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Capacity to provide caring nursing practice is impacted by: aspirations for career progression, burnout, isolation and support for sustained provision of care.

6.9.1 Progression

Career progression is affected by a nurse’s capacity to meet organisational and unit needs. Meeting these needs often comes at a cost to themselves and to the nursing profession:

Finally I have role progressed to Triage after two years working in this department, despite my six years previous emergency nursing experience working in triage roles and above. It has been challenging, despite knowing the data entry system and having experience in triaging there are so many site specific nuances and internal politics that make it far from an enjoyable experience. Three twelve hour shifts at the Triage desk wears anyone down, I feel my voice fading and becoming croaky even before the end of a shift that I have to excuse myself despite the line of people in front of me because I haven't had a chance to go to the toilet for hours and I'm starting get uncomfortable and having trouble concentrating. (P246)

The repeated inability to meet organisational expectations affects individual confidence which is sometimes not evident until career progression enables hindsight:

Over the past 10 years of teaching I feel my personal confidence in myself … has developed and I have more to offer patients, albeit indirectly! Because I never thought I could provide adequate true nursing care. (P971)

As with the reflection above for some participants years in nursing and career progression allowed for a reflection of how transition affects patient care and ability to understand and support more junior staff:

I probably was like that at a younger age but as my exposure to many roles over the years I have a bigger insight so always happy to share the knowledge. (P157)

And to know which battles will have an impact on patient care and on development of staff:

… . I use the mediating effect and to be honest avoidance of these nurses and sometimes I give them tools to process what is going on. (P157)

Sometimes the personal cost of meeting organisational and unit needs is very high.

6.9.2 Burn out

There were personal consequences for persevering with nursing as a career. Images of a sometimes violent and challenging work environment emerged:

It’s also the faces and bodies of the dead people I’ve touched and cleaned or crushed their sternums, the gangrenous maggoted wounds on limbs, the young traumas burns to the face and bones piercing skin, litres of blood drained from chests soaking in my shoes, the stench of sickness and body fluids needing to be cleaned up, sagging pasty skin and breathlessness, the relentless screams and bells and alarms, the constant adrenaline and the exhaustion of processing it all. You are left feeling uncared for yourself and it seems the onus is on you to then provide that self-care. (P246)

The pressure to keep performing is recognised in this statement:

The system recognises the issues of burnout on staff … I feel pressure is placed on nurses by the system. (P350)

And with it comes hard decisions about quality of care:

… Not having time to care impacts me personally and professionally it robs me of job satisfaction and lends itself to burnout, more sick days and looking for opportunities to leave and find a more fulfilling job. Burn out occurs when a person feels that they have no control. I have been there. (P350)

On a busy ward filled with drama one nurse reflected:

I didn't need all this drama … the ward was very busy. I kept saying to myself that no job was worth this, especially as I was feeling sad. (P640)

6.9.3 Isolation

As nurses struggle with the impact of lack of time to care, they feel isolated from team support and from organisational support. Burnout is often not understood, and the sense of isolation is felt deeply:

I want to share my concerns and have some solid feedback on coping or moving forward in this challenging environment but no one has the answer. "If you don't like your job just quit" is an over simplification because I don't think I actually dislike my job, it's just difficult. (P246)

Others reflected on isolating themselves from colleagues as a means of coping and preserving their mental health:

I isolated myself from conversation within the office (work related and personal). (P769)

Some isolated themselves from patients as a means of preserving their own physical health:

I feel my voice fading and becoming croaky even before the end of a shift that I have to excuse myself. (P246)

6.9.4 Sustaining provision of care

Despite the often difficult task of providing caring nursing practice, participants saw benefits in sustaining care. Sustained caring nursing practice is seen to support patient outcomes, departmental outcomes and organisational imperatives.

I was in our recovery area, and had a gentleman waiting for a procedure, which is normal practice. Unfortunately, due to circumstance out of our control, he had to wait quite a long time. … . He stated he would rather go home and re-arrange. … . I explained that we couldn’t put time limits on our procedures and that it would be beneficial for him to wait as at least he would get a definitive answer as to why he was getting chest pain. The patient stated he would rather end up having a heart attack, to which I gently explained that if he did that, he would be in a worse predicament than he was in now and he may not survive. I told him I would try and find out how much longer he would have to wait. Unfortunately, an emergency patient came in which pushed his procedure back even more. I explained again that he would have to wait and we couldn’t predict how things progress within the cath lab. He accepted he would have to wait … after another hour he was still sat waiting I offered him sandwiches, which he accepted. I firmly believe that a friendly face and a smile can put people at ease. (P434)

Sustaining caring nursing practice is not always easy. Personal qualities of empathy and caring values may be the foundation for practice:

I managed to provide some sort of relief/empathy to the son that these conflicts are normal and that every family goes through this. Invested my time into explaining. (P449)

Reflection was seen as one way of sustaining CNP:

…I reflected on this episode and I believe it made me stronger and in fact gave me more confidence and improved my self-esteem therefore I was able to confidently do the same for other patients just knowing that it helps to listen, show empathy, and display the caring side of my profession. (P640)

As outlined above a complex interplay of factors have an impact on the ability and desire to sustain CNP.