Challenges of respect as promoting healthy work environment in nursing: A qualitative study

Abstract

CONTEXT:

An increasingly common complaint of staff nurses in hospitals is not receiving respect. One of the strategies to create a healthy and positive work environment is to strengthen the respectful behaviors among nurses.

AIMS:

This study aims to explore the barriers of respect in nursing workplace.

SETTINGS AND DESIGN:

This qualitative content analysis was carried out at the School of Nursing and Midwifery of Golestan University of Medical Sciences.

SUBJECTS AND METHODS:

The semi-structured interview method was employed in this qualitative study on 14 nursing staff in 2018. We transcribed the interviews verbatim and analyzed them using the conventional content analysis approach.

RESULTS:

Data analysis led to the emergence of 377 primary codes, 13 categories, and 4 themes. The four themes were as follows: (a) feeling of ignored; (b) socio-cultural conditions in society; (c) lack of Support by Managers; (d) poor organizational climate.

CONCLUSIONS:

Nursing managers can promote a healthy work environment in the nursing workplace through recognizing these challenges and applying mitigation strategies and take benefits of their consequences such as self-efficacy, self-confidence, and organizational commitment.

Introduction

Nowadays, health-care organizations confront a number of challenges, an important one of which is related to organizational and workplace environment.[1] A positive workplace environment increases the level of job satisfaction as well as staff maintenance and retention, which needs to be developed as one of the key responsibilities of nursing managers.[2] A policy helping improve the workplace atmosphere is to improve the respectful behaviors among nurses.[3] The American Nurses Association believes in respect for human dignity, as the first ethical duty of all nurses, which is a part of their professional responsibility of nurses,[4] and professional socialization in Nursing.[5] Based on the evidence, it is necessary to create a culture of respect and improvement at all levels of health care.[6] According to studies, respectful behavior in the nursing workplace leads to improve the nursing image in the community.[7,8] Bhargava et al. express that respect-based behaviors in workplace by health-care providers cause improved information transition, thereby reducing human error in the workplace.[9] Lee has introduced “respect” as one of the seven agents influencing the quality of the nurses’ working life, which also influenced the tendency to quit the organization.[10] Khademian refers to respect as one of the factors that make the nursing profession an ideal career.[11] According to studies, lack of respect has detrimental effect on the interaction between patient and nurse.[12,13] Nurses frequently refer to disrespect as one of the grounds of dissatisfaction with their career and work environment.[14,15] Smith et al. stated that there is a significant relationship between lack of respect in workplace and nurses’ tendency to leave the workplace.[16] Although it seems that respect is a practical aspect of nursing profession, there is no accurate definition of that in the arena of nursing.[17] There are less empirical data available for the respect in health-care organizations; On the other hand, the concept of respect is different from the viewpoints of various groups living with this phenomenon.[18] Therefore, this study was conducted aiming to comprehend respect from the perspective of clinical nurses.

Subjects and Methods

This qualitative content analysis was performed in Golestan University of Medical Sciences in 2018. Content analysis methodology, generally utilized in research and nursing education,[18] helps the researcher understand the data well and provide valid inferences of the data in the relevant area.[19] Data were collected on nurses of medical- surgical wards. The inclusion criteria consist of employment in clinical practice for at least 6 months, having a bachelor's degree or higher, and the ability to share experiences. Purposive sampling was done until the data reached saturation. Fourteen unstructured individual interviews were conducted. The participants’ details are shown in Table 1. Duration of the interviews ranged from 40 min to 60 min. Each interview commenced with the general question “What is your opinion concerning respect in the workplace?” and continued according to the participants’ responses. To gather the in-depth information, questions such as “Can you cite an example” were used. Participants were encouraged to freely express their experiences. All interviews were first recorded, transcribed and then analyzed through conventional content analysis. The researcher reviewed the transcriptions several times to immerse in the data and the essential part of the transcriptions were divided into meaning unit. According to the content, the meaning units were summarized and condensed. Then based on the similarity of conceptual and semantic classifications under more abstract categories, they become as short as possible and the data were put on the main category. Finally, the hidden content of the data was introduced as the main theme, by comparing the classes with each other. To assess the consistency of the data Lincoln and Guba evaluation criteria were utilized. Data credibility was obtained through selecting participants with different experiences and perspectives as well as diversity of gender and age. confirmability of the data was considered by the verification of participants and clarification of interviews. On the other hand, to determine the accuracy of coding, the results were examined by experts in qualitative studies. All ethical consideration such as approval of the research project in nursing faculty and the permission derived from the ethical consideration committee (IR.GOUMS.REC.1395.304), oral consent of participant to attend this study, confidentiality of information, and freely exit the study were all totally guaranteed.

Table 1.

Demographic characteristics of the participants

Organizational position	n	Age (year)	Work experience (years)
Nurse	12	27-55	4-23
Head nurse	2	28-45	5-20

Results

Fourteen individual interviews were conducted with clinical nurses on the related challenges of respect in workplace. Four main themes of 1) Feeling of ignored, 2) socio-cultural conditions in society, 3) lack of support by managers, 4) poor organizational climate, were obtained from the data analysis. The themes and subthemes extracted from the data are displayed in Table 2. The following categories explain the conditions and cultural and contextual factors affecting on respectful work environment in nursing.

Table 2.

Themes and subthemes of the challenges of respect in the nursing workplace

Themes	Subthemes
Feeling of ignored	Nonparticipation in decision-making Inadequate feedback lack of addressing problems and requirements
socio-cultural conditions in society	Prevailing culture of community The public image of nursing
Lack of support by managers	Mistrust of nursing managers Lack of support of nurses
poor organizational climate	Inappropriate job circumstances Interpersonal communication Lack of participatory space

Feeling of ignored

An obstacle to have a respectful workplace in nursing is the lack of attention and lack of use their opinions, which nurses described it as being ignored. Participants had encountered the aforementioned experience through nonparticipation in decision-making, inadequate feedback, and lack of addressing problems and requirements.

Nonparticipation in decision-making

Nurses experience numerous situations in the clinical workplace that shows the lack of use of their opinions, expertise, and experiences. According to the experiences of most participants, participatory planning and decision-making were cited as an example of a respectful workplace and nonparticipation in surveys were addressed as one of the factors of being ignored, They know. In this regard, participant no. 5 states: “… they have merely one meeting with me per month, while they would have two or three meetings with others; so, this is discrimination …” or participant no. 1 states: “… the hospital manager doesn’t recognize me at all… despite my age, long job experience….”

Inadequate feedback

Participants interpreted failure to receive adequate feedback from direct or indirect managers as ignoration. For instance, participant no. 4 states: “… feedback is necessary, unfortunately in nursing there is too much punishment and too little encouragement, people's actions are not observed properly. When you work hard and you are not encouraged, you feel neglected …” by the way, some participants expressed a conspicuous lack of appropriate feedback from the patients and their companions. For instance, participant no. 12 states: “You feel your efforts are never recognized. Nobody thanks you. You keep feeling ignored…” or participants no. 6 says: “While patients always thank the doctor, they would see the nurse's failure if the any issue occurs. They won’t thank you when leaving, that's why we, nurses, feel less respected.”

Lack of addressing problems and requirements

in nurses’ perspectives, considering workplace problems and managers’ accountability are of the criteria for to get attention. In this regard, participant no. 13 says: “For example, I had a terrible time… There were such issues as excessive hospital admissions, the device failure, low workforce… merely being responsible and addressing the problem, to say nothing of problem solution, and having a good relationship mean a lot to me; it says they’re seeing me and listening to me.” Another factor causing neglect feeling was the managers’ lack of attention to their needs. In this regard, participant no. 7 says: “No one cares about our problems, if you have a kid, put the little baby in the kindergarten… no matter it is eve night, new year, traditional events like Sizdah Bedar, you always have to come….”

socio-cultural conditions in society

Another influential agent in the creation and maintenance of a respectful work environment in nursing is public image of the nursing position in the health-care system, which is typified in the relation among nurses, patients, and their companions. Participants explained this concept through two features of “prevailing culture of community” and “the public image of nursing.”

Prevailing culture of community

Participants’ concerns include the physician-centered culture in community and the lack of recognizing the role of a nurse in health care by the community which hinder respect in nursing workplace. For instance, participant no. 11 says: “Society should accept that you are an expert who has studied for four years in bachelor's…” and in other part participant no. 7 states: “When the doctor is late visiting to the patient, their companions insult the nurse badly while no one is allowed to do it towards the doctor….”

The public image of nursing

An obstacle to have a respectable workplace for nurses is the lack of attention of the community to the dignity of the nursing profession, according to participants’ perspectives. This makes nurses feel disrespectful. For example, participant no. 7 says: “People's point of view to nurses didn’t well early, and considered them as person who inject merely, now it's the way better… now they realize that you have studied for this position you are in charge of….”

Lack of support by managers

Through creation of a friendly and supportive atmosphere as well as a workplace in which there are respect, dignity, trust, and effective communication, the managers in nursing section can play a crucial role in creating a respectful work environment. Participants pointed to the lack of managerial support as a significant hindrance to creating a respectful work environment.

Mistrust of nursing managers

there is no doubt that relationships based on trust and mutual respect can contribute to a positive workplace in hospitals. Participants cited the mistrust of nursing managers as another hindrance to a respectful ambience. For instance participant no. 14 states: “Supervisor doesn’t trust me; so that when coming here and talk to me, while I say this is an empty bed, for example, he doesn’t believe me and goes to look at his system to check if I’m right or not… if the supervisor trusts me, he doesn’t need to double-check.”

Lack of support of nurses

Shortage of financial support, nursing workload, inaccurate performance evaluation, and failure to fulfill the rightful complaints and demands, were cited by participants as grounds of lack of respect in their profession. In this regard, participant no. 14 says: “When it comes to financial subjects, like merit pay, bonus… there is no longer such respect among colleagues as it is used to compare all the employees….” This participant continues elsewhere: “After twenty-three years’ experience, based on the instruction of productivity, I can get once a week off, but they won’t let me in. While setting the rule, they knew I wouldn’t be able to work six shifts a week after twenty-three years.”

Poor organizational climate

In participants’ perspectives, another factor affecting a respectful work environment in nursing was inappropriate working and professional circumstances, ineffective communication, and lack of collaboration in workplace.

Inappropriate job circumstances

Participants see exclusive occupational conditions such as work pressure, nursing shortage, work stress and burnout as the other influential agents that increase tension in the workplace. For instance, participant no. 5 says, ” Unfortunately, the shortage of nursing staff and the workload available in workplace, increases inappropriate behaviors between nurses.” Furthermore, conditions such as 24 hours a day, seven days a week working and rotating shifts were mentioned by the participants. Participant no. 3 says: “Since our shift changes, guys are always unhappy: they say why does that person always come in the morning or doesn’t come at night? In other professions there is not such disorderliness.”

Interpersonal communication

One of the most significant features of health-care staff members is the ability to communicate appropriately, which contributes to a respectful work environment. Participants consider the inability to interact precisely as another factor in their workplace disrespect. They mentioned the lack of attention to staff work experience, inaccurate verbal communication, and disregarding hierarchy as obstacles to preserve a respectful workplace. As participant no. 3 says: “In spite of the past, the juniors don’t respect the seniors properly; colleagues call each other without any prefix like sir, miss….”

Lack of participatory space

According to the participants’ experiences, cooperation and participation in the work is an agent in maintaining respect and lack of it might lead to disrespect. Participant no. 2 states: “Sometimes it happens that while I am in charge of nine patients and my colleague has seven to care after, I have to handle the new ones as well; it is embarrassing for me, and in my opinion it's kind of disrespectful.”

Discussion

In this study, nurses’ experiences concerning the obstacles to creation and maintain the respectful workplace in the clinical nursing were examined. According to the findings, four themes of 1) feeling of ignored, 2) socio-cultural conditions in society, 3) lack of support by managers, and 4) poor organizational climate were revealed and discussed. Participants argued that feeling of ignored was typified through the factors of participation in decision-making, receiving feedback, and addressing problems and demands. In other words, nonparticipation of nurses in decision making and not utilizing their experiences make them feel neglected. Studies have proved that not only is nurses’ participation in decision-making influential in maintaining a respectable workplace, but also it leads to improvement of professional autonomy in nurses.[19] In this regard, in the findings of a qualitative study, participants pointed to feelings of being ignored and forgotten as disrespectful behavior.[20] Likewise, the socio-cultural conditions in the community, including nursing culture and public image, were considered as other respect hindrances in the workplace of nurses. There is a close relationship between the nursing image and the identity and role of a nurse; this concept has now become one of the challenges of the nursing profession. The image is in fact the public perception of a person, job, or an organization; therefore, the public's image of nursing and public sensitivity toward that has made a particular image of this profession, which can affect the selection of this field in university and the lack of nursing employees.[21] Moreover, the poor public image of nursing might result in neglect feeling and lack of appreciation and respect among nurses[22] which is approved by the findings of the present study. Given the nursing image, people think of the nursing image more positively compared to the nurses themselves, for instance they keep respecting knowledgeable, competent, and skilled nurses.[23] Therefore, increasing the nurses’ knowledge and skills is a way to gain respect from the community and improve the general image of nursing. Another outcome of the present study is the mutual relation between respect in nursing and prevailing culture in community. In other words, respect for nursing community is influenced by community culture as a part of the whole. Taylor also introduced culture as a major influential factor on nurses’ perceived respect, in her study,[1] so culture creation will be one of the factors facilitating respect in the nursing workplace. Another finding of the study was the significant role of managers in supporting and dealing with dishonest behaviors. Most participants believed that the support of managers in disrespectful situations was not sufficient. These findings are consistent with outcomes of a qualitative study, in which the nurses’ experiences of perceived support in the workplace have been examined. As that study in which participants described their work environment as unsupportive, in this study also, the poor organizational ambience, low social dignity, workplace circumstances, and ignoring individual and professional values were come up as obstacles to nurses’ perceived support.[24] Another finding of the present study was the prevailing atmosphere in nurses’ workplace, undermining the respect in the nursing work environment. Participants pointed to the nursing shortage, high work pressure, busy shifts, and occupational stress as obstacles to have a respectable workplace. Laschinger has demonstrated in a quantitative study that nurses’ job satisfaction, trust in management, and retention in the profession are the consequences of perceived respect in the workplace, In other words, empowering nurses requires workplaces with high levels of perceived respect.[25] These outcomes also comply with empowerment Kanter's theory with regard to improving workplace circumstances. According to the very theory, managers must create efficient working circumstances through supporting employees and providing them with the required data and resources.[16] Therefore, nursing managers can provide conditions for increasing the sense of respect in the nurses’ workplace based on Kanter's theory, thereby, increasing their job satisfaction and commitment to organizational goals.

Conclusions

According to the findings of this study, clinical nurses do not perceive respect in their workplace positively, due to the available challenges. These challenges can affect nurses’ job satisfaction and efficiency, thereby reducing the quality of care. Eventually, caution in generalization is one of the limitations of the qualitative research outcomes. Thus, vigorous attempts were made to improve data strength, and it is also proposed to carry out similar research in different organizational and cultural contexts.

Financial support and sponsorship

This study was financially supported by Golestan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.