Nurse Students' Thoughts on a Sustainable Professional Life as Nurses: A Qualitative Study.

INTRODUCTION: In a global context of an increasing and aging population, along with environmental changes, nurses play an important role in relieving suffering among vulnerable people and groups in society. Sustainability in nursing contributes to sustainable development through providing an environment that is not detrimental to/protects present and future generations' opportunities for good health. There is a global shortage of nurses, and it has been shown that, locally, every fifth newly graduated nurse considers leaving their new profession five years after graduation. The aim was to describe how nursing students' thought about a sustainable professional life as nurses before their graduation.
MATERIALS AND METHODS: A qualitative design with a written data set was used, and a thematic analysis was performed. One hundred five students (80 women and 25 men) in semester six out of six of the nursing education program participated.
RESULTS: The analysis resulted in three themes: 1) to have an ethical foundation that guides the individual nurse in protecting the nursing care and developing the nursing care for their patients; 2) to be in a listening, reflexive and supportive workplace enabling a professional nurse to continuously grow and learn and 3) to be a proud professional nurse with integrity, not risking with their own health or personal professional development.
CONCLUSION: The nursing students describe their thoughts on the requirements for having a sustainable professional life as nurses as having a strong inner ethical compass to help guide, protect and develop the nursing care for the patients. In addition, it requires a workplace with a reflexive and supporting culture. However, the nursing students also put their own health and the opportunities for professional growth at the top of their priorities, and if these conditions are lacking, they will switch to another workplace.

Plain Language Summary

In a global context of an increasing and aging population, along with environmental changes, nurses play an important role in relieving suffering among vulnerable people and groups in society. There is a global shortage of nurses and it has been shown that, locally, every fifth newly graduated nurse considers leaving their new profession five years after graduation. Nursing students’ thoughts on asustainable professional life as nurses have been only sparsely studied. The common outset of most studies describes aspects that facilitate or hinder new graduated nurses in their professional life. In this study nursing students describe their thoughts on the requirements for having a sustainable professional life as nurses as having a strong inner ethical compass to help guide, protect and develop the nursing care for the patients. In addition, it requires a workplace with a reflexive and supporting culture. However, the nursing students also put their own health and the opportunities for professional growth at the top of their priorities and if these conditions are lacking, they will switch  to another workplace.

Introduction

The global need for nursing care exceeds the capacity to provide people with good quality nursing care, and this is linked to the lack of nurses and nursing faculties.1,2 In a global perspective, researchers in nursing have pinpointed that there is and will continue to be a shortage of nurses.3–5 In a context of an increasing and aging population, along with changes in the environment ill health, natural disasters, humanitarian crises, and immigration, nurses play an important role in relieving suffering among exposed people and groups in society.6–8 Sustainability in nursing contribute to a sustainable development by providing an environment that does not injure present and future generations′ opportunities for good health.9 At the same time Rudman et al10 show that every fifth nurse have firm plans to leave the profession five years after graduation. The interest in leaving the profession increases during the first years after graduation. High levels of burn-out among the participants were related to an increase in interest in leaving the profession.10 Stress is common among newly graduated nurses, but it differs between workplaces. Surgical departments often generate more stress than other departments. Newly graduated nurses who receive supervision in groups reported lower levels of stress.11 In addition, a poor workplace environment and lack of support are also aspects important for those leaving their profession as nurses.12

The workplace culture at a healthcare unit can both create a pattern for and challenge nurse students’ adaptation to the health care environment and create a space for learning. On arrival, the students’ task is to enter through the semipermeable membrane of the community of practice and to understand and adapt to its culture, and to try to become accepted.13 During workplace learning in the last semester of the nursing programme, nursing students learn to collaborate and build relationships and to interact interprofessional and with patients. In addition, they learn to act independently on the workplace ward, to take responsibility and to prioritise in complex situations. Further, they learn to create a structure and a space for learning, to tolerate hierarchies, to adapt to shifting situations and to manage stress.14

Through collaboration between theoretical education and workplace learning, the transition to work life for nurse students can be supported.15 Nurse students develop professionally mainly through the experiences acquired through clinical work.16 The challenge of workplace learning is to facilitate the development from novice to practising nurses.17 Nurse students typically highlight their professional identity as the basis for commitment.18 To have a clear goal, to be able to evaluate ideas and to use their own experiences as a tool for learning are important aspects of nursing students learning during their education.19 Nursing students realise that knowledge about nursing science as a theoretical subject gives them both opportunities and potential possibilities to influence the provision of nursing care.20

A theory of transition from nursing student to graduated nurse is presented by Duchscher,21 as a journey where new nursing graduates advanced through the stages of doing, being, and knowing. The journey involved ordered processes that included anticipating, learning, performing, concealing, adjusting, questioning, revealing, separating, rediscovering, exploring, and engaging. As this journey was by no means linear or prescriptive nor always strictly progressive, it was evolutionary and ultimately transformative for all participants.21 Further, newly graduated nurses could identify their initial professional transition in terms of feelings of anxiety, insecurity, inadequacy and instability. A transition shock could offer focus on the aspects of the new graduate’s roles, responsibilities, relationships and knowledge that both facilitate the intensity and duration of the transition experience and qualify the early stage of professional role transition.22 Respect, feedback on their performance, recognition of a work well done,23 orientation programs and supportive mentors are also important for a successful transition.24

To summarise, there is a global shortage of nurses and it has been shown that, locally, (eg in Sweden) every fifth newly graduated nurse consider leaving their new profession five years after graduation. Therefore, this study was undertaken to add to the knowledge of the following aspects: What responsibility does the health care organisations have to create a sustainable working life? How should nursing programmes prepare nursing students for the working-life of a nurse? How should newly graduate nurses act to achieve a sustainable working life? The aim was to describe how nursing students’ thought about a sustainable professional life as nurses before their graduation.

Materials and Methods

Study Design

For this study, a qualitative design with a written data set (nursing students written reflections) was used to describe students’ thoughts about a sustainable professional life as nurses.

Setting

The undergraduate nursing program in Sweden consists of three years at the academic level resulting in a bachelor’s degree in nursing science and a professional degree as a registered nurse. Learning activities at the Red Cross University College are partly based on the tradition of the International Red Cross and its basic principles. The undergraduate nursing program is based on the basic principles of the International Red Cross Movement, with a strong focus on humanity, impartiality and neutrality. These principles involve preventing and alleviating human suffering, protecting life and health, and protecting respect for human dignity. A local and global perspective are integrated into all the courses. The courses include nursing knowledge, public health and medicine. Only The Swedish Red Cross University College was included in this study.

Data Collection and Participants

During the last semester, semester six, of the education program, all students in that semester (n=110) were given a mandatory, final assignment where they were to reflect on their coming working life as a nurse. They were asked to answer the following questions: What do I need to think about in order to achieve a sustainable working life as a nurse? What advice should I give to myself? Each student wrote a single A4-page with their reflections. The students wrote between 350 and 440 words on the single A4-page. After the assignment was graded the students were asked if we could use their reflections in the present study. A total of 110 students were asked to participate and 105 students, 80 women and 25 men with a median age of 28 (22–56) years old, agreed to participate in the study, ie, to share their reflections.

Data Analysis

We applied an inductive thematic analysis by Braun and Clark25 on the data set. The analysis consisted of six different phases: familiarising with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes and finally reporting.

Phase one – familiarising with the data - the entire research group read the whole of the data set familiarising themselves with the data to get an understanding of the content.

Phase two – generating initial codes – the second author read the data set again. The data that corresponded to the aim of the study was marked and coded relating to the content without losing its meaning. The aim was to code the material in order to organise the data into meaningful groups.

Phase three – searching for themes – the second author sorted the codes into potential themes and subthemes. During this phase codes were moved between different themes and subthemes. New themes were developed, and themes were merged. Finally, there was a distinct demarcation between different themes and subthemes.

Phase four – reviewing themes – the second author reviewed the potential themes and went back and forth between the data extractions and the codes to ensure that the themes were correctly applied.

Phase five – defining and naming themes – the research group discussed and analyzed the potential themes to deepen the specification of each theme and subtheme, and the overall story told by the analysis. This generated clearer definitions and names for the final themes.

Phase six – reporting – the authors wrote this scientific manuscript.

To improve the appraisal of the transferability, the setting, data collection and the analysis process were carefully described.26 Quotes are used to reinforce the analytical findings. Certain linguistic and grammatical revisions have been undertaken to facilitate the transition from spoken to written language and when texts were translated from Swedish into English.27

Results

The analysis resulted in three themes (Table 1) describing the prerequisites for a sustainable working life for nurses. These themes are interconnected and described as the building blocks for a sustainable work-life for nurses.

Table 1

Themes and Subthemes Describing the Prerequisites for a Sustainable Life as Nurses

To have an ethical foundation that guide the individual nurse to protect and develop the nursing care for their patients	To be in a listening, reflexive and supportive workplace enabling a professional nurse to continuously grow and learn	To be a proud professional nurse with integrity not risking with their own health or personal professional development
Through an active reflexive dialogue or confrontation when needed, protecting human rights and ethical values, but at the same time being aware of the nature of the ethical dilemma - that is, that an ethical value can be lost	Dare to be new as a nurse but also dare to trust myself and the knowledge I have acquired	Balance between being there for the patient and their own health
Always prioritize and stand up for the patients and their loved ones	Continuously reflect, listen and discuss with colleagues (minus) to learn and support each other, which requires self-awareness, but also humility for the knowledge of others	Do not have too high demands or be too hard on themselves as new nurses
Important to be professional, to work person-centred, evidence-based and patient-safe	Counteract stress by planning, prioritize, organize, delegate and ask for help, but at the same time remember that I do my best based on the resources available and we are a team around the patient, so that I can and will put demands also on the other professions	Clear boundaries between work and leisure
	Contribute to a good working climate and going to work with a positive attitude, not pulled down in negative patterns and a dull jargon	Take care of me - eat, exercise, rest and sleep
		If I do not like the job, I change workplace to continue to develop professionally
		In conclusion, I am a proud nurse with a Red Cross brooch
		Good working conditions with the possibility of recovery and rest

To Have an Ethical Foundation That Guides the Individual Nurse to Protect the Nursing Care and Develop the Nursing Care for Their Patients

The students describe the importance of protecting and defending human rights and the right to equality and equal treatment, as well as a caring environment free from racism, sexism and discrimination. They achieve this by actively reminding themselves and their colleagues about the nurse’s ethical code and the medical principles, eg autonomy, do-good, do-not-harm and fairness. In addition, they also describe the importance of analysing the ethical dilemmas and care situations that may arise from an intersectional perspective.

The students state that a prerequisite for developing their ability to navigate in the situations and ethical dilemmas that may arise is to continuously carry out a reflexive dialogue with their colleagues in the daily work. It is also necessary to have the courage to highlight and confront possible behaviours and irregularities in the workplace that contravene professional ethical codes. For example, to speak up if something is not ethically justifiable but also to intervene when someone is treated in an unworthy way, well aware that ethical dilemmas can also mean that sometimes an ethical value can be lost.

Similarly, the students state that they want to work in a work environment and culture where it is permissible to ask questions when the work situation, work environment or culture is deficient or not sustainable. It is important for nurses to be able to stand up for themselves and their colleagues, in order to protect the nursing profession and to promote a culture free from threats and violence, and free from discrimination.

The students indicate in various ways the importance of using the patient’s best interests as a starting point in all situations. They also indicate the importance of always listening to the patient and to be the patient’s “lawyer” by standing up for and fighting for the patient in various situations. They also state that they want to:

“be part of a strong working group that has the courage to defend the voices of the patients”. [Student no 1]

The students describe that the nursing they want to pursue should be person-centred, and that patients and their close relatives should be treated professionally. Their meeting with patients and their relatives should be genuine, humble and respectful and should encourage participation even in situations where the patients or their relatives appear unsympathetic.

Furthermore, the students want to be able to work with a focus on the safety of the patient by following routines and guidelines, but at the same time to be able to speak up whenever patient safety is under threat or if someone is being treated wrongly. They also want to work in accordance with an evidence-based approach by actively seeking new knowledge, being up to date with research in nursing and striving to change for the better but at the same time be critically critical.

The students point out that they want to act with a professional and at the same time become a good fellow person. In addition, they would like to never stop caring about their patients. If they stop caring about people, then it is time to change workplace. Further they do not want to lose the drive to want to make a difference.

“The gratitude you get from the patient is a driving force.” [Student no 101]

To Be in a Listening, Reflexive and Supportive Workplace Enabling a Professional Nurse to Continuously Grow and Learn

The students describe how they want the courage to embrace being a novice in their roles as nurses, and to dare to ask for help. They want to be able to allow themselves to not be able to do everything directly from the start, but to be allowed to let things take their time and to allow themselves time to adapt to their new role. However, at the same time they want the courage to rely on the knowledge and the skills they acquired through their education. To dare to rely on yourself, your knowledge and to trust your gut feeling. To be brave but at the same time careful and patient:

“Remember I am good at what I do!”[Student no 4]

The students state that in their daily work it is important to be aware of their actions by continuously reflecting and discussing with colleagues, always asking themselves:

“What did we do and what could have been done better?” [Student no 104]

According to the students, another important aspect is being able to listen to and to learn from colleagues and other professions. Yet another aspect is to be able to share their own experiences with colleagues. The students also mention the importance of accepting help from colleagues, asking and double-checking when they are uncertain or when something feels difficult. This, in turn, requires humility and an acceptance of your own limitations, but also an ability to learn from your mistakes, to receive criticism and to not be prejudiced.

The students describe how they do not want stress to affect their way of working. In order to avoid negative stress, the students state that they need to be able to take breaks, but to also have the tools necessary to manage stress. Among the tools mentioned were being able to plan and structure their work, to have a clear picture of the target, and to work on the basis of the nursing process. It also included being allowed to be proactive and to be able to delegate and prioritize the tasks. In order to avoid negative stress, it is important to be able to talk to colleagues and to be able to delegate tasks and, when resources and or time are inadequate, to be able to hand over to colleagues without feeling guilty.

They also state that it is important to remember that they, as new nurses, do their best based on the resources available. It must be okay not to manage to do everything, to allow yourself to realize that you are not always going to be able to do enough in all situations. Seeing yourself as a limited resource and not doing everything yourself but to be able to take help from colleagues. To not forget that there is a team around the patient and therefore it is important to be able to make demands on the other care professions and to lead the nursing care by leading by example.

The students point to the importance of trying to have a positive attitude and approach to the work. Going to work with the attitude of doing their best, contributing to a good working climate and a tolerant work environment and culture, focusing on solutions. Work to not be lured into a negative jargon based on opinions and prejudice. To dare fight prejudice and to fight to change any kind of negative culture in the workplace. When something feels wrong, take it up with the person concerned and if this does not work, talk to the manager.

To Be a Proud Professional Nurse with Integrity, Not Risking Their Own Health or Personal Professional Development

The students describe the importance of finding a balance between doing their best for the patient and their own health, ie taking care of their own health in order to give the patients more of themselves. However, at the same time being able to keep a certain distance to the patients’ feelings or grief in order not to be unduly affected emotionally by the patients’ situation.

The students write that they want to be careful not to demand too much of themselves or to be too harsh on themselves. Trying to be generous to themselves, to not take all criticism personally, not to worry so much about what others think and not to be too self-critical or to blame themselves unnecessarily. Demand respect!

“Much can be done better but it was good enough”. [Student no 25}

To be given time for recovery, the students state that it is important to set limits so that work does not take over their spare time. This can for example be achieved by not bringing work home, and to do spend time on things supporting recovery like spending time with friends and family.

The students point to the importance of not forgetting to take care of themselves. They state that it is important to be honest, to listen to their bodies, to make health-promoting decisions about themselves and to develop strategies to maintain health and fitness. This includes eating healthy, having breakfast, bringing your own lunch boxes to work, physical exercise, getting enough sleep and to be well rested when they go to work.

The students state that to thrive it is important to have fun at work and that the work should feel meaningful and developing for them to remain in the workplace. If the work is boring and the working conditions are bad or if it is too stressful and “I begin to feel bitterness” they will switch workplace.

They state that they want to choose a workplace based on curiosity and courage, and not only based on salary. They want to continue to be curious, to continue to develop and to learn new things. To dare to take chances that contribute to personal development, to dare to get involved in new projects and to be open to new ideas. To dare to take the next step in their professional careers, to continue educating themselves, to attend specialist nursing education.

“Continue to develop, everything is possible as a nurse, research, innovation and leadership”. [Student no 89]

I need to remember why I wanted to become a nurse, to be proud of myself as a nurse and about what I do, that I make a difference in people’s lives. Wear the Red Cross brooch with respect and pride!

The students point to the importance of paying attention to risks in the work environment, to work ergonomically and to say whether something is too heavy physically and/or mentally. Daring to “apply the brakes when it is too stressful” and not to allow your workplace to wear you out. Furthermore, the students state that it is important to take their allotted breaks, to sit down and eat even when it is stressful. To dare to say no to too much work or to extra work, to handle and to plan their schedule with enough time for recovery. They also state that it is important to use their vacation time despite financial incentives from the employer to postpone it. It is also of importance to make demands on the employer with regard to work environment, working hours, working conditions, professional duties and development, and on salary. A few students also suggested getting involved in the union to promote better working conditions for nurses.

Discussion

The aim of the study was to describe nursing students’ thoughts on a sustainable professional life as nurses. The analysis resulted in three interconnected themes describing the building blocks for a sustainable work-life as nurses; 1) to have an ethical foundation that guides the individual nurse to protect and develop the nursing care for their patients; 2) to be in a listening, reflexive and supportive workplace enabling a professional nurse to continuously grow and learn and 3) to be able to work in a reflexive and supportive workplace and to not risking their own health or personal professional development. The themes can be seen as the building blocks and the prerequisites for a sustainable work-life as nurses.

The study shows that the participants want to have an ethical foundation that guides the individual nurse in protecting and developing the nursing care for his or her patients. The ethical code of nursing is clearly defined by the International Council of Nurses28 and it states that a nurse should contribute to an ethical organisational environment and should challenge unethical practices and settings. According to Holmgren and Kraft29 advocacy, activism and sustainability are important aspects, which will constitute an important foundation of the nursing students’ knowledge and skills.

Our study shows that certain prerequisites must exist in the workplace for the participants to become activists. As it is currently expressed, it appears to be the manager’s responsibility, not the individual’s, to change the situation when needed. There is a need for employers to provide space for reflective discussions, not least in ethically challenging situations where the entire healthcare team must be given the opportunity to gather. Otherwise, there is a risk for empathy fatigue. Slettmyr et al30 has stated that humanity created a sense of ambivalence and vagueness, described as a growth of independent expressions of life caused by “the other’s” need, but also an unwillingness to take unconditional responsibility for “the other.” In addition, the lack of senior colleagues may also be a hindrance to becoming an activist. A lack of nurses is not only a problem in the Swedish health care context, but as previously mentioned, it is a global phenomenon.

In this study, the participants expressed that they want to have the courage to be recently graduated nurses and to work in a reflexive and supportive environment. According to Ten Hoeve et al31 newly graduated nurses need to feel both practical and emotional support from their colleagues. However, Leong and Crossman32 has elucidated that colleagues often expect that newly graduated nurses, on day one, should know how things should be performed. If they do not perform a task in the right way right from the start colleagues were complaining about their performance. Kasman et al33 has stated that insecurity, feeling powerless, a loss of control and a heavy workload could be negative emotional triggers. In addition, the responsibility could be overwhelming for a newly graduated nurse.34

This study shows that it was important for the participants to create clear boundaries between work and leisure. These findings are strengthened by Ten Hoeve et al31 who stated that a feeling of control in both your working life and your private life is important. The participants pointed out the importance of a good working environment. In situations with a poor working environment the quality of care could be negatively affected. A good working environment includes good working conditions with opportunities for both rest and recovery. According to Hasson and Gustavsson35 there is a continuous decline in sleep quality among nurses beginning during their last semester of nursing education and continuing for the first three years of their working life. The most distinct short-term decline in sleep quality corresponds with their transition from student life to working life. According to Frögéli et al36 supporting the development of the socialization activities could be one strategy to reduce levels of stress among recently graduated nurses. Stress among new professionals is not unique to the nursing profession, and the nursing activities are considered important facilitators of new professionals’ adaptation.

This study provides new knowledge about nursing students’ willingness to work using a strong inner ethical compass to guide, protect and develop the nursing care for the patients. There is a need for a supportive workplace which gives the nursing students time to perform their work based on rules and regulations. However, the nursing students also regard their own health and the opportunities for professional growth as important aspects for staying at a workplace.

Method Discussion

Given the design of the study, we did not perform any interviews regarding nursing students’ thoughts on a sustainable professional life as nurses. The results are based on nursing students’ written descriptions of their perceptions of a sustainable professional life as a nurse. To increase trustworthiness and transferability, we have included qualitative data from a large number of students. All authors have long experience both as medical educators and as nurses. This preunderstanding and experience of the context allowed the analysis to be performed in more depth. From another perspective, a plausible bias of a researcher with preunderstanding and experience of a studied context may lead to important aspects remaining unnoticed. However, investigator triangulation was applied, and all researchers engaged in the analysis contributed different professional perspectives and experiences to ensure credibility and mitigate the risk for bias.26 We studied nursing students’ thoughts about a sustainable professional life as nurses before their graduation and the results might be transferable in similar settings.

Conclusion

The nursing students describe their thoughts on a sustainable professional life as nurses as having a strong inner ethical compass to guide, protect and develop the nursing care for the patients, which requires a workplace with a reflexive and supporting culture. However, the nursing students also put their own health and the opportunities for professional growth at the top of their priorities and if the conditions are lacking, as proud nurses, they will switch to another workplace.