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Nurses' satisfaction with their work environment and theoutcomes of clinical nursing supervision on nurses� experiencesof well-being – a Norwegian study

INGRID BEGAT M N S c , R N T1, BODIL ELLEFSEN R N T , D r P o l i t

2 andELISABETH SEVERINSSON M N S c , R P N , D r P H

3

1Midwife and Lecturer, Department of Nursing, Health and Culture, University Trollhattan-Uddevalla, Sweden andDoctoral Student, Institute of Nursing Science, University of Oslo, Oslo, Norway, 2Professor, Institute of Nursingand Health Sciences, University of Oslo, Oslo, Norway and 3Professor, Department of Health Studies, StavangerUniversity of Stavanger, Stavanger, Norway

Correspondence

Ingrid Begat

Nordskogsvagen 4

SE-451 91 Uddevalla

Sweden

E-mail: [email protected]

B E G A T I . , E L L E F S E N B . & S E V E R I N S S O N E . (2005) Journal of Nursing Management 13,

221–230

Nurses' satisfaction with their work environment and the outcomes of clinicalnursing supervision on nurses' experiences of well-being – a Norwegian study

Background Various studies have demonstrated that nursing is stressful and that theincidence of occupational stress-related burnout in the profession is high.

Aim This descriptive-correlational study examined nurses� satisfaction with their

psychosocial work environment, their moral sensitivity and differences in outcomes

of clinical nursing supervision in relation to nurses� well-being by systematically

comparing supervised and unsupervised nurses.

Methods Nurses were selected from two hospitals (n ¼ 71). Data collection was by

means of questionnaires and analysed by descriptive and inferential statistics.

Results The nurses� satisfaction with their psychosocial work environment was

reflected in six factors: �job stress and anxiety�, �relationship with colleagues�,�collaboration and good communication�, �job motivation�, �work demands� and

�professional development�. The nurses� perceptions of moral sensitivity comprised

seven factors: �grounds for actions�, �ethical conflicts�, �values in care�, �inde-

pendence patient-oriented care�, �the desire to provide high-quality care� and �the

desire to provide high-quality care creates ethical dilemmas�. Nurses well-being

were reflected in four factors �physical symptom and anxiety�, �feelings of not

being in control�, �engagement and motivation� and �eye strain sleep disturbance�.The moral sensitivity �ethical conflicts� were found to have mild negative corre-

lations with psychosocial work environment �job stress and anxiety professional

development� and with �total score� psychosocial work, moral sensitivity factor

�independence were correlated with psychosocial work factor �relationships with

colleagues� and �total score�, moral sensitivity were mildly correlated with �col-

laboration and good communication and had a negative correlation to psycho-

social work factor �work demands�. In addition, significant correlations were

found between the nurses� well-being profile and demographic variables, between

�engagement and motivation� and �absence due to illness� and between �time

allocation for tasks�, �physical symptoms and anxiety� and �age�. Mild significant

differences were found between nurses attending and not attending group

supervision and between �physical symptoms and anxiety� and �feelings of not

being in control�.

Journal of Nursing Management, 2005, 13, 221–230

ª 2005 Blackwell Publishing Ltd 221

Introduction

During the last few decades, nursing has changed in

many ways, putting extra pressure on nurses. Several

researchers describe nurses� work as stressful (Humpel

& Caputi 2001). Political and administrative autho-

rities demand that more work be done in less time,

especially within the health care system (The Swedish

Public Health Report 2001).Work under pressure,

stress and dissatisfaction with working hours are some

of the negative factors (Burke et al. 2000). Butterworth

et al.�s (1999) research on stress, coping, burnout and

job satisfaction among British nurses showed that

occupational stress levels are rising in the profession.

The shortage of nurses and high staff turnover rates

within the health care system are compromising the

nurse’s ability to provide competent and compassion-

ate care. High rates of staff turnover cause negative

effects on productivity and effectiveness (Hinshaw &

Atwood 1984). As nurses make a unique contribution

to the multidisciplinary teams they work in (Baxter

2002), job satisfaction influences the quality of the care

they provide, just as nurses� job dissatisfaction influ-

ences the nurse–patient relationship (Takase et al.

2001). When nurses feel dissatisfied with their work,

they have a tendency to distance themselves from

patients, from nursing tasks (Demerouti et al. 2000),

and from their inner selves (Cameron 1997). Further-

more, nurses who feel that their efforts are not fully

appreciated tend to leave the profession (Lewis &

Urmston 2000).

During their education, nurses learn the importance

of ethical practice, of being the patient’s advocate and

of caring. Their ability to provide high-quality care

influences their perception of job satisfaction (Tovey

1999). In addition, nurses� collaboration with other

health care personnel can influence their job satisfac-

tion. Collaboration with other professionals as well as

with colleagues is important for their professional

development and quality of care, and an issue for the

clinical nurse leadership (cf. Johns 2003). In a study,

Ellefsen (2002) found that nurses in both Scotland and

Norway experienced stress in relation to the public as

well as tension in their collaboration with other pro-

fessionals. Findings from research investigating what

the staff perceived as creating job satisfaction in their

psychosocial work environment (PWE), as well as

ethical dilemmas experienced within acute psychiatric

care showed that factors contributing to job satisfac-

tion or dissatisfaction can be related to the nurse’s

value system. Ethical dilemmas were specifically con-

cerned with how to care for and handle the work in

relation to patient autonomy and how to approach the

patient (Severinsson & Hummelvoll 2001). In an

investigation by Chaboyer et al. (2001), collaboration

and autonomy were significantly correlated with job

valuation. In addition, the reality for nurses is that they

work in an organization with an ever-increasing

number of changes and structural upheavals. This

affects job satisfaction at all levels, mainly in a negative

and stressful way.

Nurses are involved in patients� suffering, and the

interpersonal aspects of nursing are dependent on the

autonomy and courage of the individual nurse (Begat &

Severinsson 2001). To be able to meet the challenges of

their profession, nurses need to be clear about why they

think and act as they do, and they need to perceive

themselves as being empowered. Clinical nursing

supervision (CNS) can facilitate the supervisees� reflec-

tions on the difficulties involved in caring (Hyrkas

Conclusions We conclude that ethical conflicts in nursing are a source of job-related

stress and anxiety. The outcome of supporting nurses by clinical nursing supervision

may have a positive influence on their perceptions of well-being. clinical nursing

supervision have a positive effect on nurses physical symptoms and their feeling of

anxiety as well as having a sense of being in control of the situation. We also

conclude that psychosocial work have an influence on nurses experience of having

or not having control and their engagement and motivation.

Keywords: clinical nursing supervision, ethical conflicts, job stress, moral sensitivity,

psychosocial work environment

Accepted for publication: 4 November 2004

I. B�gat et al.

222 ª 2005 Blackwell Publishing Ltd, Journal of Nursing Management, 13, 221–230

2002). In organizations with transformational leader-

ship, CNS is considered as an opportunity to facilitate

learning (Johns 2003).

A systematic supervision structure helps the nurses to

reflect, analyse, solve problems, plan actions and learn

for future practice (Severinsson 2003). Perceived bene-

fits of CNS are improved patient care, stress reduction,

enhanced skills and job satisfaction (Sloan 1999).

There is a paucity of research in the area of CNS in

Norway and the Nordic countries. The findings of a

Norwegian study revealed that nurses attending super-

vision experienced stress and perceived shortcomings to

a higher degree (Severinsson & Hummelvoll 2001).

However, a Swedish study found that health care pro-

fessionals who received CNS as a support in their

clinical nursing work perceived that they felt more

secure in decision-making as well as safer in their

relationship with patients (Magnusson et al. 2002). It

has also been reported that support and supervision can

be used as a strategy for achieving control over the

patient’s everyday life when providing home care for

people with long-term mental illness (Magnusson et al.

2003). A Norwegian study showed that health profes-

sionals in community care called for more frequent

forums for professional guidance in order to better

evaluate the outcomes of care (Holst & Severinsson

2003). Restorative and supportive outcomes of CNS in

Finland have been described in terms of reduced stress,

less burnout and decreased workload as a result of

a more organized approach to work (Hyrkas 2002).

According to previous literature on CNS, there is no

study available that focuses on nurses� health status.

The aim of this study was therefore to examine nurses�satisfaction with their PWE and moral sensitivity (MS)

as well as differences in CNS outcomes on nurses� well-

being by systematically comparing supervised and

unsupervised nurses.

Method

This questionnaire study had a descriptive-correlational

design (Polit & Hungler 1991).

Instruments

The instrument package contained three questionnaires

on the subject of nurses� satisfaction with their PWE and

MS as well as their well-being profile. The first ques-

tionnaire included demographic data such as: gender,

age, years in nursing, attending or not attending

supervision, experiences of supervision and well-being

related variables. The second questionnaire, The Work

Environment Questionnaire (WEQ), contained the

areas of job satisfaction and PWE: commitment to

career, influence on duties, routines, communication,

meaningful work, organizational changes, workload,

job stress, job motivation, job expectations and security

at work (Severinsson & Kamaker 1999). The instru-

ment consisted of 29-items answered on a 6-point

Likert scale anchored by the terms �not at all� (1) and

�very much so� (6). The content validity, construct

validity and reliability of the WEQ have been previously

established (the overall a-coefficient was 0.91, Seve-

rinsson & Hummelvoll 2001). The third questionnaire,

which was devoted to the subject of MS, was a modified

version of The Moral Sensitivity Questionnaire (MSQ).

A 27-items, 7-point scale was used to measure the

nurses� MS (Lutzen 1993). This questionnaire was

designed to investigate: benevolence or a moral moti-

vation to do �good�, focusing on interpersonal orienta-

tion, such as building a trusting relationship with the

patient and finding ways of responding to his/her indi-

vidual needs; structural moral meaning, which concerns

ways of deriving moral meaning from decisions made

and actions taken; modifying autonomy which refers to

a strategy taken when a nurse perceives the need to limit

a patient’s autonomy, while at the same time recogni-

zing the principle of self-choice; and experiencing both

a moral conflict and confidence in medical and nursing

knowledge (Lutzen 1993). We obtained permission

from the copyright holder, Professor Lutzen, to omit

3-items from the instrument. The content validity,

construct validity and reliability of MSQ have been

previously established (a-coefficient 0.73, Lutzen et al.

1995).

Subjects

The participants in this survey consisted of Norwegian

registered nurses (n ¼ 71). Subjects were selected from

two hospitals in order to obtain as large a group of

participants as possible. Approximately 150 question-

naires were given to nurses working in either acute

medical-surgical or geriatric wards in the two chosen

hospitals. The head nurse on the ward distributed the

questionnaires, and the completed questionnaires were

returned to one of the researchers (E.S.) in a sealed

envelope either by post or through the hospital’s nur-

sing department. The response rate was low (n ¼ 53).

To increase the sample size, a clinical nurse coordinator

was requested to distribute an additional 40 question-

naires to staff who had not already participated in the

study. This procedure resulted in a further 18 completed

questionnaires.

Nurses' work environment and supervision

ª 2005 Blackwell Publishing Ltd, Journal of Nursing Management, 13, 221–230 223

Statistical analysis

Data were analysed by descriptive and inferential

statistics. SP SS pc+ version 10.0 was used for the

statistical analysis (SPSS Inc. 2000). Each item of data

was derived by means of principal component factor

analysis with varimax rotation in order to condense

the number of items (Polit & Hungler 1991). Internal

consistency was tested by Cronbach’s-a, while the

Spearman rank correlation coefficient was used to

calculate the correlation between the factors (Siegel &

Castellan 1988). A P-value of <0.05 was regarded as

significant.

Ethical considerations

The study was conducted at two community hospitals in

Eastern Norway with a total of approximately 400 beds.

The chief nurse at the two hospitals reviewed and

approved this research proposal and ensured con-

fidentiality. All participants received both oral and

written information about the aim of the study from one

of the authors (E.S.) and from a contact person at the

hospitals. They were informed that participation was

voluntary. An assurance was given that subjects�responses would be handled anonymously and with

confidentiality. The questionnaire had a cover sheet

indicating that all data would be used for research pur-

poses only and would be safely stored in a locked fire-

proof cabinet.

Results

The mean age of the nurses was 35 years (SD: 8.6). The

mean length of nursing experience was 9.3 years (SD:

7.6). Twenty-two nurses of 71 attended systematic

supervision (mean 1.5, SD: 1.1). The most common

frequency of CNS was once a fortnight, and the focus in

CNS was feelings evoked by work and cooperation with

colleagues.

Factor analysis of PWE

The outcome of the factor analysis of items concern-

ing the nurses� view of their PWE resulted in six

factors, as presented in Table 1. Factor I reflected the

nurses� �job stress and anxiety� and factor II �rela-

tionship with colleagues�. Factor III reflected �colla-

boration and good communication� and factor IV �job

motivation�. Factor V dealt with �work demands� while

factor VI concerned the nurses� �professional develop-

ment�. This structure explained 64.3% of the variance,

the eigenvalue was >1.5, and the overall a-coefficient

was 0.75.

Factor analysis of MS

A 7-factor analysis was chosen for the responses related

to MS in nursing care. These factors reflected the nurses�grounds for actions, ethical conflicts, values in care,

Table 1Principal component analysis and Cronbach's-a coefficient ofresponses regarding nurses� perceptions of their psychosocial workenvironment (PWE; factors below 0.42 were excluded)

Factors and loadings

Loading onprimaryfactor

Factor I (eigenvalue 5.7, percentage of variance 15.05, Cronbach's-a0.83)Job stress and anxietyI have too much to do 0.90I feel stressed out in my job 0.87I am working �flat out� 0.81I feel my work takes time from �direct� work withpatient

0.63

I am concerned about my job 0.57I am feeling pressures of time andthere is a risk of failure

0.50

Factor II (eigenvalue 3.5, percentage of variance 13.66, Cronbach's-a 0.63)Relationship with colleaguesI can discuss my problems 0.80I feel responses from my subordinates 0.77I feel that my colleagues are open for new ideas 0.75I get the information I need 0.64I am worried that I cannot manage well at work )0.58I can get information of changes and restructuring 0.47I feel that my colleagues are open to new ideas 0.42

Factor III (eigenvalue 2.9, percentage of variance 11.2, Cronbach's-a0.72)Collaboration and good communicationI belong to a fellowship 0.88I collaborate well with others 0.84I get support from others when I need it 0.66I can discuss when not in agreement 0.48

Factor IV (eigenvalue 2.8, percentage of variance 10.7, Cronbach's-a 0.74)Job motivationI feel engagement in my work 0.81I feel my job is interesting and stimulating 0.75I can use my capacity at work 0.67I agree with my boss about goals for the workplace 0.50I have an possibility to learn new things 0.47

Factor V (eigenvalue 2.0, percentage of variance 7.8, Cronbach's-a0.64)Work demandsI have difficulties in planning my job becauseof no job description

0.79

I have difficulties in planning my job becauseof routines

0.78

Factor VI (eigenvalue 1.5 percentage of variance 5.9)Professional developmentI have possibility to develop my skills 0.85

I. B�gat et al.


independence, patient-oriented care, the desire to pro-

vide high-quality care and the desire to provide high-

quality care creates ethical dilemmas (Table 2). This

structure explained 70.2% of the variance, the eigen-

value was >1.8, and the overall a-coefficient was 0.54.

The correlation between the nurses� PWE and MS

There was a mild correlation between the PWE factors

�professional development�, �job stress and anxiety� and

�ethical conflicts� (P < 0.05). The MS factor

�independence� had a mild correlation with �relationship

with colleagues� (P < 0.05). Moreover, there was a mild

correlation between �MS� (total score), �collaboration

and good communication� and �work demands�(P < 0.05), see Table 3.

Factor analysis of nurses� well-being

The outcome of the factor analysis of items concerning

nurses� well-being resulted in four factors. Factor I

reflected the nurses� �physical symptoms and anxiety�,factor II concerned �feelings of not being in control� and

factor III dealt with nurses� �engagement and motiva-

tion�. Factor IV focused on the nurses� health problems,

concentration difficulties, and eye- and sleep problems

(Table 4). These factors explained 63.4% of the vari-

ance, and the overall a-coefficient was 0.64.

Table 2Principal component analysis and Cronbach's-a coefficient of responses regarding nurses� perceptions of moral sensitivity (MS; factors below0.39 were excluded)

Factors and loadingsLoading on

primary factor

Factor I (eigenvalue 3.9, percentage of variance 15.3, Cronbach's-a 0.66)Ground for actionsI mostly rely on my own feelings when I have to make difficult decision for the patient 0.78I believe that it is important to have firm principles for the care of certain patients 0.63I rely mostly on other nurse� knowledge about a patient when I am unsure about him/her 0.61I always base my actions on medical knowledge of what is the best treatment, even if a patient should protest 0.60

Factor II (eigenvalue 3.1, percentage of variance 12.0, Cronbach's-a 0.70)Ethical conflictsI often face situations where it is difficult to know what actions is ethically right for a particular patient 0.74I often face situations where I have difficulty in letting a patient make his or her own decision 0.67I am often confronted with situations where I experience a conflict as to how to approach the patient 0.56I am often caught in predicaments where I have to make decisions without the patient 0.56If I am unacquainted with the case of a patient, I follow the rules that are available 0.53

Factor III (eigenvalue 2.9, percentage of variance 11.5, Cronbach's-a 0.59)Values in careWhen I have to make difficult decisions for the patient, it is important to always be honest with him or her 0.71I think that good care often includes making decisions for the patient 0.62I believe that good care includes patient participation 0.60It is important to have rules when a patient refuses treatment 0.52

Factor IV (eigenvalue 2.8, percentage of variance 10.7, Cronbach's-a 0.53)IndependenceI often think about my own values and norms that may influence my actions 0.68I find meaning in my role even if I do not succeeded in helping a patient gain insight into his or her illness 0.65My relationship with the patient is the most important aspect of care 0.52

Factor V (eigenvalue 2.1, percentage of variance 8.2, Cronbach's-a 0.54)Patient-orientedIt is important that I get a positive response from the patient in everything I do 0.67Most of all, it's the reaction of patients that lets me know if I have made the right decision 0.64My work would be meaningless if I never saw any improvement in my patients 0.57As a nurse I must always know what individual care a patient on the ward is entitled to 0.42

Factor VI (eigenvalue 1.7, percentage of variance 6.4, Cronbach's-a 0.43)The desire to provide quality careI believe that good care includes respecting the patient's self-choice 0.77My own experience is more useful than theory in situations where it is difficult to know what is ethically right 0.52In situations where it is difficult to know what is right, I consult my colleagues about what should be done 0.40If I were to lose the patient's trust, I would feel that my work would lack meaning 0.40

Factor VII (eigenvalue 1.6 percentage of variance 6.1, Cronbach's-a 0.35)The desire to provide quality care creates ethical dilemmasWhen I need to make a decision against the will of a patient, I do it according to my opinion about what is good care 0.74I find it difficult to give good care against the will of the patient 0.54It is my responsibility as a nurse to have knowledge of the patient's total situation 0.54



The correlation between CNS and the nurses�well-being, demographic variables and PWE

There was a moderate correlation between �engagement

and motivation� and �absence due to illness� (P < 0.01)

and a mild correlation between �time allocation for

tasks� and �physical symptoms and anxiety� as well as

between �engagement and motivation� and �age�(P < 0.05). There was also a mild correlation between

�physical symptoms and anxiety� �and �feelings of not

being in control� in relation to �clinical supervision�(P < 0.05). There was a mild correlation between PWE

and the nurses� well-being concerning �feelings of being

nor being in control� and �engagement and motivation�(P < 0.05).

Discussion

The aim of this descriptive-correlational study was to

examine the nurses� satisfaction with their PWE and MS

as well as differences in CNS outcomes on nurses� well-

being by systematically comparing supervised and

unsupervised nurses. Questionnaires were employed,

and the data were analysed by descriptive and inferen-

tial statistics. Construct validity was addressed by

means of factor loading, and the overall a-coefficient

was 0.75 for PWE, 0.54 for MS while the nurses� well-

being profile was 0.64. The sample in this study con-

sisted of registered nurses (n ¼ 71). They were chosen

from two hospitals to provide a broad perspective on

the study issue. However, there are several limitations

that have to be considered in this study. First, the

study’s low response rate must be taken into consid-

eration. The number of nurses in the factor analysis was

small; the factor analysis was only used to explain the

responses in the sample. The factor analysis with �var-

imax rotation� was used to condense the number of

items and focus on underlying structures in the des-

criptive and inferential analyses. A larger sample might

have given additional interrelated factors. Secondly,

statistically the factor analysis can be viewed as a rather

Table 3Spearman's correlation analysis of PWE and MS factors for nurses (71) in Norway

PWEJob stressand anxiety

Relationshipwith colleagues

Collaborationand good

communicationJob

motivationWork

demands

Professionaldevelopment

scoreTotalscore

MSGrounds for actions 0.12 )0.14 0.23 0.10 )0.13 0.11 0.10Ethical conflicts )0.33* 0.20 )0.08 )0.22 0.07 )0.26* 0.30*Care values )0.07 )0.13 0.10 )0.04 0.05 0.05 )0.08Independence )0.02 0.33* 0.27 0.19 0.10 )0.27 0.10Patient-oriented care 0.12 )0.02 )0.09 )0.17 )0.14 )0.03 )0.11The desire to provide high-quality care 0.13 0.06 0.22 0.12 )0.09 )0.12 0.12The desire to provide high-quality carecreates ethical dilemmas

0.21 )0.21 0.14 0.11 )0.19 )0.08 )0.02

Total score 0.05 0.03 0.28* )0.02 )0.29* )0.24 0.11

PWE, psychosocial work environment; MS, moral sensitivity.*P < 0.05, **P < 0.01.

Table 4Principal component analysis and Cronbach's-a coefficient ofresponses regarding the nurses� well-being (factors below 0.45 wereexcluded)

Factors and loadings Loading on primary factor

Factor I (eigenvalue 4.2, percentage of variance 29.8, Cronbach's-a0.76)Physical symptoms and anxietyPain 0.78Headache 0.73Endocrine symptoms 0.72Fatigue 0.50Anxiety 0.46

Factor II (eigenvalue 1.9, percentage of variance 13.7, Cronbach's-a0.74)Feelings of being nor being in controlImpatience 0.87Irritability 0.79Restlessness 0.62

Factor III (eigenvalue 1.6, percentage of variance 11.4, Cronbach's-a0.67)Engagement and motivationEngaged 0.86Energetic 0.83Content 0.52

Factor IV (eigenvalue 1.2, percentage of variance 8.5, Cronbach's-a0.54)Eye- and sleep problemsUnconcentrated 0.68Eye strain 0.63Sleep disturbances 0.45

I. B�gat et al.


subjective method although it is undoubtedly a fruitful

method for handling a large number of variables (Polit

& Hungler 1991, pp. 473–478). The psychosocial work

(PWE) and MS instruments have been used in combi-

nation prior to this study (Begat et al. 2004). Although

the results cannot be transferred to other groups, they

nevertheless indicate a useful perspective for future

research as nurse managers and leaders all over the

world are likely to be interested in the well-being of

nurses. Although nurses reported differences in well-

being after taking part in CNS, this does not amount to

a case for advocating supervision at management level.

Lack of knowledge about the costs involved in CNS

makes it impossible to estimate its actual economic

value. The results of this study clearly reveal the dif-

ferences between the nurses who received CNS and

those who did not, as well as the need to maintain

nurses� well-being and job satisfaction.

Factors influencing nurses� psychosocial PWE andMS

The main factor �job stress and anxiety� (factor I,

Table 1) showed a significant correlation with ethical

conflicts. This relationship is well-known and corres-

ponds with previous research (cf. Takase et al. 2001). In

addition to job stress and reported feelings of anxiety, it

is not surprising that ethical conflicts emerge as well. In

stressful situations it is important to control anxiety,

not only for the nurse but also from the perspective of

the patient. High levels of anxiety may reduce the

ability to adequately care for patients. Previous research

on anxiety by Benner et al. (1999) suggests that anxiety

contributes to a lack of understanding and perception

about the caring situation. Anxiety is described as a

feeling of fear related to some uncertain or future event

or mental distress caused by a threat to a person or his/

her values (The Cassell Concise Dictionary 1997). This

finding also explains the factor called �work demands�(factor IV, Table 1), where nurses experienced difficul-

ties because of insufficient job description and compli-

cations in planning their job because of routines. Being

able to plan and finding meaning in one’s work most

likely influence nurses� well-being. Nursing work is

demanding and stressful, and decisions have to be made

in critical situations. These decisions must nevertheless

be sound and relevant in order to achieve high-quality

care. In this study it was found that, in difficult ethical

situations, nurses� base their actions on knowledge,

principles, other nurses� knowledge and their feelings

(factor I, Table 2). This finding is similar to those of

Benner (1995), who reported that the �expert� nurse

bases his/her actions on intuition and feelings. The

problem with actions based on feelings is that it is not

possible to explain them by means of logical reasoning.

This could ultimately result in a breakdown in com-

munication between the nurse and other professionals

leading to a lack of cooperation, which has a negative

impact on the patient. Moreover, it may also contribute

to a feeling of resentment towards the duties as the

nurse’s knowledge is being questioned, resulting in

disempowerment (cf. Lewis & Urmston 2000). In a

stressful situation, being questioned can be yet another

burden on an already stressed nurse. Nurses wish to and

want to be involved in ethical decision-making together

with other professionals, for example, doctors, and they

would like their opinion to be listened to and respected.

Nurses are part of a technically advanced PWE and, as

in the rest of society, technology is highly appreciated

while the more �caring� aspects of nursing, such as

feelings, emotions, inner processes, imagery, intuition,

etc. tend to be ignored (cf. Watson 1999).

One important finding in this study was a significant

correlation between the factor �independence� and

�relationship with colleagues� as well as between �colla-

boration and good communication� and �work demands�(P < 0.05, Table 1). Nurses� own values and norms

influence their actions. The organization’s set of values

is part of the nurse’s PWE. However, there may be a

conflict between the values of nurses and the organi-

zations in which they work, as reflected in policies and

regulations. These situations create ethical conflicts for

nurses and force them to compromise their moral

integrity for the sake of the institution in which they

practice (Olsson & Hallberg 1998). It is the nurses�values that give them the courage to review other pos-

sibilities rather than conforming to existing conditions

(Watson 2002). In this study the results showed that, in

morally sensitive situations, nurses chose values such as

honesty, patient participation and taking responsibility

for the patient’s decision as well as respecting rules

(factor III, Table 2). In the humanistic part of nursing,

where nurses seek to sustain and preserve caring,

wholeness and humanity, nurses are viewed as the

human environment creating the caring field, in which

their awareness and basic values serve as the human-

environmental field (Watson 2002). The human envi-

ronment, the �desire to provide high-quality care� (factor

VI, Table 2) in morally sensitive situations and respect

for the patient’s autonomy are important for nurses, in

addition to being truthful to the patient and trusting

their own experience of what is ethically right in diffi-

cult situations. However, nurses also tend to consult

their colleagues when in doubt as to what is right.



CNS and the outcome of nurses� well-being

In this study, it was possible to easily differentiate

between nurses who systematically attended supervision

and unsupervised nurses in terms of outcomes on nur-

ses� well-being. There was also a mild correlation in

respect of �clinical supervision� between �physical

symptoms and anxiety� and �feelings of not being in

control� (P < 0.05). The CNS provides nurses with the

possibility to reflect upon experiences from their clinical

practice (Sexton-Bradshaw 1999). Being able to address

feelings evoked by collaboration with colleagues helps

the nurse to understand her own moral stance in rela-

tion to other nurses and to organizations. This is in line

with Hyrkas (2002), who found that safety in CNS

increased the courage to discuss feelings in the team.

The ability to use one’s feelings to guide the decision-

making process is based on empathy, warmth, personal

convictions and a consistent value system (Pajak 2002).

Nurses� ability to provide quality care is in many ways

dependent on the ward climate (Koivula & Paunonen-

Ilmonen 2001). The more nurses are able to care with

empathy and compassion, the better the human

environment will be for the patients. The reduction of

stress and anxiety has also been shown to be an effect of

CNS (Severinsson 2003). Several researchers have

found cooperation with colleagues to be an issue in

clinical supervision (Begat et al. 2003). Cooperation

and collaboration are factors that contribute to quality

of care (Begat & Severinsson 2001). Cooperation means

working together for a common purpose and includes

willingness to cooperate as well as accepting help from

another person (The Longman Dictionary of Con-

temporary English 1987, p. 227). This is line with the

findings of Koivula and Paunonen-Ilmonen (2001), who

found that cooperation is one factor in the development

of a working community and necessary for adequate

care. The moral meaning of cooperation, the will-

ingness to share responsibilities, implies generosity and

altruism (Tschudin 1999, p. 95), and sharing can

empower people to be aware of their own possibilities

as well as their limits. Sharing enables one to see the

whole rather than the parts and, furthermore, �When we

share – because we can share – we become able to say

��no�� and ��yes�� creatively. When we reach the stage of

authentic sharing we will have reached the possibility of

genuinely and morally saying ��no’�� (Tschudin 1999,

p. 99). To be able to say �no� is important when it comes

to protecting the patient from further medical inter-

ventions, especially when such interventions go against

the patient’s wishes. Then the �no� is �for� a good reason,

not merely �against� the opinion of others and is based

on knowledge and the willingness to provide high-

quality care for the patient. The result shows that en-

gaged and motivated nurses are less absent from work

(P ¼ 0.01) and that their engagement and motivation

increase in line with age (P ¼ 0.05, Table 5). Newly

registered nurses often feel insecure in their profession,

as evidenced by a lack of managerial ability to provide

information and education to patients as well as being

unable to handle the medical-technical skills involved in

patient care (The National Swedish Board of Health &

Welfare 2001). Professional experience leads to greater

confidence, and the nurse’s life-experience as a whole

may be an additional factor. Stress also has a direct

correlation with physical symptoms. The result suggests

that the less time the nurse has for his/her duties, the

more physical symptoms he/she exhibits, showing a

Table 5Spearman's correlation analysis between the factors of nurses' well-being, demographic variables and psychosocial work environment (PWE;n ¼ 71)

Nurses� well-beingFactor I: Physical

symptom and anxietyFactor II: Feelings ofnot being in control

Factor III: Engagementand motivation

Factor IV: Eye strain,sleep disturbance

Years of nursing experience )0.15 )0.17 0.08 0.05Absence due to illness 0.05 0.63 0.38** )0.08Time allocation for tasks )0.27* 0.00 )0.18 )0.02Years of experience in present employment )0.21 )0.03 )0.16 )0.05Working hours 0.02 )0.03 0.04 )0.06Overtime )0.10 )0.18 )0.10 )0.10Year of birth )0.17 )0.14 0.26* )0.05Attending supervision )0.26* )0.25* )0.13 )0.06Number of years in supervision )0.15 )0.16 0.27 )0.42Frequency of supervision )0.02 )0.19 0.17 )0.35Trained as a supervisor 0.04 )0.19 )0.07 )0.15Psychosocial PWE )0.17 0.33** 0.27* 0.12

*Correlation is significant at 0.05 level (2-tailed).**Correlation is significant at 0.01 level (2-tailed).

I. B�gat et al.


mild correlation between �time allocation for tasks� and

�physical symptoms� (P < 0.05, Table 5). Job satisfac-

tion is likely to have a positive influence on the number

of sick-days, which is confirmed by Petterson’s (1997)

research, where the group reporting less satisfaction had

twice the number of sick-days than the more satisfied

group. A similar finding was made by Johansson

(1994), who established a correlation between poor

PWE and musculoskeletal symptoms. The mean of PWE

showed a moderate correlation with �feelings of being

not being in control� (P ¼ 0.01) and a mild correlation

with �engaged and motivated� (P < 0.05). The better the

PWE, the happier the nurse is. A direct connection

between the morale of the nurse and the quality of the

care she/he provides is indicated by comparison with

the study performed by Callaghan (2003). Callaghan

(2003) found that the low morale among nurses was

due to, among other things, their poor PWE.

The results of the present study show a mild corre-

lation between the total MS score and �collaboration

and good communication� (P < 0.005, Table 3). This

could indicate that, when nurses realize that they are

able to communicate and collaborate, they feel that they

find it easier to deal with morally sensitive situations.

This, in turn, helps the nurse to provide quality care.

�Job stress and anxiety� and �work demands� were found

to have a mild correlation with �ethical conflicts� and

with the total MS score (P < 0.005, Table 3). Previous

research on ethical distress indicates that the more

nurses experience moral distress, the more likely they

are to become burned out and even abandon their

profession (Cameron 1997).

Conclusions

We conclude that nurses� perceive their PWE as stress-

ful, which has a negative effect on their job satisfaction.

Supporting nurses by CNS may have a positive effect on

their perceptions of well-being. Nurses attending CNS

reported less physical symptoms, reduced anxiety and

fewer feelings of not being in control.

Acknowledgements

The authors would like to thank the nurses who participatedin this study, Statistician Vibeke Horstmann for statisticalsupport and Gullvi Nilsson for reviewing the English.

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