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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 23  |  Issue : 1  |  Page : 95-101

Engaged or not?: A case study on nurse's engagement in clinical settings in India


Ph.D Scholar, Department of Management and Labour Studies, Tata Institute of Social Sciences, Mumbai, Maharashtra, India

Date of Submission10-Jan-2021
Date of Decision14-May-2022
Date of Acceptance26-May-2022
Date of Web Publication05-Jul-2022

Correspondence Address:
Ms. Shruti Bhardwaj
171, Paramanand Colony, Didwana - 341 303, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcn.ijcn_5_21

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  Abstract 


Engagement is a much-debated term relating to its interpretation and direct outcomes. Engagement has a direct link to first-level outcomes such as turnover intention or employee performance. Engagement, in nursing, has also risen as an area of interest to health-care professionals and researchers. Extreme views about the nursing profession, female-centric workforce and different health systems in the nursing profession worldwide make this profession unique. This case study, combined with the grounded theory data analysis technique, aims to explore the nurse engagement practices in clinical settings in India and their impact on the turnover intention of nurses. Face-to-face interviews with nurses providing direct patient care from two tertiary care hospitals in India were conducted for data collection. A total of 17 interviews were analysed using the grounded theory coding mechanism. Five major themes emerged in this study. First, Leadership styles; second, social influence and nursing as a career of choice; third, the philanthropic side of nursing; fourth, generational difference towards nursing and fifth, the unfairness of treatment toward nurses. The study results suggested that there is a lack of engagement models in the Indian health-care delivery system, especially in the public sector. Nurses, while burdened with work, were found to be less valued and undercompensated at work, leading to low engagement and high turnover intention. Different generations of nurses had different views of the nursing profession. This study indicated a need to address nurse engagement according to age groups as the motivation of choosing nursing as a career has changed over the generations, resulting in varying degrees of engagement.

Keywords: Burnout, engagement, nursing, turnover intention


How to cite this article:
Bhardwaj S. Engaged or not?: A case study on nurse's engagement in clinical settings in India. Indian J Cont Nsg Edn 2022;23:95-101

How to cite this URL:
Bhardwaj S. Engaged or not?: A case study on nurse's engagement in clinical settings in India. Indian J Cont Nsg Edn [serial online] 2022 [cited 2022 Dec 7];23:95-101. Available from: https://www.ijcne.org/text.asp?2022/23/1/95/349820




  Introduction Top


A severe shortage of nurses coupled with high turnover rates poses a great barrier to achieve a sustainable workforce needed to meet the increasing healthcare demand of developing countries including India. Turnover intention is an immediate precursor of actual turnover.[1] The most common factors associated with nurses' turnover intention identified in recent studies are a gap between career need and career development programmes, job dissatisfaction, pay dissatisfaction and, low organisational and professional commitment.[2],[3],[4],[5],[6],[7] Engagement, often mistaken as a repackaging of job satisfaction or organisational commitment,[8] is much less researched in association with the high turnover intention of nurses. Nurse engagement reduces compassion fatigue, burnout, turnover and improves teamwork, as well as improves organisational outcomes such as building a positive work environment, high patient satisfaction and reduced patient errors.[9] On the contrary, the absence of engagement leads to burnout, reduced business outcomes and notably increased turnover intention.[10],[11],[12]

There has been a significant rise in the studies focusing on engagement among nurses including identifying the real-life strategies to increase engagement levels at the workplace. As Simpson (2009) identifies, there exist four major lines of research in engagement.[13] Lack of clarity between these different constructs of engagement and the idiosyncrasies of the nursing profession poses a challenge to understand the engagement of nurses in clinical settings. Engagement among nurses can be understood in two ways; one, nurses' level of commitment with the employing organisation; Second, their commitment to the nursing profession.[9] Engagement's direct association with turnover intentions and quality of care serves as a cause to explore the engagement among nurses' in Indian clinical settings. This study explores the various nurse engagement practices and elements of engagement, followed by health-care organisations in India and their perceived impact on the turnover intention of nurses.


  Background Top


The emergence of engagement at work can be traced back to the 1990s Kahn's model.[14] Kahn defined engagement as the 'harnessing of the organisation's members' selves to their work roles'. Kahn explained that when engaged, a person employs and expresses himself 'physically, cognitively and emotionally'. Conversely, disengagement is the 'uncoupling of selves from work roles'. Disengaged persons tend to 'defend or withdraw themselves physically, cognitively and emotionally'. Further three psychological conditions were explained that influence an individual's engagement and disengagement, namely: Psychological meaningfulness, psychological safety and psychological availability. Meaningfulness is a sense of investment. Safety is if an individual can employ himself without any fear of negative consequence to image or status and availability refers to a sense of possession of physical, emotional and psychological resources that will be needed to invest oneself at work. Further, in 1992, Kahn expanded this model. This expansion included the antecedents of engagement such as work elements and social systems, as well as the outcomes of engagement.[15]

The second conceptualisation of engagement presents engagement to be the direct opposite of burnout. Burnout is defined as 'a syndrome of emotional exhaustion, depersonalisation, and reduced personal accomplishment that can occur among individuals who do people work'.[16] Burnout is characterised by exhaustion, cynicism and ineffectiveness. An employee, while facing burnout deals with a high level of these three characteristics. On the contrary, an engaged employee has energy, involvement and efficacy at work. Another line of research is work engagement and employee engagement, which are used interchangeably. Work engagement can be perceived as a motivational concept. A person fully engaged strives to fulfill the challenges in the workplace. They are energetic and intensively involved in work. They do not hesitate to go beyond their roles. It is a positive fulfilling motivational state of work-related well-being characterised by vigor, dedication and absorption.[17] Work engagement can be seen in an organisation where companies have been successful to bring congruence between individual and organisational values. A clearly articulated value system can inspire a value system within the employee, making her fully engaged. As noted by Simpson (2004), the fourth conceptualisation of engagement is employee engagement. The employee engagement study led by Harter et al., which used the Gallup Organisation's research data, was a meta-analysis of 42 studies conducted in 36 different countries. This study provided empirical evidence for a relationship between employee engagement and business outcomes such as customer satisfaction and employee turnover.[18] Further, in 2003, Harter et al. delineated the model of employee engagement predicting four antecedents of employee engagement: clarity of expectations, feeling a sense of contribution to the organisation, a feeling of belongingness and finally, the realisation of availability of opportunities to grow and progress.[19] This model is very much in agreement with Kahn's model.[15]

In recent years, the private health-care sector has become more driven and has been promoting engagement through some real-life strategies. One such example is relationship-based nursing, also known as artful nursing. In artful nursing, the emotional needs of the patient are purposefully used to become more connected with him, so a memorable experience can be created for the patient and nurses to feel more involved in the caregiving process. Building a strong bond with patients makes nurses more fulfilled and satisfied, leading to high engagement.[20] Another real-life strategy to engage nurses at the workplace is mentoring, making nurses more familiar, comfortable and confident about their job.[20] Mentoring of nurses consistently improves the social relationships at the workplace, which is also the precedent of engagement. Participative decision-making, trust in senior management and a safe and effective grievance redressal system might lead to engaged nurses.[21]


  Methods Top


The present study is a combination of case study and grounded theory. A case study is a particular inquiry that usually answers 'how' and 'why' research questions.[22] A case study inquiry is relevant in a real-world context where the researcher wants to investigate a contemporary phenomenon and the boundaries between the phenomenon and context are not clear. This study uses a grounded theory coding mechanism to analyse the interview data following the sequence of open coding, axial coding and selective coding.[23] Over the time, use of the grounded theory coding technique has become a popular choice to analyse qualitative data.[24] Patton (1999) also recommends using grounded theory analysis for qualitative data.[25]

Sampling

For this study, nurses who were involved in direct patient care at tertiary care hospitals served as respondents. Participants of this study had qualifications (B.Sc. or above) as per the guidelines of the Indian Nursing Council and Indian Nursing Council Act 1947. The Indian health-care system is a mix of public and private health-care organisations and to ensure equal representation, participants were recruited from one public and one private hospital in Hyderabad. Both the hospitals are multi-speciality hospitals and are identified as the best in their own respective sectors, but due to the nature of ownership, human resources management in these two hospitals is considerably different.

Data collection

Interviews were the primary method of data collection for this study. Face-to-face interviews took place in the meeting room of hospitals. Interviews lasted for an average of 1–1.5 h. Participants of this interview were employed in various positions such as ward nurse, nurse educator and trainer, nursing superintendent and administrator. The age of the participants of this study ranged from 23 to 58. All of the participants belonged to the southern part of India. Interview questions were designed to answer two major questions. First, How Indian health-care delivery organisations are engaging nurses at the workplace? Second, if hospitals have some engagement practices, has this led to reduced turnover intention among nurses? The interviews were focussed on understanding the process and models of nurse engagement and their impact on the turnover intention of nurses. Since multiple sources of data collection are always a precedent for a good case study,[22] this study also used direct observations and field notes for the analysis. The researcher recorded observations into the patient wards, waiting areas of the hospital, nurse stations and reporting authority's office for a total period of 2 months.

Analysis

Interviews were recorded and later transcribed. Atlas.ti software was used for coding the data. Interviewees were recruited until the data saturation. The grounded theory coding process involves breaking down qualitative data into labels. Later, these labels are clustered into categories/sub-themes, finally merging into themes. A total of 17 interviews were used for analysis. Data were labelled with concepts and sub-themes were identified. In the final stage, these sub-themes merged into themes. For example, sub-themes such as 'feeling of being inferior', 'feeling of being devalued at the workplace', 'lack of respect from doctors', 'feeling of inequality' merged into the theme 'unfairness in treatment'. Theme 'leadership style and managements had sub-themes such as 'lack of a grievance redressal system', 'lack of participative decision-making', 'disagreement with authority' or 'perceived unfairness in skill assessment by senior management'.

Ethical declaration

Informed consent was obtained verbally before participation and participants were furnished with adequate details about the researcher and the purpose of the study. No personal data were collected. Initials have been used while quoting the statements. Approval was obtained before conducting interviews from the appropriate authority/officials (for public hospitals) and senior management. Nurses were assured about anonymity and confidentiality of data and were informed that data will not be used and will not be shared with their reporting authority in its individuality. Participants were informed that they have a right to decline to participate and can withdraw from the study at any stage.


  Results Top


Leadership style and management

The leadership style and management are very different in a public hospital and a private hospital. Private Hospital A has a dedicated HR team to identify employee engagement issues and address them, whereas government hospitals rely on a multitasking team of administrative personnel. Hospital A, after an internal survey, has designed a range of engagement activities to reinforce the positive behaviour of nurses towards the hospital. One such initiative is a sabbatical leave system that enables nurses to take a break from the job for further study or any other personal/professional issue. Exit interviews revealed that most of the nurses cited further studies as a reason to leave the organisation. These nurses often came back to the organisation looking for a job and re-employing them involved a lot of cost and paperwork. The sabbatical leave option has smoothened the process for hospitals and nurses who wish to join back the institution. These activities aim to increase the cohesion in the culturally diverse workforce, sharpen nurses' skills and expose them to international standards of healthcare.

On the contrary, in a public hospital being a bureaucratic system, there is very limited scope for participative decision making and implementing any such programmes on the organisational level. Public hospitals do not have any formal engagement practices. According to management, it is a difficult task. The overburdened staff and workload coupled with funding issues do not allow any for any such activities. If there is any issue or complaint, it has to be processed through various levels of authority. The time and cost involved in the grievance redressal system in the public hospital make the nurses lose his/her trust in the system. E complained, 'Someone should be there to address our complaints'.

MR is a head nurse in hospital B and is been working in this hospital for a long time. She has a passion for nursing and entered this profession even after her parents' denial. However, claims that the uncooperative and biased nature of management is the cause for her not being focussed on her job and constantly thinking about leaving. Another influencing factor is assigning wards to nurses on a random basis rather than based on their skill, experience and specialisation. K, who is currently employed in maternity wards but is specialised in the intensive care unit explained her current situation:

Many people are not being used properly in an area where they are talented. You are forced to do something, where you do not know the subject. The person loses his confidence…and he does not have a voice and is suppressed... There are no healthy relationships.

According to K, the authority has not been able to optimise the workforces' skills. Placing them in the right place might lead to fulfilment and satisfaction on the job, but there is no system to access her competence and potential. L from the paediatric ward stated:

If I look at the administration. I feel like leaving. However when I look at my senior sisters, who are so dedicated, I feel like staying. They are so dedicated but the problems are low salary, lack of benefits and the lack of coordination between the administration and employees.

E has been working here for a long time. Her idol is Mother Teresa, and she wants to set an icon for her juniors by working with dedication. She is working as a social worker also and has earned the reputation of 'Didi' among fellow nurses, was highly dissatisfied when she could not get the promotion despite being a deserving candidate. She expressed her dissatisfaction with the system saying '…this is all just a not-so-fair system. I am much more talented and deserving…but no! It was my chance…I feel like quitting. I will definitely leave...Could you please tell me if I have other career options'?

Throughout the interview, E reiterated that how the promotion of a less experienced candidate over her has increased her turnover intention significantly. She wants to leave the hospital or probably leave nursing and focus on her non-governmental organisation instead of waiting for some farfetched opportunities for promotion and career growth. The realisation of no opportunities to grow in the public-sector system has turned E dispassionate towards the profession.

It is not just the nurses who have disagreements with the authority. Few administrative personnel, trainers also feel that the higher authority is responsible for the inefficacy and disengagement of nurses. They think some of the major issues can be fixed by the initiatives of management.

I gave a suggestion that every Saturday some psychologists should take classes…so many nurses are from rural areas... They don't know anything about city life. After coming here, they are so confused and easily get trapped. If we tell them there won't be much effect but if some outsider teaches them that will have more impact. But you know the leadership. It changes every day.

As per S, who has been training nurses for over a decade, and Nurses who have never experienced the fast-paced and glittery life of cities face an adjustment issue. It is very easy for new entrants to get distracted from the job and the trainer was concerned about the career and future of nurses. By providing professional help she wanted to ensure that the new entrants remain focussed on their duty, but the management didn't find the trainer's idea appealing and it got rejected. Above all, a work-load at work and mandatory night shifts leading to a work-life imbalance was reported to be another cause for disengaged nurses at both the hospitals.

Social influence and nursing as a career of choice

Nursing in India is an intergenerational career and most of the participant nurses of this study were motivated or greatly influenced by their family members or some acquaintances to pursue nursing. A nurse had another nurse in the family by whom they were inspired to enter this profession. M (NS2) clarifies 'Well, I belong to the background where every second person chose this profession'.

The mindful choice of career and passion for nursing is a crucial element for engagement. L who is associated with public medical college and is about to retire recollected her teenage days 'My sister in law was a nurse. She used to wear that white frock and leave for duty. I was so inspired by her and that uniform. That time I decided I am going to be a nurse'.

However, the younger generation working at the hospital had opposite views. The simple motivation behind going for nursing was to earn and support the family. The government promoted contract-based recruitment drives to deal with the nursing shortage has provided employment opportunities to the rural populations, but a mere availability of employment does not generate the flare for nursing. In the absence of passion for nursing, one very crucial element appeared to be missing, personal engagement. AM, who has spent her life in nursing said 'My son wanted to be a doctor. I convinced him to be a nurse. Moreover, finally, it's his last year…I am happy…soon he will be a nurse'. Social influence emerges to be a significant underlying cause for choosing nursing as a career.

Philanthropic side of nursing

As stated previously, there exist multiple lines of research on engagement. The absence of a unique conception of engagement at the workplace has resulted in the vagueness of the policies and assessment mechanism. As far as the public hospitals are concerned, formal engagement programmes and policies were non-existent. The reason might be either lack of resources or non-realisation of the need for engagement of nurses. On the other hand, private sector hospitals, are actively indulged in designing engagement activities and assessing the level of engagement of nurses. As personal engagement is identified with the person's energy, vigour and dedication, a nurse's dedication to the job with the conscious choice of nursing, can be understood as personal engagement. Participants of the study exhibited an element of personal engagement, with an insignificant role of the organisation and its resources. As ME said 'Actually...I came here (in teaching) accidentally...But I wanted to be bedside only. I was a spleen victim. No spleen means more chances of getting an infection...This is why I joined here...Otherwise, I would not have come here'. ME wanted to be a nurse always. Despite the government hospital's unhygienic surroundings, understaffed wards and uncooperative leadership, ME has remained in this job and missed her bedside life. Nurses in the age group of 45–60 had a passion for nursing that defines their personal engagement, not work engagement. ME further adds 'This is the profession, I have chosen. God has given me an opportunity to work with patients. If a patient discharge and says. 'chalte h Amma' (Goodbye sister) and 'thank you Amma' (Thank you sister). Hence, whatever the recognition is there that was very satisfactory'. Another participant SM stated, 'Students must be dedicated. They must come with an intention... If I give care to the patient myself and the patient must be satisfied. That (motivation) should develop within the student'.

SM, here is explaining the element of personal engagement, which would lead to personal satisfaction and commitment to the profession, but it does not mean satisfaction with the organisational resources. They want to remain in the profession but might leave the organisation. Similarly, M said 'They have taught is 'service to humanity is the service to God'. I knew I wanted to be a nurse and became one. I am not here for a career or money. I am here to serve people'.

On the other hand, work engagement which is characterised by congruence between individual and organisational goals was absent from both the hospitals. Public sector hospitals have misunderstood the nurses' passion to serve humanity with the employee and work engagement and have used this as an excuse to not make sufficient provisions on a job.

The generational difference in nursing as a career

The approach towards nursing that emerged with this study, was the contrasting views about the nursing career in the different generational cohorts. The nurses who were in the age group of 50–60 or have spent considerable time in this profession does not consider it as a career or profession, more specifically, a mean to earn bread. According to them, nursing is a passion, a service to humanity, they chose this profession because they wanted to do something good for society on their part. The choice of the career was not driven by the idea of choosing a suitable profession, rather it was a conscious decision of serving mankind. S, expressed her views about nursing as a career saying 'Money, we can earn many ways. Whichever profession you choose, you should have a motive. And wherever I go, I must work with dedication'. As per S had they been career-driven women, they would not be here. They are here to serve the sick and sufferings, not to make money or a career. Similarly, NS grade 2, who is retiring soon and have spent her life in this job, said '…if it was for making a career, I won't be here... It's a service I chose to do. If you want to make money… go somewhere else. This is not the place for you'.

Whereas the younger generation is completely driven by the concept of career development, better working opportunities and monetary benefits. They are vocal about their career needs and the preference for better working opportunities is dominant in their decision-making process. B., who is currently employed in hospital A, said 'Of course! If I get a better salary and job position, I would definitely leave'.

These paradoxical statements are a reflection of the different motivations while choosing to nurse as a profession in different generations. It indicates that the motivation towards pursuing nursing has changed over the years. For nurses in the age group of 45–60, it was an opportunity to serve God by serving sick people, whereas, for younger generation, it's a job/career.

Unfairness in treatment

The unfair treatment of nurses on many fronts emerged as a cause of lack of engagement in this study such as inferiority of the nursing profession compared to doctors or unfair compensations. Nurses, despite being skilled and trained professionals, are often underutilised for the care purpose, not for treatment.[26] This treatment of nursing as a non-professional discipline makes doctors ignore their professional capabilities. A very similar attitude of management towards nurses emerged as a hindrance to performance in this study, especially in public sector hospitals. The health-care workforce has been conventionally doctor-centred and nurses are the overlooked part of the workforce. There was a consistent feeling of underutilisation of their skills among nurses. S, who is working at Hospital A's management team, says, 'It's all collective responsibility. You have to respect nurses. You have to treat them with dignity... This encouragement we do not have here... This changes their (nurses') attitude towards the job... Doctors should respect nurses.'

The respect for nursing as a career choice was much sought for the nurse in both the hospitals. Nurses felt they are not being valued at the workplace leading to a deterioration in their energy and dedication. The feel and sense of being the less valued section of the health-care team emerged as the major culprits for low personal engagement. There was a low sense of belongingness in nurses and admitted that this treatment is bringing them down. As M said, 'We should be treated equals. Doctors, management has to realise that we are one family. At that point, we would be able to optimise our services'.

Treatment of being the inferior workforce hinders nurses' engagement towards the job.[27],[28] Nurses have been reported to find nursing as an unsuitable career choice and not recommend someone else to take up this career. This feel of worthlessness eventually leads to an increase in turnover intention.[26]

This bias towards this profession is mirrored in the employment contracts too. Compensation, which plays a major role while choosing a profession, also emerged as a reason for the turnover intention in private sector hospitals. In India, hospitals have a very low salary band for the nurses even for the top management position. K, who became a relationship manager after serving bedside, trains new interns, pointed out:

They (nurses) have done a 4 year, 4.5 years' course. And they are equal to a graduate. If we take a person with a mathematical background that (he) is earning more than nurses. So, they (nurses) feel that dignity is going... Salary is of major importance...at the end of the day...it's all about how much you earn.

The scenario is little different in public sector hospitals, as they offer a better salary to nurses compared to private hospitals and other benefits such as Provident Fund, pension and gratuity. This superior labour contract does attract nurses to the public sector healthcare organisations however does not serve as the sole reason for staying in the hospital as suggested by participants of this study. M clarifies this part by saying 'It's a government job. It comes with benefits. Once you manage to stay here you will be earning more than private-sector nurses. They do not earn this even after years of service'. She further explained that the new generation is having a hard time dedicating themselves to the job. In the early stages of the job, they constantly find themselves eager to leave.


  Discussion Top


Five major antecedents of engagement among nurses emerged in this study. First, Leadership styles, second social influence on choosing nursing as a career, third, philanthropy, fourth generational difference towards nursing and fifth the perceived unfair treatment. Different generations of nurses had different views of the nursing profession. The motivation behind this job has radically changed over the generations. Older age group nurses showed a lower and rather insignificant need for engagement and were quite happy and satisfied with the job. They did show fewer signs of burnout in the absence of engagement programmes. Leiter et al. (2009) have noted a similar pattern in a study that states Generation x suffers a lower satisfaction than baby boomers and experiences more burnout.[29] The level of cynicism and exhaustion is much greater in the millennial generation and a greater turnover intention. Nurses who were close to retirement displayed a greater vocation (Vocation meaning 1. A job you do because feel that this job is a purpose of your life, especially because you want to help other people 2. A special ability for or devotion to a particular job or activity, especially one that gives service to other people: [Longmans Dictionary of Contemporary English, 1995)) towards the nursing profession, and an absence of the same was seen in millennials. Younger nurses, who have just graduated or spent a couple of years in this profession, repetitively, complained about the exhaustion at the workplace. Generation X and millennials had an elevated need for job resources as they felt more burn-out. It has been observed that the shorter tenure, the greater is the turnover intention.[29] The younger generation had more materialistic aspirations compared to nurses in the age group of 50-60, the latter considered nursing more of a service to mankind.

In public sector health-care organisations, no well-defined model of nurse engagement was found. However, the case A's approach to engagement was close to Harter et al. model for employee engagement. This model provides the clarity of expectation as the first need to engage the employee. Second, the employee has to have a feeling of contribution to the organisation. A sense of person-environment fit can induce this feeling of contribution.[19] If an employee thinks that he/she has chosen the right place to work and his/her skill is being utilised at the job, he would consider it a fit. This feeling is also influenced by relationships and developmental opportunities. A connection of love and care, recognition to an employee at the workplace can help grow positive emotions. At hospital A, managers recognised nurses by their names showed their concern for any discomfort nurses are facing. This induced a feeling of being valued and recognised in the workplace. The third condition is to promote a sense of belongingness via including the employee in the big picture.[19] Hospital A was promoting the behaviour of belongingness among nurses via social and cultural exchange. Managers expressed that they want nurses to attach the identity of the hospital with their own identity. They want them to say 'it is my hospital'. The fourth requirement is creating an environment where an employee can grow professionally. This study also acknowledged that besides all fulfilling engagement conditions, there is one more important factor, which affects the positive emotion of employees at the workplace, i.e., monetary benefits.[19] Non-fulfillment of financial needs impacts the turnover intention of nurses significantly. Similarly, in the private sector hospital, nurses frequently quoted their unfulfilled monetary needs as a contributing factor to their turnover intention.

In Hospital A, Educational programmes were successful to create a positive image of the hospital among nurses and nurses agreed that it is great for an employer to prepare them for future employment opportunities, imparting them the skills and knowledge they need to excel in their field. Every interviewee nurse agreed, that this strategy makes hospitals stand out from other hospitals. On asking nurses if the engagement activities have affected their turnover intention at any level, nurses expressed their satisfaction with the training and development programmes but appeared to be discontent on being under-compensated. Nurses repeated that if they get an opportunity to work for a better salary, they would consider leaving the hospital.

In Hospital B, nurses frequently expressed a high intention of leaving the job and attributed this intention to various issues such as salary, leadership and lack of workplace support. However, as the data provided by management suggested, turnover intention does not result in an actual turnover in this hospital. While this study does not explain this phenomenon, this could be due to superior employment contracts of a government job. Turnover might not be an issue here but public sector hospitals have various other consequences of disengagement such as unhappy workforce, absenteeism, deteriorating quality of healthcare which may lead to an overall performance loss for the hospital.

Apart from the compensation, nurses expressed a need for greater recognition of nursing as a profession. Privatisation of the health-care industry demands a large number of nurses to deliver effective health-care services, but the misconceptions related to the nursing profession have been playing a major role in the projected shortage of nurses.[30] The majority of countries do not provide due respect and dignity to the nursing profession.[31] Respondents, in this study also expressed their views that how the inferior treatment at work is affecting their engagement and performance at work. Years after the professionalisation nursing still suffers from various stereotyping. Be it feminine work, dirty work, polluted work, low-status work, or loose-woman work, every single term speaks of the stigmatisation of the job and exclusion from the category of professionals.[32],[33],[34],[35] The objectionable and wrongful depiction of nurses through media, ignorance and devaluation at the workplace and stigmatisation by society has negatively affected this profession.[36],[37] Expressions such as nobody cares for us or respects us affirmed a self-realised devaluation of nurses. Recent studies indicate that private health-care centres are putting a little more effort to make nursing relationship-centred to keep nurses engaged.[38]


  Conclusion Top


A projected shortage of nurses coupled with the high turnover intention of the existing nursing workforce has emerged as a worrisome issue for the health-care industry in India. This study, in the unique context of the Indian health-care delivery system, has attempted to dig deeper to understand the nurse engagement models, followed by Indian health-care organisations and their effect on the turnover intention of nurses, in public as well as private settings. A vacuum of engagement model in the public health-care system and a lack of a well-defined formal system of engagement in the private sector was found. Nurses, while burdened with work, were found to be less valued and under-compensated at work, leading to burnout and high turnover intention. This study also indicated a need to address the engagement per different generational cohorts as the motivation of career choice has changed over the generations, resulting in the varying degree of engagement. Nursing stands as a unique profession in various ways and above all being a female-dominated profession. The author suggests adopting strategies that support the natural roles of being a woman and lead to a better work-life balance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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