Clémence Dallaire, PhD
Nurse, Professor at the Faculty of Nursing Sciences Université Laval
Paul-André Lapointe, PhD
Director of the Department of Industrial Relations
Faculty of Social Sciences Université Laval
This article was inspired by a study carried out in the critical care units of a hospital in Quebec, with the help of 42 semi-conducted interviews among nurses and union representatives. This group played a major role in the establishment of priorities in the numerous solutions, which emerged from the interviews and in the accepted choice of solutions.
The results highlight the real-life experiences of the longest serving or most experienced nurses, and a certain inter-generational conflict between the experts and novices. The main remark is that there is a very large instability of working teams, due to the modes of administration of the employment statutes, whether it be the excessive recourse to precarious statutes, high absenteeism, or a significant level of voluntary departures including departures of those taking retirement.
Besides an inferior quality of care given, the instability creates a deficit of individual and joint competences, which translates into work overload for the experts and additional stress for those who are not so experienced. Individual competences are partly acquired thanks to work experience and exposure to specific problems. They are sometimes transmittable only through personal interaction.
Within a working team, individual competences are really effective when they are combined and articulated together, in a synergistic way. For a working team, it is the capacity of effectively cooperating, coordinating and communicating on the basis of a common language, verbal or non-verbal, with a view to achieving complex interventions. This collective way of knowing how to react is particularly sought after in critical care units, where complex problems call for teamwork and the coordinated intervention of nurses, at the same time or sequentially. This teamwork is a must and is based on the quality of joint competences.
Such cooperation may be more difficult when a particularly ruthless conflict arises between stable/expert staff and provisional/novice staff, which could in part be associated with an inter-generational conflict. New generations of nurses would look for flexible hours, greater career mobility and a better balance between personal/family requirements and professional requirements. As a result, the younger ones would be less involved in work and would take fewer initiatives. This behaviour is also attributable to a strategy of protection: Less experienced nurses who are occasionally introduced to critical care teams and units avoid having to take initiatives for fear of making mistakes.
Without denying the existence of differences between the generations, the strength lies in noting that by granting stability and the best working hours (of the day and week) to some and by confining others to precarious and unpleasant working hours (evening, night and weekend), the administration modes of the employment statutes aggravate the differences between the generations, even transforming them into an inter- generational conflict, and induce particular behaviour.
The inventory of solutions was built by compiling the totality of the solutions proposed by the nurses interviewed. The solutions proposed converge towards a central objective, that is, the stabilisation of the teams, and mainly favour interventions with regard to competences. They simultaneously aim to adapt resources to the acuteness of the patient’s condition and to raise competences while acting on the internal and external aspects of work organisation.
The adaptation of resources to the acuteness of the patient’s condition can assume different forms:
• The redistribution of work between existing resources. In fact, it has been noted that some people work too much, while others do not work enough. It is thus a question of increasing the number of full-time positions and reducing their precariousness.
• The reduction of working time for units in order to dedicate the time thus freed-up to training and involvement in special projects.
• The raising of competences, which reduces the stress and psychological demands of work, linked to un certainty and the loss of control, often generated by a lack of competences.
• The revision of the professional and nonprofessional composition of care teams: for example, the addition of assistants and clerks in order to lighten the workload of nurses and enable them to dedicate themselves to the real aspects of their profession.
The raising of competences can also assume different forms:
• Increased exposure time to complex problems in the units. In more concrete terms, it is a question of making the more “precarious” nurses work harder and more regularly, so that they acquire the experience and competences necessary to better carry out their work.
• The overlapping of schedules ensuring the sharing of competences between ex perts, who are older, and who generally work during the day, and novices, who are younger, and generally work in the evenings and during the night.
• Mentoring: Assigning an experienced nurse with teaching qualities who may serve as a point of reference to a specific group of novices.
• Involvement in special projects: Problem resolution leads nurses to analyse a specific situation, to review the relevant literature and to discuss within a group diagnosis and possible solutions.
These possible solutions are currently being put to the test in a pilot project and could enable the expectations of older nurses to be met in terms of joint competences while helping the young to develop their individual competences. They are all based on a fundamental fact to the effect that the more experienced and older nurses are of greater importance in the context of the complexification of care.
These nurses, who could be tempted to abandon critical care due to the heaviness of care and the workload, nevertheless have individual expertise allowing them to quickly react and manage acute cases in an efficient manner. They are, in short, absolutely essential in the practical training of young nurses and in the building of joint competences.