09 Dec 2010
A nurse’s career is not only professionally challenging but also puts great demand on physical and mental resources to cope up with the continuously changing environment within a healthcare setting. A nurse practitioner is expected to comply with the orders of the physician meticulously and flawlessly as well as take appropriate decisions on her own according to the ever changing situation in a patient care setting. Expectations from a nurse are enormous, especially from the patient’s perspective. This requires discipline, punctuality; evidence based and informed decision making capability, as well as thorough professional competence in terms of theoretical and practical skills. In fact a nurse has to play the role of a physician, counselor, pharmacist, family member and psychologist all rolled into one at the same time while dealing with her patients. No doubt, this requires a high level of competence which can easily break a normal person. Issues such as satisfaction with one’s career, ability to cope up with personal and professional challenges and the question whether the nursing profession allows one to lead a happy, fulfilling life, which is the ultimate human goal, therefore need to be addressed. Nemcek (2007) and Brown (2009) have attempted to address these particular issues precisely in their quantitative and qualitative studies respectively. The former has followed a thorough and well designed approach to evaluate the three facets of life of a nursing practitioner identified by her, which she labels as the ‘ability to promote self nurturance’, ‘satisfaction with life in general’ and ‘career’ in particular. She has conducted a quantitative study to arrive at a statistically significant inference, which might serve to indicate the relationship between the three aspects she has identified as vital in nursing practice. Brown, on the other hand has attempted to conduct an incisive and precise qualitative analysis of the capabilities of established nurse leaders in comprehending the essence of self care and its vital role in allowing them to function effectively in a challenging work environment by obtaining their personal views.
The framework for analysis of a research article must identify what problem is being addressed, the purpose for research in the problem area, and a gist of previous and current research on an aspect in order to arrive at a sensible and statistically valid conclusion. The theoretical framework and hypothesis should be clearly stated and the sample size selected for the study should be adequate to provide a valid result. Both studies have satisfied these criteria within the limits imposed by the apparently small sample sizes.
Critical Appraisal, Paper 1
Nemcek, 2007 who is an Assistant Professor at the Decker School of Nursing at Binghamton, NY and an experienced registered nurse herself, has conducted a descriptive correlational study by designing questionnaire based measures of ‘self nurturance’ and ‘life’ and ‘career’ satisfaction, which were administered to 136 shortlisted registered nurses, believing that if these measures related in any way to each other, could contribute towards improving the mental health and safety among nurses. The title of the paper is succinct and self explanatory though it does not portray that the relationship between the three aspects enumerated is the focus of the study. The abstract is a succinct summarization of the intention behind the research and explains the salient points of the inference obtained as a result. Building upon the current necessity for promotion of a healthy, safe and satisfied workforce in the nursing profession due to paucity of professionals, the author has cited previous work on such aspects which have identified ‘self-nurturance’ which she explains to be a holistic nourishment of body, mind and spirit in an endeavor to promote personal growth as one of the primary factors contributing to satisfaction. In her introductory paragraph, she has stressed upon the necessity of an occupational health nurse to employ ‘self nurturance’ strategies to inculcate a feeling of satisfaction among her employees. She feels that such strategies should involve regular programs aimed at teaching and assisting nurses to modify personal lifestyle behaviors and their work environment in order to lead more fulfilling lives. She has opined that thoroughly satisfied nursing professionals can deliver better healthcare services to the public which can serve to relieve them of undue stress and ultimate burnout, which are forcing younger nurses in particular to opt out from the profession altogether in the current era, resulting in serious shortages.
The author has thoroughly researched what ‘self nurturance’ actually means and its implications on normal human being as well as nursing professionals in an effort to lay down the background for her proposed study. Building upon her own definition of the term published in an earlier paper, she has eulogized the benefits of happiness and satisfaction in general life for success in any professional pursuit. She has cited numerous studies done on people from diverse backgrounds such as students, single parents and old women which prove that satisfaction with one’s working environment and the ability to exert professional control translates into more meaningful work performance. In fact, the author insists that ‘self nurturance’ is an entity in itself whose regular practice enables one to achieve better work outcomes. She has pointedly referred to just one study about the effects of ‘self nurturance’ in nurses which she felt was reason enough for exploration into this area. Past quantitative studies on this aspect had mainly concentrated on finding the differences self nurturance exerts between normal and psychologically perturbed subjects. The author believes that a positive correlation between ‘self nurturance’ with help and well being has firmly been established and this needs to be probed in those involved in the nursing profession as well.
The author has approached the subject of her inquiry with a thoroughly researched methodological design in which she conducted a pilot study initially to ascertain the appropriateness of her design on 6 volunteer nurses’ selected from a private university. This was followed by the actual study conducted on 136 volunteer nurses who were recruited through an online advertisement. Adequate provisions were made by the author to obtain institutional approval and informed consent in both pilot and the actual study. This seems to be an appropriate sample size at this stage as it eliminates variation due to institutional differences and also makes the volunteers to be adequately prepared for the type of questionnaires they are going to be subjected to. Although a larger sample size could have been more indicative of the results but as this study was the first effort of its kind, the novelty of the idea compensates for the small sample size. Moreover, an already accepted descriptive, correlational statistical design was chosen by the author, which is appropriate for this kind of study. The questionnaires were carefully planned to yield pertinent data as far as the motives for the desired ends are concerned. SPSS is the most common statistical software employed these days for analysis of various kinds of data with assured accuracy due to dependence on computers rather than manual calculations. The statistical instruments included MSNS (Modified Self Nurturance Scale; 53 items) from a pre-established design, SWLS (Satisfaction With Life Scale; 5 items) and NCSS (Nursing Career Satisfaction Scale; 3 items) with response scales of 1-7 ranging from ‘Strongly Agree’ to ‘Strongly Disagree’, which suggests that, a lot of data must have been generated for the statistical analysis. The author has described all instruments in detail as far as their historical origin and validity for this particular study are concerned. In identical studies done in the past, correlations were found to be within permissible limits of consistency as well as accuracy required to form valid inferences.
The results have been depicted in easily comprehensible tabulated forms which describe the demographic details of the participants, mean values obtained for the three instruments under study and the correlational attributes within the three. The age range of the participants in the study is fairly wide and represents inexperienced as well as experienced nurses. Errors due to sex or demographic variations seem to be minimal as most respondents were female and White. Expectedly the statistical analysis revealed no significant variation between demographics and self nurturance or life and career satisfaction scales. Mean scores of all parameters under study revealed scores of 3.5, 4.9 and 4.7 for MSNS, SWLS and NCSS respectively with permissible levels of standard deviation. Extremely significant correlation was established between MSNS and SWLS, MSNS and NCSS, and SWLS and NCSS. The results are more representative of the younger lot of the white, female participants as majority of them (42%) belonged to the category which had a work experience ranging from 1-10 years. The MSNS score of 3.5 obtained in this study has been claimed by the author to consistent with data obtained from normal or ‘well’ individuals in past studies. The SWLS score also compared well with that from ‘well’ persons at 4.87. In short, all instruments studied by the author showed a statistically significant positive relationship with each other leading the author to conclude that ‘self-nurturance, career satisfaction, and life satisfaction were positively correlated with each other’ (Nemcek, 2007).
The variables which could have affected the results of this study and can be considered dependant include age variations, differences values of life due to individual perception, ethnic and cultural backgrounds, educational level, job setting, home environment and personal circumstances. The independent variable was the same profession of the participants.
The author has later described how a highly structured and organized environment as in Magnet Hospitals can impact overall satisfaction in a nursing practitioner in a positive manner. Greater autonomy and participation in administrative decisions in such locations facilitates career satisfaction which has a direct impact on satisfaction in life in general and promotes self nurturance. Implications for occupational nurses in particular have been discussed as the author believes that they are the pertinent link in inculcating self nurturance tendencies affecting career and life satisfaction of the employees working under their guidance.
The limitations of this study, as admitted by the author herself are the inability of correlation based studies to provide evidence for causality, and the sample being a ‘convenience sample’ as participants were aware of the motives of the study. This suggests that the study should involve a predictive design i.e. measures of the same construct should be measured sometimes in the future and the similar sets of data are compared for ascertaining validity.
Critical Appraisal, Paper 2
The second paper by Brown, 2009 addresses the same issue as the above quantitative study by Nemcek but through a qualitative lens, by assessing the way registered nurse leaders felt about the need for self care after being exposed to a project which introduced and inculcated the importance of the sense of ‘caring-for-self’ in them. The title of the study is self explanatory as it suggests that self renewal can only be established through self care and the author’s attempt at gaining insights from the lived experience of carefully selected nursing practitioners who are themselves leaders in their specific capacities. The abstract briefly introduces the necessity for eliminating stress among nurses due to their overt vulnerability due to the high demands the profession places upon them. The research methodology has been clearly defined as a hermeneutic phenomenology which evaluated the lived experience of 10 carefully selected nurse leaders by intimate interaction with them. The abstract enumerates the findings in the form of four common themes, based on which the author has recommended the use of holistic and creative methods to reinforce self renewal among nurse leaders.
The introductory section begins with a quotation highlighting the emphasis on ‘self’ and how everything emanates from it. The author has pointedly explained that though nurses are accustomed to caring for others, they are themselves subject to neglect due to the high demands of the profession. She cites a number of previous studies which have substantially proved the importance of holistic self care practices among nurses and its contribution to their positive image among the patients. Her primary aim in this study was to reinforce the concept of self care in nurse leaders who had been exposed to a caring-for self program in a community hospital setting.
A research project lasting ten weeks was initiated at the behest of the chief nursing officer of a private 185 bedded hospital in South Florida within a community setting after the delivery of a seminar on caring for self by the author. During the subsequent sequence of events, the author decided to conduct a personal interview based study on the lived experience of shortlisted participants on an individual basis. This approach seems to be ideal, as getting information directly from the proverbial horse’s mouth is most likely to yield appropriate end points. The author has cited profusely from pertinent literature to highlight the challenges which necessitate the need of caring for self among nurses who might be exposed to the precipitation of physical, emotional and behavioral disorders due to stress factors at work. She has enumerated the various standards accepted and being practiced by appropriate organizations like the American Holistic Nursing Association (AHNA) for holistic nurse self care and its pertinence in actual practice. The author has justified the use of Hermeneutic Phenomenology as the right approach for her study which she has explained to be an ‘interpretive study of being in the world’ (Brown, 2009). She has quoted substantially to explain the nuances related to this phenomenological approach. The author’s experience and qualification are most appropriate for this kind of study as she is an expert in the field and most likely to extract the most appropriate information commensurate with the research methodology employed, in a person to person interaction.
The ten nursing leaders chosen as participants were carefully selected based on the vital positions they occupied in the community hospital setting and appropriate environment for the interactions was created after obtaining due approval and sanction of pertinent authority. Care was taken that the interviews and the post interview interactions took place in a quiet, stress free environment with no disturbance. The number of years in nursing which ranged from 18-32 years as well as the number of years in leadership roles which ranged between 8 months to 24 years suggest that the participant selection was most appropriate, as it is likely to yield common viewpoints as well as differences of opinion, if any due to age and experience variations. Moreover the participants were for a wide variety of sub specialties which could allow one to understand whether any variations could occur due to the area of one’s practice. Other variables were educational background and family affiliations such as responsibility towards children or aged parents. All participants were pre-exposed to a 10-week caring-for-self project at the hospital itself and had adequate time to interact with each other and participate in activities designed to enhance self growth and creativity. Although the ten participants were reluctant to being interviewed after the 10 week period in a taped conversation, they continued to meet monthly and agreed for the same after an elapse of one year.
The data collection and analysis was in the form of carefully prepared and reviewed transcripts of the one-to-one taped interviews between the researcher and individual participants with due respect to privacy by omitting details of the participants which were mutually decided upon as being too personal. Interviews lasted 45-60 minutes each and began with general questions about self care after which the verbal cues were built upon to pose specific queries about self care. The participants were free to express themselves in the form of anecdotes and stories which explained their personal values and viewpoints. Line by line analysis of the transcripts was carried out by employing special software called ATLAS.ti which has been claimed by the author to provide a consistent decision trail as far as theme analysis was concerned.
The primary themes that emerged through analysis of the data were ‘Reflection on the Journey’, ‘Why to Care for Self on the Journey’, ‘How to Care for self on the journey’ and ‘Wisdom Learned along the Path’. These themes have been elaborated by the author one by one with generous excerpts of the interviews which she considered as pertinent for arriving at the inferences which aided her in building the theme categories. Climbing atop to a mountain peak emerged as the primary metaphor for depicting the overall experience of self care along life’s journey. Caring for self increased the ascent atop the mountain as it increased the level of what the nursing practitioners could give to their patients in terms of positivity. Setbacks along the way on this upward journey were referred to as ‘getting caught in a whirlwind’, ‘being pulled away in multiple directions’, ‘a constant hammering’ and ‘being at the bottom of the ladder’ which made the participants realize the gravity of such situations and spurred them on to making efforts to overcome the barriers through self care. All participants had their moments of realization when they felt the need for self care in adverse circumstances as they found that the work pressures had gotten too much or their involvement had been so intense that they failed to recognize that they were not taking care of themselves. Their healing efforts for self included indulging in personal hobbies such as driving or reading books, which gave them adequate diversion from their respective routines, to reestablish their self identities.
The discussion in the study focuses on the comprehension of self care by the participants and the ways and means they adopt to overcome the obstacles encountered in their life’s journey which make them wiser along the years. Sharing and assisting other in the profession were considered as vital in promoting the awareness about self care and attain a balance between work and life in general. Holistic self care practices on a shared platform have been recommended by the author in her conclusion which she believes will enable registered nursing leaders to encourage their employees and prevent burnouts as well as promote professional achievement and growth. The limitations in this study include the small number of participants as well as an environment and methodology which might have elicited subdued responses due to privacy concerns.
The articles analyzed above stress upon the importance of self care in nursing practitioners which has assumed greater significance in recent years due to reduced workforce and the high attention span required in the workplace. Excess work does not allow a nurse to stop and think about caring for self though she is expected to care for others. This has resulted in situations where some practitioners contemplate withdrawing from the profession altogether or suffer burnouts which are extremely damaging physically as well as emotionally. The first article is a quantitative analysis of the relationship between self nurturance, life and career satisfaction which have been found to be positively correlated with each other (Nemcek, 2007). The second article though philosophical in content, uses an appropriate phenomenological approach to probe the values attributed to self care by established nursing practitioner leaders from various fields through personal interviews (Brown, 2009). Both articles not only suggest further research in this aspect but also offer suggestions to future nursing leaders to incorporate self care and self nurturance into their professional sphere for optimum growth and satisfaction with nursing as a career.
Brown, C. J. (2009). Self-renewal in nursing leadership: The lived experience of caring for self, Journal of
Holistic Nursing, 27(2), 75-84.
Nemcek, M. A. (2007). Registered Nurses’ Self-Nurturance and Life and Career Satisfaction, American
Association of Occupational Health Nurses Journal, 55(8), 305-310.