3.1. Nurses’ trajectories and conditions in long-term care hospitals
Participants reported entering long-term care hospitals to achieve a good work-life balance, or due to the difficulty of finding a job in a large acute care hospital. They had moved from one LTCH to another twice and eventually remained in these hospitals and separated into three groups: thriving, surviving, or leaving (Fig. 1).
All participants reported that they chose to work in an LTCH to achieve a good work-life balance. Work-life balance means balancing one’s personal life (such as home and hobbies) with one’s occupation. Work-life balance, identified by all participants as an important factor, includes geographical proximity from home, limited number of required weekend shifts, and flexible work shifts. Geographic proximity from home saved both transportation costs and the time required for family responsibilities. Flexibility of work time was described by all nurses as the ability to negotiate work shifts in advance of employment, aligning the future work schedule with personal life and obligations outside of work, including family schedules or study time, to advance their careers.
“I wanted to care for my kids simultaneously… This hospital is very close to my house and convenient in terms of caring for my kids…and this hospital gave me the working conditions that I wanted. Working time is from nine to five. It’s a good time to take care of my kids. Also, I can take every Sunday off. These working conditions were suitable for me, so I came here.” P7RO
Besides work-life balance, the difficulty of finding a job in a large acute care hospital was another motivating factor for entering LTCHs. Nurses who were new to practice, nurses who had been on long career breaks, and early retired transfer nurses referenced the limited opportunities available to obtain a job in large acute care hospitals due to conditions of recruitment timing, ability, and their age, which contributed to their decision to work in an LTCH. Newly qualified nurses added that, due to their current limited opportunities, LTCH was an effective way to launch their careers by allowing them to gain experience in nursing while they were wait-listed for grand acute care hospitals.
“I failed the (school nurse) exam. I could not apply to grand acute hospitals after I had graduated one year later. There were not enough opportunities for me to take except working here. So, I came here” P14N
“It was hard for me to enter acute care hospitals because I had a very short nursing career in hospital, and had stayed at home too long after marriage. I forgot everything…” P7RO
“When I was getting old, it was so stressful studying at my work. In the previous acute hospital, I had to continually study and teach younger nurses … That was why I came here. I wanted to have a more relaxed life.” P8T
Trajectory-related conditions were categorized as work environment, organization, relationship, and intrapersonal conditions. Nurses were seeking better systems, equipment, payment, and opportunities to improve their work environment. Organizational conditions included opportunities for development and role ambiguity. Relationship-related conditions included seeking less conflict, having good relationships, and having a supportive nursing leader. Lastly, intrapersonal conditions comprised finding meaning in the profession and recognizing social stigma.
Over time, some participants stayed at the same hospital while others moved on to new LTCHs. Ten participants stayed in the same LTCH that they had first entered. These nurses were younger and had had shorter nursing careers than those who moved. Work-life balance was important to them as well as having a supportive manager who influenced their decision to work in the same hospital. Nevertheless, participants sometimes wanted to quit the hospital due to the physical burden or conflict with coworkers. At this point, the supportive role of head nurses to change them to a more relaxed schedule or to encourage staff nurses had an important influence on their decision to stay at the same LTCH.
“My head nurse always encouraged me to stay here. Whenever I was so exhausted physically, she made my schedule more suitable for me. She tried to do her best for me to stay here. Because of her, I could not leave here. I could not betray her great help. I am still working here because of her.” P14N
Seven participants had experience moving within LTCHs with a maximum of two moves. These nurses were older and had had longer nursing careers than those who stayed. In this moving process, work-life balance was also revealed as the common cause. Participants moved to be closer to their homes in a bid to find a better work-life balance. Participants also moved hospitals to seek better compensation.
“This hospital gave me more holidays, more holidays... and more salary (quietly), a little bit… so I moved here.” P15RY
Participants also moved hospitals to seek better organization with a better owner philosophy and better equipment. Participants presented profit-seeking owners as a salient and strong reason for moving. They discussed LTCH owners’ concerns about making and saving money through examples of patients’ documentation methods and restriction of the resources required in nursing care. This ownership directly affected nurses’ negative feelings towards LTCHs, decreased their morale to work there, and eventually induced nurses to move to another organization.
“The hospital manager was not a medical-oriented person. He was just a businessman. So, we—nurses—could not talk with him about the stuff we needed. Whenever we asked for something to be bought for patient care, he always rejected it. I was so shocked at him and left just one month later.” P9T
Participants also moved to new LTCHs due to better equipment, including hospital computer systems (OCSs). Nurses commented that in most LTCHs, they had to write all patients’ documentation by hand because OCSs were not common. However, sometimes re-entry nurses did not want to use OCSs because they were not familiar with them. Transfer nurses from acute care hospitals, on the other hand, were good at using OCSs, and this was revealed as a moving condition for transfer nurses.
“The computer system, OCS, was the most important reason I came here. In other places, nurses have to write tons of paperwork by pencil, then write and erase with ‘white’ (eraser), and write it again… that job made my wrist and hands hurt so much. OCS was the biggest merit of working here.” P9T
Therefore, seeking better compensation and better organization were identified as the other reasons for participants moving to new LTCHs. The final moving condition of participants was seeking less conflict with a nursing manager. They perceived nursing managers to lack the leadership skills required to manage nursing staff and their work. If nurses had several conflicts with nursing managers regarding communication and jobs, they left and moved to new settings.
“The nursing manager was extremely self-righteous. I had several conflicts with her, so I could no longer be tolerant there. So, I decided to leave there and came here.” P9T
“In the previous LTCH, the nursing manager was very obsessive about the work, too obsessive… so I could not be patient with her. She was just controlled by the hospital owner to earn money.” P3T
3.2. Thriving, surviving, and leaving
Over time, participants separated into three groups: thriving, surviving, and leaving. Participants in the thriving and surviving groups wanted to stay longer in LTCHs in contrast with the leaving group who intended to leave. The thriving group represented nurses who enjoyed their work in LTCHs, even though they perceived the setting as lacking opportunities for professional growth and lacking recognition. They were also confronted with the unappealing everyday working conditions, had conflicts with people at work, and perceived there to be social stigma, just like the surviving and leaving groups. Age was not relevant to the thriving experience; these participants had a will that could not be swayed by external conditions. One participant said that if she had the opportunity over again to obtain a job as a new nurse, she would definitely select LTCHs as a working place without hesitation.
The conditions for thriving were finding meaning, making good relationships, and seeing opportunities to improve. Such participants perceived their job as intrinsically valuable and were satisfied with gerontological work.
“When I go to work in the morning, I have a new expectation every day. I have lots of experiences of working value here. I am very satisfied. When I go back home after finishing my duty, I am always thinking about my patients… It’s my pleasure...Every female patient looks like my grandma. One elderly person who had not eaten anything for seven days said to me ‘I want to eat beef soup.’ So, I made some at my home and brought it in to her the very next day. She said it was so delicious and thanked me so much. Oh, I was so touched and I felt my worth as a nurse working in LTCH.” P14N
Another salient condition that contributed to nurses thriving in LTCHs was forming good relationships with elderly patients and their families, and nursing staff. Thriving nurses spoke with patients about everyday life, family issues, and even their secrets. Therefore, they knew everything about the patients: their characteristics, preferences, families, and even very personal matters. Thriving nurses described patients as their new family members but real ones made while working in LTCHs. Moreover, when patients’ families perceived the good relationship they had with their parents, the family responded with a reciprocal relationship to the thriving nurses. Furthermore, when patients’ families visited their parents, the thriving nurses explained their parents’ conditions using common vocabulary to ensure ease of understanding. Finally, elderly patients and their families felt close to and trusted thriving nurses. These good relationships were not limited to elderly patients and their families; they also had good relationships with nursing staff, including nursing assistants and care workers. Thriving nurses respected these staff personally, listened to their demands, and helped them with their difficulties. This behavior fostered good mutual relationships with nursing staff in LTCHs.
“I talk with them about everyday life. They open their minds to me so that I know everything about their lives. I have made a new family there, and they really are my family that I have here. My patients and their families trust me. They look like a real family to me. They like me very much and rely on me.” P14N
“When nursing assistants had to insert IVs in elderly patients, they felt very upset. Whenever they asked me to help, I ran over to them and helped them. And when they had communication issues with my head nurse, I played a bridging role between them and the head nurse to communicate well. So, these things made them trust me and it went well with them.” P13RY
“I try to respect them (nursing assistant (NA) s, care-workers) as precious nursing staff, and to listen to what they want. When they made trouble while working here, I always tried to understand their position… When I treat them well, they will do well by me too.” P3T
The final condition necessary for participants to thrive was seeing opportunities to improve the unorganized hospital system. Participants proposed and changed the system in LTCHs, focused on patient-centered care, and developed nursing staff care quality.
“At that time, if a patient couldn’t afford to get fluid therapy, then he/she could not get it. I thought ‘this system isn’t right.’ The patient should be first and the money next! I suggested this to my head nurse, and she brought the issue to the committee meeting. So, the system was changed.” P14N
“I changed the rounds system in the morning. When I went to see patients, I took all of them (the NAs) together and I explained and showed them the nursing care suitable for each patient in front of them, for them to learn. In the past, only a nurse went on patients’ rounds, so they (NAs) did not know anything about the patients’ conditions. If they do not know the patients, can they care for patients?” P13RY
“I had considered the bath issue for elderly patients several times and I have finally changed it. I thought that if all nursing staff participated in bathing patients, they could know the general conditions of every patient from head to foot better. When it was changed, the NAs resisted it too much. But I changed it!” P3T
Therefore, those nurses who found meaning made good relationships and saw opportunities to improve the hospital system were thriving in LTCHs.
The surviving group nurses mentioned that they were merely enduring their jobs in LTCHs without finding any meaning. These were the oldest of the three groups.
“Because this working condition fits me, fits me, I am trying to spend day after day. That’s all. I do not have any value here… that story is too sad (weak voice).” P5RY
The work-life balance was the salient condition for surviving in LTCHs.
“Though the salary is small, it is close to my house and I can live in a more relaxed way than before. I think here is a good place for me to work after the age of fifty.” P9T
Another condition that induced surviving nurses to stay was having a supportive nursing leader, either a head nurse or nursing manager. They expressed how, whenever they experienced difficulties with others or in completing their work, the nursing leaders managed the personnel, duty schedule, and work to support participants to stay on. These supports prevented nurses from leaving LTCHs.
“My head nurse controlled them (NAs) so that they did not exert territorial power over me. I was so much younger than them and I did not know about the LTCH system. They were trying to catch me in their nest. Without her (head nurse) help, I would had been left here.” P17N
“When I considered leaving here, my head nurse considered me very much. She changed my schedule from day to evening, because evening duty is easier than day. She also encouraged me to stay here. Because of her, I endured and endured…” P6RY
“The best of this is my nursing manager. She defends me in everything... When I received phone calls at night from the hospital, it made me very stressed in my previous LTCH. But here she takes the phone at nights. She does it for me, for me.” P9T
Some participants also perceived their jobs to be dead-end because of the limited job opportunities that emerged from LTCHs due to their old age.
“I am old, so it seems hard to work in other places. I think this is suitable for me, so I’m just here…” P9T
Despite the good work-life balance, leaving group nurses wished to leave LTCHs. These were the youngest group and had an entire nursing career of over five years. The conditions contributing to intent to leave were lack of professional growth, unappealing work, and dissatisfaction with managers, continuing conflict, and social stigma. These participants felt that their nursing knowledge and skills were becoming old-fashioned, due to the lack of opportunity to learn in LTCHs. Some participants expressed their eagerness to learn about the required care of the elderly: medications, fall prevention, counseling, hospice, and end-of-life care.
“I feel that I am becoming out-of-date day by day. I can’t remember the medical terms that I used so often before. I am falling behind, so I have thought about moving to an acute hospital several times. LTCH doesn’t give me any chance to develop my career (such as) in hospice, end of life care…” P15RY
“I forgot everything to be learned here. Even though when I was a part-time employee in a community health center, it gave me lots of time to learn things such as PowerPoint skills or teaching methods… I learned new things there. But here I have never learned anything over the years… I have just forgotten all the things that I knew before. I am thirsty for education. I feel too distressed as a professional nurse.” P4T
Some participants declared their dissatisfaction with managers, both nursing managers, and hospital owners, as the condition influencing their leaving intention. They strongly perceived that they had not received any recognition for their effort in working in LTCH due to the biased personnel assessment from the nursing manager.
“I always think about leaving here… I think I will leave here after childbirth and maternity break; I will leave here… I didn’t receive any reward for my master’s degree… and I had a terrible experience. I acted as a substitute for the head nurse and nursing manager while they were away but I didn’t receive any rewards on my job in my performance appraisal. She doesn’t utilize any evidence to appraise nursing staff, she just gives better evaluations to the people she likes. I think she is unfair and she does not show any leadership like managers in acute care hospitals.” P1RY
Participants also cited as bad hospital managers, who were not concerned about staff morale, as a leaving condition.
“I do not have any satisfaction or pride as a nurse and so I want to leave LTCH. Moral support for staff is urgent. But we don’t get it here. If we got it, we would serve our patients well… so the owner should be more concerned about the staff. Staff management comes first. If the hospital owner continues to act like this, then lots of staff will leave here including me…” P11RY
Another reason for leaving LTCHs was the unappealing work conditions, including elderly deaths and lots of paperwork. Some participants discussed the difficulties of elderly deaths as an unappealing job condition since they felt frustrated by the amount of death they saw in a day.
“When patients are discharged with recovery, nurses can feel that their work has some value. But here in the LTCH, most patients are only discharged when they die. I feel so depressed when I see so many dying cases here. One or two elderly people pass away every day. Most of the elderly patients can’t recover but eventually die. I can’t find any value in working here as a nurse. So, I seriously think of leaving very often.” P5RY
Head nurses actively reported paperwork as another unappealing job condition because head nurses played a role in regular governmental evaluation.
“That regular accreditation evaluation is obligatory for LTC hospitals. But it gives too much paperwork to do. That pile of papers. When it arrives, the patients are almost left alone. We don’t have time to take care of them. Nurses are always saying, ‘I will leave before this coming accreditation.’” P15RY
Continuing conflict with nursing assistants was another reason cited by participants for wanting to leave LTCHs. They discussed how LTCHs are a nursing assistant driven setting because NAs outnumber RNs as nursing staff and play a similar role to RNs. Therefore, nurses perceived NAs as having power in LTCHs and reported that if nurses could not endure this environment, then they could not work in LTCHs. This continuing conflict was prominent in transfer nurses, who mentioned that the structure was very different from acute care hospitals.
“The hardest job in here is to manage them (NA) as a head nurse. They have power here to control things because there are more of them than (registered) nurses and they are also older than us (RNs). I have heard that the previous head nurses left here because of them. It’s a hard job for me…” P3T
“NAs pushed RNs, including the head nurse out of the ring. They are too harsh to control. They have a territorial power here. If a nurse can’t endure this situation, the nurse will leave the LTCH. It’s very important to manage them here, LTCH.” P4T
“The hard job is to manage them here. I don’t know how to treat them, because their job is very similar to mine, RN. They are too much older than me, like my mom. It is so hard…” P12T
The final condition for leaving was the social stigma. Participants perceived this from elderly patients, their families, acute care nurses, and nursing teachers. They also perceived their ignorance as unknowledgeable nurses compared to acute care nurses. They described how elderly patients and their families tested their medical knowledge. They also felt ignorance from nurses working in acute care hospitals when a patient who had transferred there asked something about the elderly patients. Even nursing teachers were curious about why participants would choose to work in LTCHs. This social stigma prompted participants to leave LTCHs.
“(My teacher asked me) Why are you working there as a young (nurse)? That’s a place for old nurses who can’t get a job anywhere else. My friends don’t know that I am working here. I have not told them. I am not sure, but I feel a little ashamed. I think I am working here, in an LTCH, because of my lack of competence to work at acute hospitals, which seem like very active and vivid places. But here, it seems like a very passive and dim place to stay with old patients, nurses who are too old, and old physicians. Frankly, I do not want to stay here any longer.” P16N
Therefore, nurses entering LTCHs for a work-life balance, either staying in the same place or moving to a new place, were finally divided into thriving, surviving, and leaving groups over time. The most noticeable condition in this passage was work-life balance, although thriving participants had also found new meaning at work. Therefore, seeking a work-life balance and meaning through caring were the essential components of the pathway for nurses working in LTCHs.