Coping Strategies to Hinder Intention to Leave in Iranian Nurses: A Qualitative Content Analysis.

BACKGROUND: Due to the high clinical challenges, differences in coping strategies, and high workload in nurses, there is a need to develop strategies to keep them in the profession. The aim of the present study was to explore the Iranian nurses' coping strategies to deal with intention to leave.
METHODS: A qualitative content analysis was used to obtain rich data. We performed 13 in-depth face-to-face semi-structured interviews with nurses working in hospitals affiliated to Tabriz and Urmia Universities of Medical Sciences in Iran, selected through purposive sampling. Constant comparative method was used for data analysis.
RESULTS: Three categories and eleven subcategories emerged during data analysis. The extracted categories and sub-categories consisted of (I) Self-empowerment (practical knowledge increase, responsibility, finding identification of the nurse, balancing work and life, seek support and humanitarian interests), (II) Self-controlling (tolerance, avoidance, the routine-based performance), and (III) Pursuing opportunities for advancement and promotion (community development, planning for higher education).
CONCLUSION: Nurses make attempts to individually manage problems and stressors perceived from bedside that have led them to leave the bedside; these efforts have been effective in some cases but sometimes they are ineffective due to discontinuous training and relative competence in terms of how to manage and deal with problems. It is suggested that nurses should learn strategies scientifically to meet the challenges of bedside. Through enabling and supporting behaviors and creating opportunities for growth and professional development, nursery managers can help nurses to stay and achieve improvement of the quality of cares.

INTRODUCTION

Recently, there has been a growing demand for medical care due to social trends such as diversity of population structure, raising awareness of rights, and changes in the social system. It has been associated by the growing demand for nursing manpower. Nurses are the biggest professional workforce at the hospital and have become a key factor in improving productivity and competitiveness of hospitals.[1] The nursing profession because of its inherent nature, organizational strategies, extensive communication with other members of the health team and patients and their families’ exposure to more potential problems and can cause a variety of effects of stress and discomfort, leading to exhaustion and burnout.[2] Physical environment problems, heavy workload, conflict with patients and management of their companions’ violence, dealing with health and safety risks, lack of support from managers, absenteeism of physicians in emergency situations, and lack of facilities as the stressor sources for Iranian nurses.[3] This can lead to the staff’s stress, burnout, and dissatisfaction.

Turnover intention occurs when an employee encounters in his current job a bad work environment with high stress, which, in turn, can give them the intention to leave.[4] In consequence, most nurses (71.42%) every day think to leave the nursing profession.[5] According to a study conducted on Iranian nurses, the average burnout intention (3.03±0.75) is high.[6,7] Therefore, reduction in turnover should be considered by researchers.[4] Regardless of the strategies to retain the staff, critical shortage of nurses not only continues but will worsen over time. Health authorities that spend much time and human and financial resources to hire nurses should be aware that it is equally important and affordable to attract and retain their employees utilize similar efforts.[8]

Coping style is defined as persistent psychological and behavioral strategies to overcome or endure the internal and external challenges or stressors.[9,10] How individuals use coping strategies may vary according to cultural, individual and psychological factors[3,9] and is determined by their internal and external resources, including beliefs, health, support, responsibilities, material resources, and social skills.[11] Ineffective coping strategies of nurses have resulted in a worsening of relationship between the nurse and patient, and experience of more failures causing a gradual sense of loss of personal development.[12] On the contrary, with successful coping style, the nurses are able to achieve their objectives and enhance their professional effectiveness.[9] Issues related to intention to leave and coping among the nurses are of global concerns of all administrators and managers in the healthcare field.[13]

As to the prevention of burnout, the mainstream thought is that the more money earned by employees in the organization, the more the chances of staying. The idea is not valid today. Researchers believe that staff retention will not be successful only with payments in the long run. They emphasize the plan to create and promote an environment in which employees choose to stay by themselves, and believe it is achievable by group efforts of employees, training and professional improvement of performance.[14] Clinical management, encouragement and support, monitoring programs, culture of support of teamwork and experienced work force are presented as the ways to stay in the nursing profession.[15] Also, the use of management development programs to stimulate nurses to remain in the nursing profession is emphasized.[16] In a quantitative study in Iran, nurses used self-control methods and positive reappraisal to deal with stress and the least used strategy in them was responsibility. In this study, more nurses had used the coping- focused strategies, while problem-focused approaches were used less.[3]

According to several studies, it seems that the methods used for retention of nurses in clinical practice are different, and as we have seen, each of the studies have pointed to various aspects and since these methods are usually influenced by cultural, social and religious fields; therefore, it reveals the need to do qualitative research to understand, identify and describe the coping strategies with a tendency to leave the bedside among the nurses to be constructive for further research to strengthen, modify, adapt and change coping mechanisms. The specific aim of this study was to gain a deeper understanding of coping strategies among Iranian nurses to deal with intention to leave. So the acquired knowledge will be useful in the formulation of recommendations for improving the health of the nurses, thereby improving the quality of care provided in hospitals.

MATERIALS AND METHODS

Nurses who participated in this study were selected from several teaching hospitals affiliated with Tabriz and Uremia Universities of Medical Sciences in Iran. The sample selection process was based on the following criteria: 1) having a baccalaureate degree or higher, 2) having at least one year of work experience in clinical nursing practice, 3) being willing to participate in the study, and 4) having the ability to express their experiences. A total of 13 nurses met the inclusion criteria and agreed to enroll in the study.

From May to February, 2014,(during ten months) the participants attended semi-structured interviews by asking open-ended questions to investigate the coping strategies used by Iranian nurses for overcoming the intention to leave the clinical practice. Researchers interviewed each participant individually for 40 to 60 minutes at work (n=8), and outside of work environment (n=5). The interview began with a general question about coping strategies used by Iranian nurses for overcoming intention to leave and moved to more specific, detailed questions as the interview advanced, such as “ How do you try to provide the scenarios/situations more for yourself?”, “What things help you along the way?”. Interviews were recorded with permission and later transcribed. Verbatim raw data were computer coded using MAXQDA10 (version 10 R 160410 by udo kuckartz, Berlin, Germany) before analysis.

Sample and Setting

Among the 13 nurses who participated in this study, there were 11 women and 2 men aged 24 to 47 years; 9 of them had a baccalaureate degree, four had a master’s degree. They had 2-15 years of clinical nursing experience in internal medicine, surgery, infectious disease, poison control, intensive adult care and emergency nursing care. Eight participants were married and five were single.

Data Analysis

Content analysis method as described by Hsieh and Shannon[17] was applied for its appropriate fit to meet the objectives of this study. Through inductive process, data were coded and categorized.[18] Data analysis continued simultaneously after the first interview until saturation was reached. Researchers encrypted the copied text, and discussed coding refinement for each emerging theme. Classified codes were categorized, compared and interpreted within the context of general transcripts.

Trustworthiness of the Study

During the study, specific methods were used to ensure rigor and trustworthiness of data. For reporting of qualitative study finding, trustworthiness of methods instead of validity and reliability are widely considered[18] and for this study four supporting processes of trustworthiness such as conformability, dependability, credibility and transferability were applied. Credibility was confirmed by selecting the appropriate data collection method of interviews. Researchers interviewed the participants for their views and experiences in their practice environment. Moreover, member check was used in addition to prolonged involvement of the researcher to increase the credibility of the data. Also, after encoding, the interview transcripts were returned to the participants to ensure the accuracy of the codes and the relevant interpretations. Dependability was established by detailed and descriptive data analysis and direct references to individual professional experiences. Raw data were translated by a professional translator from Farsi (Persian) into English and back translated to preserve maximum accuracy of the participant expressions within the context. Conformability and consistency of analysis were maintained through research team meetings to discuss and analyze the preliminary findings. Thematic analysis and coding process occurred through consensus; and transferability of the findings was increased by descriptive statistics and the participants’ demographic features to represent the nursing views within the professional context.[19]

Ethical Considerations

The present study was approved by the Ethics Committee of Tabriz University of Medical Sciences (Grant no. 5/4/3861), Iran. Before data collection, researchers obtained an oral and written informed consent to ensure anonymity, privacy and confidentiality and emphasized their voluntary enrollment. Information on the study objectives and goals were detailed and contact information for the principal investigator was offered to answer participants’ questions.

RESULTS

Content and thematic analysis revealed three major categories: I) Self-empowerment, II) Self-control, and III) Pursuing opportunities for advancement and promotion. Each category had several subcategories as listed in table 1. Participants’ reflections for each category and subcategory were further expanded and later compared with other published studies.

Table 1

Categories and subcategories coping strategies among Iranian nurses to deal with intention to leave

Categories	Sub-categories
Self-empowerment	Practical knowledge increase
	Responsibility
	Finding the nurse identity
	Balancing work and life
	Search of support
	Humanitarian tendencies
Self-controlling	Tolerance
	Avoidance
	The routine -based performance to overcome the pressure of work
Pursuing opportunities for advancement and promotion	Community Development
	Planning for Higher Education

I: Self-Empowerment

Nurses had used five strategies to manage problems and stressors perceived in different aspects that lead to creation of a desire to leave the bedside in them, and gaining new energy and vitality in the organization. From this category, five subcategories emerged as I.1) Practical knowledge increase, I.2) Responsibility, I.3) Finding the nurse identity, I.4) Balancing work and life, I.5) Searching for support, and I.6) Humanitarian tendencies.

I.1. Practical knowledge increase: It was one of the subcategories derived from interviews and led to promotion in self-reliance and empowerment of nurses. One of the participants said:

“When I talk with many colleagues, they say it is no longer important. I finished university, while I often refer to my books. For example, when in the ward I’m dealing with some cases, I refer to my books. I ask the doctors. I participate in the courses that are held to teach how to work with the devices.” (Participant #2, age 29, 5 years of work experience)

I.2. Responsibility: there is another subcategory that leads to empowerment of the participants. In this regard a participant said:

“….. But then I come and say: no! I care for the patient wholeheartedly and from now on I go and check point by point my tasks. I got this decision myself; I say because I am in the hospital environment. If I continue like this, it is tormenting to me. But, the patient is helpless and it is difficult for me and I get my colleagues annoyed. If his vein is ruined, I perform vein puncture for him; I keep telling myself that this is easy; vein puncture is not so hard; I should do vein puncture for him. If the tubing was spoiled or had expired, I changed it.” (Participant #3, age 26, 3 years of work experience)

I.3. Finding the nurse identity: One of the participants said:

“…. After I entered the research team of hospital, I began with the doctor residing in ICU. We just ran processes clinically (such as the gavages, how to suction, drug interactions, how to properly care for the patients, etc.…). I felt that yes this really is not like that. Unlike our imagination, nursing work was not only injecting. But our task was more than that.” (Participant #9, age 36, 3 years of work experience)

I.4. Balancing work and life: establishing a balance between family and career roles is a big challenge for nurses. On the one hand, they are obliged to carry out their tasks within the rules and regulations of the work and on the other hand they must perform family duties, and in this context conflict between family and work is inevitable.

“One day I work in the morning shift- one day in the evening shift- and another day in the evening shift. But I know the program I plan- for example, I am planning to do it the morning of the tomorrow if I work in the evening, or conversely, if I work in the tomorrow morning, I have to do something. Because of the shift, I am not too annoyed because I know the program.” (Participant #11, age 37, 3 years of work experience)

I.5. Search of support: Another nurses’ strategy to overcome the tendency to leave service was “support search.”

“Our head nurse says that if you want to go, I will not let you. I keep you. Because of what I do for the patient, I feel that I have satisfied others. That is, I have satisfied the head nurse that does not let me go.” (Participant #13, age 25, 2 years of work experience)

I.6. Humanitarian tendencies: Altruistic motives are another reason for the participants to tolerate the clinical situation. Despite all the problems that exist in nursing, considering that in this profession the opposite side of nurse is patient that needs him and nursing care is effective on relieving the patient’s pain and suffering and precipitates the recovery. This inner satisfaction in the nurse, as result improvements of patient’s condition, can be achieved, especially in our culture it has a significant impact on tolerance clinical condition.

“When I go to the patient’s bedside and I just do my duties in a right way… when I feel satisfied and the patient is pleased, it is the most enjoyable stage for me. These are the strong points that motivate me to carry on. And even I frankly say that I’m just happy that I can help somebody. My humanitarian beliefs help me to handle the harsh conditions. It is just the point.” (Participant #6, age41, 8 years of work experience)

II: Self-Controlling

The control of personal moods, behavior and reactions in situations of work and family is one of the abstracted individual coping strategies in relation to the desire to leave the bedside, which contains the following three categories: 1) tolerance, 2) avoidance, and 3) routine -based performance to overcome the pressure of work.

II. 1. Tolerance: The results indicate that one of the strategies of self-control is tolerance. In this regard, one of the participants says:

“I try not to touch them. I trying to say ok whatever happens; I usually say you are right. Just in this way I can prevent conflicts.” (Participant #7, age24, 3 years of work experience)

II. 2. Avoidance: “Some colleagues don’t answer their phone- they don’t answer the hospital calls, because nurses know that they are called to go for a shift or have not done something for the patient; that is, they stress me even in the house”. (Participant #4, age 24, 2years of work experience)

II. 3. The routine-based performance to overcome the pressure of work: Participants have found from experience that in many cases nurses have no choice but to deal with and do things routinely. One of the main reasons for this is the high workload. The disproportion between the number of nurses and patients imposes more pressure on people. According to the participants, doing things routinely in the conditions governing the treatment system in the country, particularly in terms of the shortage of nurses, has the highest rate.

“You have to work routinely if you want to do something; it is clear that the number of patients and workload are very high in the ward with only two nurses. If you want to function appropriately, you cannot.” (Participant #8, age 25, 2 years of work experience)

To reduce stress and workload, you have to learn to act professionally, gain acceptance of others and also learn better skills to carry out their routine. This partly causes the nurses to acquire a degree of confidence and not to be humiliated and rejected by colleagues. This makes his/her stress lower and the individual is hopeful to stay.

“My colleague worked as a routine and had more time opportunities and finished his work sooner, but I, instead of a minute to give drug to the patient- get the symptoms, maybe I spent 5-10 minutes for patients; I had learned it, but my colleagues had said I didn’t work correctly. They said my tasks were not done and the request of drug was not provided. The shift ended but I still had not finished. As a result, it caused dissatisfaction of colleagues. Discontent led to a bad background. Maybe he doesn’t want always to work with me or work with me at the same shift. Because he thought my duties are not done on time.” (Participant #1, age 34, 4 years of work experience)

III. Pursuing Opportunities for Advancement and Promotion

III. 1. Communication Development: Development of relationships with managers and colleagues was the other subcategory; these relationships benefit the nurses and provide opportunities in the bedside to overcome the desire to leave the bedside.

“I saw only expertise is not enough to go to the special ward; I should be able to show myself to head nurse and doctor; my interactions with them must be strong” (Participant #10, age 33, 1.5 years of work experience)

III. 2. Planning for Higher Education: Following studies in nursing was the other aspect of the development opportunities. Participants mentioned that motivation to follow studies in nursing is an effort to promote their position in the bedside and interest in nursing management tenure.

“Because I was interested in learning, I always planned to follow my studies so that I can become the educational supervisor or perhaps I can go to the other ward where there is not so much labor. The medical ward is a general ward; I thought maybe if I go to the special ward, my problems reduce.” (Participant #12, age 34, 5 years of work experience)

The final analysis of the findings showed that nurses individually think the use of coping strategies is working as much as possible to manage clinical problems and tensions in the bedside in order to provide job satisfaction and desire to stay in bedside and also be able to provide relief to the patients.

DISCUSSIONS

According to the results of this study, to address the perceived problems in the workplace that led to the desire to leave the bedside, the nurses used the strategy of empowerment and self-controlling and seek out opportunities for advancement and promotion. The results of this study have some similarities and differences with the national and international studies. The interesting finding of this research which is in contrast with those of similar studies[20,21] was that coping strategies to overcome the tendency to leave the bedside among the nurses were mostly individualized and managers and the role of organizations in this context was not that important. Another difference between this study and similar studies[22-24] was that unlike other studies nurses were not tired and had some degree of willingness to leave the bedside.

In the present study, it was found that the most common strategy used by nurses was “Self-empowerment”. The methods that nurses used in this study for self-empowerment included increasing practical knowledge and responsibility, finding identification of the nurse, balancing work and life, and seeking support and humanitarian interests. Self-empowerment was very valuable for nurses and reduced their stress, boosted their morale and satisfaction and increased their willingness to stay in the bedside. The results of the investigations[25] also showed that empowering is a predictor of job satisfaction and retention factor of employees in the workplace to avoid leaving the profession. Active coping was positively associated with professional efficacy, and negatively with fatigue and emotional exhaustion and pessimism.[12] Empowered and independent behavior, decentralized decision-making, relationships, open communication and collaboration with doctors, and cooperation with other clinical nurses caused job satisfaction and finally led to quality of care, retention of nurses.[26,27] In this study, one of the strategies for self-empowerment of nurses was searching support. Therefore, increase in social support for nurses is related to high power to deal with stress, in a very critical and stressful profession like nursing, increased attention to social support through improved management of nursing and administrative communication; also, better social security may be useful for nurses.[28] Nursing administrators are advised to pay more attention to nurses who work in vulnerable conditions and ensure that they have enough support in the workplace.[10] Personal feelings about the working group is as important as seeking social support and enjoyment of the job.[29] A study on newly graduated nurses during 5 years of graduation demonstrated that support from colleagues and nursing team was of secondary importance which was one of the reasons for leaving their first position.[30] Moreover, it is a positive and flexible professional identity to perform multiple roles of nurses in patient quality care, reduce the stress of workplace, and overcome the tendency to leave the bedside is important.[31]

One of the very important concepts and categories that emerged in interviews with nurses was humanitarian approach with the characteristics of loving patient as a human and enjoying helping fellow. The feeling was clean, strong and valuable so that despite the problems and stresses of work, nurses are encouraged to continue working and serving; having a humanitarian approach, the participants in this study ignored their work problems and preferred health and well-being of patients and actually showed devotion. The findings of a study on nurses in special wards are consistent with the subcategory of humanitarian approach in our study because, despite certain mental conditions governing the patients in the special wards, it has strengthened helping the fellows, sense of being useful in care, motivation to continue work in these wards.[32]

The second most common strategy used by the Iranian nurses, self-controlling, was recognized when nurses spoke of “Tolerance”, “Avoiding conflicts” and “The routine-based performance to overcome the pressure of work”. Cultural character trait common in nurses within Asia is self-controlling. Previous research has shown that self-controlling is the main coping strategy of nurses in Japan, Thailand and China.[13,33] Also, the three most common coping mechanisms were positive reappraisal, full problem solving, and self-control.[13] The major source of stress for nurses was work conditions and applied positive assessment, self-controlling skills and social support to cope with job stress.[34] In another study, 25% of female preoperative nurses employed avoidance coping strategies, while 83% of the males used problem-solving strategies.[35]

And the third theme, pursuing opportunities for advancement and promotion, was recognized by “Community Development” and “Planning for Higher Education”. Findings of this inquiry support the work of others; for example, nurses’ intentions to stay primarily depends on relationships with patients, colleagues and administrators; conditions in the workplace; reward of work; organizational support; and psychological response to work.[36] These results look logical because when employees are satisfied with their job, they will stay with the organization.[37] Most respondents in another study felt that nursing profession was unable to provide professional development opportunities and mental challenges for nurses. So these people have acquired these strategies by applying for graduate studies and by starting a new career.[38] As was observed in this study, turnover can be useful for the individual nurse.[38,39] Changing workplace and career could provide an opportunity for nurses to move into better positions which is appropriate with motivations, ambitions, skills and career goals.[38] According to this study, we think that it would be beneficial for the health care system to keep this group of nurses in the profession by opening new opportunities and challenges in nursing. More in-depth research is needed to better understand why nurses leave, and even more significantly and how we can motivate young generation of nurses to stay in nursing.

As in other qualitative studies, one of the limitations of the present study is generalizability of the results. Accordingly, maximum effort was made to improve the rigor of data. Restricted the field of study to teaching hospitals was another limitation; so, it is recommended that, in future studies, experiences of people from non-teaching hospitals should be considered. This study only focused on coping strategies of nurses in the background and culture of Iran, so it is necessary that more studies be carried out in different fields and cultures in order to document and track the results of a recent study; also, increasing our knowledge as to various aspects of coping strategies of nurses is recommended.

CONCLUSION

Iranian nurses use mainly “Self-empowerment”, “Self-controlling”, and “Pursuing opportunities for advancement and promotion” strategies to deal with challenges in the clinical field and intention to leave. It is crucial for health organizations to address these issues promptly in order to avoid high attrition and turnover rates which affect the effective functioning of Iran health-care delivery system. Thus, it is recommended that nursing managers recognize the need to provide appropriate strategies for nurses and maintain them in the profession. Creating magnet workplace, staff appreciation, taking the nurses’ suggestions into consideration, providing communication and interactions based on mutual respect, and finally taking the nurses’ mental and emotional needs into account can all increase job satisfaction, sense of commitment and responsibility among nurses, and ultimately promote the quality of care. Nursing educators and teachers can also foster efficient, competent and resistant manpower to clinical challenges by teaching coping strategies.