of the same 20 articles to establish consensus, minimization of error, and clarity between reviewers regarding the choice of data selected for extraction. Discussion led to the identification of additional data extraction fields and to the development of categories within fields to facilitate coding of data from the articles. Information related to article characteristics, aim, methodology, context including jurisdiction, level of analysis (micro-, meso‑ and macro-), and main findings was collected and entered into the data extraction spreadsheet.

3.4. Data analysis

Thematic analysis techniques (Braun and Clarke, 2012) were used to organize the key findings of included articles. All data were synthesized, and evidence was mapped according to the PRISMA-ScR guidelines for scoping reviews (Tricco et al., 2018).

This literature review did not require ethics approval.

4. Results

Fig. 2 summarizes the settings by jurisdiction in which the included studies were conducted. Most of the studies were conducted in the United States of America (USA) (n = 38), Canada (n = 20), Australia (n = 15), and Sweden (n = 13), with many other countries represented with smaller numbers. Three multi-national reports, two produced by the WHO and one by the Organisation for Economic Co-operation and Development (OECD), synthesized findings across jurisdictions. The majority of studies employed a quantitative (n = 67) or qualitative (n = 50) approach. Other approaches included reviews (n = 16), mixed/multi methods (n = 8), and reports (n = 3). A large majority of studies (n = 107) were published from 2010 onwards, predated by a landmark report prepared on the part of Fernández and colleagues with the WHO (Fernández et al., 2009) and a number of other reports in the late 2000′s prepared by prominent entities, including the Organisation for Economic Co-operation and Development (OECD); 32 studies were published between 2000 and 2009. Only five studies were published prior to 2000.

Fig. 2.

Number of articles by study setting.

Note: UK = United Kingdom, USA = United States of America

4.1. Nurses work & work environments in long-term care

4.1.1. The changing nature of nursing work in long-term care

While reliance on nurses for direct care has been the historical norm in the long-term care sector, nurses’ roles have evolved considerably over the past 20 years. While these changes have occurred at difference paces in different jurisdictions that operate according to different long-term care policies, they have ultimately manifested very similarly. The direct care in this sector associated with activities of daily living is now performed predominantly by health care aides (Berta et al., 2022), with nursing staff increasingly relied upon for the supervision and surveillance of health care aides and allied health professionals (Dellefield et al., 2015; Siegel et al., 2010). And, as noted by a number of researchers, the scope of nurses’ roles has not so much shifted as expanded, where nurses now face dual work demands comprising both medical and administrative responsibilities (Prentice and Black 2007). Several authors pointed to role expansion as a source of dissatisfaction amongst nurses in long-term care, where nurses felt that they did not have enough time to supervise health care aides in addition to completing their regular nursing duties (Lane and Phillip 2015; Prentice et al., 2017; Perry et al., 2003: Hunter and Levett-Jones 2010; Roussillon et al., 2021).

As the nature of nurses’ work in long-term care has changed, role ambiguity or a lack of role clarity has also been identified as a major health and human resources concern. An integrative review found registered nurses’ roles difficult to define across jurisdictions, including Canada, the USA, and the United Kingdom (UK), resulting in an “all-encompassing” role that has increased the ambiguity of nurses’ positions vis-à-vis those of other long-term care workers (Montayre and Montayre, 2017). Role ambiguity was observed amongst nursing staff (e.g., registered nurses and licensed practical nurses) and extended to other care providers, including physicians; it hindered communication and job performance (Wagner et al., 2013; Irvin, 2000) and influenced job satisfaction and retention (Knecht et al., 2015). Studies set in diverse geographies including Norway (Kada et al., 2009; Munkejord and Tingvold, 2019), Switzerland (Gransjon Craftman et al. 2016; Zuniga et al., 2015), and the USA (Brown et al., 2016; Cready et al., 2008; White-Chu et al., 2009) showed that initiatives to enhance interprofessional collaboration between and amongst nursing staff and health care aides can improve role clarity, enhance work attitudes, and positively influence job performance, including quality of resident care.

Demographic and regulatory trends appeared to have precipitated these shifts in nurses’ roles. For example, studies set in Canada (Hall and O'Brien-Pallas, 2000; McGilton et al., 2014;), the USA (Carr and Kazanowski, 1994; Cherry et al., 2007; Jervis 2002; Storm et al., 2017), and Australia (Moyle et al., 2003; Ostaszkiewicz et al., 2015) revealed that the increasingly complicated care plans needed for residents who qualified for complex care, combined with an increased emphasis over the past two decades on performance measurement in the long-term care sector, have necessitated more paperwork that falls to nursing staff to complete.

Shifts toward activities relating to coordination and administration, with less time spent in care provision, were indicative of the larger general issue of resource shortages noted in this sector, with arguably the most important shortage relating to time. Time pressure was a key predictor of intent to leave long-term care amongst Norwegian nurses (Bratt and Gautun 2018), a key indicator of stress for Swedish registered nurses (Juthberg et al., 2010), and a contributing factor to licensed practical nurses’ job dissatisfaction in the USA (Knetch et al. 2015). In the USA, time limitations have forced nurses to “bundle” care by attempting to perform two care tasks at once – for example, feeding a resident while administering eye drops – which may put the well-being of residents at risk (Bowers et al., 2001). In Sweden, registered nurses reported that time limitations prevented them from following up, analyzing, or reporting errors during medication management (Bengtsson et al., 2021). This underscored the point made by other researchers that, despite the increasing reliance on health care aides to provide direct care, there were still issues with the strategic or efficient use of skilled nursing resources in the long-term care sector (WHO 2021; Baldwin et al., 2003). Some researchers suggested that this inefficiency has arisen with the relatively recent introduction of health care aides to long-term care, which was not accompanied by adequate consideration for role differentiation (Nhongo et al., 2018). Authors of one Swiss study commented that the development of nurses’ supervisory role and acquisition of related skills should be “cultivated in line with the accelerated transformations [to resident-centered care models] that nursing homes are going through”, suggesting that this was generally not being done (Bedin et al., 2012:117).

4.1.2. The importance of organizational & supervisory support to nurses’ work

Supervisory support is generally perceived by workers as a reflection of the value that management places on them, and it influences worker attitudes and outcomes. Organizational support describes resources given to workers by their employing organizations to enhance their abilities to carry out their roles. Both forms of support are known to be important to workers’ outcomes, and there is some evidence that supervisory support is a more important contributor to worker productivity and attitudes than organizational support – an important finding for resource-poor sectors like long-term care. Numerous studies included in our review, set in diverse long-term care systems including Canada (Chu et al., 2014; McGilton et al., 2014), Taiwan (Kuo et al., 2014), the Philippines (de Guzman et al.2009; de Guzman et al. 2009), Norway (Heponiemi et al., 2012), Switzerland (Bedin et al., 2012), and South Korea (Lee et al., 2018) demonstrated strong positive associations between managerial/supervisory support and nurses’ attitudes and work outcomes. One Swedish study observed that long-term care managers providing social support and good leadership significantly reduced the work strain experienced by nursing staff and health care aides (Backman et al., 2018). Supervisory support was not reliably high in long-term care; researchers from Canada, for example, reported that nursing staff often feel under- or unsupported by leadership (McGilton et al., 2014).

Studies in Australia (Hunt et al., 2012), the USA (Anderson et al., 2004), and Canada (Chu et al., 2014) demonstrated significant associations between leadership practices and registered nurse/licensed practical nurse turnover, and a study set in France showed that impaired relationships with managers were a primary factor associated with nurses’ intentions to leave (Pelissier et al., 2018). A review article with studies from Canada, the USA, Australia, and several other countries in diverse geographic regions found that strong clinical leadership in long-term care was fundamental for nursing retention and satisfaction and may enhance the quality of resident care (Enghiad et al., 2022). In Norway, researchers observed how nursing staff perceptions of the work environment were impacted by the quality of leadership and how good leadership was associated with worker motivation (Andre et al., 2022). Supervisor support was demonstrated in different ways; researchers in Switzerland and Australia showed that managers were supportive by offering clarity around the roles of nursing staff and helping them develop their leadership potential (Bedin et al., 2012), in addition to relaying resident and resident care information that assisted nursing staff in their work (Hunter and Levett 2010). Similarly, studies of leadership style in long-term care identified its influences on work environments and associations with outcomes of nursing care in Finland (Raikkonen et al., 2007), Sweden (Haggstrom et al., 2004; Silen et al., 2019), and Switzerland (Schwendimann et al., 2016; Tong et al., 2017), where the general observation was that "core leadership values of trust, open communication, and teamwork…promoted strong lateral decision making" (Forbes-Thompson et al., 2007). Researchers from Australia (Jeong and Keatinge 2004) and the USA (Tyler and Lepore 2017; White-Chu et al., 2009) concluded that managerial support increases nursing staff participation in quality improvement and change initiatives.

Organizational support relates to the provision of resources, including human resources, at a level that is adequate for doing the work of long-term care and supports worker development. Findings from a number of studies conducted over the last two decades point to persistent organizational support deficits, generally, in the long-term care sector. Specifically, this relates to the scarcity of human resources noted in many and varied jurisdictions, including Australia (Eley et al., 2007; Moyle et al., 2003; Wells et al., 2019), Brazil (Mariano et al., 2015), Canada (Morgan et al., 2002; Wagner et al., 2013), France (Pelissier et al., 2015), Malaysia (Yasin et al., 2019), and the USA (White et al., 2019; 2020; Zhang et al., 2019). Staffing shortages were both the cause and consequence of staff turnover and were associated with increased costs of hiring and training, reduced workforce productivity, and reduced quality of care (Zhang et al., 2019). An American study found a significant relationship between resource allocation and turnover for registered nurses and the number of worker hours per resident day and turnover for licensed vocational nurses (Anderson et al., 2004). One French study found that only 20% of care home staff believed that there was a sufficient workforce (Pelissier et al., 2015).

Resource shortages in long-term care have direct impacts on nurses’ work, as they increasingly manage human and material resources as part of their job (Bedin et al., 2012; Hunter and Levett-Jones, 2010). In one American study, nurses reported feeling a sense of failure when limited resources impacted their ability to work and offer adequate end-of-life care (Irvin, 2000). In a Canadian study, long-term care nurses' perceptions of an underfunded system were one of several conditions prompting them to consider leaving their jobs (McGilton et al., 2014). A separate Canadian study looking at registered nurse turnover in long-term care found a relationship between resource availability and turnover (Chu et al., 2014).

Organizational support is essential to equipping nurses with the skills and competencies to do their work and to respond to changes in the sector. Registered nurses in one Canadian study reported receiving “minimal preparation in gerontology and supervisory experience” prior to commencing long-term care work, impacting retention rates and resident outcomes (Prentice et al., 2017). Studies set in Sweden (Engstrom et al., 2011) and the USA (Ersek et al., 1999) observed significantly worse work outcomes, manifesting as reduced quality of care for residents in homes where nurses lacked sufficient training or knowledge. Studies set in Australia (Lane and Phillip 2015), Canada (Brazil et al., 2012), South Korea (Lee et al., 2018), and Taiwan (Li et al., 2008), as well as a systematic review with studies from Canada, the USA, and Europe, noted deficits amongst nurses in palliative care training, infection prevention and control knowledge, and medical error detection and reporting. Lacking the necessary knowledge and skills to look after residents was the greatest stressor for long-term care nurses in a study from Taiwan (Li et al. 2008).

Beyond adequate resourcing, organizational support often manifests as professional development of the workforce. Organizations’ support of their workers’ professional development stands to influence workers’ attitudes toward their work. Organizational support was important for career transitions and for supporting diversity amongst licensed practical nurses practicing in the USA (Jones et al., 2021). Nurses from Canada (Prentice and Black 2007; Wagner et al., 2013), the Netherlands (van Rumund et al., 2014), Sweden (Ericson-Lidman et al., 2014), and the UK (Thompson et al., 2018) have expressed a need for further education and training. Researchers from Norway found that registered nurses with specialized training had high “hope attitudes” – a measure of workers’ optimism – when compared with licensed practical nurses and other care staff, suggesting that education levels acted as a predictor of work attitude (Kada et al., 2009). Educational programs, hosted by employing organizations, have long been suggested as a measure for improving the self-confidence of nursing staff in their ability to conduct their work, their self-esteem, and their leadership skills (Carr and Kazanowski 1994; Harvath et al., 2008). In the USA, researchers found that participation in a continuing education program improved registered nurse retention (Cramer et al., 2014). One Australian study found that resilience could be learned and developed through educational programs and suggested that this may positively impact long-term nursing staff retention in long-term care (Cope et al., 2016). A recent review of studies set in Canada, the USA, the UK, Japan, and Europe observed that continuing educational interventions involving resident-centered care afforded positive outcomes for nurses and residents,including lower levels of emotional exhaustion and a reduction in psychotropic drug use (Pakkonen et al., 2021).

4.1.3. Nurses influence organizational culture

As with other industry work settings, the articles that we reviewed demonstrated the effects of organizational culture on worker performance and work attitudes in long-term care settings. The culture of an organization refers to shared assumptions or beliefs amongst its workers about their work and workplace, which manifest in everyday organizational practices. A review article on the impact of work culture on quality of care noted that improvements to quality of care in long-term care were achieved through creating a more positive, inclusive culture with initiatives that increased staff empowerment, encouraged adoption of more supportive management styles, and enhanced participation in decision-making amongst all care staff (Andre et al., 2014). Using the competing values framework, which identifies four culture sub-types, Dutch researchers found that clan culture, characterized by consensus and commonality of goals, led to increased quality of care for residents (Van Beek and Gerritsen, 2010). Authors of one American study emphasized that the creation of a safety-oriented culture was associated with better identification of issues relating to missed care compared to a culture that punished nurses for individual mistakes (White et al., 2019). A hierarchy-oriented culture, as opposed to a more flexible organizational culture, was positively associated with registered nurse retention in the USA (Banaszak-Holl et al., 2015) and with happiness experienced by registered nurses in South Korea, along with increased job stability, reduced job stress, less use of sick days, and a decreased likelihood of changing jobs (Hwang, 2019). Strong bureaucratic rules were thought to support registered nurses’ administrative duties and provide a stable work environment, which in turns positively impacted worker outcomes (Banaszak-Holl et al., 2015).

4.1.4. Workplace health and safety

The prevalence of workplace health and safety concerns in long-term care homes has been highlighted for decades (Castle et al., 2009). Worker safety concerns appear to correlate with the increasing frailty of older people entering long-term care and an increasing proportion of people living with dementia requiring long-term care (Morgan et al., 2002). Authors of a recent report focusing on workplace health and safety in long-term care observed that “more than 60% of long-term care workers report being exposed to physical risk factors at work, across OECD countries” (OECD, 2020, p. 22).

Studies exploring workplace health and safety often refer to the concept of safety culture as an explanatory variable or pre-condition. Safety culture in long-term care is a pressing issue with strong associations between safety culture and quality of resident care found in one study from Switzerland (Zuniga et al., 2015). A review article on error disclosure in long-term care found that nurses felt that error in care was primarily the fault of the healthcare system or work environment rather than the fault of the individual nurse (Vaismoradi et al., 2020). In a study set in the USA, researchers concluded that clinical staff (including nurses and health care aides) taking care of residents perceived safety culture as worse than their nursing home administrators did, suggesting the need to address variations in safety culture experienced amongst different types of long-term care workers (Banaszak-Holl et al. 2017). Researchers in Singapore found that the introduction of a novel incident reporting system improved nurses’ knowledge and confidence in handling resident incidents and increased awareness and information regarding resident safety issues in long-term care (Goh et al., 2021)

4.2. Nurses’ work attitudes

4.2.1. Stigmatization and self-stigmatization

Stigma has long been an issue within long-term care. Prior to the pandemic, a 2015 WHO report noted: “Media representations of long-term care issues are often ageist, narrow and ill-informed” (WHO, 2015). And while acute care workers were depicted as heroes by the media during COVID-19, long-term care workers were blamed for the high death rates experienced in their sector (White et al., 2021).

In one American study, 28% of participating long-term care nurses reported that ageism was a problem that influenced how their work was viewed by others (Carr and Kazanowski, 1994). Negative representations of long-term care work as unprofessional, unskilled, and “lesser” than acute care work have been noted in studies from Sweden (Haggstrom et al., 2004) and Australia (Moyle et al., 2003; Ostaszkiewicz et al., 2016). As well, a general lack of recognition of the importance of long-term care on the part of the government was noted in a study set in Slovenia (Leskovic et al., 2020), and an overall feeling of isolation and “otherness” from healthcare professionals in other sectors was reported by UK nurses working in long-term care (Thompson et al., 2018). Long-term care nurses in South Korea reported the devaluation of their professional roles by negative stereotypes that were perpetuated through media, not only impacting workers personally but influencing resident transfers between long-term care and acute care (Tsai et al., 2016). Two separate studies examining the experiences of foreign nurses working in the UK, from Nigeria (Aboderin 2007) and Nepal (Adhikari and Melia 2015), highlighted how they were stigmatized in their workplaces as immigrants and faced deskilling from the time they relocated to work in the UK. A study from Canada found that some nurses doubted their decision to work in long-term care (Prentice and Black 2007), possibly the consequence of self-stigmatization. Low wages were a prominent concern amongst registered nurses and contributed to further reinforce stigmatization. One American study observed that 48% of registered nurses were dissatisfied with their pay (White et al., 2019). Low wages for registered nurses in long-term care compared to wages in other sectors were attributed to there being more part-time workers, fewer years of experience, regional wage differences, and a lack of union representation in a study from Canada (Wagner et al., 2021).

4.2.2. Work engagement, motivation and commitment

Both work motivation and engagement impact worker outcomes and are determined by a variety of factors. Engaged workers generally express more positive work outcomes, including better work performance. Work engagement is also related to work attitudes. For example, a Canadian study showed that work engagement, measured as vigor and determination, was associated with nurses’ job satisfaction in long-term care (Aloisio et al., 2019). Work motivation, work engagement, and job satisfaction are related: A study of Japanese long-term care nurses found that intrinsic motivation and job satisfaction exerted a significant positive impact on work engagement. (Zeng et al., 2022).

The absence of advancement opportunities for long-term care nursing staff was shown to be significantly related to work motivation and engagement (White et al., 2019) and to nurses leaving their jobs in the sector (Hodgin et al., 2010; Hunt et al., 2012). In a series of studies set in the USA, White and colleagues concluded that career development opportunities, such as career ladders, may improve nurse engagement in long-term care (White et al., 2019; White et al., 2020; White et al., 2021).

Organizational commitment amongst nursing staff in long-term care has been shown to influence a broad array of worker outcomes. Researchers in the Netherlands suggested that organizational commitment may influence absenteeism, given the significant association found between worker health complaints and organizational commitment (Schalk 2011). In Switzerland, researchers found that high organizational commitment may lower intention to leave amongst nursing staff and health care aides (Gaudenz et al., 2019). Many factors contributed to organizational commitment amongst nursing staff. In a study from Spain, researchers found that registered nurses depended on access to information to develop organizational commitment, while for registered practical nurses (i.e., licensed practical nurses) access to support via feedback and guidance from superiors, peers, and subordinates was the more critical factor (DeCicco et al., 2006). A study set in the USA found that higher levels of organizational commitment amongst nursing staff were positively associated with perceptions of the quality of the work environment (Woznyj et al., 2019). A study from Switzerland found that leadership, job satisfaction, quality of care, and collaboration with nursing home directors contributed to affective (emotional) organizational commitment amongst nursing staff and health care aides in long-term care (Graf et al., 2016). One American study found a positive association between age, tenure, and levels of organizational commitment amongst registered nurses, licensed practical nurses, and health care aides working in long-term care (Steffen et al., 1996). In their supervisory roles, registered nurses were shown to contribute to the development of organizational commitment amongst health care aides (Perreira et al., 2019). Some research suggests that work engagement can be enhanced through human resource management strategies with career ladders as one way in which to improve commitment to the organization (Cohen-Mansfield 1997).

4.2.4. The relationships between nurses’ psychological empowerment & other work attitudes

Empowerment “is the opportunity to take action that will generate positive results at both the individual and organizational levels” (Kuokkanen and Katajisto 2003). Autonomy of judgment allows long-term care nurses some flexibility when administrating care to residents with multiple health-related issues. Registered nurses generally enjoyed a high level of autonomy in their work (Bedin et al., 2012), along with psychological empowerment (Li et al., 2013). One study of long-term care nurses in South Korea found that when nurses were satisfied with the level of autonomy that they had at work, their happiness increased, which positively impacted job stability and reduced sick days and job stress/turnover (Hwang 2019). Similarly, a study set in Australia showed that well-being improved when long-term care nurses had control over their work (Elliot et al., 2017). Another South Korean study found that nursing staff working in resident-centered care environments had more control over their work, which increased levels of empowerment and job satisfaction (Choi et al., 2021). Associations between psychological empowerment and job satisfaction were also shown for long-term care nurses in Canada (Aloisio et al., 2019; Aloisio et al., 2021). Researchers from Sweden found that psychological empowerment accounted for 40% of the variance in job satisfaction amongst nursing staff and health care aides with formal and no formal competence (Engstrom et al., 2011). Amongst the articles that we reviewed, suggestions for improving levels of empowerment experienced by nurses included stating clear guidelines concerning decision-making authority, supporting nurses in redesigning their workday, and providing training on delegation and monitoring skills (Campbell 2003).

4.3. Nurses’ work outcomes

4.3.1. Physical health in hazardous long-term care work environments

Nurses working in long-term care in Canada were shown to be at high risk for poor physical health (Hoben et al., 2017). Similarly, Swiss registered nurses and licensed practical nurses reported high rates of compromised physical health (Dhaini et al., 2016). Many factors were found to influence nurses’ physical health in the long-term care sector. Long shifts and physically taxing work combined to heighten the risk of musculoskeletal symptoms, including shoulder, lower back, neck, and joint pain (Dhaini et al., 2016; Iridiastadi et al., 2019), which occurred significantly more often in long-term care than acute care (OECD, 2020). Research set in Brazil and Estonia observed that musculoskeletal disorders were particularly prevalent amongst nurses in long-term care (Mariano et al., 2015; Sepp et al., 2015). The most frequently reported types of physical injury in long-term care included back pain/injury, joint pain, and shoulder pain/injury (Dhaini et al., 2016; Iridiastadi et al., 2019). An Estonian study measuring fatigue in nursing staff's thumb muscles after a shift suggested modern equipment as a solution to reducing nurses physiological stress in long-term care (Sepp et al., 2015). The introduction of mechanical aids to reduce awkward postures for nurses as they work can reduce the risk of workplace injury (Alperovitch-Najenson et al., 2015).

The high prevalence of workplace violence in long-term care further increases physical health risks for nurses. An Australian study found that approximately 36% of nurses reported physical assault, emphasizing the connection between job demands and rates of workplace violence in long-term care (Rodwell and Demir 2014). Workplace violence was influenced by the physical work environment, organizational factors, and characteristics of residents/workers (Isaksson et al., 2009). Nurses have reported being verbally abused, pulled, choked, and spat on, as well as other physical altercations resulting in injury (Ostaszkiewicz et al., 2015).

4.3.2. Nurses’ mental health and well-being in long-term care work environments

Long-term care nurses had a high risk of professional exhaustion (Sanchez et al., 2015), which negatively impacted their mental health and well-being. Research on burnout and stress experienced by long-term care nurses has found direct associations with job dissatisfaction in Slovenia (Leskovic et al., 2020) and with negative work environments in Brazil (Mariano et al., 2015). These findings were corroborated in a review of studies set in Canada, the USA, the UK, and Europe (Sanchez et al., 2015).

The mental health of nursing staff was impacted by several factors. An American study correlated physical safety, violence at work, psychological demands, and work-family conflict with mental health of licensed nursing staff working in the long-term care sector (Zhang et al., 2016). These findings have implications for worker performance, in addition to other work outcomes. One American study reported that registered nurses experiencing burnout were five times more likely to miss care (White et al., 2019). Similarly concerning were findings from a Spanish study, where 85% of participating nurses experienced moderate to severe levels of emotional exhaustion, which was positively associated with compassion fatigue (Sarabia-Cobo et al., 2021). A French study of long-term care nurses found that psychological distress was associated with intention to leave their jobs (Pélissier et al. 2018). A study from Switzerland suggested that this distress may be amplified with exposures to harassment in the workplace, occurring in the form of bullying, with these exposures tending to impact licensed nursing staff more than health care aides working in the sector (Tong et al., 2017). Consequent to the COVID-19 pandemic, some researchers advocated the promotion of mental health and well-being amongst nurses and other care staff working in long-term care as a top priority for healthcare leaders and policy makers (Hung et al., 2022).

4.3.3. More nuanced perspectives on nurses’ work performance

Work performance has historically been measured as quality of long-term resident care. However, some contemporary researchers have considered additional measures of work performance, including turnover, retention, and extra-role behaviors.

Long-term care nurse retention, turnover, and intention to leave are outcomes that have garnered particular attention over the past two decades, as they have become increasingly problematic. All are complex concepts, and they relate to many of the concepts associated with work environment and work attitudes that we have discussed previously. For example, findings from a study set in China amongst nurses working in long-term care indicated that intrinsic motivation, pay satisfaction, and job burnout all contributed significantly to predicting turnover intention (Wang et al., 2019). A review article exploring factors influencing turnover intentions amongst long-term care nurses asserted that job satisfaction was the most influential factor, with higher job satisfaction translating to reduced turnover intentions (Lee 2022). And an American study found that long-term care nurse retention was potentially improved through programs aimed at increasing employee engagement (Boakye-Dankwa et al., 2017).

Extra-role behaviours amongst long-term care nursing staff were less frequently studied aspects of work performance (Perreira et al., 2019). Extra-role behaviors are those demonstrated outside of the scope of formal roles that serve to help colleagues perform their work or benefit the employing organization. Quality of care, alongside other measurable work outcomes, is thought to improve when staff engage in extra-role behaviours. Extra-role behaviours are intrinsically motivated. In a study from the Philippines, researchers found that nurses were driven by intrinsic factors to engage in meaningful personal relationships with residents and that these relationships satisfied them spiritually and improved the care environment for residents who were treated like family (de Guzman et al. 2009).

5. Discussion

While the range of themes and sub-themes observed across the articles included in this review was seemingly broad, they were relatable through several common macro-environmental factors. The pervasive shortage of resources and staff support in the long-term care sector was the unifying theme across the articles, where general infrastructure funding and human resource shortages were arguably connected to the myriad other themes and issues that we identified across the articles relating to long-term care nurses’ work environments and to their work attitudes and work outcomes.

Increasing demand for long-term care in conjunction with persistent under-funding and resource shortages in the long-term care sector have, in recent decades, driven the trend of hiring health care aides to provide the majority of direct care to nursing home residents as an alternative to direct nursing care. This response to the health and human resource shortages has, in turn, led to the shift in nurses’ scope of work from direct care to more coordination and administrative work and has led to concerns about the adequacy of management and communication skills amongst nurses and role clarity amongst all types of care staff. The role of nurses in long-term care, then, has become more complex as nurses continue some of their traditional care duties with the addition of supervisory tasks. Increasing complexity of care has resulted in larger volumes of paperwork and care planning, which generally falls to the nursing staff. Several studies suggested that nurses did not generally feel adequately prepared for the dual demands of their roles, nor appropriately skilled to communicate with, collaborate with, or supervise staff. These concerns and their influences of nurses’ work attitudes and outcomes are generally under-acknowledged in the sector. This, in turn, has served to exacerbate related issues, such as role clarity. Despite shifts in direct care to other types of staff, nurses continued to express that they felt responsible for anything medical. Some of the articles that we reviewed suggested that when nurses’ roles were not clearly defined from those of other staff, they tended to take on additional tasks – presumably preferring to err on the side of caution and not leave any tasks undone. A few studies in our review, from diverse geographies, suggested promising change initiatives on the part of employing organizations and oversight to address role clarity – including clearly defined skillsets required of each role – amongst nurses, health-care aides, and other professionals, including physicians. While changes such as these have not historically been the focus of evaluation, we see the merit in formally assessing the impacts of efforts like these on workers’ attitudes, outcomes, and quality of life.

One striking finding across numerous articles in this review was the importance to staff work attitudes and outcomes of supervisory and organizational support. Put simply, support appeared to be protective of negative impacts on long-term care nurses’ work outcomes and attitudes in the severely resource-constrained environments in which they work. Supervisory support can positively influence the immediate work environment, assist nurses in fulfilling their roles, and afford greater role clarity. Supervisors can influence their nursing staff's perceptions of the safety of the work environment and the value that the organization places on staff. Organizational support can come in the form of higher compensation, which can reduce stress, enhance feelings of self-worth, and mitigate some of the self-stigmatization that influences nurses’ attitudes toward themselves and their work, compared to other health sectors. Organizational support can potentially influence work outcomes, including job performance and quality of resident care. Some researchers described organizational support that took other forms, including the allocation of resources to education and training initiatives for nursing staff. Several articles provided evidence that this promoted positive staff outcomes and enhanced resident outcomes. Other researchers have shown that limited organizational resources to support nurses’ work significantly increased the chance of negative work outcomes. Going forward, consideration of ways in which to enhance organizational support and to build support capacity amongst supervisory staff strike us as promising avenues of health and human resource development that are likely to yield benefits in terms of enhanced worker attitudes and outcomes.

Other forms of organizational support targeted the health and safety of workers. The work environment in long-term care was acknowledged as hazardous (WHO 2021), impacting the physical health of nursing staff and their ability to care for residents. The incidence of physical injury amongst long-term care nurses was higher than in any other health sector, with high workplace violence an exacerbating feature of the care environments. Some recent studies showed that health risks to nurses in long-term care work environments extended to their mental health and well-being. Perceptions of safety culture in long-term care were found to be generally low amongst nurses. Several studies included in this review showed that higher levels of training and education might be protective against the health and safety risks of long-term care work environments. Several other studies also suggested that organizational support in the form of direct investment in improving workplace safety stood to enhance perceptions of safety and afford a sense of safety culture. This, in turn, was shown to positively impact nurses’ work attitudes (like job satisfaction) and outcomes, including stress, burnout, intention to leave, productivity, and quality of resident care.

5.1. Limitations

We acknowledge several limitations relating to our work. First, our database searches were limited to English or English-translated articles, potentially excluding relevant studies published in other languages. Second, gray literature was not included, which served to exclude observations produced by policy entities; we suggest that this omission was outweighed by the inclusion of peer-reviewed literature (Adams et al., 2017). We incorporated reports prepared by global entities, such as the World Health Organization, into our background and discussion sections, and these frequently if judiciously synthesized both peer-reviewed and gray literature. Finally, the definitions of “nurses” varies internationally; to address this variation, we consulted with experts in nursing and long-term care to ensure that our search terms were comprehensive in this review of global literature.

5.2. Conclusion

Work stress, burnout, increased turnover, decreased morale and work motivation, increased health and safety concerns, and decreases in job satisfaction accompanied by increased self-stigmatization are all indicators of a system that has failed nurses, other care staff, and nursing home residents in the long-term care sector. Despite the system-structural and policy differences across the jurisdictions in which the included articles were set, we are struck by the similarities – in terms of general trends relating to nurses’ work (e.g., role expansion), observations relating to nurses’ work psychology (e.g., relationships between psychological empowerment and job satisfaction and amongst features of the work environment and mental health), and the challenges inherent to reform in this increasingly complex sector. Our review demonstrates that a great deal of work has been done that highlights contemporary issues relating to nurses’ work and to their work psychology, including work-related psychological health, in the long-term care sector. Through our review, we were able to identify associations amongst features of nurses’ work environments; work psychology variables, including nurses’ work-related psychological health; and nurses’ work outcomes, including care quality, that are consistent and persistent across the jurisdictions in which the included studies were set. These are helpful to both underscoring the prevalence of these issues globally and advancing our understanding of how associations might be leveraged through local change efforts and broader reform to improve the work lives of nurses in long-term care. That said, changes of any scale will be non-trivial, as they are likely to be challenged by established sociocultural norms and extant policy specific to each jurisdiction, relating to nurses and nurses’ work in long-term care.

Funding sources

The development of this paper was funded through a Canadian Institutes of Health Research Rapid Research Grant.

Declaration of Competing Interest

None.