The aim of this study was to explore factors that positively and negatively affect ageing HCNs’ work motivation and occupational self-efficacy belief to continue working until the expected retirement age. The findings showed that several factors concurrently affected both work motivation and self-efficacy belief. When the factors were well-functioning, they positively affected both motivation and self-efficacy belief, and when they were insufficient, they negatively affected either or both motivation and/or belief. Our results are supported by many findings from previous research on work motivation and prolonging work life in home care and health care sector among mixed aged (8; 14) and older nurses (38; 39; 40). Since our study included solely HCNs of 45 years and older, it conveys important knowledge about ageing HCNs. Although age management should include all age of workers, addressing ageing workers’ needs might help to deal with the lack of skilled health care workers and to promote their work careers, receiving workers with better well-being and work ability (41).
HCNs perceived that their health highly affected their self-efficacy belief to continue working. Current health declines, and concerns about future deteriorations, caused uncertainty. Furthermore, the high physical and mental workload experienced, raised concerns regarding health and thoughts to change work field. Therefore, it is of great importance to obtain a balance between resources and demands. This is supported by earlier studies; unmanageable work demands in the nursing sector must be handled (14; 38). Considerations about individual health (42) and feelings of being worn-out influences older workers’ decisions on whether to continue working (38; 43). When having a physical form of work, poor health affecting the work ability may force the worker out of work (44; 45). Self-rated health is considered a better predictor of extended working life among older health care personnel, compared to diagnosed diseases (43). Self-rated health is therefore an important predictor of work ability perceptions (46).
Self-rated health is highly affected by the workers’ perceived job satisfaction (43), as well as having meaningful tasks (47). Perceived meaning of work might also moderate the negative effect of age on work ability (15). HCNs in our study emphasized the meaningfulness and satisfaction, both increasing work motivation and self-efficacy belief to continue working. The meaningfulness was considered as an intrinsic motivation for the home care nursing itself. These results are consistent with previous research (12; 10; 14; 15; 5). Additionally, external response and recognition from employers, clients, and relatives increased work motivation in our study. Likewise, supportive colleagues, a good workplace community, and good teamwork improved both work motivation and belief to continue working. These results are also supported by earlier research (8; 14; 38; 42). Nevertheless, intrinsic motivation is found superior to extrinsic motivators in maintaining job satisfaction (17). A recent systematic review and meta-analysis stressed the importance of focusing on organizational strategies enhancing intrinsic factors, through building a professional and workplace meaning, and value-driven strategies to improve job satisfaction (17). Job satisfaction is important when an ageing worker decides whether to continue working life (48; 17), and stated critical to relieve the shortage of nursing staff (17). Lack of motivation as a barrier to continue to work until retirement age was mentioned only a few times in our study, supporting that motivation does not generally decrease with age (10). To ensure the quality of home care, enhancing HCNs’ intrinsic work motivation through meaningfulness of work is essential (1; 8).
At a deeper level, the health lacks meaning without a meaning in life (49), and the meaningfulness of work itself and the work content emerged as essential values for HCNs in our study. A sustainable health can be achieved only when the human being is becoming aware of the deeper dimensions of health within herself/himself and is actively following the inner values which are leading her/him towards health (49). Health declines might entail new vital necessities. If health declines restrain the ability to continue working, a valuable issue in life may be lost. The familiar existence and the wholeness of life is lost, and a suffering arise (49). In this study, the care work, close to the clients, brought meaning to the HCNs’ life. In the Nordic tradition of caritative caring, vitality is considered the inner essence of health and an important inner resource of health (50). The meaningfulness of life is significant to the vitality. The vitality emerges when a human being experiences that her/his activities are valuable, that she is valued as a human being, and that she is living in harmony with the meaning of life (49). In this study, the caring work close to the clients increased the meaningfulness of life, as well as the vitality. Belief in own capabilities, i.e. self-efficacy, can be understood as an expression for willpower and vitality, meaning that factors enhancing self-efficacy are also supposed to strengthen vitality. In this study, HCNs emphasized ill-health as a threat against own capability to continue working until expected retirement age. Therefore, the leaders’ and organizations’ responsibility for supporting occupational health remain extremely important; not only in general, but in a person-centered perspective (51).
Self-efficacy belief is found effective in promoting health behaviour change (52; 53); crucial for both motivation and actions towards health improving changes (53). Expected outcomes, goals rooted in one’s values, benefits and losses from changing behaviour, and the perceived self-satisfaction influence one’s health behaviour (53). People with high self-efficacy belief have the power to produce desired changes by their actions and will translate health knowledge into health enabling practices with minimal support. They have the incentive to act and persevere in the face of difficulties. Contrary, people with self-doubts about their efficacy, or belief that health habits are beyond their control, need considerable support and guidance to strengthen their perseverance, and to build progressive success through mastery experiences by overcoming challenging obstacles (53). Thus, the level of individual support needed depends on the level of the workers’ self-efficacy belief. Self-efficacy can be developed by mastery experiences by overcoming challenging obstacles, modelling by seeing peers succeed, positive feedback, and group support and encouragement, until one starts believing in one’s capabilities (54). Since self-efficacy is an important prognostic factor for work ability among HCNs, enhancing self-efficacy is recommended in workplace interventions to promote HCNs’ work ability, as well as focusing on other changeable factors such as physical job demands and musculoskeletal well-being (9).
Many positively and negatively affecting factors mentioned by the HCNs’ in our study refer to their personal health and resources in relation to experienced work demands and resources. To influence the factors addressed and take actions to make a sustainable working life for the ageing HCNs, the leaders and the work organizations must be involved to succeed. They have the empowerment to make changes that on a long term influence the workers’ ability to remain in working life (42; 39). The swAge model (42) is a new concrete tool for leaders and organizations, as well as for workers, to both identify risks and develop work issues that contribute to a sustainable working life, throughout the whole working career. Areas important to the HCNs in our study fits into the model and need to be considered by the supervisors and the organization; the health, and its relation to physical and mental work demands, leadership, development, meaningful work, workplace community, and social support. Due to the results in our study, leaders engaging in dialogues with HCNs, actively expressing feedback and support, and inviting HCNs to influence their work with their great knowledge, could facilitate HCNs’ self-efficacy belief to continue working. Likewise, support and feedback from colleagues, and a wealthy work community provided self-efficacy belief in our study. According to the swAge model, social support should be reinforced by social inclusion in the work group (42). Despite the travelling character of home care work, it is therefore important that employers make opportunities for team and informal meetings among home care staff to strengthen the social relationships (14).
Even though the home care nursing was perceived as both mentally and physically challenging in our study, the autonomy, flexibility, and multifaceted character, conveyed both motivation and belief to continue working in conditions of balanced resources and demands. Similar factors have been found to contribute to HCNs’ intention to continue working (14).
The HCNs in our study felt skilful in their work and were strengthened using their various skills and succeeding in challenges. Although a reduction in energy was perceived as a hindrance for one’s own development, HCNs still wanted to face new challenges and develop in their work. Positively valued demands might have a motivational potential (55), since enough job resources are available (56). Among elderly care nurses it has been noticed that they want to improve the care being provided (38). Thus, HCNs should be offered opportunities for continuous education and development (8; 14; 42; 57; 58), as well as the opportunity to influence the improvement of home care work. Earlier studies have confirmed, that by offering regular education to ageing workers, their self-efficacy can also improve (59; 57).
The health is not only a personal matter; it is also a societal matter. Factors on individual, organizational and societal levels influence health and workers’ intentions to remain in working life (60; 39; 40; 53). Work organizations are responsible to arrange work in a way that supports workers (22). However, societal demands on increased workplace measures might further stress companies to implement strategies to retain older workers in work life (42; 61; 62). Therefore, interventions enhancing working life must pay attention to the complexity of work life (42), and be performed in parallel on the different levels (9; 53; 42).
Still, the workers are responsible for taking care of their own health and lifestyle habits, as well as for their mind-set towards work, including their values, attitudes, motivation, and other personal factors (22). Nevertheless, both health and personal resources are always influenced by work related factors manoeuvred by the work organization. When a worker’s resources are scarce, the work demands are experienced tougher, thus lowering the resources even more, and the worker might lack the energy to change the situation (63). According to a study exploring support after comprehensive vocational rehabilitation, workers’ initiative greatly influenced the amount and kind of support received (63). However, the initiative to request support from occupational health care or supervisor might be a major challenge to a worker with already scarce resources. In these cases, it is important that employers together with occupational health care experts capture these workers to provide adequate support and actions.
However, due to high individual differences among ageing workers, they should not be considered as a homogenous group (13). They want to be seen as an unique person; also found important when an ageing worker decides whether to continue working life (48). Although positive aspects of ageing are publicized, negative attitudes against older workers are still present (57; 61; 62). Notably, in our study only a few HCNs mentioned their ageing as a concern. Still, they wanted the employers to notice their age in a positive manner, not as a barrier. Changes of managers’ attitudes to ageing workers is important, since managers can influence factors to improve ageing workers’ working life (62). However, because all workers, all workplaces and work situations are unique, the solutions to improve working life must be individually adapted (42; 40). Thus, also taking into consideration the factors improving work motivation and belief in capabilities to continue working. A good interplay and shared responsibility between the worker and the working environment, taking the workers’ capacities and the work requirements into account to attain a good balance between individual resources and work demands, is needed for sustainable employment (64).
The employer is responsible for the promotion of workplace health trough creating prerequisites for a healthy work environment (49). An organization’s focus only on profitability tend to draw on the human values. Fundamental to good care outcomes and a sustainable occupational health is that the leader meets the HCNs in a person-centred way with dignity, respect, and trust, and allows them to work in harmony with own values in an organizational culture where both the workers’ and the clients’ health and well-being as well as good relationships are in focus (51). The results in our study emphasize the value of good community and relations at the workplace to stimulate work motivation and belief to continue working. Experiencing community and a sense of belonging is generally an elixir of life for human beings (49), and therefore, also for the ageing HCNs, their motivation and belief to continue working.
4.1. Methodological considerations
Using a cross-sectional study, prevalence of multiple outcomes could be measured, and many participants could be reached at the same time (65). All HCNs in the chosen region, aged 45 years and older, were invited, and were considered as representatives of ageing workers in the home care sector. Another strength of this study was the use of multi-methods, including both qualitative and quantitative analysis of the research data. The manifest qualitative analysis provided a deeper knowledge and understanding of the issues (32; 37). Moreover, the quantitatively measured frequencies of utterances gained reliability since the focus of HCNs’ experiences was acknowledged (32). However, there are some limitations when using a cross-sectional study. The outcomes in the participants are measured concurrently, describing the phenomena at one specific time, and it is difficult to derive causal relationships (65). When using a questionnaire there is a risk of high numbers of dropouts. The response rate was 51%, which could imply a possible bias of the outcome. In agreement with the close supervisors, who administered the survey, the use of paper-based and/or web-based questionnaire was decided. The response rate was slightly lower among the web-based respondents. Hence, some none-responding HCNs might have answered a paper-based survey. Moreover, the research data consisted of open-ended questions. The answers were often short, which despite manifest analysis, might have caused some interpretation bias (37). Therefore, we returned repeatedly to the meaning units as well as all the respondent’s answers to check the entirety and the meaning (32; 37). The response rate of the open-ended questions among the answering respondents was high (86–97%, n = 202–227 for each question), although the open-ended questions were placed last in quite a large-scaled survey. This indicated that HCNs had an interest to articulate their work motivation and belief in their capabilities to continue working. Another strength was that the findings not only highlighted factors that motivates HCNs to perform work tasks, but also an intrinsic motivation to care, reflected by internal feelings of care for clients and a deeper meaning of the work.
The HCNs’ responses were either in Swedish or Finnish language. None of the researchers had Finnish as their mother tongue, although two of them mastered Finnish well. In the case of linguistic doubts, a person with Finnish as their mother tongue, also skilled in health care, was consulted. The researchers’ pre-understanding consisted of long experience in health care, occupational health service and rehabilitation as well as experience in qualitative and quantitative research. To minimize the pre-understanding, the qualitative data analysis followed a structured procedure in several steps (32; 37). Dependability was established by repeatedly going back to the encoding, verifying the encoding to the meaning units and the open-ended answers, and checking the reliability of the categories (32; 37). Notes about the encoding were made throughout the analysis process. To increase conformability, triangulation between researchers was used. Quotations were used to support authenticity in presented categories (Table 2) (32). Moreover, our study addressed the explicit views of the ageing HCNs, in the context of both rural and urban areas, including home care services conducted by municipalities, cities, and social- and health services consortiums. The categories that emerged through manifest content analysis were considered logical and answering the purpose of the study. The findings from our study can likely be transferred to other Nordic countries, due to their similarities in home care service (5). Despite home care including distinct elements concerning care in clients’ homes; the results might be transferable to ageing workers in other nursing contexts (32; 37). Due to the high number of participants, a generalization to a broader population of ageing HCNs might be applicable.
4.2. Practical implications
The results of this study convey important understandings of the ageing HCNs’ views of work motivation and occupational self-efficacy belief to continue working until expected retirement age. By supporting HCNs’ health and emphasizing the meaningfulness and positive aspects of the work, offering overcoming challenges and learning opportunities, the HCNs’ work motivation and belief to continue working can be strengthened. This information could be used by supervisors, organizational management, occupational health personnel, safety personnel, and by HCNs themselves, to consciously reflect on and develop a sustainable work life for ageing HCNs. Addressing the needs of ageing HCNs could also help employers deal with the lack of workers in the home care sector. In turn, employers could receive more workers with better well-being and with possibly longer work careers.