Abstract
In my role as a facilitator for the Foundation of Nursing Studies (FoNS), I am privileged to work with nurses and nurse-led teams across a multitude of health and social care settings. Within this work, the dominant conversations relate to workload and workforce issues – too much work and not enough staff. Rarely are the conversations about the nature of nursing work, just frustration at not being able to deliver the care and services that they want to.
I began my doctoral studies back in 2015 with a focus on the well-being of nurses as even then, I was aware of the impact that the relentless pressures in healthcare was having on staff. Yet, much water has passed under the bridge since then. As West et al. (2020: 1) identified, the:
‘workforce had been struggling to cope even before the pandemic took hold. Staff stress, absenteeism, turnover and intentions to quit had reached alarmingly high levels in 2019, with large numbers of nurse and midwife vacancies across the health and care system. And then the pandemic struck.’
Indeed, the International Council of Nursing (ICN) states that we are now facing the daunting prospect of a ‘global health emergency’ (Buchan and Catton, 2023) as healthcare systems struggle to secure adequate nursing and healthcare workforces.
And so, this paper is set against a backdrop of nursing workforces under strain. It is therefore understandable why there is much interest in the experiences of nurses, how they respond to excessive stressors and the impact on patient care. The authors here choose to focus on how job stress and lack of colleague support can lead to burnout, compassion fatigue and loneliness, suggesting that resilience could be a mitigating factor. Looking back over the 2023 issues of the Journal of Research in Nursing, I notice that there are also papers which report on studies that have explored possibly related concepts such as moral distress and moral injury, burnout syndrome and emotional exhaustion to name a few.
What challenges me when reading such papers is the underlying assumption that these concepts are related to well-being, yet what is not clear is how the authors understand the nature of well-being and therefore what knowledge can be generated about it. This raises questions for me when thinking about enhancing the well-being of the nursing workforce: Which of the multitude of concepts would it be best for us to focus on and why? How, if at all, might all these concepts be related to each other and indeed well-being?
Reading this paper also took me back to an online debate that was co-hosted by the Journal of Research in Nursing and FoNS back in November 2020. The two opposing assumptions to be debated were: ‘nursing work will inevitably deplete staff well-being’ versus ‘nursing work can be a source of well-being’. I sense that the research in this paper is underpinned by the first assumption, whereas I declare myself to be a believer of the second, drawing upon eudaimonic understandings of well-being which are situated within virtue ethics.
If we assume that nursing work inevitably depletes well-being, it seems to take us down an interventionist approach. As suggested in this paper, education and training and support groups are some examples of activities that might help nurses to develop resilience and reduce loneliness. This largely places the onus on the individual nurse to access these interventions and to take responsibility for their own well-being as highlighted by the authors: ‘Nurses need to learn how to manage compassion fatigue, develop coping skills, and receive support to ensure job satisfaction.’ I contend that this perspective aligns with an ‘engineering’ approach to resilience (Joseph, 2013) which relies on nurses’ ability to build personal strength so that they can continuously ‘bounce-back’ (Hart et al., 2014). I would prefer to align myself with an ecological understanding of resilience, which recognises the role of communities and systems. It acknowledges complexity and instability, calling for the mobilisation of multiple approaches and resources (Gunderson et al., 2012; Walker and Salt, 2006). Whilst not ignoring the responsibility of individuals, this understanding also calls into question the role of organisations. This view is now being strongly advocated by the ICN as Buchan and Catton (2023: 27) note the often ‘absence of a systematic organisation and employer response’ to high levels of burnout in nurses, ‘with further burden being placed on individual nurses to be ‘resilient’. They go on to cite Maben et al. (2023: 28) who argued that ‘interventions targeting individual staff neglect the wider structural and organisational constraints/contexts’.
In agreement with le May (2013), rather than focusing on the individual nurse and what the authors call ‘occupational deformations’, I believe that the onus now must be on a system-wide approach to fixing the health and social care system. This requires organisations taking responsibility for the working environment and its impact on health and social care workers. Maybe then we can move towards a state where nursing work can become a source of well-being, as nurses gain a sense of purpose, meaning and fulfilment (Sanders, 2023).