H. M. Hasselhorn, MD
University of Wuppertal,
FB D – Department of Safety Technology
Email: [email protected]
Peter Tackenberg, MSc
N DBfK-Bundesverband Berlin, Germany
The work carried out in hospitals is characterised by a considerable amount of social interaction. Contact with colleagues, supervisors, other staff and clients can be a positive resource that is perceived as enriching. Permanent contact can, however, cause considerable psychological stress. Nurses cannot cope with stress during working hours by choosing not to perform a task. Research on stress has produced mounting evidence that the prevailing workplace social climate is a leading cause of burnout among employees. Using the findings of the European NEXT Study, a research team investigated the role of social relationships, and its impact on the intention to leave the nursing profession.
The European NEXT Study (www.next-study.net) investigated the working conditions and career prospects of nursing staff in ten European countries. Conducted between 2002 and 2006 and financed by the European Commission (QLK6-CT-2001-00475), the study attracted more than 56,000 responses over four surveys. The questionnaires circulated in 2002-2003 asked the following question about the quality of social relationships:
“How would you describe the relationship between nursing staff and:
a) nursing management,
d) physicians, and
e) hospital management?”
Respondents were offered five options from a spectrum ranging from “friendly and relaxed” to “hostile and tense”. To enhance data comparability the analyses were restricted to registered nursing staff in hospitals (N=23,223, Table 1).
Table 1 shows that nurses rarely reported negative relationships with other members of the profession (reported by 3.8% of respondents). Tensions with superiors and physicians were more common (reported by 13.5% and 12.7% of respondents, respectively). On average, 27% of respondents reported that relations with hospital management were poor, while 30.4% gave a negative rating to relationships with nursing management. Substantial differences emerged between countries. In Italy, for example, relationships with all groups were characterised as negative. In this case, restructuring processes underway in the Italian health service and nursing profession are most probably to blame. Similarly, French nurses frequently reported negative relationships with nursing and hospital management. Negative relationships with physicians were reported relatively frequently in France, Belgium, Slovakia, Poland and Italy (ranging from 12.2% to 22.4% of respondents). However, contrary to expectations, poor relationships with doctors were reported infrequently in other countries. The results from Finland were conspicuous in that relationships with nursing management were rated negatively while those with colleagues and physicians were not particularly poor.
Differences in perception between age groups were identified in the study, with younger staff more likely to take a critical view than older colleagues of relations with nursing and hospital management and a more positive view of relations with other nurses.
The quality of the relationship between nursing staff and nursing management is shown in a more differentiated light in Figure 1. Around a quarter of respondents in Belgium, Germany, Finland, Britain, The Netherlands and Slovakia, and approximately one third of respondents in France, Italy and Poland reported a strained to hostile relationship.
The quality of social relationships has a significant impact on nurses’ intent to leave the profession. Figure 2 shows that the relationship with nursing management plays an important role (solid black line). Where the relationship is considered “friendly and relaxed”, only 10% of all nurses frequently (at least once per month) consider leaving the profession. This figure rises to roughly 30% when the relationship is perceived to be “hostile and tense”. If, instead of “negative or hostile” the relationship with nursing management were perceived as “neutral”, the proportion of nurses intending to leave the profession would fall from 17.2% (3,506 persons) to 15.6% (absolute number = -564 persons). This effect is most pronounced in Italy (where the reduction in those intending to leave would decline from 20.7% to 16.7%, n = -163), France (16.3% to 13.4%, n = -73) and Germany (19.2% to 16.5%, n = -60). It is less pronounced in countries where low rates of intent to leave are reported, namely, Slovakia (12.4% to 10.7%, n = - 29), The Netherlands (10.6% to 9.2%, n = -32) and the United Kingdom, where relations between nursing staff and nursing management were found to be best (36.8% to 34.2%, n = -44). If relations were “friendly and relaxed”, the percentage of the overall group intending to leave nursing would fall to 10.1% (n = -1,485). The impact on intent to leave is halved when the same calculations are applied to relations with hospital management.
A similar picture emerges in relation to burnout among nurses. If the relationship with nursing management were perceived as “neutral” as opposed to “negative or hostile”, burnout among nurses would fall by 12%. This figure would rise to 25% if relations were “friendly and relaxed”.
We have shown the scale of the impact of the hierarchical relationship between nursing staff and nursing management. Intent to leave nursing increases where this relationship is poor. A new finding to emerge from our investigations is that nursing managers have the potential to shape the social setting in a way that actively promotes staff retention, particularly when those involved are qualified employees. It is clear that nursing managers are involved in a balancing act as they try to reconcile the conflict between implementing the restructuring measures required for commercial success and the need to maintain a positive work climate that supports staff in meeting the growing demands presented by increased workload, shorter patient stays and new treatments while avoiding the phenomenon of burnout. Nursing managers must, therefore, utilise their expertise in operational processes to ensure internal procedures adapt and innovate in a manner that maintains high quality care. However, this goal cannot be achieved without motivated and committed nurses.