Towards a sustainable working life for registered nurses in a hospital setting: Factors explaining why they remain in work and profession – A salutogenic interview study

Background There is extensive research on how nurses experience their working conditions and environment; this research shows high job stress, job dissatisfaction and intention to leave the workplace. The aim was to describe and explore success factors explaining why hospital nurses remain in work and profession. Methods A qualitative, descriptive and explorative study based on a theory-driven (the salutogenic theory by Antonovsky) approach was conducted. Data collection took place from March to June 2018. Individual semi-structured interviews with twelve registered nurses working in a hospital in western Sweden were conducted. The sense of coherence and its three dimensions, comprehensibility, manageability and meaningfulness, were used as a tool to structure the analyses of the qualitative data. Hence, a deductive (theory-driven) and an inductive (data-driven) approach with qualitative content analysis of manifest and latent content were used. Results The results showed that a sense of meaningfulness, manageability and comprehensibility involved the factors having fun at work, being acknowledged, feeling togetherness in the team, having varying tasks with a manageable workload, good interaction between colleagues and patients, doing good work, feeling committed to and pride in the professional role, and having a balance between work and leisure time. Conclusions One precondition of improving registered nurses’ health and well-being was having clear leadership. Another precondition was having a sense of coherence in relation to both the working group and the organization. Experiencing job satisfaction and being acknowledged for one’s good work were important; acknowledgement was received not only from patients, but also from colleagues, other professionals and the nurse manager. In this way, the nurses felt acknowledged and could create a sense of meaningfulness, manageability and comprehensibility in their work.


Background
High turnover among nurses is a global concern and negatively influences healthcare services. Human services, in the present case hospital settings, are characterized by high complexity owing to the interaction between patients, nurses and the organization. Nurses play a pivotal role in the healthcare provided to patients. In the European context, there is currently a nursing workforce crisis due to the shortage of trained nurses in most countries [1]. The "Registered Nurse forecasting in Europe study" (RN4CAST, 2009-2011 [2] brought together researchers from 12 European countries to generate a large evidence base focused on nursing workforce issues [3][4]. The study results revealed great differences throughout Europe. As many as 20-50% of nurses in every country intended to leave their current job during the next year. In general, nine percent of the nurses intended to leave nursing, most of them after only a few years in the profession. With this knowledge in mind and given the fact that demographic data show an increasing older population that will doubtless be in need of healthcare, it is extremely important to explore factors that may promote nurses' feelings of wellbeing at work and that encourage them to stay in the profession, that is, it is important to discover what factors promote a sustainable working life for nurses. However, despite increasing interest in the risk factors for stress-related diseases among nurses, there is less research on factors promoting a sustainable working life for nurses. Therefore, the present study intends to fill the knowledge gap that exists concerning factors that may increase nurses' willingness to stay in the profession.

Previous research
There is extensive research on how nurses experience their working conditions and environment; nursing work has been shown to involve high job stress [5], job dissatisfaction and intention to leave the workplace [6][7], as well as burnout and intention to leave the profession [8]. In a cross-sectional study in a Swiss hospital setting, one in six nurses thought frequently about leaving the profession. According to Hämmig [8], temporal, physical, emotion and mental workloads and job stressors were strongly and positively associated with burnout symptoms. A similar scenario was seen among Taiwanese clinical nurses (N=26945 and 19386), where five main paths were found from job stress to intention to leave the hospital [9]. Job stress directly affected job satisfaction and depressed mood, which in turn affected intention to leave the hospital. Intention to leave the hospital preceded intention to leave the profession. These results highlight how important it is for nurses to be able to deal with stress, in both the short and the long term. Workplace stress, work environment and job satisfaction were the focus of a study among newly graduated nurses [10], which showed that higher levels of workplace stress were associated with higher levels of depression and anxiety as well as lower levels of resiliency and job satisfaction.
This leads to ideas from stress management and resource-oriented research, which highlights people's ability to manage stress and stay well [11][12][13]. It becomes increasingly important to ask not only how nurses survive at work, but also how they thrive [14][15].
One way to look at this is to explore how nurses create and maintain a sense of coherence (SOC) and find strategies for managing stress [16]. Salutogenesis is a dynamic and flexible approach with a persistent focus on being able to manage stress [17]. In a Swedish context the level of the three dimensions of SOC varied; manageability was weakest and decreased the total sense of coherence. The meaningfulness dimension was as strongest. On a national level, nurses reported weaker SOC than the general population, but stronger in an international comparison of nurses. Hospital nurses found their work difficult to manage, but meaningful [18]. Among community nurses who thrive, the critical role of job engagement in the face of adversity has been described [19].
Habitual introspection and reflection concerning job engagement helped nurses make positive, adaptive adjustments in their working life. The self-tuning exhibited by these nurses strengthened their mental health and evoked their job engagement [19]. Sasso and colleagues [20] describe "push and pull" factors involved in nurses' intention to leave their job. Dissatisfaction was the most important reason for intention to leave the job (35.5 percent), and of these 33.1 percent intended to leave the nursing profession. Push factors were among other things understaffing, emotional exhaustion and poor patient safety. Pull factors for staying included positive perceptions of the quality of care, patient safety and performing core nursing activities.

Aim
The aim of the study was to describe and explore factors explaining why hospital nurses remain in work and profession.

Design
A theory-driven (the salutogenic theory) approach was applied in this qualitative, descriptive and explorative study, based on individual interviews with registered nurses [21]. The study design was adopted to gain a deeper understanding of success factors promoting a sustainable working life for registered nurses. This new knowledge can help in studying nurses' subjective understanding of the dimensions of the SOC, that is, comprehensibility, manageability and meaningfulness (SOC). The qualitative, descriptive and exploratory approach is appropriate when researchers wish to gather a maximum amount of information within a particular domain [22].

Setting and context
The study was conducted at a hospital in western Sweden. The hospital consists of four areas: emergency medicine, specialist medicine, surgical care and adult psychiatric

Participants
The participants (N=12) were registered nurses working at a hospital in western Sweden and with long experience working as a nurse (mean 16 years). The interview inclusion criteria were: understanding and speaking Swedish and at least five years of experience working as a nurse. The participants' sociodemographic variables are shown in Table 1. Table 1. Socio-demographic characteristics of the participants (N=12).

Data collection
The nurses who consented to participate were contacted by telephone by an interviewer to

Data analysis
Twelve experienced registered nurses participated in an individual, digitally recorded, semi-structured interview. The study design is based on the salutogenic theory and the collected data was analyzed both deductively as well as inductively. Three phases were employed: 1) a deductive (theory-driven) approach was used to create the interview guide, using questions derived from the salutogenic theory and its core concept SOC [21]; 2) an inductive (data-driven) approach was adopted to analyze data using qualitative content analysis [23][24] and 3) a deductive approach was employed to theoretically discuss the findings [21].
Data were transcribed verbatim and subjected to qualitative content analysis of both the manifest and latent content. Initially, the entire text was read several times to achieve an overall understanding. In the next step, the texts were reduced into meaning units related to the study aim. The meaning units were condensed, retaining their most significant parts. Thereafter, the condensed meaning units were abstracted and labelled with a code.
The codes were continually adjusted to make the inductive process more rigorous [23].
Based on the patterns emerging from the analysis, the codes were deductively structured into the dimensions of the SOC, that is, meaningfulness, manageability and comprehensibility, which thus constitute the themes in the presentation of the results [21]. Subthemes were then identified; they were categorized together into the three main themes and described the latent meaning of the overt statements [23][24]. By doing so, the extracted themes enable a deeper understanding of the content nurses put into the three dimensions of the SOC. An example of how the data were analyzed is shown in Table   2.

Ethical considerations
The nurses were informed about the study both orally and in writing. Informed consent was obtained from the nurses willing to participate in the study. They were told that participation was voluntary and that they were free to withdraw from the interview and the study at any time without giving a reason.

Trustworthiness
Trustworthiness can be defined as credibility, dependability, confirmability and transferability. When evaluating qualitative data, these issues must be considered [22][23]. To ensure credibility and provide a broad picture of the problem, participants from several occupational categories and with rich experience of caring were included in the study. Credibility (Morse, 1994) was also achieved by choosing individual interviews in which the nurses described what they did to create sustainability in their working life. The procedures for data analysis and generation of themes and subthemes have been described above. The analysis process was characterized by critical review on the part of the researchers, who read the interviews and jointly defined the themes and subthemes to ensure the study's dependability. Confirmability was attained by checking the codes, themes and subthemes against the interviews throughout the analytical process.
Confirmability was also strengthened by relating the results to earlier research. The participants' unique answers and the inductive and deductive process ensure the study's confirmability. To facilitate transferability, a description of the context, selection and characteristics of the participants has been provided. The methods for identifying and condensing meaning units have also been clearly described, thus allowing readers to easily understand the background of the presented results. Furthermore, excerpts from

Results
According to the theory-driven (the salutogenic theory) interview guide and data-driven analysis of the interviews, the results are presented in relation to the three dimensions of the core concept of SOC: meaningfulness, manageability and comprehensibility. This means that the participating nurses have provided a deeper understanding of the content of the three dimensions of SOC. The nurses described factors explaining their ability to remain in work and profession, that is, factors that strengthen them in everyday life (Table 3).

Meaningfulness
In the workplace, the nurses are in a context that is important to them and feels straightforward. The nurses have a need for acknowledgment from colleagues, patients and their relatives, as such acknowledgement makes the usefulness of their work efforts clear to them and increases the meaningfulness of their work. In this way, the nurses feel they are productive; they can see the results of their own work. The nurses also need to be included in meaningful healthcare teams that are characterized by job satisfaction and humor.

Feeling job satisfaction and having fun at work
The nurses see job satisfaction as one of the most meaningful factors for remaining in the workplace for a long time. This can involve job satisfaction in the team or the joy felt when a patient expresses something positive.
Job satisfaction for me, it's getting someone to smile. Try to spread positive emotions. Be happy and make it easier for others. That gives me job satisfaction, I feel good. A patient who looks at you and says "thank you," and you can see that everything you did went well (Nurse, medical outpatient care).
Having fun at a workplace marked by humor is also something the nurses describe as important to remaining in the workplace for many years. This can entail, for example, using humorous jargon in the team, colleagues having a twinkle in their eyes or being able to laugh together. The nurses also describe how important it is to have work that is meaningful; they go to work with a positive feeling.
Now we have a very fine atmosphere. Our students say that they've never been on a ward where they felt so welcome right away, a basic positive feeling and that's how we want it.
We are able to joke and talk to each other. However, I almost see my colleagues more than I see my family (Nurse, psychiatric inpatient care).

Being acknowledged and feeling productive
According to the nurses, the meaningfulness of their work increases when they are acknowledged. It is often patients who provide this acknowledgment, either directly or when the nurses have contributed to patients' improved health. But it can also be colleagues or relatives who acknowledge the nurse.
Every day when you get this feedback from patients, whatever it may be, it feels like I've done something good. But, it's not always so, there are others too. Most of the time I've done something good every day/…/I feel good about being seen and acknowledged and seeing and acknowledging others (Nurse, surgical outpatient care).
The nurses have a great need to feel productive and useful in their work. They can provide self-acknowledgement, especially when patients recover. Then they see how their involvement has contributed to the positive outcomes.
A workplace where I thrive and feel I easily go to, that I'm useful, needed in any way.
That's what I get from both patients and staff (Nurse, psychiatric inpatient care).

Feeling togetherness and secure in the work team
Feeling togetherness and secure in the work team is central to nurses' experience of meaning at work. Cohesion means a great deal to the nurses, that is, working as a team and solving problems together, especially in precarious care situations.
I think togetherness gets a little stronger in crisis situations. I actually think that there are probably many institutions that feel that way, that you get a little tighter during crisis situations. Togetherness gets stronger in strained situations (Nurse, medical inpatient care).
The nurses experience togetherness when they are accepted, involved and part of the work team. They feel they are not alone and have full responsibility for care provision.
They feel they are part of a greater whole.
Being accepted by the group, that you're part of the group, being seen and heard. That people listen to what you have to say, and being involved in making decisions. I think it's important to belong to a group, because that's probably what being a nurse means, that you're independent but still part of the whole. Having colleagues and supporting each other (Nurse, medical inpatient care).

Manageability
High demands are placed on the nurses as regards being able to manage their day-to-day work. These high demands concern both more routine tasks and stressful situations, but the nurses find ways to cope with the different care situations. Factors that make the work situation manageable include receiving support from colleagues and managers, being involved and being able to interact with colleagues and other healthcare professionals. A good balance between work and leisure makes the work more manageable. An additional factor is being able to mentally leave work duties behind at the end of the workday.
Having an individual work schedule is valuable for the nurses, as it allows them to have a great deal of flexibility. They also express a need to have a manageable workload, that is,

Having varied tasks
Nurses' professional role involves a variety of everyday tasks and challenges. Although many tasks are based on experience and routine management, nurses are exposed daily to challenges and trials. The nurses feel their tasks are positive challenges in that they create variation, which means working as a nurse never becomes monotonous.
No days are identical, there are encounters with different people, patients and situations.
Nothing gets boring, you have to be on the ball all the time and this makes you more mentally alert (Nurse, surgical outpatient care).

I'm very pleased with my situation, that I have a bit of everything, I come in when
someone is sick or when there is a shortage of nurses, so it feels good (Nurse, psychiatric inpatient care).
The varying tasks mean that the nurses are constantly learning, especially when their knowledge is tested in more challenging situations.
That it's varied, it's very instructive, it never gets monotonous, and it never gets old.
There are always new things happening all the time. Both in the way we work and how we handle our duties. The fact that the tasks themselves are varied means that you are never really done learning (Nurse, surgical outpatient care).

Having a work-leisure balance
If nurses are to recover properly and cope with their work, they need to find a balance between work and leisure. This means having an active leisure time and feeling good at home, while having the energy to deal with patients.
If you have a good home life and leisure time, it's reflected in your work, then you can do a good job. If you've had a good weekend at home and feel that it's given something, then you're more rested and positive when you come to work (Nurse, medical inpatient care).
The nurses need to be able to leave their duties behind and feel they are "finished" with them at the end of the workday. This entails being able to leave their work behind, both physically and mentally, so that it does not accompany them home and affect their leisure time.
Work must not take over so that I can't cope with my spare time, and the same thing, the leisure time should be energizing and help me cope even better at work, so that there's a

Having good interactions and strong leadership
Interacting with others is an important precondition for managing the work situation. In interaction with others in the team, the nurses have the opportunity to get support, which helps them handle different care situations. Nurses can also receive support and expert help from other professionals, such as doctors, physiotherapists and auxiliaries.
We work well together, we all work together, support each other and discuss things. We cooperate really well, I think. If there's something you don't know how to do, then you're not afraid to get help from someone else, or to say "I can't, but…" It challenges you, I think that's really important (Nurse, psychiatric inpatient care).
In order for nurses to develop good manageability, clear leadership is needed and, thus, a clear and strong manager. Such leadership provides security and is a precondition for the work team to function satisfactorily.
A good manager makes the whole team work, she does almost everything for us, I almost said. She plays around with the schedule/…/she makes a special schedule for those who work until five and some work every other weekend, then they have special schedules.
She really spends time and energy on us, which makes people want to stay and enjoy being on the ward, and you gain confidence (Nurse, psychiatric inpatient care).

Comprehensibility
Creating sustainable work situations for registered nurses means making these situations comprehensible. Comprehensibility is created when the nurses can reflect on their role and the work they do. Comprehensibility helps the nurses understand that they are needed and that they are providing good care for their patients. The nurses need varying tasks, so that their work is not trivial and monotonous. Nurses develop and learn when they face new challenges on a daily basis. In this way, the professional role is constantly evolving. The nurses are proud of their professional role, and their professional role and function are valuable in the healthcare organization.

Feeling valuable, needed and doing good work
The nurses understand that their professional role is of great value owing to the knowledge they have and the tasks they perform, which involve great responsibility. They feel needed and that they are contributing something important to patients' health.
To me, my professional role means feeling I am capable. Having sufficient knowledge so that I can help people and have the energy to help when someone is powerless. Being able to support that person is a strong driving force for me (Nurse, psychiatric inpatient care).
I am thriving as a nurse, I enjoy meeting new people, and I enjoy helping, doing something for someone else, and as you can see... it usually turns out good for them (Nurse, surgical outpatient care).
Sometimes, it is only the feeling of doing something that benefits someone else (the patient) that gives this satisfaction.
Yes, being able to help and provide support gives me satisfaction, that it works in all ways for our patients (Nurse, psychiatric inpatient care).
It's the best profession in the world. Being able to help someone who needs it and to alleviate problems or support or treat in the best way. That's what I want to do (Nurse, medical outpatient care).

Being committed
The nurses feel highly committed to their work, which means they get deeply involved in their patients and try to do that "little extra" for them. It is important for nurses to not only carry out basic nursing, for example, patient hygiene care, but also help patients by talking with them and building trusting relationships.
I try to do that little extra, even for the patients, "to give of oneself." If I get good treatment in return, it means a lot to me. I hear someone say, you did great, yes it means a lot to me (Nurse, medical outpatient care).
At the same time, the nurses understand that they cannot get too deeply involved in patients' situations; they must also think about themselves. This is an approach they have developed over a long period of time to prevent work-related stress and ill health.
You have to take care of yourself, not get involved in everything. It's important that you don't do everything yourself, that you can ask others for help and know their limitations, I think that's important. That you don't wear yourself out, because that helps nobody, if you have to stay at home sick just because you've gotten too involved. Somehow, it's about getting involved in the right things (Nurse, psychiatric inpatient care).

Feeling pride in your professional role
The nurses are proud of their professional role and the responsibility it entails. According to the nurses, their expertise is also of great value, and this further strengthens their The results reveal that nurses perceive a SOC and that this is important to their wellbeing. The present findings on nurses' engagement in patient care and work in general are in line with previous research among community health nurses, showing that nursing gives life meaning through the essence of job engagement [19]. Aspects of job engagement were feeling a calling, a zest for work and vitality.
The registered nurses also clearly describe a care-related driving force that is the source of their great commitment to their work. There are also clear altruistic elements involved, such as wanting to contribute something extra and not just to perform tasks in a technical or routine manner. This also influences their experience of doing something good and giving that 'little extra,' which is largely based on personal commitment to patients' needs. The nurses experience a strong affinity with the working group and the collective, from which they receive a great deal of support and energy, which help them cope with everyday tasks.
Although the nurses in the present study report feeling highly committed to their work and patients, they must not get too involved. The nurses try to set limits -an approach they have developed over a long period to prevent work-related stress and ill health. In this way, they identify strategies for managing stress and creating and maintaining a SOC [16]. Factors that can maintain nurses' good health in stressful work environments are: strengthening nurses' professional pride; stressing the great value of their knowledge and duties; reinforcing their feeling of being needed and doing good; increasing opportunities for them to work with nursing duties such as talking with patients and building trusting care relationships; creating a SOC the promotes meaningfulness, manageability and comprehensibility in work. Previous research has stressed the importance of job engagement, support from colleagues, personal characteristics and self-knowledge [17,19].
The results demonstrate that, to achieve good recovery, the nurses need to be able to leave work behind them, both physically and mentally, after their workday. The nurse manager can give nurses the opportunity to take some time for reflection before the end of the workday. Tiller's "Everyday Reflections" model can help nurses reflect and take a daily timeout [27].

Strengths and limitations of the study
The most important strength of the present study is that it expresses the nurses' perspective; their perceptions are valuable and needed in nursing research. Use of a salutogenic approach -from designing the study and interview guide through the data analysis -can also be considered a strength. To obtain a broad and comprehensive description of the issue, that is, to describe and explore success factors promoting a sustainable working life for registered nurses, registered nurses from various care units were selected. Thus, registered nurses from emergency medicine, specialist medicine, surgical care (both inpatient and outpatient care) and adult psychiatric inpatient care participated in the study. The current focus on success factors expanded our understanding of how to create the best possible working conditions for nurses in hospital settings.
One limitation of the present study may be that all of the participating registered nurses were female and that they all worked in hospital healthcare. No registered nurses from community care were included. The fact that the study is based on a small number of registered nurses, working in one setting, could have resulted in a one-sided picture of success factors the promote a sustainable working life for registered nurses. It is possible that inclusion of registered nurses from community care would have provided a broader picture of the phenomenon. However, the purpose of qualitative content analysis is to highlight individual experiences, and the findings may therefore be transferable to other healthcare settings in similar circumstances.
The researchers' background (five of the six researchers are registered nurses) may also be an advantage in understanding, analyzing and interpreting the success factors promoting a sustainable working life for registered nurses. However, familiarity may be an obstacle, as nuances may be left out when the interviewer and interviewee have common understandings and experiences. By continuously maintaining a conscious and critical approach to this understanding during the study, this problem can be avoided. The researchers have also worked a great deal with the theory of salutogenesis, which facilitated both the inductive and deductive analysis process.

Implications for nursing practice
To create a good workplace for nurses, the nurse manager can develop action programs for various activities, such as individual schedules, skills development, cooperation between nurses and other professionals to reduce the workload and strengthen clear leadership. The action programs can promote a sustainable working life and prevent nurses from terminating their employment. In this way, nurses can develop experiencebased knowledge generated through many years of working with patients and teams at the same workplace. This also applies to familiarity with technical skills and the caring approach. Moreover, experience-based knowledge is an important basis for personcentered care and patient safety.

Conclusion
Clear leadership on the part of the nurse manager is an important prerequisite for increasing nurses' job satisfaction and ability to develop a sustainable working life. Nurses must feel an affiliation with both the working group and the organization. If nurses are to feel secure and joyful in their work, it is essential that they be acknowledged for their work performance, not only by patients but even by colleagues, other professionals and the nurse manager. In this way, nurses can achieve meaningfulness, manageability and comprehensibility in their work.