Work motivation and occupational self-efficacy belief to continue working among ageing home care nurses: a mixed methods study

In many municipalities in Finland, home service and home nursing care are combined as home care [28]. Home care work is organized in accordance with the Finnish legislation, and usually entails day-to-day assistance and nursing to help older persons and individuals with diminished functional capacity, due to disabilities and illness, cope with their everyday needs and activities [28]. Home care tasks have changed in recent years because of organizational fluctuations [6]. Nowadays core services include personal care, health care, lifting and documenting, and there is less time for social support, cooking, and shopping. In many municipalities it is possible to obtain home care also in the evening, at night and on weekends [28]. Lunches and breaks are usually included in enterprise resource planning in connection with transfers between clients [8]. Home care personnel in Finland primarily consist of practical nurses and home support workers [8]. In 2015, 73% of home care personnel had more than 2 years, and 23% one to 2 years of care education (vocational level) [6]. In 2020, the expected retirement age for a 50-year-old in Finland was 63.8 years [29]. In this study, we use the term “home care” since it was commonly used in the municipalities where the study participants worked. The term “home care nurses” will be used for all personnel working in home care.

The design of the study is exploratory using a mixed method with a qualitative to quantitative approach [30].

The study is part of the larger research project “Personal resources supporting work ability”, aiming to provide knowledge about ageing workers’ personal resources during their final working years. In this study, we considered ageing workers 45 years and older. Forty-five years has often been used as a criterion for ageing workers since major changes in function that can affect work ability and personal resources often occur at this age; yet preventive measures are still possible [31]. The study was carried out in May to September 2018. The questionnaire included three well-reputed, valid, and reliable measuring scales and four open-ended questions, which were analysed separately in two different phases. The results from the measuring scales Work Ability Index [32], Utrecht Work Engagement Scale [33] and Occupational Self-Efficacy Scale – Short Form [25] are presented elsewhere (accepted, not yet published).

The HCNs’ answers from the open-ended questions composed the source of this study. An English translation of the open-ended questions is provided as Additional File 1. From a region of Western Finland with mostly rural areas, HCNs were recruited using their home care manager, that is, the manager of the home care unit. Eight municipalities and cities, conducting home care services by themselves, and two social- and health services consortiums consisting of three to four municipalities or cities each, and who all were organizing public home care in accordance with Finnish legislation, were included. All HCNs, 45 years and older, were recruited to answer an anonymous pilot tested paper-based or web-based questionnaire available in Swedish or Finnish languages. In the open-ended questions, the HCNs were asked to name three things that give work motivation and three things that impact negatively on their work motivation, and correspondingly that make them believe that they can continue working until expected retirement age and that impact negatively on their belief to continue working (i.e. occupational self-efficacy) (Fig. 1). In this study, motivation refers to willingness to work well [13], and occupational self-efficacy to belief in one’s capabilities to successfully perform work until expected retirement age [25].

Out of 460 invited participants, 234 HCNs answered the questionnaire after three reminders, yielding a response rate of 51%. Participants were 45–66 years old, and the majority were women with an average of 18 years work experience in home care (Table 1).

The numbers are either % or mean (median), standard deviation.

Work ability index: poor (7-27), moderate (28-36), good (37-43) and excellent (44-49) work ability. Occupational self-efficacy: 0–7, higher mean scores indicate better self-efficacy. Work engagement: 0–6, Higher mean scores indicate better work engagement.

A mixed methods approach was used, including qualitative and quantitative research [30, 34]. Using mixed methods enables a better understanding of the complex topic, using the strength of integrating both qualitative and quantitative analyses to generate new knowledge. First, the answers from the open-ended questions were analysed by qualitative manifest content analysis, to gain a deeper knowledge and understanding [30, 35] of ageing HCNs’ work motivation and occupational self-efficacy belief. Answers from the open-ended questions were organised in Microsoft Excel, with answers from each participant in a separate row. To become familiar with the text, all responses were read through several times. From each question, responses were grouped into topics. Further, for each individual question, the topics were analysed by manifest qualitative content analysis. The condensed text was coded, and the codes were interpreted and compared repeatedly for similarities and differences. Codes with similar content were sorted into sub-categories and categories. Finally, sub-categories were sorted into categories that corresponded to the meaning of the material, the context, and the aim. To confirm conformability, investigator triangulation was used. SW made the initial analysis of the responses into similar topics and condensed the text. In addition to SW, AFW and LF read the condensed answers and the codes independently, and the codes were compared and discussed until agreement was reached [30, 35]. Next, descriptive statistics were performed using Microsoft Office 2016 Excel, based on the results of the qualitative analysis. The categories created from the qualitative analysis were quantitatively ranked, based on the frequencies of which they were mentioned in all the data for each open-ended question [30]. Reporting the frequencies and percentages enabled examination of where the main point in HCNs’ responses was located in the large amount of data (2339 utterances from the four questions taken together). An integration of both the qualitative and the quantitative approach was used, in the aim, the data analysis, results and discussion [30, 34].

The category “Work environment” included the sub-categories “Satisfaction with colleagues” and “Satisfaction with leadership and organizational resources”. HCNs were motivated by satisfaction with colleagues including good relationships, a sense of belonging in the work community. Well-functioning teamwork was emphasized. It was considered a product of reliable and supportive colleagues with good collaboration skills. HCNs’ motivation was increased by satisfaction with leadership, which included that the labour management trusted the HCNs, and allowed them to take responsibility and influence their work content, routines, work schedules, work quantity, and vacations. Opportunities to perform other tasks for a change or supervise new colleagues were also expressed. Furthermore, home care leader, applying a supportive leadership style, including having a good attitude with workers and good dialogue skills seemed to improve work motivation. High quality work was possible if the following necessary organizational resources were available: appropriate work equipment, enough staff, and good work planning, for example, functioning work schedules and sufficient time to perform client work.

The category “Significance of the work” included the sub-categories “Meaningful work” and “Enriching client meetings”. Home care work itself was a source of work motivation, and was considered important, meaningful, and necessary. An intrinsic motivation to help other people was emphasized; having the willingness, ability, and permission to help clients and make a difference in their everyday life, as well as to bring them happiness. HCNs enjoyed working with the clients and cared for their well-being. Furthermore, home care work entailed recurrent social contacts; HCNs got to know their clients well and felt close to them.

The category “Stimulating challenges” included the sub-categories “Multifaceted work” and “Competence and desire to develop”. Another motivating factor was that home care work comprised both responsibility and freedom. The opportunity to do shift work and the work content were brought up. The feature of home care work; unpredictable, including varying and challenging tasks and client situations, mostly in the clients’ homes, was emphasized. The demanding work, requiring both physical and mental power as well as social skills, seem to increase work motivation, providing it is manageable. According to HCNs, they had the work they desired and were educated for. Additional motivating factors were work experience and professional skills. HCNs trusted themselves and had belief in their skills and competence. They felt motivated by results of work done and success in problem solving. Moreover, they wanted to continue developing their professional skills.

The category “External response” yielded the sub-categories “Recognition from clients and relatives” and “Recognition from colleagues and management”. Positive feedback received externally from others for work done seemed to increase work motivation. Feedback received from the clients appeared as appreciation, praise, and encouragement. A hearty welcome from the clients, who were grateful for getting help and a good care improved motivation. Likewise, recognition from relatives showing their thankfulness for good care. Positive feedback from colleagues as encouragement and displayed satisfaction were found to be important for motivation, as well as home care managers and employers expressing their appreciation.

Moreover, less frequently mentioned responses yielded the categories “Income stability”, “Close relationships and leisure”, and “Sufficient health and energy”.

The category “Organizational work environment” included the sub-categories “Lacking resources” and “Unsatisfactory leadership”. Due to a reduction in financial resources and optimization, worsening care conditions, resources not meeting the needs of care, and inequalities between work teams had a negative effect on work motivation. HCNs stressed inadequate, or lack of, necessary work tools and inappropriate workspaces. Frequent changes in existing responsibilities, new tasks, and ways of working, that often occurred at short notice were perceived as both difficult and burdensome, and caused concern. Additionally, incompetence among the permanent workers and difficulties in finding skilled staff were negatively affecting motivation. Nevertheless, accessible skills among HCNs remained sometimes unused. Moreover, a negative effect on work motivation was a weak leadership. Significantly leaders’ negative attitude towards workers, and their lack of response, support, and appreciation. Insufficient dialogue between workers and leaders was emphasized, including poor information, work instructions and guidance at work. Leaders being inaccessible, escaping their responsibilities or making too high demands, sometimes without adequate follow-ups. Injustice in everyday work, unclear job descriptions, as well as poor work planning and scheduling were accentuated, in addition to HCNs not being involved in the work planning. Further hindrances stressed were unclear criteria and purposes of the home care work, and an overall unsystematic work organization.

The category “Time constraints” generated the sub-categories “Significant rush and stress” and “Negative consequences of time pressure”. According to HCNs, a constant time stress causing a negative strain decreased their work motivation. The work pace was perceived as too high due to time pressure, leading to a considerable and sometimes unreasonable rush. Physical and mental stress were present in everyday work. Among some HCNs, the stress arose periodically, while others considered it a constant and extreme stress. Too many client visits a day and time pressure when driving from one client to another triggered the stress. HCNs were often behind the scheduled time. They experienced less time for completing tasks, and for listening to the clients. Consequently, tasks were left unfinished or undone, with the quality of work suffering and the workload perceived as too hard.

The category “Job characteristics” yielded the sub-categories “A challenging work” and “Job discontentment”. The solitary and highly demanding home care work requiring great responsibility felt burdensome and decreased work motivation. HCNs expressed feelings of uncertainty and being unsatisfied. There were many client visits per day, with often new clients and new tasks. The shift work was perceived as hard, and additionally home care nurses worked a lot of overtime. Little opportunity to influence working hours and schedule, work routines and job tasks, as well as not being involved in decision making were negatively affecting work motivation. An increased amount of administrative work during the last years was perceived as taking too much time from the client work, and some assignments were considered unnecessary. Additionally, the work environment in clients’ homes was often warm and non-ergonomic, and many clients were physically heavy to assist. The weather conditions of the seasons were at times challenging. Many kilometres were driven by car, sometimes in demanding weather and bad road conditions. Alarming was that the already high workload was perceived as increasing, because of a higher amount of work, increasing requirements, and more complex clients with more challenging care needs. HCNs wished to improve their skills, but at the same time they experienced declining levels of energy and willingness. The work became an old habit, and the attitude and the feeling towards work became increasingly negative negatively affecting work motivation.

The category “Work community” yielded the sub-categories “Negative atmosphere” and “Poor engagement”. A poor work community, including a bad atmosphere and negative and tired colleagues, was negatively affecting work motivation. Poor cooperation and conflicts in the working group along with the complaining of others, arrogance, gossip, slander, and jealousy were brought up. In addition, a language barrier between Swedish and Finnish speakers was mentioned, although only by a few HCNs. Lack of commitment and motivation were expressed as poor work ethic and poor activity among the staff; colleagues being lazy, high usage of private mobile phones, and not participating in tasks other than client work. HCNs emphasized that poor responsibility among colleagues when tasks were left undone, and colleagues not helping each other even though needed decreased work motivation. As a result, a loss of confidence in colleagues was seen.

Additional categories decreasing work motivation, although mentioned less, were “Weakened health and energy”, “Feedback from clients and relatives”, “Salary level”, “Staff shortage”, “National controlled decrees” and “Age”.

The category “Own health” generated the sub-categories “A resource and a challenge” and “Health supporting activities”. Overall, HCNs conveyed their health as important on their belief to continue working, worth investing effort in. The health was both a resource and a challenge. Good health and wellbeing, or manageable health challenges, provided confidence. In contrast, some HCNs felt anxious about their deteriorating health; they perceived worries about their future work ability and voiced the need to prioritize their health before continue working. However, HCNs declared an intention to and an interest in promoting and maintaining their health, by participation in rehabilitation programs, and with appropriate physical exercise, rest and eating habits.

The category “Workplace resources” yielded the sub-categories “Satisfactory organizational resources” and “Strong workplace community”. Well-organized work highly influenced HCNs’ belief to continue working, and included both material resources, good leadership, and good relationships with colleagues. HCNs emphasized having and retaining a sufficient number of both temporary and skilled workers by using continuing employment agreements. The supply of necessary ergonomic tools and possibilities to adapt the clients’ homes for their care needs, as well as job training to cope with demanding clients, provided belief. Furthermore, the availability of modified tasks in line with current work ability, as well as supply of adequate occupational health care service were stressed. A good leader that is supportive, responsive, understanding and encouraging, showing appreciation for efforts made and treating workers equally seem to improve belief to continue working. Moreover, HCNs emphasized the importance of having influence over working hours, workload, work content and opportunities for job rotation. Although age itself was rarely mentioned, HCNs wanted the employer to notice age in a positive way. A strong work community was essential and produced job satisfaction and belief. The HCNs mentioned likable colleagues, with whom they got on well and sometimes developed deeper friendships. In well-functioning work teams, colleagues supported and helped each other. However, sometimes work in another work team in the case of a poor work community could enhance belief to continue working.

The category “Meaning of the work” generated the sub-categories “Intrinsic motivation” and “Satisfaction from work”. A great intrinsic motivation and a strong desire to help and take care of people were positively affecting HCNs’ belief to continue working. HCNs experienced the work as meaningful and highlighted the large amount of people in need of assistance. They stressed feelings of love for their work and stated home care nursing as their dream profession. HCNs liked their clients and the client relations provided social interaction and rewarding meetings. Furthermore, satisfaction with the work tasks and the workplace seem to improve the belief to continue working. However, own work morale was considered essential to continue working.

The category, “Profession in demand” yielded the sub-categories “Continuous need of home care” and “Skilled in demanding work”. Employment stability in the home care sector increased HCNs’ belief to continue working. HCNs emphasized a continuous need of staff, and future demand due to changes in society regarding more people living at home longer. To continue working within the same field and work team also gave a sense of security. Feeling skilled in the multifaceted home care work, with confidence in managing the varying work tasks improved HCNs’ belief to continue working. HCNs saw manageable continued changes and work-related challenges as inspiration, and they wanted to further develop their own professional skills. However, a reasonable mental and physical workload, as well as for a better status for the home care work would further increase HCNs’ belief to continue working.

Furthermore, but in less degree, the categories “Family life and leisure”, “Joy of living and wisdom”, “Income needed” and “Appreciation and feedback” emerged.

The category “Health-related decline” yielded the sub-categories “Current life and health” and “Future health challenges”. Simply if the overall health remains; the HCNs did not see any hindrances to continue working until the expected retirement age. However, the current health and balance in life revealed challenges in belief to continue working. HCNs brought up a long list of diagnosed diseases, such as mental health disorders, musculoskeletal diseases, and hypertension. Many reported aches and pains in the back, shoulders, knees, or fingers. Due to the current health limitations, HCNs expressed concerns and uncertainties of whether the current diseases will deteriorate, and about future illnesses. Along with physical decline, high mental strain, insomnia, reduced energy and weakened recovery caused uncertainty about the future. Moreover, the concern of close relatives’ health was also stressed. However, only a few mentioned their ageing as a concern.

The category “Multifaceted work” included the sub-categories “Demanding work” and “Imbalance between individual resources and demands”. HCNs perceived home care work as burdensome, which negatively affected their self-efficacy belief. The shift work was intense and hard, with irregular and inconvenient working hours, and composed of too many shifts without days off. Extended working days, frequent overtime and being asked to work at short notice caused even more aggravation. HCNs stressed an increase in the number of clients, often with more demanding care needs, and yet often less time for caring and assistance. An additional source of discontent lowering self-efficacy belief was the increased number of administrative tasks, sometimes at the expense of client work. Increased work areas also entailed longer work trips and more travel time in the car. Furthermore, an increased requirement on knowledge was experienced, and some HCNs stressed an inadequate knowledge level in relation to the requirements. Moreover, concerns about an imbalance between individual resources and an already heavy, and still increasing, physical and mental workload negatively affected belief to continue working. Care giving in clients’ homes, often with insufficient ergonomic tools, entailed physical heavy workload. The already high and increasing work demands, as well as the uncertainty about future demands and an even greater workload, were mentally challenging. To be constantly flexible at work was also stated to be mentally challenging. Likewise, was dealing with clients and relatives. HCNs sometimes perceived too much responsibility and were concerned about the poor quality of the final home care being provided. In contrast, lack of challenges, personal development, and promotional opportunities also negatively affected belief in being able to continue working in the home care sector.

The category “Organizational resources” yielded the sub-categories “Consequences of lack of resources” and “Unsatisfying leadership”. Lacking resources and economic savings negatively affected HCNs’ belief to continue working and were conveyed as staff reductions, understaffing, hiring freezes, incompetent workers, and the continuous employment of temporary workers. Involuntary team and workplace changes were forced. Additionally, home care work was exposed to frequent and continuous changes due to the organizational changes and fusions of organizations. Many changes were considered irrational, causing either deterioration, or not achieving the expected results, and were mentally stressful and energy draining. Other changes were considered as uncontrollable, and the uncertainty and fear of losing one’s job was revealed. Dissatisfaction with leadership and poor leadership skills were other sources negatively affecting HCNs’ belief to continue working. Lack of support, appreciation, respect, justice, and equality were disclosed, as well as unclear or missing information. HCNs experienced that they sometimes were not listened to, and that their home care managers had inadequate understanding of home care work. Moreover, excessive demands with no resources for realization, as well as poor and unfair work distribution had a negative influence on HCNs’ belief to continue working until retirement age.

The category “Work related strain” generated the sub-categories “Constantly present rush” and “Imminent threat of stress”. A constant rush causing stress reactions was negatively affecting HCNs’ belief to continue working until the expected retirement age. The hurry was an existing companion in the everyday work, perceived to be further increasing, and too hard. Some HCNs wanted to change work, because of the rush. Additionally, concerns about continuous stress decreased HCNs’ self-efficacy belief. Home care nurses expressed reduced stress tolerance, including thoughts about work interrupting their sleep, and that they were worried about future stress aggravated reactions.

In addition, categories with less responses were “Political and national decisions”, “Workplace community”, “Financial reasons”, “Retirement and family life”, “Lack of motivation”, and “Unemployment”.

A strength in our study was the use of a cross-sectional survey, since the prevalence of multiple outcomes could be measured, and many participants could be reached at the same time [68]. All HCNs in the chosen region, aged 45 years and older, were invited, and were considered as representatives of ageing workers in the home care sector. However, their experience of home care work differed, and this may have affected the answers regarding perceived challenges and resources. Another strength of this study was the use of mixed methods, including both qualitative and quantitative analysis of the research data. The manifest qualitative analysis provided a deeper knowledge and understanding of the issues [30, 35]. Moreover, the quantitatively measured frequencies of utterances gained reliability since the focus of HCNs’ experiences was acknowledged [30]. Nevertheless, the cross-sectional design, describing the phenomena at one specific time, limited the ability to derive causal relationships [68].

A limitation when using a questionnaire is a risk of high numbers of dropouts. The response rate was 51%, which could imply a possible outcome bias. The close managers who administered the survey decided whether a paper-based and/or web-based questionnaire was most suitable in their team. The response rate was slightly lower among the web-based respondents. Hence, some none-responding HCNs might have answered a paper-based survey. Moreover, the research data consisted of open-ended questions. The answers were often short, which despite manifest analysis, might have caused some interpretation bias [35]. Therefore, we returned repeatedly to the meaning units as well as all the respondent’s answers to check the entirety and the meaning [30, 35]. The response rate of the open-ended questions among the answering respondents was high (86–97%, n = 202–227 for each question), although the open-ended questions were placed last in quite a large-scaled survey. This indicated that HCNs had an interest to articulate their work motivation and belief in their capabilities to continue working. Another strength was that the findings not only highlighted what motivates HCNs to perform work tasks, but also an intrinsic motivation to care, reflected by internal feelings of care for clients and a deeper meaning of the work.

The HCNs’ responses were either in Swedish or Finnish language. None of the researchers had Finnish as their mother tongue, although two of them mastered Finnish well. In the case of linguistic doubts, a person with Finnish as their mother tongue, also skilled in health care, was consulted. A strength was that no linguistic misunderstandings appeared in the pilot testing of the questionnaire. The researchers’ pre-understanding consisted of long experience in health care, occupational health service and rehabilitation as well as experience in qualitative and quantitative research. To minimize the pre-understanding, the qualitative data analysis followed a structured procedure in several steps [30, 35]. Dependability was established by repeatedly going back to the encoding, verifying the encoding to the meaning units and the open-ended answers, and checking the reliability of the categories [30, 35]. Notes about the encoding were made throughout the analysis process. To increase conformability, triangulation between researchers was used. Quotations were used to support authenticity in presented categories (Table 2) [30]. Moreover, our study addressed the explicit views of the ageing HCNs, in the context of both rural and urban areas, including home care services conducted by municipalities, cities, and social- and health services consortiums. The categories that emerged through manifest content analysis were considered logical and answering the purpose of the study. The findings from our study can likely be transferred to other Nordic countries, due to their similarities in home care service [6]. However, educational requirements for staff may differ in different countries. Despite home care including distinct elements concerning care in clients’ homes; the results might also be transferable to ageing workers in other nursing contexts [30, 35].

The results of this study convey important understandings of the ageing HCNs’ views of work motivation and occupational self-efficacy belief to continue working until expected retirement age. By supporting HCNs’ health and emphasizing the meaningfulness and positive aspects of the work, offering overcoming challenges and learning opportunities, the HCNs’ work motivation and self-efficacy belief to continue working can be strengthened. This information could be used by home care managers, organizational management, occupational health personnel, safety personnel, and by HCNs themselves, to consciously reflect on and develop a sustainable work life for ageing HCNs. Addressing the needs of ageing HCNs could also help employers deal with the lack of workers in the home care sector. In turn, employers could receive more workers with better well-being and with possibly longer work careers.