Psychological Ownership of Nursing Care: A Qualitative Content Analysis

1. Background

Caring is a crucial concept in nursing. This concept was first introduced by Leninger in the 1950s. Since then, caring has been considered an essential component of nursing practice (1). Nurses provide continuous care to patients, and their services play an important role in achieving health systems’ goals and patient satisfaction (2). Therefore, if nothing is improved in the hospital except nursing care, the treatment outcomes are still very important (3) because nursing care is an essential component of healthcare (4). Today, although nursing care has a theoretical basis, the quality of nursing care is still criticized, and numerous studies have shown that the quality of nursing care in some departments is not satisfactory (5). In addition, the results of a meta-analysis have shown that patient satisfaction in hospitals is below average (14.1%) (6). Other studies have shown that one of the main concerns of healthcare providers and patients is that the quality of nursing care needs to be improved (7, 8).

A concept called psychological ownership (PO) has emerged in the literature related to job performance. This complex concept is essential to the provision of high-quality care (9-11). Therefore, when a person considers himself/herself as the owner of something, he/she experiences certain feelings and thoughts. Even individuals’ self-concept is related to these objects (Black, 1988). Individuals feel ownership not only of physical objects but also of intangible objects and even in the workplace (12). In the workplace, individuals feel responsible for their organization or their role (13). Psychological ownership and caring behaviors are significantly related (14), and studies have shown that nurses with higher PO exhibit better caring behaviors (11, 14). Healthcare providers who feel more involved in their patient’s care are more active and better prepared to make decisions. In these situations, healthcare providers also have greater personal responsibility (15).

Psychological ownership is not only a personal concept but also a shared social or collective reality (16) that, as a multidimensional structure, reflects the personal feelings of the individual or a group of individuals. This occurs in such a way that the individual considers a tangible or intangible object as his or her own (“it is mine”) (17). Patient care ownership is also defined as a cognitive-emotional state, and the caregiver uses both cognitive and emotional processes to make decisions. With a high level of ownership, the decision-maker can consider his/her knowledge, beliefs, experiences, and skills (the cognitive component) and his/her sense of self-efficacy and competence (the emotional component) (10). Recent studies have shown that increasing PO can have significant effects on the emotions, behaviors, and attitudes of those who experience a sense of ownership. Extensive research in a variety of fields emphasizes the important influence of ownership on human motivation, attitude, and behavior (15). This is because an individual’s sense of ownership can have a powerful motivational effect on him/her (18).

In achieving business objectives, human resources are considered a key factor. Therefore, the effective factors to increase the efficiency and productivity of nurses should be identified to formulate the necessary plans for their growth (19, 20). To this end, it is important for nurses to have a sense of PO regarding nursing care, as this will not only enable better quality of care and better nursing outcomes but also reduce the number of nursing absenteeism. The current unfavorable conditions in nursing care require a focused study to analyze the PO of nursing care. Therefore, it is required to determine how nurses explain the PO of nursing care.

2. Objectives

Since there is a lack of qualitative studies on the concept of ownership in nursing, this study aimed to investigate the PO of nursing care in hospitals.

3. Methods

3.1. Study Design

This study, with a qualitative (conventional content analysis) design, aimed to explain the concept of the PO of nursing care.

3.2. Setting and Sample

The participants in this study included hospital nurses, faculty members, and master’s degrees and Ph.D. students of nursing in Iran. The participants in this study were purposively selected. Sampling continued until new concepts emerged, the data were not repeated, and data saturation was reached. The inclusion criteria were having at least 2 years of clinical and nursing care experience, the ability to communicate, and sufficient time for interviews. The exclusion criterion was an unwillingness to participate in the study. The present research setting included the hospitals (the nurses from various wards, including the intensive care unit, coronary care unit, internal medicine, emergency, and surgery) affiliated with Iran University of Medical Sciences, Tehran, Iran, Mazandaran University of Medical Sciences, Mazandaran, Iran, and nursing schools in the country.

3.3. Data Collection/Procedure

In this study, semi-structured interviews were conducted face-to-face with nurses or via Skype (due to coronavirus disease 2019 [COVID-19]). An interview guide with open-ended questions was used, and the questions were prepared based on expert opinion and a review of relevant literature. The interviews began with a brief introduction about the purpose of the research and obtaining written informed consent separately from the participants. In total, there were 13 interviews with minimum and maximum duration of 40 and 90 minutes, respectively, with an average of 65 minutes. The following is a list of the open-ended questions that were asked prior to the interview:

How do you take care of your patients?

How do you describe ownership in nursing care?

To get a fuller explanation, ask probing questions, such as “Please explain more”. In addition, various techniques, such as silence or “aha” and repetition of the participant’s speech, were used. The nurses were assured that the recorded audio interviews would be kept confidential and deleted after the completion of the study. Then, the primary and exploratory questions were asked. MAXQDA software (version 10) was used to manage the information and text of the interviews, and the principle of confidentiality and data protection was observed.

3.4. Ethical Considerations

Written informed consent was obtained from all the participants. Moreover, the study was conducted in accordance with relevant guidelines and regulations. The participants were assured of anonymity and keeping the data confidential. In addition, the Ethics Committee of Iran University of Medical Sciences approved this study (approval code: IR.IUMS.REC.1399.1105).

3.5. Data Analysis

The methods of Granheim and Lundman were used for the analysis (21). First, the interviews were transcribed. Then, the data were analyzed and coded, and the categories and main categories were extracted. This method consisted of five steps. The first step was to transcribe the interviews. The second step was to review the text of the interviews several times to obtain a general understanding. The third step, based on the objectives of the study, was the identification of the units of meaning related to nurses’ perceptions of the PO of nursing care, and each unit of meaning was assigned a corresponding code. The fourth step was the categorization of the codes according to commonalities and differences of subcategories. Finally, as the fifth step, the subsets were compared several times; then, the latent content was identified, and five main categories were extracted (Table 1). The categories were reviewed by all authors.

3.6. Trustworthiness

In this study, credibility, reliability, conformity, and transferability were used to assess the quality of the data and results (22). Regarding credibility, the researcher engaged with the data over a long term when collecting and analyzing them and had frequent contact with the participants. To ensure transferability, the researcher carried out all the steps of the study accurately and in detail and constantly compared the data. To be reliable, the data were provided to peers. In addition, the researcher checked the obtained codes twice during coding, and the codes were checked by two experts in qualitative research. To verify the results of the study, more than two questions were asked during the interview, and the results were returned to the respondents for confirmation.

4. Results

A total of 13 individuals participated in this study, including 3 Ph.D., 4 master’s degrees, and 6 bachelor’s degrees. Demographic characteristics showed that 69% of the participants were female, and 53.84% were single. The average age of the nurses was also 39 years (range: 30 - 61). The average practical experience of the nurses was 13.84 years (Table 1). In this study, the concept of PO of nursing care includes the four dimensions of professional competence, practical efficacy, holistic advocacy, and professional identity (Table 2).

4.1. Professional Competence

Based on the results of this study, professional competence in the PO of nursing care refers to scientific mastery, professional ability, interactive role, and responsible performance.

4.1.1. Scientific Mastery

Based on nurses’ experiences and perceptions of patient care, it was their scientific mastery that made nurses feel responsible for their care. This sense of ownership of their patient care led them to acquire current and specialized knowledge on each unit. These nurses had less fear of nursing, made fewer mistakes, and had a more transparent and accepted status.

4.1.2. Expert Ability

Nurses who have a sense of ownership in their patient care want to become experts. They apply the nursing process, critical thinking skills, and clinical reasoning to nursing care and gain insight and stability as they gain experience in practice.

4.1.3. Responsible Performance

According to nurses, one of the things that create a sense of ownership in nursing is responsible performance of patient care. In addition to providing safe care, they are committed and responsible for the consequences of care, follow the law, and play a responsible role in their organization.

4.1.4. Interactive Role

The experience of the nurses showed that they demonstrated one of the professional competencies in patient care by interacting with the patient, the attendant, and the treatment team, acknowledging the patient, and respecting individual differences in communication.

4.2. Practical Efficacy

Practical efficacy refers to the nurse’s participatory role in practice and having authority and initiative.

4.2.1. Participatory Role

From the nurses’ point of view, the nurse can perform more effectively and be effective if he/she participates in the treatment process and collaborates with the physician. By strengthening his/her influence in practice, he/she acquires a sense of ownership over the care and says that I was the one who improved my patient’s condition.

4.2.2. Authority

Nurses said that they must gain power and authority and access to sources of power (e.g., communicating with managers and supervisors) to be effective, and the acquisition of power can be achieved over time through the acquisition of knowledge, experience, skills, and competence.

4.2.3. Initiative

Nurses indicated that another factor in their practical efficacy is their dynamism in patient care and independent role in performing tasks. To reach this level, the nurse must gain self-knowledge to take initiative and be effective.

4.3. Holistic Advocacy

Holistic advocacy refers to a range of caregiver support for patients and their families and peer support.

4.3.1. Patient Support

Nurses viewed their patients’ care support, including physical, emotional, and economic support, in a way that respected their patients’ values, protected them, and provided them with a supportive role by offering them appropriate information, education, and holistic care.

4.3.2. Family Support

Family support is provided through empathy, education, and reassurance of the family. This support should be such that it makes them feel valued by involving them and helping them make decisions.

4.3.3. Colleague Support

Nursing professionals have expressed that nurse support should encompass the well-being of their colleagues, thereby enabling them to attend to novice nurses, show empathy for their peers, accord them due attention, and acknowledge their contributions.

4.4. Professional Identity

Professional identity also includes a set of identity characteristics to gain trust, value-based care, and compassion in patient care.

4.4.1. Job Identification

Job identification can be achieved by becoming a nurse, acquiring a professional personality, promoting a professional identity, and playing a role in society that is influenced by the attractiveness of the profession and the nature and characteristics of the ward. Nurses’ job identification increases their sense of PO of patient care.

4.4.2. Gain Trust

Gain trust is another factor that helps nurses get a sense of PO. This is because when a nurse is trusted by others in the workplace, she/he feels seen and considers her/his role in the organization important. To gain credibility, nurses must gain the trust of physicians and patients, and organizational trust is effective for nurse credentialing.

4.4.3. Clinical Position

The position of a nurse in a clinical setting is very effective in gaining a sense of responsibility. Nurses indicated that they can achieve this through their unique and special performance, playing their role in the physical and psychological care of the patient, promoting and improving health, and making clinical and organizational decisions.

4.4.4. Self-discovery

Nurses indicated that they should achieve self-confidence through self-awareness, self-efficacy, and belief in their worth.

4.4.5. Care with a Value Approach

Another aspect of nurses’ professional identity is value-based care, which includes conscientiousness, justice in care, ethics, and altruistic care.

4.5. Compassion

Nurses indicated that other aspects of creating a professional identity include empathy with the patient and self-sacrifice in providing care.

5. Discussion

Based on the results of this study, professional competence, practical efficacy, holistic advocacy, and professional identity concepts have been identified as the five dimensions of the PO of nursing care. In this study, professional competence is the first dimension of PO nursing care. A sense of PO occurs when nurses invest their time, energy, and effort in improving patient care. One of the three routes introduced in the theory of PO is the investment of self (17). This sense of ownership encourages nurses to invest themselves to become competent in patient care. Therefore, nurses seek to differentiate themselves from other non-professionals by acquiring knowledge and nursing skills and expertise. Since they consider nursing the property of the nurse, they feel an obligation and responsibility toward it and try to establish good communication with the patients and colleagues in the clinical setting.

In this study, practical efficacy is the second dimension of the PO of nursing care. According to Pierce, a theorist of the concept of PO, this dimension is one of the three motivations of this concept (17). Efficacy motivates an individual. Consequently, an individual is interested in efficacy and the ability to achieve the desired results in the environment. A part of the human being manifests itself in the individual’s search for the environment, which results from the motivation to influence, such as the individual’s desire to interact effectively with his/her environment. Motivation to influence is generated by changing something in the environment, and it persists when an individual’s actions cause further change. However, motivation wanes when nothing new is created (12). Nurses also feel a greater responsibility to provide care in an environment with their greatest influence. This is because the ability to control the environment creates a sense of efficiency and joy that comes from “being the cause” and changing the environment by exercising one’s control (12). In this study, the nurses also indicated that a participatory role could enhance authority and initiative.

In this study, holistic advocacy is the third dimension of the PO of nursing care. This holistic advocacy includes patients, their families, and colleagues. When a nurse feels that caregiving is her job, she inevitably volunteers to protect the patient, family, and colleagues from harm. Watson, a nursing theorist, identified patient advocacy as a fundamental part of humanistic nursing philosophy (23, 24). Simultaneously, by identifying with nursing care, the nurse assumes the role of both protector for the patient and their family in relation to bureaucratic treatment team decisions and supporter for his/her fellow colleagues. The nurses indicated that advocacy in the design of PO care includes physical, emotional, economic, informational, and educational support for the patient. A nurse who feels responsible for nursing care strives to be attentive to the value of his/her patients. Studies have also shown that appreciation is an important component of patient support. A nurse also does not neglect to support his/her patients’ families and acts responsibly to protect his/her colleagues even when he/she gets into trouble (25-27).

Professional identity is the fourth dimension of the PO of nursing care. According to Pierce et al., personal identity is also one of the roots of PO, helping individuals to define themselves and show their identity to others (12). Professional identity is a part of everyone’s overall identity and is strengthened by an individual’s position in society, interactions, and experiences (28). It is a sense and perception of the role that an individual acquires at work (29). Individuals carry a variety of different titles as a symbol of their identity (12). The symbol of the nursing profession is also related to the concept of care, which is the main pillar of nursing tasks.

This study showed that confidence is important in creating a professional identity. A nurse with a sense of professional identity not only feels a sense of confidence as a resourceful nurse but also conveys this feeling to others. According to Erikson et al.’s psychosocial development theory, the nurse will not develop a true professional identity only after developing confidence (30). As defined by Stenbock-Hult, a nurse with a sense of professional identity feels obligated to follow professional standards and ethical principles in caring for the patients (31, 32). Furthermore, this investigation also revealed that in order to develop a professional identity, nurses are required to pursue an identity that prioritizes value-based care and compassion in the provision of patient care. Meanwhile, previous studies have also shown that compassion plays a role in the development and growth of the professional identity of nurses and is considered to be one of the most important professional values and an integral part of the identity of nurses (33).

5.1. Limitations

One of the limitations of the current study was the unavailability of the participants during COVID-19, which was addressed via Skype. In addition, some participants had to be dropped out of the study because they did not have access to virtual networks. As this study was conducted in one country, further studies are needed in the future.

5.2. Conclusions

Despite the above-mentioned limitations, some important results are reported. It was observed that the concept of the PO of nursing care has four dimensions, including professional competence, practical efficacy, holistic advocacy, and professional identity. In conclusion, PO is an important concept for quality patient care. In order to create a sense of PO in nursing care, nurses need to have professional competence and holistic support in nursing care and consider their professional status and identity.