Ways of being resilience on nursing home nursing staffs: A phenomenographic approach

doi:10.21203/rs.3.rs-1516213/v1

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Ways of being resilience on nursing home nursing staffs: A phenomenographic approach

https://doi.org/10.21203/rs.3.rs-1516213/v1

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Aim: The study’s aim is to identify the methods behind nursing staff resiliency in nursing homes (NHs)

Method: Phenomenography was used. Data collection was conducted with semi-structured interviews with 20 nursing staff members in NHs, and a data analysis based on phenomenography was conducted.

Results: Eight categories were derived. The eight categories were then divided into two groups of four representing perception and strategy. Perception had three levels of awareness, valuing, and assuring, while strategy had three levels of identifying, introspecting, and concretizing.

Conclusion: The ways NH nursing staff enhanced and employed their resilience to overcome professional crises included considering both internal and external factors for residents and themselves while seeking a positive direction for growth. This study will suggest a roadmap for future educational interventions to improve the resilience of nursing staff working in NHs.

Nursing home

Nursing staff

Resilience

Psychological

Qualitative research

The steady increase in the global elderly population [1] has been accompanied by a growing interest in nursing homes (NHs), residential facilities for many in the elderly population [2]. NHs provide not only medical support but also living support [3]. The composition of NH workforces and the tasks and roles they perform do not differ significantly from country to country [5, 6, 7], and in Korea consist mainly of nursing care workers, nursing assistants, and nurses [4]. With the expanding number of and demand for NHs, the need for medical professionals to staff them is also rising, yet the supply of such workers is so far proving insufficient [8]. In addition, existing nursing staffs are exposed to various difficulties, such as high labor intensity and poor working environments [9]. Accordingly, they are experiencing high levels of stress and burnout, as well as mental health issues [10, 11]. Such stress and job dissatisfaction among nurses in NH can lead to missed care and a lower quality of care [11]. Therefore. it is imperative to examine strategies that can prevent nursing staff mental health problems, which can have a negative influence on their quality of life as well as the care they provide residents.

Resilience has been widely used as a protective factor that helps the subject overcome difficult situations [14, 15] and has been emphasized as an effective concept that can be important in overcoming mental problems in nursing [12, 13]. It has been studied in various fields, such as psychology, psychiatry, education, and social work, and has been defined in various ways. Resilience is sometimes defined as a personal characteristic that helps positive adaptation in difficult situations [16, 17] and has been described as a dynamic process that can be possessed only in the presence of adversity [18]. The meaning of resilience is expanding, and attention is being paid to the importance of building resilience in education, sociology, and public health policy [18, 19, 20]. According to Masten and Obradovic [21], many attributes are involved in the building of resilience, which, it has been argued, is not a single characteristic or process but a complex family of concepts. In addition, several studies have asserted that resilience can be learned as a process of struggling against hardship [22, 23, 24].

The importance of education in improving resilience has been continuously emphasized [25]. To date, various education-related studies of resilience have been conducted, such as educator strategies to strengthen the subject's internal resources [26, 27], effective teaching methods [28, 29], educators’ roles [30], and curriculum development-related studies for improving resilience [31]. An examination of these studies reveals that an educator-centered perspective on what to teach and how to teach plays a central role. Many viewpoints on how to improve educational effectiveness have been expressed, highlighting the importance of comprehending and assessing the related learning phenomena. Martton [32] suggested focusing on the learner as the subject of experience for understanding more about such learning phenomena. Because each learner has a different way of learning, thinking, and experiencing, it is vital to conceptualize and analyze such phenomena from the learner's perspective in order to provide successful learning. Consequently, it has been proposed that understanding how learners perceive and experience phenomena can lead to far more effective learning [32, 33].

Ungar emphasized that resilience requires a contextual approach that fits the culture to which the concept belongs [34]. This suggests that the need to explore the nature of how the subject experiences resilience varies depending on the context. Moreover, since resilience includes subjectivity and individual differences can be very large depending on the subject, a suitable method considering these factors is required for an in-depth investigation of resilience.

Phenomenography is a research method that seeks to understand an individual's experience of a phenomenon and focuses on differences between individuals in their ways of experiencing the world [32, 33]. Therefore, this study to identify the various experiences of nursing staff on their methods of being resilient in NHs was conducted using phenomenological methods. This study can provide foundational data and specific directions for developing future educational programs and various strategies to improve and maintain resilience of nursing staffs in NHs.

Aim

The purpose of this study is to identify the ways of being resilience of nursing staff in NH using a phenomenological method.

Design

This study used phenomenography to identify the ways of being resilience of nursing staff in NH. Phenomenography is a methodology that studies the relationship between subject and phenomenon, exploring how the subject experiences the world with a focus on differences in perception based on individual experiences [32, 35, 36]. Therefore, it was considered appropriate for the purpose of this study and was thus selected.

Data collection

Data were collected through semi-structured interviews, which are a data collection method suitable for phenomenology [37]. The key criterion in selecting research participants is whether the participants possess enough experience to represent the phenomenon of interest rather than the sample’s size [33, 35]. The researchers first identified the attributes of resilience through a literature review. After the managers of three domestic NHs were explained the attributes of resilience revealed through the literature review and the phenomenon to be identified through this study, they recommended suitable subjects from among the care workers, nursing assistants, and nurses at their facilities.

Since phenomenography does not set an appropriate number of study participants, the number of participants in previous studies varied from 5 to 90 [38, 39]. In phenomenography, the number of participants is determined by the saturation of the data rather than the number of people [40]. Data saturation is achieved when no new data turns up in the data collection [41]. As the interviews for the present study progressed, it became clear that data saturation had been reached after 31 interviews with 20 participants. Additional interviews were then conducted for clarity of meaning, for a total of 42 interviews, all of which were conducted by the corresponding author.

In phenomenography, an in-depth conversation can best proceed by prior to the interview presenting a specific scenario related to the phenomenon to be explored [42]. The three scenarios used in this study were created through discussion by two of the study’s researchers with the purpose of describing three levels of NH nursing staff resilience: high, medium, and low (Table 1). Two experts, a professor of gerontological nursing and a NH manager, verified whether the contents of the scenarios were appropriate. The specific interview guidelines are presented in Supplementary File 1. As the interviews progressed, participants were free to move to topics of interest, interview questions were flexibly changed according to the content of the conversation, and not all participants were asked all the questions in the guidelines.

Table 1

Scenarios demonstrating the resilience of nursing home nursing staff
Instructions: Please read the following three scenarios and rate them for low, medium, and high resilience. After you have read all the scenarios, the researcher will ask you questions about them.
1	Ms. Park (female/32 years old), who is a care worker and has worked for six years at a nursing home, has recently had the number of patient care tasks she has to perform increased due to the resignations of her co-workers. Because she has to work two hours overtime every day, she is having a very hard day physically. She thought about quitting her job several times a day, but she couldn't because of her concern for the patients she would leave behind. She felt comforted when she talked to like-minded co-workers about the difficult situation. She also talked to her manager about a problem she didn't think she could solve and asked for the manager’s help. Through these actions, Ms. Park's desire to quit her job subsided, and she decided to work harder, thinking of the people who helped her.
2	Mr. Kim (male/35 years old) is a nursing assistant who has worked at a nursing home for five years. The facility’s manager recently changed, and Mr. Kim was always being scolded by the new manager. Mr. Kim was afraid of being scolded in front of his co-workers, and he wanted to quit his job. He became unsure about caring for patients, and he felt that he was unqualified to be a nursing assistant. However, his colleagues comforted him and sympathized with him. He appreciates his co-workers' efforts, but he thinks he'll quit one day because he's become obsessed with the idea that he's not the right person for nursing home work.
3	Ms. Lee (Female/28 years old) is a nurse who has been working in a nursing home for eight months. Ms. Lee did her best to take care of the residents, but recently discovered that one of the patients she took care of had pressure sores on the tailbone. A week ago, she received from the patient's daughter a severe complaint about the patient's pressure sores. Mr. Lee felt guilty about the patient's worsening condition contrary to her intentions, and she felt depressed as she began to think she was unqualified to be a nurse. Eventually, she resigned and left the nursing home.

Data analysis

The theoretical foundation of phenomenography is a phenomenological interpretive approach [32]. Therefore, the validity of phenomenography is determined not by how accurately the result reflects the objective reality, but how persuasively the result describes the phenomenon [43]. To ensure such a study’s validity, the seven-step analysis process of phenomenography [44] is strictly followed as a procedure, and the logic of the descriptive category and output space derived from the analysis process is confirmed [43]. Accordingly, to logically derive and describe the descriptive categories and output spaces of the nature of experience of the resilience of NH nursing staff, Marton’s [32] phenomenography research method was used, and each step was faithfully performed. The first step is 'familiarization', in which the researcher considers the collected empirical data. For this study, the researchers transcribed the recordings of 20 participants and read them repeatedly until they could clearly perceive the statements. The second step is 'condensation' and involves an intensive reading of the transcribed material to identify its most important elements. The researchers found commonalities and differences by classifying and organizing meaningful sentences or important statements using color highlighters. The third step is 'comparison', which identifies potential concepts and compares them with each other to discover the concept’s essential characteristics. The researchers then proceeded with coding by deriving tentative concepts centered on simplified semantic sentences and keywords. In this process, researchers tried to derive concepts by focusing on context rather than direct language. The fourth step, 'grouping', pre-groups or classifies similar statements, while the fifth step. 'articulating', sets boundaries between categories. The researchers carried out the process of confirming the exact meanings and correcting the categories through additional interviews for any ambiguous or unclear content. The sixth step is the 'labeling' step, in which appropriate names were given to categories. In the seventh step, 'contrasting', the conformity between the finally derived categories was checked. During this process, we reached agreement through discussions with two qualitative research experts. Each analysis step was analyzed independently by the same researchers as above, and consensus was reached through discussion at each step. The analysis results were confirmed by the participants to increase the validity of the analysis, and debriefings were performed between researchers was performed during the analysis process to increase the reliability of the study.

Ethical consideration

The investigation was approved prior to the start of the study and followed the principles specified in the Declaration of Helsinki. This study was reviewed and approved by the Korea University Institutional Review Board (KUIRB-2021-0384-01). The researchers fully explained the purpose and method of the study to each participant before the start of the study and obtained informed consent. It has been explained that personal information will be protected, that the information obtained will be used only for research and that it will be destroyed after a certain period. All participants voluntarily consented to participate in the study.

The participants consisted of 10 nurses, 6 nursing assistants, and 4 care workers. Their ages ranged from in the 30s to 60s, and their average work experience in an NH was 8.12 years. All the participants were women (Table 2).

Table 2

General characteristics of the participants (N = 20)
Characteristics	N (%)	Mean (SD)
Occupation
Nurse	10 (50.0)
Nursing assistant	6 (30.0)
Care worker	4 (20.0)
Age (years)
30–39	3 (15.0)	52.75 (10.05)
40–49	4 (20.0)
50–59	10 (50.0)
60–69	3 (15.0)
Work experiences in NH (mean, years)
1–5	8 (40.0)	8.12 (9.15)
6–10	9 (45.0)
10–15	3 (15.00)
Gender
Women	20 (100)
Men	0
Education
College	15 (75.0)
Master’s degree	5 (25.0)

As a result of analyzing the collected data, eight categories were derived and then divided into two groups: perception, which represents a cognitive process, and strategy, which represents a process for transitioning to concrete implementation. Perception confirmed the process in which the subjects in difficulty became aware of the situation, thought about their responsibility to the patient and their own values, and became confident about problem-solving while considering their inner strength and growth. Strategy consisted of the process of evaluating oneself and one’s environment to discover the possibility of problem-solving, taking care of oneself first so as to remain strong, and finding a way to solve problems and grow one step further.

Categories in perception of the ways NH nursing staffs demonstrate resilience

Four categories were found under the perception of NH nursing staff resilience: grasping the situation, thinking about one’s responsibility for the resident and personal values, considering one’s strengths, and thinking of an improved self.

Category P1: Grasping the situation. When NH nursing staff were faced with a difficult situation, they first tried to find out what the situation was and its cause(s). They sought to determine whether the difficulty was caused by some specific situation, the environment, or themselves. Having awareness of the situation was crucial for setting their future direction in problem-solving.

There is too much work and too much complexity going on around me. In any difficult situation, the most important thing is to know why it happened. If I don't recognize the reason, it will mix with other situations, and I won't be able to identify it [Participant 3].

Category P2: Thinking about one’s responsibility for the resident and personal values When the nursing staff found themselves in a difficult situation, they thought of the residents and worried about the residents who would not be cared for. Since their job is to provide care for residents, they tried to do their best to fulfill their duties, even when they were difficult. Additionally, they recalled their values and beliefs while determining what they ought to do.

Due to the resignation of a coworker, I was forced to work excessive overtime. There were many days when I didn't want to go to work, but all I could think about were the faces of our patients. I pity them if I don't show up for work. The patients do nothing wrong. I persevere and overcome every time I think of my patients [Participant 5].

Since I was a child, I've been trained to be responsible, that whatever I do carries with it the burden of accountability. And, because having fun is crucial in any work, I strive to laugh and have fun when I'm having a bad day. It is quite effective [Participant 12].

Category P3. Considering one’s strength Nursing staffs strove to uncover their strengths in tough situations. They believed this was their fundamental ability to overcome obstacles and were sure that they could do so on their own.

As I faced numerous challenges, I recognized that responding to difficult events one by one would be more difficult. These trying times strengthened me. With patience, I look after my inner self. This approach allows me to see the situation objectively and concentrate entirely on myself [Participant 7].

Category P4. Thinking of an improved self Nursing staff found that developing and improving themselves were very helpful in overcoming difficult situations. They encouraged themselves not to give up, envisioning themselves as better off in the future. They studied more about the elderly and nursing, tried to show a more developed image, and thought about how to provide better caring to residents. To accomplish that, they thought they had to study and learn more. In addition to these occupational perspectives, they continued to strive to remain physically and mentally healthy human beings.

Inner growth, in my opinion, is attained via the process of overcoming adversity. Furthermore, I believe that the desire to grow, especially in the face of adversity, is the driving force behind issue solutions. To overcome obstacles, I believe that a goal must be set and that the objective must be forward-looking. I used to make a lot of mistakes when I was caring for patients, and I was angry because I thought I didn't have any qualifications. I thought at the time that I should learn more about nursing and expand my expertise [Participant 19].

Categories in strategy for supporting NH nursing staffs resilience It was identified that the strategy behind NH nursing staff resilience included four categories: Evaluation of oneself and one’s environment, taking care of oneself, finding concrete ways to manage the problem, and self-development for growth.

Category S1. Evaluation of oneself and one’s environment. For problem-solving purposes, the nursing staff evaluated themselves and their surroundings. To confront difficulties, they needed to figure out how much problem-solving capacity they and their environment possessed, as well as what resources were available to them. This is the most basic step in developing a plan, and the future course was determined based on this assessment.

It's important to know what level of problem-solving abilities I have, whether I'm in a supportive setting, and what kind of assistance I can get. I won't be able to solve anything if it is beyond my capabilities. First and foremost, I must gain a better understanding of myself and my environment in order to establish concrete plans for the future.

Category S2. Taking care of oneself. The nursing staffs respected themselves and believed that in order to get through the crisis, they first needed to take care of themselves. Through doing so, they attempted to improve their inner strength. They looked back on their prior experiences and sought to develop their strengths with the belief that they could overcome things on their own. Furthermore, they bolstered themselves with positive energy to avoid being overcome.

There was a moment when the patient's family was quite upset with me because I was not taking proper care of the patient, and I was hurt. I was crying a lot and having a terrible time, but whenever I'm exhausted, I remember that period. Even when things are difficult, I strive not to cry. I try to keep my mind in check so that I don't injure myself or that my heart becomes too hard. I believe in taking care of my inner self and strengthening it to prevent it from collapsing [Participant 1].

Category S3. Finding concrete ways to manage the problem. The nursing staffs devised specific solutions to the situation. They devised their own approaches for dealing with stress and common problems while developing bonds with their coworkers. Work-life balance was achieved by clearly separating work and personal life. These practical methods directly aided them in resolving their problems.

I try not to think about work when I get home. At home, I take time to unwind and heal while focusing only on myself [Participant 20].

Conversations with coworkers provide me great relief. To relieve stress, I normally get together with my coworkers after work and talk for a while. After discussing the tense situation, I begin to believe that serious work is not such a big deal. That is why I enjoy socializing with my coworkers [Participant 2].

Category S4. Self-development for growth. The nursing staffs devised ways toward personal growth based on the development of a stable live. They didn't merely consider how to deal with emergencies and challenges, but instead aspired to live a life of gradual development. They attempted to live lives that progressed by gaining information and expertise while also discovering particular strategies for improving themselves. In addition, they had concrete plans for the future.

For the future, I have particular plans. Life planning, in my opinion, is similar to constructing the skeleton of a building. No matter how difficult things are right now, if I have a clear strategy and vision, I will be on the correct track one day [Participant 17].

I want to write a book on my life. I feel that the difficult things I'm going through right now are laying the groundwork for me to achieve my goals in the future. That is why I try to keep a diary and write down both the good and bad days [Participant 9].

I'm studying and learning a lot in the hopes of one day becoming a nursing facility administrator. In two years, I intend to attend graduate school. It's a lot of fun to devote time to my personal development [Participant 10].

Outcome space

In phenomenography, findings are described as categories and relationships between categories and are expressed as outcome spaces [45, 46]. An outcome space can be divided into a referential aspect meaning 'how' and a structural aspect meaning 'what'. The referential aspect describes the general meaning of the phenomenon, while the structural aspect describes how each concept relates hierarchically [47]. The outcome space of this study was identified by broadly dividing it into perception and strategy (Fig. 1). The referential aspects of perception were identified as awareness, valuing and assuring, and the referential aspects of strategy were found to be identifying, introspecting and concretizing. The structural aspect was confirmed from the relationships between the eight categories, with each category representing a hierarchical structure linked with a referential aspect. In regard to the structural aspect in perception, nursing staff showed the characteristics of understanding their own situations and thinking about their responsibilities for patients and their life values based on this. These provide support for thinking about their strengths and growth and give them the confidence that they can solve problems and overcome adversity. In the structural aspect of the strategy, the possibility of problem solving is discovered while evaluating oneself and the environment, while by taking care of themselves, they establish a stable foundation on which they can stand. Through this process, they find concrete ways to overcome difficult situations.

Various studies have been presented to show that education has a positive effect on improving resilience. Pedagogical studies suggest that acknowledging learners’ diversity and reflecting their different viewpoints enhances the effectiveness of education. Accordingly, this study sought to reveal the structure of the ways NH nursing staffs build resilience by focusing on the subjects’ diversity of experiences.

The methods behind NH nursing staff resilience were divided into perception and strategy. In perception, they sought to understand the situation, took responsibility for the resident, and thought about the value of life. They thought about their strengths and how they could improve themselves. In their perception of ways of being resilient, it was underlined that when in difficult situations, they strove to overcome obstacles while thinking about their obligations to residents and the value of their own lives. A previous study that analyzed the experiences of NH staffs identified that NH staff felt a high sense of responsibility due to the low functional ability of NH residents and thought a great deal about ways to increase the residents’ independence [48]. In particular, it was reported that they experienced conflicting values in order to provide high-quality care without infringing upon the dignity of residents [7]. These prior studies support the results of this study, and these characteristics appear to be reflected in the resilience of NH nursing staffs. In addition, NH nursing staff consider their strengths and think of how to improve themselves. This process can be seen as a process of acquiring the confidence that they can overcome difficult situations and improve their skills and knowledge.

In strategy, nursing staffs look internally to contemplate growth in the process of overcoming difficult situations. In the same context, a previous study that explored the resilience experience of nurses found that nurses developed self-esteem by valuing their profession and wanting to develop their professional selves for a more rewarding future [49]. Two other approaches emphasized in strategy were taking care of oneself and actively looking for concrete ways to solve problems. Among the strategies shown in the results of this study, evaluating oneself and one’s environment in strategy, can be interpreted as confirming one's own capabilities and resources to help them overcome adversity. This basic work of the strategy is also the basis for the next strategy. In the strategy, taking care of oneself, various strategies such as mindfulness, meditation, and finding one's strength have been suggested in previous studies [50]. NH nursing staff found ways to solve problems on their own and concretized strategies. They demonstrated a self-directed attitude in problem-solving and in developing strategies for growth.

The characteristics of the perceptions shown in this study are that the sense of responsibility for residents and the value of life appear as resilience. The NH nursing staff felt a sense of responsibility for their residents, which led them to not give up and became a driving force for growth. Another characteristic of the strategies presented in this study is that by taking care of oneself, one strengthens the inner self, and based on this, finds specific methods to manage the problems and grows. These findings provide important evidence for developing programs that improve resilience.

Resilience is a complex and subjective concept; hence, studying various perspectives concerning it is essential to enrich resilience-related knowledge. This study, which presents ways of being resilient from the subject's perspective, can provide practical guidelines for education focused on improving NH nursing staff resilience. The referential aspect of this study could be utilized when developing a tool to measure that resilience, and the structural aspect could provide practical knowledge to a resilience improvement education program for NH nursing staffs.

Competing interests

No conflicts of interest have been declared by the authors.

Ethics approval and consent to participate

This study was approved by the Korea University Institutional Review Board (KUIRB-2021-0384-01) before the start of the study, and followed the principles specified in the Declaration of Helsinki. The researchers fully explained the purpose and method of the study to each participant before the start of the study and obtained informed consent.

Consent for publication

Not applicable

Availability of data and material

All data generated or analyzed during this study is included in this published article

Funding

This study was supported by a National Research Foundation of Korea grant funded by the Korea government (NRF-2021R1I1A1A01048956), (2022R1A2C1004542).

Author contributions

Conceived and designed the study: SOC, EYK

Performed the data collection: SOC, EYK

Analyzed the data: SOC, EYK

Contributed materials: SOC, EYK

Wrote the first draft of the manuscript: SOC, EYK

Agree with manuscript results and conclusion: SOC, EYK

Prepared figures 1 & Table 1,2 : EYK

All authors reviewed the manuscript

Acknowledgments

This study was supported by a National Research Foundation of Korea grant funded by the Korea government (NRF-2021R1I1A1A01048956), (2022R1A2C1004542).

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Ways of being resilience on nursing home nursing staffs: A phenomenographic approach

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Findings

Categories in perception of the ways NH nursing staffs demonstrate resilience

Outcome space

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