EMPIRICAL STUDIES
doi: 10.1111/scs.12201
Caring behaviour perceptions from nurses of their first-line nurse managers Xiao Peng RN, MSN (Lecturer)1,2, Yilan Liu PhD, RN (Director)1 and Qingsong Zeng MM (Resident Doctor)3 1
Department of Nursing, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China, 2School of Nursing, Medical College of Yangtze University, Jingzhou, China and 3Department of Obstetrics and Gynecology, First Affiliated Hospital, Yangtze University, Jingzhou, Hubei, China
Scand J Caring Sci; 2015; 29; 708–715 Caring behaviour perceptions from nurses of their first-line nurse managers
Background: Nursing is acknowledged as being the art and science of caring. According to the theory of nursing as caring, all persons are caring but not every behaviour of a person is caring. Caring behaviours in the relationship between first-line nurse managers and Registered Nurses have been studied to a lesser extent than those that exist between patients and nurses. Caring behaviour of first-line nurse managers from the perspective of Registered Nurses is as of yet unknown. Identifying caring behaviours may be useful as a reference for first-line nurse managers caring for nurses in a way that nurses prefer. Aims: To explore first-line nurse managers’ caring behaviours from the perspective of Registered Nurses in mainland China.
Design: Qualitative study, using descriptive phenomenological approach. Methods: Fifteen Registered Nurses recruited by purposive sampling method took part in in-depth interviews. Data were analysed according to Colaizzi’s technique. Results: Three themes of first-line nurse managers’ caring behaviours emerged: promoting professional growth, exhibiting democratic leadership and supporting work-life balance. Conclusions: A better understanding of the first-line nurse managers’ caring behaviours is recognised. The three kinds of behaviours have significant meaning to nurse managers. Future research is needed to describe what first-line nurse managers can do to promote nurses’ professional growth, increase the influence of democratic leadership, as well as support their work-life balance. Keywords: first-line nurse manager, nurses, caring, behaviour, qualitative study. Submitted 29 May 2014, Accepted 5 November 2014
Introduction Many studies have reported that there is a severe shortage of nurses in Chinese hospitals. With a population of 1.34 billion people, China had 2.21 million nurses by the end of September 2011, averaging 1.65 nurses per 1000 people (1). Liu et al. (2) investigated 126 hospitals using observation and questionnaires and reported that 88% of the hospitals reported a shortage of nurses. Nurses in China have to undertake many nursing and nonnursing tasks in their daily work (1). Research has shown that nurses experience more psychological distress than the general population (3) and often leave to pursue less
Correspondence to: Yilan Liu, Department of Nursing, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jie Fang Avenue, Wuhan 430022, China. E-mail: [email protected]
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demanding careers, (4) which makes the nurse shortage more severe. One solution to reduce nurse turnover is to care for the nursing staff (5). Caring for the nursing staff is imperative for nurse leaders; it is a moral agency linked to job satisfaction and high-quality care (5). The ancient philosopher Lao Tzu (6) suggested that leaders whose position will endure are those who are the most compassionate in the Tao of Power, which applies to everyone in positions of power and leadership, including nurse leaders (7). First-line nurse managers (F-LNMs) are the direct link between the senior nurse leaders and nursing staff (8). They are responsible for an individual unit or a ward (9) and have a pivotal role in influencing the staff (10, 11). However, according to Boykin and Schoenhofer’s (12) theory of nursing as caring, not every behaviour is caring even though each person possesses the ability to care. Therefore, identifying which of the F-LNMs behaviours Registered Nurses perceived as caring could be a necessary step to find effective ways to care © 2015 Nordic College of Caring Science
Caring behaviours of nurse managers in hospital for Registered Nurses. Previous research has discussed the role of F-LNMs (13, 14); however, there is limited evidence on perceptions of the F-LNMs’ caring behaviour. This study aimed to improve this gap in knowledge by examining Registered Nurses’ perspectives.
Background The role of F-LNMs is defined as ‘nurses or nonnurses in positions with line responsibility for nursing and acute care patient units/wards with staff nurses reporting to them. There is no level of management below them; however, they may have charge nurses, supervisors or team leaders who report directly to them’ (15). Other labels for the role are clinical nurse manager (16), front-line nurse leader (17), head nurse/supervisor (18), nurse leader (19), nurse administrator (20) and first-line manager (15). In healthcare organisations, the role of the first-line nurse manager is very important in nurse management. Significant evidence has demonstrated that F-LNMs have a direct impact on organisational performance, including quality of care, financial stability, patient satisfaction, staff nurses’ job satisfaction and their caring ability (8, 21). A good F-LNM facilitates the attainment of organisational goals and objectives (22) and can significantly reduce stress and increase communication to enhance elements of the work environment conducive to job satisfaction and patient safety (23). Nursing is acknowledged as being the art and science of caring (24). Caring has been generally regarded as the core of nursing that produces therapeutic results in the person being served (25). The theorists of caring science, Boykin and Schoenhofer (12), contend the concept of nursing as caring. In their theory, they assume that caring is an essential feature and expression of being human. All persons are caring by virtue of their humanness (12). Personhood is a process of living grounded in caring which is enhanced through participating in nurturing relationships with caring others (12). It is important to note that the assumption that all persons are caring does not mean that every behaviour of a person necessarily is caring. Many experiences of life have taught us that not every behaviour of a person is caring (12). Those behaviours are obviously not expressions of the self as a caring person and may be labelled noncaring (12). Developing the fullest potential for expressing caring is an ideal; therefore, even though a behaviour or behaviours may be interpreted as noncaring, the person remains caring (12). According to this theory, F-LNMs have the nature and willingness to care for their subordinates, but not every behaviour will be perceived as caring behaviour by Registered Nurses. Thus, there is a gap between the caring behaviours of F-LNMs and nurses’ perceptions of these behaviours. © 2015 Nordic College of Caring Science
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Caring behaviours in the relationship between F-LNMs and nurses have been studied less than those that exist between patients and nurses (26). In a study addressing how staff nurses’ perceptions of nurse managers’ behaviours influenced job satisfaction, findings revealed that open and honest communication, an increased level of respect and the feeling of being cared for were preferred behaviours (27). Another study on F-LNMs perceptions about their caring for nurses conducted by Uhrenfeldt and Hall (5) identified that assistance in bedside care, dialogue with the staff and planning for staff development were caring behaviours towards nurses. However, it is worth noting that the study was conducted from the F-LNMs viewpoint rather than the viewpoint of nurses themselves. Turkel and Ray (7), in a study of creating a caring practice environment, held that caring for nurses results in nurses transmitting their own caring values to both the patient and the patient’s family. They put forward some strategies for nurse leaders to care for nurses, such as creating a ‘healing room’ for nurses, beginning executive and board meetings with a story where a nurse’s caring made a difference in his/her patient’s care, helping nurses achieve work/life balance by not expecting overtime or frequent shift rotation, offering flexible scheduling and having nurses develop a plan for self-care as part of their annual evaluation and respect the implementation of their plan. The above studies have drawn attention to the issue of caring for nurses. Unfortunately, no research has yet been carried out to explore what behaviours of F-LNMs are perceived as caring for nurses from the viewpoint of nurses themselves. As the result, the aim of this study is to explore F-LNMs caring behaviours from the perspective of Registered Nurses. The information gained may be useful as a reference for F-LNMs caring for nurses in a way that nurses prefer.
Methods Design This study employed the descriptive phenomenological approach developed by Edmund Husserl to discover nurses’ caring experiences and perception of the F-LNMs caring behaviours. Descriptive phenomenology is a type of qualitative research method used to reach the true meanings of an individual’s experience or perception through engaging in-depth into reality (28). One of the important assumptions of this approach is that researchers should avoid imposing any of their own assumptions on the data collection process or the structure of the data. The purpose of this is to keep what is already known about the description of the phenomenon separate from participants’ description (28). During the entire research process, all the researchers in this study declared
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personal biases, assumptions and presuppositions and put them aside. They examined their own beliefs continuously while keeping field notes as well as reflections for constant evaluation. Data analysis was done by using Colaizzi’s technique which is based on Husserl’s descriptive phenomenology (29). This method provides the researcher with a step-by-step procedure for performing data analysis (30).
Sampling A purposive sampling technique was used in this investigation. Inclusion criteria of nurses for this research were as follows: (i) participants must be Registered Nurses (all the nurses are full-time nurses), (ii) who have worked at their present clinical department for more than 1 year and (iii) do not hold executive positions. Data collection continued until no new themes emerged from the participants, (29) and a clear picture of Registered Nurses’ lived experience of caring behaviours was obtained.
Data collection Data were collected from February to May 2013. Indepth interviews were conducted at a mutually convenient time and a quiet place such as the meeting room, duty room or office room in each unit. Participants were prompted to discuss their perspective of F-LNMs caring behaviours. Open-ended questions were used to promote discussion. All the interviews were conducted in Mandarin Chinese. Each interview was audio-taped, lasting from 30 to 40 minutes. At the end of each interview, the researcher who conducted the interviews invited the participants to a second session with them to discuss the study findings and to make sure that the study findings reflected their own feelings and experiences. After each interview, the recordings were transcribed into Chinese verbatim immediately to allow for ongoing data analysis throughout the interview process. Transcripts were checked by listening to the tape and reading the script word-byword to ensure accuracy for analysis. All the collected data were stored on a computer and U-disk protected by a password known only to the researchers. Participants were assured that their names would not be disclosed and the confidentiality of the data would be maintained by the researchers. Interview responses that are quoted to support the themes in this study were translated and transcribed into English by a nursing graduate student and an English translation graduate student. The transcript was translated back to Chinese by the research supervisor to check for its validity and accuracy. The following questions guided the interviews: (i) Have you experienced caring moments with your F-LNM? If you have, please illustrate
some of them and (ii) How do you expect the F-LNM to care for you or your nurse peers?
Ethical considerations The study was approved by the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (IORG No.: IORG0003571) and administrative department of the study hospital. Researchers explained the study purpose and the detailed interview procedure to participants. Confidentiality and anonymity were strictly observed. Interviews were tape-recorded with participants’ permission. All the participants signed a consent form prior to the interviews.
Data analysis All the interviews were tape-recorded, fully transcribed and analysed initially at the stage of data collection. Then, two researchers analysed the interview transcripts independently by using MAXQDA 10, which is a qualitative analysis software developed by Professor Udo Kuckartz that supports a multilingual user interface, including Simple Chinese. The transcripts were analysed according to Colaizzi’s technique (31). The primary feature of Colaizzi’s method is an inductive and emergent approach to data analysis (32). It consists of seven steps, which are outlined below (28). 1 Obtaining a picture of the whole of perception. Reading and rereading all the participant’s descriptions and field notes to obtain a general picture of the whole of perception of caring behaviours. 2 Extracting significant statements. Identifying and extracting significant statements regarding how the Registered Nurses perceived F-LNMs’ caring behaviours. Each phrase or sentence directly relating to caring was marked using MAXQDA 10. 3 Formulating meanings (hidden and disclosed) from these significant statements. Each underlying meaning was coded and typed in the code system of MAXQDA 10. Two researchers compared the formulated meanings with the original meanings to maintain the consistency of descriptions. However, minimal differences were found between the two researchers’ results. After that, the whole statements and their meanings were checked by the research supervisor, who is an expert researcher in qualitative research. 4 Aggregating the formulated meanings into categories, clusters of themes and themes. Each cluster of themes was coded to include all formulated meanings related to that group of meanings. After that, groups of clusters of themes that reflect a particular issue were incorporated together to form a distinctive construct of theme. Three themes of F-LNMs caring behaviours emerged: promoting professional growth, exhibiting © 2015 Nordic College of Caring Science
Caring behaviours of nurse managers in hospital democratic leadership and supporting work-life balance. 5 Writing an exhaustive description. In this step, the significant statements, the formulated meanings and the themes were integrated into three exhaustive descriptions of caring. 6 Reconstructing the whole of the perceptions. This step involved describing the fundamental structure of the phenomenon, the essence of the perceptions. Here, a reduction of findings was done in which redundant, misused or overestimated descriptions were eradicated from the overall structure, allowing for a clear picture of the themes of promoting professional growth, exhibiting democratic leadership and supporting work-life balance. 7 Returning to participants for member checking validation. A follow-up appointment was conducted between the researchers and each participant via telephone calls by the researcher who conducted the first interview with each participant. Each nurse was given the chance to respond to the analysed data, and alterations were made according to their feedback. Eventually, all of them agreed that the results reflect their real experiences.
Results Fifteen participants took part in the study, and their demographic data were collected (see Table 1). The study group consisted of thirteen females and two males. Participants ranged in age from 22 to 43 years. Nurses in mainland China have five levels of professional qualification, which are professor of nursing, associate professor of nursing, nurse-in-charge, nurse practitioner and nurse.
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Generally speaking, the top two nurse levels have executive positions, and they are not in the charge of F-LNMs. The level of attained professional qualifications ranged from Nurses (n = 4), Nurse Practitioners (n = 6) and Nurses-in-charge (n = 5). Their departments covered internal medicine, surgical medicine, gynaecology, paediatrics, ICU and emergency medicine. In total, three themes of caring behaviours of F-LNMs perceived by nurses emerged from the data: promoting professional growth, exhibiting democratic leadership and supporting work-life balance. These themes are further elaborated below.
Promoting professional growth In the data, promoting professional growth involved career guidance, empowerment, constructive criticism and recognition for work. Career guidance, such as giving nurses support in career development, urging nurses to continue nursing education and sharing updated information or new ideas was identified as caring. In the following quotation, Participant N1, a nurse of 18 years, described how she became a nurse specialist in breathing machines with the help of her F-LNM and expressed gratitude to her: Many thanks for her (the F-LNM) great support so that I could become a breathing machine nurse specialist. I was very interested in the breathing machine, but I found that knowledge gained from books could not satisfy my thirst for updated knowledge of this field. She shared some breathing machine information with me and gave me chances to take part in some related meetings, and helped me to get the precious opportunity of authorized
Table 1 Participant characteristics (n = 15)
ID
Dept.
Gender
Age
Marital status
Professional qualifications
Highest degree earned
Years employed as a nurse
Years at current dept.
N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15
NICU Urology Nephrology Endocrinology Neurology CCU Gynaecology Emergency room General ICU Ophtalmology General ICU Geriatrics General surgery Stomatology Paediatrics
Female Female Female Female Female Male Female Female Male Female Female Female Female Female Female
30 24 31 38 29 27 43 34 30 35 36 27 25 24 22
Married Single Married Married Married Married Married Married Married Married Married Single Single Single Single
Nurse Practitioner Nurse Nurse Practitioner Nurse-in-charge Nurse Practitioner Nurse Practitioner Nurse-in-charge Nurse-in-charge Nurse Practitioner Nurse-in-charge Nurse-in-charge Nurse Practitioner Nurse Nurse Nurse
Bachelor Bachelor Bachelor Bachelor Bachelor Bachelor Bachelor Master Bachelor Bachelor Bachelor Bachelor Associates Associates Associates
10 2 8 20 5 3 24 10 7 18 18 8 3 3 2
3 2 6 12 5 3 15 9 4 18 13 8 3 3 2
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certification training for breathing machine nurse specialist. The quotation illustrates a nurse’s experience of obtaining support in career development from an F-LNM. In addition to her own initiative, the F-LNM’s support was an important, positive factor for the nurse’s success in becoming a nurse specialist. Some young nurses shared that they appreciated F-LNMs’ efforts to help them master important professional knowledge. Participant N2, a nurse of 2 years, stated that I am a junior nurse here. I have no much experience. . .I have to learn much knowledge in order to be competent for my job. You know, the upper leaders evaluate our theoretical knowledge every month. Sometimes, I am really frustrated to remember so much knowledge, especially some nursing rules or norms. The F-LNM often spends only 10 minutes to review important knowledge with us every morning. It’s more interesting to study with peers than only yourself. Your memory is enhanced if you persist in learning and reviewing something everyday. This way helps me a lot to relieve my anxiety for exams. Empowerment was also mentioned as a nice way to promote their professional growth. They explained that caring F-LNMs could recognise their subordinates’ potential and would distribute tasks or challenging work according to each person’s ability or interest in order to bring out their full potential. In addition, they emphasised that they gained a lot from F-LNMs constructive criticism. ‘It is inevitable to make mistakes in nursing work even though everyone does not want it to happen’, one participant said, ‘It’s important to help us learn lessons from mistakes rather than only harsh criticism’. When an medical adverse event occurred, they hoped nurse managers could handle them as follows. First, the F-LNM would give the duty nurse an opportunity to tell how the accident happened. Then, the nurse manager would analyse the main reason and responsibility objectively. If the duty nurse was responsible for the adverse event, then the nurse manager should reprimand him/her in private. Finally, the manager should formulate preventive measures with all nurse peers, if necessary. Nurses also identified F-LNMs recognition of their hard work as caring because leaders’ recognition gave them a sense of achievement and encouragement. Recognition was regarded as a spiritual reward to them, which encouraged them to work harder. As participant N3 noted: If a nurse does a good job, the F-LNM should praise her (or him) in a timely manner. This is the best way to care for a person because everyone likes to hear words of praise. An important role leaders should play is to recognize their excellent work timely when their job is well-done.
Exhibiting democratic leadership Data analysis revealed that nurses perceived democratic leadership as caring because it resulted in a relaxed humanistic environment in the workplace where each member was acknowledged for his or her indispensable talents. In this type of environment, they would not be anxious about sharing opinions that differ from those of the F-LNM. Caring behaviours of democratic leadership included mutual respect and fairness in this study. All of the participants placed great value on mutual respect. They perceived that a good attitude, more encouragement and a less-commanding tone, encouraging nurses to participate in the decision-making process and preventing damage to staff self-esteem were all essential components of respecting them. Many nurses stated that being respected by their F-LNMs could increase their commitment to the organisation. Fairness, such as transparent bonus distribution, treating employees equally and protecting nurses’ legitimate rights, was identified as an essential quality of being a good F-LNM. They argued that the F-LNMs who have the ability to tell right from wrong and have the courage to deal with disputes impartially could be trusted and respected by subordinates. ‘When I am involved in a dispute with my patient’, one participant said, ‘I do not mean my F-LNM should be partial to me, but she must stand on the right side’.
Supporting work-life balance Many nurses mentioned that it was not easy for them to keep the balance between work and life. Empathy was an important quality of a caring F-LNM because an empathetic F-LNM could sense nurses’ needs, listen to what they said (and did not say) and read nurses’ reactions. Nurses gave examples of some caring moments with F-LNMs in their workplace. Some nurses shared that F-LNMs organised them to celebrate their peers’ birthdays. Some stated that their F-LNMs listened to them patiently when they were very depressed. Some said their F-LNMs often bought many fruits and desserts for them during festivals. Caring moments were experienced at these times and nurses felt cared for by the FLNM. Participant N3 described her feelings about her last birthday celebration: I worked as usual that day, and I forgot that day was my birthday. At about 12 o’clock, when I opened the door of Nursing Duty Room for lunch., there was a beautiful cake and a greeting card with my name on the table. ‘happy birthday,’ the F-LNM and colleagues said to me together. . .it was a surprise to me. . . I was moved at that time and felt very warm inside. © 2015 Nordic College of Caring Science
Caring behaviours of nurse managers in hospital Another support of work-life balance was embodied in flexible working arrangements, which meant that the FLNM tried her best to meet nurses’ needs as long as nurses could meet patients’ needs. For example, a good practice for F-LNMs was to have a notebook for nurses to write down their working time requirements before scheduling because nurses sometimes needed to deal with private affairs at a specific time and were afraid of time conflicts with work. With this notebook, the F-LNM could know nurses’ needs and try to avoid time conflicts when scheduling. Nurses also reported that they hoped the F-LNM could give them several days off to have a vacation with their family every year. But shortness of time could be barriers to this. Some nurses complained that it was difficult for them to have a short vacation, say 5 or 7 days because of staff shortages and heavy nursing workloads. As a result, nurses, especially young ones, often had no time to go. Even so, some nurses indicated that F-LNMs could organise some colourful group activities regularly for entertainment, such as having a dinner party, singing karaoke, going on a picnic or having a spring outing, which could let them reduce work pressure temporarily and relax.
Discussion The study of caring behaviours in the relationship between first-line nurse managers and Registered Nurses is also an important component of caring science. In this article, Boykin and Schoenhofer’s theory of nursing as caring is regarded as the foundation of this study. Three kinds of behaviours perceived as caring by Registered Nurses in the setting of a regional hospital. The results confirmed the assumption that not every behaviour of F-LNMs is caring when perceived by nurses even though all persons are caring. According to results of this study, one aspect of caring for nurses involved promoting professional growth. The finding agrees with an earlier study in which planning for staff development was a preferred way to care for nurses (5). The result also confirms a quantitative study conducted by Gibson (33) in which the main cause of nurses’ turnover was a lack of career development. This is not surprising, as it can be easily understood by the theory of Maslow’s (34) hierarchy of needs. In his theory, the need of self-actualisation, which refers to identifying and realising a person’s full potential, is ranked as the highest layer of the pyramid. Nowadays in China, material life is relatively abundant for nurses, and self-actualisation has gradually become their most pressing need, especially for experienced nurses. Nurses held that professional growth was the best way to achieve it. It is worth noting that nurses with years of experience have different professional development needs. Junior nurses © 2015 Nordic College of Caring Science
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valued learning their organisation’s norms, enhancing professional knowledge and nursing skills to fit into their job, while senior nurses valued reappraising their professional values and goals and wanted to make choices appropriate to middle adult years, such as considering to be a nurse specialist. This phenomenon can be explained by a model Greenhaus’s career development (35). He claimed that one’s career development can be divided into five stages – preparation for work, organisational entry, early career establishment and achievement, midcareer reappraisal of early career and adulthood, and late career – and people have different pursuits at different stages (35). Results from this study indicate that nurses value their professional growth and they desire to gain career development support from the F-LNM. Therefore, to achieve the goal of caring for nurses, F-LNMs are recommended to establish a mechanism for career improvement for nurses. Another aspect of caring for nurses concerned F-LNMs’ exhibiting democratic leadership. This finding was not mentioned in similar studies (5, 26). This difference may result from the Chinese hierarchical social system in which managers are decision maker and have a higher rank than staff, and subordinates have to obey their orders even though sometimes the subordinates are unwilling to accept their managers’ opinions or decisions. This traditional management style is called rigid management, which has been widely used in nursing management so far in mainland China. But, nurses appear to prefer a democratic leadership style to the rigid management style perhaps because democratic leadership encourages individuals to express themselves and members of the group feel more engaged. Democratic leadership involves respect and fairness in this study. Previous studies have found that employees’ job satisfaction results not just from money or benefits but also from feeling respected (36) and that caring relationships are grounded in respecting and valuing each other (12). Fairness means that one deals objectively with issues, remains neutral, treats everyone equally or shows no partiality (37). Respect and fairness help create a democratic working atmosphere. Furthermore, supporting work-life balance was recognised as caring towards nurses. This finding is similar to a study conducted by Longo (26), which found that nurses (including F-LNMs) demonstrated caring behaviours towards their colleagues by coming to know them on both a professional and a personal level. The concept of work-life balance is about achieving a state of equilibrium between the demands of work and home life (38). A vast body of literatures has documented the issue of work-life balance (38, 39), which indicates the importance of balance between people’s professional and personal lives. Striking balance between work and life is the foundation of wellbeing and incorporates elements such
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as developing and maintaining good physical health and fitness, maintaining an appropriate level of energy and vitality, enjoying emotional and psychological stability, engaging in harmonious relationships and developing effective stress management strategies and coping skills (39). In mainland China, the vast majority of nurses are women. Although the social and family structure have changed dramatically over the years, some aspects of Chinese traditional culture cause people to think that women should be mainly responsible for household affairs and child rearing, and many nurses are primary caregivers for family members, including children, parents and spouses. Gradually, time and stress management for work-life balance can come to be an overwhelming problem for these nurses (38). Therefore, they appreciate F-LNMs support of work-life balance and perceive it as caring towards them. Empathy, flexible working arrangements and organising activities were identified as strategies of supporting for them.
Limitations The research has painted a picture of nurses’ experiences being caring for by F-LNMs. Nevertheless, due to the fact that sampling was conducted only in one tertiary comprehensive hospital, the results may not be applied to all nurses in different levels and different regional hospitals in China. Further research is necessary with other populations working in different institutions and regions so that more conclusive evidence can be obtained. Another matter to consider is that the interviews were conducted in Mandarin. The verbatim data presented in this study are in direct translation from Chinese and in places may be difficult to understand due to cultural differences. Another limitation was that member checking was done via telephone calls. It saved time and was convenient but might not have been as reliable as face-to-face validation. In spite of these limitations, we think the study adds to knowledge of caring behaviours between F-LNMs and nurses and could serve as a reference for caring science.
achieve this goal. The F-LNM plays an important role in nurses’ working lives; therefore, it is important to understand what kinds of their behaviours are caring to nurses from nurses’ own viewpoints. In this study, promoting professional growth, exhibiting democratic leadership and supporting work-life balance were identified as caring behaviours towards nurses. These three kinds of behaviours each have significant meaning. Professional growth is a way to achieve self-actualisation for nurses. A relatively relaxed, humanistic working environment is expected through democratic leadership. Balanced work and life help nurses enjoy both work and life. Future research is likewise needed to describe what F-LNMs can do to promote nurses’ professional growth, increase the influence of democratic leadership and support their work-life balance.
Acknowledgements The authors would like to thank the 15 nurses who generously volunteered to participate in this study. Their willingness to share their perception makes this research possible. And thanks to XmN for her kindness to help the researchers translate and transcribe the interview responses from Chinese to English.
Author contributions Study conception and design: Yilan Liu, Xiao Peng; data collection: Xiao Peng; data analysis: Xiao Peng, Yilan Liu, Qingsong Zeng; Drafting of manuscript: Xiao Peng, Qingsong Zeng; Yilan Liu made critical revisions to the paper for important intellectual content and supervised the study.
Ethical approval This study was approved by the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (IORG No.: IORG0003571).
Conclusion
Funding
Nursing staff are the most important assets in nurse management. How to improve their job satisfaction and decrease the rate of nurse turnover is an important issue for nurse managers. Caring for nurses is one solution to
This research has received no specific grant from any funding agency in the public, commercial or not-forprofit sectors. The authors declare that they have no conflict of interests.
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doi: 10.1111/scs.12201
Caring behaviour perceptions from nurses of their first-line nurse managers Xiao Peng RN, MSN (Lecturer)1,2, Yilan Liu PhD, RN (Director)1 and Qingsong Zeng MM (Resident Doctor)3 1
Department of Nursing, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China, 2School of Nursing, Medical College of Yangtze University, Jingzhou, China and 3Department of Obstetrics and Gynecology, First Affiliated Hospital, Yangtze University, Jingzhou, Hubei, China
Scand J Caring Sci; 2015; 29; 708–715 Caring behaviour perceptions from nurses of their first-line nurse managers
Background: Nursing is acknowledged as being the art and science of caring. According to the theory of nursing as caring, all persons are caring but not every behaviour of a person is caring. Caring behaviours in the relationship between first-line nurse managers and Registered Nurses have been studied to a lesser extent than those that exist between patients and nurses. Caring behaviour of first-line nurse managers from the perspective of Registered Nurses is as of yet unknown. Identifying caring behaviours may be useful as a reference for first-line nurse managers caring for nurses in a way that nurses prefer. Aims: To explore first-line nurse managers’ caring behaviours from the perspective of Registered Nurses in mainland China.
Design: Qualitative study, using descriptive phenomenological approach. Methods: Fifteen Registered Nurses recruited by purposive sampling method took part in in-depth interviews. Data were analysed according to Colaizzi’s technique. Results: Three themes of first-line nurse managers’ caring behaviours emerged: promoting professional growth, exhibiting democratic leadership and supporting work-life balance. Conclusions: A better understanding of the first-line nurse managers’ caring behaviours is recognised. The three kinds of behaviours have significant meaning to nurse managers. Future research is needed to describe what first-line nurse managers can do to promote nurses’ professional growth, increase the influence of democratic leadership, as well as support their work-life balance. Keywords: first-line nurse manager, nurses, caring, behaviour, qualitative study. Submitted 29 May 2014, Accepted 5 November 2014
Introduction Many studies have reported that there is a severe shortage of nurses in Chinese hospitals. With a population of 1.34 billion people, China had 2.21 million nurses by the end of September 2011, averaging 1.65 nurses per 1000 people (1). Liu et al. (2) investigated 126 hospitals using observation and questionnaires and reported that 88% of the hospitals reported a shortage of nurses. Nurses in China have to undertake many nursing and nonnursing tasks in their daily work (1). Research has shown that nurses experience more psychological distress than the general population (3) and often leave to pursue less
Correspondence to: Yilan Liu, Department of Nursing, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jie Fang Avenue, Wuhan 430022, China. E-mail: [email protected]
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demanding careers, (4) which makes the nurse shortage more severe. One solution to reduce nurse turnover is to care for the nursing staff (5). Caring for the nursing staff is imperative for nurse leaders; it is a moral agency linked to job satisfaction and high-quality care (5). The ancient philosopher Lao Tzu (6) suggested that leaders whose position will endure are those who are the most compassionate in the Tao of Power, which applies to everyone in positions of power and leadership, including nurse leaders (7). First-line nurse managers (F-LNMs) are the direct link between the senior nurse leaders and nursing staff (8). They are responsible for an individual unit or a ward (9) and have a pivotal role in influencing the staff (10, 11). However, according to Boykin and Schoenhofer’s (12) theory of nursing as caring, not every behaviour is caring even though each person possesses the ability to care. Therefore, identifying which of the F-LNMs behaviours Registered Nurses perceived as caring could be a necessary step to find effective ways to care © 2015 Nordic College of Caring Science
Caring behaviours of nurse managers in hospital for Registered Nurses. Previous research has discussed the role of F-LNMs (13, 14); however, there is limited evidence on perceptions of the F-LNMs’ caring behaviour. This study aimed to improve this gap in knowledge by examining Registered Nurses’ perspectives.
Background The role of F-LNMs is defined as ‘nurses or nonnurses in positions with line responsibility for nursing and acute care patient units/wards with staff nurses reporting to them. There is no level of management below them; however, they may have charge nurses, supervisors or team leaders who report directly to them’ (15). Other labels for the role are clinical nurse manager (16), front-line nurse leader (17), head nurse/supervisor (18), nurse leader (19), nurse administrator (20) and first-line manager (15). In healthcare organisations, the role of the first-line nurse manager is very important in nurse management. Significant evidence has demonstrated that F-LNMs have a direct impact on organisational performance, including quality of care, financial stability, patient satisfaction, staff nurses’ job satisfaction and their caring ability (8, 21). A good F-LNM facilitates the attainment of organisational goals and objectives (22) and can significantly reduce stress and increase communication to enhance elements of the work environment conducive to job satisfaction and patient safety (23). Nursing is acknowledged as being the art and science of caring (24). Caring has been generally regarded as the core of nursing that produces therapeutic results in the person being served (25). The theorists of caring science, Boykin and Schoenhofer (12), contend the concept of nursing as caring. In their theory, they assume that caring is an essential feature and expression of being human. All persons are caring by virtue of their humanness (12). Personhood is a process of living grounded in caring which is enhanced through participating in nurturing relationships with caring others (12). It is important to note that the assumption that all persons are caring does not mean that every behaviour of a person necessarily is caring. Many experiences of life have taught us that not every behaviour of a person is caring (12). Those behaviours are obviously not expressions of the self as a caring person and may be labelled noncaring (12). Developing the fullest potential for expressing caring is an ideal; therefore, even though a behaviour or behaviours may be interpreted as noncaring, the person remains caring (12). According to this theory, F-LNMs have the nature and willingness to care for their subordinates, but not every behaviour will be perceived as caring behaviour by Registered Nurses. Thus, there is a gap between the caring behaviours of F-LNMs and nurses’ perceptions of these behaviours. © 2015 Nordic College of Caring Science
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Caring behaviours in the relationship between F-LNMs and nurses have been studied less than those that exist between patients and nurses (26). In a study addressing how staff nurses’ perceptions of nurse managers’ behaviours influenced job satisfaction, findings revealed that open and honest communication, an increased level of respect and the feeling of being cared for were preferred behaviours (27). Another study on F-LNMs perceptions about their caring for nurses conducted by Uhrenfeldt and Hall (5) identified that assistance in bedside care, dialogue with the staff and planning for staff development were caring behaviours towards nurses. However, it is worth noting that the study was conducted from the F-LNMs viewpoint rather than the viewpoint of nurses themselves. Turkel and Ray (7), in a study of creating a caring practice environment, held that caring for nurses results in nurses transmitting their own caring values to both the patient and the patient’s family. They put forward some strategies for nurse leaders to care for nurses, such as creating a ‘healing room’ for nurses, beginning executive and board meetings with a story where a nurse’s caring made a difference in his/her patient’s care, helping nurses achieve work/life balance by not expecting overtime or frequent shift rotation, offering flexible scheduling and having nurses develop a plan for self-care as part of their annual evaluation and respect the implementation of their plan. The above studies have drawn attention to the issue of caring for nurses. Unfortunately, no research has yet been carried out to explore what behaviours of F-LNMs are perceived as caring for nurses from the viewpoint of nurses themselves. As the result, the aim of this study is to explore F-LNMs caring behaviours from the perspective of Registered Nurses. The information gained may be useful as a reference for F-LNMs caring for nurses in a way that nurses prefer.
Methods Design This study employed the descriptive phenomenological approach developed by Edmund Husserl to discover nurses’ caring experiences and perception of the F-LNMs caring behaviours. Descriptive phenomenology is a type of qualitative research method used to reach the true meanings of an individual’s experience or perception through engaging in-depth into reality (28). One of the important assumptions of this approach is that researchers should avoid imposing any of their own assumptions on the data collection process or the structure of the data. The purpose of this is to keep what is already known about the description of the phenomenon separate from participants’ description (28). During the entire research process, all the researchers in this study declared
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personal biases, assumptions and presuppositions and put them aside. They examined their own beliefs continuously while keeping field notes as well as reflections for constant evaluation. Data analysis was done by using Colaizzi’s technique which is based on Husserl’s descriptive phenomenology (29). This method provides the researcher with a step-by-step procedure for performing data analysis (30).
Sampling A purposive sampling technique was used in this investigation. Inclusion criteria of nurses for this research were as follows: (i) participants must be Registered Nurses (all the nurses are full-time nurses), (ii) who have worked at their present clinical department for more than 1 year and (iii) do not hold executive positions. Data collection continued until no new themes emerged from the participants, (29) and a clear picture of Registered Nurses’ lived experience of caring behaviours was obtained.
Data collection Data were collected from February to May 2013. Indepth interviews were conducted at a mutually convenient time and a quiet place such as the meeting room, duty room or office room in each unit. Participants were prompted to discuss their perspective of F-LNMs caring behaviours. Open-ended questions were used to promote discussion. All the interviews were conducted in Mandarin Chinese. Each interview was audio-taped, lasting from 30 to 40 minutes. At the end of each interview, the researcher who conducted the interviews invited the participants to a second session with them to discuss the study findings and to make sure that the study findings reflected their own feelings and experiences. After each interview, the recordings were transcribed into Chinese verbatim immediately to allow for ongoing data analysis throughout the interview process. Transcripts were checked by listening to the tape and reading the script word-byword to ensure accuracy for analysis. All the collected data were stored on a computer and U-disk protected by a password known only to the researchers. Participants were assured that their names would not be disclosed and the confidentiality of the data would be maintained by the researchers. Interview responses that are quoted to support the themes in this study were translated and transcribed into English by a nursing graduate student and an English translation graduate student. The transcript was translated back to Chinese by the research supervisor to check for its validity and accuracy. The following questions guided the interviews: (i) Have you experienced caring moments with your F-LNM? If you have, please illustrate
some of them and (ii) How do you expect the F-LNM to care for you or your nurse peers?
Ethical considerations The study was approved by the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (IORG No.: IORG0003571) and administrative department of the study hospital. Researchers explained the study purpose and the detailed interview procedure to participants. Confidentiality and anonymity were strictly observed. Interviews were tape-recorded with participants’ permission. All the participants signed a consent form prior to the interviews.
Data analysis All the interviews were tape-recorded, fully transcribed and analysed initially at the stage of data collection. Then, two researchers analysed the interview transcripts independently by using MAXQDA 10, which is a qualitative analysis software developed by Professor Udo Kuckartz that supports a multilingual user interface, including Simple Chinese. The transcripts were analysed according to Colaizzi’s technique (31). The primary feature of Colaizzi’s method is an inductive and emergent approach to data analysis (32). It consists of seven steps, which are outlined below (28). 1 Obtaining a picture of the whole of perception. Reading and rereading all the participant’s descriptions and field notes to obtain a general picture of the whole of perception of caring behaviours. 2 Extracting significant statements. Identifying and extracting significant statements regarding how the Registered Nurses perceived F-LNMs’ caring behaviours. Each phrase or sentence directly relating to caring was marked using MAXQDA 10. 3 Formulating meanings (hidden and disclosed) from these significant statements. Each underlying meaning was coded and typed in the code system of MAXQDA 10. Two researchers compared the formulated meanings with the original meanings to maintain the consistency of descriptions. However, minimal differences were found between the two researchers’ results. After that, the whole statements and their meanings were checked by the research supervisor, who is an expert researcher in qualitative research. 4 Aggregating the formulated meanings into categories, clusters of themes and themes. Each cluster of themes was coded to include all formulated meanings related to that group of meanings. After that, groups of clusters of themes that reflect a particular issue were incorporated together to form a distinctive construct of theme. Three themes of F-LNMs caring behaviours emerged: promoting professional growth, exhibiting © 2015 Nordic College of Caring Science
Caring behaviours of nurse managers in hospital democratic leadership and supporting work-life balance. 5 Writing an exhaustive description. In this step, the significant statements, the formulated meanings and the themes were integrated into three exhaustive descriptions of caring. 6 Reconstructing the whole of the perceptions. This step involved describing the fundamental structure of the phenomenon, the essence of the perceptions. Here, a reduction of findings was done in which redundant, misused or overestimated descriptions were eradicated from the overall structure, allowing for a clear picture of the themes of promoting professional growth, exhibiting democratic leadership and supporting work-life balance. 7 Returning to participants for member checking validation. A follow-up appointment was conducted between the researchers and each participant via telephone calls by the researcher who conducted the first interview with each participant. Each nurse was given the chance to respond to the analysed data, and alterations were made according to their feedback. Eventually, all of them agreed that the results reflect their real experiences.
Results Fifteen participants took part in the study, and their demographic data were collected (see Table 1). The study group consisted of thirteen females and two males. Participants ranged in age from 22 to 43 years. Nurses in mainland China have five levels of professional qualification, which are professor of nursing, associate professor of nursing, nurse-in-charge, nurse practitioner and nurse.
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Generally speaking, the top two nurse levels have executive positions, and they are not in the charge of F-LNMs. The level of attained professional qualifications ranged from Nurses (n = 4), Nurse Practitioners (n = 6) and Nurses-in-charge (n = 5). Their departments covered internal medicine, surgical medicine, gynaecology, paediatrics, ICU and emergency medicine. In total, three themes of caring behaviours of F-LNMs perceived by nurses emerged from the data: promoting professional growth, exhibiting democratic leadership and supporting work-life balance. These themes are further elaborated below.
Promoting professional growth In the data, promoting professional growth involved career guidance, empowerment, constructive criticism and recognition for work. Career guidance, such as giving nurses support in career development, urging nurses to continue nursing education and sharing updated information or new ideas was identified as caring. In the following quotation, Participant N1, a nurse of 18 years, described how she became a nurse specialist in breathing machines with the help of her F-LNM and expressed gratitude to her: Many thanks for her (the F-LNM) great support so that I could become a breathing machine nurse specialist. I was very interested in the breathing machine, but I found that knowledge gained from books could not satisfy my thirst for updated knowledge of this field. She shared some breathing machine information with me and gave me chances to take part in some related meetings, and helped me to get the precious opportunity of authorized
Table 1 Participant characteristics (n = 15)
ID
Dept.
Gender
Age
Marital status
Professional qualifications
Highest degree earned
Years employed as a nurse
Years at current dept.
N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15
NICU Urology Nephrology Endocrinology Neurology CCU Gynaecology Emergency room General ICU Ophtalmology General ICU Geriatrics General surgery Stomatology Paediatrics
Female Female Female Female Female Male Female Female Male Female Female Female Female Female Female
30 24 31 38 29 27 43 34 30 35 36 27 25 24 22
Married Single Married Married Married Married Married Married Married Married Married Single Single Single Single
Nurse Practitioner Nurse Nurse Practitioner Nurse-in-charge Nurse Practitioner Nurse Practitioner Nurse-in-charge Nurse-in-charge Nurse Practitioner Nurse-in-charge Nurse-in-charge Nurse Practitioner Nurse Nurse Nurse
Bachelor Bachelor Bachelor Bachelor Bachelor Bachelor Bachelor Master Bachelor Bachelor Bachelor Bachelor Associates Associates Associates
10 2 8 20 5 3 24 10 7 18 18 8 3 3 2
3 2 6 12 5 3 15 9 4 18 13 8 3 3 2
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certification training for breathing machine nurse specialist. The quotation illustrates a nurse’s experience of obtaining support in career development from an F-LNM. In addition to her own initiative, the F-LNM’s support was an important, positive factor for the nurse’s success in becoming a nurse specialist. Some young nurses shared that they appreciated F-LNMs’ efforts to help them master important professional knowledge. Participant N2, a nurse of 2 years, stated that I am a junior nurse here. I have no much experience. . .I have to learn much knowledge in order to be competent for my job. You know, the upper leaders evaluate our theoretical knowledge every month. Sometimes, I am really frustrated to remember so much knowledge, especially some nursing rules or norms. The F-LNM often spends only 10 minutes to review important knowledge with us every morning. It’s more interesting to study with peers than only yourself. Your memory is enhanced if you persist in learning and reviewing something everyday. This way helps me a lot to relieve my anxiety for exams. Empowerment was also mentioned as a nice way to promote their professional growth. They explained that caring F-LNMs could recognise their subordinates’ potential and would distribute tasks or challenging work according to each person’s ability or interest in order to bring out their full potential. In addition, they emphasised that they gained a lot from F-LNMs constructive criticism. ‘It is inevitable to make mistakes in nursing work even though everyone does not want it to happen’, one participant said, ‘It’s important to help us learn lessons from mistakes rather than only harsh criticism’. When an medical adverse event occurred, they hoped nurse managers could handle them as follows. First, the F-LNM would give the duty nurse an opportunity to tell how the accident happened. Then, the nurse manager would analyse the main reason and responsibility objectively. If the duty nurse was responsible for the adverse event, then the nurse manager should reprimand him/her in private. Finally, the manager should formulate preventive measures with all nurse peers, if necessary. Nurses also identified F-LNMs recognition of their hard work as caring because leaders’ recognition gave them a sense of achievement and encouragement. Recognition was regarded as a spiritual reward to them, which encouraged them to work harder. As participant N3 noted: If a nurse does a good job, the F-LNM should praise her (or him) in a timely manner. This is the best way to care for a person because everyone likes to hear words of praise. An important role leaders should play is to recognize their excellent work timely when their job is well-done.
Exhibiting democratic leadership Data analysis revealed that nurses perceived democratic leadership as caring because it resulted in a relaxed humanistic environment in the workplace where each member was acknowledged for his or her indispensable talents. In this type of environment, they would not be anxious about sharing opinions that differ from those of the F-LNM. Caring behaviours of democratic leadership included mutual respect and fairness in this study. All of the participants placed great value on mutual respect. They perceived that a good attitude, more encouragement and a less-commanding tone, encouraging nurses to participate in the decision-making process and preventing damage to staff self-esteem were all essential components of respecting them. Many nurses stated that being respected by their F-LNMs could increase their commitment to the organisation. Fairness, such as transparent bonus distribution, treating employees equally and protecting nurses’ legitimate rights, was identified as an essential quality of being a good F-LNM. They argued that the F-LNMs who have the ability to tell right from wrong and have the courage to deal with disputes impartially could be trusted and respected by subordinates. ‘When I am involved in a dispute with my patient’, one participant said, ‘I do not mean my F-LNM should be partial to me, but she must stand on the right side’.
Supporting work-life balance Many nurses mentioned that it was not easy for them to keep the balance between work and life. Empathy was an important quality of a caring F-LNM because an empathetic F-LNM could sense nurses’ needs, listen to what they said (and did not say) and read nurses’ reactions. Nurses gave examples of some caring moments with F-LNMs in their workplace. Some nurses shared that F-LNMs organised them to celebrate their peers’ birthdays. Some stated that their F-LNMs listened to them patiently when they were very depressed. Some said their F-LNMs often bought many fruits and desserts for them during festivals. Caring moments were experienced at these times and nurses felt cared for by the FLNM. Participant N3 described her feelings about her last birthday celebration: I worked as usual that day, and I forgot that day was my birthday. At about 12 o’clock, when I opened the door of Nursing Duty Room for lunch., there was a beautiful cake and a greeting card with my name on the table. ‘happy birthday,’ the F-LNM and colleagues said to me together. . .it was a surprise to me. . . I was moved at that time and felt very warm inside. © 2015 Nordic College of Caring Science
Caring behaviours of nurse managers in hospital Another support of work-life balance was embodied in flexible working arrangements, which meant that the FLNM tried her best to meet nurses’ needs as long as nurses could meet patients’ needs. For example, a good practice for F-LNMs was to have a notebook for nurses to write down their working time requirements before scheduling because nurses sometimes needed to deal with private affairs at a specific time and were afraid of time conflicts with work. With this notebook, the F-LNM could know nurses’ needs and try to avoid time conflicts when scheduling. Nurses also reported that they hoped the F-LNM could give them several days off to have a vacation with their family every year. But shortness of time could be barriers to this. Some nurses complained that it was difficult for them to have a short vacation, say 5 or 7 days because of staff shortages and heavy nursing workloads. As a result, nurses, especially young ones, often had no time to go. Even so, some nurses indicated that F-LNMs could organise some colourful group activities regularly for entertainment, such as having a dinner party, singing karaoke, going on a picnic or having a spring outing, which could let them reduce work pressure temporarily and relax.
Discussion The study of caring behaviours in the relationship between first-line nurse managers and Registered Nurses is also an important component of caring science. In this article, Boykin and Schoenhofer’s theory of nursing as caring is regarded as the foundation of this study. Three kinds of behaviours perceived as caring by Registered Nurses in the setting of a regional hospital. The results confirmed the assumption that not every behaviour of F-LNMs is caring when perceived by nurses even though all persons are caring. According to results of this study, one aspect of caring for nurses involved promoting professional growth. The finding agrees with an earlier study in which planning for staff development was a preferred way to care for nurses (5). The result also confirms a quantitative study conducted by Gibson (33) in which the main cause of nurses’ turnover was a lack of career development. This is not surprising, as it can be easily understood by the theory of Maslow’s (34) hierarchy of needs. In his theory, the need of self-actualisation, which refers to identifying and realising a person’s full potential, is ranked as the highest layer of the pyramid. Nowadays in China, material life is relatively abundant for nurses, and self-actualisation has gradually become their most pressing need, especially for experienced nurses. Nurses held that professional growth was the best way to achieve it. It is worth noting that nurses with years of experience have different professional development needs. Junior nurses © 2015 Nordic College of Caring Science
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valued learning their organisation’s norms, enhancing professional knowledge and nursing skills to fit into their job, while senior nurses valued reappraising their professional values and goals and wanted to make choices appropriate to middle adult years, such as considering to be a nurse specialist. This phenomenon can be explained by a model Greenhaus’s career development (35). He claimed that one’s career development can be divided into five stages – preparation for work, organisational entry, early career establishment and achievement, midcareer reappraisal of early career and adulthood, and late career – and people have different pursuits at different stages (35). Results from this study indicate that nurses value their professional growth and they desire to gain career development support from the F-LNM. Therefore, to achieve the goal of caring for nurses, F-LNMs are recommended to establish a mechanism for career improvement for nurses. Another aspect of caring for nurses concerned F-LNMs’ exhibiting democratic leadership. This finding was not mentioned in similar studies (5, 26). This difference may result from the Chinese hierarchical social system in which managers are decision maker and have a higher rank than staff, and subordinates have to obey their orders even though sometimes the subordinates are unwilling to accept their managers’ opinions or decisions. This traditional management style is called rigid management, which has been widely used in nursing management so far in mainland China. But, nurses appear to prefer a democratic leadership style to the rigid management style perhaps because democratic leadership encourages individuals to express themselves and members of the group feel more engaged. Democratic leadership involves respect and fairness in this study. Previous studies have found that employees’ job satisfaction results not just from money or benefits but also from feeling respected (36) and that caring relationships are grounded in respecting and valuing each other (12). Fairness means that one deals objectively with issues, remains neutral, treats everyone equally or shows no partiality (37). Respect and fairness help create a democratic working atmosphere. Furthermore, supporting work-life balance was recognised as caring towards nurses. This finding is similar to a study conducted by Longo (26), which found that nurses (including F-LNMs) demonstrated caring behaviours towards their colleagues by coming to know them on both a professional and a personal level. The concept of work-life balance is about achieving a state of equilibrium between the demands of work and home life (38). A vast body of literatures has documented the issue of work-life balance (38, 39), which indicates the importance of balance between people’s professional and personal lives. Striking balance between work and life is the foundation of wellbeing and incorporates elements such
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as developing and maintaining good physical health and fitness, maintaining an appropriate level of energy and vitality, enjoying emotional and psychological stability, engaging in harmonious relationships and developing effective stress management strategies and coping skills (39). In mainland China, the vast majority of nurses are women. Although the social and family structure have changed dramatically over the years, some aspects of Chinese traditional culture cause people to think that women should be mainly responsible for household affairs and child rearing, and many nurses are primary caregivers for family members, including children, parents and spouses. Gradually, time and stress management for work-life balance can come to be an overwhelming problem for these nurses (38). Therefore, they appreciate F-LNMs support of work-life balance and perceive it as caring towards them. Empathy, flexible working arrangements and organising activities were identified as strategies of supporting for them.
Limitations The research has painted a picture of nurses’ experiences being caring for by F-LNMs. Nevertheless, due to the fact that sampling was conducted only in one tertiary comprehensive hospital, the results may not be applied to all nurses in different levels and different regional hospitals in China. Further research is necessary with other populations working in different institutions and regions so that more conclusive evidence can be obtained. Another matter to consider is that the interviews were conducted in Mandarin. The verbatim data presented in this study are in direct translation from Chinese and in places may be difficult to understand due to cultural differences. Another limitation was that member checking was done via telephone calls. It saved time and was convenient but might not have been as reliable as face-to-face validation. In spite of these limitations, we think the study adds to knowledge of caring behaviours between F-LNMs and nurses and could serve as a reference for caring science.
achieve this goal. The F-LNM plays an important role in nurses’ working lives; therefore, it is important to understand what kinds of their behaviours are caring to nurses from nurses’ own viewpoints. In this study, promoting professional growth, exhibiting democratic leadership and supporting work-life balance were identified as caring behaviours towards nurses. These three kinds of behaviours each have significant meaning. Professional growth is a way to achieve self-actualisation for nurses. A relatively relaxed, humanistic working environment is expected through democratic leadership. Balanced work and life help nurses enjoy both work and life. Future research is likewise needed to describe what F-LNMs can do to promote nurses’ professional growth, increase the influence of democratic leadership and support their work-life balance.
Acknowledgements The authors would like to thank the 15 nurses who generously volunteered to participate in this study. Their willingness to share their perception makes this research possible. And thanks to XmN for her kindness to help the researchers translate and transcribe the interview responses from Chinese to English.
Author contributions Study conception and design: Yilan Liu, Xiao Peng; data collection: Xiao Peng; data analysis: Xiao Peng, Yilan Liu, Qingsong Zeng; Drafting of manuscript: Xiao Peng, Qingsong Zeng; Yilan Liu made critical revisions to the paper for important intellectual content and supervised the study.
Ethical approval This study was approved by the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (IORG No.: IORG0003571).
Conclusion
Funding
Nursing staff are the most important assets in nurse management. How to improve their job satisfaction and decrease the rate of nurse turnover is an important issue for nurse managers. Caring for nurses is one solution to
This research has received no specific grant from any funding agency in the public, commercial or not-forprofit sectors. The authors declare that they have no conflict of interests.
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