Resilience for working in Ontario home and community care: registered practical nurses need the support of themselves, family and clients, and employers

Abstract

Background

The context of practice is often not explicit in the discourse around the personal and professional resilience of nurses. The unique factors related to providing nursing care in home and community care may provide novel insight into the resilience of this health workforce. Therefore, this research addressed how nurses build and maintain resilience working in the home and community care sector.

Method

A qualitative study was conducted between November 2022 to August 2023 using 36 in-depth interviews (29 registered practical nurses [RPNs], five supervisors of RPNs, two family/care partners (FCPs) of clients receiving home and community care services). Analysis was consistent with a grounded theory approach including coding and comparative methods.

Results

The factors of personal and professional resilience were not distinct but rather mixed together in the experience of nurses having resilience working in the home and community care sector. The process of building and maintaining resilience as home and community care nurses was informed by three categories: (1) The conditions of working in HCC; (2) The rapport RPNs held with FCPs; and (3) The nurses’ ability for supporting the ‘self’. Multiple components to inform these categories were identified and illustrated by the words of the nurse participants.

Conclusion

The process of building and maintaining resilience by RPNs working in the home and community care sector was guided by the day-to-day experiences of providing care for clients and the conditions of being a mobile health care provider. However, nurses may sense when they need to support their ‘self’ and must be empowered to request and receive support to do so.

Introduction

Demand for home and community care (HCC) services is growing [1,2,3], commensurate with the global increase of older adults aging-in-place [4, 5], and rising number of people living with chronic health conditions [4]. HCC services provide health care for individuals of all ages at home, school, or the community [6]. The HCC environment has been described by nurses as unpredictable, while also ideally situated to support optimal client outcomes while ensuring effective and appropriate use of health human resources [7]. In HCC, nurses largely practice alone, outside the formal structure of an institution, with less opportunity for physical organizational protections [8]. In this sector, day-to-day working conditions may place more onus on nurses themselves to manage work stressors and to initiate reaching out for supports when needed, as opposed to other clinical settings, like hospitals, where peers and other sources of support are proximate. As a result, resiliency among HCC nurses may differ from how resilience is experienced by nurses working in other health care sectors. Understanding how HCC nurses build and maintain resilience in the context of HCC may provide insight into strategies for the recruitment and retention of this workforce.

Resilience came to the fore in health care workforce discourse during the Coronavirus 2019 (COVID-19) pandemic in response to the immense personal and professional pressures experienced by nurses. Personal resilience, as a construct applied to nurses in the literature, is the ability of the individual to cope despite adverse circumstances [9]. A definition of professional resilience for nurses was not found in the literature. And so, three sources were combined to represent the construct of professional resilience. Thus, professional resilience is described as the ability of a nurse to maintain personal and professional health while both facing stress on the job, including physical and mental health [10, 11], and maintaining clinical service quality [11, 12], resulting in personal and professional growth [13]. Previous research suggests that nurses draw upon their personal and professional resilience to counter the day-to-day challenges in the context of their work in health care [14, 15]. The development of personal and professional resilience has been shown to contribute to nurse retention across a variety of clinical settings other than HCC [11, 13, 16,17,18].

In Ontario, home care organizations are contractually obligated to the provincial government [19]. In Ontario, referral rejection rates for HCC nursing jumped from 5% pre-pandemic to 30% by August 2021 secondary to the shortage of nurses working in the sector [20]. The demands on the HCC system are felt by nurses who are asked to take on increasingly larger caseloads. The increased home care client caseload resulted in part when many nurses and other home care providers abruptly left the HCC sector to take up new and better-paying positions in acute care settings and public health roles that were added during the COVID-19 pandemic to meet new patient care needs (such as contact tracing, vaccinations, and COVID-19 assessments) [21]. The HCC workforce was left in a state of crisis [21]. Maintaining recruitment and retention of nurses in the HCC sector was an ongoing challenge before the pandemic [22,23,24], with continually increasing year-over-year demands for HCC services [2]. Previous studies of community nurses, who comprise approximately 22% of the HCC workforce in Ontario, Canada [25], reported that the most substantive reasons for low nurse recruitment and retention were high workload [26], employment insecurity [12] and latent workplace violence or harassment [27]. Moreover, the inherent challenges associated with practicing as mobile care providers, and unpredictable schedules to accommodate patient care needs [28], impose difficulties for recruitment and retention in this sector. The negative effects from the COVID-19 pandemic persist for nurses in HCC working conditions including burnout [29,30,31], heavy workloads and lower wages [7, 32]. Moreover, nurses reported experiencing fear and anxiety working in-person with clients during the pandemic globally [33]; responses that were particularly pronounced among nurses working in clients’ homes [34,35,36].

Registered Practical Nurses (RPNs) comprise a large segment of the nursing workforce in HCC in Ontario, Canada. RPNs provide a range of health care services integral to meeting the growing health care needs of patients in this sector [32, 37,38,39,40]. RPNs are a category of nurse in Ontario with similar scope of practice as Registered Nurses (RNs), albeit differentiated according to education (i.e., RPNs hold credentials accredited at the diploma level whereas RNs are licensed at the baccalaureate level). RPNs and RNs share the core values of providing safe, compassionate and ethical care [41, 42]. To facilitate comparison, it is of note that RPNs provide nursing care with some similarity to Licensed Practical Nurses (LPNs) in other Canadian provinces [43], Enrolled Nurses (ENs) in Australia [44] and New Zealand [45], and Associate Nurses (ANs) in the United Kingdom [46]. Nurses in HCC largely manage their own schedules, in that they receive a referral for a new client and have the choice to accept or decline [28]. However, home care organizations often dictate the length of time they can spend with a client, which can leave the nurse feeling rushed during visits [47].

Statistics from a 2022 survey by the Registered Practical Nurses’ Association of Ontario (WeRPN) support the growing crisis in the HCC workforce. RPNs working in this sector reported experiencing burnout at unprecedented levels, abandoning the sector due to lower wages, employment insecurity, high levels of moral distress, and declining mental health due to work-related stress created by short staffing [13]. Despite these challenges, some RPNs chose to continue working in HCC throughout the COVID-19 pandemic, and remain in the sector today. There is currently a gap in the research literature related to the resilience of HCC nurses, and how this construct influences nurses to stay in the HCC sector. Therefore, this study aimed to explore the personal and professional resilience of RPNs working in HCC to inform recruitment and retention strategies for this critical nursing workforce. The overarching research question guiding this study was “how do nurses working in home and community care build and maintain resilience”?

Methods

This study used a constructivist grounded theory approach [48] to co-construct knowledge of personal and professional resilience of nurses working in the HCC sector from research participant HCC experiences. The co-construction of new knowledge considers historical, social and cultural contexts [49]. To develop a rich understanding of personal and professional resilience of nurses in HCC, interviews were conducted with RPNs working in HCC, RPN supervisors in the HCC setting, and family/care partners (FCPs) of clients receiving home care services from nurses.

Ethical considerations

This study was approved by the Western University Research Ethics Board (REB: 2022-120941-70131). Study participants were informed that they could terminate the interview at any time and decline to answer any question(s) they wished not to answer. Confidentiality was maintained by de-identifying personal characteristics from interview transcripts and thereafter referring to interviews by a numerical identifier. All data were stored on a secured institutional One Drive online account that was only accessible to the research team.

Participant group of focus

For this research study, we chose to focus on RPNs as a specific segment of the nursing workforce who are strongly represented in HCC (e.g. work as direct care coordinator, clinical educators and supervisors) and provide the majority of nursing care in this sector [25].

Sampling

Charmaz [48] supports the concept of ‘sampling adequacy’ [49, 50] whereby the size of the sample is determined by the appropriateness of the participants and the amount of data used to describe the phenomenon and identified concepts. As such, the recruitment and interviewing of RPNs, RPN supervisors and FCPs continued until the phenomenon was adequately described by participants. Initially, purposeful sampling was used to recruit participants [51], and snowball sampling was used subsequently to increase access to RPN supervisors and FCP participants through participants’ networks [52].

Inclusion criteria and recruitment of RPN participants

RPNs working in a variety of HCC settings (including client homes, schools or retirement communities) since January 2020 were eligible to participate in the study. Other healthcare professionals, including RNs, Personal Support Workers and nursing students, were ineligible. Eligible RPNs who had participated in an online survey (recruited through emails and social media sent by WeRPN) were asked at the conclusion of the survey if they were interested in participating in a virtual interview. The interview was briefly described to participants as being comprised of a set of questions intended to elicit RPNs’ perceptions about personal and professional resilience while working in HCC. Interested participants could use an online link to access an alternate letter of information describing the purpose of the interviews and to complete an electronic consent form, giving permission for research candidates to be contacted by a member of the research team to schedule a virtual interview.

Inclusion criteria and recruitment of supervisors and FCPs

Emails and social media posts distributed by WeRPN were also used to recruit supervisors of RPNs. Additionally, snowball sampling, based on referrals received from RPN participants, was used to identify supervisors and FCPs for recruitment. Further, to recruit FCPs of clients receiving home care services, electronic flyers were emailed to community centres and libraries, and an advertisement was placed in a local online newspaper. Interested supervisors and FCP participants followed an embedded electronic link to the letter of information outlining the study’s purpose. In the electronic letter of information, research candidates were able to provide their electronic informed consent to be contacted by the research team to schedule an interview via a virtual platform (i.e., Zoom).

Interview guides

A separate interview guide was created for each of the three groups of participants - RPNs, RPN supervisors, and FCPs. Interview questions were developed by the research team using an iterative process informed by reviewed literature on personal and professional resilience among health care providers, including RPNs, and expertise as researchers and/or nurses in HCC. The research team included collaborators who were RPNs and RNs with experience working in HCC to ensure the interview questions addressed relevant concepts and were tailored to the HCC context. The interview guide developed for the RPNs asked questions such as what does resilience mean to you?, what does resilience look like and feel like for you working in the home care sector?, what do you like about working in this sector and what is challenging for you as a home care nurse? The interview guide developed for RPN supervisors asked questions regarding their experiences working with RPNs such as, what do you look for when recruiting RPNs?, what health and wellness supports are in place for RPNs within your organization?, how do you promote balance for your staff? Finally, the interview guide for FCPs asked questions regarding their experiences interacting with RPNs in their respective homes. The questions included tell me about a great experience you had when the nurse came in, tell me about how you feel about a nurse coming into your home to provide care during the COVID pandemic, how does the experience of having a nurse in your home compare to the nursing care you (have) receive(d) in other settings? (see interview guides in Additional files 1–3).

Probing questions were added to elicit further information from participants as necessary (e.g., “what do you mean when you say, ‘X’?”). Data analysis was ongoing, in an iterative fashion, to inform subsequent interviews and contribute to the developing theoretical model of how nurses build and maintain resilience when working in HCC. Data collection ceased when no new knowledge was shared by participants, indicating that sufficient data was available to address the identified research question.

Data collection

After obtaining the informed consent of research candidates to participate, RPNs, supervisors and FCPs were invited to complete a brief online survey of demographic questions to provide information about the study sample. Interview data from RPNs, RPN supervisors and FCPs were collected during semi-structured one-on-one interviews with one or two female study authors (postdoctoral associates KP, MH) using the secure Zoom platform licensed by Western University. Both interviewers had extensive training in conducting interviews at the doctoral level. No research team member had relationships with any of the participants. Interviews were completed between November 2022 and August 2023 on a day and time of the participant’s choosing. Interviews were guided by a semi-structured interview guide created by the research team. At the onset of the interview, participants were reminded of the study’s purpose and were asked to provide their verbal consent for the interview to be audio recorded. Memos were written throughout the data collection phase to enable and support processes of reflexivity [51]; these were included in the study data and informed the data analysis to provide greater context of the research findings.

Data analysis

All de-identified interviews were transcribed verbatim, either by a member of the research team or by a professional transcription service. In line with a constructivist grounded theory approach, data analysis entailed two-step data coding, comparative methods, and reflexive note writing to build conceptual analyses and the construction of a theoretical model [51, 53].

Prior to coding, all transcripts were read several times so the researchers could familiarize themselves with the study data. Three authors were engaged in the coding process (KP, AG, DC). Data were coded line-by-line and organized using the qualitative research software NVIVO Version 14 [54]. Once the data were coded line-by-line, analysis progressed to focused coding, that is, the process of combining observations and codes between participants to create units of meaning, or categories. A constant comparative method of analysis allowed the research team members to iteratively compare participant experiences with the developing categories [8]. The data analysis process assisted in conceptualizing the intersecting elements of personal and professional resilience of RPNs into a theoretical model.

Positioning of the researchers

A component of constructivist grounded theory is developing and maintaining methodological self-consciousness by the researchers to be aware of any biases and unearned privileges that may emanate from their positionality and worldviews [48, 55]. As such, the three authors completing the coding and data categorizing acknowledge their white Anglo-North American background, advanced research education and positions as academic researchers within a research-intensive institution. Also, they acknowledge their individual clinical lenses, as that of nurse, physiotherapist and recreation therapist, which influenced and informed their understanding of the study data.

Rigor

Three quality criteria commensurate with grounded theory [51], namely originality, resonance and usefulness, were used to ensure rigor throughout the study. Originality in the data was sought by gathering experiences about the resilience of RPNs from RPNs themselves, their supervisors, and the family of the clients of whom they provide care. Considering the experiences of three key perspectives (i.e., supervisor, care professional and FCP) together provides an original perspective on nurse resilience and contributes new understandings about how RPNs working in the HCC sector maintain their resilience. Quotes obtained from all three sample groups illustrate the categories used to develop the theoretical underpinnings of this model (i.e., resonance). The study findings may inform future research and the development of work resilience resource modules, informed by care professionals, supervisors and FCPs in the HCC sector (i.e., usefulness). Additionally, the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist was used to improve rigor, comprehensiveness, and credibility of the study [56] (see Additional file 4).

Results

Participants

Demographic and interview data were collected from 29 RPNs, five RPN supervisors and two FCPs. Together RPNs and supervisors of RPNs (n = 36) comprised five of the six Ontario Health Regions (West, n = 15 (41.7%); Central, n = 11 (30.5%); Toronto, n = 5 (13.9%); East, n = 4 (11.1%); North East, n = 1 (0.03%); and North West n = 0). The duration of interviews spanned 20–90 min (median 60 min).

The average age of RPN participants (n = 29) was 35.6 years (ages ranged from 24 to 65 years) and included 19 women (65.5%) and 10 men (34.5%). The average number of years worked as an RPN was 10.8 years (ranging 3–47 years), the average number of years worked in HCC was 6.8 years, (min, max = 2, 21 years), and the average number of hours worked per week was 39.7 h (min, max = 5, 58 h/week).

The average age of RPN supervisors (n = 5) was 32.5 (min, max = 29, 36 years); the sample included four women and one man. The number of years working as a supervisor in HCC ranged from four-five years to 12 + years. Four out of the five participants had Practical Nursing diplomas and one had a Bachelor’s degree. Four of the five had worked in the institutional Long-Term Care (LTC) sector in addition to HCC. Two supervisors had worked in sectors other than LTC and HCC.

Two FCPs participated in interviews. Both participants were women (aged 27 and 30 respectively) and lived in two-story houses in the Central Ontario Health Region with their family member receiving HCC services. The family member of one participant was receiving HCC services for 7–12 months and the other for over five years.

The process of building and maintaining resilience

The process of building and maintaining resilience in the nurses of the study was guided by the day-to-day experiences of providing care for clients in the HCC setting. This process was conceptualized as ongoing, since the capacity of the RPN participants to provide health care was under fluctuating influences of favorable and negative conditions. New variations in the day-to-day work of health care provision were described, including client-specific needs, status of interpersonal relationships, and navigating the challenges of working as a mobile health care provider. Distinctions between factors of personal and professional resilience that contributed to building and maintaining resilience in the nurses were not found. Rather the factors influencing resilience expressed by the nurses were drawn from both constructs of personal and professional resilience into an experience of work resilience. The process of building and maintaining resilience by the HCC nurses was comprised of three categories based upon participants’ descriptions of how they continued working in HCC: (1) the conditions of working in HCC; (2) the rapport RPNs held with FCPs; and (3) the nurses’ ability for supporting the ‘self’ (see Table 1). Analysis revealed that personal and professional resilience were not separate entities but were intertwined, with individuals demonstrating characteristics of personal and professional resilience while working in HCC settings. Moving forward, the term ‘resilience’ will be used to describe the experience of the nurses in this study.

Table 1 The categories and respective components that contribute to the process of building and maintaining resilience of nurses working in the HCC sector

The conditions of working in HCC

The conditions of being HCC nurses

Participants reflected on various attributes of the HCC sector that shaped RPNs’ nursing practice, particularly with reference to their ability to adapt to challenging situations, thereby building and maintaining resilience. RPN participants described characteristics of working in the HCC sector that were both beneficial and challenging to their ability to cope with the job. Positive aspects of the role that helped nurses to maintain resilience included being able to provide care so people can stay in their own home/at school/community, building relationships with clients and FCPs, flexible hours, and being afforded autonomy in their practice. In contrast, low wages, staff shortages, burnout, heavy workloads and unsafe environments increased stress and constrained nurses’ ability to provide care in some situations:

Community care is very high risk because you go into hotels and provide care on the side of the road if you have to…[I’ve had] a couple of incidences where I’ve been attacked in people’s homes and on the side of the road. (RPN6)

Extensive travel with limited reimbursement is an HCC-specific challenge that was an issue for some participants. One RPN participant stated, “…New tires, oil changes, all my gas receipts, anything related to the vehicle would be just a tax write-off, but the expenses itself associated with the upkeep of the vehicle, you are responsible for it” (RPN13). Some participants did not have access to a vehicle of their own, which posed its own challenge in the performance of their work, “I don’t have a ride for now. Trying to transport myself to my patient’s home has been so challenging for me” (RPN14). Another RPN participant noted that HCC was the “lowest paid sector in healthcare” (RPN3).

Although there were many challenging characteristics of the sector, RPNs also discussed the benefits associated with working in the community. For instance, flexibility of hours: “It’s very attractive to a lot of people that have children in school” (RPN28), and the autonomy, “I love it…the freedom we have. I love the flexibility…” (RPN5). One RPN described the environment as “dynamic, it is fast paced and it is – every day is kind of different, which is why I fell in love with it…” (RPN10) and the sense of “calm [as compared to the hospital setting]” (RPN27) that emanated in it. RPNs also preferred attending to only “one person at a time” (RPN18) and working in a community in which they had some familiarity. The RPN participants suggested that positive aspects of the job served as promoters of resilience, “…which is why I stayed in [HCC] as long as I have” (RPN10).

Supervisor and organizational influences

RPNs were supported by their leaders through the ongoing availability and dependability of supervisors. One RPN participant reported that supervisors were available to teach new skills when necessary, “Management…they could be available if you had any questions, like, if you needed to learn something, a new skill or what not…which was really good” (RPN3). Others found their supervisors were a “great resource” (RPN8), “compassionate and passionate about helping other people” (RPN19), and “supportive” (RPN24). One participant noted, “…If I had issues at work, I would speak to [my supervisor]…let them know about my professional problems” (RPN22).

Supervisors supported their staff by being approachable and within reach e.g., “…as a supervisor, I tend…to be accessible for the RPNs” (Supervisor3). RPN supervisors reflected on their past experiences as point-of-care nurses, which impacted how they led their teams of RPNs in HCC. Additionally, supervisors supported RPNs by providing training, educational opportunities, team building, and access to resources. One participant discussed establishing a buddy system when RPNs first started their jobs to help them become more comfortable with their skills before being on their own:

They shadow one-to-one with somebody for usually two to three shifts and then often what we do is we buddy them with somebody for the first six months… I know years ago when I was a new nurse, I had that and that’s kind of why we started it because it just stuck with me and how supportive it felt in the first - especially when you’re out in the community …you have to kind of critical[ly] think very quickly and problem solve and it’s really nice to have that (Supervisor1).

In contrast, in some professional experiences, RPN participants reported that they did not feel like they received adequate support from their supervisors. One participant suggested that management should be checking in more on nurses to promote their personal well-being, as “they can do a better job allowing nurses to disconnect…, and part of it is because I don’t believe management is doing enough check-ins to see how much nurses are actually working” (RPN6). Another participant felt they were asked to complete tasks that were unethical (asked to work beyond their clinical abilities), had insufficient clinical practice support, and experienced difficulty advocating for themselves.

Sometimes your supervisors would put you in scenarios that are ethically not right, and if you stood up to them… ‘that is not within my scope’, it was just really difficult…it was not like a floor where you can consult with another nurse. […] You really had to know your own scope of practice well because I think just at the end of it, they didn’t really care about what you knew, they just cared that the visit was filled, and that the job was done. (RPN13)

Perceptions of support for their nursing work during the pandemic influenced how RPNs felt about the value of their work. One participant reported feeling inadequately supported by their organization during the COVID-19 pandemic, “My organization did not do anything [to support] us…even like on nurses’ week during COVID, we didn’t get an email to say thank you. Like, we got nothing]” (RPN7). Despite feeling a dearth of support from some of their organizations at times, RPNs persisted in providing care.

The rapport RPNs held with FCPs

Familiarity shown by nurses impacted patient and FCP experiences

RPNs, supervisors, and FCPs all emphasized the unique nature of home care, underscored by lasting relationships between nurses, clients, and their care partners. Considering the complex interplay of benefits and challenges faced by RPNs in HCC, each nurse seemed to identify influential attributes of the environment that helped to build and maintain resilience, including in their interactions with FCPs in client homes. FCP participants described positive experiences they had working with nurses in their homes. They recognized sector-specific challenges and praised how nurses persevered in maintaining safe environments and professional conduct for the FCP and their family member receiving HCC services, despite the various and ongoing difficulties they faced.

FCPs expressed gratitude for their experiences with the RPNs, describing them as “kind, nurturing [and] caring” (FCP1). Moreover, FCPs seemed to value if their RPN “never felt rushed during visits” (FCP2) and when “nurses always paid full attention [to their family member] while working” (FCP2). One FCP participant supported the notion that some RPNs “felt like family” (FCP2) and an RPN participant described it as “being a member of [their] unit” (RPN6). Another RPN participant had described the relationship with their patients as “trusting”, as it had been “built over time” (RPN14), allowing for the development of a comfortable working environment. The other care partner participant suggested that RPNs who had a similar cultural background and spoke the same language as their family member receiving services made a “really big impact” in care provision (FCP1).

There were some days where I wasn’t able to be home and I felt perfectly comfortable leaving my loved one at home alone, knowing that the RPN was going to come because there was no language barrier. My loved one felt very comfortable with them as well. I think that was a very positive experience. (FCP1)

Care partner compassion for nurses in the HCC sector

The FCPs affirmed the respect they had for HCC nurses in the face of health system challenges. One participant reinforced the notion that RPNs carry heavy workloads due to the nursing shortage and are significantly underpaid, “…they’re really short-staffed…and they’re really severely underpaid. I think they do a lot of the legwork of our healthcare system…” (FCP1). The other participant acknowledged the long hours they work, “Sometimes they’re working really long hours and I know it’s not an easy job for sure, and that’s why I really do give my ultimate respect for the nurses and what they do, I’m really grateful for all their help.” (FCP2) One of the RPN participants added that having a “well-established relationship” with their ongoing patients was conducive to being able to “pull back their availability” when they needed to engage in self-care (RPN4).

Nurses’ professional conduct cultivated a safe caring environment

The FCPs discussed having positive care experiences when RPNs maintained a high level of professional conduct, suggesting that it helped them to build a sense of trust and safety between nurses, clients and care partners. For example, RPNs who followed COVID-19 protocols in their home helped FCPs feel safe (FCP1 & 2). One FCP indicated the RPN “always addressed their concerns” (FCP1) regarding the client receiving home care services. The other FCP shared that they trusted their nurse to be careful when entering their home:

…I remember at the beginning of the COVID-19 pandemic the nurses would wear a shield, a mask, as well as like this yellow gown that they would always put on when they come in and remove when they [were] leaving. That gave me a little bit of peace of mind, knowing that they did take all the necessary precautions and measures as they could to be as careful as possible. (FCP2)

Some of the RPNs maintained a professionalism mindset of “I’m going into their home, how do I need to act…” (RPN6) to help support their therapeutic relationship with patients.

Both FCP participants reported that they had positive experiences with HCC services most of the time, but there were times when RPNs did not demonstrate the highest level of professionalism. One participant shared an experience about when an RPN asked inappropriate questions, and it caused the FCP to feel uncomfortable (FCP2). This had happened on more than one occasion but was not frequent. One RPN participant admitted that maintaining professionalism with patients was challenging sometimes when they had a close relationship, “it’s very hard on the patient’s side…as well as my side to keep completely professional in a care provision role” (RPN4). These occurrences notwithstanding, FCP2 reiterated the gratitude they had for the positive experiences they had with the HCC nurses. Through these positive experiences and development of relationships with FCPs, the RPNs could cope with challenges encountered on the job.

The nurses’ ability for supporting the ‘self’

Evidenced in RPNs’ stories were depictions of decisions to protect and support their sense of ‘self’. RPNs in HCC suggested that setting boundaries, self-advocacy, seeking support, maintaining professional conduct, and having passion for their profession contributed toward building and maintaining their resilience as nurses in the sector. Additionally, RPN supervisors shared stories that showed support of the characteristics of RPNs that help them to maintain resilience in HCC.

Setting boundaries for well-being

RPN participants described how they set boundaries for themselves and their clients to safeguard their well-being to continue working in HCC. One participant expressed that it was their responsibility to set those boundaries, “if I don’t put the brakes on, nobody else will, right?” (RPN28). RPN participants set boundaries for themselves to keep their work and home life separate:

I try to work hard through the day, so that I don’t have a lot of things that are lingering at the end…I turn my [work] phone off, so that I am not tempted to look at emails in after-hours, or if a phone call comes in because that never ends; home-care is 24/7 round the clock, there is never down time. (RPN3)

Boundaries were also set with clients. One participant suggested that having been assertive about safety parameters in a client’s home helped them build rapport and their working relationship with the client. The RPN reported that some clients used drugs regularly and would have their drugs and paraphernalia visible during visits, which interferes with the home care organization’s safety policy. The RPN needed to set a clear boundary with the client to ensure these rules were not breached. They described, “…my first step is to walk in the door and put down a boundary very clearly. […] I make sure that the safety is assessed and report back. I can be very firm on these points.” (RPN28).

Further, participants described setting boundaries with their employer organization by putting a limit on the amount of work they would accept to cope with the heavy workloads “…boundaries are a big thing. We may get pressured to do extra or do more after hours, and just say ‘no’, like it’s okay” (RPN3). Taken together, establishing boundaries was a method of job containment that would leave space for RPNs to pursue hobbies, leisure activities and self-care processes that helped them maintain their professional health. One supervisor shared that they hired RPNs who had hobbies outside of work, knowing that these could help counterbalance work stress. The participant indicated this decision came from personal experience about the importance of separating work and personal life, “I’ve had two cell phones for the past nine years, and being able to put those down is not always easy. It’s something that I burnt out from a couple of years back…” (Supervisor2).

Engaging in self-advocacy

RPN participants explained how they advocated for themselves to maintain their personal well-being in the HCC sector. This included advocating for their safety by declining unsafe visits and working to change unfair and/or inadequate policies. Participants emphasized the importance of individual nurses demonstrating self-advocacy to maintain safety in the HCC sector: “If it’s that big of a threat…why are you sending anyone in there at all? In community, it’s up to each nurse to advocate for themselves” (RPN28).

Another participant described proposing a change to their current policy at work that helped create a safer work environment for themselves and their clients:

I had already been attacked a few times…because my last one was pretty recent, I had rejected this visit and said I wasn’t going to do it. […] I wanted [an] escort… Prior to [COVID-19 vaccine mandates], our companies provided us escorts because they had the staff available…following [COVID-19 vaccine mandates], we don’t have the staff to provide escorts for safe visits. But regardless I refused. I said provide me an escort or I’m not going. […] I proposed an alternative plan to escorting…I am going to offer a solution to make this a safe visit for myself and the patient, which I did. (RPN6)

In addition to safety concerns, participants noted that RPNs needed confidence in recognizing what required their attention most in their self-advocacy endeavours because, as a healthcare professional, they are responsible for maintaining their own license to practice. “Especially in a new job nobody is really good at advocating for themselves especially at the get go, but you are responsible for you and your license, and your growth…” (RPN13). Part of being responsible for themselves included advocating for further training and education:

The new hire will get two weeks of in-car training with another nurse, and… really advocating [that] I need more than two weeks, I need more time. I have not been exposed to the things that I need to be exposed to or I don’t have the connections that I need to have… self-advocating is the biggest thing…(RPN13).

Moreover, supervisors indicated that they hired RPNs with “leadership skills” (Supervisor1) and “critical thinking skills” (Supervisor5) as these would be key attributes in succeeding in their role as an RPN in HCC settings.

Receiving extra support from partners, families and friends

Several RPN participants discussed receiving extra support from partners, family, friends, patients, and the community while they continued to work in HCC. They expressed feeling motivated and grateful from the support they received:

…The motivation most times, pushes you…a little bit of motivation keeps the person going. Motivation most times is not in monetary form. Can be emotional support, right, it could be words of encouragement. (RPN12)

The RPNs also expressed receiving support from patients when they did a good job, “They say, you are doing a good job…people that work in organizations always like it when they get praised…Simply we can then feel good” (RPN17).

Some RPN participants provided examples of how their friends and the community showed support and appreciation for the work that they did in the community, including dropping off food at their homes and sewing masks, “I have a friend who works for the ballet as a seamstress, and she made me about 20 masks…just out of their own goodness…and it was just lovely…because we were desperate” (RPN4). However, some participants did not feel supported by their communities during the pandemic. “What did [my community] do? They did nothing” (RPN10). Although at times they lacked support from their community, the RPNs continued to provide care and kept their patients safe during this challenging time of COVID-19.

Seeking help in the professional context

In addition to receiving external support, participants turned to their organizations for help when confronted by adverse circumstances and conditions in the HCC sector. Several RPN participants sought assistance from their supervisors, peers, and online counselling for personal and professional issues. One participant obtained professional help because they did not want to burden their spouse with challenges they faced at work. Instead, they chose to speak with a counsellor, “… I couldn’t always talk to my spouse or my family about everything that’s going on at work and I don’t want them to bear that either, so the counselling definitely was very supportive” (RPN11). Online counselling helped the participant to manage their self-care, “…taking those little breaks to focus on yourself…just to like hit refresh, I think that really helped me. It helped me form some healthier habits… I started going to the gym again, which was great” (RPN11). Supervisors were also readily available to support RPNs when necessary. For example, they were able to empathize with RPNs if they were experiencing challenges on the job, “My supervisor… he has had experience, and he knows – can relate to what I am saying. He makes sure he gets every detail and motivate[s] [the] best he can” (RPN19).

Some RPNs sought support from their peers because they understood what they were going through, “it would be, ‘just vent if you have to vent. If you have to cry, you have to cry’” (RPN11). They in turn offered support to their peers. For instance, one participant discussed how they would take on extra burdens to support their peers, “If I have a co-worker that’s struggling…I want to be the one to say, ‘okay, what can I do?’ Even though my plate is up to here…” (RPN11). For some participants, seeing their peers engaging in clinical skills taught in training and seminars provided them with the motivation to improve their own practice, “I see not only myself, but other nurses and my seniors implementing the things we have been taught in the seminars and the trainings…I think that also motivates me to try hard and be better” (RPN24).

Leaning on professionalism

RPN participants chose to maintain their professionalism when working with others, despite challenges and incidents of discrimination they faced while working. For instance, some participants experienced racism from patients, but chose to ignore their comments and continued with their professional obligations nonetheless:

I have learnt to ignore stuff like that…people that are racist don’t really know much…if they are being rude, I would report to my superior and all that, but I’ve learned to ignore them, and just go about with my duties. (RPN24)

Another participant insisted on not letting the patients’ attitudes affect them, “I just told myself that I need to help them… I don’t let the bad attitude bite…” (RPN18).

Passion fuelled professional identity

RPN participants projected passion for their role, how they enjoyed “making people happy” (RPN29) and shared how being a HCC nurse was a key part of their identity. They described their enthusiasm for delivering quality patient care in the community: “The community has helped me so much in my growth, and I feel that it is time I should give back to the community” (RPN14). They also discussed the influence of seeing the impact of their work, and how their professional identity helped them push through difficult times while at work. HCC nursing allowed RPNs to connect with people and support them to live in their own homes:

I [love] connecting with the people in the community and I like hearing their hobbies, what they still do, what they used to do, where they used to live. But most importantly I like that we’re helping them stay in their home. (RPN11)

For some RPNs, home care nursing was more than just a job, and this sense of purpose helped them persevere through trials and tribulations: “No matter what, my patients are the priority. I’m not after money, I’m after [their] well-being.” (RPN12). Similarly, another participant shared, “If you see [the job] not just being the means of income…. a profession you love so much, you tend to tolerate people.” (RPN14). Passion for their professional identity helped them to push through challenging times, “…I don’t overthink, and I always find a reason to keep on loving my job. I don’t want to find any reason to hate what I do because I have grown to love who I am in my profession” (RPN20). Perseverance and pride in their profession ultimately contributed toward cultivating resilience, which allowed them to continue their work in the HCC sector.

Discussion

This grounded theory study described how the conditions of working in HCC, the rapport RPNs held with FCPs, and the nurses’ ability for supporting the ‘self’ were components for building and maintaining resilience as nurses working in the HCC sector. Sustaining and building the nursing workforce in the HCC sector is a global concern [57]. As such, strategies to recruit and retain the health workforce in this sector are critical [58]. The study findings add to the extant body of knowledge by providing insight into the influence of contextual factors for resilience in HCC nurses working in HCC. Previous research has theorized that resilience among nurses is influenced by context, including resources, policies, practices, and time [9, 17, 59]. The results of this research support those of Cooper et al. [60] in suggesting that, for nurses to remain resilient, they must draw upon their own resources in addition to supports from their work environment, organizations and communities. Moreover, similarly to Cooper et al. [61], the findings from this study revealed that when supervisors showed support and understanding to their staff, resilience was maintained; however, a lack of support resulted in feelings of increased stress and diminished resilience. However, because the supervisor participants in this study were RPNs themselves, it is possible they could relate to their staffs’ experiences and may have been more understanding of their situations than supervisors with different healthcare provider backgrounds.

Within the HCC health service sector, there are particular contextual attributes, which uniquely influence nurses’ experiences in care provision. For instance, the construction of caregiver roles and client relationships are negotiated differently in a home setting [62]. While rapport remains central to relationships between nurses and clients in the home, there are inherent risks in providing nursing care in clients’ homes [63]. There may also be an ‘emotional cost’ to home care for nurses taking on the weight of their clients’ concerns [64]. As such, there is a two-sided vulnerability that must be addressed. To empower nurses to ask for supports, care for themselves, and build relationships with clients and their care partners, organizational leaders must provide their nursing staff with opportunities to foster these behaviours based on their passion for the profession and the support they feel from nurse-client relationships. Addressing compensation, including increased wages and reimbursement for travel-related costs, would help HCC nurses to feel more valued. Additionally, greater support for nurses’ self-care – including boundary setting and advocacy skills, as well as encouragement from family, friends, supervisors, patients and the community – may make an invaluable contribution to nurses’ development and maintenance of resilience.

The current study found that nurses’ experiences of resilience at work in the HCC sector appeared to be formed from a combination of personal and professional resilience. The inseparable factors of these ‘resiliencies’ in the HCC nurses aligns with the personal and professional resilience description posited by Norouzinia et al. [11] as the ability to maintain health while facing professional stress and difficulties. Moreover, the findings resonate with previous research about factors affecting nurses’ resilience at work, which noted a mix of elements from personal and professional resilience scales, including work-life balance, hope, control, support, professional identity, and clinical supervision [10, 11]. HCC nurses’ enjoyment of autonomy of practice has also been linked to resilience and retention [65]. HCC nurses who were found to be more resilient were self-compassionate, easy going, optimistic and had a sense of humour [17]. Many of these elements were addressed by the nurses supporting themselves and working in an environment with organizational support. The expressed need to support the ‘self’ should be further studied in the context of the HCC sector, as the strategies identified in the current study address all major sources of stress for nurses - workload, the nature of nursing work, family, expectations, interpersonal relationships, and patient contact [66]. Previous research identified that nurses’ turnover intentions often result from psychological responses to negative aspects at work [67]. Supervisory feedback has been identified as an important environmental feature [68], which may be even more important for home care nurses working primarily by themselves. Belgian home nurses suggested positive support from supervisors was key to improving the work environment and influencing their turnover intentions [69]. Together, these findings support the idea that environment as context for resilience in HCC nurses is a key factor for nurses to handle stressful situations and prevent emotional exhaustion, mental fatigue, lack of motivation, and intention to leave [70].

HCC nurses are regularly exposed to challenges on the job, but adapting to these stressors over time requires building and maintaining resilience. This suggests that resilience is a process; a finding congruent with the American Psychological Association [71] who describe resilience as the “process and outcome of successfully adapting to difficult or challenging life experiences, especially through mental, emotional, and behavioral flexibility and adjustment to external and internal demands” (p. 1). In addition to resilience being process-oriented, Rutter [72] suggests resilience is dynamic, characterized by “steeling effects” or exposure to stressors that increase or decrease an individual’s vulnerabilities (p. 337). RPNs from this study demonstrated how positive aspects of the job helped them to build resilience in their responses to recurrent exposure to multiple stressors in the HCC setting. Moreover, the findings highlight how the buddy system, shadowing and peer support were memorable experiences for participants when they were entering the sector as new nurses. Increased attention to mentorship strategies can lead to new nurse growth [73]. Because resilience can be built over time, perhaps new nurses would benefit from longer and more supportive practices of mentorship while being exposed to stressors in the HCC sector. Although new HCC nurses can expect to have ongoing organizational support, it may take time to build the diverse skillset and coping strategies required for HCC practice. It may also take time to establish relationships with patients [74] and their care partners, meaning that it may also take time to receive support from those relationships while experiencing challenges on the job. Because change is consistent in the home care environment (e.g. staff attrition, heavy workloads, frequent schedule changes), cultivating support for nurses to develop and maintain resilience is vital.

Strengths and limitations

There were limitations to this study. In particular, only two FCPs to represent clients and family receiving home care services could be recruited. A number of recruitment strategies for FCPs were exhausted within the timeframe of the project. No clients receiving HCC services were included, which is a potential limitation as they could have different views on their experiences with RPNs providing care than their family members. Also, this study was conducted only in the province of Ontario, using a single category of nurses, and although there was extensive geographic coverage across the province, the findings related to conditions of home and community care may have been different if other provinces were included.

The strengths of the study included a sampling of RPNs recruited from five out of the six health regions in Ontario, including representation of RPNs working in rural and urban home and community care settings. Another aspect of this study was using Zoom technology to provide access to RPNs as mobile health care providers, which was a strength. They were able to share their experiences working in HCC despite their work schedule and mobile nature of their work in community settings. However, there were limitations in using Zoom technology for interviews. Several participants working in the community were unable to find a private location with stable internet connection during their interviews. As a result, many participants needed to complete the interview with their camera turned off, as the internet connection often cut out when using their camera, which led to expressed frustration from the participants. Despite these challenges, video conferencing technology is an effective way to collect data remotely [75].

Implications and conclusions

The findings suggest that building and maintaining resilience in RPNs working in HCC is supported when nurses can support themselves, have relationships with the families and clients on their caseload, and have supports from their supervisors. Attention to these conditions of working in HCC provides guidance for HCC organizations to cultivate resilience among their nursing workforce. Home and community care organizations can implement workplace infrastructure through policies to augment workplace safety and update in-service and onboarding training to help keep nurses safe when entering client homes. Strategies to recruit and retain HCC nurses are needed to ensure individual nurses’ workloads are manageable and better promote work-life balance. Rather than a continual focus on recruitment, investments in training and supporting the existing workforce would likely help cultivate the broad skillsets required for practice in this unique sector and promote workforce stability. In addition to addressing compensation for clinical time and travel-related expenses, supporting a culture of pride for the nursing profession and the meaningful nature of nurses’ work as care providers is necessary to increase rates of retention in this sector. Organizations can encourage staff to practice self-care and self-advocacy by providing resources and fostering an environment that respects nurses’ personal boundaries. They can also invite nurses to voice their needs to protect their own health and well-being. Further, understanding the relationship between resilience and workload can be useful in helping build practices that foster positive work environments and promote nurse retention. Longitudinal research is needed to determine the effectiveness of interventions designed to enhance nurse resilience in the HCC sector over time.