It is not a secret that nursing morale is low and that there are ongoing problems in the recruitment and retention of nurses and that those in the profession feel they are undervalued, underpaid and overworked.
This is an issue not only in the UK, Sweden, USA, Canada and Australia among others also have reported low morale in nursing (Callaghan 2002).
"The main drive for people to enroll in the nursing profession, even when the work conditions are so oppressive, is the compassionate side of it (Zeldin 1995)".
What is nursing morale?
Morale can be defined as the confidence, enthusiasm, and discipline felt by a person or group of people, especially in a dangerous or difficult situation (Cambridge University Press 2017, Oxford University Press 2017). Morale was first used meaning confidence in 1831 and related to the military.
Assurance, self-esteem, attitude, mood and humour are synonyms while fear and weakness are considered antonyms (Philip Lief Group 2009).
The person/group have morale when they feel confident and safe, there is passion, a deeper feeling of power, determination and energy to achieve certain goals. But also, discipline and team working.
Low morale is a negative state of mind which impacts on feelings, emotions, confidence, motivation, determination, cheerfulness and willingness to do certain actions.
Burnout is a psychological term that refers to long term exhaustion and diminished interest in work. The symptoms are similar to those of clinical depression. The Oxford dictionary also includes that in burnout there is physical impact caused by overwork or stress. There are different kinds of stress, pressure of work would be classified as routine stress however, chronic stress is reported to have serious health effects.
It could be said that prolonged low morale due to chronic overwork could be a potential trigger for physical and mental problems (burnout) as it has negative effects on emotions, confidence and motivation.
The components of the morale of nurses can be divided in:
-extrinsic (out of control of the individual nurse or the group they work in): organisational structures, operational issues, leadership traits/management styles, communication and staffing.
-intrinsic (nurses have some control over them): professional worth and respect, opportunity/skill development, work group relationships and patient care.
The factors that enhance morale appear to be intrinsic factors, whereas the extrinsic components dominate the factors that reduce morale (Day et al 2006).
What are the causes of low morale?
-hospitals more concerned about finances than with patient care (Castledine 1997, 1998).
-low pay (Callaghan 2002, Day et al. 2006, Day et al 2007).
-lack of support for education and training, despite emphasis on further qualifications, nurses feel they are not supported in gaining these qualifications (Callaghan 2002, Day et al 2007).
-the quality of nursing education (Day et al. 2006, Day et al 2007).
-frustration about limited opportunity for promotion (Callaghan 2002, Day et al 2007) and the lack of recognition for job performance and professional achievement (Day et al. 2006, Day et al 2007).
-lack of resources (Callaghan 2002).
-job insecurity, despite the shortage of nurses, interviews carried out in Scotland indicated that there was a strong feeling of insecurity in relation to jobs, the uncertainty of the future of the health service, the number of changes and the lack of resources (Callaghan 2002).
-job pressure and overwork (Callaghan 2002, Day et al 2007).
-shortage of workers (Day et al. 2006, Day et al 2007)
-difficulties in recruitment and retention of staff (Day et al. 2006, day et al 2007).
-professional support and prospects (Day et al 2006)
-fiscal responsibility, litigious environment and increased client expectations (Day et al 2006).
-autonomy, recognition and interpersonal relationships (Day et al 2007).
-nurses strongly value the ability to provide good patient care and the failure to do so can lead to feelings of low morale. There is evidence of of the negative effects of high workloads and low staffing levels and its subsequent effect on providing quality patient care and morale. Demoralization may be exacerbated by continual and incremental pressure to provide care in an environment driven primarily by cost containment at the expense of patient care (Day et al 2007).
-how nurses are perceived in the workplace, how they perceived they are undervalued as professionals, and how they are excluded from the organizational decision-making process. Nurses find themselves in a system over which they have little control or little ability to do so(Day et al 2007).
-nurses are finding that they are being loaded with additional administrative and reporting tasks while expected to undertake an increasingly complex clinical load (Day et al 2007).
-abuse and violence in the workplace either from patients, families and other health professionals (Graydon et al. 1994, Laschinger 2014)
-increased role ambiguity that leds to decreased job satisfaction and increased perceived stress. Occupational stress has a strong influence on the development of depressive symptoms in nurses (Revicki and May 2010).
What are the consequences?
-anxiety, stress, decreased performance and increased professional negligence (Castledine 1997, 1998, Day et al 2007).
-costly to organizations and a key source of poor patient outcomes and care (Day et al 2006).
-negative impact on staff's health and well-being, focusing specifically on mental health problems, Borrill et al (1996) found that 28% of nurses in the NHS were suffering from minor mental health problems, generally identified as anxiety and depression. Similar findings were reported by a study that concluded that mental health problems were significantly correlated with increasing workload, understaffing, job insecurity and perpetual organisational change. So serious have nursing absence and sickness rates become that they were estimated in 1998 to be costing the NHS about £700 million annually. Also, a report found the risk of health professionals killing themselves was 24 per cent higher than the female national average, adding: "This is largely explained by high suicide risk among female nurses" (Daily Mail 2017). Suicide risk among nursing professionals is associated with symptoms of depression and correlated with Burnout Syndrome (Dos Santos et al 2015).
-nursing has undergone a great deal of change, growing pressures to increase efficiency and cost-effectiveness, changes in management roles, decreased number of qualified nurses working in wards, the system of "integrated care" which emphasizes communication between specialities, and ongoing training and updating of knowledge. Also, there has been a change in the education of nurses from a hospital-based to an university-based programme.
In summary, rising costs resulted in a reorganization of the health services changing the working environments of nurses, these changes, including increased workloads and a climate of uncertainty lead to high rates of nurses leaving the profession. This FACT is not a recent problem, there are studies from the 1980's stating that the NHS was having difficulties recruiting and retaining nurses and there were predictions of future nursing shortages (Price Waterhouse 1988).
-negative impact on patient experience, satisfaction and even outcomes (Yang and Huang 2005).
"Unless the factors contributing towards low morale are addressed, qualified nurses will continue to leave, potential recruits will be discouraged from entering the profession and those remaining will continue to be overworked" (Day et al 2007).
Any solutions proposed?
-increased health service resources, in particular for nurse education, might improve nursing morale, but it would take time before any changes would be felt at the ward and individual nurse level. A successful strategy for nursing education has to be consistent and provide resources to pay for this education, time off to do this courses and cover wards when staff are absent for this purpose (Callaghan 2002).
-better pay and better work conditions (Castledine 1997, 1998)
-analyse why morale is so low (Castledine 1997, 1998)
-develop appropriate workplace strategies (Day et al 2006)
-good relationships with co-workers (Day et al 2007)
-participatory supportive management styles, decentralized organizational structures, adequate staffing, flexible working schedules, professional autonomy and responsibility, emphasis on teaching, education and career advancement opportunities (Day et al 2007).
-consider alternative management styles that allow greater flexibility of clinical practice and decision-making while minimizing the level of "non-essential! paperwork and bureaucracy (Day et al 2007).
-encouraging and fostering team work, reducing organizational impediments, antiquated management structures and a mindset of cost-reduction to allow nurses to deliver quality patient care, creating an environment where nurses are recognized for their skill, experience and important contribution to health care provision and consulting and involving nurses in the changes to the health care system (Day et al. 2007).
Nursing is one of the major workforces in the healthcare system, ensuring that nurses are treated fairly and that their morale is protected will increase staff retention and patient safety while potentially, improving patient experience and outcomes (Bengoa et al 2016).
If research is not applied, what is the point of it?
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-Links to articles:
"Subjectivity can be considered a human trait and, as long as humans carry out research objectivity can be questioned. The best thing that researchers can do is acknowledge this reality and attempt to control it."