Nurses’experiences of perceived support and their contributing factors: A qualitative content analysis

Abstract

Background:

Following professional standards is the main concern of all managers in organizations. The functions of nurses are essential for both productivity and improving health organizations. In human resources management, supporting nursing profession is of ultimate importance. However, nurses’ experiences of perceived support, which are affected by various factors in workplace, have not been clearly explained yet. Thus, this study aimed to explain nurses’ experiences of perceived support and their contributing factors.

Materials and Methods:

This study is a qualitative research in which 12 nurses were selected through purposive sampling among nurses in university hospitals affiliated to University of Medical Sciences, Urmia, Iran, during 2011-2012. Data collection was conducted through deep interviews with semi-structural questions. All interviews were first recorded and then transcribed. Finally, data were analyzed through conventional content analysis.

Results:

The four main themes indicated that nurses experienced their workplace as non-supportive. Themes such as poor organizational climate, low social dignity, poor work conditions, and managers’ ignorance to individual and professional values were considered as inhibitory factors to support.

Conclusion:

Nursing managers can promote nurses’ positive support perceptions through recognizing inhibitory factors and applying fair solutions and take benefits of their positive consequences including high efficacy, self-esteem, and organizational commitment to promote the quality of care.

INTRODUCTION

Nurses are the largest professional group within the health services organizations. Generally, nurses provide 80% of direct patient care.[1] They are expected to provide good-quality care by diagnosing and treating human responses to health and illness and empower their clients by directing them toward an independent, self-regulated, and healthy life. They must become empowered before they can empower others.[2] It is obvious that the performance of nurses can be affected by both their empowerment and the social and psychological conditions of workplace.[3]

In other words, the factors affecting performance of employees are their perceptions of support from their managers. Studies of adverse events in Canadian hospitals (2009) show that 36.9% of these events are preventable and lack of resources and non-supportive performance of managers are regarded as the contributing factors. The researchers of these studies believe that if nurses in their team work are respected and valued, they will eagerly cooperate in providing safe-care. Even the evidences show that the mortality rate in hospitals with supportive workplace is less than in the other settings.[4] Several studies have been carried out on factors affecting the productivity of nurses. Abualrub (2008) conducted a study on job stress, recognition, job performance, and intention to stay at work among Jordanian hospital nurses. The findings of the study indicated a direct and buffering effect of recognition of nursing performance on job stress.[5] Recognition of nurses’ performance was defined by Blegen et al. as a series of head nurse behaviors that acknowledge staff nurses’ performance, achievement, and good work.[6]

Several studies stress the role of encouragement to creativity, innovation, and continuous learning opportunities in workplace and transformational leadership in enhancing employees’ performance.[7,8] Peachey (2002), during a quantitative study, showed that nurses’ perceptions of leadership empowering behavior were significantly related to workplace empowerment structures such as access to opportunity, recourses, support, formal power, and informal power.[9] Indeed, in addition to the supportive role of managers, workplace can also affect nurses’ mental positive perceptions. In several studies, Laschinger et al. (2009) considered work environments and organizational structures as the factors affecting the performance of nurses and highlighted the importance of nurses’ access to information, resources, support, and opportunities for growth and promotion. They concluded in their study that structural empowerment is the result of hospital work environments known as “magnet hospitals.” In these hospitals, the organizational structure is decentralized and organizational leaders and managers behave democratically. Also, the sense of autonomy and empowerment among nurses is high. These hospitals have a favorable culture that is characterized by a climate of cooperation and trust. The magnet hospitals recruit and retain nurses better than other places, and cultures of participation, delegation, adequate staffing, and cooperative wages are prevailed over.[10,11,12,13]

In Iran, a limited number of quantitative studies have been conducted in this regard. Asadzandi et al. (2007) demonstrated that nurses perceive their head nurses to have high empowering behaviors. “Confidence” in the employees was rated as the most empowering leaders’ behavior, and “autonomy” and “bureaucracy reduction” were rated lower.[14] Homayoni (2006) in another quantitative study reached a different finding and stated that not only nurses face a non-supportive feeling from their workplace, but also they are provided with no feedback from managers, so that they receive neither any special comments from managers and colleagues about their potential weakness, nor any correcting alternatives.[15]

Poor organizational climate can also lead to an adverse effect on employees, their performance, and ultimately in achieving effective organizational goals. The mentioned factor assumes ultimate importance in hospital settings due to different specific working conditions, nature and goal of work, as well as its unique customers. The researches done in Iran highlighted the point that the indicators of organizational culture are not so desirable and nurses do not receive fair respect and support, and mutual interactions between nurses and physicians are at a low level.[16] In summary, literature has shown that perceptions of positive support can lead to organizational commitment, effectiveness, and high self-esteem.[17] Therefore, in order to optimize human resource management, looking for employees’ perceptions of their managers’ performance and their work environment is very important. Previous studies prove that since there has not been any qualitative study conducted on experiences of nurses regarding factors affecting the perceptions of support in Iran, this study intends to discover and explain these phenomena in a natural setting using the nurses’ own perceptions of support.

MATERIALS AND METHODS

As the aim of this study was to explore the experiences of nurses’ perceptions of support, a conventional qualitative content analysis method was used to reach the objective of the study.

In a qualitative research, researchers try to make sense of phenomena and interpret them in terms of semantics provided by people in their natural position.[18] According to the nature of qualitative research, purposive sampling was used at first and then continued with theoretical sampling using maximum variation. In purposive sampling, the researcher is seeking people who have rich experiences of the phenomenon and possess ability and willingness to express them.[19] Thus, the participants were selected out of clinical nurses in university hospitals affiliated to University of Medical Sciences, Urmia, Iran, during 2011-2012. Inclusion criteria were nurses with a B. S. or a higher degree in nursing, clinical work experience of at least 1 year, and a desire to express their experience. Thus, the first sample was selected based on the criteria listed above using convenience method. Further samples with maximum variation were selected out of nurses with different nursing experiences and of various genders. The method of data collection was interviews and field notes. The researcher first referred to the potential participants and explained the research objectives. If the participants agreed to take part in the research, an interview was scheduled. The interview guide consisted of open-ended questions to allow respondents to fully explain their own experiences and follow-up questions were the result of the participants’ responses. The two main questions that the nurses were asked in interviews were: Have you ever been in situations to have that feeling of being supported? Why do you feel you have been supported or not?

Duration of the interviews ranged from 30 min to an hour and 50 min, and some participants were interviewed twice by necessity. After interview 10, data were collected for theoretical saturation.

Field notes were another method of data collection in this study, which were recorded by the researcher in the hospital ward and performed in different shifts. Notes were recorded in a proper position after the completion of the detailed observations. In general, 15 interviews, and 5 field notes with 12 nurses were conducted in this study. Interviewing stopped when data saturation occurred. Data saturation occurred when no more codes or themes could be emerged in the last two interviews.

Methods of data analysis

The process of data collection and data analysis was conducted concurrently. Interviews were recorded on a tape duplicator and transcribed. As a qualitative research requires that the researcher be immersed in the data, the listener listened to the interviews and reviewed handwritten notes several times. The meaning units were extracted based on the participants’ own statements in the original codes. Then, based on the similarity of semantic and conceptual classifications, they became as short as possible and were condensed. Declining trend in the data reduction in all analysis units and in all categories and subcategories was going on. Then, the data were put on the main categories which were more conceptual, and eventually the themes became abstracted.[20,21]

During the study, certain procedures were used in order to ensure consistency of the data. Data credibility was obtained through reviewing the handwritten notes by the participants using their comments and the researcher's prolonged engagement with the data as well. In addition, two experts in qualitative studies monitored and audited the whole process of the research. Using a combination of interviews, field notes, and maximum variation sampling, transferability of data was made possible.[22]

In addition, all ethical considerations such as approval of the research project in medical faculty and the permission taken from the ethical considerations committee, participants’ oral consent to be in the study, maintaining anonymity of the participants, and the freedom to withdraw of the study were all totally guaranteed.

FINDINGS

Twelve nurses who were mostly female participated in this study. Majority of the participants (10) had a B. S. degree in nursing, mean age of 39 years, and 3-18 years of working experience in the profession. They were working in different wards such as a medical-surgical, a coronary care unit, emergency, etc., Analyses of the findings were extracted from interviews and field notes resulting in four main themes [Table 1]. The resulted themes included managers’ ignorance to individual and professional values, poor organization climate, low social dignity, and poor working conditions. The main themes showed that nurses perceived lack of support from their working environments. They frequently explained the managers’ ignorance to individual and professional values as the main factor affecting nurses’ lack of support experience.

Table 1.

The themes extracted from interviews and field notes

Besides, few key factors such as poor organizational climate, low social dignity, and poor working conditions were experienced as supplementary factors and barriers to perceived support. Each theme included some categories and sub-categories demonstrating a set of dimensions and various aspects which led nurses to lack of support experience. The mentioned themes have been explained in Table 1.

Theme 1: Managers’ ignorance to individual and professional values

During interviews, nurses tried to express the main theme (the managers’ ignorance to individual and professional values) with different statements. The indicators of the main theme included superiors’ ignorance to competency and unfavorable interactions with nurses. They are addressed in details.

Ignorance to competency

Nurses often complained that their managers refused to notice their professional abilities and competency. This category included some subcategories with indicators such as refusal to notice nurses’ professional capabilities, lack of a clear plan for promotion, and refusal to employ competent managers. An individual nurse tells her experience as:

“I had been a head-nurse for six years in a hospital ward. I passed several workshops and training courses for this purpose but suddenly they took my responsibility with no reason and replaced somebody else from somewhere with no experience even as a staff nurse in that ward.” (Participant No. 3).

Another factor expressed by the participants was lack of employed competent managers. This caused the managers’ lack of capability in recognizing competent staffs, and in some cases, managers consciously failed to notice nurses’ competency and even argued verbally due to the danger which threatened their own positions.

In this way, the feeling of ignorance became widespread among individuals. Participant Nos 2 and 12 expressed their feelings as:

“Managers are selected from those who are not experienced and they are often ready to annoy and tease. Managers only know how to give an irrelevant or vague answer.” (Participant No. 2).

“Due to the danger which threatens our matron's position and since he does not deserve his place and competency, he always tries to argue, tease and ignore those who are actually more competent.” (Participant No. 2).

On the other hand, the lack of a clear plan for promotional opportunities was regarded as a factor causing managers’ ignorance to nurses’ professional values:

“I do not really know what is going on in the next ten years. There is no plan for promotion. What should I do to avoid being a simple nurse?” (Participant No. 7).

Inappropriate interactions between nurses and managers

This category, with the other previous categories, indicated the managers’ ignorance to individual values and perceived lack of support. Nurses in various situations experienced humiliation, threat, lack of appreciation, and ignoring their suggestions.

Nurses humiliated by managers

Participants in the study believed that nurses, humiliated by the managers, had negative effects on their morals and experienced of lack of support. One participant expressed thus:

“I remember the day I forgot to chart the patient's blood sugar, but I injected his insulin based on the 6.00 am test of blood sugar. The head-nurse came to me and publicly humiliated me before my colleagues, patients, and patients’ relatives. He added that how it is possible that an employee with several years of clinical experience does not know how to manage his job. Sometimes, it happened that the manager tried to humiliate me by shaking his head over some small and trivial matters.” (Participant No. 1).

On the other hand, ignoring the abilities and knowledge of a nurse is the factor that caused the sense of humiliation among nurses. Another participant expressed thus:

“Someday, our matron told me to connect to the web and download the patients’ forms. I tried that a few days, but I could not. He replied, you could not because you do not know how to do it.” (Participant No. 3).

Lack of appreciation of nurse managers

Nurses believed that lack of managers’ appreciation toward nurses was regarded as an inhibitory factor for their experienced support. One of the participants stated thus:

“Often, at the time of discharge, the patients’ relatives acknowledge doctors more than the nurses, the doctors who just ordered on the phone and refused to visit patients in the hospital. So do our officials and the head of the hospital. They value doctors more than nurses.” (Participant No. 8).

Managers’ focus on nurses’ weak points and magnifying them makes nurses feel lack of appreciation too. Two nurses stated thus:

“We are not understood by the managers; instead, we are also crushed by them. They always focus on the weak points and magnify them. They never pay attention to positive points.” (Participant No. 3).

“Managers do not acknowledge even the excess work. I was sick and had a perforated appendix. I had to go to sick leave a few days but the second day, they called me to come over to shift as they could not find anyone else. I returned to the shift immediately but I was not appreciated well. Just as much as the phone thanks.” (Participant No. 8).

Not taking care of nurses’ suggestions

The indicators of this category include not being allowed to express shortages, not listening to the demands of a nurse, changing nurses’ wards without taking them into consideration, and giving no response to the requests of the nurses. The participants added thus:

“We do not know what the natures of these meetings are. Feedback sessions in the wards are just superficial. Finally, they apply their own ideas.” (Participant No. 5)

“Before they sent me back to this ward, I went to matron and said, ‘please do not change my ward anymore. I got so tired of my circulation. If you change my ward, at least let me stay for a year. Do not circulate me anymore, or promise me not to move me if you employ a new staff.’ He did not listen and did the swap again.” (Participant No. 6).

Nurses threatened by managers

“When we protest against, the managers say, ‘did I lose your monetary rewards?’ Therefore, I feel lax on my duty. Indeed, his statement is a kind of threat.” (Participant No. 8).

Theme 2: Poor organizational climate

During interviews, nurses mentioned both supplementary and inhibitory factors affecting their experience of lack of support. Indicators of organizational factors were injustice, work orientation, physician centeredness, and a relationship-centered climate.

Injustice

Nurses also complained about injustice in preparing shift schedules, giving monetary rewards, and evaluation. Nurses complained thus:

“Giving monetary rewards by managers is periodical instead of being based on staffs’ effort.” (Participant No. 10).

During interviews, nurses regarded the relationship-centered climate in choosing managers, giving organizational positions and receiving no or little appreciation as barriers to their experience of lack of support. Statement of nurses was:

“There is now a team who has been a manager or a head-nurse for more than eight years. We have head-nurses who have been in this post more than fifteen years.” (Participant No. 4).

Physician-centered climate

Physician-centered climate is a subcategory of poor organizational climate. One of the nurses said:

“Look, it is just eleven o’clock. The physician has not visited the patients yet. There are more than 29 patients in this ward. This makes high workload.” (Participant No. 3).

“Frequently, we hold meetings on physicians’ late visit. Even we informed Health Care System but all our efforts were in vain. Our officials all support them.” (Participant No. 6).

Theme 3: Low social dignity

Sociological factors are the other supplementary factors affecting experience of lack of support among the nurses. This theme includes lack of support from the media and low social status of the nurses. The nurses emphasized thus:

“The public did not recognize nurses. The criterion here is still not working: The one who is working with the patients day and night is a nurse not a physician.” (Participant No. 11).

“The media should inform the public about what the profession is.” (Participant No. 12).

Theme 4: Poor working condition

This theme consisted of nursing staffs’ shortage, lack of time, high workload, and mandatory overtime. Participants remarked as follows:

“Now, following the productivity rule, our duty shifts have decreased, but still, we face nursing staffs shortage and have to work overtime.” (Participant No. 2).

“Our main concern is mandatory overtime and inadequate staffing.” (Participant No. 15).

DISCUSSION

The results of this study showed that nurses experienced lack of support from their workplaces and they considered managers’ ignorance to individual and professional values, poor organizational climate, low social identity, and poor working conditions as barriers to experience support. Although experts stressed necessary attention to psychological needs of individuals, such as being respected and appreciated, and further stated that the mentioned support increases the sense of self-efficacy and self-esteem, in contrast, the findings of the present study stated that nurses had perceptions such as humiliation, threats, and not taking their suggestions into consideration. Indeed, the findings reported contradictory results about nurses’ perceptions. A study in Canada showed that 82% of Canadian nurses had sense of being respected by their colleagues and managers. The result of the Canadian study is inconsistent with our findings. The reasons for this contradiction can be related to various working conditions and leadership style. However, the findings of the present study confirm the findings obtained by Laschinger and Fulkner (2008). They reported that many nurses feel that they do not receive the respect they deserve in hospital settings.[23] Nasrabadi (2006) in his qualitative research found out that burning out thoroughly dominated Iranian nurses. He added that nurses should be cared before they can care others. They should be valued and should receive appropriate and fair feedback for their work.[24] Positive organizational environment enhances nurses’ understanding of respect and has positive outcomes on nurses and organization as well. Thus, empowered managers can create a cooperative climate and sense of empowerment among staffs to help them consider their tasks meaningful and valuable. By showing mutual respect and trust, managers can also direct nurses in achieving organizational goals.

Poor organizational climate can adversely affect employees, their performance, and finally their achievement of organizational objectives. The mentioned factor assumes ultimate importance in hospital settings due to different specific working conditions, nature and goal of work, and unique customers. The researches done in Iran highlighted the point that nurses do not receive fair respect and support, and the mutual interaction between nurses and physicians is at a low level.[16] Wilson (2006) and Blegan et al. (1992) reported that nurse administrators and managers should use a variety of methods to recognize nurses’ performance and achievements. Examples of such methods would be a positive feedback from managers, written and verbal acknowledgment for good work or achievements, monetary rewards, financial and emotional support for getting on an educational degree, attending workshops or conferences, and promotional opportunities.[6,25] With regard to the above issues, the findings of this study and other similar studies may enhance the managers’ performance. Managers can create a sense of professional and humanitarian values by meeting the psychological needs of employees and paving the ground for their future growth and development. Then, in return, they benefit from employees’ positive outcomes to achieve individual and organizational goals.

Another finding of this study was poor organizational climate. Dominance of physician-centered as well as relationship-centered climates in appreciation and selection of hospital managers was perceived as barriers to nurses’ experience of lack of support which finally led to lose one's moral. However, if managers were more efficient, competent, and experienced, organizations would be more successful in achieving their goals. In addition, in this case, with minimum amount of facility, organizations would achieve maximum efficiency.

Tayebi et al. (2010) found out that hospital managers had the least ability in human resource management.[26] Another barrier affecting nurses’ experience of lack of support was perception of injustice. Nurses in this study complained of imbalance between effort and reward. McVicar's (2003) meta-analysis from 21 researches illuminated that lacks of rewards and lack of appreciation were the two most important sources of distress in the workplace.[27] Schulz (2009) explained that imbalance between effort and reward among nurses led to burnout.[28]

The results of the present study are consistent with the findings of studies on nurses’ experiences of productivity done in Iranian setting. Majority of the nurses in this study believed that factors such as inadequate staffing, high discrimination, along with miscellaneous non-nurse affairs and inappropriate interactions cause reduction of productivity among nurses.[29] Yet, researches show that organizational justice is associated with job satisfaction and organizational commitment.[30] Therefore, according to the results of this study and findings of similar researches and the vital role of managers on changing and shaping organizational culture, managers at all levels should restructure the organization and do interventions for improving staffs’ moral and their perceptions of support.

Poor working conditions including inadequate staffing, lack of time, high workload, and mandatory overtime were considered as indicators affecting nurses’ experience of lack of support. Another research finding in Canada in a neonatal intensive care unit (NICU) showed that burnout is a response to workplace stress, resulting in emotional and mental exhaustion and finally decreased quality of care. Thus, nurses and managers have a responsibility to take steps to reduce burnout.[31]

Moola et al. (2008) carried out a qualitative study to understand the factors involved in stress and reported a lack of support system in nursing.[32]

Sociological factors such as low social dignity were another finding of the present study. These factors, along with the other mentioned variables, caused perceived lack of support of the nurses from the public and media side. Abualrub (2008) states that when nurses receive strong social support, the quality of care improves. He believes that high social support reduces job stress and retains nurses in organizations.[33] Most of the researches conducted in Iran indicate that in spite of fundamental changes in improving nursing status, social image of nursing in the country is still poor so that the public perception of the nursing profession is vague and even nurses are seen as physicians’ handmaidens.[34] Also, the finding of the mentioned study stresses the necessity of adequate attention which should be provided to nursing field and proper introduction of the profession through media to publicize the community. Generally, the findings of our study demonstrate that clinical nurses lack positive and supportive perceptions of their workplace due to some organizational and cross-organizational reasons which belong mostly to psychological factors. These factors can reduce their mental and psychological abilities and ultimately affect the quality of care.

Limitations of the study

Although in generalizing the findings of a qualitative study we should behave cautiously, we can nurture psychologically empowered nurses by identifying and understanding factors affecting perception of support and finally improving the quality of care. As a rule of thumb, nurses should be empowered before they can empower others.

CONCLUSION

One of the key roles of nurses is their supportive role. They should be able to play a supportive role for the patients. First, it is necessary that they themselves perceive and experience the supports. Besides, following the professional standards is regarded as a key challenge for nursing managers. Therefore, the managers have to follow and apply some effective behaviors and interventions to achieve the mentioned standard goal. Creating magnet workplace, staff appreciation, taking nurses’ suggestions into consideration, providing communication and interactions based on mutual respect, and finally taking nurses’ mental and emotional needs into account can all increase job satisfaction, sense of commitment and responsibility among nurses, and ultimately promote the quality of care.