Older nursesʼ experiences of providing direct care in hospital nursing units: a qualitative evidence systematic review protocol

Review question/objective The objective of this review is to understand the experience of older nurses providing direct care in hospital nursing units. The review question that will guide this review is: what is the experience of older nurses providing direct care in hospital nursing units? Background In most developed countries throughout the world, corresponding with an aging population is an aging nursing workforce. The average age of nurses in both Canada and the United States is 45 years.1,2 Ironically, despite an increase in the number of older nurses relative to younger nurses potentially available to work in hospitals, the retirement of aging nurses has contributed to a critical global nursing shortage that is anticipated to increase.3 This global nursing shortage is in part due to a consistent pattern of nurses leaving hospital settings or the workforce after the age of 50 years.4 There are many reasons why older nurses leave the workforce early. First, direct care nursing in hospitals has long been known to be stressful for nurses.5 Work stressors, including shift work, heavy workload, violence, increased acuity of patient care, and perceived lack of responsiveness to nurses' concerns, has led to an increase in work stress and job dissatisfaction.6 The level of job satisfaction has been determined to be highly predictive of employee turnover.7 Numerous predictors of job satisfaction amongst nurses have been identified and include: co-worker support, teamwork, retirement benefits, adequate equipment, healthcare benefits, open-door policy, respect from physicians and administrators, job security, shift of choice, paid time-off per year, educational opportunites,8 organizational commitment, perceived job alternatives, job-search behavior, links with other employees, and sacrifices they would have to make if they left their current job.9 Furthermore, it has been reported that over 50% of registered nurses eventually experience burnout.10 In the 2006 white paper, Wisdom at Work: The Importance of the Older and Experienced Nurse in the Workplace, it was recommended that retention strategies for older nurses include flexible work options, workplace redesign and ergonomics, strategic management for demographic and workplace changes, training and lifelong learning, caregiver and grief resources, retirement planning and boosting participation in benefits, along with phased retirement.11 A second reason older nurses leave the workplace prematurely is that older nurses themselves have cohort specific health needs. Middle-age is a time of increasing likelihood of chronic disease12 as well as age-associated health changes such as a gradual decline in aerobic power, reaction time, and acuity of the senses and the symptoms found in menopause.13,14 Furthermore, job related morbidities such as musculoskeletal injuries, depression and chronic pain12 may further cause many older nurses to abandon their careers early. The global health workforces is in a state of chronic, critical and worsening shortage, and is a fundamental constraint to reaching health and development goals.15 Nurses account for the largest proportion of this workforce. In an era of increased healthcare demands and a critical nursing shortage, it is important to understand the experience of older nurses in high paced hospital nursing units to lend knowledge on ways to lessen the loss of highly skilled experienced workers and to lessen negative patient outcomes. Patient outcomes have been directly linked with number of registered nurse (RN) hours: more RN hours being associated with shorter patient hospital stays, and lower rates of upper gastrointestinal bleed, urinary tract infection, pneumonia, and cardiac arrest.16 Very few studies have explored the experiences of older nurses providing direct care in hospital units. Friedrich and colleagues utilized a grounded theory approach to ascertain what motivates and inspires seasoned nurses to continue to practice in acute care after the normal age of nurse retirement. Four themes identified from the data were: existing attitudes and experiences, retention factors, important needs, and unique contributions.17 Storey, Cheater, Ford and Leese conducted a cross-sectional survey using a semi-structured questionnaire on nurses between 40 and 59 years (78%) in different care venues, including hospital based nurses. Results showed that older nurses were more likely than younger ones to report that their role had lived up to expectations. Older nurses reported that they wanted to be valued for the work they do and to be consulted regarding potential changes in the workplace. Furthermore they were more likely to stay if they received good pension benefits, reduced working hours near retirement, and reduced workload.18 Muller and colleagues used a mixed-method design which included semi-structured interviews to demonstrate a positive relationship between the effects of selection, optimization and compensation on work ability in nurses between 21 and 63 years of age.19 Gabrielle, Jackson and Mannix, using a feminist perspective, interviewed 12 female nurses between the ages of 40 and 60 years to determine their health and aging concerns. Two major themes were identified: the aches and pains of aging and evolving lifestyles, and work in progress whereby exercise was seen as a health imperative in the light of existing constraints, such as chronic pain.20 In conclusion, only a limited number of studies have qualitatively addressed older nurses' experiences of providing direct care on hospital nursing units. Also, a search of the JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, CINAHL, PubMed and PROSPERO revealed no existing systematic reviews or protocols on this topic. This systematic review seeks to integrate the literature on the experiences of older nurses providing direct nursing care. Based upon this, the review may also contribute to the development of retention strategies for older nurses on high-paced hospital nursing units. Inclusion criteria Types of participants This review will consider studies that include registered nurses 45 years and older who work as direct care nurses on any type of in-patient hospital nursing unit. For the purposes of this study older nurses will be defined as 45 years and above as this is consistent with the literature. Studies that include nurses both over and under the age of 45 years will be included if findings for nurses 45 years and older can be separated from nurses under the age of 45 years. This review will exclude studies consisting entirely of enrolled nurses, licensed practical nurses, and licensed vocational nurses. The rationale for this is that registered nurses have a level of competence and skill that enables them to perform nursing competencies at a much different level than enrolled nurses, licensed practical nurses, and licensed vocational nurses, thus the nature of their nursing experience is most likely quite different. Types of intervention(s)/phenomena of interest The phenomenon of interest is the experience of providing direct nursing care as experienced by the population of older nurses. Types of outcomes/context The context is the provision of direct nursing care in an in-patient hospital nursing unit. Types of studies This review will consider studies that focus on qualitative data including, but not limited to the following methodologies: phenomenology, grounded theory, ethnography, action research and feminist research. Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of PubMed (MEDLINE) and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. Non-English studies will be excluded. There is no date limit on this review because it is not clear when the first studies in this area were published. The databases to be searched include: CINAHL PubMed Psycinfo Embase AgeLine Sociological Abstracts SocINDEX The search for unpublished studies will include: Dissertation Abstracts International MEDNAR OpenGrey OAlster Google Scholar Google Initial keywords to be used will be: Nurses+ Older nurses Hospitals+ “Nursing staff, Hospital” Baby boomers In middle age Middle aged Aging Age factors Employment of older workers Experienced +nursing Experiences Qualitative studies+ Audiorecording Phenomenology Focus groups Narrative Observational methods+ Vignettes Interviews+ Lived experience bedside nursing Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data extraction Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Qualitative research findings will, where possible be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. Following the synthesis process, the ConQual approach will be used to establish confidence in the evidence produced.21 Conflicts of interest The authors have no conflict of interest to declare.

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