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Care providers’ narrated experiences of working in private non-profit residential care for older people during downsizing and reorganisation, focusing on troubled conscience
Umeå University, Faculty of Medicine, Department of Nursing.
Umeå University, Faculty of Medicine, Department of Nursing.
Umeå University, Faculty of Medicine, Department of Nursing. Department of Health Care Sciences, Ersta Sköndal University College, Sweden.ORCID iD: 0000-0001-5994-4012
Department of Health Care Sciences, Ersta Sköndal University College, Sweden.
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2017 (English)In: Nordic journal of nursing research, ISSN 2057-1585, E-ISSN 2057-1593, Vol. 37, no 4, p. 177-185Article in journal (Refereed) Published
Abstract [en]

Knowledge about care providers’ experiences of working in residential care of older people during times of downsizing and reorganisation is scarce, and it is not known whether/how their conscience is influenced by such changes. The aim was to describe care providers’ experiences of working in private residential care for older people during downsizing and reorganisation, focusing on troubled conscience. This study adopted a qualitative descriptive design based on interviews with seven care providers. A qualitative content analysis was used. The overall understanding was revealed as perceiving oneself as pinioned in between current circumstances to provide care and what one’s conscience conveyed. Care providers perceived: deteriorating working conditions as exhausting, downsizing and reorganisation as triggering one’s conscience when collaborating, troubled conscience when downsizing and reorganisation decrease the quality of care, and good management as crucial during downsizing and reorganisation. The results highlight that adequate communication strategies, well-functioning leadership and opportunities to know together and share what one’s conscience tells are aspects that need consideration.

Place, publisher, year, edition, pages
Sage Publications, 2017. Vol. 37, no 4, p. 177-185
Keywords [en]
care providers, conscience, content analysis, downsizing, reorganisation, residential care of older people
National Category
Nursing
Research subject
Caring Sciences
Identifiers
URN: urn:nbn:se:umu:diva-100067DOI: 10.1177/2057158516678160OAI: oai:DiVA.org:umu-100067DiVA, id: diva2:789752
Projects
Stress of conscience and burnout among healthcare personnel in elderly care
Funder
Swedish Research Council, K2011-70X-21823-01-3Forte, Swedish Research Council for Health, Working Life and Welfare, 2010-0296
Note

Previously included in thesis in manuscript form, with title "Care providers’ narrated experiences of working in private residential care for older people during downsizing and reorganisation with focus on troubled conscience". 

Available from: 2015-02-20 Created: 2015-02-20 Last updated: 2022-03-15Bibliographically approved
In thesis
1. Stress of conscience and burnout among healthcare personnel working in residential care of older people
Open this publication in new window or tab >>Stress of conscience and burnout among healthcare personnel working in residential care of older people
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background This thesis was part of the research programme ‘Stress of Conscience and Burnout among Healthcare Personnel in Elderly Care’ at Umeå University. Relationships have been found between stress of conscience, perception of conscience, burnout, and social support. No longitudinal studies investigating these relationships have been performed previously, thus it was not known how these relationships develop over time. Neither was it known how stress of conscience and other phenomena of importance might vary between organisations because no comparative studies have been performed. It seems important to organize the care of older people in such a way that healthcare personnel can stay healthy at their workplace, especially because the aging population is expected to grow. Studies have shown that stress of conscience is associated with the well being of healthcare personnel and the quality of care they provide. In order to develop measures against stress of conscience, it seems important to gain a deeper understanding of the aspects in daily work that can generate troubled conscience among healthcare personnel.

 

Aim The overall aim of this thesis was to describe, compare, and investigate longitudinal relationships between stress of conscience, perceptions of conscience, burnout, social support and person-centred care among healthcare personnel working in two different organisations for residential care of older people. Furthermore, the aim was to deepen the understanding of some aspects of importance that generate troubled conscience at each of the two organisations. Based on the emerging knowledge from the research programme and the results from studies І and ІІ, important aspects that can generate troubled conscience among healthcare personnel were shown to be working with guidelines and working during times of downsizing and reorganisation.

Methods Studies Ι and ΙΙ took quantitative approaches with a longitudinal design (Ι) and a cross-sectional design (ΙΙ), while studies ΙΙΙ and IV were based on a qualitative approach. In study Ι, the participants were healthcare personnel working in an organisation for residential care of older people with a public mode of operation located in a small town in northern Sweden (baseline n = 488, follow-up n = 277). In study ΙΙ, the participants were healthcare personnel working in two different organisations chosen to be as different from each other as possible regarding their characteristics. In this study, an organisation with a private mode of operation and located in a large city in the south of Sweden (n = 98) was compared to the baseline data from the publically run organisation from the small town in study Ι (n = 488). In studies ΙΙΙ (n = 8) and IV (n = 7), the participants were care providers working at the same public organisation (ΙΙΙ) and private organisation (IV) as in studies Ι and ΙΙ. Quantitative data were analysed using partial least square regression with jack-knife approximate t-tests, hierarchical cluster analysis with multiscale bootstrap resampling, descriptive statistics, hypotheses tests, effect size measures, and confidence intervals. Qualitative data were analysed using qualitative content analysis.

Results The main results showed that the healthcare personnel reported higher levels of stress of conscience than have been reported in other studies. Perceiving one’s conscience as a burden, having high levels of emotional exhaustion and depersonalisation, and noticing disturbing conflicts between co-workers were positively associated with stress of conscience. Associations between stress of conscience and perceiving one’s conscience as a burden and burnout were similar among healthcare personnel despite the differences in the characteristics of the organisations they worked in. Women reported higher levels of stress of conscience and less social support from their co-workers compared to men. This thesis also provides new insights about how working according to guidelines and during times of downsizing and reorganisation can be burdensome issues for care providers and can generate troubled conscience. An overall understanding of care providers experiences of guidelines in daily work was revealed as struggling to do their best; prioritising between arcane guidelines while keeping the residents’ needs in the foreground.  They described experiences that guidelines were coming from above, were controlling and not sufficiently anchored at their workplace. They also described guidelines as stealing time from residents, colliding with each other, lacking practical use and complicating care, and challenging their judgment. An overall understanding of care providers’ experiences of working  during times of downsizing and reorganisation was revealed as perceiving oneself as pinioned in between current circumstances to provide care and what one’s conscience conveyed. They perceived loss of good management, changed working conditions as exhausting and activating their conscience. They also expressed how they perceived troubled conscience when working conditions decreased the quality of care.

Conclusion The results is reflected on in relation to a nursing care model as it seems important to understand the results from a society- and organizational perspective as well as from an individual perspective. The results of the thesis show that it is important to provide healthcare personnel with opportunities to follow and express what their conscience tells them at their workplace in order to buffer the effects of stress of conscience. Support, knowledge, involvement, time, and additional resources are key issues that can help care providers to work more constructively with guidelines in their daily practice. The results show that in times of downsizing and reorganisation it is important to exercise leadership that promotes care providers’ feelings of involvement, security, and togetherness in order to relieve some of the healthcare personnel’s burdensome experiences. An overall understanding of the results is that it seems important to organize the residential care of older people in such a way that registered nurses and leaders are able to be present in healthcare personnel’s daily practice. Healthcare personnel need attendant and supportive leaders who can help them to solve various forms of work-related problems and to help them make priorities in the daily care of residents. This seems important regardless of whether the priorities are between guidelines and residents’ needs or a consequence of an increasingly stressful work environment during times of downsizing and reorganisation. Further studies are needed in order to investigate the importance of gender in relation to stress of conscience and if different kinds of support are needed for women than for men in order to buffer the effects of stress of conscience. Finally, more longitudinal multilevel studies are needed in order to investigate how organisations’ characteristics and organisational changes affect healthcare personnel’s levels of stress of conscience.

Abstract [sv]

Bakgrund Denna avhandling var en del av forskningsprojektet ”Samvetsstress och utbrändhet bland personal inom äldreomsorg”, vid Umeå universitet. Resultat har visat att det finns samband mellan samvetsstress, syn på samvete, utbrändhet och socialt stöd. Inga longitudinella studier som undersöker dessa samband har utförts tidigare och därför är det inte känt hur dessa samband kan utvecklas över tid. Det är inte heller känt hur samvetsstress och andra betydelsefulla fenomen kan variera mellan organisationer eftersom jämförande studier saknas. Det är viktigt att organisera vården av äldre personer på ett sådant sätt att vårdpersonal kan hålla sig friska på sina arbetsplatser, i synnerhet med tanke på att andelen äldre i befolkningen förväntas öka. Studier har visat att samvetsstress är relaterat med vårdpersonalens välbefinnande och kvaliteten på den vård de tillhandahåller. För att utveckla åtgärder mot samvetsstress är det viktigt att få en djupare förståelse om aspekter i det dagliga arbetet som kan generera dåligt samvete hos vårdpersonal.

SyfteDet övergripande syftet med avhandlingen var att beskriva, jämföra och undersöka longitudinella samband mellan samvetsstress, syn på samvete, utbrändhet, socialt stöd och personcentrerad vård bland vårdpersonal som arbetar inom två olika organisationer för äldreomsorg. Syftet innefattade även att fördjupa förståelsen av betydelsefulla aspekter som genererar dåligt samvete inom båda organisationerna. Baserat på den framväxande kunskapen från forskningsprogrammet och resultaten från delstudierna І och ІІ framkom det att viktiga aspekter som kan generera dåligt samvete var att arbeta med riktlinjer och att arbeta i tider av nedskärning och omorganisering.

Metod Studierna Ι och ΙΙ baseras på kvantitativa metoder, en med longitudinell design (Ι) och en med tvärsnittsstudie design (ΙΙ).  Studierna ΙΙΙ och IV baseras på kvalitativ metod. Deltagarna i delstudie Ι bestod av vårdpersonal som arbetade inom en offentlig organisation för äldreomsorg lokaliserad i en liten stad i norra Sverige (baseline n = 488, uppföljning n = 277). Deltagarna i delstudie ΙΙ var all vårdpersonal som arbetade inom två olika organisationer för äldreomsorg valda att vara så olika varandra som möjligt gällande olika karaktäristika. Den ena organisationen hade privat driftsform och var belägen i en stor stad i södra Sverige (n = 98), baseline data från studie Ι (n = 488) användes beträffande den andra organisationen. Delstudierna ΙΙΙ (n = 8) och IV (n = 7) bestod av vårdpersonal som arbetar inom samma offentliga organisation (ΙΙΙ) och privata organisation (IV) som i delstudierna Ι och ΙΙ. Kvantitativt data analyserades med ‘partiel least squares regression’ och ‘jackknife’ approximativa t-tester, hierarkisk klusteranalys med ‘multiscale bootstrap resampling’, beskrivande statistik, hypotestester, olika effektmått, konfidensintervall. Kvalitativa data analyserades med kvalitativ innehållsanalys.

Resultat Huvudresultaten visade att vårdpersonal skattade högre nivåer av samvetsstress jämfört med vad som har rapporterats i andra studier. Resultaten visade att uppfatta sitt samvete som en börda, höga nivåer av emotionell utmattning och cynism samt att bevittna störande konflikter mellan medarbetare var positivt korrelerat med samvetsstress. Trots stora skillnader gällande organisationernas karaktäristika var sambanden mellan samvetsstress och att uppfatta sitt samvete som en börda samt utbrändhet samstämmiga. Kvinnor skattade högre nivåer av samvetsstress och mindre socialt stöd från sina arbetskamrater jämfört med män.  Denna avhandling ger också nya insikter om hur arbete i enlighet med riktlinjer och under tider av nedskärningar och omorganisering kan vara en tung börda för vårdpersonal att bära och hur det kan generera dåligt samvete. Den övergripande förståelsen av vårdpersonalens erfarenhet av riktlinjer i det dagliga arbetet visade att vårdpersonalen kämpar för att göra sitt bästa, prioriterar mellan svårbegripliga riktlinjer samtidigt som boendes behov hålls i förgrunden. Vårdpersonalen beskrev hur dom upplevde att riktlinjer kommer från ovan, är kontrollerande och inte tillräckligt förankrade.  De beskrev också hur riktlinjer tar tid från de boende, krockar med varandra, saknar praktisk nytta och komplicerar omvårdnaden samt utmanar det egna omdömet. Den övergripande förståelsen av vårdpersonalens erfarenheter av att arbeta under tider av nedskärningar och omorganisering visade att vårdpersonalen uppfattar sig själv som bakbundna mellan rådande omständigheter att ge omvårdnad och vad deras samvete förmedlar. Vårdpersonalen upplevde sig vara utan gott ledarskap och förändrade arbetsvillkor som utmattande och aktiverade samvetet. Vårdpersonalen uttryckte också hur de fick dåligt samvete när de upplevde att arbetsförhållandena försämrade vårdkvaliteten.

Slutsatser Eftersom det förefaller viktigt att förstå resultaten utifrån ett samhälls- och organisationsperspektiv likväl som ur ett individperspektiv utförs reflektioner av resultaten utifrån en omvårdnadsmodell. Resultat i denna avhandling visar att det är viktigt att ge vårdpersonalen möjligheter att på sin arbetsplats följa och uttrycka vad deras samvete säger för att effekterna av samvetsstress ska mildras. Stöd, kunskap, engagemang, tid och övriga resurser är faktorer av betydelse som kan hjälpa vårdpersonal att arbeta mer konstruktivt med riktlinjer i sitt dagliga arbete. Resultaten visar att i tider präglade av nedskärningar och omorganisering är det viktigt med ledarskap som främjar vårdpersonals känslor av engagemang, trygghet och gemenskap för att en del av vårdpersonalens betungande erfarenheter ska kunna lindras. En övergripande förståelse av resultaten är att det förefaller vara av vikt att äldreomsorgen organiseras på ett sådant sätt att sjuksköterskor och chefer har möjlighet att vara tillgängliga i vårdpersonalens dagliga praktiska arbete. Vårdpersonal behöver stödjande och tillgängliga ledare som kan hjälpa till att lösa olika former av arbetsrelaterade problem och att göra prioriteringar i den dagliga omvårdnaden. Detta förefaller vara av vikt oavsett om prioriteringarna är mellan riktlinjer och boendes behov eller en konsekvens av en av en alltmer stressig arbetsmiljö under tider av nedskärningar och omorganisering. Ytterligare studier behövs för att undersöka vikten av genus i relation till samvetsstress och om olika former av stöd behövs för kvinnor och män i syfte att mildra effekterna av samvetsstress. Det behövs fler longitudinella ‘multilevel’ studier för att kunna undersöka hur organisationers karaktäristiska kan påverka vårdpersonalens nivåer av samvetsstress.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2015. p. 69
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1702
Keywords
Healtcare personnel, stress of conscience, burnout, social support, guidelines, downsizing, reorganisation, care of older people., vårdpersonal, samvetsstress, utbrändhet, socialt stöd, riktlinjer, nedskärningar, omorganisering, äldreomsorg.
National Category
Nursing
Research subject
Caring Sciences
Identifiers
urn:nbn:se:umu:diva-100068 (URN)978-91-7601-229-1 (ISBN)
Public defence
2015-03-20, Vårdvetarhusets aula, Vårdvetarhuset, Umeå universitet, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Projects
Stress of Conscience and Burnout among Healthcare Personnel
Funder
Swedish Research Council, K2011-70X-21823-01-3Forte, Swedish Research Council for Health, Working Life and Welfare, Dnr: 2010-0296AFA Insurance, 090136
Available from: 2015-02-27 Created: 2015-02-20 Last updated: 2018-06-07Bibliographically approved

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Johan, ÅhlinStrandberg, GunillaAstrid, NorbergEricson-Lidman, Eva

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