Remaining in the nursing profession: The relevance of strong evaluations

Abstract

Background:

Why nurses remain in the profession is a complex question. However, strong values can be grounds for their remaining, meaning nurses evaluate the qualitative worth of different desires and distinguish between senses of what is a good life.

Research question:

The overall aim is to explore and argue the relevance of strong evaluations for remaining in the nursing profession.

Research design:

This theoretical article based on a hermeneutical approach introduces the concept strong evaluations as described by the Canadian philosopher Charles Taylor and provides examples of nurses’ experiences in everyday nursing care drawn from a Norwegian empirical study.

Participants and research context:

Data collected in the original study consisted of qualitative interviews and qualitative follow-up interviews with 13 nurses. The research context was the primary and secondary somatic and psychiatric health service, inside as well as outside institutions.

Ethical consideration:

The article uses data from an original empirical study approved by the Norwegian Social Science Data Services. Information was given and consent obtained from the participants.

Findings:

Remaining in the nursing profession can be understood as revolving around being a strong evaluator. This has been concretized in issues of being aware of different incidents in life and having capacities as a nurse.

Discussion:

Why nurses remain is discussed in relation to how nurses have shaped themselves by reflecting on what is of significance in their life. However, being a strong evaluator cannot be seen as the casual condition for remaining.

Conclusion:

Remaining in the nursing profession is obviously not a contingent matter, rather it is a matter concerned with the qualitative worth of different desires and values. Nurses’ awareness of a life choice impacts on whether they remain or not. Consequently, nurses may need to articulate and reflect on their priorities for remaining.

Keywords

Everyday nursing experiences nursing profession remaining self-understanding strong evaluations

Introduction

Over the last few decades, nursing literature has documented a global shortage of nurses. There is worldwide concern about this shortage, which is difficult to quantify, and great variations exist in the scope.^1,2 This implies a dramatic increase in the need for nurses and the demand is expected to be greater than the growth in the supply. The shortage of nurses can also be related to turnover, although this does not necessarily mean nurses leave nursing.³ Nevertheless, the cost of a turnover nurse is a lot more than the cost of a typical nurse who remains,⁴ including aspects such as lost productivity, decreased efficiency, and lost human capital.⁵ This is expected to have a serious impact on the quality of nursing care,^2,5,6 which again might have impact on nurses themselves.

Research has previously documented that the question of why nurses remain in the profession is a complex one, and it is problematic to understand what influences it⁴ and which casual mechanisms can explain it.⁵ In recent decades, researchers have developed several theoretical and empirical models to understand why nurses remain.^7
–9 Some models focus on nurses’ intention to stay^7,9,10 or their desire to stay,⁸ while other models focus on intention to move on.³ These models point out various sets of dimensions, such as characteristics of the nurse, organization, manager, and work, that are expected to exert influence.^3,7,9 Notably, the intention to stay seems to be influenced by the same dimensions as the intention to leave.² Few models have been statistically tested.⁸ It has nonetheless been pointed out that both the theoretical and empirical models can be used as a guide for development of effective nurse retention strategies.^2,4

More specifically, research has documented that organizational factors, such as working environment, collaboration with colleagues, and balanced work load, as well as manager’s leadership and power over work coordination, relationship with and support from one’s manager, have influence on why nurses remain.^5,7,10
–12 Additionally, research has also previously documented that factors described as other-oriented values, for example, delivering high-quality nursing, meeting the patients’ needs,^1,11
–13 and psychological engagement,^10,14 and more self-oriented values, such as professional development and development opportunities,^10,11,12,15 job-satisfaction,^16
–18 support for work-life balance, and lifestyle preferences,^19

–23 can be involved.

Against this background, it is possible to point out that previous research has developed several models and given a broad picture of dimensions and factors related to the question of why nurses remain in the nursing profession. In other words, it is well documented that the question is important. Nevertheless, the question seems difficult to answer, as there is no consensus on the issue. There is still a need to better understand impacting factors. To our knowledge, there are few studies which can be linked explicitly to nurses understood as human beings with a capacity to base their evaluations on strong values. Such evaluations give opportunity to focus on the qualitative worth of different desires and contribute to distinguishing between senses of what is a good life. Thus, this theoretical article aims to contribute to a more elaborate understanding of what is of significance for remaining.

Aim

The overall aim is to explore and argue the relevance of strong evaluations for remaining in the nursing profession.

The article first introduces the concept of strong evaluations based on the well-known philosophical anthropology of the Canadian philosopher Charles Taylor,^24,25 meaning that mainly one concept of his philosophical anthropology is used. Taylor’s philosophical anthropology is internationally and nationally known and used within nursing.^26

–29. It can be argued that his view on the human being’s capacity to be a strong evaluator is a useful basis for deepening understanding of what is of significance for remaining in the nursing profession, particularly because he specifically connects the concept to self-understanding and to morality by spotlighting on what constitutes a good life. The concept of strong evaluations is thus seen as suitable for the endeavor to comprehensively understand everyday experiences of remaining.

This article then explores nurses’ expressions of what is of significance for them to remain in the profession by drawing empirical examples from a larger Norwegian study.¹¹ The examples are considered as relevant in interpreting what is of significance for remaining based on Taylor’s^24,25 clarification of strong evaluations, indicating a hermeneutical approach.³⁰ Such an approach and analytical strategies in generating the examples are nevertheless underplayed here.¹¹ It is important to mention that the larger empirical study, which focuses on remaining in nursing practice and the nurses’ life-view,¹¹ was based on a hermeneutical research design.³⁰ The empirical data in the larger study consisted of qualitative interviews and qualitative follow-up interviews (in all 27 interviews). Qualitative follow-up interviews were used to deepen the already collected data about day-to-day experiences of caring for patients.^11,31 Data analysis was based on a phenomenological hermeneutic approach.³² The different steps in the analysis were narrative reading, different thematic readings, and a comprehensive understanding. In order to interpret, the analysis was dialectical, moving between the spontaneous understanding of the text gained through naive understanding and the comprehensive interpretation mediated by the thematic analysis.³²

Ethical consideration

The original empirical study was approved by Norwegian Social Science Data Services (NSD). Written information about the study was given and consent was obtained from the participants.¹¹ Permission to proceed with using anonymized data as empirical examples is generally given by NSD, and therefore, the participants were not contacted again.

Strong evaluations based on the view of Taylor

To introduce how Taylor^24,25 describes strong evaluations, it is relevant to start with his view on human beings’ capacity for self-understanding.

Human beings’ capacity for self-understanding

Taylor states that human beings are self-interpreting animals.²⁴ This means that he links his view on human beings to a capacity to understand, which basically requires feeling and thinking. More precisely, Taylor^24,25 claims that feelings attribute imports, implying that they open us to the domain of what it is to be human. Feelings thus reveal what being a human being involves for us in that they contribute to giving things different values. Taylor^24,25 explicates that feelings can be expressed by what we want to do, have or experience, and also as something deeper, such as having a sense of what the good life is for a subject. This implies that feelings are closely linked to the human being’s capacity to think and are consequently intentional and not solely linked to inner feelings. In other words, feelings and thoughts are described as mutually constitutive of each other, even though Taylor^24,25 admits that feelings can be irrational or inadequate as well as rational or adequate.

Taylor^24,25 further clarifies that feelings and thoughts are used to make qualitative discriminations. To explore what such a capacity incorporates, strong evaluations need to be elaborated upon.

Strong evaluations

Taylor defines strong evaluation as an evaluation concerned with the qualitative worth of different desires and goals.²⁴ This means that using our capacity to feel and think we can distinguish between senses of what the good life is. It is by distinguishing we can make qualitative discriminations between our desires and goals. Taylor^24,25 points out that making qualitative discriminations involves seeing some desires or goals as higher and others as lower, some as good and others as discreditable, still others as evil, some as truly vital, and others as trivial. Thus, he establishes a philosophical distinction between strong and weak values.

It is worth noting that the distinction between strong and weak values is closely linked to worth. More precisely, Taylor^24,25 emphasizes that strong values are understood as things with categorical or unconditioned worth, while weak values are understood as things with conditioned or less worth. This implies that strong evaluations involve a background of distinctions between things which we recognize as of categorical, unconditioned or higher importance or worth, and things which lack this or are of lesser value. It also implies that strong evaluations are involved in our self-understanding as a background, meaning that we essentially see ourselves against a background of strong evaluations. Importantly, this involves seeing strong evaluations not as just a matter of circumstances,²⁴ but as actions, or even ways of life.²⁴ Another way of stating this is to say that strong evaluations do not revolve around single and more continuous situations. Instead, Taylor^24,25 introduces the distinction between strong and weak evaluations to contrast the different kinds of self that each involves. Consequently, strong evaluations are quite different from weak evaluations.

By describing weak evaluations, we can better understand strong evaluations. Taylor²⁴ clarifies that in weak evaluations, for something to be judged good it is sufficient that it be desired, and thus, when one desired alternative is set aside, it is only on grounds of its contingent incompatibility with a more desired alternative. This means that setting aside one desired alternative based on weak evaluations does not imply that the alternatives must be contrastively described. It is also worth noting that for Taylor,^24,25 self-understanding solely based on a weak evaluation can be understood as an identity crisis and in extreme cases characterized as narcissistic personality disorders.

Although strong evaluations imply a much richer language than weak evaluations, they are more or less articulated. Taylor²⁴ points out that human beings have a largely inarticulate sense of what is of decisive importance. Nevertheless, it is through language we can bring to explicit awareness what we formerly had only an implicit sense of. This means that by articulating what is of significance in life, we can bring it to fuller and clearer consciousness. By emphasizing language, Taylor^24.25 makes it evident that articulating can contribute to a change in the human being’s self-understanding.

In the following sections, empirical examples describing how nurses expressed what is of significance for remaining in the nursing profession are explored.

Exploring empirical examples of nurses’ everyday experiences related to what is of significance for remaining in nursing

The empirical examples demonstrate that nurses are aware of different incidents in life and having capacities as a nurse.

Being aware of different incidents in life

Incidents or events in life experienced as what simply occurred within life can be more or less articulated, and thereby part of an individual’s awareness. Empirical examples show that some nurses described incidents in life as “seemingly random.” Despite this, the empirical examples demonstrate that choosing the nursing profession was not completely random because the nurses admitted they were influenced by a desire to pursue an exciting career or to follow friends’ recommendations, a mother’s highest wish or grandparents’ advice. This means other people provided support in an uncertain situation and choosing nursing as a profession involved relying on them.

Choosing nursing as a profession could also be articulated as an incident influenced by a sense of being in love with human beings in general. One nurse working in a medical ward said,

I’m very fond of people who are less fortunate in life. If I look back to my life as young, I had a perception that I liked to care about people and so I was suited to becoming a nurse. (1)

Here, it is possible to see how the nurse expressed important values, such as caring about human beings with bad life conditions and evaluated the value as related to nursing.

Other nurses articulated less positive experiences connected to incidents in life. Empirical examples nevertheless demonstrate that they contributed to choosing nursing as a profession. One nurse working in a psychiatric ward said,

I sometimes wonder if my commitment is related to my own childhood and having someone close who was ill and depressed. So my commitment might be something that is deep rooted because I experienced strong things at a young age and despite this, I have not lost my faith. (2)

Another psychiatric nurse said,

I had a family member who was mentally ill and lobotomized, perhaps there is a link, possibly, I’ve reflected upon it, and it comes up in my consciousness: you must do something else. (3)

These empirical examples demonstrate more concretely how nurses expressed that relationships with sick and disabled family members presented challenges and thereby inspired an understanding of what really matters in life. Because the nurses had experienced how something was skewed or should have been better in life, a more general desire to help others became increasingly important. It contributed in turn to engaging with patients and maintaining the hope that the patient’s life would become better. In other words, this basically revolves around questions of who one is and will become as a human being and a nurse.

The empirical examples further demonstrate that being aware of personal experiences related to incidents in life made it possible for the nurses to value their own lives as nurses more highly than if there were not nurses. One medical nurse said,

I have an understanding that the profession is like that. There are difficult situations. Although I want good days, I understand that there is meaning in what is difficult. In a way, it revolves around being completely inside the core of things, a lot is peeled away and many patients live well amid difficulties. (4)

This empirical example can be understood as an expression of the nurse’s insight into how life unfolds in nursing care related to patients’ life conditions. Choosing another profession is nonetheless experienced as not preferable because merely leading a good life is seen as unrealistic. Articulating that the nursing profession is not necessarily better or worse than other life professions implies evaluating life contrastively.

Having capacities as a nurse

Empirical examples show that having capacities as a nurse is related to articulation of their own professionalism. One psychiatric nurse said,

In some areas I have professional confidence, meaning I have worked with patients who experience strong symptoms, acting out and sexual abuse, and I’m not significantly dragged down by these symptoms. This means that I can work closely with patients and distance myself from them at the same time, enabling me to achieve something, and I know that I have a calming effect on agitated patients. (5)

Here, it is possible to see how the nurse valued her own professionalism in being able to withstand demanding situations in encountering patients without becoming insensitive or uncaring. This confidence can be seen because the nurse articulated that her own professionalism provided the basis for nursing care and strengthened her capacity to help patients. Another nurse working in a nursing home said more concretely,

I’m not that afraid any more. I don’t feel anxiety like I did before. At the beginning of my career I had many strange thoughts before entering the patients’ room. It was an inner feeling of disquiet even though nobody could see it from outside. (6)

This nurse’s awareness of her own capacity contributed to presenting a kind of authority, which in turn reduced her fear of demanding situations. The empirical example demonstrates how feelings and thoughts about worst case scenarios had dissipated, implying that the nurse experienced a better understanding of what goes on in nursing care and was able to answer questions about who she was as a nurse. This again may give the individual nurse great satisfaction and pleasure.

Pleasure related to personal capacity as a nurse was connected to a lasting feeling related to nursing care situations. Empirical examples show that this kind of pleasure was experienced when the nurses made the day better for patients. One nurse working in a nursing home concretely expressed how she evaluated such situations:

There is more than enough pleasure to me if a nursing care situation changes from less good to good, for example, when the most agitated patient calms down and tells me what is needed, and consequently calms down. (7)

An intensive care nurse said,

When we can reduce sedation and ventilator treatment and the critically ill patient is more awake while still lacking voice because of tracheostomy, and despite this, tries to move their lips to express words—this gives me a lot. (8)

This empirical example shows how important the nurse experienced the body’s healing process, particularly every moment a vulnerable patient expressed a wish to be alive and live. This can be understood as an articulation of the nurse’s reverence for life, which contained a pleasure in itself which was possible to carry a long while afterward, so giving the nurse something to live for.

The empirical examples further demonstrate how personal capacity as a nurse also gave rise to the sense that pay, in monetary terms, feels superfluous. Such a sense may be supported by the fact that nursing is not seen as a profession that gives status through high salary. One nurse working in a nursing home expressed it thus,

What makes me think that today I don’t need pay in terms of money—such days exist—is experiences of star moments in meeting with patients, when their despair turns to joy while disaster reactions disappear. (7)

Here, it is possible to see how the nurse gave priority to other values than pay in monetary terms, meaning that values were evaluated contrastively. In particular, values of a completely different kind to money were chosen because the nurses’ capacity for work load was already stretched to the maximum, so no amount of effort for money could be afforded.

It is also worth noting that the empirical examples document how career opportunities within the nursing profession contribute to development as a nurse. Nurses expressed how they appreciated opportunities such as taking a Master’s degree or PhD, or working part-time. Such different career opportunities gave them energy when they were back at work, made it possible to avoid sick leave, or gave them the capacity to work until retirement.

Discussion

The relevance of strong evaluations for remaining in the nursing profession are discussed by exploring nurses’ everyday experiences further on a comprehensive level, first, using the concept of strong evaluation stemming from Taylor’s^24,25 philosophical anthropology, and second, by considering the strength and shortcomings of the study.

The relevance of being a strong evaluator for remaining in the nursing profession

This article highlights that remaining in the nursing profession can be understood as essentially revolving around being a strong evaluator. This can be highlighted as a relevant statement because the article’s empirical examples have documented that being aware of different incidents in life and having capacities as a nurse were of significance for remaining in the nursing profession. The empirical examples show more concretely how the nurses described everyday experiences that inspired their choice to enter nursing and also influenced their professionalism. This means that the empirical examples can be understood as articulations of desires and values which was an integral part of nurses’ self-understanding. Another way of stating this is to say that the articulations show how nurses have shaped themselves by reflecting on what is of significance in their life. Taylor^24,25 states that understanding of self incorporates our seeing ourselves against a background of strong evaluations, that is, distinctions between things and consequently, this is connected to worth. The nurses’ articulations of what is of significance for remaining in the nursing profession can thus be understood as an expression of things with categorical or unconditional worth. It incorporates what they evaluated as strong values used to morally justify the priority of remaining. This priority can then be classified as based on qualitative discriminations because it is evaluated as something higher, more virtuous and fulfilling, noble and profound than not remaining.

Furthermore, understood as essentially revolving around being a strong evaluator, remaining in the nursing profession is related to making a life choice, meaning one main choice in life which is not understood as what Taylor²⁴ describes as just a matter of circumstances, but rather as actions, or even ways of life. This implies that remaining is not understood as an expression of how the nurses articulated their single, continuous, or random priority. On the contrary, it is essentially connected to an acquired capacity to be critical of their own desires and values, involving judging and discriminating between life choices. This means more concretely that remaining in the nursing profession can in itself be a kind of answer to what matters in life, which again implies taking stances in a way that affects the nurses’ self-understanding. Consequently, remaining involves a question of what life nurses want to have and incorporates an understanding of which life conditions are incompatible with realizing what is of significance. According to Taylor,²⁴ a capacity for being a strong evaluator implies realizing one’s own strong values, which in turn constitute life.

Highlighting the idea that remaining in the nursing profession revolves around being a strong evaluator is a statement which can be understood as largely in line with previous research. It has been tangibly demonstrated that choosing nursing as a career is related to desires and values.³³ Notably, it is also demonstrated that nursing practices possess desires and values connected to what the good life is and the relevance of articulating nursing experiences is emphasized.²⁹ Nurses develop their professional competence^34,35 and moral resilence³⁶ and reduce their uncertainty through nursing experiences.³⁷ A sense of success, recognition as a nurse,^11,14,38,39 job satisfaction,^16,18,40 and opportunities to take care of oneself^41,42 were also important. Additionally, correlations between lifestyle preferences and attitudes, values, and goals in life^20
–22 have been documented, implying that individually related factors have relevance.⁴³ However, the article emphasizes that all of the above can essentially be understood as an expression of making a life choice. This is emphasized because strong evaluations constitute a basis for reflections and throw light on what is significant in life. The nurses expressed their experiences of what is of significance for remaining in the nursing profession, and thus how they evaluated their life choice contrastively. By articulating what is recognized as of categorical, unconditional, or higher worth, and the things which lack this or are of lesser value, the nurses can become aware of what matters in their lives.

Strength and shortcomings

The trustworthiness of this study is considered a strength inasmuch as the article’s empirical examples fit this article’s aim. One argument for this claim is that the examples are based on findings from an original empirical study,¹¹ where Taylor’s^24,25 philosophical phenomenology was used as a theoretical perspective. Moreover, the theme and comprehensive understanding validated the naive interpretation in the original empirical study.¹¹ This indicates that the analysis was performed appropriately and in such a way that that study’s findings were found to be credible.⁴⁴ This further indicates that using Taylor’s^24,25 concept of strong evaluations as an interpretation of what is of significance for remaining in the nursing profession is not an over-interpretation of the article’s empirical examples. Obviously, there is still a risk that this study’s interpretation of what is of significance for remaining in the nursing profession may imply an over-interpretation of data. One particular difficulty lies in whether or not the nurses’ articulations meet the criteria for strong evaluations.

However, it is seen as a strength that the article does not state that being a strong evaluator can be seen as the causal condition for why the nurses remain in their profession, rather, it opens up for the fact that they might have a largely inarticulate sense of what is of significance for remaining. This means that while the article’s empirical examples can be seen as an expression of how the nurses articulated strong evaluations, it does not exclude that these may nevertheless be more or less incomplete, uncertain, or inarticulate. Notably, Taylor²⁴ emphasizes that human beings have a sense of what is of decisive importance. Furthermore, the article does not exclude that nurses may be weak evaluators. According to Taylor,²⁴ it follows from being a weak evaluator that one desired alternative can be set aside only because of its contingent incompatibility with a more desired alternative. This means that remaining in the nursing profession based on weak evaluations may then be understood as setting aside desired alternatives without judging the alternatives contrastively. Being a weak evaluator may therefore be seen as relevant in relation to remaining in the nursing profession, although in a different way. The alternative of remaining is evaluated as good solely because it is desired. These points can be supported by previous research which has documented that nurses may be indifferent to nursing care¹³ and uncertain in their decision-making.⁴⁵ A weak evaluator may nevertheless develop into a strong evaluator, for example, when influenced by the nursing profession itself.^24,25 In addition, the article does not state that being a strong evaluator or a weak one has no impact on a nurse’s priority to remain in the profession driven by values such as earning a living.^11,13,46,47

Second, it might be a shortcoming that this article’s statement may not hold in other contexts or at some other time.⁴³ It is particularly worth to mention that in the terms of Taylor’s,^24,25 being a strong evaluator is a capacity based in community and society, between human beings in general and thus between nurses in particular, as contributions from such resources give something to reflect upon. Without access to such resources, it may be very difficult to remain in the nursing profession. Previous research has also documented that factors created in community and society were important.^14,39,47

Implications

The article points out some important implications. A specific responsibility for promoting nurses’ awareness of themselves as strong evaluators is linked to leadership and organizations.^14,48,49 Leaders in particular can contribute to reflective intraprofessional discussions to find words and descriptions needed to articulate desires and values, thereby helping nurses to judge and discriminate between these things. It implies helping nurses to prioritize and take action,⁵⁰ meaning they realize what is of significance in their lives, and this again may promote nurses remaining in the nursing profession.¹¹ Here, it is worth noting that Tourangeau et al.¹⁴ concluded their study by emphasizing that “ignoring the importance of human relationships in promoting nursing retention may place all other retention promotion strategies at risk of failure.” Regarding the international and national nurse shortage which represents a threat to global health and patient safety,^51
–53 and becomes more severe when related to increasing population growth and changes in the healthcare needs of the population,⁵³ the relevance of being a strong evaluator may be of ultimate concern in bringing into focus so that nurses can contribute to quality in health services by remaining in nursing practice.

Conclusion

The article concludes that remaining in the nursing profession is obviously not a contingent matter, rather it is a matter concerned with the qualitative worth of different desires and values. Nurses’ awareness of a life choice impacts on whether they remain or not. Thus, their personal life choice may be an important resource related to prioritizing remaining in the nursing profession and consequently nurses may need to articulate and reflect on their priorities for remaining, as these emerge more basically from their self-understanding.⁵⁴

Footnotes

Acknowledgements

The authors wish to thank the nurses who made it possible to carry out the empirical study drawn on in this article.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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