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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234

Rev. esc. enferm. USP vol.48 no.spe2 São Paulo Dec. 2014

http://dx.doi.org/10.1590/S0080-623420140000800010 

Artigo Original

Supplemental nursing staff´s experiences at a Spanish hospital: Qualitative phenomenology research

A experiência das enfermeiras de turno num hospital espanhol: estudo qualitativo-fenomenológico.

Yolanda Raquel Lapeña-Moñux1 

Luis Cibanal-Juan2 

Mª Isabel Orts-Cortés3 

Mª Loreto Maciá-Soler4 

Domingo Palacios-Ceña5 

1PhD, Assistant Lecturer of the Department of Nursing, University Jaume I, Castellón de la Plana, Spain. ylapenna@hotmail.com.

2PhD, Professor of the Department of Nursing, University of Alicante, Alicante, Spain. luis.cibanal@ua.es.

3PhD, Professor and Director of the Department of Nursing, University Jaume I, Castellón de la Plana, Spain. isabel.orts@uji.es.

4PhD, Professor of the Department of Nursing, University of Alicante, Alicante, Spain. loreto.macia@ua.es.

5PhD, Professor of the Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, University Rey Juan Carlos, Madrid, Spain. domingo_palacios@yahoo.es


ABSTRACT

The objective of this study was to describe the Supplemental Nursing Staff´s experiences at different hospital units. A qualitative phenomenological approach was conducted; a purposeful and theoretical sampling was implemented with supplemental nursing staff at Santa Barbara Hospital of Soria (Spain), to gain a more in-depth understanding of the Supplemental Nursing Staff ´s experience. Data were collected by in-depth interviews and through a field notebook. Data were analyzed using the Giorgi proposal. Twenty-one nurses with a mean age of 46 years were included. Three main topics emerged from the data analysis: building the first contact, carving out a niche and establishing interprofessional/interpersonal relationships. We conclude that the experience of hosting the supplemental nursing staff in changing clinical environments is conditioned by various factors. It is necessary for nurses and hospital managers to establish clear objectives with regard to the supplemental nursing staff´s role in the units.

Key words: Nursing; Supplemental Nursing Staff; Organization and Administration; hospital; Hospitals; Qualitative Research

RESUMO

O propósito deste estudo é descrever a experiência das enfermeiras de turno nas diferentes unidades hospitalares. Seguiu-se um enfoque fenomenológico e qualitativo. Realizamos uma amostragem teórica com o pessoal de enfermagem de turno do Hospital Santa Bárbara de Soria (Espanha), com a finalidade de obter uma compreensão mais profunda do fenômeno. Os dados foram coletados a través de entrevistas e de diário de campo. Os dados foram analisados usando a proposta de Giorgi. 21 enfermeiros de turno com uma média de idade de 46 anos foram incluídos. Três temas principais, que descrevem a experiência das enfermeiras, emergiram dos dados: construindo o primeiro contato, buscando um espaço e estabelecendo relações interprofissionais/interpressoais. Concluimos que a experiência de acolher as enfermeiras de turno em ambientes clínicos mutáveis está condicionada por diferentes fatores. É preciso estabelecer objetivos claros a respeito do papel das enfermeiras de turno nas unidades por parte de enfermeiras e gestores.

Palavras-Chave: Enfermagem; Enfermeiras de turno; Administração Hospitalar; Hospitais; Pesquisa Qualitativa

RESUMEN

El propósito de este estudio es describir la experiencia de las enfermeras “de apoyo” en las diferentes unidades de hospitalización. Seguimos un enfoque fenomenológico cualitativo. Realizamos un muestreo por propósito y teórico de dicho personal del Hospital Santa Bárbara de Soria (España), con el fin de obtener una comprensión más profunda del fenómeno. Los datos fueron recolectados a través de entrevistas en profundidad y diario de campo. Los datos fueron analizados usando la propuesta de Giorgi. Veintiuna enfermeras “de apoyo” con una media de edad de 46 años fueron incluidos. Tres temas principales que describen la experiencia de los enfermeros emergieron de los datos: construyendo el primer contacto, buscando un hueco y estableciendo relaciones interprofesionales/interpersonales. Concluimos que la experiencia de acoger dichas enfermeras en entornos clínicos cambiantes esta condicionada por diferentes factores. Es preciso establecer objetivos claros respecto al rol de las mismas en las unidades por enfermeras y gestores.

Palabras-clave: Enfermería; Enfermeras volantes; Organización hospitalaria; Hospitales; Investigación cualitativa

Introduction

Nowadays, hospitals must adapt to the continuous changes that exist in everyday clinical care. These changes lead to the need for nursing staffing for various reasons (absence of permanent nurses (PN), workload, etc.)(1,2).

Health centres shall pay attention to the management of human resources, focusing on professional skills(3,4), avoid the mismatch between nurses' training and the skills required for the job, and encourage nurses' postgraduate continuing education(5,6).

Variability in nursing staffing and job rotations has serious implications for the workload, the quality of care and the increase in the cost of care(7). Therefore, the same staff should be kept in the different units to allow these to gain experience and training in the management of care.

Other studies have shown advantages of job rotation such as learning new skills and techniques, eliminating the fatigue caused by routine work and facilitating the knowledge of other units; which, ultimately, improve job satisfaction and organizational commitment(2,8).

In Spain, the average number of nurses per 1000 inpatients is 5.28, well below the average of OECD countries (8´7)(7). This means that there is a low nursing coverage in the Spanish health system, which might cause a significant impact on the population's health with regard to nursing care in health promotion, disease prevention and the clinical care provided in healthcare institutions. This nursing shortage is covered by professional nurses called "Supplemental Nursing Staff" (SNS). SNS belong to the same workplace, depend on the Nursing Management Team (NMT), don't have a fixed allocation unit and rotate throughout the various hospital units depending on the organization of work and usually have less professional experience but similar training(1,2).

In USA, some authors explain how supplemental nurses are used to strengthen staffing in the short term. These may belong to the same centre or come from an outside agency(10).

Most of the studies conducted internationally focus on the evaluation of adverse events in patient care associated with the presence of SNS(1,2,10). Other results show how hospitals with a greater number of SNS have worse health outcomes (greater number of falls, readmissions, etc.) in relation to their education level, as most of them hold a high school or GCE diploma(1). Likewise, other authors describe how staffing shortage covered by SNS involves an increase in the risk of nosocomial infections within surgical units(2).

This is the first research study in Spain that aims to understand the SNS's experiences. The aim of this study was to describe the SNS´s experiences at a Spanish hospital.

Method

Design

A phenomenological qualitative research based on Giorgi's analysis was conducted(11). Qualitative studies are used to achieve a deeper understanding of, and find explanations for people’s behaviour under specific circumstances, such as disease or social exclusion(12). The main characteristic of this qualitative methodology is that the researcher is intimately involved in data collection and analysis; data collection requires the researcher to interact with the study participants and their social context, which allows some degree of mutual influence. Phenomenological studies tend to understand how individuals construct their worldview. Therefore, the qualitative design uses first-person narratives from the SNS(11).

Sampling strategies

A two-phase sampling strategy was employed. The first phase involved purposeful sampling to gather information from nurses themselves. The purposeful sampling was performed within the various clinical units to enhance the wealth of information(13). The second phase involved theoretical or in-depth sampling of the remaining nurses to gain a deeper understanding of specific aspects of the information retrieved during the first phase(12) (Table 1).

Table 1 Sampling strategies and data collection method. 

Participants

Inclusion criteria consisted of: SNS from Santa Barbara city Hospital in Soria (Castilla-y-León State, Spain); having been working in the hospital during the time the research study was conducted, and having belonged to the group of SNS for at least 1 year. Twenty-one nurses with a mean age of 46 were included; no one withdrew from the study. Participants continued to be included in the study until no new information was obtained. Nurses were not excluded on the basis of their gender or the king of services of units where they were worked.

Procedure

Researchers made an initial contact with the nurses through the Nurse Manager in each unit. Researchers explained the purpose and design of the study to the nurses on a first face-to-face contact. A two-week period was then allowed for nurses to decide whether or not they wished to participate. At the second face-to-face contact, they were asked to give informed consent and permission to tape the interviews if they wished to participate in the study. Following this, data was collected and the interview was completed.

Data collection method

Data was collected over a period of 1.5 years, from February 2010 to June 2011. Data collection methodology followed the sampling methods as outlined in Table 1. The first phase consisted of unstructured interviews(14), beginning with the following question: What is your experience as SNS?; the aim was to look for emerging themes and topics that could be further expanded upon during the second phase of the study.

The second phase consisted of semi-structured interviews based on a questions guide (Table 2) aimed at eliciting further information regarding specific themes and topics of interest which had emerged from the first round of interviews. The question guide was developed after reviewing the nurses’ accounts obtained during the purposeful sampling and following a literature review. It consisted of direct, open questions to allow nurses to share their own experiences. The interviews were tape-recorded and transcribed verbatim.

Table 2 Questions guide for the semi-structured interview. 

During the interview, the researcher made notes including environment description, nurses’ non-verbal responses to questions, the use of metaphors in their narratives and other relevant points raised by the interviewed nurse.

A total of 26 interviews involving 21 nurses were conducted: 11 were unstructured interviews (phase 1), and 10 were semi-structured interviews (phase 2). The interviews produced recordings totalling 1988.78 minutes (33.14 hours). Documentation of approximately 14-16 pages was produced from each of the interviews. All interviews were conducted at the Hospital.

Data analysis

Texts were collated to allow qualitative analysis to be performed(11). The Giorgi method, which consists of 4 essential steps, was used to implement qualitative analysis of data(15): a) The entire description is read over in order to get a general sense of the whole statement; b) Once the sense of the whole has been grasped, the researcher goes back to the beginning and reads through the text once more with the specific aim of discriminating `meaning units´ from within the perspective and with focus on the phenomenon being researched; c) Once `meaning units´ have been delineated, the researcher then goes through all of the meaning units and express the insight contained in them more directly; d) Finally, the researcher synthesizes all of the transformed meaning units into a consistent statement regarding the subject´s experience.

Quality considerations:

Guidelines for conducting qualitative studies established by the Consolidated Criteria for Reporting Qualitative Research (COREQ)(16) were followed.

The data reliability method consisted of: a) cross-triangulation by the researcher, which included session planning where the cases analysed by each team member were presented in order to reach consensus; b) auditing the material obtained from 10 randomly selected cases by an external researcher(17); and c) nurse verification(11,17). The nurse´s verification was carried out in two steps: post-interview and post-analysis. To allow transferability, researchers provided sufficient detail on the context of the fieldwork for the reader to be able to decide whether the prevailing environment is similar and whether the findings can be justifiably applied to the other setting. Details of the context are: the number of participants involved in the fieldwork; the data collection method employed; the number of the data collection sessions; and the length of the study.

This study was reviewed and approved by the Health Research Unit in Soria (Spain), the institution in which the study was conducted and which gave its approval on April 27, 2010. Special attention was given to the ethical considerations related to the data collection tools used (interviews and researcher field notes), and to the treatment and management of personal data. Permission to record the interviews was always sought prior to their being performed. Informed consent was obtained beforehand and in the event of any emotional response during the interviews, the participant was offered the possibility to either suspend the interview or withdraw the study. All personal data and information that might identify nurses was replaced with a numerical code.

Results

Table 3 shows details of the socio-demographic data for the 21 nurses included in the study. The length of duty in Hospital was variable and ranged between 1 and 59 years, with a mean of 10.52 years. Most nurses worked at medical and surgical units (66.66%).

Table 3 Sociodemographic data. 

The themes that represent the SNS´s experiences at a Spanish hospital were extracted from the interviews. Three specific themes emerged from the analyzed material: a) building the first contact, b) carving out a niche, and c) establishing interprofessional/interpersonal relationships.

Building the first contact

This refers to every element that facilitates and/or hinders the establishment of a first contact between the SNS and the PNs who work in different units.

The SNS highlight the key importance of the first contact with the PNs for the effectiveness of work and working relationships. During this, the PN shall develop skills such as active listening and empathy in order to reassure and guide the SNS.

"How you feel when you are welcomed the first time is going to influence the development of all your work. If you are well welcomed, you'll be willing to help and you'll do your best to get the job done ... "(Nurse8-interview)

In their accounts, the SNS described their feeling uncertain, nervous and stressed when they arrived at the unit. Some of them felt fear, panic to new things, especially to sounds and alarms, which usually coincide with their going to units such as the intensive care unit.

"There are certain units you get to with real fear, and I am terrified of the devices I'll find there and I’ll have no idea how to use". (Nurse15-interview)

Similarly, some nurses described their suffering at certain times.

"Being hired as SNS has caused me much stress. I feel safer if I’m in the same job position every day because I know how it works. I'm in control." (Nurse8-interview).

Carving out a niche

This theme refers to how the SNS should work within a changing clinical environment, in the absence of a reference unit, with unknown patients and an adverse environment, where they must "find their place".

The SNS's main role is to deal with any unexpected medical care within the hospital during any shift. This makes them feel like "hospital fire-fighters".

"I hardly ever know where I'm going to work. I accept I extinguish fires anywhere in the hospital. When I get to my shift, I am told where I have to go to work. There is no programming." (Nurse8-interview)

The excessive mobility to which SNS are subjected, even within the same work shift, is considered by them as one of the greatest difficulties.

"... I came in the morning and I was sent to a unit, but that very morning I worked in three different places...". (Nurse12-interview)

This group of professionals is affected by the inability to achieve expertise and/or gain certain skills and abilities related to their job specialization due to their constant rotation.

"The worst thing is that you don't get to control things you have to do because you're constantly changing and of course this affects the quality of care." (Nurse18-interview)

"...you don't have a physical department to which you belong, which involves drawbacks such as the lack of location, materials, techniques, treatments and specific care of the unit, the inability to specialize in a particular area ..." (Nurse17-interview).

Establishing interprofessional/interpersonal relationships

This theme focuses on how SNS establish interprofessional and interpersonal relationships with nurses from other units and other professionals such as doctors, nurse assistant, laboratory technicians, etc.

SNS feel that when they happen to meet other nurses who have carried out this very role, they find it easy to empathize.

"There are colleagues who don't empathize with us, they just don't care. I've met other nurses who have worked as SNS like me and they treat me better, they help me with the protocols used ... I wonder: "If they had to spend a day in a certain unit and the next in a different one and start from scratch, how would they feel?" (Nurse4-interview)

Some participants consider the PNs and the NMT's attitude towards the SNS and their work in the unit as a key element to develop a good working environment and good relationships. Nurses describe how the PNs judge the SNS and their ability to work, without considering their situation, just as the nursing management team does not consider or control the environment the SNS face when they arrive at the new units.

"We feel unhappy, but unit nurses feel the same way, and that affects the quality of our care. In this regard, the management team should be more responsible, we are not a number ... ". (Nurse10-interview)

"... The Nursing Management Team leaves us to the unit nurses' fate and good mood, who seldom ask about your preferences and experiences or the way you feel when you are given a destination" (Nurse5 -interview).

Discussion

Building the first contact

The SNS usually work in different units even in the same work shift and establish relationships with multiple professionals.

Generally, the arrival at a new unit makes the new professional perceive both environmental (shift rotations, high job demand, inability to reach physicians) and professional stimuli (role ambiguity, lack of knowledge and skills) that cause them a sensory overload(18).

In our research study, supplemental nurses emphasized the importance of the first contact at the unit, as well as the PNs' attitude in their reception. According to various research studies(19,20), a positive feedback from an experienced professional to a novel professional may result in the improvement of their reception, recognition and learning opportunity. Likewise, the experienced permanent staff's empathic ability helps the newly hired staff to attain the objectives set in each unit(21).

The SNS's attitude upon their arrival at the new unit will condition their socialization process during their workday. Consistent with our results, previous studies show how SNS experience different feelings about the rotation process throughout the various units: functional impairment, communication problems and inability to take responsibility, stress related to the workload, interpersonal relationships and lack of support, affecting their physical and mental health(22,23).

These feelings are strengthened when the work is carried out at special units such as intensive care units (ICU). In this regard, some authors show that most nurses who rotate through the ICU feel they must constantly prove their knowledge and skills to be accepted by their colleagues(20). Consistent with our results, other authors show that the confidence gained when doing things well, mastering the tasks carried out within the unit and enjoying work command contribute to enhance the adaptation to the frequent changes throughout the units(24). In Spain, one research show that 36% of the SNS disagreed on rotating to other units for fear of criticism, and 31% did not want to be SNS for fear of not being accepted(7).

Carving out a niche

Every time NSN are sent to a particular unit and must adapt to its working reality. Therefore, these professionals must have sufficient time to adapt to the new team's culture. In this regard, it is highly important for these rotating professionals to be accepted in the team, which also means their having found a "niche"(25). In our study, it can be observed that SNS don't know the unit they are to work in until they start their workday. This means they have a certain period of time to adapt and this will affect their ability to establish social bonds with the rest of the team.

In this line, according to other researches, no nurses described positive experiences when were changed to a different unit in the rotation process established by the hospital. Instead, they showed high levels of stress, anxiety and uncertainty towards the new location. Similar results are obtained from our participants' accounts(26). However, according to these, some of the interviewed nurses described their having to rotate to up to three different units in the same working day, which made them feel out of control.

On the other hand, Benner describes the process of clinical judgment and skill development at 5 levels of proficiency: Novice, advanced beginner, competent, proficient, and expert(27). Thus, SNS would be likely to stay in a particular role and may never reach the level of expert(7).

Previous studies show how feeling part of the team facilitate achieving a level of expert, which can only be obtained once you've been working at least one year in the same unit(18).

Establishing interprofessional/interpersonal relationships

The presence of new nurses implies a work overload for the rest of nurses and involves a difficult relationship with the most experienced staff(18).

In our results, nurses report their feeling understood by the PN who had belonged to the group of "SNS". Not so for those PNs that are not able to understand the newcomers' insecurities, as they believe these shall go through all the stages, as they did in their day(26).

Therefore, when there is a rejection from the PNs towards the SNS, isolation and marginalization occurs, starting the vicious circle of rejection-isolation-lack of relationships-poor quality of work. Likewise, when there is a mutual respectful relationship between all professionals results in a greater work effectiveness and mutual learning, which is positive for everyone(28).

The unit supervisor and the hospital NMT's attitude condition the SNS's reception in the units throughout which they rotate. Thus, a study show most new nurses stated having received an unprofessional behaviour on the part of their experienced colleagues in both the transition and integration process. Furthermore, unit supervisors did not know exactly about the new nurses' behaviour at the different units(23).

Other authors describe how the unit assigning process carried out by the managers shall aim at building expertise in order to provide an outstanding care(7). Thus, the NMT should assign the units based on the SNS's experience and training, facilitate friendship between equals, especially in the first months of employment, as well as try to find the balance between the hospital and these professionals' expectations(29). In our study, nurses state that their preferences are not heard when being assigned a hospital unit.

In this line, other study state that nearly 70% of new nurses undergo an adaptation program in their first days of employment, in which they were assigned a clinical unit of their choice, allowing them to assimilate the challenges of the new environment and gain more responsibility and knowledge(25).

In Spain, other researches show that the SNS's dispersion among different workspaces hinders the establishment of stable relationships with patients, colleagues and work(30).

Limitations

There are some limitations in the current study. Firstly, some nurses stated their being concerned about expressing their opinion, as they were afraid their job provision might change as a result of this. However, to counter this, nurses were reassured that all the researchers were separate from the manager team, and all discussions would be confidential. Finally, since this is a qualitative research conducted within a specific context, that of a country in the South Europe, similar qualitative studies should be carried out in multiple environments to gain a better understanding of the phenomenon.

Conclusions

The PNs' attitude and involvement of PN and NMT influences the SNS's adaptive capacity to the units and the establishment of interprofesssional relationships. It is necessary to avoid frequent changes of units and assign a PN to guide and support the SNS.

The results of this study can be used by the hospital MT to improve the SNS's daily work. Understanding the PNs' perception can help develop more realistic environments within clinical settings. SNS's integration programs need to be developed within the units. Introducing joint action protocols will improve the SNS's work effectiveness and ensure a greater quality of care.

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Received: April 30, 2014; Accepted: July 16, 2014

Correspondence Yolanda Raquel Lapeña Moñux. ylapenna@hotmail.com. Departamento de Enfermería. Universidad Jaume I. Tfn: +34 652499598 C/ Avda. Sos Baynat, S/N. 12071 - Castellón de la Plana- España

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