Opportunities and Obstacles for Good Work in Nursing

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2006 13: 471Nurs EthicsJoan F Miller

Opportunities and Obstacles for Good Work in Nursing

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OPPORTUNITIES AND OBSTACLES

FOR GOOD WORK IN NURSING

Joan F Miller

Key words: caring; good work; mentoring; quality care; virtue ethics

Good work in nursing is work that is scientifically effective as well as morally and sociallyresponsible. The purpose of this study was to examine variables that sustain good workamong entering nurses (with one to five years of experience) and experienced professionalnurses despite the obstacles they encounter. In addition to role models and mentors,entering and experienced nurses identified team work, cohesiveness and shared values aslevers for good work. These nurses used prioritization, team building and contemplativepractices to overcome obstacles. Entering professional nurses tended to avoid conflict inthe work setting. Experienced nurses reported forming teams of decision makers whoshare similar values to resolve conflict. These findings have implications for nurseeducation and nursing practice. Reflection on the importance of values and virtue insustaining good work is important. Entering professional nurses should be encouraged toseek positive role models and reflect on the lessons that can be learned from experiencedexemplary nurses.

IntroductionNurses are expected to cope with rapid change in a complex health care systemthat values the ‘bottom line’ and efficiency while sustaining excellence in caringand healing practices, to which nurses struggle to maintain their commitment.Despite barriers to excellence in nursing practice, such as diminished resources,time constraints and perceived threats to quality of care, many nurses performwhat may be called good work. Good work in nursing is defined as work that istechnically and scientifically effective as well as morally and socially responsible.When nurses perform good work and remain committed to excellence, they experiencefulfillment as they contribute to the well-being of their patients. Experienced nursescommitted to excellence during challenging times serve as exemplars for othersseeking to sustain a commitment to good work. Using the qualitative methodology ofthe GoodWork† Project,1 this study was designed to explore variables that havesustained entering nurses (with one to five years of experience) and experiencedprofessional nurses in their attempts to perform good work despite the challenges theyencounter in today’s rapidly changing health care environment. Both entering and

Address for correspondence: Joan F Miller, Bloomsburg University, Department of Nursing,Bloomsburg, PA 17815, USA. Tel: �/1 570 275 5224; E-mail: [email protected]

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experienced professional nurses were chosen to participate in the study based on theassumption that their experiences and perceptions of variables affecting practicewould differ. Benner’s2 framework for professional development was used to informdiscussion on the experiences of professional nurses at varying stages of theirprofessional development.

Background and significanceIn 1995, a team of researchers from the GoodWork Project at Harvard Universityembarked on a study of the concept of ‘good work’, defined as ‘work that is bothexcellent in quality and responsible to the broader society’.3 The GoodWork Project isunder the direction of Howard Gardner, Professor of Cognition and Education atHarvard Graduate School of Education, Mihaly Csikszentmihalyi, Professor at theSchool of Management at Claremont University, and William Damon, Professor ofEducation at Stanford University. Researchers from the GoodWork Project have beeninterviewing young persons on entering a profession and experienced professionalswho have achieved distinction in a variety of disciplines, including journalism,genetics, theater and business, to learn more about the strategies individuals use tosustain their good work at a time when market forces and greater emphasis onproductivity and profit make commitment to quality work difficult.4 They have foundthat most workers take pride in what they do and aim to do work that makes adifference and serves society well. They have also learned that good work is influencedby professional standards, mentors, peer behavior, internal values and social values.When conflict arises among these forces, sustaining good work in one’s professionbecomes difficult. The GoodWork Project aims to extend its understanding of goodwork in a variety of professions, including the caring professions. Consequently, thisstudy was designed to explore the concept of good work in nursing and the variablesthat influence good work among entering and experienced professional nurses whohave been identified as exemplar professionals.

Defining good work in nursingGood work in nursing may be defined as providing quality care for and assistingpersons in achieving a level of wholeness and health that would enable them to attaintheir desired goals or life plan.5 To the extent that professional caring is essential inhelping persons to achieve their desired life goals, nurses committed to good workmust be skilled in professional caring. Elements essential to professional care include:(1) affection, a positive regard for the one receiving care; (2) cognition, the knowledgeof what is essential to achieve the well-being of the one receiving care; (3) volition, thecommitment to use one’s knowledge in the best interest of the one receiving care;(4) imagination, the capacity to share the lived experience of the one receiving care;(5) motivation, the predisposition to place the interest of the patient before one’s owninterest; and (6) expressiveness of action, use of verbal and non-verbal behaviors toconvey care.5 These conditions are supported by virtues such as respect, compassion,intellectual honesty, accountability, empathy, altruism and caring, all supporting theprimacy of caring in the nursing profession.

472 JF Miller

Nursing Ethics 2006 13 (5)



The concepts of values and virtue are integral to the concept of good work innursing and therefore merit definition. Burns6 defines values as end states, goals orexplicit purposes according to which decisions about behavior are made. Accordingto Pellegrino,7 healing, helping, caring well and acting in the best interest of the patientare the end states or goals of nursing and medicine. Virtues predispose a person to actwell in pursuit of end states, goals or explicit purposes. Virtues, such as fidelity totrust, compassion and caring predispose the nurse, physician or other healthprofessional to act habitually in the best interest of the patient. Pellegrino acknowl-edges that the health professional may not achieve a state of perfection in the pursuitof excellence. However, the good nurse or physician will always strive to be better bygoing beyond mere expectations to achieve a higher end or goal. Virtue ethics providesa framework and principles of conduct to guide the nurse or physician acting in thebest interest of the patient.

There is growing concern that the values and virtues supporting good work innursing have lost priority under the pressure of market forces. Taylor5 states:

In the not so distant past, one could safely assume when speaking to practicing nurses thateach nurse in the audience shared as a valued starting assumption that nursing was amoral practice. I no longer find this to be true. (p. 71)

Today many nurses struggle to maintain their integrity and secure their survival asthey cope with change in the health care environment.

The struggle to maintain good work in nursingNurses report dissatisfaction and low morale as they cope with time constraints andstaffing shortages. Cummings et al.8 point out that dissatisfaction among nurses isoften related to concern over unattended patient care needs, emotional strain anddisruption in workgroup collaboration. Insecurity, uncertainty about the future of theprofession, and lack of support for education and career advancement also contributeto low morale. Some nurses regret their decision to enter the nursing professionand others admit they would not recommend nursing to a child of their own.9 Manynurses report intent to leave a current position as a consequence of dissatisfaction.10,11

More than ever before, nursing needs exemplars willing to take a stand against forcesthat threaten their personal integrity, the integrity of the profession and the well-beingof those whom they serve. Through their example, exemplar nurses help to shape thecharacter of other nurses, ultimately forming moral communities of care to sustain thetradition of the profession.

MethodsThis study employed the research methodology of the GoodWork Project,1 whichinvolves semistructured interviews addressing goals, practices, values and supports,as well as obstacles encountered in one’s work and strategies used to overcome them.After interview, each participant completed a Q-Sort, a tool requiring them to rank-order 30 values held by them in their professional lives. They also completed aninstitutionally approved consent form prior to the interview. A second signature was

Opportunities and obstacles for good work 473




recorded on a permission form to release the identity and affiliation of the participantshould that be relevant in the discussion of results.

The participants included eight entering professional nurses and 16 experiencednurses. Entering professional nurses were nurses with one to five years of nursingexperience. With the exception of one, who worked in an outpatient setting, allentering professional nurses worked at the bedside. Supervisors, former facultymembers and peers nominated entering new professional nurses based on the qualityof their work and their apparent commitment to excellence in nursing. Experiencednurses were either nominated by fellow colleagues or selected by the investigator onthe basis of national or international distinction. Experienced nurses held adminis-trative roles in hospital or university settings. Four held positions of leadership innational or international professional nursing organizations. Potential participantswere contacted by telephone or e-mail and invited to take part in a researchproject involving a taped interview and completion of a 30-item Q-Sort. Interviewswere conducted to answer the following research questions: (1) What do nurseswishing to do good work see as their overriding goal or mission in their work?(2) What opportunities or obstacles have nurses encountered as they attempt to carryout good work? (3) What strategies do nurses employ to deal with obstacles andwhat success do they achieve? Interviews were audiotaped and transcribed verbatimto ensure accuracy of responses. Each interview lasted between one and one and a halfhours.

A phenomenological approach using steps described by Moustakas12 was used inthe analysis of interview transcripts. After extensive review of the transcripts,statements about the overriding goal or mission in work for each participant, theopportunities or supports for achieving that goal or mission, obstacles encountered,and strategies used to overcome obstacles were extracted and clustered into themes. Anarrative description of the experiences of the nurses in this study followed.Throughout the interview process, the investigator bracketed her own ideas aboutgood work in nursing and focused on the experiences of each participant in order toestablish a broader understanding of the phenomenon under study. The results of theQ-Sort were computed to determine the average rank for each attribute across levels ofprofessional development.

Findings

Overriding goal or mission of work

The first major theme addressed the overriding goal or mission of work for enteringprofessional and experienced nurses. Entering professional nurses reported thatproviding quality care for patients was the primary mission of their work. Theyused expressions such as ‘caring well’, ‘making a difference’ and ‘knowing the person’to describe what is meant by quality care. One entering professional nurse offered adefinition of quality care and what it meant to her.

I think it [quality care] involves respecting people as individuals, looking at peopleregardless of their wealth or poverty, and trying to do for the patients here what youwould like to have done if you were a patient here. In other words, putting yourself in thepatient’s position.

474 JF Miller




Other attributes of quality care cited by the nurses included treating others withrespect and honesty, providing support for patients and being present to patients.

Experienced nurses also cited quality care as their primary mission in work. Onenurse educator stated:

To me, good care means caring for the vulnerable and believing you can make a differencein the life of another. Good care also means recognizing the person as one with physical,emotional, psychological and spiritual needs, and . . . you give that care with honesty andintegrity.

Other experienced nurses described indirect ways in which they influence care,through interventions such as promoting excellence, advocating for others, modelingexcellence, empowering others and promoting quality education. Additional state-ments and themes related to the overriding goal or mission for work are presented inTable 1.

Table 1 Goal or mission of work for entering professional and experienced nurses

Goal or mission Example

Entering professional nursesProviding good care I think some of the best care I’ve been able to give people

is just being at the bedside giving them what they need.Making a difference in the lives

of othersI value going home at night knowing I changedsomeone’s life.

Treating others with respect,honesty and compassion

To care for them [patients] well is to treat each one as animportant human being, no matter who they are or wherethey came from and to give back as much dignity as I can.

Providing support for patientsand their families

I give my patients love and compassion; I know I have theopportunity to make their experience the best that’spossible in their situations �/ it’s heartwarming andfulfilling.

Being present to my patients Caring well is listening to patients, really hearing theirconcerns or fears or complaints.

Experienced nursesPromoting excellence in nursing Our goal is to deliver the best care we can. I hope we get

better at it every day so that we are always movingforward making our ultimate goal of serving patientswith dramatic excellence.

Advocating for underprivilegedpeople

I am committed to the caring, humanitarian parts ofnursing, to the forgotten members of our society so theyget the care they deserve.

Creating a positive learningenvironment for nurses

The key element in any health care institution is tostabilize nursing and that means creating an environmentthat allows nursing to grow, change, blossom as nursingevolves.

Empowering others Enable nurses. Empower them. Help them become theclinical leaders of tomorrow at a very young age.

Promoting quality education My basic belief is that the future happens at theintersection of knowledge and service. The moreknowledge you have, the better the service you canprovide.





Opportunities for good work

Opportunities for good work are those experiences that support one’s goal to do goodwork in nursing. Analysis of the interview transcripts revealed two subthemes relatedto the major theme, opportunities for good work in nursing: (1) formative influences;and (2) a supportive work environment.

Formative influencesFormative influences included those of role models and mentors. Parents served asrole models and sources of support, particularly for entering professional nurses. Oneyoung nurse remarked, ‘I watched my mother take care of people before they had to gofor tests. They were anxious and she made them feel better. My mom was my rolemodel.’

When asked about the influence of mentors on their professional careers, severalentering professional nurses referred to preceptors as mentors. For example, one nursestated:

I’ve never had anybody in the profession in the same place where I worked serve as amentor. I had a preceptor in my first job. She was very skilled, had over 20 years ofexperience. So in some respect, she was a mentor.

Experienced nurses also described how family members served as role models. Forexample, one leading nurse educator spoke about her grandmother’s influence.

We would sit for long hours in the living room of a family where a mother or father wasgrieving for a parent or child. And I would say, ‘What are we doing? We’ve just beensitting here for, like, three hours not saying anything.’ And she would say in Spanish,‘Estamos acompanando esta familia en su dolor.’ ‘We are accompanying this family intheir pain.’

Experienced nurses were more likely to report the enduring influence of mentors.A nurse executive recalled the influence of a mentor with whom she worked early inher career.

She was a nurse leader in the organization who had very strong patient care qualities,always made sure that we were doing the right things for the patients. She was very upfront, honest and instilled in me that, whatever you do, always be true to yourself.

Another recalled the enduring influence of a former teacher.

My most positive influence was one of my professors from nursing school. She was so fullof energy and spirit and would come to clinical everyday and say, ‘Alright, let’s save livesand stamp out disease.’ And she would walk into a room and hold a patient’s hand and itwould be like the world is right. You could just see it on the patient’s face. It was just hersort of presence.

Although experienced nurses described mentoring as essential for the professionaldevelopment of young nurses, several acknowledged that mentoring has not been apriority in the profession. One stated, ‘Some people think they just can’t do it. Othersdon’t want to take the time.’ Another experienced nurse remarked,

I don’t think we are emphasizing mentoring at all. You’ve heard the old saying, ‘we eat ouryoung.’ That’s so true. And it really starts in school. Some teachers prey on students. Theirempathy is lacking.

476 JF Miller




The qualities of individuals who served as positive role models or mentors for bothyoung and experienced nurses were:

. Compassionate;

. Flexible;

. Willing to listen;

. Loving;

. Empathic;

. Energetic;

. Spirited;

. Wise;

. Respectful of others;

. Professional;

. Innovative;

. Empowering;

. Caring;

. Attentive.

Supportive work environmentAmong entering professional nurses, teamwork, cohesiveness, shared values andexpressions of gratitude from clients emerged as the predominant themes relating to asupportive work environment. A recent graduate stated, ‘We’re always there for eachother and we like teamwork. That’s how we get things done.’ Expressions of gratitudefrom patients also contributed to a positive work experience. For example, one youngnurse stated,

I think what brings me back is that a lot of the days �/ sometimes I have frustrationand sadness, but a lot of days I will make a difference. People will say, ‘I don’t wantyou to leave. Please stay. Thank you for brushing my hair. Thank you so much for talkingto us.’

Among experienced nurses, teamwork, cohesiveness and shared values alsoemerged as characteristics of a supportive work environment. However, experiencednurses also cited a supportive institution as an opportunity for good work.When describing the importance of a cohesive work environment, one nurse educatorstated:

I have a faculty and a school environment that is very cohesive. People are willing tochallenge each other. They’re willing to have great discussions, but they come backtogether and figure out the best way to really address the issue without making a personalconfrontation with somebody else.

Another described the importance of shared values: ‘Support for good work comesfrom an environment where all share the same values, work for a common goal, andare committed to excellence.’ A nurse executive remarked, ‘I think your environmentand where you work, when it’s respectful and trusting and flexible, you like what youdo. When it’s not those things, you don’t like what you do.’ Additional statementsdescribing opportunities for good work among young and experienced nurses arepresented in Table 2.





Obstacles to good work

Entering professional nurses cited four major obstacles to good work in nursing:(1) nurse shortage; (2) demands on time; (3) conflicting values among peers; and(4) lack of autonomy. For example, one nurse stated:

The staffing shortage makes me feel insecure and unsafe. It makes me feel uncomfortableand it directly affects my patients. I’m not able to spend enough time with them. We don’thave a secretary, so I am the secretary. I’m half tech, and I am the nurse in charge. It is not agood situation.

When describing conflicting values in the work setting, a recent graduate stated:

It’s interesting, some nurses that I’ve worked with just have the attitude just get in, get out,get the physical job done, the rest doesn’t matter. Part of me just �/ I try to ignore it andcontinue. It was hard as a new nurse when you’re trying to fit into an environment andyou have nurses set in their ways and they don’t necessarily practice the way you practice,and they would in their advisement of you say, ‘Oh, you don’t have to do that.’ Well, Idon’t know that I have to, but I want to and I should. I feel like I should because it is part ofmy role.

Obstacles to good work among experienced nurses were similar to those reportedby entering professional nurses in that they included: (1) the nurse shortage; (2)demands on time; and (3) conflicting values. However, experienced nurses weremore likely to describe the frustration they experienced in dealing with marketforces, including the growing emphasis on productivity and managed care. Oneexperienced nurse commented on the nurse shortage and its implication for thepracticing nurse:

Table 2 Characteristics of a supportive work environment

Characteristic Example

Entering professional nursesTeamwork We’re all fighting the same fight. We are united as a team.Cohesiveness We have a close connection with each other. It’s a collaborative unit.Shared values I think the medical center where I work and the unit I work on

really support integrity and honesty and just excellent patient care.Expressions of gratitude Just the smallest thing you can do for them [patients], they’re so

grateful. And that’s everything. That’s one of the reasons I lovenursing

Experienced nursesTeamwork We’re all on the same team at the same level with all the strengths

we bring to the table to do the job we have to do.Cohesiveness I have a faculty and a school environment that are very cohesive.

People are willing to challenge one another without making apersonal confrontation.

Shared values I think there’s a lot of what I would call spirituality here, not justreligious spirituality but spirituality in the broader sense as well,being good, doing good and respecting other people.

Supportive institution Freedom to be trusted, respected for what I do, the ability to becreative and flexible �/ that’s how the institution supports me.

478 JF Miller




As resources have tightened and as the nursing shortage has gotten worse, I thinkwe see an increased sense that the only thing nurses focus on are tasks. I hear abouthow difficult the climate is. They [nurses] can’t practice to the full scope of their edu-cation or ability. They’re not taken seriously at the table of discussion. They don’t have avoice. I think they find it [work] physically and mentally grueling, not just taxing, butgrueling.

Another described the influence of managed care on nursing practice:

I am a voice for those who are at times voiceless, a voice to make known how we can betterlive out our mission. I am in palliative care, which is in essence good quality care forpatients. But it [palliative care] is not something that fits like hand and glove within ourpresent reimbursement system or system of managed care. I perceive managed care as afragmented system, one that has more limitations than benefits. It creates constantly achallenge to work within the reality of what is and try to accomplish the greater good atthe same time.

Additional themes and statements relating to obstacles that entering and experi-enced professional nurses encounter in their attempts to do good work are presentedin Table 3.

Table 3 Obstacles to good work in nursing

Obstacle Example

Entering professional nursesNurse shortage If I could change just one thing in nursing it would be staffing. It’s just

not safe when you have so many patients. I worry something willhappen.

Demands on time For the most part, I’ve never had the time to give really excellentquality care because of the amount of work that I’ve had to do, theamount of physical tasks.

Conflicting values You have nurses who work just for the money . . .They don’t form arelationship with the patient. They just do the minimal standard thatthey need to do to get a paycheck.

Lack of autonomy You are responsible for everything that happens to them [patients], butyou wouldn’t actually be able to do anything without somebody tellingyou that it’s okay.

Experienced nursesNurse shortage My goal is to ensure that we have hopefully trained the best caregivers

that we can to provide care for the patients, that we have adequateresources to do that. But because of the nursing shortage, it’s always achallenge. In the past four years it’s been a kind of catch-up. We neverreach a steady state.

Demands on time I’m having a harder time distinguishing between those [demands] as Imove along. The thing I’ve learned is that you need courage and youneed to be able to take risks and you have to have vision.

Conflicting values When someone asks me to do something I believe is not correct, I willnot do it regardless of the risk. And that has caused me turmoil overmy career but I still feel I need to be able to sleep at night.

Market forces With managed care, often the mere profound act of sitting down, wedon’t have time for that. We’re so busy about the process that beingpresent gets lost.





Strategies used to overcome obstacles to good work in nursing

After analysis of the data, several themes emerged relating to strategies that young andexperienced nurses use to overcome obstacles to good work in nursing. Among youngnurses, these themes included: (1) prioritization; (2) team building; (3) contemplativepractices; (4) avoidance; and (5) reflection on initial reasons for entering the profession.For example, when asked about the strategies used to meet demands at the bedside,one young nurse stated, ‘Prioritizing what’s really critical and what needs to be done.And appropriate delegation, ensuring that the tasks I may delegate get done in anappropriate manner.’ Among experienced nurses, strategies used to overcomeobstacles to good work also included prioritization, team building and contemplativepractices. However, experienced nurses were more likely to report seeking valuealignment and using innovative measures to overcome difficulties in the work setting.For example, when faced with the challenge of achieving financial stability in a majormedical center, one nurse executive stated,

There are two things that need to be done in order to achieve stability �/ one, hire hard,choose candidates who fit with the culture and don’t be afraid to do it even in the face of anursing shortage; two, go for the BSNs. By hiring hard you create a work environment thatpeople want to stay in and they don’t want to go.

Table 4 Strategies used to overcome obstacles to good work in nursing

Strategy Example

Entering professional nursesPrioritization When I am stressed at work, I prioritize. I think about my patients

and decide who needs care first.Team building We’re always there for each other and we like teamwork and that’s

how we get things done.Contemplative practices Journaling and reading and praying and having my coffee �/ if I

don’t do that for a long period of time, I lose my sort of balance.Avoidance When it gets bad at work, I withdraw. I deal with my own patients

and worry about myself.Reflection on entering

the professionI just keep remembering why I became a nurse . . . and try to keep tomy own personal beliefs.

Experienced nursesPrioritization It’s prioritization. Once you prioritize, everything pretty much falls

into a natural hierarchy of what needs to be done, first, second andthird.

Team building I’m a big believer in negotiating and building that golden bridgethat people can walk over together.

Contemplative practices There’s a point when I know myself well enough to know I’vegot to pull back. It’s the alone time . . . I do what I need to do tore-collect myself and restore myself.

Value alignment I think that if people you are working with or people you areinteracting with on a very frequent basis are not completely honestor are promoting themselves more than what your mission is, thenI think at some point you have to step back and say, ‘Is this the rightplace for me?’

Innovation It’s about how I create an environment and a future that not onlywould be pressing forward, but first and foremost does somethingto make people’s lives better �/ quality and safety in patient care.

480 JF Miller




When asked how one would identify a candidate who would fit with the culture ofthe institution, this nurse executive replied, ‘It’s hard to find the fit on paper; you lookfor the passion that is nursing, the passion to help others get well or die with dignity.’Additional themes and relevant statements addressing strategies that young andexperienced nurses use to sustain good work in nursing are presented in Table 4.

Inventory of values

The participants rank-ordered 30 values held by them in their professional lives.Ranked in order are the four values considered most important among enteringprofessional nurses in their professional lives: (1) understanding and helping others;(2) honesty and integrity; (3) faith; and (4) quality of work. Also ranked in order are thefour values listed by experienced nurses as most important in their professional lives:(1) honesty and integrity; (2) quality and excellence of work; (3) teaching andmentoring; and (4) hard work. Both entering and experienced nurses cited fame andsuccess as least important in their professional lives.

Discussion

Facilitating good work in nursing

As anticipated, providing quality care and helping others emerged as the overridinggoal or mission for both entering and experienced professional nurses. This finding isconsistent with the hallmark of nursing, which is caring well for others. To assistnurses in reaching their mission to care for and help others, both entering andexperienced nurses cited the influence of role models and mentors. Role modelsincluded parents who were nurses and other family members who modeled caringbehaviors. However, new nurses in this study reported little contact with professionalmentors. With the exception of one, all the entering professional nurses practiced at thebedside. This finding raises questions about the role of mentoring in the nursingprofession, particularly in the clinical unit. What impact does mentoring have on theexperience of a new nurse? Do demands on time limit accessibility to mentors fornurses entering the profession? Do experienced nurses value the role of mentor? Donew nurses value the time and commitment necessary to build effective mentoringrelationships with experts or experienced nurses in the field? McKinley13 emphasizesthe role of mentoring in creating positive work environments, yet acknowledges thatthe mentoring process is time consuming and involves relationship building. Nursesentering the profession may be more focused on developing clinical skills andestablishing their identity as professional nurses and less focused on forming arelationship with an expert or veteran nurse. However, if valued and integrated intothe work environment, mentoring can be an effective means of promoting professionaldevelopment and empowerment among young nurses. Ciulla14 cautions, however,that empowerment must be authentic if nurses are to feel a sense of responsibility forthe work environment. Leaders within the profession must have the courage to behonest and sincere as they mentor young nurses and assist them in their professionalgrowth. According to Ciulla,14 moral concepts behind authentic empowerment includehonesty, trust, respect and loyalty. When these virtues are absent, mentors lose the





respect of their mentees. If new nurses are to flourish, experienced nurses must modelvirtuous behavior and a scope of practice that will facilitate what Benner2 refers to asthe transition from novice to expert.

The work environment

In addition to role models and mentors, entering and experienced nurses identifiedteam work, cohesiveness and shared values as dimensions of a supportive environ-ment that facilitated the work they hoped to accomplish. These characteristics allowthe development of what Benner2 describes as organizational or work-role competen-cies that include co-ordination, prioritization and management of multiple responsi-bilities. A supportive work environment may also contribute to quality of care, moraleamong staff, and successful recruitment and retention. Roberts et al.11 found that newnurses were more likely to stay in their current position if they were satisfied withaspects of the work environment, including co-workers, interaction, professionalopportunities and recognition.

Experienced nurses cited the positive influence of institutional support. This wasfurther clarified as the understanding that one could be flexible in one’s workcommitment. Flexibility allowed experienced nurses to pursue professional interests,such as research and program development. According to Benner,2 the beginningnurse operates more on explicit rules and expectations for performance. Explicit rules,Benner suggests, may be useful in terms of quality control, but rigid control ofbehavior may limit internalization of the basic values that a young nurse brings to theprofession. Beginning, or entering, nurses in this study stated they seldom had theopportunity to interact with nursing administrators. A common remark was, ‘I see mysupervisor but I seldom see the head of nursing.’ Exceptions to this perception werefound in comments made by mid-level managers who spoke of the leaders in theirinstitution who created a culture of concern for nurses at all levels. One managerdescribed the way the vice-president of nursing in her institution created a culture ofcaring as she visited departments on different shifts, getting to know staff by name.Perhaps it is the culture of an institution that makes a difference in the work experienceof both entering and expert nurses. Creating a positive culture in which nurses canflourish is the responsibility of leaders in the profession who model the behaviors thatsupport good work in nursing.

Overcoming obstacles

Despite reports of support for their good work, entering professional nurses describedthe difficulties they encountered in being able to offer the type of care they believepatients deserve. They cited the nurse shortage, demands on time, conflicting valuesand lack of autonomy as major obstacles to good work in nursing. Enteringprofessional nurses discussed the nurse shortage in terms of how staff shortagesaffected their ability to provide what they viewed as quality care. Demands on timeinvolved the need to perform multiple tasks with fewer resources, such as supplies orassisting staff. New nurses expressed disillusionment when they observed othersworking for financial incentives, often at the cost of quality care for patients andfamilies. When new nurses discussed lack of autonomy, they expressed perceivedinadequacy in the ability or capacity to effect change. These factors are consistent with

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those reported in the literature as major contributors to job dissatisfaction and attritionin the nursing profession.15 Pressure to adapt to adversity in the workplace is costly interms of recruitment, retention and job satisfaction.15 The burden to adapt seems to begreatest among new nurses who are struggling to form their identity as professionals.As new nurses transition into professional roles they focus primarily on technicalcompetence.

Entering professional nurses in this study employed strategies, such as team workand prioritization, to accomplish assigned tasks. These strategies are consistent withthe organizational and work-role competencies Benner2 describes as integral to roledevelopment for the beginning nurse. Beginning nurses focus on co-ordinatingcare, prioritizing tasks, and building and maintaining a therapeutic team to promotequality care for clients. When tasks remained unfinished or care appeared substan-dard, young nurses in this study articulated a sense of personal responsibility. Benneret al.16 describe this sense of agency among new or novice nurses as one of ‘hyper-responsibility’ associated with a focus on discrete facts about situations. As nurses gainexperience and become more competent, they develop the interpersonal andnegotiating skills required to navigate complex situations. They feel less overwhelmedand more confident in their ability to grasp situations and convey their concerns.Entering professional nurses in this study tended to avoid conflict rather than seekways to collaborate with other professionals and share responsibility for problemsolving. One new nurse remarked that she felt ill-prepared to deal with conflict in thework setting. When asked what she thought was the most important issue in nursingtoday, this nurse replied: ‘Professionalism, not so much teaching it but modeling it,dressing professionally, taking things seriously.’ These comments convey the need forindividual nurses and the nursing community to model good work and honor thecommitment to provide quality care.

Although experienced nurses cope more easily with work-related challenges, theystill confront issues that make it difficult to accomplish the work they would like toperform. Experienced nurses in this study cited financial constraints and diminishingresources as major obstacles to providing quality care. Staff nurses and nurseexecutives responding to national surveys also cited financial constraints anddiminishing resources as major factors contributing to the inability to provide qualitycare.17 However, rather than avoid conflict or assume personal responsibility for thedifficulties they encounter, experienced nurses in this study were more likely to viewobstacles to good work as opportunities for change. For example, they describedefforts to restore a focus on quality care in an era characterized by increasing emphasison productivity and financial stability. They employed strategies such as formingteams of decision makers who share similar values or establishing an institutionalculture where quality care and patient concerns surpass individual needs. Theyworked together to resolve conflict between clinical and organizational values thatmay influence the quality of patient care.

As nurses gain experience, they are more likely to develop perspectives that allowthem to see the potential for change in situations otherwise viewed as fixed. Inaddition, they may feel secure in their identity as professional nurses and are thereforemore prepared to focus on change and long-term goals. Whether it is experience,perspective or skill that allows the experienced nurse to adapt to challenge, it seemsapparent that these exemplary nurses facilitated what Heifetz18 refers to as adaptivechange in challenging situations. Adaptive change involves managing distress,





maintaining a disciplined focus on relevant issues, and empowering others to takeresponsibility for the changes that need to occur. Exemplary nurses in this studyaccomplished these measures by prioritizing tasks, creating a supportive workenvironment, creating teams of colleagues who share similar values, and employinginnovative measures to overcome adversity.

Preparing the next generation

Experienced nurses placed emphasis on preparing the next generation for challengesthat lie ahead. Leaders within the profession bear responsibility for helping enteringprofessional nurses to assume positions of leadership. In his theory of transformationleadership, Burns6 describes the role of a leader as one who takes the initiativein helping others to achieve higher levels of motivation and purpose. The transfor-mational leader focuses on shared goals and end values, such as justice. Therelationship between the leader and the one led has a moral dimension grounded invalues such as fairness, responsibility, kindness and compassion. Both the leader andthe person led engage in mutual pursuit of higher goals. Experienced nurses groundedin an ethic of virtue can transmit this grounding through mentoring relationships.Together, experienced and entering professional nurses can pursue excellence andquality of care, even during times of increased demand and diminishing resources.

Honesty and integrity above all

Despite the challenges they encounter, both entering and experienced nurses statedthey would not compromise personal values such as honesty and integrity. Thisfinding is consistent with what Smith and Godfrey19 describe as the connectionbetween being good and doing good (ie the connection between character and action).Virtue ethics provides a framework for examining the importance of character as thefoundation of the caring relationship between the nurse and the patient. Pellegrino7

comments on this relationship and points out that caring involves two promises: (1)that the health professional is competent and possesses the knowledge necessary toprovide good care; and (2) that the health professional will use that knowledge in thebest interest of the patient. This bond takes on additional meaning when the patient isill or more vulnerable. Virtues, such as honesty, compassion and integrity help topreserve this bond. When circumstances in the work setting, such as increaseddemands and time constraints, make honoring the promise to provide good care moredifficult, nurses need strength of character to sustain their commitment to excellence.

Concern within the profession about the influence of the work environment onquality of care has prompted several initiatives:

. The American Association of Critical-Care Nurses standards for establishing andsustaining healthy work environments;20

. The American Nurses Association bill of rights;21

. Magnet Recognition Program.22

These attempts underscore the importance of communication, collaboration,effective leadership and sufficient resources to provide quality care, ensure patientsafety, and promote recruitment and retention of excellent nurses. However, they maynot fully capture the role character and virtue play in sustaining the tradition of caring

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that gives nursing its particular mission and purpose. MacIntyre23 addresses the roleof virtues in sustaining what a tradition or profession is and ought to be by saying that‘virtues . . . enable their possessors to pursue their own good and the good of thetradition of which they are the bearers even in situations defined by the necessity oftragic, dilemmatic choice’ (p. 223). Nurses as moral agents must seek ways to sustaintheir own good work and the work of the profession. As a caring profession, nursing isgoverned by virtues essential to the act of caring, which include fidelity to trust,attending to the best interest of the patient, suppression of self-interest and courage.McCauley, President of the American Association of Critical-Care Nurses,20 empha-sizes the importance of maintaining the trust the public places in the nursingprofession:

The public repeatedly identifies nurses as the profession most trusted to act honestlyand ethically . . . The public relies on nurses to bring about bold change that assuressafe patient care and sets a path toward excellence. These standards honor the public’strust (p. 4).

Nurses will more likely be able to honor the public’s trust when the values theyconsider important in their professional lives are aligned with those of the people withwhom they work. New nurses will flourish when exemplar nurses model for themexcellence of character and work.

LimitationsSeveral limitations to this study exist. First, the sample size was small, limitinggeneralization of the results. Second, entering professional nurses and mid-levelmanagers were nominated by peers or experts in the field, which may reflect selectionbias. However, creators/leaders who participated in the study were selected onthe basis of national recognition for leadership in nursing, as defined in this article.Third, the interview questions captured a glimpse of opportunities and obstacles togood work in nursing at a particular point in the professional experience of eachparticipant. As Gardner et al.4 point out, ‘each of us is dealing with a world in whichchange is rapid, market forces and opportunities are extremely powerful, and conceptsof time and space are rapidly altered’ (p. 247). As changes occur in the nursingprofession and in society in general, the concept of good work in nursing meritscontinued study.

Conclusions and implicationsThe findings from this study extend understanding of what it means to perform goodwork in a caring profession. The nurse participants identified quality care as theiroverriding mission, yet they articulated obstacles to achieving their goals, such as thenurse shortage, demands on time, diminishing resources and conflicting values.Levers for good work identified by the participants are consistent with those identifiedby professionals from other disciplines: (1) early experiences; (2) long-standing beliefsand value systems; (3) role models and mentors; (4) supportive work environment;and (5) opportunities to share with like-minded peers.





These findings have implications for nurse education and practice. Integration ofphilosophical reflection on the importance of values and virtue in undergraduatenurse education may provide a perspective to supplement the principles, rules andstandards of practice that usually guide behavior for young nurses when faced withdifficult choices. Reflection on virtue ethics may influence actions that best illustratethe values of nurses striving to do good work and also the values of the profession.24

Entering professional nurses should be encouraged to seek positive role models andreflect on the lessons that can be learned from observing exemplary nurses whosebehavior demonstrates good work in nursing. New nurses also need opportunities todiscuss concerns with like-minded peers. Experienced nurses must create collaborativeenvironments to allow discussion and problem solving with newer nurses. Workshopsand interest groups that confirm the mission of nursing and the meaning of good workin nursing may also provide opportunities for dialogue among entering andexperienced professional nurses, allowing for shared responsibility and authenticempowerment.

Acknowledgements

The author wishes to acknowledge Carol Taylor, CSFN, RN, PhD, Director, Center forClinical Bioethics, Georgetown University Hospital, who provided support anddirection throughout this project. The author also wishes to acknowledge Dr HowardGardner, Hobbs Professor of Cognition and Education, Harvard Graduate School ofEducation, and the team of researchers from the GoodWork Project who providedsupport for the study of good work in nursing.

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21 American Nurses Association. American Nurses Association bill of rights. 2002. Retrieved 23September, 2005, from: http://www.nursingworld.org/tan/novdeco2/rights.html

22 American Nurses Credentialing Center. ANCC magnet recognition program �/ recognizing excell-ence in nursing services. 2005. Retrieved 23 September, 2005, from: http://www.nursingworld.org/ancc/magnet/index.html

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Opportunities and Obstacles for Good Work in Nursing

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