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• To recognise the importance of enhancing nurses’ well-being in the workplace
• To understand the work-related factors that can adversely affect nurses’ well-being
• To consider self-care practices that may be beneficial for you and your colleagues
Nurses experience a range of challenges in their practice that can adversely affect their well-being, for example work-related stress and workforce issues. These challenges may have been intensified by various factors, such as the coronavirus disease 2019 (COVID-19) pandemic and shift working. This article considers the concept of well-being and explores nurses’ well-being in the context of ongoing stressors and workforce issues. It also examines some of the effects of shift work on nurses’ well-being and how these could be mitigated. The authors outline a range of self-care practices that nurses could engage in and consider how they may be supported in this by their line managers and healthcare organisations.
Nursing Standard. doi: 10.7748/ns.2023.e12206
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Tremayne P, de Bourg L (2023) Exploring nurses’ well-being and strategies to support self-care. Nursing Standard. doi: 10.7748/ns.2023.e12206
Published online: 16 October 2023
Well-being is a broad, complex and dynamic concept. There is no international consensus on the definition of well-being, which has resulted in the concept being described and measured in various ways (Simons and Baldwin 2021). For example, the World Health Organization (WHO) (2021) defines well-being as ‘a positive state experienced by individuals and societies. Similar to health, it is a resource for daily life and is determined by social, economic and environmental conditions’. The Office for National Statistics (ONS) (2023) considers personal well-being to be based on a measure of how satisfied people are with their lives, their levels of happiness and anxiety, and whether they think the things they do are worthwhile.
In a critical review of the definition of well-being, Simons and Baldwin (2021) noted that it is not the same as health and discussed the Cambridge dictionary definition – ‘the state of feeling healthy and happy’. According to Simons and Baldwin (2021), this definition infers that a person who is unhealthy is not automatically excluded from a state of well-being and that, in this context, well-being is judged by how the person feels about their health. This may be a more person-centred way of considering the concept, particularly for people with long-term and manageable conditions. It is also a useful way of considering the concept of well-being in relation to nurses, since it is important that they feel healthy and happy.
This article discusses various workplace-related challenges experienced by nurses and explains how they may affect their well-being. It also examines some of the literature on the effects of shift work on nurses’ well-being and considers self-care practices that nurses may engage in to enhance their well-being.
The issue of nurses’ well-being, and that of other health and social care professionals, was magnified by the coronavirus disease 2019 (COVID-19) pandemic. Before the pandemic, nurses’ well-being was already under threat due to work-related stress and fatigue (Davey et al 2022). Work-related stress has been defined as the negative emotional and physical responses occurring when an individual’s job requirements do not match with their capabilities, resources or needs, subsequently affecting their ability to perform the role (Abdali Bardeh et al 2016). The unique circumstances of the pandemic brought these issues to the fore and emphasised the need for nurses to be mindful of their well-being and work-life balance.
During the COVID-19 pandemic, various issues resulted in nurses experiencing additional work-related stress. For example, many nurses worked in intensely pressured workplaces and witnessed illness and sometimes death among their colleagues (Davey et al 2022). Additionally, many nurses were redeployed to unfamiliar work environments, at times without adequate training or infection prevention and control measures (Couper et al 2022).
Nurses may also have sustained moral injury during the pandemic (Rowlands 2021). Moral injury occurs when a person is aware of the ethical action they should take in a specific situation but perceive that they are prevented from taking that action either due to external constraints, such as limited resources, or internal issues, such as self-doubt, fear of conflict or lack of confidence (Moss et al 2016, Rushton et al 2017). During the COVID-19 pandemic, moral dilemmas appeared to become increasingly frequent and acute, with nurses having to make decisions that conflicted with best practice standards and which may have been morally questionable (Lesley 2020). According to Williamson et al (2021), moral injury can cause profound feelings of shame and guilt, as well as maladaptive coping responses such as substance use, social withdrawal or self-destructive acts.
The pandemic has exacerbated various long-term issues experienced by healthcare staff, such as chronic excessive workload (The King’s Fund 2022), while nursing vacancies remain high, with The Health Foundation (2022) suggesting there will continue to be a shortage of nurses into the next decade. In the UK there has been a decrease of 16% in the overall number of applicants to nursing courses in 2023 compared with 2022 figures (Royal College of Nursing (RCN) 2023), increasing the challenges associated with nursing recruitment.
The effects of ongoing workforce issues, alongside the high demands placed on healthcare services, are illustrated by the results of the 2022 NHS Staff Survey (Survey Coordination Centre 2023). In the survey, 46% of NHS staff reported they ‘often’ or ‘always’ felt worn out at the end of their working day or shift, while 34% said they experienced burnout because of their work (Survey Coordination Centre 2023). Meanwhile, the Nursing and Midwifery Council (NMC) (2023) identified that one of the main reasons given by nurses for leaving the register was burnout. The International Classification of Diseases 11th Revision (ICD-11) (WHO 2023) defines burnout as ‘a syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed’. The ICD-11 states that burnout is characterised by: feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy (WHO 2023).
There is a growing body of evidence on the detrimental effects of shift work on nurses’ well-being. However, it is important to note that much of this research has involved convenience sampling, which may attract more participants with negative experiences than those with positive experiences. Additionally, self-reported data is often collected, which may be subjective and carry a risk of bias.
Shift work can be beneficial for some staff, for example it can support childcare requirements or offer financial benefits. However, for others it can have a negative effect on their well-being.
Dall’Ora and Dahlgren (2020) noted that it is not only the presence or absence of shift work that is potentially detrimental to nurses’ health and well-being, but also the way in which shifts are organised, for example in terms of length, type of schedule (such as rotational or permanent) or length of time off between shifts. Furthermore, a large survey of nurses (n=873) by Dall’Ora et al (2023) found that long hours, inadequate staffing and little choice in shift pattern were associated with a higher risk of burnout and exhaustion.
NHS Confederation (2020) guidance on the health, safety and well-being of shift workers in healthcare environments notes that shift work can have a detrimental effect on staff and on the workplace in general if it is inadequately designed. For example, an inadequate number of rest days or expectations of working lengthy hours may result in individuals experiencing suboptimal sleep patterns or in workforce issues such as increased sickness, errors and patient safety incidents (NHS Confederation 2020). There is also evidence which suggests that working 12-hour shifts or longer may have a negative effect on care-related factors, such as hygiene practices (Ritterschober-Böhm et al 2020).
In an Australian study exploring how nurses (n=449) cope with shift work, Savic et al (2019) reported that excessive sleepiness and chronic sleep disturbance were the most commonly reported adverse effects, resulting in an increased likelihood of errors in patient care. Furthermore, factors such as work stress and burnout may adversely affect the quality and duration of nurses’ sleep (Chana et al 2015, Savic et al 2019). Han et al (2020) noted that newly registered nurses who experienced severe sleep disruption were more likely to leave the profession in their first two years.
Some of the nurse participants in Savic et al’s (2019) study expressed a lack of concern about, and stoic attitude towards, shift work and appeared to dismiss the idea of the need for coping strategies, despite reporting exhaustion from working shifts. The researchers theorised that these attitudes may have reflected a belief that circumstances and stressors, such as shift working, were outside of the participants’ control, therefore they simply had to accept or get used to working in this way. Alternatively, the researchers considered that displaying stoicism may have enabled participants to avoid becoming affected by the negative effects of shift work (Savic et al 2019).
There are various ways in which nurses can be supported by their employing organisations to mitigate or reduce the adverse effects of shift working. For example, employers should work within the parameters of the Working Time Regulations 1998 – the legislation that governs employees’ rights and obligations regarding working time. These regulations should be used by employers to inform the hours an employee should legally work in a week, including entitlement to breaks within shifts, breaks between shifts, days off and annual leave (Health and Safety Executive 2023).
Employers could also consider nurses’ preferences in terms of type and length of shift, which may counter the sense that these are outside the individual’s control. In a scoping review of studies of nurses’ experiences of and preferences around shift patterns, Ejebu et al (2021) found that nurses’ personal characteristics and circumstances are not often considered during rostering and decisions were often based on the needs of the service rather than the individual. Ejebu et al (2021) suggested that nurses’ preferences often depended on their personal circumstances, such as their age, time in role and additional caring responsibilities. Other authors have reported that nurses’ access to self-rostering may have a positive effect on their well-being and work-life balance (Nijp et al 2012, Barrett and Holme 2018). Nurses’ preferences could be met if the person organising the rota consults individuals beforehand or introduces self-rostering.
Williams et al (2022) discussed the need for nurses to use a range of self-care practices to promote job satisfaction and achieve a healthy work-life balance. There is also a need for employers to encourage nurses to consider self-care and to provide workplace strategies that support their well-being. This is supported by the NHS (2020) People Plan, which states that ‘leaders, teams and employers must keep offering people support to stay well at work, and keep offering it consistently, across teams, organisations and sectors’. The NHS (2020) People Plan and the NHS (2021) People Promise describe a range of measures for implementation across healthcare organisations to support staff well-being and to encourage staff to use self-care practices. Examples include providing safe spaces in which staff can rest and reflect, flexible working, and support to ensure staff remain safe and healthy.
Savic et al’s (2019) analysis of nurses’ strategies for coping with shift work identified four interconnected themes: health practices; cognitive coping strategies; work-related coping strategies; and social and leisure. In this section, the authors of this article have used these themes as a basis for discussing self-care practices for nurses.
Nurse participants in Savic et al’s (2019) study identified a range of health practices to manage shift work, including sleep, relaxation and exercise or physical activity. However, many of them also reported that working shifts affected their ability to undertake these activities. Sleep-related issues in nursing may be compounded by the fact that in the UK it is a female-dominated profession with around 285,200 registrants aged 41-55 years and around 167,000 registrants aged 56 years or over (NMC 2023). This is the age range at which women may experience perimenopausal or menopausal symptoms, including sleep disturbance and fatigue (Converso et al 2019). A study by Converso et al (2019) found that menopausal symptoms were significantly associated with emotional exhaustion, leading the researchers to call for increased education of managers to enable them to support those experiencing the menopause.
Medlin (2019) suggested that shift work may negatively influence dietary intake, for example by causing tiredness that leads to a ‘craving’ for carbohydrates. Additionally, maintaining adequate hydration can be challenging for nurses working shifts due to lack of time to take a break – an issue which some managers do not always recognise as a well-being priority (Dean 2019). In a 2019 Nursing Standard well-being survey, only one in five of the almost 2,250 nurses who responded said they always had a chance to hydrate at work (Dean 2019). To address such issues, managers could consider encouraging nurses to use personalised water bottles at work, using posters to encourage staff to drink fluids or placing urine colour charts in staff toilets to prompt them to stay hydrated (Dean 2019).
• Well-being has been defined in various ways, including as ‘the state of feeling healthy and happy’
• Several factors may adversely affect nurses’ well-being, including work-related stress, shift work, burnout and fatigue
• Healthcare organisations should support nurses to prioritise well-being activities, undertake exercise, eat healthily and take breaks during their shift
• Recommended steps for improving mental well-being include connecting with other people, being physically active, learning new skills, giving to others and practising mindfulness
Managers should also ensure nurses can take the breaks they are entitled to under the Working Time Regulations 1998. These regulations state that employees are entitled to a minimum break of 20 minutes when working time is more than six hours and that this break should (Dean 2019):
• Be uninterrupted.
• Be away from the workstation.
• Be during working time.
• Not be taken at the start or end of the working day.
• Not overlap with daily rest.
Box 1 shows some recommended health practices for nurses in the workplace.
• Nurses should be encouraged to prioritise well-being activities, such as mindfulness
• Nurses and their managers should be supported to develop menopause awareness
• Nurses should be supported to undertake exercise. Healthcare organisations may consider offering staff discounts on health-related activities, for example gym membership
• Nurses should be supported to eat healthily. Healthcare organisations should ensure there is access to healthy food at work, for example in the canteen or vending machines
• Nurses should be encouraged to take breaks during their shift, in accordance with national legislation
(Adapted from Converso et al 2019, Medlin 2019, Rangel et al 2022)
A study by Chana et al (2015) found that cognitive coping strategies, such as self-regulation, self-efficacy and a positive attitude towards their role, may mitigate exhaustion and low morale. Self-regulation describes an individual’s ability to plan, monitor and evaluate their behaviour, while self-efficacy relates to how one perceives one’s ability to think, feel, motivate and potentially act to change a behaviour (de la Fuente 2022).
Cognitive coping strategies, such as cognitive behaviour-oriented training or mindfulness-based programmes, can reduce the risk of occupational burnout if used regularly and may improve overall well-being (Lee et al 2016).
Yu et al (2019) suggested that workplaces need to be innovative in developing activities that may increase staff resilience, reduce emotional exhaustion and enhance well-being, for example through the provision of mindfulness, meditation and yoga sessions. Furthermore, a study by Uysal and Çalışkan (2022) found that weekly access to mindfulness-based interventions appeared to decrease nursing student participants’ depression, anxiety and stress levels, while also increasing their cognitive attention and concentration.
The NHS (2020) People Plan has called for every staff member to have a well-being conversation with their line manager and to develop a personalised well-being plan that should be reviewed at least annually. Therefore, line managers should seek to develop and implement such plans with nursing staff. The RCN (2019) has provided resources to support employers to foster healthy workplaces and for nurses to develop self-care plans. Additionally, managers and staff may draw on a range of resources provided by Health Education England (2023), which range from well-being apps to guidance on flexible working. These resources can be used by all levels of staff to promote workplace well-being and self-care.
Inadequate rest days can negatively affect nurses’ and other shift-workers’ well-being (NHS Confederation 2020). Bernhofer (2016) defined rest as a ‘human need, a beneficial state that is intentional, temporary and restorative, involving cessation, minimisation, or change in physical, mental, or spiritual work, fatigue, trauma, illness or stress’. However, Bernhofer (2016) also suggested that while people are often advised to rest, it remains a misunderstood and subjective concept.
The Rest Test survey (Hammond and Lewis 2016), a global online survey completed by more than 18,000 people across 134 countries in 2016, explored people’s habits and attitudes towards rest. The findings indicated that a lack of rest had a direct adverse effect on well-being. In her book The Art of Rest, which draws on the findings of the Rest Test survey, Hammond (2019) suggested that restful activity could be active or inactive and that both were of equal benefit. Box 2 lists the popular restful activities according to the Rest Test survey.
According to the Rest Test survey, the ten most popular restful activities are:
Despite the reported benefits, people often neglect rest because of their competing priorities and roles (Hammond 2019). Some of the challenges for nurses in prioritising rest include the financial issues, which may result in many of them needing to work additional hours, or the expectation that they should be accessible at all times, which Hammond (2019) described as being continually ‘wired’. Switching off one’s phone or work notifications on days off and learning to say ‘no’ – for example to requests to cover last-minute absences – without experiencing feelings of guilt may offer nurses an opportunity to ‘step back’ from their work responsibilities and prioritise rest. Although these actions may be challenging for individual nurses and management, they are essential to enable nurses to focus on self-care.
Since well-being is closely linked to mental health, nurses may consider adopting some mental well-being strategies as part of their social and leisure activities. Table 1 outlines five steps for improving mental well-being (NHS 2022).
(Adapted from NHS 2022)
Workplace stresses experienced by nurses and the need to support their well-being have been magnified by the COVID-19 pandemic. Additionally, it has been identified that shift working can adversely affect nurses’ physical and mental health. Line managers and healthcare organisations can use various strategies to support nurses who work shifts, including adherence to Working Time Regulations 1998 in the workplace and self-rostering. Additionally, line managers and healthcare organisations can support nurses to engage in self-care, for example by providing adequate breaks and encouraging mindfulness activities. Implementing tailored, practical, work-based support interventions and providing appropriate resources are essential to support nurses to maintain their well-being and to fulfil their roles effectively.
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