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   Table of Contents      
ORIGINAL ARTICLE
Year : 2021  |  Volume : 26  |  Issue : 4  |  Page : 349-354

Contextual barriers of respectful workplace in nursing: A focused ethnography


1 Nursing Research Center, Golestan University of Medical Sciences, Gorgan, Iran
2 Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission31-Aug-2020
Date of Decision06-Oct-2020
Date of Acceptance05-Feb-2021
Date of Web Publication20-Jul-2021

Correspondence Address:
Dr. Akram Sanagoo
Nursing Research Center, Golestan University of Medical Sciences, Gorgan
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnmr.IJNMR_274_20

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  Abstract 


Background: Respectful relationship among nurses is an important influencing factor of positive work environment and nursing outcomes. Disrespectful interpersonal behaviors set the scene for an unpleasant and unhealthy workplace in nursing. This can be harmful to persons and their organization and affect health care outcomes. This study was designed in order to search for contextual barriers to respectful behaviors in the context of nursing. Materials and Methods: This study was a focused ethnography that was carried out in medical-surgical wards of Shahid Chamran Hospital in Isfahan in 2018-2019. The data collection method consisted of 140 h of participant observation and semi-structured interviews with 34 informants. The nformants comprised 29 nurses, 2 assistant nurses, a physician, and 2 patients who were selected by purposive sampling. The first author of the study made direct observations as an outsider. The data were analyzed by Spradley's method. Results: Three main categories and eight subcategories were obtained from data analysis that are as follows: 1) Personal self: challenges of perceived respect (negative self-concept, unpleasant feelings, and ineffective communication), 2) Organizational-based perceived disrespect (poor organizational climate, inadequate job condition, restrictive organizational structure), 3) Social self: challenges of showed respect (implicit social norms, cultural gap). Conclusions: Individual and social attitudes, interactive communication, and organizational factors are the contextual determinants of a respectful workplace in nursing. Consequently, improving self-concept and effective communication skills as well as adjust organizational conditions and value conceptualization in society may effect a respectful workplace in nursing.

Keywords: Anthropology, environment, nursing, respect, workplace


How to cite this article:
Nouri A, Sanagoo A, Jouybari L, Taleghani F. Contextual barriers of respectful workplace in nursing: A focused ethnography. Iranian J Nursing Midwifery Res 2021;26:349-54

How to cite this URL:
Nouri A, Sanagoo A, Jouybari L, Taleghani F. Contextual barriers of respectful workplace in nursing: A focused ethnography. Iranian J Nursing Midwifery Res [serial online] 2021 [cited 2021 Jul 24];26:349-54. Available from: https://www.ijnmrjournal.net/text.asp?2021/26/4/349/321917




  Introduction Top


Recently, health care has focused on creating a healthy and positive workplace with the purpose of attracting and retaining nurses.[1] One of the strategies in order to create a healthy workplace is to establish respectful behaviors among nurses.[2] In the literature, respect is defined as protecting the dignity and privacy of individuals and maintaining their psychological integrity.[3] The American Nurses Association (ANA) has introduced respect as a basic principle of professional ethics[4]; furthermore, they have emphasized respectful interactions between nurses, their mutual support, and their responsibility for the respectful workplace.[5],[6] According to studies, respectful behaviors in the nursing workplace improve the image of nursing,[7] reduce multigenerational conflicts among nurses,[8] increase the quality of work-life in nurses,[9] reduce human error through information sharing in their workplace,[10] and finally increase the quality of patient care.[11] Despite the need to create a culture of respect and its effect on positive health outcomes, evidence indicate low levels of respect in the nursing workplace, which is a factor in job dissatisfaction and the tendency of nurses to leave the profession.[12],[13] Therefore, it is necessary to create a culture of respect and improve it at all levels of health care.[14]

Donahue (2020) in his study indicated that disrespect in the workplace in nursing is associated with unpleasant feelings such as disability, ignorance, and discouragement. He mentions that nurses received disrespect in many cases from their colleagues.[15] Mayfield et al. (2019) in their study showed honoring culture and beliefs as one of the main themes in relation to nurses' experiences of respect.[3] Clucas et al. (2019) showed the effect of nurses' beliefs and attitudes (toward themselves and patients), and socio-cultural factors on respectful communication between nurse and patient.[16] Although negative behaviors in nurses' workplaces affect their ability to provide effective care, little research has been done to address this problem.

Nurses working in hospitals should treat their patients and colleagues with respect because the consequences of a disrespectful workplace, such as a tendency to leave work, job dissatisfaction, and reduced motivation, can be harmful to the persons, patients, and organizations. At the same time, most studies in this field have dealt with the interactions between nurses and patients, and few studies have been conducted on the interactions between nurses. Accordingly, there is a need for more research on inhibitors of the respectful environment in the nursing context with focusing on interactions between nurses. Based on the evidence, cultural factors such as attitudes, beliefs, and feelings are effective in creating a respectful work environment in nursing, and these are the elements of culture; therefore, it is necessary to explore the concept of respect according to the cultural context This study was designed with the aim of creating a deep understanding of the underlying contextual barriers in relation to a respectful workplace in Iranian nursing.


  Materials and Methods Top


This paper is part of a larger study that examines the cultural aspect of respect through the lens of the interaction between nurses in Iran entitled ”Culture of Respect in Clinical Nurses”. This study is performed by a focused ethnographic approach and adapted from the Developmental Research Sequences (DRS) method introduced by Spradley from October 2018 to December 2019 in Iran. This method focuses on ethnographic research and has been widely used as a research method in health care studies including quality of care in the emergency ward[17] and palliative medicine.[18] In this study, barriers to a respectful workplace in the context of clinical nurses have been investigated using the DRS method. As the focus of this study was the interactions between nurses, the focused ethnography method was used.

The present study environment was adult general wards of the cardiac hospital (3 internal wards and 2 surgical wards). The informants were 29 nurses, 2 patients, 2 assistant nurses, and a physician (in total 34 participants) that selected using purposive sampling. Informants were selected from different wards, different age groups with different experiences; furthermore, observations were made in different shifts (morning, noon, night) and different situations. The data collection methods in this study were participant observation and in-depth semi-structured interviews to complete the observations.

The first author of the study made direct observations as an outsider. The researcher observed the interactions and behaviors of nurses such as verbal and nonverbal communication, tone of voice, facial expressions, and gestures during communication with each other. During the research process, the researcher participated in nursing practice in this cultural scene and became an insider. Despite this, she tried to maintain a balance between being an outsider and an insider. During the observations, the field notes were recorded in a condensed account, then they were converted to an expanded account after each fieldwork. Each observation lasted from a few minutes to 40 min. The participants were observed for 140 h. Depending on the purpose of the observations, three types of observations were used: descriptive observation, focused observation, and selective observation. In order to complete the observations, semistructured interviews were conducted with the informants. Because this study focused on nurses' interactions, the key informants of this study were nurses. Thirty-four formal interviews and three group interviews were conducted with an average duration of 55 min. To complete the data, seven informal interviews with an average duration of 15 min were conducted from other people in the nurses' work environment such as a physician, nurse assistant, and patient. Interviews were conducted at the staff restroom and header room of the wards. The key informant was selected by several criteria such as having at least a bachelor's degree in nursing, full-time employment in the workplace for at least 6 months, do not leave the environment, interest in the subject of study. An example of interview questions is as follows “Which factors would affect respectful behaviours in your workplace?” The researcher tried to encourage informants to express their experiences and their perceived feelings.

Data analysis was performed through Spradley's DRS method (2016) and included four stages of domain analysis, taxonomic analysis, component analysis, and theme analysis, which was performed as a cyclic pattern during the research process.[19],[20] In order to analyze the domain, the researcher first chose a potential semantic relationship such as “x is a kind of y” according to the type of activity, and “x is a way to do y” according to the ways of communication. For example, the feeling of ignored is a kind of personal factors, lack of support by managers is a kind of organizational factors, or public image of nursing in society is a kind of social factors, the culture of paternalism is a kind of cultural factors, and low salary is a way to a feeling of disrespect in nurses. Next, the researcher searched for the included terms and cover terms that fit these semantic relationships and entered the structure of each domain in the domain analysis worksheets. Based on the data obtained from the observations, inhibitory factors affecting respect in the nursing workplace emerged and categorized into three general domains including personal factors, organizational factors, and socio-cultural factors. The steps of domain analysis in this study are shown in [Figure 1]. In the taxonomic analysis, the organized and simplified data from each domain, and classified them into smaller categories based on the similarities of the included terms using single semantic relationship. At this stage, data from observations and interviews were used to explore the similarities. In the component analysis, units or components are compared with each other based on dimensions of contrast and reclassified according to the differences in the data. Finally, during theme analysis, general semantic relationships are established between cultural domains. In addition, a list of cultural themes was created. The data collection in this study continued until the researcher gained a general understanding of the cultural scene, and no new data interpretation was created with further observations and interviews. During the study, the researcher recorded her beliefs and insights regarding respect in the nursing work in the form of a fieldwork journal. Reflexivity was achieved by fieldwork journals, reflection, and rethinking and using them in the analysis of the data. Methodological rigor was assessed throughout the study using credibility, confirmability, dependability, and transferability.[21] The variety of observation situations in terms of time and place, the variety of informants regarding gender, age, and position, and the use of verification questions in the interviews were performed in order to ensure the credibility of the data. To ensure the consistency of the data, accurate recording of all stages of research, recording of interviews, and accurate recording of all stages of data analysis were carried out. To ensure confirmability, the research process was recorded accurately and reported exactly. The card sorting technique was used to confirming the domains. In this way, each of the included terms was inserted on a card, and the informants were asked to classify them in the obtained domains [Figure 2].
Figure 1: The steps of domain analysis

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Figure 2: Card sorting technique for verification of the data by the informants

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Ethical considerations

This study was approved by the ethics committee of Golestan University of Medical Sciences with the code of ethics IR.GOUMS.REC.1395.304. Ethical considerations such as obtaining informed consent, maintaining the principles of anonymity, the confidentiality of data, and the freedom of participants to leave the study at any stage of the research and tacit and verbal consent of the participants were observed during the research process.


  Results Top


The findings of this study were analyzed in the form of three domains: 1. individual factors, 2. organizational factors, and 3. socio-cultural factors. Three main categories and eight subcategories were obtained as a result of data analysis which are as follows: 1. Personal self: challenges of perceived respect (negative self-concept, unpleasant feelings, and ineffective communication), 2. Organizational-based perceived disrespect (poor organizational climate, inadequate job condition, restrictive organizational structure), 3. The social self: challenges of showed respect (implicit social norms, cultural gap). The main categories and subcategories are illustrated in [Table 1]. The informants in this study were 34 persons (21 women, 13 men) between the age of 29 and 59 [Table 2]. The range of experience of nurses was 5 to 25 years and they work in the internal cardiac ward (63%) and surgical cardiac ward (37%).
Table 1: Main categories and subcategories explaining the contextual barriers of the respectful workplace from the point of view of informants

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Table 2: Demographic characteristics of informants

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Personal self: Challenges of perceived respect

This theme refers to personal features which cause disrespectful feeling in person. The subthemes of this theme include the concept of a negative self-concept, unpleasant feelings, and ineffective communication.

Negative self-concept: In general, lack of self-respect, negative self-image, and low self-confidence are the most significant factors of the feeling of disrespect in nurses. ”From the point of view of our society, for various reasons, manual work, for example, work that must be done by hand, is not considered as clean and stylish work that deserves respect …” (nurse).

Nurses in the cultural setting under study believed that using nursing knowledge and skills in patients' clinics increases their self-confidence and considered it as a factor to gain the trust and respect of others in their work environment. ”I remember in the night shift, the patient had chest pain, I found ST elevation in his EKG. the patient was exposed to MI. I immediately informed the doctor; he came and visited the patient. Finally, the patient's condition Stabilized and did not MI. If the nurse uses her knowledge and experience in the patient's clinic, she will feel efficient and this will create a sense of respect.” (nurse).

Unpleasant feelings: Feelings such as rejection by others, feelings of ignored, and worthlessness are characteristics that affect the perceived respect in nurses. “New nurses are ignored by their colleagues when they make decisions about nursing care. It makes me feel rejected” (Nurse).

The existence of destructive feelings in nurses such as the feeling of not acceptance and feeling ignored effect on their personal attitude and is an obstacle in effective relationships in the workplace.

Ineffective communication: Respect is considered a communication element, so ineffective communication such as inappropriate literature and incivility behaviors are the reasons for the feeling of disrespect in nurses. “The patient companion goes to the nursing station and asks: When does the doctor come to visit my father? The nurse, while entering the patient's medication into the HIS software, says without raising her head: She is coming at night. The companion says it is night now. The nurse looks up and says angrily: “Sir, it is our duty to inform the doctor, I do not know when he will come?” (observation).

Organizational-based perceived disrespect

This theme refers to the inhibitors and barriers to respect associated with organizational conditions. The subthemes of this theme include poor organizational climate, inadequate job conditions, and restrictive organizational structure.

Poor organizational climate: The nurses numerated lack of adequate support from managers, injustice, mistrust, and lack of psychological security in their organization as obstacles to creating a respectful workplace. “… there is a big difference between the salary I receive and the salary of a doctor … If justice is done in the organization, I feel respected.” (nurse).

Inadequate job conditions: nursing shortage, high workload, and lack of facilities are the obstacles to creating a respectful environment based on the organization. ”Anyway, our ward is very important, patients have heart disease which means as soon as possible we should take care of them because they might even be in danger… that cause the staff be stressful and this stress has an effect on creating tension among nurses.” (nurse).

According to the findings, the lack of human resources, heavy workload, and insufficient equipment in hospitals, causes fatigue in nurses and reduces their tolerance in stressful situations. So, inadequate job condition is one of the obstacles to creating a respectful work environment in nursing.

Restrictive organizational structure:

Nurses cited factors such as high responsibility and low authority and nonparticipation in decision making as obstacles to feeling respected. ”…. There are a number of decisions that apply directly to you, so therefore you should participate in decision making, but you aren't” (nurse).

In the cultural setting under study, categories such as insufficient support by managers, high hierarchy in nursing, inappropriate working conditions, insufficient authority of nursing managers and lack of participation in decision making classified as restrictive factors associated respectful workplace.

Social self: Challenges of showed respect

The other obstacle in respective job environments are values and norms in society in relation to respect. So that social values and implicit norms create a gap between “personal self” and “social self”, considered as a challenge for showing respect for others in Iranian society.

Implicit social norms: one of the implicit norms which expressed by nurses, is the respect to position, power, situation, and influence of the person, instead of respecting the inherent dignity of the people. ”Everyone is respectable…, but in our society who ever be high educated, have more money, more power, therefore has more respect.” (patient).

Cultural gap: The participants cited conflicts between different generations of nursing and cultural gap in different social classes as barriers to a respectful work environment in nursing. ”Today in our society, topics like respect to elders, respect to senior, respect to competency is becoming fade, I feel the tradition has fade, and senior and junior not observed.” (nurse).

In general, the change of value system in the current society and the implicit norms in the society are considered as a determinant of the respectable workplace. According to the findings, respect in nurses can be divided into three categories: showed respect to others, perceived respect from the environment, and self-respect. Socio-cultural factors are those challenges that affect the perceived respect of nurses by the patients, their family, physicians, and other members of the health care team who are influenced by the larger community.


  Discussion Top


In this study, barriers and deterrents of a respectful workplace in nursing were identified in the form of three domains including personal factors, organizational factors, and socio-cultural factors. This section discusses the main themes of the study.

In the domain of personal factors, the results of the present study indicate a negative self-concept as one of the factors associated with feelings of disrespect in nurses. Self-concept is the result of a person's beliefs and evaluations of himself that affect his behavioral tendencies. Hamim (2017) also showed in his study that nurses' self-concept is effective on their caring behaviors and respect for themselves and others.[22] In the present study, unpleasant feelings such as being ignored, feeling worthless and inefficient, and feeling rejected by others in the workplace were among the barriers to the feeling of perceived respect by nurses. Unpleasant feelings created as a result of feelings of disrespect can affect nurses' performance. Donahue (2020) in a study showed that feelings of disrespect are associated with feelings such as inability, feelings of not being seen, feelings of stupidity, and feelings of discouragement in nurses. The author believes that these emotions perform the communication and behavior patterns of persons.[15] In the present study, ineffective communication and negative behaviors are considered as a factor associated with feelings of disrespect in nursing, on the other hand, disrespectful climate in the nursing workplace increased inefficient communication and inappropriate behaviors in the cultural setting under study. In a study, Najafi also introduced disproportionate professional communication as one of the five main findings related to incivility in nurses' workplace.[23] In their study, Wang et al. showed that one of the strongest predictors of effective communication in nurses is perceived respect.[24] Therefore, mental attitudes and self-concept can be considered as determinants of the feeling of respect in nurses.

In the domain of organizational factors, the findings of the present study indicated that the restrictive organizational structure including inadequate support, injustice, and distrust are the barriers to respect in the workplace of nurses. In other words, having a supportive atmosphere in the organization can help create a respectful workplace. Augsberger (2012) in the study showed that the lack of adequate support by the managers and colleagues and lack of justice are the most significant predictors of feelings of disrespect in nurses.[25] But this finding contradicts Tervo-Heikkinen's study. He showed that support by managers at various levels does not pose a significant issue for creating a positive work environment in Finland. He argues that nurses' perceptions of job adequacy, respect, and good working relationships, and professional standards play a more important role than support by the managers.[26] But the results of the present study showed that the feeling of respect in their nurses depends on the adequate support by managers. This difference in findings may indicate a cultural difference between Finnish society and the cultural field under study. Other barriers to a respectful workplace related to the organization in the present study were inadequate job conditions. High workload, the nursing shortage, and job stress increase tension in the workplace. In a study, Laschinger introduced high workload as one of the predictors of perceived respect in nurses.[27] Therefore, integrating and modifying the structure and atmosphere of the organization can increase the understanding of respect in nurses.

In the domain of socio-cultural factors, implicit social norms and cultural differences served as barriers to a respectful workplace in nursing. Implicit social norms, such as respect for the status, social and economic status of individuals, are on the contrary of respect for the dignity and inherent dignity of individuals. Because physicians in Iranian society have a high income and a special social status, the image of nurses in Iranian society has also been influenced by these values. Braganca (2017) in a study showed that nurses' perception of their general professional image is effective in their self-concept and their performance.[28] Majority of participants in this study assessed the negative public image of nursing in Iranian society. These results are inconsistent with Donelan's study. In his study, he showed that the public image of nursing in American society is positive and nurses perceived respect by society.[29] Another barrier to respect in the nurses' workplace in the present study was the cultural differences that manifested themselves in multigenerational conflicts and conflicts between a physician and nurse. In the cultural scene under study, nurses were in different age groups. One of the reasons for the conflict in different generations of nursing can be the gap between cultural values such as the tradition of respect for elders and social values. In other words, social values change over time, but cultural values remain the same. Therefore, the existence of a gap in the value system of different generations of nursing justifies the multigenerational conflict among nurses. Stanley (2010) obtained similar results in his study. He states that nurses of the previous generation believe in a value hierarchy; moreover, respect in the workplace is a value for them.[30] Thus, conceptualization of values in society and social attitudes are introduced as a factor to show respect for others in nursing. Babaei and Taleghani, in their study, cited socio-cultural factors as an obstacle to compassionate care. They introduced respect as one of the components of compassionate care.[31]

Based on the findings of this study, self-improvement, effective communication, support for nurses by the managers, integration of organizational structure, improve the job conditions and create cultural competency in nurses and can be considered as a facilitator of a respectful work environment in nursing. This study was conducted in a medical-surgical ward, on the other hand, the majority of key informants were women, which can limit the generalization of the study results to other settings.


  Conclusion Top


Generally, the findings of this study are based on three categories of factors including individual attitude and social attitude towards respect, as well as organizational structure and atmosphere. In the professional dimension, nurses can experience more respect in their workplace by improving self-concept, increasing knowledge and skills and self-confidence. In the organizational dimension, managers can help maintain nurses by creating an atmosphere of participation and cooperation, providing more support to nurses, and addressing the challenges of the nursing profession, such as force shortages. In the social dimension, improving community attitudes toward nurses can affect nurses' perceived feelings of respect.

Acknowledgements

This article has been extracted from the Ph.D. dissertation. The researchers are grateful to the nurses and officials of Shahid Chamran Hospital in Isfahan for their cooperation in collecting data.

Financial support and sponsorship

Golestan University of Medical Sciences

Conflicts of interest

Nothing to declare.



 
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