It is essential that nurses find meaning in their work to give them strength to carry on even in the midst of very demanding environments. Finding meaning as a life’s pursuit has been a central feature of philosophy since the Socratic era and most recently in existentialism. Discussions among nurses make it evident that in a profession with such high demands in terms of extended care and interpersonal contact with vulnerable patients, the need for a workplace that fosters personal growth through meaning and mentorship is paramount. It is essential that nurses find meaning in their work to give them strength to carry on even in the midst of very demanding environments.

We will begin by offering a brief background review of the work of key scholars of existentialism and hardiness, noting how their work has related to meaning and meaningful work. Next, we will describe the method and analysis processes we used in our qualitative study asking how nurses find meaning in their challenging work and report the four themes that emerged from the comments shared by nurses, specifically relationships, compassionate caring, identity, and a mentoring culture. After noting the limitations of this qualitative study, we will offer a discussion of our findings and conclude that nursing leaders and a culture of mentorship play an important role in fostering meaningful work and hardy employees.

Background

Existentialism, despite its many variations, is unified in the premise that the individual has the capacity for free will and is ultimately responsible for personal behaviour. Existentialism, despite its many variations, is unified in the premise that the individual has the capacity for free will and is ultimately responsible for personal behaviour (Kaufman, 1956). Frankl (1964), perhaps best known for his work, Man’s Search for Meaning, argued that not only do we have the capacity to choose our behaviour, but we also have the capacity to choose our meaning in life. Further, this search for meaning is the primary drive or will for humans to survive. Frankl, writing post World War II and following his own interment in concentration camps, contrasted his view, namely ‘logotherapy’ or ‘meaning therapy’ with the work of Freud and Adler, who were the dominant figures in psychoanalytic psychology at the time, asking ‘If one accepts the notion that we have free will and that we can find our own meaning in this life, how does one go about doing this?’ Frankl (2010) suggested we do this in one of the following three ways: (a) in what we create or what we ‘give’ to the world through our careers (e.g., nursing) or perhaps our leisure (e.g., music); (b) in our relationships with others or with nature – what we ‘take’ from the world; and (c) in choosing our attitude toward ‘suffering.’ Courage and dignity in the face of disappointment, difficult situations, and death can give us meaning.

The notion of meaning, particularly in the context of work, was explored further by Kobasa (1979) and subsequent work by Maddi (2002) in the development of the concept of ‘hardiness’ or ‘existential courage.’ Kobasa (1979) first empirically explored hardiness, as a derivative of meaning. In her initial work, she identified three dimensions – commitment, control, and challenge – each necessary for an individual to display existential courage. Commitment suggests that individuals are emotionally attached to the endeavour, such as a job or a relationship; control refers to the belief that individuals have a role to play in the outcome of their endeavours; challenge implies that new situations and/or unfamiliar situations are welcome and that there is a high tolerance for ambiguity and change.

...hardiness and meaning are key variables in the work world... Brooks (2003) has stated that “hardiness has been found to explain variability in human responses, identifying the hardiness characteristic in patients with multiple chronic illness has practice implications for nursing” (p. 11). Further, hardiness has been found to lessen the use of maladaptive avoidance strategies, such as avoiding social situations because of social anxiety, or putting off a chore/responsibility in order to prevent short-term stress, or avoiding essential but potentially stressful conversations. It has also been found to lessen feelings of alienation, employee turnover, powerlessness, and burnout, and improve problem solving, planning skills, and overall job performance (Bowsher & Keep, 1995; Leiter, Harve, & Frizzell, 1998; Maddi, 2002; Marques da Silva et al., 2014; Zakin, Solomon, & Neria, 2002). It is clear from the above discussion that hardiness and meaning are key variables in the work world, and that they influence a variety of workplace ‘pathologies,’ such as burnout and absenteeism (Abdollahi, Talib, Yaacob, & Ismail, 2014).

While research is available that has explored hardiness quantitatively, there is a paucity of reported work in this area from a qualitative perspective (Cohen & Sarter, 1992; Deems, 1997; Strandberg, Ovhed, Hakansson, & Troein, 2006). This is surprising given that meaningfulness is such a subjective and narrative-laden construct. Pavlish and Hunt (2012) has observed that “scant evidence exists about how nurses find meaning in their work or the workplace factors that influence nurses’ perceptions of meaningfulness” (p.113). In view of this, and as part of a larger international qualitative study of nurses, we had the opportunity to ask members of several focus groups about their thoughts on meaning and their work as nurses.

...finding meaning in work is what will ultimately sustain the individual in situations of stress. Nursing is a profession that embraces profoundly challenging work and demands interaction with patients in their most vulnerable and intimate contexts (Abdollahi et al., 2014; Hart, Branna, & De Chesnay, 2014; Marques da Silva et al., 2014). To cope successfully with the demands of this profession, nurses need considerably more than monetary and/or job security rewards. Finding meaning in one’s work is also essential for coping with stresses inherent in the work of nursing. The ‘will to meaning,’ according to Frankl (1964), while latent, is ubiquitous among humans. Further he argues that finding meaning in work is what will ultimately sustain the individual in situations of stress. We conducted our international study of nurses (described below) to explore the extent to which individual nurses had found meaning in their work; and to identify what factors assisted nurses in finding work meaningful and what factors in their environment were obstacles to their ability to find this meaning.

Method and Analysis

This qualitative study is one strand of a larger international investigation exploring nursing ethics (Malloy, Hadjistavropoulos, et al., 2009; Malloy, Sevigny, et al., 2009). Countries were selected based upon religious and cultural variation, as well as the availability and willingness of domestic researchers to participate. Research ethics approval was obtained in each of the five countries.

Research colleagues affiliated with hospitals in each country recruited participants through the snowball sampling method (Sheu, Wei, Chen, Yu, & Tang, 2009). They used social and/or professional networks of the initial informants to nominate participants for the study (Morgan, 2008). The study included a total of 11 focus groups, involving 60 nurse participants. There were two focus groups each in Canada, Korea, Ireland, and Japan, and three in India (see Table 1). The average number of participants per country was 12, with 14 participants from Canada, 13 from Ireland, 10 from Japan, 14 from India, and 9 from Korea. Two-thirds of the participants identified themselves as specialists in ‘older person care,’ while the remaining third represented a variety of specialty areas, including oncology, coronary care, and psychiatric nursing (see Table 1).

We used focus groups to explore the concept of meaning among an international sample of nurses to allow for not only depth and insight, but also for spontaneous discussion amongst peers (Kruger, 1994; Seal, Bloom, & Somlai, 2000). Focus groups in Canada, India, and Ireland were led by the first author, while focus groups in Korea and Japan were led by local bilingual collaborators. Each focus group was conducted in a conference room in a hospital setting. Consent forms were distributed and signed by each participant; all were informed that the conversations were to be recorded, but no individual attribution would be made in subsequent publication or presentation of the data. All focus groups were audio-taped, transcribed verbatim, and where necessary, translated and back translated into English to assure accuracy. The participants were asked to respond to the following single question that pertained to meaning, “Do you consider your work meaningful?”

Guba (1981) identifies the following four criteria to demonstrate the trustworthiness of qualitative research: credibility, transferability, dependability, and confirmability. In this study, the authors were cognisant of these criteria and made every effort to adhere to them. Credibility was achieved, as our participants were active nurses in a variety of contexts. Their daily-lived experience (Shenton, 2004) was the basis of the conclusions reached by the authors. Transferability refers to the application of the findings to a wider population. While this study was limited to 60 nurses, it did involve participants from five countries and cultures. Thus, as common themes emerged, it can be argued that they are somewhat representative of a common nursing zeitgeist. Guba’s (1981) third criteria, somewhat related to reliability, is dependability of the findings. In the case of this study, a standard question was asked of each focus group, the first author led seven of 11 focus groups, and the remaining focus groups were conducted with the first author present and involved with the domestic co-investigator. As a result, there was a considerable amount of consistency in the ’data’ collection. Finally, the notion of investigator bias was addressed by having each of the eight investigators read the manuscripts and confirm that the thematic analysis was consistent with their experiences in focus group sessions.

Table 1. Demographic data

A qualitative software package, NVivo 9 (Richards, 1999), was utilized to assist in the organisation and identification of themes. Using NVivo9, 57 statements relating to meaning in work were extracted from the 11 transcribed focus group interviews. Thematic content analysis was used to categorize nurses’ responses (de Groot, 1969; Sandelowski & Barroso, 2010; Scherl & Smithson, 1987). Thematic content analysis allows for coding of the text that is conceptually and contextually related to categories, but repetition of specific words is not necessary (Smith, 1992). The first author and two doctoral students initially examined participant data and though an iterative process of assigning statements to ‘distinctive bins’ were able to identify the recurrence of common themes expressed by the nurses. Co-investigators read transcripts from their focus group sessions to verify the veracity and interpretation of translated focus group discussions.

Findings

From the analysis of the 57 statements, four themes emerged that captured almost all of the salient, participant comments. These themes were: Relationship, Compassionate Caring, Identity, and Mentoring Culture. Each theme will be discussed below.

Relationship

This theme captured a variety of statements that described nurses’ relationships with each other and with their patients. This was particularly evident in nurses who worked in long-term facilities and who were able to create a sense of community with co-workers and patients.

Canadian Nurse 1: We really developed a community with our patients on our long-term care unit; we went out together because there were so many young people, and we were young; it taught me something that I didn't expect to be taught from. I had the good fortune as it turns out to work in the long term care facility, and learn what people honestly had to teach me.

This intimacy did cause some nurses a level of distress in terms of their ability to maintain a distance from these relationships.

Canadian Nurse 2: In working in community... I try to maintain a degree of professionalism, even some of the people that I have had on my case load for 11 years; you know, I know I know their family inside out and very very well. Inside and out of the working community we run into people outside of the work place but it is still I think, I try to keep a level of professionalism.

Irish and Japanese nurses also identified their preference in establishing relationships with older patients.

Irish Nurse 1: For me it’s more meaningful because just working with the elderly people, they have so much to offer… they just give back so much of themselves as well to you. At the end of the day… you know it means a lot, it is a lot more meaningful.

Japanese Nurse 1: I started getting interested in dealing with senior people. Now I find dealing with senior people is more interesting than dealing with children. I used to think it was interesting to hear unexpected words from children. But the seniors who I meet at the ward are even more unexpected and interesting… When they regain the consciousness, they start saying normal things. I try to connect the conversations then and when they were delirious. Sometimes it makes sense…. I don’t know what I am saying here. But I….like to take care of them

Compassionate Caring

Many indicated that they had chosen this profession because their mothers had been nurses... The second theme was deeply articulated by the nurses from each country. Many indicated that they had chosen this profession because their mothers had been nurses; others selected nursing as a limited career option. Regardless of their original impetus to select this career, there was near unanimous agreement that it had become over time a commitment to compassionate caring. Quotations reflecting ‘Compassionate Caring’ can be found in Table 2.

Table 2. Quotations Supporting 'Compassionate Caring'

Identity

There were several comments from nurses that related meaning with how they identify themselves. There were several comments from nurses that related meaning with how they identify themselves. They felt being a nurse was who they were, as opposed to simply being a job they do for pay. Nursing as a job gave the participants an identity and meaning in their lives. In seeking to discern their understanding of their identity as persons, they reflected on their lives as nurses and the challenges inherent in their professional and inter-professional roles. Personal life experiences also shaped their understanding of their developing roles as nurses.

Canadian Nurse 6: I think part of it is just who I've become as a person.

Japanese Nurse 5: For me, the choice of becoming a nurse was my ultimate decision in my life. This is my life, but it also gives me worries. There are lots of emotions and feelings involved that come from patients, other staff, and doctors. But at least it makes me think all the time for what to do. I like my life that is not boring. I am grateful to have a job like this. It makes me grow and I like talking about these issues with others. I have to have a job…without…routine work.

Mentoring Culture

Mentoring student nurses appeared to add meaning to nurses’ work and fulfilment. Mentoring student nurses appeared to add meaning to nurses’ work and fulfilment. Equally, nurses appreciated mentorship during their own formative years. The nurses appeared to value the organisational support of this role as mentor or preceptor. This was particularly strongly articulated by nurses from the Canadian cohort. Quotations reflecting ‘Mentoring Culture’ can be found in Table 3.

Table 3. Quotations Supporting ‘Mentoring Culture’

Discussion

Viktor Frankl (1964) identified three possibilities for finding meaning in life – what we do, what relationships we have, and the attitude we bring to face difficult circumstances. From our focus group discussions with nurses from Canada, India, Ireland, and Korea, it became evident that the nursing profession is ripe with potential for philosophical meaning.

The work that nurses do relates not only to the physical health of the patient, but also his or her personal dignity. The work that nurses do relates not only to the physical health of the patient, but also his or her personal dignity. Nurses identified challenging situations (e.g., resuscitation orders, end of life decisions, restraint, and artificial nutrition modalities) that demand more than a calculative response and demeanour, but rather a deep consideration for personhood and respect for patient and family members. One mundane yet profound example was offered by a Canadian nurse who suggested that it was her privilege to assist one of her patients toileting as it represented complete trust in a highly personal situation.

The development of relationships, or making connections with patients, appears central to meaningful work for physicians (Horowitz 2003) and nurses (Marques da Silva, et al., 2014; Pavlish & Hunt 2012). We found the relationships among the nurses and/or their patients and families, community, and workplace to be central to meaningful work in our study. These relationships and their compassionate caring strengthened the nurses’ commitment to their profession over time and created a sense of personal identity for them. Within the nurse-patient relationship, especially in dementia care or older person care, the nurse and the patient (and family) confirm the other’s identity. The patient (family) confirms the nurses’ personal and professional identities and the nurse confirms the client’s personal identity (Holst, Edberg, & Hallberg, 1999).

Among the themes that emerged, the most impassioned discussion came from the Canadian nurses regarding the topic of mentorship and its effect on attitudes (Armitage & Burnard, 1991; Hart et al., 2014; Marks-Miran et al., 2013). Mentorship is an important concept in nursing and it can facilitate a supportive work environment. Block, Claffey, Korow, and McCaffrey (2005) stated that “mentoring in nursing affects nurse retention and nurse retention influences issues such as patient satisfaction and a positive financial bottom line … mentorship should be recognized as vital to healthcare organizations” (p.135). These outcomes of mentorship can both enhance the experience of meaning in one’s work life.

From an organisational perspective, it has been argued that there is a qualitative difference between those who manage and those who lead (Hodgkinson, 1996). Managers function with a bureaucratic mindset and leaders lead through passion, creativity, and vision. It may not be unreasonable to suggest that those who find work meaningful have the capacity to become the true mentors in the healthcare system, whereas those who lack meaning can at best manage in a technical or bureaucratic fashion (Hodgkinson, 2006). If this is even somewhat the case, then the need at the organisational level to foster meaningful work becomes all the more imperative. The role of the mentor needs to be supported and promoted by institutional administration. Hodgkinson (2006) makes a clear distinction between leaders (i.e., those focused on vision and principles) and managers (i.e., those focused on procedure and bureaucracy); it is the former who spawn meaningful work.

Limitations

The very nature of the focus group technique, while offering an environment for open and fluid discussion, may create a relatively unsafe climate for opinions that are outside the group norm, thus limiting participants’ willingness to express their true feelings. In addressing such sensitive issues as meaningful work and the care of the elderly, divergent views may be frowned upon by peers. Additionally, this was an international study in which ‘data manuscripts’ from three of the five countries required translation. As a result, there may have been some inaccuracies in reporting dialogue, especially in cases of words that may be conceptually challenging, such as ‘meaningfulness.’ Although our study included a relatively large sample of 60 nurses from five different countries, the findings can only be representative of this sample and not generalized to the broader population of nurses in general nor even sub-sets of nurses in these countries.

Conclusion

...nurses’ interactions with co-workers was a dominant theme across the conversations as a source of meaning. In this study, nurses from five countries participated in focus group discussions about the meaning they derive from their work. Four themes— relationship, compassionate caring over time, identity, and a mentoring culture—emerged from the interviews describing the nurses’ sense of meaning, as well as ways through which meaning was fostered in their careers. Consistent with Frankl’s (1964) belief in the power of relationships, the nurses’ interactions with co-workers was a dominant theme across the conversations as a source of meaning. In line with the work of Maddi et al. (2006) about hardiness, the passion or commitment to their work over a period of time was a central theme for these nurses in each of the countries studied.

With contemporary work in meaning and hardiness being philosophically based in existentialism, it is no surprise that the nurses’ identity-as–a-person was fostered through their relationships, passion for their work, and through the mentorship they received as nurses. Finally, the role of mentors and a mentoring organisational culture contributed to perceptions of meaningful work. Participants also noted that the over-institutionalisation of care was a deterrent to finding meaning in work. From this study it is apparent that the mentorship culture and leadership of the healthcare facility has an important role to play in fostering meaningful work and hardy employees. Administrators who fail to heed the ‘will to meaning’ may risk not only decreased job satisfaction and productivity among employees such as nurses, but also may place at risk the level of care that patients receive.

Acknowledgement: This research was funded by the Social Sciences and Humanities Research Council of Canada in a grant awarded to D.C. Malloy and T. Hadjistavropoulos.

Authors

David Cruise Malloy, PhD, RN
Email:David.malloy@uregina.ca

Dr. Malloy is the Principal Investigator for the International Healthcare Ethics Research Team at the University of Regina in Regina, Saskatchewan, Canada. He holds BA and MA degrees from the University of Western Ontario and a PhD in Educational Administration from the University of Ottawa in Ontario, Canada. Dr. Malloy's research focus is in applied philosophy in healthcare. Specifically his interests include ethical decision making, codes of ethics, existential hardiness, personhood, and ethical climate/culture. He has published numerous refereed articles and is the co-author of four texts dealing with applied ethics and philosophy. His current research has been funded by the Social Sciences and Humanities Research Council of Canada (SSHRC) and Canadian Institutes for Health (CIHR).

Elizabeth Fahey-McCarthy, PhD, RGN, RM, RNT
Email: FAHEYMCE@tcd.ie

Dr. Fahey-McCarthy is an Assistant Professor in the School of Nursing & Midwifery at Trinity College in Dublin, Ireland. She has held the position of Director of Teaching & Learning Postgraduate and Course Coordinator for MSc Programmes over the past 15 years. Dr Fahey-McCarthy was the lead curriculum developer for the first interdisciplinary MSc in Dementia Program in Ireland. Research interests include ethics in healthcare, dementia, palliative and end-of-life care, and reflective practice.

Masaaki Murakami, MD, PhD
Email: murakami@soc.meijigakuin.ac.jp

Dr. Murakami is a Professor of the Faculty of Sociology, Meiji Gakuin University in Tokyo, Japan. He is a designated psychiatrist and also a certified industrial physician. He serves as a board member for the Japanese Society of Social Psychiatry and for the Japanese Society for Prevention and Early Intervention in Psychiatry.

Yongho Lee, PhD
Email: gophers@snu.ac.kr

Dr. Lee is currently an Associate Professor in the Department of Physical Education at Seoul National University (SNU) in Korea. Prior to holding his current position at SNU, Dr. Lee held academic positions at the University of Toledo in Toledo, Ohio and at the University of Regina, Regina, Saskatchewan, Canada.

Eunhee Choi, PhD, RN
Email: ichoi9201@hanmail.net

Eunhee Choi is an Assistant Professor of Nursing at the University of Korean Bible in Seoul, Korea. Professor Choi is a Critical Care Nurse Specialist and a Basic Life Support Instructor. She represented the Korean Society of Critical Care Nursing in this study.

Eri Hirose, MA, RN
Email: hirose@aichi-nurs.ac.jp

Eri Hirose is a registered nurse at Toranomon Hospital in Tokyo, Japan and an Associate Professor of Adult Nursing at the School of Nursing & Heath, Aichi Prefectural University, Aichi, Japan. She has also served as a lecturer at Tokyo (Japan) Metropolitan University of Health Sciences. Ms. Hirose is a graduate of the Master of Arts – Human Science Program at the Graduate School of Toyo Eiwa University in Tokyo, Japan.

Thomas Hadjistavropoulos, PhD
Email: Thomas.hadjistavropoulos@uregina.ca

Dr. Hadjistavropoulos is Professor and Research Chair in Aging and Health at the University of Regina, Regina, Saskatchewan, Canada. He studied Psychology at McGill University, Montreal, Quebec, Canada and the University of Saskatchewan, Saskatoon, Saskatchewan. He has published five books and over 150 peer reviewed articles focusing primarily on health research. His work is supported by the Canadian Institutes of Health Research, the Saskatchewan Health Research Foundation and the Canada Foundation for Innovation. He is a Past President of the Canadian Psychological Association.