Self‐reported perceptions of Registered Nurses working in Australian hospitals

Self-reported perceptions of Registered Nurses working inAustralian hospitals

GARY DAY R N , E M , B N u r s , D i p A p p S c ( N u r s i n g M g t ) M H M , D H S M1, VICTOR MINICHIELLO M S c P h D

2 and JEANNEMADISON R N , M P H , P h D

3

1Lecturer, Health Services Management, School of Public Health, Queensland University of Technology, Brisbane,QLD, 2Professor, School of Health, University of New England and 3Associate Professor, School of Health,University of New England, NSW, Australia

Introduction

This paper examines the work perceptions of a sample

of Registered Nurses (RNs) practicing in three Austra-

lian hospitals. As nurses socialize and work in ever

increasing multi-disciplinary clinical teams that are

characterized by more complex litigious, budget-centric

work environments, a study of the key elements of the

working environment among the largest group of the

health care workforce is timely. This study describes

how work and organizational factors influence the

working lives of nurses and how nurses react and are

affected by certain organizational structures and con-

straints. This understanding can also provide insights

into the impact work environments have on workforce

issues such as morale (Traynor & Wade 1993,

MacAlister & Chiam 1995, Nolan et al. 1995, 1998a,

Chambers 1996, Matrunola 1996, Schaefer and Moos

Correspondence

Gary Day

Victoria Park Road

Kelvin Grove

Brisbane

Qld 4059

Australia

E-mail: [email protected]

D A Y G . , M I N I C H I E L L O V . & M A D I S O N J . (2007) Journal of Nursing Management 15, 403–413

Self-reported perceptions of Registered Nurses working in Australian hospitals

Aim The purpose of this study is to develop an understanding of work environmentsby analysing the perceptions of a sample of Registered Nurses (RNs).

Background Within the context of high staff turnover and a shortage of nurses

in the health workforce, it is important that we understand how nurses perceive

their work context and view the organisational factors that influence their attitudes

towards their workplace.

Methods Data was collected using a 160-question survey instrument seeking

information from RNs in relation to work and perceptions of the work environment and

the organisation. The sample was recruited from a convenience sample of three acute

hospitals in Queensland, Australia. A response rate of 41% was achieved (n ¼ 343).

Results Respondents across the three survey sites identified a number of variables

that had particular impact on their working lives. Team interaction, providing good

patient care, communication, and abuse towards RNs elicited strong responses by

the study respondents. As well, organisational direction, strategy and management

returned strong negative responses. In responding to the questions related to per-

sonal and organisational morale it was clear that respondents saw them as two

distinct concepts.

Conclusions The results of this study have implications for nurse managers in terms

of understanding the nursing workforce as well as key organisational factors that

have both positive and negative influences on the perceptions of nurses.

Keywords: attitude to work, job security, morale, nursing, team interaction

Accepted for publication: 11 May 2006

Journal of Nursing Management, 2007, 15, 403–413

� 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd 403

1996, Cronin & Becherer 1999). The literature clearly

demonstrates that there are a number of critical vari-

ables that have been identified that impact on the role,

function and perceptions of RNs. A greater under-

standing of the issues and themes that impact upon

work perceptions is considered timely in terms of de-

veloping approaches to improve the working

environments of nurses and having a positive impact on

the recruitment and retention of staff.

The research surrounding nurses and their work can

be divided into a number of key themes. These themes

include aspects of the team nurses work in, how nurses

are valued as health care providers, the nurses’ ability to

provide nursing care and a number of key organiza-

tional issues such as staffing levels, financial impera-

tives, opportunities for staff development and growth,

leadership and communication. These variables are

explored in terms of their effect on Australian RNs.

Literature review

The literature points to team work, group interaction

and the social element of nurses working together as an

important element in how RNs cope with the rigours of

nursing (Cavanagh & Coffin 1992, Daum 1993, Grant

et al. 1994, Gaynor et al. 1995, Flannery & Grace

1999, Breidenbach 2001, Cox 2001). These teams not

only provide professional support and guidance but also

shield the members from unwanted organizational

stressors. The �quality’ of the social interaction can play

a major role in how RNs perceive their work. Similarly,

the way in which RNs are �valued’ by the health care

system and the organization can also have profound

influences on how nurses perceive elements of their

working lives. A range of studies have drawn the link

between the nurses’ concept of professional worth and

respect in the health care system and outcomes such as

morale (Smith 1985, Burda 1992, Flannery & Grace

1999, Livesley 2000, Finlayson 2002a).

Another key theme that emerges from the literature

centres on the nurses’ ability to deliver quality nursing

care. A number of studies (Jones 1988, Nolan et al.

1995) have argued that nurses strongly value the ability

to provide good patient care and the failure to do so can

lead to adverse organizational outcomes. The failure to

provide quality nursing care can be seen as an outcome

of a range of negative organizational processes. Closely

linked to the inability to deliver adequate patient care is

the concept of overwork. The literature highlights issues

surrounding adequate staffing and how this affects the

working lives of nurses. Overwork and under-staffing

has been linked to organizations concentrating on cut-

ting operational costs. A number of studies over the last

20 years all point to negative effects of high workloads

and low staffing levels and its subsequent effect on

providing quality patient care and the perceptions of

staff towards their organizations (Haw et al. 1984,

Smith 1985, 1988, Cochrane & Jowett 1994, Traynor

1995, Nolan et al. 1998a, Sibbald 1999, Livesley 2000,

Clarke et al. 2002).

Organizational issues also figure prominently in the

literature. There is a growing body of evidence that

links the financial performance of health care facilities

and its effect on nurses in those organizations. Research

points to the anxiety, stress and poor morale as a result

of issues such as downsizing, concentrating on the

financial �bottom line’ and cost containment

(MacRobert et al. 1993, Shindul-Rothschild 1994,

Decker et al. 2001). These issues impact directly on

staffing and the ability to deliver quality patient care.

The ability to learn new skills and maintain clinical

competence has been noted as an important theme.

Research suggests that there were negative organiza-

tional consequences attributed to a lack of support for

education and training as well as frustration about the

limited opportunity for professional growth (Haw et al.

1984, Grant et al. 1994, Nolan et al. 1995, Traynor

1995, Livesley 2000, Callaghan 2003).

Communication and the quality of leadership have

been noted as important themes. Shared leadership and

communication are ways of not only improving

organizational conditions but also decreasing injuries.

The literature suggests that for organizational morale

and perceptions of staff to improve, there must be a

shared vision of what health care professionals are

trying to accomplish together, as well as an under-

standing of the problems and pressures on both the

management and employees (Smith 1985, 1988,

MacRobert et al. 1993, Cochrane & Jowett 1994,

Colledge 1995, Hinton 1997). There is a growing body

of literature that examines how particular proactive

organizational approaches are improving workplace

culture and its subsequent positive effect on the well-

being of staff (MacRobert et al. 1993, Coile 2001,

Buchan 2002). These so-called �magnet’ hospitals are

promoting culture as more important than wages to

attract staff. These hospitals have been able to attract

and retain nurses through the adoption of positive

characteristics such as participatory supportive man-

agement styles, decentralized organizational structures,

adequate staffing, flexible working schedules, profes-

sional autonomy and responsibility, emphasis on

teaching and education and career advancement

opportunities.

G. Day et al.

404 ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 403–413

Understanding the perceptions of RNs towards their

work assists in the awareness of wider issues that im-

pact on the practice of nurses in the contemporary

Australian health care sector (Smith 1985, 1988,

MacRobert et al. 1993, Cochrane & Jowett 1994,

Colledge 1995, Hinton 1997). This study is specifically

designed to establish how hospital-based RNs perceive

their work and what variables impact in a positive and

negative way on their everyday working lives.

Methods

This paper uses data extracted from a cross-sectional

survey of the determinants of morale among Queens-

land RNs in 2002. The study sample was drawn from a

convenience sample of three hospitals in South-east

Queensland (one large, 230-bed tertiary metropolitan

religious-based, not-for-profit private hospital, one

medium sized, 112-bed community public hospital, one

large, 350-bed tertiary semi-rural public hospital). A

total of 843 RNs (site 1 ¼ 243 RNs, site 2 ¼ 188 RNs,

site 3 ¼ 417 RNs) were working in the three survey

sites and invited to participate in the study.

The themes described above have been shown to

impact upon the perceptions of RNs and were used in

the development of a survey instrument to measure the

level of influence these variables had on the working

lives of nurses. A 160-question self-administered survey

instrument, along with a covering letter and an infor-

mation sheet, was distributed to all full-time, part-time

and casual RNs in the three sites. The variables used in

the survey instrument were drawn from the contem-

porary literature and included: team interaction (Smith

1985, Cavanagh & Coffin 1992, Gaynor et al. 1995,

Hartley & Turner 1995, Koeske & Kirk 1995, Flannery

& Grace 1999, Cox 2001), job security (Roberts et al.

1993, MacAlister & Chiam 1995, Nolan et al. 1995,

Macdonald & Bodzak 1999), communication (Nolan

et al. 1995), consultation (Smith 1988, Robertson

1994, Hartley & Turner 1995, Weir et al. 1997, Cronin

& Becherer 1999), patient care provision (Smith 1985,

Matrunola 1996, Gilliland 1997, Hetherington &

Hewa 1997), work performance (Hartley & Turner

1995, Cronin & Becherer 1999), professional recogni-

tion (Smith 1988), organizational direction, strategy

and management (Cochrane & Jowett 1994, Robertson

1994, Nolan et al. 1995, Hetherington & Hewa 1997,

Brooker et al. 1999, Macdonald & Bodzak 1999),

abuse towards RNs (Carroll 1996, Bouchard 2000,

O’Connell et al. 2000, Jackson et al. 2002, Spurgeon &

Barwell 2002, World Health Organisation 2002) and

professional autonomy (Roberts et al. 1993, Cochrane

& Jowett 1994). As there was no single suitable

instrument to cover the wide range of variables, a

composite tool was devised using a range of available

tools (Fisher and Fraser 1990, Moos 1994, Koeske &

Kirk 1995, Nolan et al. 1998b, Cronin & Becherer

1999). The instrument was designed to elicit informa-

tion regarding, for example, socio-demographic char-

acteristics, self-perceptions, team interaction, job

security, perceptions about the workplace and percep-

tions of personal and staff morale.

The instrument successfully underwent internal and

external validity testing. Factor analysis showed that the

questions all loaded onto the first component and could

not be broken down further, therefore providing evi-

dence of construct validity. Additionally, Kaiser–

Meyer–Oklin (KMO) values ranged from 0.5 (abuse

towards RNs) to 0.91 (team interaction and commu-

nication). Leaving abuse towards RNs aside, all the

other 10 variables ranged from 0.76 to 0.91 in their

KMO values. The 11 work-related variables also

underwent reliability testing with all variables returning

Cronbach’s alpha coefficients in excess of 0.7 (Cron-

bach’s a 0.70–0.92). The University of New England

and individual hospital Human Research Ethics Com-

mittees approved the study.

After the initial distribution, several reminder news-

letters were distributed. Multiple sealed return boxes

were provided in each of the three survey sites. The

researcher collected completed questionnaires on a

regular basis. A response rate of 41% was achieved

(n ¼ 343, site 1 ¼ 97, site 2 ¼ 98, site 3 ¼ 151).

Measures

The instrument sought information regarding socio-

demographic characteristics, perceptions of �self’ and

the work environment and measures of personal and

organizational morale. In light of the unsuitability of

the available data collection instruments, a tool was

devised comprising of questions from available instru-

ments and additional questions drawn from the litera-

ture to explore variables developed specifically for the

project.

A number of scales were used in the survey ques-

tionnaire. The most common was a four-point scale

asking respondents to indicate the response that best

described whether they �strongly agreed’, �agreed’, �dis-

agreed’ or �strongly disagreed’ with each question. The

variables employed in this scale were team interaction,

job security, communication, consultation, patient care

provision, work performance, professional recognition

and organizational direction, strategy and management.

RN perceptions working in Australia

ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 403–413 405

The four-point �Likert-style’ scale was employed to en-

sure that respondents provided a definitive response and

to avoid central tendency with �neutral’ answers. A

number of studies have used a similar four-point scale

rather than the more commonly used five-point scale

(Burckhardt et al. 1991, Russell 1996, Sampson et al.

1996, Walther 2003). For the purpose of analysis, the

percentage tables aggregated the four responses into

two categories, �strongly disagree’/’disagree’ and �agree’/

�strongly agree’. The collapsing of the four responses

into two culminated in either a �positive or negative’

response to each question. To simplify and organize the

tables, responses, where the respondent did not answer

questions or provided a response other than those

offered, were excluded from the tables.

Five variables (abuse towards RNs, professional

autonomy, work climate, organizational morale and

personal morale) used a different scale to the variables

previously discussed. The variable that explored abuse

towards RNs used a four-point scale that asked the

respondent to tick the response that best described

whether they had �never’, �sometimes’, �frequently’ or

�repeatedly’ been subjected to physical or verbal abuse

from patients. Professional autonomy was scored on a

four-point scale asking the respondents to indicate the

frequency that best described whether they �never’,

�sometimes’, �usually’ or �often’ had autonomy in a

number of key professional areas. The measurement

scale for both organizational and personal morale was

developed from comments made by nurses in the

everyday work context. A four-point scale was adopted

to measure morale (very high, high, low and very low).

A four-point scale was preferred as it was assumed that

it is improbable to have �neutral’ morale. This type of

scale is reported in the literature and has been used for

similar types of studies (Flowers & Pepple 1987). This

four-point scale was later collapsed into two categories

for ease of analysis, where very high and high became

�positive’ morale, and very low and low were reclassi-

fied as �negative’ morale.

Data analysis

The statistical package used for data analysis was S P S S

11.5 (S P S S Inc., Chicago, IL, USA). Descriptive statistics

were used for the initial analysis of the survey data.

Categorical data were presented as counts and per-

centages, continuous variables as means and standard

deviations. The data are presented by way of descriptive

bivariate analysis on how the respondents perceive their

workplaces and their own role within their organiza-

tion.

Results

Socio-demographic profile

The socio-demographic characteristics of the respond-

ents were largely representative of both the general and

RN population of Queensland. The sample profile

showed that the respondents were predominantly

female (90%, n ¼ 312), a majority were aged between

31 and 50 years (58%, n ¼ 199), married or living in a

de facto relationship (51%, n ¼ 174) and had a com-

bined family income between $35 001 and $65 000

(50%, n ¼ 171). The respondents had been largely

educated in the hospital setting (66%, n ¼ 228), had

been an RN for an average of 17 years

(SD ¼ 10.9 years) and had been with their current

employer for an average of 7 years (SD ¼ 7.02 years).

Team interaction

Respondents were asked to rate their perceptions of the

people they work with and teamwork within their work

setting. The questions sought to measure both the

interaction of working within a team and the personal

aspects of being a team member. Working together and

interacting as a team came out strongly as a positive

perception where a majority of respondents strongly

agreed or agreed that staff interacted well (79.6%,

n ¼ 273), they supported each other on important

issues (68%, n ¼ 233), and they worked well as a team

(78.1%, n ¼ 268). Additionally, respondents strongly

agreed or agreed that they could count on their

co-workers when feeling pressured (68%, n ¼ 233),

they could share their problems and concerns (67%,

n ¼ 230), co-workers actively encouraged each other

(63.8%, n ¼ 219), there was a sense of belonging

(74%, n ¼ 254) and new staff were made to feel wel-

comed in the group (81.3%, n ¼ 279). While team

interaction came out strongly positive, 32.1%

(n ¼ 110) of the respondents strongly agreed or agreed

that bullying was part of their workplace culture.

Job security

Respondents were asked to state their views regarding

whether they felt their jobs were secure and what ele-

ments may threaten this security. While respondents

strongly disagreed or disagreed that they were worried

about job security (79.3%, n ¼ 272) and felt they could

say what was on their mind without the fear of losing

their job (56.9%, n ¼ 195), the same could not be said

for making mistakes. A majority of the sample (69.4%,

G. Day et al.

406 ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 403–413

n ¼ 238) strongly disagreed or disagreed that they

could make mistakes without the fear of losing their

jobs. While it has been shown that the respondents

work and interact well together, 62.1% (n ¼ 213)

strongly agreed or agreed that staff turnover in their

organization was high.

Communication

The importance of communication as a basis to build

positive workplace morale has been supported by a

number of studies (Cochrane & Jowett 1994, Colledge

1995, Livesley 2000). Respondents were questioned

about their perceptions of communication between

co-workers and how the organization communicates

with staff. Additionally, the questions also sought

responses to the different modes of �official’ communi-

cation within the organization.

Respondents strongly agreed or agreed that commu-

nication with co-workers (76.1%, n ¼ 261) and med-

ical staff (79.6%, n ¼ 273) was positive. However,

there were areas of poor communication identified

within the sample sites. While a majority of respondents

strongly agreed or agreed that they could speak openly

to their direct superior (63.8%, n ¼ 219), general

communication with the hospital leadership was seen as

problematic. About two-thirds of the respondents

(62.7%, n ¼ 215) strongly disagreed or disagreed that

communication from administration was clear, with a

similar percentage strongly disagreeing or disagreeing

that they were provided with communication that gave

them clear direction as to where the organization was

heading (62.4%, n ¼ 214). This could shed light on the

reason why 67.9% (n ¼ 233) of the respondents

strongly disagreed or disagreed that they knew what

was happening in their organization. A majority of the

respondents (65%, n ¼ 223) strongly disagreed or dis-

agreed that their hospital had the ability to listen and

respond to their concerns and ideas.

While respondents had negative perceptions of com-

munication with the leadership within their organiza-

tions, the sample strongly agreed or agreed that written

communication such as memorandums were displayed

clearly in the workplace (74.1%, n ¼ 251) and they

were easy to understand (70%, n ¼ 240), with email

being a good way to communicate with staff (59.6%,

n ¼ 214).

In line with the respondent’s negative perceptions of

communication with the leadership within their

organizations, consultation generally rated similarly.

Respondents strongly disagreed or disagreed about the

organizations ability to adequately consult staff before

making major changes (70.6%, n ¼ 242) and the feel-

ing of inclusiveness in organizational decision-making

(76.7%, n ¼ 263). These responses were supported by

the respondent’s strong disagreement or disagreement

that their workplaces encouraged their input and feed-

back (49.9%, n ¼ 171).

Patient care provision

While over three-quarters of the respondents (78.1%,

n ¼ 269) strongly agreed or agreed that they feel pos-

itive about the quality of care they provide to patients, a

similar number strongly agreed or agreed that patients

missed out on the care the respondents would like to

provide because of work pressures (78.2%, n ¼ 278).

Supporting this concern, 62.9% (n ¼ 216) of respond-

ents strongly agreed or agreed that they believed that

because of their workload, they often went home with

tasks left undone.

Table 1 shows that an overwhelming majority of the

respondents strongly agreed or agreed (82.7%,

n ¼ 287) that medical technology helped them provide

Table 1Respondents' perceptions about patient care provision in their workplace

n Strongly disagree/disagree (%) Agree/strongly agree (%)

I feel positive about the quality of care I provide to patients 340 21 78.1Patients miss out on the level of care I would like to providebecause of work pressures

339 23.6 78.2

I often go home with patient care or administrative tasks left undonebecause of my workload

338 35.6 62.9

My workplace has enough physical resources to providegood patient care

339 51.6 47.2

Medical technology in my workplace, such as intravenous pumps,electronic records, patient-controlled devices, helps me to providebetter patient care

335 14 83.7

My organization seeks patient feedback on satisfaction with care 336 31.5 66.8Good patient feedback has a positive effect on how I perform my job 337 16.3 81.9Staffing in my organization is adequate to provide good patient care 339 72.6 26.2

RN perceptions working in Australia

ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 403–413 407

better patient care. However, in contrast to this belief,

about half of the respondents (51.6%, n ¼ 177)

strongly agreed or agreed that their organization did not

have enough physical resources to enable them to pro-

vide good patient care.

Patient feedback was considered an important ele-

ment to how respondents perceived their professional

�value and worth’ in the patient care setting. Over two-

thirds of respondents (66.8%, n ¼ 229) strongly agreed

or agreed that their organizations sought patient feed-

back on their satisfaction with the care provided, with

81.8% (n ¼ 283) of the sample strongly agreeing or

agreeing that good feedback had a positive effect on

how they performed their jobs.

These responses showed a dichotomy of results, with

respondents indicating that they believed they provided

quality patient care, providing good patient care was

important to them and that they responded positively to

good feedback from their patients. However, they felt

equally strongly that their patients miss out on care they

would like to provide and that respondents often go

home with task left undone because of their workloads,

primarily because of lack of resources. Supporting this

perception, 72.6% (n ¼ 249) of the respondents

strongly disagreed or disagreed that there was adequate

staffing to provide good patient care.

Abuse towards RNs

Table 2 reveals that over three-quarters (75.9%,

n ¼ 262) of the respondents indicated that they had

been subjected to some form of physical abuse from

their patients, with a majority of those surveyed

indicating that they had been subjected to patient abuse

sometimes (63%, n ¼ 216).

When it came to verbal abuse from patients, 89.2%

(n ¼ 306) of respondents indicated that they had been

verbally abused when providing care, with 53.9%

(n ¼ 185) saying sometimes and a further 21.6%

(n ¼ 74) indicating frequent verbal abuse. Only 9.6%

(n ¼ 33) of respondents indicated that patients had

never verbally abused them.

Work performance

There was a general agreement from the sample

regarding the organizations’ commitment to improving

the skill and expertise of the workforce. About half of

the respondents (50.4%, n ¼ 173) agreed or strongly

agreed that their organization took steps to enhance

curiosity, knowledge and professional practice.

Respondents agreed or strongly agreed that organi-

zations took time to develop staff skills and expertise

(56.3%, n ¼ 193), allowed enough time for annual

competency assessment (56.9%, n ¼ 195) and were

committed to staff development to improve work per-

formance (61.5%, n ¼ 211). While there was a com-

mitment to ongoing development of the work group,

the respondents indicated that there was a fair level of

control and direction placed over the staff. This was

borne out by 77% (n ¼ 264) of the sample agreeing or

strongly agreeing that superiors not only decided the

course of action for the team, but also enforced polices

and rules (75.8%, n ¼ 260) and planned and monitored

the teams’ activities (51.6%, n ¼ 177). With this gen-

eral level of control over a professional workforce of

RNs, it is not hard to see that 51.9% (n ¼ 175) of the

respondents disagreed or strongly disagreed that their

organizations appreciated or encouraged new and

innovative ways of doing things. Similarly, 49.9%

(n ¼ 171) of the respondents disagreed or strongly

disagreed that their organization motivated the team to

try out new things.

In another negative response to how RNs perform in

their roles, respondents disagreed or strongly disagreed

that they were encouraged to express feelings of self-

Table 2Respondents' perceptions about abuse towards RNs in their workplace

n Never (%) Sometimes (%) Frequently (%) Repeatedly (%)

I have been subjected to physical abuse from patients 339 23 63 7.9 5I have been subjected to verbal abuse from patients 339 9.6 53.9 21.6 13.7

Table 3Respondents' perceptions about professional autonomy in their workplace

n Never (%) Sometimes (%) Usually (%) Often (%)

I am autonomous in terms of practice 339 2.9 15.7 47.2 32.9I am autonomous in terms of decision-making 340 4.1 25.9 41.7 27.4I am autonomous in terms of problem-solving 339 2.3 17.5 48.7 30.3

G. Day et al.

408 ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 403–413

doubt without being criticized (53.9%, n ¼ 185).

Additionally, 63.6% (n ¼ 218) of respondents disag-

reed or strongly disagreed that they received regular

feedback on their performance. The level of control and

direction set by the nursing leadership over the nursing

workforce had some benefits, where 64.1% (n ¼ 220)

of the respondents agreed or strongly agreed that their

team has had tangible results to show for their efforts.

Professional autonomy

Table 3 shows that despite a perceived level of strong

organizational control in relation to work performance,

respondents indicated that they were often or usually

afforded professional autonomy by their organizations

in relation to practice (81.1%, n ¼ 275), decision-

making (69.1%, n ¼ 237) and problem-solving (79%,

n ¼ 271).

This level of professional autonomy fits with

Stogdill’s (1959) view of morale being freedom from

constraint to meet organizational goals. This approach

is supported in the literature where it is argued that

professional autonomy is a basis for improved morale

(Haw et al. 1984, Grant et al. 1994, Hartley & Turner

1995). Table 3 also shows that only a small number of

respondents indicated that they were never afforded

professional autonomy in relation to their work per-

formance (practice 2.9%, n ¼ 10; decision making

4.1%, n ¼ 14; problem-solving 2.3%, n ¼ 8).

Professional recognition

Respondents were asked their views on how they per-

ceived they were recognized by their organization and

whether they felt a feeling of professional �worth’ or

�value’. The results show that respondents generally felt

recognized as a professional by their organization.

Respondents agreed or strongly agreed that their

organizations recognized RNs for their skill and

expertise (54%, n ¼ 199), respected them for their

contribution (68%, n ¼ 233) and treated the RNs as

professionals (77%, n ¼ 264).

Additionally, 60.1% (n ¼ 206) of the RNs agreed or

strongly agreed that they felt they had equal status with

that of other members of the health care team (doctors,

allied health professionals), their organization suppor-

ted them as RNs (72%, n ¼ 247), they were trusted with

responsibility and authority (74.9%, n ¼ 257) and their

organization supported and encouraged their profes-

sional development (63.6%, n ¼ 218). However,

despite the strong positive response to the perception

that the organizations entrust RNs with responsibility

and authority and treated them as professionals, 51%

(n ¼ 175) of the respondents disagreed or strongly dis-

agreed that they had professional power within their

workplaces. The theme of being valued as a professional

is an important concept and respondents supported this

by indicating that their organizations recognized them

for their skill and expertise. However, 69.4% (n ¼ 238)

of the sample disagreed or strongly disagreed that their

organizations honoured good nurses.

Organizational direction, strategy andmanagement

The instrument asked the respondents their views on

how they perceived their organization in terms of its

future directions, objectives to be achieved and how it

provides the necessary resources to achieve organiza-

tional goals. About two-thirds of respondents (65.3%,

n ¼ 224) agreed or strongly agreed that their organi-

zations had a sense of common purpose, while 85.1%

(n ¼ 292) indicated the organization had a mission/

vision statement. However, despite having clear

organizational goals, 71.7% (246) of respondents dis-

agreed or strongly disagreed that staff had a clear idea

of these goals.

Respondents provided an insight into their percep-

tions of the resources required to provide patient care.

There was a clear indication that respondents did not

believe there were adequate resources provided to meet

the goals of the organization. The data showed that

respondents disagreed or strongly disagreed that the

organization provided sufficient staff (74.1%,

n ¼ 254), funds (72.3%, n ¼ 248), equipment (49.6%,

n ¼ 170) and infrastructure (54.8%, n ¼ 188) to

achieve organizational goals.

When asked about the goals of the organization,

respondents were split with their responses. Less than

half of respondents (48.4%, n ¼ 166) agreed or

strongly agreed that their organizations had clear goals

to be achieved over the next year. This is surprising as

nearly the same number of respondents (46.6%,

n ¼ 160) disagreed or strongly disagreed that the

organization had clear goals, with a further 5%

(n ¼ 17) not answering the question. Additionally,

44.9% (n ¼ 154) of the respondents disagreed or

strongly disagreed that their organization had achieved

the goals it had set for the previous year, with 15.6%

(n ¼ 54) not answering the question. Despite respond-

ents being roughly divided as to whether their organi-

zations had clear goals and had achieved them for the

previous year, over half of the respondents (58.6%,

n ¼ 201) agreed or strongly agreed that they felt a sense

RN perceptions working in Australia

ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 403–413 409

of achievement when the organization did meet its

goals.

There also seemed to be some �mixed messages’ pro-

vided by respondents in relation to how they perceive

their organization as an employer. There were strong

positive responses amongst the sample where 64.5%

(n ¼ 221) of the respondents agreed or strongly agreed

that RNs were an important resource to the organiza-

tion, their leadership knew them (63.3%, n ¼ 217) and

that they would recommend their organizations to other

RNs as a place of employment (65%, n ¼ 224). How-

ever, despite these clearly positive perceptions, there

were elements of the organizations about which the

respondents were concerned. Over half of the

respondents (52.8%, n ¼ 223) agreed or strongly

agreed that their organization was more interested in

financial performance than patient care. A similar per-

centage of respondents (51.9%, n ¼ 178) agreed or

strongly agreed that there was a culture of blame in

their organization, and 62.5% (n ¼ 215) of respond-

ents disagreed or strongly disagreed that promotion in

their organization was by merit.

Morale

Table 4 shows that respondents overwhelmingly per-

ceived morale in their organizations to be low or very

low (70.8%, n ¼ 243). However, they perceived their

own morale to be different with 48.1% (n ¼ 165) of the

respondents indicating low or very low personal mor-

ale. While there was a clear indication of the perception

of negative organizational morale, respondent’s per-

ception of his or her own morale was divided almost

equally between �negative’ and �positive’ morale. The

high number of respondents that indicated low or very

low morale in this research is in line with the literature,

where in one major international study, 74% of nurses

in the study reported organizational morale of be fair to

poor (Peter & Hart Research Associates 2001).

Discussion

It was evident that team interaction was an important

and positive aspect of their work for respondents. This

finding was supported by the health care literature in

that teamwork and the people that you work with were

highlighted as important social variables (Smith 1985,

Roberts et al. 1993, Hartley & Turner 1995, Koeske &

Kirk 1995). The results indicated that there was little

concern with job security, although respondents

indicated that they worried about their positions if they

made mistakes. This result may lead to questions as to

whether nurses may be tempted not to disclose mistakes

for fear that they may lose their jobs as a result.

Communication between co-workers and medical

staff was seen as positive, but communication with

administration was perceived as negative. This was

particularly evident in relation to the organization’s

ability to communicate where it is heading and what is

happening, as well as listening and responding to con-

cerns and ideas from staff. The importance of commu-

nication to a positive work environment has been

widely supported in the literature (Smith 1988,

Gilliland 1997, Nolan et al. 1998b). Consultation was

perceived to be negative with respondents believing that

their organizations did not consult with them before

making major changes, staff were not included in

organizational decision-making and their organizations

did not encourage staff input and feedback. These

findings confirm earlier study outcomes into the

importance of consulting with clinical staff (Hartley &

Turner 1995, Nolan et al. 1995, Weir et al. 1997).

Contact with patients and providing care was seen as

a key issue. This is hardly a surprising finding and

mirrors the findings of earlier studies (Smith 1985,

Traynor & Wade 1993, Nolan et al. 1995, Nolan et al.

1998a, Callaghan 2003, Scott 2004). The results also

showed that positive feedback from patients had a

positive effect on how nurses performed their jobs.

However, these findings were tempered with a majority

of respondents indicated that they had been subjected to

physical and verbal abuse from patients. The issue of

workplace violence towards nurses has been widely

reported in the Australian and international literature

(Carroll 1996, Bouchard 2000, World Health Organi-

sation 2002, Sofield & Salmond 2003, University of

Alberta 2003). This dichotomy could indicate that

nurses are neither surprised nor distressed about abuse

from patients; rather that high levels of abuse from

patients are even expected and perceived as �part of the

job’. In addition, one could wonder if unmet patient

needs and patient’s high expectations generate high

levels of hostility and disrespect towards the most vis-

ible and available health care practitioner.

While the study suggested RNs were positive about

the quality of care they provided, there was a belief that

Table 4Respondents' perceptions about staff (organizational) morale andpersonal morale

nVery

high/high (%)Low/verylow (%)

Staff morale in my organization 326 24.2 70.8My personal morale 329 47.8 48.1

G. Day et al.

410 ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 403–413

because of their workload pressures, patients missed out

on the care the nurse would like to give. Additionally,

the results suggested that because of excessive work-

loads nurses regularly go home with tasks left undone.

There was an acceptance that medical technology

assisted nurses to provide better patient care. However,

despite the recognition that technology was a positive

attribute, there was a strong belief that organizations

did not provide nurses with enough physical resources

and staff to provide that care. While this result appears

contradictory, an explanation may be that while nurses

appeared satisfied with their ability or potential to

provide care, however, organizational constraints made

this difficult or impossible to achieve.

Respondents were positive about their organizations

ability to enhance their curiosity, knowledge, profes-

sional practice and staff development. There was also a

positive response to organizations affording nursing a

level of professional autonomy, decision-making and

problem-solving. Similarly, nurses were treated and

trusted as professionals, recognized for their skills and

expertise and trusted with responsibility and authority.

Again, these results are supported by earlier studies

outlining the importance of recognition of nurses as

important members of the health care team (Blegen

1990, Coulter 1991, Cronin & Becherer 1999,

Finlayson 2002b). However, these findings were offset

by the belief that organizations exerted strong control

over direction and practice, organizations did not

honour good nurses and that the organizations did not

afford them professional power, nor provide them with

regular feedback on their performances.

The results demonstrated that the organizations in the

study had a common purpose and had a mission/vision

statement. However, despite the organizations having a

clear purpose, staff did not have a clear idea of the

organizational goals and whether they had been

achieved. In an interesting twist, respondents claimed a

sense of achievement when the organization did meet its

goals. Organizations were seen as being more interested

in financial performance than patient care. This finding

supports earlier studies and the view that there is an

ever-widening gap between the objectives of health care

organizations and the goals of care givers (Shindul-

Rothschild 1994, Decker et al. 2001).

A high percentage of respondents perceived the

morale of staff in their organizations to be negative,

while only around half of the respondents rated their

own morale as being, negative with the other half

having positive perceptions of their own morale. Man-

agers must be concerned when identifying that fully half

of their employees are experiencing low personal mor-

ale. One might suggest that such high levels of poor

personal morale are linked to the perception of seriously

high levels of poor organizational morale. In other

words, should this already large percentage of person-

ally demoralized staff increase, poor organizational

morale could further escalate, foreshadowing a serious,

almost unresolvable workplace crisis. While a number

of findings in this study are in line with earlier research,

the results around the duality of organizational and

personal morale and their interplay have not been

reported in the contemporary literature.

Conclusion

There were several clear themes arising from the des-

criptive data analysis. First, team interaction and

working with others is an important aspect of working

lives of nurses. Secondly, being consulted and informed

about the direction and goals of the organization is a

key issue for nurses. Thirdly, giving good patient care is

a central issue for nurses in the study. However, it was

evident that respondents saw challenges with providing

acceptable levels of care because of lack of adequate

staffing and resources. Additionally, while nurses see

giving good patient care as important, the very group

they are giving care to, the patients, are subjecting them

to high levels of verbal and physical abuse. Fourthly,

communication was also an important variable at two

levels. First, there was a perception that communication

between workers was positive. Countering this, com-

munication from the organization’s leadership to the

workers was inadequate.

The interplay between a nurse’s perception of their

own morale and that of the organization cannot be

underrated. It is clear from the analysis that organiza-

tional and personal morale are two quite separate con-

cepts. These concepts need to be understood further not

only to understand why there is a difference between the

two variables, but to also assess whether there are dif-

ferent variables that determine levels of organizational

and personal morale. Clearly there is a difference

between the individual’s belief and the impact of morale

on �self’ on how morale is perceived at the group level

that needs to be further investigated. Additional research

should also be considered to determine whether there

are differences in the level of morale as well as the

individual variables across organizations.

There are also clear messages in this study for

health service managers and administrators in provi-

ding insights into how nurses perceive their work and

workplace. The results may be used in planning

strategies that promote healthy organizational cultures

RN perceptions working in Australia

ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 403–413 411

that are conducive to quality care and high worker

morale. The results point to nurses wanting work

environments that are not only professionally stimu-

lating but also where they are valued and recognized

as highly skilled caregivers. Similarly, communicating

the goals and direction of the organization, consulting

with staff, providing safe working environments and

reducing the barriers (paperwork, bureaucracy and

fair workloads) to enable quality nursing care to be

practiced are well within the scope of most organi-

zations to achieve.

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