1 SEEING TO THE FUTURE THROUGH THE SHADOW OF THE NURSING STAFF SHORTAGE: THE GREEK REGISTERED NURSES VIEWS ON A POSSIBLE ESTABLISHMENT OF A FAMILY NURSING POLICY IN GREEK HOSPITALS by Despina Sapountzi-Krepia, BSc, MSc, PhD, RN, RHV, Assistant Professor, Technological Educational Institute (TEI) of Athens Ioannis Kalofissudis, Head Nurse of the ICU, Henry Dunant Hospital Maria Psychogiou, BSc, RHV, MSc Student, t, Kuopio University Darin Peterson, BSc, MSc Student, Kuopio University Evanthia Sakellari, Bsc, RHV, MSc Student Kuopio University Author to who any correspondence should be requested Dr Despina Sapountzi-Krepia 3-5 Elaion Street, New Kifissia, sia, 145 64 GREECE desapoun@teiath.gr Tel / Fax 0030 1 6202125
2 Abstract: The present study examines the registered nurses' perceptions regarding the introduction of a family nursing care policy in Greek hospitals. The target population consisted of 978 registered nurses working in six hospitals of Athens out of which a convenient sample of 53 filed an especially designed questionnaire. The majority of the sample (84%) was female with a mean age of 34 and a mean of 12 years of employment. The provision of care for patients by family is an everyday reality in hospitals due to the nursing staff shortage. 56% of the sample believed that families are not obliged to provide care for their hospitalized members. 66% of the subjects did not accept any professional responsibility to include family members in the plan of care or to provide care for them. However, 94% of them provided care for family members and all the subjects acknowledged that those family members had needs for care. The necessity for increasing the numbers of registered nurses employed in Greek hospitals, before a formal introduction of a family nursing policy, was stressed by 96% of the sample. 52% declared that, under special conditions, it was interested in applying family nursing. The chi-square tests applied revealed that the nurses' age (p=0.006) and the position in the nursing hierarchy (p=0.01) were related to the nurses' perception regarding the acceptance of a professional duty to include family members in the plan of care. The frequency on the provision of care for family members was influenced by the nurses' experience (p=0.010) and their position in the nursing hierarchy (p=0.034). Key words: Registered nurses, Perception, Family nursing, Policy, Greek hospitals
3 Introduction As the better allocation of available recourses becomes an inevitable necessity, hospitals in most of the countries try to find new ways for reducing the cost of hospitalization. From the early '70 articles in favor of family's participation in the patient's care started appearing in the caring literature, whereas it is characteristically written that '' hospital settings have to be adapted not only to permit but to actually require the presence of a family member or friend during hospital stay'' 1. In the '80 and '90 similar ideas appeared again in the international caring literature 2,3. Among the reasons for supporting the family's in patient's care it was the reduction of the hospitalization's cost, because with the continuous stay of the family members in the hospital, fewer personnel is required for the delivery care. However nurses have more than the other professionals reasons to accept and to welcome the presence of family members in hospital wards because as it is supported by the nursing literature family plays an important role for the health of its members 4,5 and any illness or hospitalization within the family causes a great deal of distress for family members 6-9 and therefore families have to be supported by nurses during any hospitalization within the family. However, in the nursing literature there are contrasting opinions about the care given to the family by nurses and the practice of including families in the plan of care does not yet seem to have been arrived at by the majority of nurses. For Greece, a country with limited economic recourses, families are not only maintaining the primary responsibility for the care of their chronically ill and disabled members at home but they also started to cover part of the care for their hospitalized members. From the early '80 family members started to stay with patients in hospital for long hours to assist them with their care 10-12 and the phenomenon influenced the way in which the nursing care is provided in hospital wards. Nurses pressed by the circumstances created started gradually to provide some kind of care for family members 10-12. The present paper presents the findings of a study carried out in six Athenian hospital to investigate the Greek nurses opinions about a formal introduction of a family nursing policy in the Greek hospitals.
4 Methodology The aims of the project were to investigate if registered nurses are interested in changing their usual nursing practice in favour of family nursing, and to clarify perceptions of various aspects of the phenomenon of provision of care for hospitalized patients by families. The formulated hypotheses were two. 1 ) Registered nurses accept including family members in the plan of care and providing care for them as part of their professional duties. 2 ) Registered nurses are interested in applying family nursing. A self-administrative semi-structured questionnaire was distributed to the registered nurses who work in six general hospitals of Athens. Subjects were informed about the purpose and the goals of the study and they were asked to participate in it. Registered nurses, who voluntary participated in the study, filled the questionnaire and they put it anonymously in collection boxes. The researchers, for eliciting information in the following areas, designed the questionnaire used as the instrument of data collection. 1. Demographic, employment and social characteristics of the sample. 2. Opinions on the phenomenon of the provision of care for patients by families in hospital wards. 3. Perceptions of family members' needs for care. 4. Opinions on a possible establishment of a family nursing policy in Greek hospitals. Two reviewers who checked the questionnaire and were asked to give their comments confirmed the content validity of the questionnaire. The analysis of the quantitative data was done by the SPSS-PW+ program by using the statistical procedures: 1) Comparison of percentages and 2) chi-square tests. The qualitative data from the open-ended questions were analyzed by the method of content analysis. For the presentation of the data descriptive statistics were used.
5 The results The questionnaire generated 268 replies, 14 of them were excluded from analysis because they were incompletely filed. The final sample consisted of 253 registered nurses. This sample derived from a target population of 978 registered nurses, who work in six general hospitals of the area of Athens, capital of Greece. The data came from the analysis of 253 questionnaires. Information of the demographic and employment characteristics of the sample is given on Table 1. Table 1. Demographic and employment characteristics of the sample Sex n % Male 41 16 Female 212 84 _ Age n % 20-29 76 30 30-39 109 44 40-49 57 22 <50 11 4 Years of employment n % 0-5 63 25 6-10 85 34 11-15 49 19 16-20 31 13 21-25 19 7 <25 7 3 Position in the nursing hierarhy n % Ward nurses 196 78 Heads of ward 54 20 Assistant directors 3 1.5 Directors 1 0.5 Regarding nursing education, 59% of the subjects were graduates from the former Higher Nursing Schools, 33.5 % from Technological Educational Institutes, and 7.5% were University graduates. The majority of the sample (n=230, 91%) declared that the phenomenon of care provision to hospitalized patients by family members is an everyday reality in hospital wards.
6 Fifty-six percent (n=141) of the sample believed that families are not obliged to stay by the bed of the patients to assist them with their care. The main reasons given for their answer are presented in table 2. Table 2. Reasons given by nurses for answering no to the question Are families obliged to provide care for their hospitalized members? n 141 Category n % * more than one possible answers allowed Hospitalized patients must be 135 96 cared for by nurses The presence of family members in hospital wards enclose the danger of an increase of in-hospital infections 54 38 Hospitals facilities are limited and inadequate to facilitate both patients and family members 34 24 The presence of family members produces problems in the normal function of the ward 87 62 Furthermore, the majority of the nurses (n=167, 66 %) declared that it is not their professional duty to include family members in the plan of care and to provide care for them. The reasons given for these answers are presented in Table 3. Table 3. Reasons given for answering no on the question Do you have a professional duty to include family members of hospitalized in the plan of care and to provide some kind of care to them? n = 167 Reasons n % * more than one possible answers allowed Nursing staff shortage 160 63 Lack of time 85 34 Nurses have to nurse patients and not patients relatives 71 28 Insufficient education and training on nursing families 158 62 Ninety-six percent (n=243) of the subjects declared that they did not apply family nursing in their everyday nursing practice. Nevertheless, as Table 4 presents, nurses acknowledged that family
7 members had needs for care, and the majority of them (n=238, 94%) stated that provided some kind of care for family members. Table 4. Needs of family members as perceived by the subjects n= 253 Category n % * more than one possible answers allowed Health Education needs 214 91 Emotional support needs 157 63 Informational needs 243 96 The kind of care provided by nurses for family members is shown in Table 5. Table 5. Nursing care provided for family members of hospitalized patients Category * more than one possible answers allowed n % Information on hospital services and social security benefits 210 82 Emotional support 71 28 Plain conversation 38 15 Health education on basic nursing care 53 21 Health education for the preparation of patient for discharge 35 14 The frequency of the provision of care by nurses for family members of hospitalized patients is presented in Table 6. Table 6. Frequency on the provision of care for family members of hospitalized patients Every day Most of the week's days Sometimes in the week Never n % n % n % n % n % 91 (36%) 104 (41%) 43 (17%) 15 (6%) 253 (100%) From the content analysis of the open-ended question (n= 202), ''Why do you provide care for family members? the majority (n=105, 52%) of the nurses who responded to the question answered that they provide care for family members for humanitarian reasons, 3% (n=6%) answered
8 because family members ask for help, and 32% (n=65) answered that they provide that care because they feel that they have a professional duty to do it. From the content analysis of the nurses' responses to the open-ended question (n=212) '' Do you agree with the introduction of a family nursing policy in Greek hospitals?'' it was also revealed that (n=178, 84%) of the subjects who responded to the question warned that before any formal introduction of a family nursing policy in hospitals, hospitals have to increase the number of registered nurses employed. Fifty-two percent (n=110) stated that, under special conditions, they were interested in applying family nursing in their everyday nursing practice. The special conditions mentioned were: a) the employment by the hospitals of more registered nurses. At this point it is interesting to quote the response of one of the nurses who characteristically stated, '.'the shortage in nursing staff produces tensions and discourages nurses to be involved in practices that are time consuming c or seem to have less priority in the wards routine'', and b) special training in family nursing interventions. Chi-square test was used to examine possible relation among the demographic characteristics and the perceptions of the nurses as per their professional practice. The various categories of the demographic characteristics were classified in special categories. For age, nurses were classified in two groups, one for the 20-39 years old and one second for the 40 years old and more. For the years of employment nurses were also classified in two groups, one for the nurses employed for 1-10 years and a second one for the nurses employed for 10 years and more. For the position in the nursing hierarchy nurses were classified as ward nurses and nurses in managerial positions. The results obtained were the following. The nurses age (p=0.006) and position in the nursing hierarchy (p=0.01) were positively related to the nurses perception on how far they have a professional duty to include family members in the plan of care and to provide care for them. Young nurses and nurses in managerial positions had more possibilities to answer yes in this particular question. The professional experience of the nurses (p=0.010) and the position in the nursing hierarchy (p=0.034) was related to the frequency on the provision of care for family members of hospitalised patients. It was more possible for nurses with less years of professional experience as well for nurses in managerial positions to provide care for family members more frequently.
9 Discussion It would be useful to discuss several concerns, which this study was faced with before its results are interpreted. One of our concerns is that the research was carried out only in Athens and not all over Greece. However Athens is the capital of Greece, nearly half of the Greek population lives in Athens. Furthermore, the Athenian hospitals are the biggest of the country employing a big number of registered nurses. Therefore we thought that through searching nurses in Athenian hospitals we have at least an idea about the opinions of the main body of the Greek nurses. One of the strengths of the study, which also makes it useful, is that it is the first Greek survey on nursing opinions about family nursing. Other strengths of the study are derived from our high response rate. A further concern was the questionnaire used in the study, because the use of standardized questionnaires with established validity and reliability measures seems to be the will provide it with the most scientific credibility. The questionnaire used was pretested concerning face and content validity. However, working in a country which as we speak - is trying to develop and expand its health care system, our initial assessment of the registered nurses opinions about a possible introduction of a family nursing policy in Greek hospitals goes in the right direction, with the goal of supporting this endeavor. As can be seen from the results obtained, the hypothesis Η1 of the present study proved to be false because the majority of the subjects did not accepted as their professional duty to include family members in the plan of care. The second Η 2 proved to be proved to be partly true because a considerable number of the participated nurses declared that under special conditions are interested to apply family nursing in Greek hospitals. The chi-square test applied revealed that young nurses have more possibilities to accept as their professional duty to include family members in the plan of care and to provide care for them. It would be speculated that the young generations of nurses have received a health-oriented nursing education as the old nursing curriculum changed in '85 and this education has influenced and broadened their understanding of nursing. Another group of nurses, nurses in managerial positions, had more possibilities to answer like the young nurses. Possible reasons for this differentiation may be that people in management position have to know and they know that the nursing role includes the provision of care to families.
10 The frequency on the provision of care for family members, as the chi-square test revealed, is related to the professional experience, the age of the nurses and their position in the nursing hierarchy. Young nurses and nurses with less years of professional experience as well as nurses in managerial positions had more possibilities to provide more frequently care for family members. That is logical because the usual practice in Greek hospitals is that young nurses spend more time in the patients rooms whereas the patients' relatives also stay and therefore young nurses have more possibilities to be asked for help. On the other hand it is something like a long lasting tradition in Greek hospitals that family members usually approach the head nurse or the director of the nursing services and the assistant directors when they face a difficult problem or they wand to say something confidential to someone. Considering further the findings of the present study one more issue becomes clear. The presence of family members in hospital wards for the provision of care to patients is an everyday reality in the surveyed hospitals and the shortage of nursing staff is, for the majority of the nurses, the main reason for that. Nevertheless, the majority of the subjects did not support the idea of welcoming the presence of family members in hospital wards. This is not a surprising attitude because in the nursing literature is also referred that hospitals are not a particularly welcoming place for relatives because of the nurses' attitudes 8,10,12. However the subjects' responses presented in table 3 give reasonable excuses for their reluctance to accept the presence of family members in hospitals wards. Furthermore almost all the sample did not include family members in the plan of care. The findings are not surprising because similar results were reported form earlier studies on Greek nursing population 10-12. A possible reason for this behavior is the fact that in most of the Greek hospitals nurses follow the task oriented nursing system in practice because of the nursing staff shortage. Therefore, even nurses who feel that they have a professional duty to include family members in the plan of care it is almost impossible in practice to do it. A considerable percentage of the sample was reluctant to accept as a professional duty, including family members in the plan of care. It could be speculated that nurses, expressing that view, express the hidden attitude that they did not want the presence of family members in hospital wards, and therefore they did not seem to share the idea that family plays an important role in the health of its members. Here, it should be mentioned that two important factors that can influence the nurses attitudes are their nursing education and their professional philosophy and culture. However, nursing education in Greece was for many years illness centered and the professional
11 reputation of nurses in the Greek language ''nosokomos'' and ''nosileftis'' are ''illness'' centred because they have as their first part the word ''nosos'' that means illness or disease 13. Therefore, nurses in Greek society culturally are expected to provide care only for ill and disabled people. Furthermore, hospitals, the main places of nurses work are called ''nosokomeia'', a word leading to the assumption that hospitals are places for sick people and of course not for healthy people. So for nurses, family members, as non-hospitalised individuals, are assumed to be healthy. Therefore, the subjects of the present study possibly were led to these attitudes trapped from their ''illness'' centered education, from their professional subculture and from the expectations of the Greek society for their professional role 14. Furthermore, the shortage of nursing staff in Greek hospitals is one of their biggest problems 9,11,13,14. The finding of the present study stressed repeatedly the problem, and once more the vast majority of the sample declared that hospitals have to increase the number of registered nurses employed, before any formal introduction of the application of a family nursing policy. Very interesting is the fact that about half of the sample declared its interest to move forward in applying family nursing, but only under special conditions. Here once again it was mentioned that the nursing staff shortage is for Greek nurses a barrier against their willingness to provide better care for their clients. However it is noteworthy to mention that the majority of the subjects and some of the subjects in contrast to their declared attitudes, provided care for family members. This inconsistent behavior of the Greek nurses could be understood by the acceptance of Thomas's 13 arguments that, even when intended behavior is declared, that still does not predict real behavior. Furthermore, a considerable proportion of the nurses who declared interested to practice family nursing said that they were not properly trained in family nursing and they need special education and training in this area. Hosp ital nursing directors have to pay attention to this message and include family nursing in their plans of continuing education programs. This finding is also a very important message for nurse educators to look further into the curriculum of the undergraduate nursing education regarding family nursing. Hence, it is important for the Greek Ministry of Health and Greek nurse managers to reconsider the problem of the nursing staff shortage and to understand that some measures must be taken immediately.
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