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Navigating the storm: the impact of Hawaiian culture on stress, burnout, and retention of Hawaii’s acute care nurses during the COVID-19 pandemic (2020–2022)
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Navigating the storm: the impact of Hawaiian culture on stress, burnout, and retention of Hawaii’s acute care nurses during the COVID-19 pandemic (2020–2022)
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Content
Navigating the Storm: The Impact of Hawaiian Culture on Stress, Burnout, and Retention
of Hawaii’s Acute Care Nurses During the COVID-19 Pandemic (2020–2022)
Erich M. Weldon
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
December 2024
© Copyright by Erich M. Weldon 2024
All Rights Reserved
The Committee for Erich M. Weldon certifies the approval of this Dissertation
Eric Canny
Monique Datta
Kimberly Hirabayashi
Alison Muraszewski, Committee Chair
Rossier School of Education
University of Southern California
2024
iv
Abstract
The COVID-19 pandemic presented unprecedented challenges to healthcare systems,
significantly increasing stress, anxiety, and burnout among acute care nurses in Hawaii. This
study investigated the determinants of burnout during the period from March 2020 to March
2022, with a particular focus on those nurses who were considering reducing their work hours,
exploring alternative employment opportunities, or leaving the profession altogether. Grounded
in Bronfenbrenner’s (1979) ecological systems theory framework, the research examined a range
of individual, organizational, and societal factors that contributed to nurse well-being and
burnout during the pandemic. The study uncovered how the interaction between personal and
work environments, coupled with Hawaii’s unique cultural norms, influenced nurses’ intentions
to remain in their roles amidst the crisis. It highlighted how the pandemic exacerbated preexisting healthcare disparities, leading to intensified nursing shortages and compromised care
quality, especially in marginalized communities. The insights gained from this research were
intended to inform interventions and policy measures aimed at mitigating burnout, enhancing the
well-being of nurses, and improving the overall quality of patient care. Ultimately, this study
contributed valuable knowledge to the growing body of literature on healthcare professional
burnout during crises, offering strategies to bolster the resilience of the healthcare system in
Hawaii and beyond.
Keywords: COVID-19, pandemic, burnout, critical incident stress, Hawaii registered
nurse, Bronfenbrenner’s ecology of human development, aloha, mālama, kuleana,
ho’oponopono, lōkahi
v
Dedication
To Wen Phu, your support throughout this endeavor has made this journey easier. Thank you for
taking care of all the things while I hunkered down in this room to write. I can now give you a
different answer to, “What are we doing today?”
vi
Acknowledgements
I would like to take a moment to thank my friends and family who have supported me
over the past 5 years. To my mom, your words of encouragement helped move me through some
tough days. Cookie, thank you for all the time you gave me, your humor, and bearing with my
tales of this journey. To you and Shana, I can say it is finally done—even though it was due
months ago. Thank you, Loc, for your weekly words of encouragement and support!
To my USC family and Hawaii cohort—thank you for walking this walk with me. Dr.
David Ambrocik, your assistance and guidance with course content and putting things in
perspective was invaluable. Your friendship and dinner conversations mean a great deal to me.
To Dr. Tanya Diaz-Chong, mahalo nui for always bringing me into the conversation and
allowing me to bounce my thoughts off you. Dr. Courtney Nall, Dr. David Bushnell, and the rest
of the LDT crew—together, we were able to tackle the 4 years it took to accomplish this great
feat! Thank you! Dr. Linda Beechinor, your assistance with survey distribution through the
Hawaii ANA was invaluable. Dr. Muraszewski, your guidance as my dissertation chair has been
invaluable. This has been quite the journey, and I appreciate your insights!
To Kate Roche, you have been more than a mentor to me. Your guidance and
encouragement continued to push me to face new challenges. Your sponsorship provided many
opportunities, and your words of wisdom helped center so many of my viewpoints. You are a
legacy to nursing. You are a great friend. Mahalo nui loa for your support!
vii
Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ....................................................................................................................................... v
Acknowledgements ........................................................................................................................ vi
List of Tables ................................................................................................................................. ix
List of Figures ................................................................................................................................ xi
Chapter One: Overview of the Study .............................................................................................. 1
Context and Background of the Problem ............................................................................ 1
Purpose and Rationale of the Study .................................................................................... 3
Research Questions ............................................................................................................. 4
Importance of the Study ...................................................................................................... 5
Overview of Theoretical Framework and Methodology .................................................... 6
Definitions........................................................................................................................... 8
Organization of the Dissertation ....................................................................................... 11
Chapter Two: Review of the Literature ........................................................................................ 12
Historical Context ............................................................................................................. 13
Review of Past Research ................................................................................................... 19
Characteristics of the Population and Stakeholders .......................................................... 39
Impact of Nurse Burnout on the Nursing Workforce in Hawaii ....................................... 49
Bronfenbrenner’s Ecology of Human Development ........................................................ 52
Gaps in Current Literature ................................................................................................ 60
Chapter Three: Methodology ........................................................................................................ 62
Research Questions ........................................................................................................... 62
Overview of Design .......................................................................................................... 62
Research Setting................................................................................................................ 64
viii
The Researcher.................................................................................................................. 66
Data Sources ..................................................................................................................... 68
Validity and Reliability ..................................................................................................... 72
Ethics................................................................................................................................. 73
Chapter Four: Findings and Results .............................................................................................. 75
Participants ........................................................................................................................ 76
Research Question 1: Nurses’ Environment on Acute Care Bedside Work ..................... 82
Research Question 2: Hawaii’s Culture on Nurses’ Acute Care Bedside Work .............. 98
Summary ......................................................................................................................... 113
Chapter Five: Discussion ............................................................................................................ 115
Research Question 1 ....................................................................................................... 115
Research Question 2 ....................................................................................................... 119
Recommendations for Practice ....................................................................................... 122
Limitations and Delimitations ......................................................................................... 134
Recommendations for Future Research .......................................................................... 136
Conclusion ...................................................................................................................... 137
References ................................................................................................................................... 139
Appendix A: Survey Questions .................................................................................................. 183
Appendix B: Responses to Open-Ended Questions .................................................................... 188
ix
List of Tables
Table 1: Data Sources 63
Table 2: Participant Self-Reported Demographics (N = 70) 79
Table 3: Participant Self-Reported Work Location as a Registered Nurse (N =
70)
80
Table 4: Participant Self-Reported Consideration to Work Direct Bedside,
Acute Care Between March 2020 and March 2022 (N = 70)
81
Table 5: Participant Self-Reported Outcome After Consideration to Leave
Direct Bedside Care (N = 42)
81
Table 6: Results From Research Question 1 of RN Overall Well-Being (N =
70)
85
Table 7: Statistical Significance of Consideration to Leave (Yes)—Overall
Well-Being (N = 70)
86
Table 8: Statistical Significance of Consideration to Leave (No)—Overall
Well-Being (N = 70)
86
Table 9: Results From Research Question 1 of RN Interaction and Support
With Family (N = 70)
88
Table 10: Statistical Significance of Consideration to Leave (Yes)—Family (N
= 70)
89
Table 11: Results From Research Question 1 of RN Interaction and Support
With Social Circles (N = 70)
92
Table 12: Statistical Significance of Consideration to Leave (Yes)—Social (N =
70)
93
Table 13: Statistical Significance of Consideration to Leave (No)—Social (N =
70)
93
Table 14: Results From Research Question 1 of RN Interaction and Support at
Work (N = 70)
96
Table 15: Statistical Significance of Consideration to Leave (No)—Work (N =
70)
97
x
Table 16: Results From Research Question 2 of Hawaii’s Beliefs, Values, and
Laws and RN Overall Well-Being (N = 70)
101
Table 17: Results for Research Question 2 of Hawaii’s Culture, Beliefs, and
Traditions (N = 70)
104
Appendix A: Survey Questions 183
xi
List of Figures
Figure 1: Bronfenbrenner’s Ecological Systems Theory 54
1
Chapter One: Overview of the Study
The COVID-19 pandemic created extraordinary challenges for healthcare systems
worldwide. Nurses, who form the backbone of direct patient care, were significantly impacted,
with numerous studies reporting increased stress, anxiety, and burnout (Chen, Sun, et al., 2020;
Lai et al., 2020; Martin et al., 2023). Acute care facilities, defined as providing short-term
medical treatment for patients with acute illnesses or injuries and typically requiring immediate
or specialized care, are experiencing unsustainable nursing turnover and staffing shortages,
negatively impacting patient care (Bae, 2022; Chervoni-Knapp, 2022). This study focused on the
specific context of acute care nurses in Hawaii who provided bedside care between March 2020
and March 2022 in acute care hospitals. The findings correlated how heightened environmental
and societal stressors affected the nurses’ considerations to remain at bedside, reduce their
working hours, look for opportunities away from the bedside, or leave the profession.
Context and Background of the Problem
Before COVID-19, nursing turnover was recorded at an average of 15.9%, but burnout
early reports indicated nurses’ intent to leave the profession increased by 11% (Raso et al.,
2021). Becker’s Hospital Review reports that 66% of nurses have at least considered leaving the
profession secondary to the pandemic (Gooch, 2021). An exodus of nurses will profoundly
negatively impact healthcare access to and quality in already marginalized communities.
Minority communities of color; lesbian, gay, bisexual, transgender, and queer (LGBTQ)
communities, and some religious communities indicated they experienced difficulties finding
compassionate, competent healthcare that was easily accessible (Ambrose et al., 2012; AyersKawakami & Paquiao, 2017; Collins et al., 2002; Healthy Communities Institute, 2015). The gap
in care will widen if primary caretakers leave the field.
2
Black, Indigenous, and people of color (BIPOC); rural; and LGBTQ communities have
historically received worse healthcare than their White, middle-class, and affluent neighbors.
Because the conversation surrounding care is not centered in the margins, that is “to shift a
discourse’s starting point from a majority group’s perspective … to that of the marginalized
group or groups” (Ford & Airhihenbuwa, 2010, p. S31), the voices and needs of underserved
populations are overlooked. At the outset of COVID-19, populations with higher Medicaid usage
typically underserved and rural areas, worked with decreased resources in nursing staff and
available facilities per capita (Mor et al., 2004). Historically, staff in these areas receive lower
wages than their counterparts in middle-class and affluent areas (Nurse.org Staff, 2021; U.S.
Bureau of Labor Statistics, 2021). A mass exodus of nurses will create profound human capital
deficits, widen the care gap, and increase significant care deficits in BIPOC and already
marginalized communities.
With inadequate facilities, lagging wages, and a shortage of nurses, nurses who do not
leave the field may look for better-paying jobs in newer facilities, leaving marginalized
communities with little to no access to compassionate, competent healthcare, something already
realized by communities of color, religious minorities, and the LGBTQ community (Collins et
al., 2002). Institutions in low-income and rural areas that lose this nursing staff will need to hire
and train new hires, with an average turnover of $51,700 per employee, causing hospitals to lose
$3.6 million to $6.5 million annually (NSI Nursing Solutions, 2023). Employers in poor
economic areas will not keep pace with the turnover. These communities will see facilities shut
their doors and be left with scarce or no services (American Hospital Association, 2020b;
Ellison, 2022; Miller, 2022).
3
Severe medical and mental health disparities and provider shortages existed before
COVID-19 on the islands of Hawai’i (Ayers-Kawakami & Paquiao, 2017), Kauai (Healthy
Communities Institute, 2015), and Moloka’i (Ambrose et al., 2012). These disparities will likely
worsen without an adequate number of care providers. The islands of Oahu and Maui realize
fewer challenges in healthcare access and services (HNN Staff, 2019) with higher populations
and greater resources (Oliveira, 2021; State of Hawaii, 2022). However, a reduction in nursing
care will significantly diminish primary and acute care access for a historically marginalized
population with limited healthcare resources.
Purpose and Rationale of the Study
The study employed Bronfenbrenner’s (1979) ecological systems theory framework to
conduct a systematic inquiry into the primary determinants of burnout among registered nurses
in Hawaii who worked at the bedside between March 2020 and March 2022 in the acute care
setting. The application of Bronfenbrenner’s framework provides for a comprehensive
understanding of how individual (microsystem), organizational (exosystem), and societal
(macrosystem) factors contribute to nurse burnout during the COVID-19 pandemic. This
research uniquely integrates the cultural dimensions specific to Hawaii and investigates how
local cultural nuances influenced nurses’ resiliency or propensity toward burnout. This study is
one of the few that applies an ecological perspective to burnout in nursing, allowing for a more
complex, multilevel understanding of the problem.
The rationale for this study is to gain insights into the unique factors leading to burnout
among Hawaii’s nurses during an unprecedented global health crisis, which can be
fundamentally different from regular work stressors. Burnout impacts nurses’ mental health and
well-being, leading to decreased productivity, high staff turnover, and increased healthcare costs
4
due to the replacement of staff (Hayes et al., 2012). Healthcare provider burnout has been linked
with decreased patient satisfaction and increased healthcare-associated infections, significantly
affecting the overall quality of care (Cimiotti et al., 2012; Halbesleben & Rathert, 2008a).
This study is critical because it addresses a timely issue, contributing to the limited body
of research on healthcare professional burnout during pandemic situations (Sasangohar et al.,
2020). The findings of this study could potentially be used to inform interventions and policies
aimed at mitigating nurse burnout in Hawaii and improving nurse well-being and the overall
quality of patient care. It will add valuable insights to the growing literature on the impact of
pandemic situations on healthcare professionals and how to better prepare and support them in
future crises. It will highlight how Hawaii’s culture affected Hawaii’s nurses during times of
crisis.
Research Questions
This study intended to determine which elements of the Hawaii nurse’s life led them to
alter their roles or commitment to the profession during the COVID-19 pandemic. The study
used Bronfenbrenner’s (1979) ecological systems theory to investigate immediate, indirect, and
sociocultural factors influencing nurses’ wellness and desire to remain at the bedside. By
identifying these criteria, hospitals can concentrate on areas important to the nurse and modify
their strategies to retain nurses in acute care.
Two research questions guided this study:
1. How did Hawaii’s registered nurses’ environment impact their decision to work at the
bedside in the acute care setting during COVID-19?
2. How did Hawaii’s culture impact Hawaii’s registered nurses’ decision to work at the
bedside in the acute care setting during COVID-19?
5
Importance of the Study
Healthcare is a career that brings great joy and significant physical and mental
challenges. Since February 2020, providers have been burdened with the additional stressor of a
global pandemic, presenting a level of psychological strain at a warzone level. Nurses dealt with
death at rates not seen in 100 years from an airborne or droplet pathogen (Poorolajal, 2021).
They expressed concern for their safety and well-being as they showed up to care for the ill and
experienced irrational confrontations while trying to keep others safe. This trauma pushed some
to the point of quitting the profession (Zhang et al., 2021) or taking their own lives (Rahman &
Plummer, 2020).
Unpacking and adjusting to the long-term effects of Critical Incident Stress (CIS), a
condition often experienced by healthcare professionals responding to crises like the COVID-19
pandemic, demands an opportunity for individuals to participate in the grief process and
sufficient time to heal (Swab, 2020). Prioritizing the psychological well-being of healthcare
providers is crucial for their health and essential to maintaining the resilience and effectiveness
of the healthcare system (Sun et al., 2021; Tong et al., 2022; World Health Organization, 2020b).
With social distancing and remote work becoming the norm during the pandemic,
traditional face-to-face therapeutic and support methods were largely disrupted. Understanding
how these virtual or modified face-to-face interactions can be employed to manage CIS became
critical, both in enhancing healthcare providers’ mental well-being and ensuring the continuity
and quality of healthcare services, emphasizing the need for innovative research and strategies to
adapt to the changing realities and challenges of global health crises like COVID-19.
Gooch (2021), Manzano Garcia and Ayala Calvo (2020), and Rossi et al. (2006) provide
evidence of a considerable rise in nurse burnout as a result of the COVID-19 pandemic,
6
impacting bedside nurses and nursing students (Sveinsdóttir et al., 2021). Since the onset of the
COVID-19 pandemic, Hawaii’s nursing profession has seen a decline in licensed workers
(Fontenot et al., 2022; Hawai’i State Center for Nursing, 2023; Oliveira, 2021). Especially in
rural healthcare settings (Miller, 2022), a reduction in bedside nurses correlates with poor patient
outcomes and the closure of underfunded hospitals (American Hospital Association, 2020b;
Ellison, 2022). The specific elements of working through the COVID-19 pandemic in Hawaii,
which contributed to increased stress and burnout among nurses, have not been studied.
Hawaii’s unique culture highlights the relationship between its cultural values,
professional obligations, and individual decision-making that is distinctive to the islands and its
nurse workforce. The cultural heritage of Hawaii emphasizes community, family ties, and
responsibility to others and is pivotal in shaping the ethos of the residents. It is imperative to
understand how these values acted as buffers or amplifiers to the strains and stressors
experienced by nurses working in Hawaii during the COVID-19 pandemic. The findings will
enrich our understanding of nurse burnout in the specific milieu of Hawaii’s culture and offer
insights to create culturally sensitive interventions.
Overview of Theoretical Framework and Methodology
This study utilizes Bronfenbrenner’s (1979) ecological systems theory as the conceptual
framework to understand the interconnected factors influencing these nurses’ burnout
experiences and contemplation of job exit. Bronfenbrenner’s theory provides a multidimensional
lens through which to explore the various levels of influence on an individual’s experience: the
microsystem (immediate environment), mesosystem (interactions of immediate environments),
exosystem (indirect environment influences), macrosystem (sociocultural context), and
chronosystem (temporal influences).
7
Considering the microsystem, for example, factors like workload, patient acuity, and
staffing ratios can be explored, which previous research indicates are closely associated with
nurse burnout (Aiken et al., 2002). The mesosystem might consider how work and home life
interactions contribute to stress and burnout, while the exosystem would look at the broader
organizational or policy issues at play. The macrosystem level examines the societal values,
norms, and economic systems that can either protect against or contribute to burnout. Finally, the
chronosystem allows for the specific period of the COVID-19 pandemic to be considered.
The survey instrument, to be implemented in 2023, is a quantitative tool designed to
retrospectively collect data from nurses who were actively employed between March 2020 and
March 2022, focusing on the height of reported burnout, which increased sharply in 2021 (Ge et
al., 2023), and shaped their roles in healthcare today. This period is of import due to the reported
escalation of burnout and its continued deterioration after that (Martin et al., 2023). The survey’s
distribution will be facilitated through a collaborative effort with the Hawai’i Chapter of the
American Nurses Association, ensuring a broad reach amongst the targeted demographic.
By applying Bronfenbrenner’s (1979) ecological systems theory and focusing on the
microsystem, exosystem, and macrosystem, this study will explore key concepts contributing to
the nurses’ desire to remain at the bedside in the acute care setting or move away from direct
patient care. Specifically, Bronfenbrenner’s microsystem, exosystem, and macrosystem will
construct a framework from which the specific experiences of the nurse affected their
positionality in and attitude toward nursing.
8
Definitions
This section provides clarity, precision, and shared understanding within this dissertation.
Defining and explicating the key terminologies and concepts employed within the research is
essential.
Acute Care
A healthcare facility that provides short-term medical treatment for patients with acute
illnesses or injuries, typically requiring immediate or specialized care. Settings typically include
emergency departments, medical-surgical, telemetry, direct observation units, perioperative
services, intensive care units, and other departments that focus on diagnosing and treating severe
and time-sensitive medical conditions (American Hospital Association, 2020a).
Aloha
“Love, affection, compassion, mercy, sympathy, pity, kindness … to show kindness … to
greet, hail” (Pukui & Elbert, 1986, p. 21).
BIPOC
Black, Indigenous, and people of color. This acronym acknowledges individuals who
identify as belonging to these racial and ethnic groups and highlights the unique experiences,
struggles, and systemic inequities they face due to historical and ongoing racial discrimination
and oppression (Crenshaw, 1991).
Burnout
A state of chronic stress and exhaustion, typically arising from prolonged work-related
demands, resulting in physical, emotional, and mental fatigue. Burnout is characterized by
cynicism, reduced work self-efficacy, detachment, reduced performance, and diminished
personal satisfaction (Maslach & Leiter, 2016).
9
COVID-19
An infectious disease caused by the severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2). The World Health Organization declared the novel coronavirus (COVID-19)
outbreak a global pandemic on March 11, 2020 (Cucinotta & Vanelli, 2020), ending the public
health emergency of international concern on May 5, 2023 (World Health Organization, 2023).
COVID-19 is usually transmitted from person to person through the droplets expelled from the
mouth and nose and can produce a variety of symptoms ranging from moderate to severe,
including fever, cough, and trouble breathing (Centers for Disease Control and Prevention
[CDC], 2021).
Health Disparities
“A particular type of health difference that is closely linked with social, economic, and/or
environmental disadvantage” (Office of Disease Prevention and Health Promotion [ODPHP] &
NORC at the University of Chicago [NORC], 2022, p. 31). Groups of people who have
consistently faced more health-related barriers because of their gender, financial status, religion,
race or ethnicity are negatively impacted by health inequalities. Sexual orientation, gender
identity, or other traits that have historically been associated with exclusion or prejudice.
Ho’oponopono
“To correct” (Pukui & Elbert, 1986, p. 82). Often referring to conflict resolution or
putting things right, ho’oponopono is similar to the mediation process in any society, and can be
different depending on the users, as the combination of different techniques and when they are
deployed vary (Wall & Callister, 1995).
10
Kuleana
“Right, privilege, concern, responsibility … authority, liability” (Pukui & Elbert, 1986, p.
179). This term embodies the concept that every individual has the responsibility and privilege to
preserve and safeguard the land and community to which they belong. (Pintor, 2023).
LGBTQ
An acronym that stands for Lesbian, Gay, Bisexual, Transgender, and Queer or
Questioning. It represents a diverse community of individuals who have non-heterosexual or
non-cisgender identities (Gay & Lesbian Alliance Against Defamation, 2022).
Lōkahi
“Unity, agreement, accord, unison, harmony” (University of Hawai’i, 2024). The term
lōkahi is used when the intent is to “bring about unity; to make peace and unity; to be in
agreement” (Pukui & Elbert, 1986, p. 210).
Mālama
“To take care of, tend, attend, care for … protect … caretaker … one who cares for
parents” (Pukui & Elbert, 1986, p. 232). Mālama refers to taking care of people and a way of
life. “Mālama relates to our environment, culture, and everything with which we interact”
(Mālama Learning Center, 2024, “Meaning of Mālama” section).
Registered Nurse
A registered nurse, also known as an RN, is a member of the nursing profession who has
graduated from an accredited nursing program, acquired a nursing license, and is qualified to
provide patients with medical care, treatment, and emotional support. Registered nurses are
employed in various healthcare settings, collaborating closely with other medical professionals to
provide patient-focused care (American Nurses Association, 2017).
11
Organization of the Dissertation
This dissertation is structured into five chapters, each addressing a key component of the
primary research objective: investigating nursing burnout and its contribution to the declining
nursing workforce in Hawaii. Chapter One introduces the study by outlining the research topic,
background, problem statement, and the significance of the research. It sets the stage for
understanding the implications of nursing burnout on Hawaii’s nursing workforce and outlines
the research questions, objectives, and study organization. Chapter Two provides a
comprehensive literature review, examining global and Hawaii-specific studies on nursing
burnout and workforce attrition. It discusses relevant theories and constructs like job satisfaction,
workload, and emotional exhaustion, focusing on the unique challenges faced by Hawaii’s
healthcare system. Chapter Three details the research methodology, describing the study’s
design, data collection, analysis procedures, and ethical considerations. It justifies the choice of a
quantitative approach and outlines measures to ensure the validity and reliability of the findings.
Chapter Four presents the study’s findings using appropriate visual aids, interpreting the results
concerning the research questions and objectives. Emerging themes that link nursing burnout to
workforce decline in Hawaii are also explored. Finally, Chapter Five discusses the implications
of the findings within the broader context of existing research, summarizes the study,
acknowledges its limitations, and offers recommendations for future research, healthcare policy,
and nursing practice aimed at reducing burnout and improving workforce retention in Hawaii.
12
Chapter Two: Review of the Literature
This literature review provides a comprehensive analysis of the critical global challenge
the COVID-19 pandemic has imposed on healthcare systems, with acute care nurses bearing the
significant brunt of the crisis (Chen, Liang, et al., 2020; Chen, Sun, et al., 2020; Ge et al., 2023;
Shreffler et al., 2020). The focus of this review is acute care nurses in Hawaii from March 2020
to March 2022, whose experiences illuminate the broader implications of the crisis (Davide et
al., 2022; Hawai’i State Center for Nursing, 2021a; Hennein et al., 2021; Litam & Balkin, 2021).
A prime tenet of the study’s problem of practice, stress, and burnout among nurses during
the COVID-19 pandemic is linked with the broader issues of healthcare system management,
health disparities, and nursing professional development. Consequently, the review is segmented
into the following major sections: an overview of the history of nursing in Hawaii within the
context of the COVID-19 pandemic; a recap of previous studies concerning burnout and critical
incident stress; a look into the working culture among nurses; an exploration of the population
and stakeholders; an investigation into the root issues surrounding nurse burnout and attrition in
Hawaii and potential solutions; a presentation of Bronfenbrenner’s (1979) ecological systems
theory—the theoretical framework used; and finally, pinpointing the gaps in the existing body of
research. These main sections will be divided into relevant subsections to provide an exhaustive
perspective.
Initially, this literature review delves into the origins of the problem—the emergence of
the COVID-19 pandemic and its immediate repercussions on global healthcare systems, with an
emphasis on Hawaii. It looks at the evolution of the crisis over time, highlighting the impact on
nurses in acute care facilities. This review delves into the resulting stress, anxiety, and burnout
experienced by nurses and how these issues have fueled staffing shortages and high turnover
13
rates. This analysis heavily relies on literature outlining firsthand accounts, studies, and reports
from March 2020 to March 2022 in Hawaii. Lastly, this analysis identifies a critical “gap” or
“need” in the current literature: the urgent requirement for targeted research and intervention
strategies to address these pressing issues Hawaii’s nurses face.
Historical Context
The historical context of nursing in Hawaii and its evolution during the COVID-19
pandemic provides a rich backdrop for understanding the challenges faced by acute care nurses
during this global health crisis. The State’s unique geographical location and diverse
demographic profile have continually shaped the nursing profession and healthcare delivery
systems (LeVasseur & Qureshi, 2015). The onset of the COVID-19 pandemic complicated this
landscape by placing an unprecedented burden on healthcare systems worldwide, leading to
elevated stress levels and burnout among frontline healthcare workers, particularly nurses
(Bruyneel et al., 2021; Ge et al., 2023; Martin et al., 2023). In Hawaii, the effects of the
pandemic were exacerbated by the state’s isolation and dependence on imports for resources,
causing a tremendous impact on acute care nurses’ well-being and working conditions. This
historical context section explores these interrelated dynamics in-depth to create a
comprehensive understanding of the escalating problem at hand.
Nursing in Hawaii: A Historical Overview
The historical trajectory of nursing in Hawaii presents a complex development,
resilience, and adaptation narrative (University of Hawai’i at Manoa, 2023). From the reign of
King Kamehameha IV (1834–1863) to the current challenges of the 21st century, the nursing
profession in Hawaii has evolved to meet the healthcare needs of the Hawaiian population
(MacLean, 1939). This section will outline the significant milestones, changes, and challenges
14
within nursing practice in Hawaii over the decades. From establishing the Queen’s Hospital and
nursing schools in the early 20th century to the advent of federal initiatives post-statehood, the
narrative charts the substantial progress in nursing education and practice alongside its associated
challenges (Kosaki, 1962; University of Hawai’i at Manoa, 2023). The second half of the 20th
century saw a shift towards an academic model of nursing education and a push for professional
standards and continued education, setting the stage for an era of specialized nursing and cultural
competence in response to Hawaii’s unique multicultural fabric (Shi & Singh, 2021). The section
will examine the developments, opportunities, and hurdles faced by the nursing profession in the
pre-COVID-19 era, highlighting the strategies implemented to address the issues of an aging
population, chronic diseases, nursing shortages, and geographical isolation. This historical
overview serves to illuminate the evolution of nursing in Hawaii, providing insights into its past,
present, and potential future.
Nursing in Hawaii: Early 20th Century
From the reign of King Kamehameha IV, Hawaii’s healthcare infrastructure began to
take form, chiefly motivated by the need to preserve the health of the Hawaiian people. Central
to this evolving system was the Queen’s Hospital, an institution named in honor of Queen
Emma’s steadfast commitment (MacLean, 1939). By 1939, the hospital had developed its ability
to care for up to 30 patients, supported by funds from the Queen Emma Estate and patient fees.
Two nursing schools in Honolulu were founded in 1939, marking a milestone by offering
a comprehensive curriculum to nursing students. These schools were affiliated with the
Department of Public Health and other hospitals, providing graduates with career opportunities
in private duty, general staff, plantation, industrial nursing, and various branches of public health
(MacLean, 1939). The healthcare system, comprised of approximately 101,000 individuals,
15
emphasized nutrition, maternal and infant hygiene, and health education. This commitment to
improvement allowed for effective management and control of diseases like malaria, yellow
fever, and leprosy (Smith, 1932).
Nursing in Hawaii: Mid to Late 20th Century
The mid-20th century to the 1990s witnessed a pivotal transformation in Hawaiian
nursing, closely linked with significant sociopolitical and economic changes. Early hospital
diploma programs led to more comprehensive associate and baccalaureate degree programs,
starting the shift toward academic nursing education. This transition was strengthened by
establishing the University of Hawaii’s School of Nursing in 1951, an institute that imparts
nurses’ extensive knowledge and skills (University of Hawai’i at Manoa, 2023). Post-1959
statehood, federal initiatives, notably the Hill-Burton Act of 1946, expedited hospital
modernization across the islands, enhancing the nursing workforce (Shi & Singh, 2021).
By 1961, Hawaii, especially Oahu, had an adequate supply of professional and practical
nurses despite enduring challenges in certain aspects of nursing education and administration
(Harris, 1964; Martin, 1962). The focus progressively shifted towards maintaining quality in
nursing practice through continuous education and adherence to professional standards (Feirer,
1960; Lum & Laughlin, 1965). The subsequent decades saw a move towards experiential
learning, a holistic patient care approach (Benner, 1984), and a surge in specialized nursing roles
in response to the unique healthcare needs of Hawaii’s aging and rural communities (Tracy &
O’Grady, 2018). Hawaiian nursing was further shaped by its multicultural context, where nurses
had to harmonize Western medicine with diverse traditional health practices, necessitating
cultural competence in nursing (McLaughlin & Braun, 1998; Oneha et al., 1998).
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Nursing in Hawaii: Pre-COVID-19 Era, Progress and Challenges From 2000–2020
From 2000 to 2020, Hawaii’s nursing sector evolved due to demographic shifts and
mounting chronic disease prevalence (Buerhaus et al., 2000). Hawaii’s nursing schools revamped
their curricula, introducing programs for advanced practice roles such as nurse practitioners and
nurse anesthetists, vital for extending services in rural and underprivileged areas (Budden et al.,
2013; Kataoka-Yahiro et al., 2011). Nevertheless, the profession faced several obstacles. Like
other states, Hawaii has grappled with a nursing shortage attributed to an aging nursing
workforce, escalating healthcare needs, and nursing school capacity constraints (Juraschek et al.,
2011). The geographic isolation of Hawaii further exacerbated this shortage by impeding the
attraction and retention of nurses (Ricketts, 2013). Initiatives were implemented to enhance
nursing school capacity, establish diversified nursing career paths, encourage advanced practice
roles, and augment job satisfaction to combat these issues (University of Hawai’i, 2022). In
2005, the Hawaii State Center for Nursing was established to lead these efforts, using data-driven
analysis to foster a well-equipped and sufficiently staffed nursing workforce (Hawai’i State
Center for Nursing, 2005; 2007).
COVID-19: Onset, Progression, and Impact
Originating from the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2),
COVID-19 first emerged in December 2019 as a cluster of severe pneumonia cases detected in
China, rapidly reaching pandemic proportions as it swept across the globe (Akande & Akande,
2020; Assefa et al., 2021). By March 2020, over 5 million cases had been reported worldwide,
compelling the World Health Organization to declare a pandemic. The unprecedented strain on
acute care facilities, health professionals, and the broader global health infrastructure resulted
from this swift onslaught of illness and resource depletion, COVID-19’s complexity represented
17
both typical and atypical manifestations of common illnesses (Akande & Akande, 2020; World
Health Organization, 2020b).
To follow is an in-depth analysis of the multifaceted impact of the COVID-19 pandemic
on global healthcare systems. First is a review of the onset of the problem, investigating the
immediate repercussions of the pandemic’s emergence and its effects on acute care facilities
worldwide. The progression of the crisis is reviewed after, focusing on the fluctuating challenges
confronting healthcare systems, notably the impacts on nursing roles across different
geographical contexts. Finally, a snapshot of the current situation at the time of writing is
examined, offering an insightful case study of Hawaii to highlight the localized implications of
this global crisis on nursing roles and healthcare systems at large (Fontenot et al., 2022).
The Onset of the Problem
The global COVID-19 pandemic, initiated by the novel SARS-CoV-2 virus first
identified in Wuhan, China, in December 2019, presented unparalleled challenges (BS & Vinod,
2020;). The disease originated as a cluster of pneumonia cases, rapidly spread beyond China’s
borders, and eventually became a worldwide crisis (Wang et al., 2020; World Health
Organization, 2020b). The exponential growth of infections strained healthcare systems and led
to a significant shortage of resources such as personal protective equipment and ventilators
(Akande & Akande, 2020; Ranney et al., 2020).
In the United States, particularly in Hawaii, the nursing profession faced unprecedented
conditions, including escalated workload, viral exposure, and emotional distress (Chen, Liang, et
al., 2020; Lai et al., 2020; Hawai’i State Center for Nursing, 2021a;). The pandemic compelled
nurses to adapt to dynamic roles and exposed systemic vulnerabilities, underscoring the necessity
for future pandemic preparedness and resilience (Brewer et al., 2023; Koholokula et al., 2020;).
18
The Progression of the Crisis
The spread of SARS-CoV-2 necessitated a comprehensive realignment of global
healthcare resources, stretching systems to their limits (Assefa et al., 2021; Kaye et al., 2021;
Ranney et al., 2020; Smith et al., 2020). The pandemic-induced strain was particularly felt in
acute care facilities in Hawaii, which grappled with severe personnel and resource shortages
(Hawai’i State Center for Nursing, 2021a; NSI Nursing Solutions, 2023; Ranney et al., 2020).
The need for urgent resource reallocation led to dynamic changes in healthcare operations
(Gonzalez et al., 2020; Smith et al., 2020).
Healthcare professionals, particularly acute care nurses, experienced intense stress and
increased attrition rates, underscoring the pandemic’s human toll (Melnyk et al., 2021; U.S.
Department of Health and Human Services, 2021). This reduction in force compelled a shift
towards telehealth and digital health tools for efficient pandemic management, and the
augmentation of mental health services for healthcare staff became imperative (Lai et al., 2020;
Smith et al., 2020; World Health Organization, 2020a). Consequently, the pandemic spurred
revolutionary transformations in healthcare systems worldwide.
Impact on Global Healthcare Systems
The seismic shift in global healthcare induced by the COVID-19 pandemic necessitates
comprehensive scholarly investigation. The impacts of the pandemic were far from confined to
clinical settings, with socioeconomic, psychological, and ethical concerns arising alongside the
direct medical implications (Chen, Liang, et al., 2020). Frontline healthcare professionals,
particularly nurses, found themselves in a crucible of high-stress and unfavorable working
conditions, inciting significant modifications to the healthcare role landscape (Hunsaker et al.,
2015; Ramzi et al., 2022). The widespread disruption to non-COVID-related healthcare services
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caused by the crisis further complicated the global health milieu (Akande & Akande, 2020;
Assefa et al., 2021).
The ensuing economic impacts of the pandemic were likewise substantial, leading to
considerable financial losses for global healthcare institutions, exacerbating existing healthcare
inequalities (Kaye et al., 2021; Shrestha et al., 2020). The pandemic also threatened the
realization of the United Nations’ sustainable development goals (SDGs), particularly SDG 3,
which aims to ensure health and well-being for all, as the attention and resources required for its
fulfillment were redirected towards battling the pandemic (Bhatia & Khetrapal, 2020).
Review of Past Research
The following section provides a comprehensive review of the literature pertinent to the
problem of burnout, particularly within the context of nursing in acute care settings in Hawaii.
This review is structured around several key themes, including the phenomenon of burnout,
critical incident stress (CIS), and post-traumatic stress disorder (PTSD). The section reviews a
contemporary understanding of burnout and its specific manifestations within nursing. It
explores evidence-based best practices to mitigate burnout among nurses, focusing on those
working in acute care environments.
To contextualize the discussion, the characteristics of the target population, acute care
nurses who worked at the bedside in acute care facilities during COVID-19, are examined
alongside identifying key stakeholders involved in addressing burnout within this group. The
review also delves into the cultural factors unique to Hawaii, including the principles of aloha,
mālama, kuleana, ho’oponopono, and lōkahi, which are integral to understanding the social and
cultural environment in which these nurses operate. These cultural values influence the nurses’
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decision-making processes regarding bedside acute care work and shape their responses to the
extraordinary challenges posed by the COVID-19 pandemic.
This review is grounded in Bronfenbrenner’s (1979) ecological systems theory, which
provides a framework for understanding the multiple environmental layers that impact individual
behaviors and experiences. By applying this model, the review seeks to illuminate the complex
relationship of personal, professional, and cultural factors contributing to burnout among acute
care nurses in Hawaii and offer a holistic perspective.
Burnout
Psychologist Herbert Freudenberger first introduced “burnout” in the mid-1970s, an
emotional state observed among idealistic healthcare professionals confronted with harsh
professional realities (Freudenberger, 1974). This concept, capturing mental and physical
exhaustion from high-stress occupations, was later generalized beyond healthcare
(Freudenberger, 1989; Maslach, 2001). Substantial research supports burnout’s significant effect
on individual well-being and organizational productivity (Jun et al., 2021; Maslach et al., 2001).
Maslach and Jackson (1981) expanded on Freudenberger’s work, defining burnout as a
syndrome triggered by chronic emotional strain from extensive interaction with others, especially
in problematic situations (Maslach & Jackson, 1981). They identified three dimensions:
emotional exhaustion, ineffectiveness and lack of accomplishment, and negativism and cynicism
(Lee & Ashforth, 1990; Maslach et al., 2001; Taris et al., 2005). Each dimension uniquely
contributes to the overall understanding of burnout (Lee & Ashforth, 1996).
Emotional exhaustion denotes feelings of overextension and depletion of emotional
resources, often resulting from occupational stress and emotional intensity typical in nursing
(Kowalski et al., 2010; Maslach et al., 1996; Patrick & Lavery, 2007). Ineffectiveness and lack
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of accomplishment reflect negative self-evaluation, especially concerning job performance,
inciting feelings of incompetence and inefficacy (Leiter & Maslach, 2009; Maslach et al., 1996;
Nowakowska et al., 2016). Negativism and cynicism, the last dimension, imply a negative or
detached response to job aspects, often due to chronic stressful work conditions (Greenglass et
al., 2001; Maslach et al., 1996).
The literature highlights the urgency of addressing burnout, notably in nursing,
accentuated during crises like the COVID-19 pandemic (Chen, Sun, et al., 2020; Ge et al., 2023;
Jun et al., 2021). Its implications for staff turnover, productivity, and workplace well-being make
tackling burnout a priority, particularly considering the pandemic’s amplification of burnout
incidence in nursing and other professions (Galanis et al., 2021; Murat et al., 2020).
Emotional Exhaustion
The depletion of emotional resources often characterizes a precursor in the development
of burnout syndrome, emotional exhaustion. This depletion can be due to job-related stressors or
personal factors and is closely linked to adverse psychological, physical, and occupational
outcomes. Emotional exhaustion is a central aspect of burnout syndrome and is often the initial
stage in a multilateral model, leading to depersonalization and reduced personal accomplishment
(Lee & Ashforth, 1996; Maslach & Jackson, 1981; Maslach & Leiter, 2016). It is mainly
evaluated via the Maslach Burnout Inventory (MBI), which emphasizes work-related emotional
overstretch (Maslach et al., 1996). This exhaustion stems from various job-related stressors,
including role ambiguity, excessive workloads, and resource scarcity, with roles in high-stress
sectors such as healthcare, education, and social work being particularly vulnerable due to
inherent emotional pressures (Bakker et al., 2005; Demerouti et al., 2001; Kowalski et al., 2010;
Leiter & Maslach, 2004; Murat et al., 2020).
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Persisting emotional exhaustion can intensify mental health disorders like depression and
anxiety, and occupationally, may decrease job satisfaction and increase turnover (Demerouti et
al., 2001; Jun et al., 2021; Lai et al., 2020; Wright & Cropanzano, 1998). Emotional exhaustion
may induce physical symptoms, behavioral withdrawal, relationship issues, and long-term
cardiovascular risk, necessitating early acknowledgment and intervention for burnout relief (De
Vente, 2003; Grossi et al., 2003; Melnyk et al., 2021).
Sense of Ineffectiveness and Lack of Accomplishment
Burnout lends to a sense of ineffectiveness and a feeling of lack of accomplishment. In
burnout dynamics, a key factor is the sense of ineffectiveness and accomplishment deficiency,
which forms a maladaptive triad with emotional exhaustion and cynicism (Lee & Ashforth,
1990; 1996; Maslach & Leiter, 1997). This sense of ineffectiveness, defined by diminished selfefficacy (Bandura, 1990; 1997), can deepen burnout’s detrimental impacts (Cox et al., 2018;
Nowakowska et al., 2016; Schaufeli & Bakker, 2004;). A narrative of futility is fostered, and the
burnout cycle is accelerated by an increased sense of ineffectiveness brought on by a lack of
perceived success, which indicates unmet goals and slow progress (Malakh-Pines & Aronson,
1988; Maslach & Jackson, 1981). Research has solidified this link, showing that the feeling of
unproductivity aggravates burnout, impairing work-life quality and intensifying dissatisfaction
and withdrawal (Leiter, 1992; Leiter & Maslach, 2004; Ventura et al., 2015).
Negativism and Cynicism
Negativism and cynicism impair workplace relationships and perpetuate a cycle of
mental health decline for the individual and general dysfunction for the organization. To fully
understand burnout, its underexplored aspect, negativism and cynicism, must be investigated,
which denotes the progression of negative, critical attitudes towards work, colleagues, and
23
clients (Leiter & Maslach, 2009; Nowakowska et al., 2016). Rather than a fleeting state of
dissatisfaction, it is a chronic condition impairing workplace cooperation and interpersonal
relationships (Jun et al., 2021). This pervasive negativity, intrinsically linked to the work
environment, is not just an individual affliction (Bakker et al., 2005).
Under the job demands-resources model, high demands and scarce resources foster
burnout, marked by negativity and cynicism (Demerouti et al., 2001; Leiter & Maslach, 2004).
Studies support the idea that this negativity explains the connection between intentions to leave
employment and perceived workplace unfairness, which has detrimental organizational and
individual repercussions (Ahola et al., 2005; Demerouti et al., 2001; Hakanen et al., 2008;
Wright & Cropanzano, 1998). Taris et al. (2005) showed that this cynical viewpoint fuels a selfperpetuating burnout cycle. Persistent exposure to such negativity may induce further mental
health issues like depression and anxiety, compromising life quality (Arandjelovic et al., 2010;
Toppinen-Tanner et al., 2005).
Critical Incident Stress and Post Traumatic Stress Disorder
The study of the cognitive mechanisms associated with traumatic experiences and their
subsequent recall is a complex yet profoundly intriguing area within cognitive psychology and
neuroscience. The primary concept discussed here examines the influence of CIS and PTSD on
memory recall of traumatic events (Leonhardt & Vogt, 2018). Of particular interest is the subtle
yet discernible leaning toward the capacity to recall such traumatic incidents. Numerous studies
have dissected the distinctive attributes of traumatic memories, especially their intrusive and
persisting nature, often with vivid sensory components (Brewin, 2014; Horowitz, 1975; van der
Kolk, 1994)
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The nature of memory recall under the influence of CIS and PTSD is not purely a factor
of these powerful attributes; instead, it manifests as an intricate balance between the durable,
vivid memories created by traumatic experiences and the potential inaccuracies and
inconsistencies that could emerge due to phenomena like memory repression and false memory
creation (Loftus, 1993, 1997). The research underscores the unique nature of traumatic memories
as deeply ingrained, easily triggered, and persisting over time, thereby distinguishing them from
other types of memories (Shobe & Kihlstorm, 1997; Toth & Cicchetti, 1998). While the intricate
mechanisms fundamental to the formation and recollection of traumatic memories and their
psychological implications warrant further exploration, the process of memory recall in the
context of CIS and PTSD is unique.
Critical Incident Stress
The global healthcare sector, particularly nurses, has confronted significant challenges
due to the COVID-19 pandemic, including unprecedented stressors. This stress, analogous to a
warzone scenario, is known as CIS (Greenglass et al., 2001; Melnyk et al., 2021; Tong et al.,
2022). This stress stems from traumatic experiences leading to a plethora of cognitive,
emotional, and behavioral reactions, further heightened by COVID-19 and the exposure to
severely ill patients, death, and personal safety risks (Everly et al., 2000; Paige et al., 2020; Sun
et al., 2020).
Acute care nurses faced the brunt of CIS during the pandemic, grappling with heightened
physical demands, emotional strain from isolation and fear of infection, and prolonged shifts in
personal protective equipment (Cohen & Rodgers, 2020; Ranney et al., 2020; Zhang et al.,
2020). The protracted exposure to these traumatic events, with limited opportunities for
psychological recovery, may escalate CIS symptoms, leading to enduring mental health effects
25
(Tong et al., 2022). Health systems and policymakers must prioritize the management of CIS,
implementing regular mental health assessments, and providing psychological support to
attenuate the severity and duration of CIS and mitigate potential long-term consequences (Caine
& Ter-Bagdasarian, 2003; Everly et al., 2002; Martin et al., 2023).
Post Traumatic Stress Disorder
Traumatic events elicit a range of psychological responses in individuals, from CIS to
PTSD. CIS and PTSD, both results of trauma, follow a similar causal path, with the COVID-19
pandemic highlighting their prevalence among healthcare workers (Everly et al., 2000; Mitchell
& Everly, 2010). The immediate reactions to trauma constitute CIS, whereas PTSD manifests as
a complex, long-lasting response when acute stress endures (Bryant, 2019).
Unmanaged CIS can evolve into PTSD, characterized by recurring trauma experiences,
avoidance behaviors, cognitive and mood disturbances, and pronounced hyperarousal (Shen et
al., 2009). Notably, nurses during the pandemic reported a high incidence of CIS, which, given
persistent exposure and insufficient recovery, risks becoming PTSD (Mitchell & Everly, 2010).
Early CIS detection and control could impede PTSD onset (Caine & Ter-Bagdasarian, 2003;
Mitchell & Everly, 2010). Group-based intervention, critical incident stress debriefing (CISD),
has shown promise in alleviating distress and preventing PTSD (Campfield & Hills, 2001).
However, its efficacy can vary based on timing and individual factors. This connection between
CIS and PTSD underscores the urgency of early CIS identification and intervention, especially
for high-risk groups like healthcare providers amidst a pandemic. Such strategies, including
CISD, are crucial in preventing CIS-to-PTSD progression, reducing long-term psychological
distress.
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Recall
The effects of CIS and PTSD on human memory, particularly recalling traumatic events,
have been the subject of extensive research and discussion in cognitive psychology and
neuroscience. This dissertation explores how memory recalls about a traumatic event are
influenced by CIS and PTSD, subtly highlighting the distinct ability to recall such incidents.
A distinctive feature of traumatic memories is their intrusive nature and persistence over
time, often embedded with vivid detail and sensory components (Brewin, 2014; Rubin, Berntsen,
et al., 2008). Contrarily, while impactful, memories of other emotionally charged life
experiences do not exhibit the same characteristics, lacking the recurring presence and visceral
experience that mark traumatic memories (Horowitz, 1975; van der Kolk, 1994). Due to their
nature of being encoded within the brain’s trauma networks, traumatic memories are effortlessly
reactivated, often without conscious intent, which is not usually characteristic of memories
related to other emotional experiences (McGaugh, 2004; van der Kolk & Fisler, 1995).
Retaining memories from extended traumatic events is a complex interplay between CIS
and PTSD. The intensity of traumatic experiences often engraves more durable and vivid
memories, even compared to other emotionally potent experiences (Brewin, 2014; Rubin,
Bernsten, et al., 2008). Debates regarding the validity and accuracy of such memories have
unfolded due to memory repression and the possibility of false memory creation (Loftus, 1993,
1997).
Despite possible inaccuracies or inconsistencies, traumatic memories appear to be deeply
ingrained, easily triggered, and persist over time, setting them apart from other types of memory
(Shobe & Kihlstorm, 1997; Toth & Cicchetti, 1998). These distinctive characteristics also give
27
rise to the need for further exploration into the intricacies of the formation and recollection of
traumatic memories and their psychological implications.
Contemporary Understandings of Burnout
Burnout, an evolving syndrome stemming from chronic occupational stress, has farreaching implications across various professions, including healthcare and research, necessitating
a multidimensional approach to foster healthier, more effective workplaces. Burnout, as defined
by the World Health Organization (2019), is an evolving syndrome born of uncontrolled chronic
occupational stress, marked by exhaustion, professional cynicism, and reduced efficiency (Lee &
Ashforth, 1996; Maslach et al., 1996; Taris et al., 2005). Although the Diagnostic and Statistical
Manual of Mental Disorders (DSM) does not officially recognize it, the evidence underscores its
detrimental effects on individuals and organizations (Bianchi et al., 2015).
This syndrome permeates various professions, including research and healthcare. It is
associated with researchers’ achievement goals (Daumiller & Dresel, 2020), complexities in
healthcare delivery (Smaggus, 2019), and elevated attrition rates among nurses (Hunsaker et al.,
2015; Murat et al., 2020). Unique settings such as Hawaii intensify burnout risk due to cultural
diversity and isolation (Hawai’i State Center for Nursing, 2021a, 2023; University of Hawai’i,
2022).
Recent models propose a multidimensional perspective on burnout, recognizing patterns
beyond exhaustion or cynicism alone (Maslach & Leiter, 2017). The current discourse
underscores the pressing need for a multifaceted approach to tackle burnout, emphasizing
healthier, more effective workplaces.
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Burnout in Nursing
Burnout in nursing, caused by the high demands of the job and its crucial role in patient
care, is a complex issue influenced by personal and organizational factors, significantly
worsened by the COVID-19 pandemic. The prominence of burnout in nursing is attributable to
the profession’s intense emotional and physical demands and its fundamental role in patient care
outcomes (Poghosyan et al., 2010). Nurses encounter significant stressors, including dealing with
patient suffering and death. Burnout, characterized by emotional exhaustion, depersonalization,
and diminished personal accomplishment, was first recognized by Freudenberger in 1974
because of chronic occupational stress. In nursing, depersonalization often leads to cynicism and
negativism, compromising patient care, safety, and collaboration (Aiken et al., 2002; Jun et al.,
2021; McHugh & Stimpfel, 2012).
The cyclical relationship between organizational commitment and job burnout has been
extensively researched, with both aspects influencing one another (Cooper, 2000; Cox et al.,
2018). Burnout can be aggravated by high patient-to-nurse ratios, unfair conditions, and
inadequate managerial support, fostering a cynical and negative work environment (Leiter &
Maslach, 2009; McHugh et al., 2011). Nurse managers’ leadership behaviors can also impact
burnout, with poor leadership potentially reducing job satisfaction and empowerment
(Laschinger et al., 2014).
Addressing burnout necessitates interventions at both individual and organizational
levels, encompassing stress management, resilience training, and enhanced work conditions
(Cooper, 2000; Cox et al., 2018). The COVID-19 crisis has compounded these challenges,
underscoring burnout’s multifaceted nature rooted in individual experiences and organizational
problems. To effectively combat burnout, a holistic approach that integrates preventive measures
29
and responsive strategies tailored to the evolving demands of the healthcare landscape is
essential, especially considering the pressures brought on by the pandemic.
Pre-existing Causes and Factors
The pre-existing causes and factors contributing to burnout among nurses have been an
area of critical concern within the healthcare industry. The repercussions of such burnout pose
severe threats to the quality of patient care, nurses’ mental well-being, job performance, and
workforce retention (Arandjelovic et al., 2010; Laschinger et al., 2001; Poghosyan et al., 2021).
This section delineates the dominant factors associated with nurse burnout documented in the
existing literature. These factors include excessive work hours, high patient-to-nurse ratios,
emotional stress, limited autonomy and support, and workplace violence.
The prevalence of burnout in nursing predates the COVID-19 pandemic, suggesting the
existence of chronic structural issues within healthcare settings. Long work hours, characterized
by extended shifts and unpredictable demands, have been repeatedly linked to nurse burnout
(Olds & Clarke, 2010; Park & Lake, 2005). The high patient-to-nurse ratios, often resulting from
inadequate staffing, exacerbate the nurses’ workload and stress levels, influencing their wellbeing and patient outcomes (Aiken et al., 2002; Chen et al., 2019). Emotional stress, a recurring
aspect of nursing, intensifies the probability of burnout, affecting job satisfaction and overall
mental health (Hayes et al., 2012; McVicar, 2015).
A perceived lack of professional autonomy and institutional support significantly
correlates with the onset of burnout (Dall’Ora et al., 2020; Raiger, 2005). Nurses often grapple
with administrative constraints and hierarchies, which impede their decision-making capacities
and increase their feelings of disempowerment. Compounding these issues is the threat of verbal
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and physical workplace violence, which further enhances the stress and anxiety experienced by
nurses (Laschinger & Fida, 2013; Liu et al., 2019).
Work Hours
Nurses are frequently required to endure extended work shifts, often exceeding 12 hours,
compounding the already challenging nature of the healthcare profession (Dall’Ora et al., 2015;
Park & Lake, 2005). Coupled with the unpredictability of healthcare needs and night shifts,
extended working hours disrupt circadian rhythms and sleep patterns, leading to a condition
known as shift work sleep disorder (Park & Lake, 2005). Burnout is prevalent due to physical
exhaustion and sleep disorder, and it is further amplified by cognitive impairment, including
slower reaction times and compromised decision-making skills, which threaten patient safety
(Greenglass et al., 2001; Olds & Clarke, 2010).
Long hours cause physical fatigue and increase medical error rates (Garrett, 2008).
Moreover, the rigorous schedule limits the ability to recover from work stressors, leading to
chronic fatigue, stress, and heightened burnout risk (Patrick & Lavery, 2007). The adverse
effects extend to the nurses’ personal lives, creating an imbalance between work and social
activities, exacerbating burnout and mental health issues such as anxiety and depression (Dyrbye
et al., 2019).
Patient-to-Nurse Ratios
The patient-to-nurse ratio, indicating the number of patients per nurse, crucially impacts
healthcare outcomes and nurse well-being (Aiken et al., 2002; Chen et al., 2019; Xie et al.,
2011). The care setting and patient severity dictate its effects. Heightened ratios have been linked
to nurse burnout, diminished care quality, and potentially higher error rates (Aiken et al., 2002;
Xie et al., 2011). In contrast, lower ratios contribute to improved patient outcomes, lower
31
mortality rates, shortened hospital stays, and greater satisfaction. They also help alleviate nurse
burnout, resulting in less job dissatisfaction and workforce attrition, preserving nursing
competence (Chen et al., 2019). Such findings influence public policy. Gutsan et al. (2018)
underscored the importance of safer staffing ratios, connecting them to better healthcare delivery
and lower nurse burnout.
Emotional Stress
The nursing profession exerts a considerable emotional and physical toll on its
practitioners, profoundly impacting their psychological and overall health. Nurses find
themselves on the front lines of human suffering, regularly facing severe disease, end-of-life
care, and the accompanying emotional trauma (McVicar, 2015). Such experiences can precipitate
what is known as compassion fatigue, borne out of the deep empathetic bonds formed between
nurses and their patients.
These emotionally strenuous circumstances, a part of their daily professional lives, put
nurses in challenging positions (Davide et al., 2022). They are caregivers and intermediaries,
sharing sensitive information and providing emotional support to patients and their families
(Kowalski et al., 2010). This emotional labor extends beyond their work lives, affecting personal
relationships and mental well-being (Huang, Lei, et al., 2020).
The profession demands considerable physical stamina, with long, irregular working
hours, substantial time spent on their feet, and exposure to potential work-related injuries and
infections. These physically challenging situations can intensify the emotional stress faced by
nurses (Xie et al., 2011), leading to burnout, affecting job performance, and leading to voluntary
turnover (Hayes et al., 2012; Leiter & Maslach, 2009; Wright & Cropanzano, 1998).
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Furthermore, burnout among nurses is associated with reduced job satisfaction and compromised
patient care (Patrick & Lavery, 2007).
Lack of Autonomy and Support
Nurses’ professional autonomy, a key determinant of job satisfaction and well-being in
healthcare, is often hampered by institutional hierarchies and physician-centric models (Dall’Ora
et al., 2020; Laschinger et al., 2001). The resultant feelings of frustration and stress can be
significant precursors to burnout. Adequate administrative support, evidenced through staffing,
resource allocation, fair policies, and effective communication, dramatically benefits the nurses’
working environment (Laschinger et al., 2014; Nogueira et al., 2018). Conversely, its absence
often cultivates an overwhelming workload, role ambiguity, resource scarcity, and a sense of
being undervalued. Such adverse experiences, if sustained, may contribute to job dissatisfaction,
escalating stress, and eventually, burnout, which is a syndrome marked by emotional exhaustion,
depersonalization, and reduced personal achievement (Alkema et al., 2008; Hunsaker et al.,
2015; Raiger, 2005). This insidious progression, if not addressed, could culminate in debilitating
burnout.
Workplace Violence
Workplace violence, encompassing verbal and physical hostility, presents a severe
challenge in nursing (Liu et al., 2019). This aggression, potentially sourced from patients,
relatives, or fellow staff, impacts nurses’ physical and emotional health. Verbal violence,
involving derogatory comments, threats, and unjust criticism (Laschinger & Grau, 2012), is often
overlooked but can deteriorate nurses’ morale, leading to emotional exhaustion. Although less
frequent, physical aggression presents a substantial risk to nurses’ safety, heightening stress
levels (Liu et al., 2019).
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These violent incidents carry broader implications beyond individual nurses; high
turnover rates, diminished job satisfaction, and lowered productivity are common aftermaths
(Liu et al., 2019). Such an environment might dissuade potential nurses, influencing the
healthcare sector’s supply of proficient professionals. Burnout, a significant consequence of this
violence, can disrupt healthcare services (Rayan et al., 2019; Rogers & Kelloway, 1997).
Compounded by emotional labor in nursing, workplace violence can amplify burnout (Kim et al.,
2018).
Exacerbating Factors of Burnout During COVID-19
The COVID-19 pandemic greatly intensified nurse burnout due to overwhelming patient
loads, resource shortages, and extended work hours, posing a risk to the healthcare workforce,
especially in marginalized communities. The COVID-19 pandemic exacerbated nurse burnout
due to surging patient numbers and resource shortages, escalating workload, and necessitating
prolonged work hours (Bruyneel et al., 2021; Kabunga & Okalo, 2021). These unprecedented
challenges, including fears of infection, inadequate resources, and dealing with high patient
mortality rates, were underscored by several studies (Aiken et al., 2002; Chen, Sun, et al., 2020;
Poorolajal, 2021; Ranney et al., 2020; Sun et al., 2020).
Systemic and operational factors, such as the deficiency of personal protective equipment
(PPE) and the persistent dread of infection, considerably influenced burnout during the
pandemic. These conditions also escalated emotional stress, moral anguish, and extended work
hours due to extended PPE use (Cohen & Rodgers, 2020; Morley et al., 2020; Ranney et al.,
2020). The constant apprehension of contagion and potential transmission to family members
further amplified psychological distress and burnout among nurses (Kackin et al., 2020;
Shanafelt et al., 2020).
34
The pandemic heightened work-related stressors, such as witnessing patient suffering and
high mortality rates, leading to emotional trauma and increased burnout. Social stigmatization
and isolation exacerbated emotional exhaustion among healthcare professionals (Gooch, 2021).
The escalation of stress and burnout due to the pandemic increased the likelihood of nurses
leaving the profession, potentially leading to a decline in the healthcare workforce (Buchan &
Shaffer, 2022; Chan et al., 2021; Fontenot et al., 2022; Oliveira, 2019). This decline will likely
impact marginalized communities disproportionately (Collins et al., 2002; Ford &
Airhihenbuwa, 2010; Juraschek et al., 2011), emphasizing the need for tailored interventions and
policy amendments to alleviate this growing concern.
Increased Workload
The pandemic resulted in a striking escalation of COVID-19 patients, heavily straining
healthcare facilities, resulting in nurses experiencing an extraordinary workload increase and
stress elevation, consequently inducing heightened burnout. A comprehensive study by Kabunga
and Okalo (2021) on nurses in central Uganda identified a wide prevalence of burnout,
correlating it directly with various pandemic-related challenges. Key factors such as extended
working hours and increased infection risk contributed to burnout. Galanis et al.’s (2021)
systematic review and meta-analysis detected a global trend of elevated nurse burnout linked
with the surge in patient numbers and heightened infection risk during the pandemic. Bruyneel et
al. (2021) investigated the elevated burnout risk among ICU nurses in French-speaking Belgium
during the outbreak, finding a significant burnout risk prevalence attributed to increased patient
numbers and longer working hours.
35
Long Working Hours
The literature has established a robust correlation between extended work hours and
nurse burnout (Aiken et al., 2002; Dall’Ora et al., 2015; Olds & Clarke, 2010). Research
indicates that nurses’ likelihood of burnout increases substantially with shifts exceeding 10 hours
(Aiken et al., 2002), a risk further magnified by physical and emotional exhaustion (Dall’Ora et
al., 2015). During the COVID-19 pandemic, heightened patient numbers, staff shortages, and
added safety protocols necessitated extended working hours, exacerbating burnout risk
(Shanafelt et al., 2020). Galanis et al.’s (2021) meta-analysis echoed this relationship, with
severe burnout precipitated by the combined strain of high mortality rates, infection risk, familial
isolation, and long hours (Cai et al., 2020; Hoseinabadi et al., 2020).
Evidence from a study involving 1,257 Chinese healthcare workers during the pandemic
suggested that working over 40 hours per week resulted in increased burnout levels (Lai et al.,
2020). Arnetz et al. (2020) reinforced this view, attributing prolonged working hours and myriad
stressors as crucial factors contributing to nurse burnout. The connection between working hours
and burnout also plays a role in nurse turnover (Hayes et al., 2012), which compounds staff
shortages, augments working hours, and perpetuates burnout rates (Galanis et al., 2021).
Lack of Personal Protective Equipment
The COVID-19 pandemic accentuated vulnerabilities in global healthcare, notably a
severe shortage of personal protective equipment (PPE), which negatively affected healthcare
workers (Cohen & Rodgers, 2020; Ranney et al., 2020). This scarcity exposed healthcare
workers, especially nurses, to amplified infection risk, increasing stress and anxiety levels
(Kackin et al., 2020). This situation highlighted the urgent need for systemic changes in the
36
supply chain and preparedness protocols to protect frontline healthcare workers during future
crises better.
The repercussions of PPE shortage were not limited to physical risks but also involved
significant psychological strain. Healthcare workers, compelled to extend PPE usage beyond
recommendations, faced augmented work conditions in high-risk environments. PPE shortages
imposed physical and emotional fatigue, leading to burnout (Maslach & Leiter, 2016),
underscoring the critical importance of addressing the physical and mental health needs of
healthcare workers to maintain a resilient workforce.
Insufficient protection compromised the psychological safety of nurses, inciting anxiety
and emotional distress, thereby elevating burnout (Shanafelt et al., 2020). This deficiency
induced moral distress as nurses dealt with the ethical dilemmas of providing care without ample
protection, intensifying burnout (Morley et al., 2020). The PPE shortage increased occupational
risks and significantly contributed to nurse burnout.
Fear of Infection for Self and Loved Ones
The COVID-19 pandemic significantly amplified fear-based psychological distress in
healthcare professionals, particularly nurses, due to their front-line roles (Lai et al., 2020). The
pervasive fear stemmed from personal infection risk in high-risk settings with insufficient PPE
and the potential for transmitting the virus to their family (Maben & Bridges, 2020). This
heightened fear corresponds with increased stress and anxiety, making nurses more prone to
burnout (Hu et al., 2020; Labrague & Santos, 2020).
Shen et al.’s (2020) survey emphasized the fear of infecting family as a prime concern
among healthcare workers, exacerbating psychological distress. Hu et al. (2020) proposed a
model linking fear, especially during pandemics, to emotional exhaustion, a precursor to burnout.
37
Fear is a potentially significant contributor to nurse burnout during pandemic crises,
underscoring the need for more supportive interventions.
Emotional Trauma
The COVID-19 pandemic emphasized nurses’ critical role during health crises and
heightened their emotional distress and burnout (Cai et al., 2020). A lethal virus and patient
distress imposed considerable emotional tolls, exacerbated by increased workloads and scarce
resources (Maben & Bridges, 2020; Shanafelt et al., 2020). A primary source of the subsequent
emotional trauma symptoms, such as fear and PTSD, was witnessing severe patient suffering
(Chen, Sun, et al., 2020). Chinese healthcare workers managing COVID-19 displayed significant
burnout indicators, including depression and insomnia (Lai et al., 2020), with subsequent studies
corroborating these findings of work overload and emotional exhaustion (Leibana-Presa et al.,
2023; Shanafelt et al., 2020).
Nurse burnout was aggravated by social stigmatization and isolation (Ramaci et al.,
2020). This situation produced detrimental consequences, including reduced care quality
(Halbesleben & Rathert, 2008a), increased intentions to leave the profession (Leiter & Maslach,
2009), and exacerbation of the nursing shortage (Ranney et al., 2020; World Health Organization
et al., 2020). The pandemic’s emotional fallout, alongside other stressors, significantly
exacerbated nurse burnout.
Best Practices to Address Burnout in Nursing
The escalating prevalence of nurse burnout is a global concern, magnified by the
COVID-19 pandemic. This section explores existing interventions to manage nurse burnout, preand post-advent of the pandemic. The investigation reviews strategies that include psychological
38
support, organizational modifications, and resilience enhancement, emphasizing the specific
needs engendered by the pandemic context. advent
Pre-pandemic Approaches
Pre-pandemic strategies to reduce nurse burnout emphasized workplace policies, worklife balance, and psychological support but were insufficient in lowering burnout rates. Before
the pandemic, the primary strategies to mitigate nurse burnout were rooted in changes in
workplace policies, improving work-life balance, increasing resources, and fostering a
supportive work environment (Hanrahan et al., 2010). A vital aspect of these strategies involved
policy interventions to manage extended working hours. By providing well-defined work
schedules, opportunities for self-care, and ensuring adequate rest periods between shifts, it was
anticipated that the rates of burnout would decrease (Maben & Bridges, 2020).
The pre-pandemic period was also characterized by considerable emphasis on providing
psychological support to nurses. This support aimed to help them cope with the stressors inherent
in their profession (Shechter et al., 2020). Despite these concerted efforts, the prevalence of
nurse burnout remained significant, underscoring the need for further research and intervention
development.
Pandemic-Era Strategies
The onset of the COVID-19 pandemic drastically altered the healthcare landscape,
imposing novel stressors on nurses and exacerbating burnout rates. This critical juncture
necessitated an evolution in intervention strategies adapted to the emergent challenges. As the
demand for healthcare services surged, the strain on nursing staff highlighted the urgent need for
sustainable workforce solutions (Buchan et al., 2022; Chan et al., 2021).
39
The early pandemic-era interventions mirrored the pre-pandemic strategies with an
increased focus on psychological support, considering the unprecedented mental and emotional
strain on nurses (Chen, Sun, et al., 2020). Simultaneously, the need for interventions designed
explicitly for the unique context of the pandemic emerged (Greenberg et al., 2020). The distinct
pressures brought about by the pandemic, such as an increased workload due to patient influx
and the risk of personal infection, demanded specialized coping mechanisms.
Fostering resilience among nurses was a vital strategy during the pandemic (Chen, Sun,
et al., 2020). By equipping nurses with the skills to bounce back from adversities, resilience
training aims to mitigate burnout’s long-term effects. This approach not only supports individual
well-being but also strengthens healthcare teams’ overall stability and effectiveness.
Comparisons and Recommendations
Juxtaposing the two periods, a clear evolution in nurse burnout interventions is evident.
While pre-pandemic strategies were primarily based on external modifications, such as policy
changes and resource provision, the pandemic-era strategies have pivoted towards internal
support, such as psychological assistance and resilience training. This shift reflects the escalating
need for an integrative approach that considers environmental factors and individual
psychological needs. Future interventions should adopt a hybrid approach, combining the best
practices of both periods. However, a thorough examination of the unique stressors imposed by
the pandemic and their long-term effects is needed to fully understand the new challenges that
nursing professionals face.
Characteristics of the Population and Stakeholders
The COVID-19 pandemic has deeply affected healthcare worldwide, including Hawaii’s
nursing workforce. These professionals operate within a unique cultural setting informed by
40
principles like the aloha spirit, mālama, kuleana, ho’oponopono, and lōkahi, which intertwine
with their professional values to bolster resilience and dedication. Analyzed through
Bronfenbrenner’s (1979) ecological systems theory, the home, social, and work environments,
shaped by these cultural values, significantly influence nurses’ decisions and experiences.
Notably, the Hawaiian culture’s emphasis on familial and community connections impacts their
commitment during crises such as the pandemic.
Despite the resilience cultivated by their cultural and support systems, Hawaii’s nurses
are susceptible to burnout due to intense emotional and physical demands, resource limitations,
and transmission fears (Hawai’i State Center for Nursing, 2021b). This susceptibility amplified
during the pandemic, leading to heightened turnover rates and consequential effects on
healthcare access, especially in underserved communities (Hawai’i State Center for Nursing,
2021a, 2023; University of Hawai’i, 2022). Beyond staff turnover, burnout imposes broader
repercussions on the healthcare system, including care deficits and substantial economic strain,
potentially causing hospital closures and further healthcare disparities.
Examining the relationship between cultural dynamics, environmental impacts, and
burnout in Hawaii’s nursing workforce during the pandemic is vital for devising effective
interventions and policies. Such comprehension can bolster the resilience and longevity of the
healthcare system amidst persistent and future challenges. Understanding these factors allows for
developing culturally sensitive approaches that address the unique needs of Hawaii’s diverse
population and healthcare workforce.
Cultural Factors: The Aloha Spirit, ‘Ohana, and Cultural Harmony
Cultural values significantly impact healthcare professionals’ work ethic and resilience,
especially during crises like the COVID-19 pandemic. The influence of these cultural factors is
41
evident in Hawaii, where nurses’ dedication can be explained using Bronfenbrenner’s (1979)
ecological systems theory, which emphasizes the role of various interrelated systems on
individual behavior, including the synergy of cultural and professional values (Pukui et al.,
1976). This cultural-professional interaction includes Hawaiian values such as the aloha spirit,
mālama, ‘ohana, respect for kupuna, and principles of kuleana, ho’oponopono, and lōkahi.
The aloha spirit, embodying love, compassion, and respect, reinforces the commitment of
Hawaiian nurses to quality patient care, especially during challenging periods such as the
pandemic (Pukui et al., 1976). Mālama, a notion of comprehensive care, aligns with nursing
principles and likely bolstered resilience during the crisis (McElfish et al., 2019). The principle
of ‘ohana, indicating extended family or social network, might have enhanced resilience and
heightened psychological stress due to the dual roles of family protection and professional duty
(Pukui & Elbert, 1986).
Cultural obligations towards elders, or kupuna, might have increased stress for nurses
during the pandemic but potentially intensified their dedication to service, given the greater
vulnerability of elders (McCubbin & Marsella, 2009). Lastly, the lōkahi, kuleana, and
ho’oponopono triad forms a complex value system (Pukui & Elbert, 1986; Wall & Callister,
1995) that likely steered Hawaii’s nurses’ responses to the pandemic. Understanding these
cultural values is critical in interpreting and anticipating behaviors in healthcare settings.
Aloha Spirit and Caring for Others (Mālama)
Hawaiian cultural tenets, the aloha spirit and mālama, embody love, peace, compassion,
and care for others and the environment, harmonizing with nursing principles such as empathy
and respect (McElfish et al., 2019; Pukui et al., 1976). These values inform nursing practices and
inspire quality patient-centered care (Watson, 2008), particularly amidst demanding conditions
42
such as the COVID-19 pandemic. They likely fostered resilience among Hawaiian nurses,
committing them to community service and aligning them with global practices focused on
healthier environments (Schluter et al., 2011). These cultural principles were potentially
instrumental in driving the dedication of Hawaiian nurses during the crisis.
Ohana (Family) and ‘Ohana Culture
The principle of ‘ohana, a foundational concept in Hawaiian society denoting an
extended family network inclusive of social connections (Pukui & Elbert, 1986), has been
instrumental for nurses during the COVID-19 pandemic. The ‘ohana culture, which highlights
family and community ties, enhanced resilience but presented a unique predicament for these
professionals. Balancing familial protection and occupational responsibilities magnified their
stress (DeBaryshe et al., 2006; McElfish et al., 2019; Mokuau, 2011). Moreover, their
comprehensive perception of ‘ohana, incorporating patients into their extended family,
reinforced a profound commitment to providing compassionate care despite the pandemic.
However, this intensified sense of duty might have escalated their psychological stress, induced
by the fear of inadvertently transmitting the virus to their kin, leading some to reconsider their
bedside roles (Hu et al., 2020; Kanahele, 1986; Labrague & Santos, 2020).
Respect for Kupuna (Elders)
A profound respect for elders, or kupuna, in Hawaiian culture significantly shaped
nurses’ resilience during the COVID-19 pandemic as they balanced cultural obligations with
intense healthcare demands. This value plays a pivotal role and significantly influences the
operations within acute care settings, especially for registered nurses (McCubbin & Marsella,
2009). The onset of the COVID-19 pandemic intensified this cultural mandate due to the
disproportionate effect on older individuals (Centers for Disease Control and Prevention, 2020b).
43
Nurses, driven by this cultural respect, demonstrated unwavering dedication amidst significant
pressure on the healthcare system, potentially fortified by the societal significance of kupuna.
The pandemic-induced disruption potentially created tensions as nurses sought to maintain a
cultural balance, a central Hawaiian societal theme (McCubbin & Marsella, 2009). Despite the
difficulties in juggling professional and personal responsibilities during this global crisis, the
imperative of upholding cultural norms was an additional catalyst for their perseverance.
Kuleana (Responsibility), Ho’oponopono (Making Things Right), and Lōkahi (Harmony)
Hawaiian culture offers a profound understanding of balance, interconnectedness, and
responsibility, highlighted in the three core principles of cultural harmony, responsibility, and
making things right. The interplay of kuleana, ho’oponopono, and lōkahi forms a complex value
system that may have guided Hawaiian nurses’ responses to the COVID-19 crisis. These
principles have particularly impacted the behavior of Hawaiian nurses during the COVID-19
pandemic and demonstrate the need to consider cultural contexts in understanding and predicting
behaviors in healthcare settings.
Kuleana (Responsibility)
The principle of kuleana offers another insight into the Hawaiian cultural fabric. Kuleana
implies responsibility and rights and speaks to each person’s responsibilities towards their
family, community, and environment (Pintor, 2023; Pukui & Elbert, 1986). For nurses in Hawaii,
their professional duties intersect with this deeply ingrained cultural concept. This intersection
likely serves as a motivating factor, compelling them to continue providing bedside care during
the pandemic.
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Ho’oponopono (Making Things Right)
Ho’oponopono, centered on reconciliation, likely motivated Hawaiian nurses to stay in
bedside care during COVID-19, seeing the crisis as a disruption to harmony they felt obligated to
resolve. The principle of ho’oponopono, a practice of reconciliation and forgiveness, provides
Hawaiians with a proactive method for resolving conflicts and restoring harmony (Pukui &
Elbert, 1986; Wall & Callister, 1995). This practice encourages open dialogue, admission of
wrongs, and seeking forgiveness (Meyer, 1995). Nurses embodying this principle during the
COVID-19 crisis likely felt the urge to stay in bedside care. They would see the health crisis as a
disruption to the balance and, consequently, as a part of their duty to help resolve this imbalance.
Lōkahi (Cultural Harmony and Balance)
Lōkahi, or cultural harmony, profoundly influences how registered nurses in Hawaii view
their work, fostering a solid commitment to maintaining community well-being and balance,
especially during the COVID-19 pandemic. An integral aspect of the Hawaiian worldview, the
value of cultural harmony, known as lōkahi, insists on a balance within relationships and respect
for the interconnectedness of all things (Pukui & Elbert, 1986; University of Hawai’i, 2024).
Working within this cultural context, registered nurses in Hawaii may perceive their work as
instrumental in promoting the well-being of their community and maintaining this balance.
Consequently, their devotion to preserving cultural harmony could motivate them to continue
bedside care during the COVID-19 pandemic, considering their role as pivotal in preserving the
health and harmony of their community (DeBaryshe et al., 2006; McElfish et al., 2019; Mokuau,
2011).
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Home, Social, and Work Factors
Through the lens of Bronfenbrenner’s (1979) ecological systems theory, this section
scrutinizes the influence of various environmental aspects on the commitment of acute care
nurses in Hawaii to persist in their roles amid the COVID-19 pandemic. The theory highlights
the importance of the microsystem, the immediate environment of interaction, in shaping
individual actions and experiences. Particularly for nurses, their home environment, a key
microsystem featuring physical, familial, and self-care aspects, is vital to their dedication to
maintaining bedside roles. This is especially true in Hawaii, where the ethos of ‘ohana
emphasizes tight-knit familial and communal ties. However, pandemic-related infection risks
have engendered apprehension, potentially challenging their occupational allegiance.
Consequently, the quality of the home environment critically affects nurses’ resilience and career
continuance decisions.
Bronfenbrenner’s theory further posits the role of the social environment, including
various micro-, exo-, and macrosystems, in guiding individuals. For Hawaiian nurses, the ‘ohana
spirit, extending to friends and community, may shape their professional interactions and social
support (Kanahele, 1986; McCubbin, 2007; McCubbin & Marsella, 2009; McGregor, 2007).
This camaraderie can strengthen their resolve, but increased interaction might exacerbate
infection-related anxiety, necessitating further study. Given Hawaii’s strong communal culture,
respect for healthcare professionals could also significantly influence their career decisions.
Lastly, the work environment dramatically impacts the nurses’ decisions (Hakanen et al.,
2008; Kowalski et al., 2010; Leiter & Maslach, 2004). Workplace conditions, work-life balance,
societal perceptions of nursing, interpersonal relations, and institutional policies are crucial,
especially during the COVID-19 crisis (Davide et al., 2022; Melnyk et al., 2021; Zhang et al.,
46
2021). Thus, the work environment constitutes a central element within the complex interplay of
personal, environmental, institutional, and societal factors, affecting the decision of acute care
nurses to remain in service.
Home Environment
In the context of Bronfenbrenner’s (1979) ecological systems theory, the role of the home
microsystem in Hawaiian acute care nurses’ decision to continue bedside roles during the
COVID-19 pandemic is scrutinized. The microsystem, comprising dwelling conditions, familial
support, and self-care resources, is instrumental in this decision-making (Cimiotti et al., 2012).
Family support, financial stability, and work-life balance are core home microsystem factors and
have traditionally affected job satisfaction and tenure of healthcare professionals (Cox et al.,
2018).
Exploring these factors within the ‘ohana culture, a characteristic feature of Hawaii’s
close-knit community, is vital, especially during the pandemic. Despite pandemic challenges, the
‘ohana ethos possibly reinforces nurses’ commitment to patients and their extended ‘ohana.
Amid the pandemic, the home microsystem faces new challenges, including infection control and
related stress, possibly destabilizing work-life balance and reevaluating bedside dedication (Hu
et al., 2020; Huang, Lei, et al., 2020; Labrague & Santos, 2020). The presence or absence of
home-based support could significantly influence these decisions, potentially boosting resilience
or augmenting burnout (Henshall et al., 2020).
Despite acknowledging these dynamics, a literature gap exists as quantitative
methodologies primarily employed may overlook nurses’ diverse experiences. Research focusing
specifically on Hawaiian acute care nurses’ pandemic experiences remains limited. Qualitative
inquiry is necessary to capture Hawaii’s nuanced and culturally unique impact of the pandemic
47
on its acute care nurses. This work could potentially reveal overlooked psychosocial and
environmental factors.
Social Environment
Bronfenbrenner’s (1979) theory highlights the influence of interconnected social systems
on individual behavior, impacting job satisfaction and career intentions in healthcare
professionals. This interconnection was evident among Hawaiian acute care nurses during the
COVID-19 pandemic, who were influenced by multiple systems, including the culturally
significant ‘ohana support network (McElfish et al., 2019). Despite fostering resilience, this
communal spirit raised infection concerns (Brewer et al., 2023; Davide et al., 2022; Huang, Lei,
et al., 2020), indicating a need for further research on the juxtaposition between the need for
social interaction and distancing based in concern for self and others.
Societal attitudes significantly impact the perseverance of healthcare professionals
(Dyrbye et al., 2019; Goel & Nelson, 2021; Shechter et al., 2020). Bronfenbrenner (1979)
identified the microsystem as vital, comprising immediate environments and relationships.
Interpersonal connections significantly influence job retention during crises (Fontenot et al.,
2022).
The mesosystem influences career decisions, reflecting the interaction of various
microsystems. The work-life balance is especially relevant for nurses with familial
responsibilities (Kim & Lee, 2021). Exosystem elements like societal norms and community
attitudes also shape choices, with societal recognition being positively correlated with nurse
retention during the pandemic (Kim & Lee, 2021).
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Work Environment
Bronfenbrenner (1979) highlighted that the work environment substantially influences
behaviors and choices, which can be applied to nurses in this situation. Applying
Bronfenbrenner’s (1979) ecology of systems theory to the experience of acute care nurses in
Hawaii during the COVID-19 pandemic reveals key factors shaping their bedside care
commitment. The microsystem, reflecting the immediate work milieu, emphasizes safety
protocols, staffing, and interpersonal relationships. Interactions between microsystems, or the
mesosystem, address work-life balance and the risk of family infection, which is vital during the
pandemic. The exosystem, or indirectly influential environments, illuminates the role of policies
on sick leave, hazard pay, and PPE availability (Bronfenbrenner, 1979). The macrosystem,
encapsulating societal beliefs about nursing and COVID-19, may inspire nurses to endure
challenges (Dreachslin et al., 2012).
The decision to remain bedside during a health crisis is multi-faceted, influenced by
personal, environmental, institutional, and societal factors. Research supports the relationship
between nurse staffing, workplace support, and nurses’ well-being (Aiken et al., 2002; Brooks
Carthon et al., 2019) and highlights the significance of supportive work relationships on job
satisfaction and retention (Aquilia et al., 2020; Brewer et al., 2023). The COVID-19 crisis
increased Hawaiian nurses’ workloads and stress, impacting job satisfaction and prompting
intentions to leave (Fontenot et al., 2022).
The pandemic further stressed work-life balance, increasing burnout (Hawai’i State
Center for Nursing, 2021a). Policies and resource shortages, part of the exosystem, exacerbated
nurses’ dissatisfaction (Hawai’i State Center for Nursing, 2021b). However, supportive societal
attitudes, or the macrosystem, bolstered Hawaiian nurses’ resilience and commitment (Davide et
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al., 2022). Bronfenbrenner’s theory elucidates the workplace’s role in nurses’ persistence at the
bedside during a pandemic.
Impact of Nurse Burnout on the Nursing Workforce in Hawaii
The COVID-19 pandemic worsened nurse burnout in Hawaii, escalating healthcare
disparities, turnover, and financial strain on hospitals. The physical and emotional demands of
nursing, especially in acute care, can exacerbate burnout, a situation heightened in Hawaii due to
its distinct geographic and cultural factors (Freudenberger, 1974). COVID-19 magnified these
challenges, escalating stress and burnout characterized by emotional exhaustion,
depersonalization, and reduced personal accomplishment (Maslach & Jackson, 1981; Wang et
al., 2020). Pre-pandemic disparities in Hawaii’s healthcare complicated this, escalating turnover
rates and risking a professional exodus with significant repercussions on patient care, particularly
for marginalized communities (Ayers-Kawakami & Paquiao, 2017; Bae, 2022; Healthy
Communities Institute, 2015).
This upsurge in turnover has economic consequences; hospitals in less affluent and rural
areas face an average cost of $51,700 per employee (NSI Nursing Solutions, 2023). Such
financial strains may induce closures, restricting healthcare access (Collins et al., 2002). The
interplay of financial pressure and healthcare delivery underlines the importance of
understanding and addressing burnout, particularly as it intensifies existing disparities.
Despite these observations, a full comprehension of the pandemic’s impact on nurse
burnout in Hawaii, considering its unique geographic isolation and cultural diversity, remains to
be explored. Further studies are needed to understand these unique stressors and inform effective
interventions and policies for healthcare system resilience and sustainability. Lacking targeted
50
strategies to mitigate burnout, Hawaii’s healthcare system may continue to be strained, leading to
worsening workforce shortages and threatening the quality of care in the State.
Impact on Mental Health
The COVID-19 pandemic has considerably intensified the mental health strain on nurses.
In Hawaii, this strain has exacerbated already high burnout levels (Arnetz et al., 2020). The
hardships stemming from Hawaii’s geographic isolation and cultural factors, augmented
workload, infection fears, and emotional losses have only amplified these challenges (AyersKawakami & Paquiao, 2017; Healthy Communities Institute, 2015). Furthermore, the
pandemic’s financial impact on healthcare services, exemplified by a decreased influx of tourists,
resulted in a deficit of temporary nurses, thereby heightening the load and stress on resident
nurses (Hawai’i State Center for Nursing, 2021a; University of Hawai’i, 2022).
This scarcity of resources and increased demand have rendered nurses susceptible to
burnout and related mental health conditions, including depression, anxiety, and stress (Hu et al.,
2020; Shanafelt et al., 2020). These adverse mental health consequences diminish nurses’ quality
of care, negatively influence job satisfaction, and raise turnover rates, intensifying pressure on an
already strained healthcare system. Long-term mental health support and systemic changes in
resource allocation require immediate attention to address the residual effects of the pandemic on
the nursing workforce.
Impact on Workforce Sustainability
Burnout among nurses threatens healthcare system sustainability Martin et al. (2023).
This threat is highlighted by Shanafelt et al. (2020), estimating that over 100,000 U.S. nurses left
healthcare during the pandemic. This issue is critical in Hawaii, which faced a nursing shortage
before the pandemic (Hawai’i State Center for Nursing, 2007; 2021b). Amplified by COVID-19,
51
burnout deepens the healthcare crisis, worsened by Hawaii’s geographical, cultural, and
demographic challenges.
Between March 2020 and March 2022, Hawaii’s nurses faced immense pressure. A 2021
survey revealed that over half reported severe burnout, leading to increased attrition (Hawai’i
State Center for Nursing, 2021a). This critical shortage necessitates immediate research into
burnout and the creation of culturally sensitive interventions, such as mental health screenings
and peer support groups. These strategies should consider Hawaii’s cultural emphasis on
community (Koholokula et al., 2020; McElfish et al., 2019).
Impact on Quality of Care
The COVID-19 pandemic worsened patient quality care secondary to nurse burnout. The
correlation between nurse burnout and patient care quality is a widely recognized phenomenon
(Arandjelovic et al., 2010; Poghosyan et al., 2010). Burnout, a state defined by emotional
exhaustion, depersonalization, and a lack of personal achievement (Maslach & Jackson, 1981),
leads to negative consequences in patient care, including elevated medical errors, reduced patient
satisfaction, and potentially increased mortality rates (Cimiotti et al., 2012).
COVID-19 has exacerbated this problem for acute care nurses due to heightened
workload, fear of infection, and resource scarcity (Sasangohar et al., 2020). These challenges,
further intensified by geographical and infrastructure constraints in Hawaii, potentially heighten
nurse burnout, causing a more drastic decline in patient care quality than in other betterresourced regions (Bernardo, 2020). The combination of these systemic and environmental
stressors can magnify burnout in ways that disproportionately affect patient care outcomes,
reflecting lower satisfaction ratings and critical health metrics.
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Unfavorable work conditions, epitomized by insufficient support, high patient-to-nurse
ratios, and chronic understaffing, can exacerbate burnout, detrimentally impacting patient
outcomes (Aiken et al., 2002). For instance, Cimiotti et al. (2012) revealed a twofold increase in
healthcare-associated infections in hospitals with high nurse burnout levels. Chronic
understaffing has been directly linked to increased adverse events like medication errors, falls,
and decreased care coordination (Garrett, 2008; Olds & Clarke, 2010).
Bronfenbrenner’s Ecology of Human Development
Urie Bronfenbrenner’s (1979) ecological systems theory fundamentally altered the
landscape of developmental psychology in the 1970s, illustrating the complex interplay between
individuals and their multilayered environments (Bronfenbrenner, 1979). EST consists of five
environmental layers: microsystem, mesosystem, exosystem, macrosystem, and chronosystem.
The microsystem pertains to immediate, reciprocally impactful environments like family and
school (Bronfenbrenner, 1977). The mesosystem and exosystem encompass interactions among
microsystems and external environments like workplaces, indirectly influencing individual
development (Bronfenbrenner, 1979; Neal & Neal, 2013). The macrosystem and chronosystem
represent broader socio-cultural contexts and temporal factors impacting development
(Bronfenbrenner, 1986). Figure 1 provides a visual of Bronfenbrenner’s theory.
EST’s implications extend across fields, including education, social work, and public
health. It emphasizes the interdependencies among parents, teachers, and communities in
education (Epstein, 2018), systemic interventions in social work (Garbarino, 2017), and multilevel strategies in public health (Stokols, 1996). However, critics argue that EST lacks clarity on
system interactions and overemphasizes environmental influences while underestimating
individual agency (Christensen, 2016; Darling, 2007; Elliott & Davis, 2020). Despite these
53
concerns, the theory’s lasting impact underscores its significance in comprehending the
multifaceted interactions shaping human development.
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Figure 1
Bronfenbrenner’s Ecological Systems Theory
From “Chronosystem Definition, Theory & Examples,” by S. J. Van Vuuren & Y. Williams,
2023, Study.com (https://study.com/learn/lesson/bronfenbrenner-chronosystem-concept-impactsexamples.html). Copyright 2024 by Study.com.
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Microsystem
Bronfenbrenner’s microsystem denotes an individual’s proximate environment,
characterized by immediate personal interactions that directly shape their development
(Bronfenbrenner, 1977). This reciprocal relationship signifies that individual actions reciprocally
influence their surrounding microsystems (Tudge et al., 2009). Examining the microsystem’s
components is essential to understanding its role in individual development.
Family, as the primary social unit, significantly impacts personal development. Factors
such as parent-child interaction, sibling count, socioeconomic status, and parenting styles
influence a child’s psychological growth (Darling & Steinberg, 1993). Educational settings,
another microsystem element, affect cognitive and socio-emotional development through school
culture, teacher-student interactions, and the quality of the learning environment (Hamre &
Pianta, 2001). Peer relationships shape behavior, particularly during adolescence. They provide a
space for honing social skills, establishing identity, and learning societal norms (Rubin,
Bukowski. et al., 2008).
Mesosystem
In Bronfenbrenner’s (1979) ecological systems theory, the mesosystem signifies the
second tier of environmental impact on a child’s development, focusing on the interaction of
various microsystems like home, school, and community (Bronfenbrenner, 1979). Mesosystemic
influence, exemplified by parent-teacher interactions, indirectly shapes a child’s development
through microsystemic dynamics (Paquette & Ryan, 2001). Positive parental involvement with
teachers, for instance, can augment academic performance by reinforcing school-set expectations
at home (Epstein, 2018), while discord between the two may lead to diminished performance due
to inconsistent feedback (Christenson, 2004). Moreover, the mesosystem affects emotional and
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social maturation; harmonious parent-teacher relations can foster emotional security, while
contentious ones may result in feelings of instability (Bronfenbrenner & Morris, 2006).
Exosystem
Bronfenbrenner’s (1979) EST delineates the indirect influence of exosystems on personal
development. This level differs from microsystems and mesosystems, which are direct
environments like family or school (Bronfenbrenner, 1979; Neal & Neal, 2013). The exosystem
comprises external structures whose circumstances impact immediate systems involving the
individual. Parental workplaces, neighborhood resources, and social policy exemplify exosystem
elements (Tudge et al., 2009). For example, a parent’s work conditions may affect a child
indirectly by modifying the parent’s emotional state or availability, hence altering the child’s
family microsystem (Vélez-Agosto et al., 2017).
Similarly, Local resources such as quality schools or healthcare facilities can influence an
individual’s living conditions or opportunities (Leventhal & Brooks-Gunn, 2000). These
resources can affect one’s health, academics, and overall well-being by altering the stressors or
resources in the micro- and mesosystems. While not directly interacting with these exosystem
structures, their conditions significantly affect an individual’s development, emphasizing the
interconnectivity of various environmental systems.
Macrosystem
Bronfenbrenner’s (1979) EST illustrates the macrosystem as the broader sociocultural
milieu that indirectly impacts individual development, encompassing societal values, economic
conditions, and political structures (Bronfenbrenner, 1979). Cultural norms, such as
individualistic or collective practices, mold individual behaviors and attitudes (Schwartz, 2012).
For instance, individualistic societies prioritize personal accomplishment and fostering
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independence, whereas collective societies encourage social harmony and altruism (Hofstede,
2001). Economic conditions, such as poverty and economic stability, influence an individual’s
resources, affecting their educational, occupational, and health outcomes (Bradley & Corwyn,
2002; Heckman, 2006). Lastly, political policies shape social structures and institutional
practices, indirectly affecting individual development (Barnett & Belfield, 2006). For instance,
policies on educational funding or healthcare provision significantly impact access to essential
services, shaping developmental outcomes.
Chronosystem
Bronfenbrenner’s (1979) EST incorporates a time-based dimension known as the
chronosystem, which is crucial for understanding human development (Bronfenbrenner, 1979).
This layer offers a dynamic perspective, highlighting the role of life transitions and sociohistorical contexts in shaping an individual’s life trajectory (Bronfenbrenner, 1986). Life
transitions such as relocating or growing from childhood to adolescence, coupled with significant
historical changes, serve as temporal influencers, redefining individuals’ roles, responsibilities,
and social engagements (Tudge et al., 2009). Consequently, these shifts, including significant
socio-historical contexts like wars or technological advancements, compel a reassessment of
identity, beliefs, and behaviors (Elder et al., 2007). For example, the digital revolution’s
transformative impact reshaped societal norms, subsequently affecting individual cognitive and
social development (Prensky, 2001).
Evaluation of Bronfenbrenner’s Ecology of Systems Theory
Bronfenbrenner’s (1979) EST has influenced diverse fields such as education, social
work, and public health, providing a multilayered perspective to understand human development
(Tudge et al., 2009). In education, EST emphasizes the synergistic contribution of parents,
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teachers, and community organizations to children’s learning, encouraging home-school
collaboration for a supportive environment (Epstein, 2018). Social work interventions and
policies, drawing from EST, focus on systemic changes and social support rather than merely
individual behavior, aligning with a holistic approach to welfare (Garbarino, 2017). Stokols
(1996) noted its relevance in public health, suggesting a comprehensive approach, including
modifying behaviors, social norms, and policy.
Despite its utility, critics highlight the EST’s limitations, primarily its vagueness in
describing the interactions among different system levels affecting human development (Elliot &
Davis, 2020). Others argued that it overemphasizes environmental influence, downplaying the
role of individual choice and initiative, calling for a more balanced viewpoint that includes both
environmental factors and individual agency (Christensen, 2016; Darling, 2007).
Key Concepts in Conceptual Framework
Burnout, work culture, leadership, and culture and politics are the key concepts and foci
of the study. Applying Bronfenbrenner’s (1979) EST, the study will explore how these key
concepts contributed to the nurses’ desire to remain at the bedside in the acute care setting or
move away from direct patient care. Specifically, Bronfenbrenner’s microsystem, exosystem,
and macrosystem will construct a framework from which the specific experiences of the nurse
affected their positionality in and attitude toward nursing.
burnout and wellbeing
family/home/social culture and support
work culture and support
hospital leadership and support
values, beliefs, and laws of Hawaii
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Bronfenbrenner’s Ecological Systems Theory in Nursing Burnout Research
Bronfenbrenner’s (1979) EST explains the various influences on human development,
providing a valuable perspective for studying burnout. The theory, not initially aimed at burnout,
conceptualizes human development as embedded within five interrelated systems: the
microsystem, mesosystem, exosystem, macrosystem, and chronosystem, each contributing
uniquely to development (Bronfenbrenner, 1979). The microsystem encapsulates immediate
environments like family or work, with burnout associated with factors such as high workload or
perfectionism (Bakker et al., 2006; Maslach et al., 2001). Furthermore, Brunsting et al. (2014)
found a strong correlation between these microsystemic elements and burnout among special
education teachers. The mesosystem, reflecting interconnections between active life settings,
implicates burnout through a poor work-life balance (Demerouti et al., 2005). At the exosystem
level, societal pressures for productivity impact burnout, as evidenced by Salazar and Beaton’s
(2000) study on urban firefighters. Societal values that prioritize work, a macrosystemic
influence, also contribute to burnout (Hakanen et al., 2008), while the chronosystem, accounting
for life’s temporal changes, shows job changes influencing burnout (Borritz et al., 2005).
Habeger et al. (2022) underscored the significance of these societal and temporal aspects in
understanding burnout. Additionally, Tian et al. (2022) found transformational leadership to be a
crucial mitigator of teacher burnout. Lastly, Alkema et al. (2008) highlighted how burnout in
hospice care professionals affected their romantic relationships, showing the ecological theory’s
broader applicability. Despite Bronfenbrenner not addressing burnout directly, his theory has
proven instrumental in enhancing our comprehension of burnout’s intricacies.
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Gaps in Current Literature
The COVID-19 pandemic has heavily strained healthcare systems, including healthcare
workers’ mental health, with acute care nurses being particularly vulnerable. However, research
explicitly examining this demographic’s experiences, particularly in Hawaii, remains noticeably
scarce (Kamaka et al., 2021). This dissertation seeks to bridge this knowledge gap, which is
essential to understanding the influence of the pandemic on nurses’ well-being and healthcare
sustainability.
Acute care nurses, who are at the epicenter of health crises, often grapple with stress and
burnout, which can escalate during a pandemic, affecting their mental health and patient care
quality. Research on this issue, especially in Hawaii’s context, is insufficient, underscoring the
need for further exploration (Kamaka et al., 2021). This gap in literature motivates the study,
with burnout, characterized by inefficacy, emotional exhaustion, and reduced personal
achievement, serving as a focal point.
The complexity of burnout, interwoven with organizational culture, job demands, and
social support, necessitates further probing. Understanding these interactions can pave the way
for effective burnout interventions tailored explicitly for unique environments like Hawaii. The
prevailing quantitative methodologies (Dall’Ora et al., 2015; Hakanen et al., 2008; Kabunga &
Okalo, 2021; Kim & Lee, 2021; Kim et al., 2021; Laschinger & Grau, 2012; Poghosyan et al.,
2010; Xie et al., 2011) may miss nuanced human interactions, especially in crises.
A multi-modal approach would afford the integration of qualitative methodologies to
capture these subtleties. This approach will provide a more comprehensive understanding of the
phenomena and assist in devising context-specific strategies. The lack of studies centered on the
lived experiences of acute care nurses in Hawaii during the pandemic limits our understanding of
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their challenges, coping mechanisms, and support systems. Prioritizing research in this area will
help reveal these nuances. Despite considerable strides in understanding the pandemic’s impact
on healthcare workers, targeted research on acute care nurses in Hawaii incorporating qualitative
methods is necessary to enrich the literature and help design effective, evidence-based
interventions.
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Chapter Three: Methodology
The methodology chapter of this dissertation is central in outlining the groundwork of the
research approach and design, which centers around a quantitative study focusing on the attitudes
and perceptions of nurses in Hawaii that influenced their desire to remain at or leave bedside care
during COVID-19. This study aimed to build upon prior studies, such as those by Fontenot et al.
(2022) and Oliveira (2019), which reported a notable decrease in the number of licensed nurses
in Hawaii. This research focused on the unique situation of acute care nurses in Hawaii who
delivered bedside care from March 2020 to March 2022, during which they encountered
escalated occupational stressors. This chapter will guide readers through the research questions,
an overview of the design, research setting, the researcher’s role, sources of data, and ethical
considerations, as well as a discussion on the reliability and validity of the findings and an
acknowledgment of the study’s limitations and delimitations.
Research Questions
Two research questions guided this study:
1. How did Hawaii’s registered nurses’ environment impact their decision to work at the
bedside in the acute care setting during COVID-19?
2. How did Hawaii’s culture impact Hawaii’s registered nurses’ decision to work at the
bedside in the acute care setting during COVID-19?
Overview of Design
The dissertation design for this study utilized a quantitative methodology to gather
objective data on the attitudes and opinions of nurses in Hawaii. The choice of a quantitative
approach was motivated by the need to gather numerical data and drive hypothesis development
(Creswell & Creswell, 2018). The primary data collection method was a structured survey
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administered digitally via email. The collection method included five qualitative questions about
the Hawaiian culture. Table 1 connects the research questions and instrument method, defining
the data sources.
The research aimed to explore the reduction in the number of licensed nurses in Hawaii.
It focused on understanding the specific factors contributing to this decline, as voiced by the
nurses. The survey built upon recent studies identifying this decline to address the research gap
regarding the decrease in licensed nurses in Hawaii (Fontenot et al., 2022; Hawai’i State Center
for Nursing, 2021a). The study uncovered some underlying causes contributing to nurses who
considered reducing working hours, exploring alternative roles, or leaving the nursing
profession. A customized survey was conducted focusing on identifying factors such as
heightened stress levels and feelings of isolation that could have influenced these thoughts
among nurses.
Table 1
Data Sources
Research questions Quantitative
survey
Qualitative
survey
RQ1: How did Hawaii’s registered nurses’ environment
impact their decision to work at the bedside in the
acute care setting during COVID-19?
X
RQ2: How did Hawaii’s culture impact Hawaii’s
registered nurses’ decision to work at the bedside in
the acute care setting during COVID-19?
X X
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The target population for this study was nurses who held a bedside nursing position in the
Acute Care division of a Hawaii hospital or hospital system between March 2020 and March
2022. The nurses may have worked at the bedside or left during the survey distribution. The
survey instrument was disseminated digitally via email and through a partnership with the
Hawaii Chapter of the American Nurses Association, leveraging previous surveys’ established
infrastructure and success. This approach ensured efficiency in data collection and the potential
for a robust and representative sample base.
Research Setting
The study was conducted in Hawaii, focusing on licensed nurses who held a bedside
nursing position in the Acute Care division in a Hawaii hospital or hospital system between
March 2020 and March 2022. Hawaii, as an isolated island state, faces distinctive healthcare
challenges. The state has a population of approximately 1.5 million, with a diverse demographic
composition of various ethnicities, including Native Hawaiians, Asians, Pacific Islanders, and
Caucasians (State of Hawaii, 2022). The healthcare system in Hawaii comprises multiple
hospitals and hospital systems catering to the population’s healthcare needs (State of Hawaii,
2023). Hawaii was ideal for this study due to its unique healthcare system and specific
demographics.
The selection of Hawaii as the research setting was justified for several reasons. The
decrease in licensed nurses in Hawaii presented a pressing issue in the local healthcare
landscape. According to the Hawai’i State Center for Nursing (2021a), there was a significant
decrease in the number of Registered and licenses practical nurses in Hawaii. The number of RN
licenses decreased by 13.7%, representing a reduction of 3,972 licenses from 29,029 in July 2019
to the end of 2021. Concurrently, the number of LPN licenses suffered a more substantial
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reduction of 30% during the same period. By focusing on this specific setting, the study provided
insights into the factors contributing to this decline, which can be used to inform targeted
interventions and policies within the state.
A substantial reduction in both registered nurses (RNs) and licenses practical nurses
(LPNs) in Hawaii could lead to a critical healthcare crisis in the region. Nurses are pivotal in
healthcare delivery, providing patient care, education, and support, and they function as the
primary contact point for patients and their families. The decrease in the number of nurses may
strain the existing healthcare resources and compromise the quality and accessibility of care.
With fewer nurses available, the remaining nursing workforce may become overworked,
potentially leading to burnout, decreased job satisfaction, and further reducing the number of
active nurses. The reduction may also affect patient outcomes negatively, as the nurse-to-patient
ratio is a key determinant of quality healthcare. Research has indicated that lower nurse-topatient ratios can lead to higher rates of patient complications, mortality, and medical errors
(Shekelle, 2013; Wynendaele et al., 2019).
The diminished nursing workforce may create access issues, particularly in rural or
underserved areas (Fagin, 2001; Kronenfeld & Penedo, 2020). A drop in their numbers can mean
a decline in the accessibility and availability of essential healthcare services. An aging
population and the ongoing global pandemic place additional strain on healthcare systems
worldwide (Munsterman, 2020; Wolf et al., 2020). The reported decrease in nurses could
exacerbate these challenges, making it more difficult to meet the increasing healthcare needs.
The acute care division of Hawaii hospitals or hospital systems was chosen as the site for
participant selection due to its direct relevance to the research questions. By focusing on nurses
in this specific division, the study examined the reasons for the reduction in licensed nurses in a
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critical area of healthcare provision, where the impact of nurse shortages can have significant
implications for patient care and outcomes. The participants in the study consisted of licensed
nurses who met the following criteria: held a bedside nursing position in the acute care division
in a Hawaii hospital or hospital system, and were employed between March 2020 and March
2022. Nurses did not need to be currently employed at the bedside or in the field or licensed in
Hawaii to be eligible to participate. The rationale for including these participants is twofold.
Firstly, acute care bedside nurses are typically at the frontlines of care and, as such, are
often the first to encounter the challenges and stressors that could be linked to the dwindling
number of licensed nurses (Fontenot et al., 2022). Southwick (2021) and Chan et al. (2021)
underscored the considerable toll these stressors can take on acute care bedside nurses’ mental
and physical health, negatively impacting their desire to remain at the bedside. By including this
group of nurses, the study captured their unique perspectives and insights into the reasons behind
the decline.
Secondly, focusing on nurses employed during the specified timeframe ensured that the
study examined the impact of the COVID-19 pandemic, which may have played a role in
shaping the attitudes and opinions of nurses during that period. Hawaii’s culture may have
influenced how nurses in Hawaii perceived and were affected by the pandemic. By including
participants from this timeframe, the study provided timely and relevant data on the factors
contributing to the decrease in licensed nurses in Hawaii.
The Researcher
Reflecting on my positionality and relationships to the study context, including acute care
facilities in Hawaii, and the study participants, registered nurses, was crucial in embarking on
this study. As a registered nurse, I am inherently connected to the problem of practice of the
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impending shortage of registered nurses in Hawaii, exacerbated by the COVID-19 pandemic and
burnout. My professional experience allows me to comprehend the intricacies and nuances of the
problem. However, my identity as a nurse leader and a White male may lead to biases. Biases
and assumptions can influence the research (Smith, 2017).
Recognizing my positionality is a significant first step. Being a White male may construct
barriers to earnest responses by nurses born and raised in Hawaii. My inquiries can potentially be
perceived as an intrusion from the mainland, which can skew the survey results or create a
negative experience for participants (Dwyer & Buckle, 2009). To address this, I approached the
study with respect and acknowledgment for the local culture. By demonstrating vulnerability and
the intent to help, rather than imposing outside solutions that may not align with Hawaiian
culture, I aimed to foster trust and ensure that nurses from Hawaii felt heard and understood
(Lopez et al., 2008).
Additionally, my director of emergency services and nursing operations role may
introduce bias. The possibility exists that constructing survey instruments could have
inadvertently led participants to respond favorably towards the institution, thereby biasing the
results. This positionality manifests social desirability bias, where respondents may alter their
responses to appear more favorable (Krumpal, 2011).
Questions were designed to have positive and negative influences to mitigate this
potential bias, with the positive ones coded in reverse. The question design strove to ensure a
balanced survey and reduce the likelihood of response bias (Grimm, 2010). Moreover, in my
introduction to the participants, I stressed my position as a student at the University of Southern
California over my role as a healthcare leader.
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Data Sources
The primary data source in this study was a quantitative survey designed specifically for
this research. The nature of quantitative research involves the gathering and scrutinizing of
numerical data. This approach provides a broad scope, allowing researchers to accumulate data
from a sizable sample, thus enhancing the potential for generalizing the findings to the broader
population under study (Johnson & Christensen, 2019). The quantitative technique was selected
for this dissertation because of the exact and measurable character of the study goals. Five openended questions allowed respondents to express, in their own words, how Hawaii’s cultural
traditions, beliefs, and values affected their decision-making. The detailed description of the
survey, its participants, instrumentation, data collection procedures, and analysis, along with
justifications for these choices, is presented in the following subsections.
Survey
The survey consisted of seven sections and included a total of 46 questions. The survey
was designed to capture a comprehensive understanding of the various elements that nurses
grapple with, helping to evaluate their influence on the decision to remain in acute care or
explore other professional opportunities.
Participants
The dissertation survey participants were registered nurses who worked bedside in acute
care settings in Hawaii from March 2020 to March 2022. The target participants were healthcare
professionals who, amidst the unprecedented global crisis, delivered direct patient care within the
high-pressure environment of hospital settings. The geographical constraint on the study’s
intended scope restricted the sample to nurses who practiced in Hawaii throughout the
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designated period. This geographical specificity provided an opportunity to probe into the unique
experiences and challenges nurses working on an island face during a global health emergency.
The recruitment strategy to garner the participation of registered nurses operating in acute
care settings in Hawaii during the specified timeframe leveraged the extensive network of the
Hawaii chapter of the American Nurses Association. The Association was instrumental in
disseminating the research survey via its newsletter. It is critical to underscore that the
application of exclusionary criteria was deployed to ensure respondents’ eligibility and the
study’s overall validity. Prospective participants were required to meet the criteria of having
delivered bedside care as registered nurses in acute care environments in Hawaii from March
2020 to March 2022. The employment of these stringent recruitment measures sought to
consolidate the research focus on those healthcare professionals who upheld their duties in highstress hospital environments amidst the global health crisis. As an incentive, 25 respondents who
satisfied the selection criteria and completed the survey were entered into a random drawing and
awarded a Starbucks gift card worth USD 10.00, financed by the researcher. This strategy aligns
with the methodology of maintaining the regional specificity of the study, which aimed to
explore and understand the unique challenges that bedside nurses in Hawaii confronted during
this critical period.
Instrumentation
The survey was a 7-section, 46-item instrument comprised of open and closed questions
(Appendix A). The closed questions were either “yes/no” inclusion criteria or Likert-style
questions. Open-ended questions allowed the participant to identify the units they worked in
between March 2020 and March 2022 for inclusion criteria or expound on Likert-style questions
in Sections 3–6. Five open-ended questions in Section 7 allow the participant an opportunity to
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describe how Hawaii’s culture affected them from March 2020 to March 2022. The results of the
open-ended questions, redacted for demographic and institutional identifiers, are in Appendix B.
The inclusionary section related to the research questions in ensuring the participants’
experiences occurred while working at the bedside in an acute care facility in Hawaii. Sections
3–7 presented questions about burnout and well-being, family and social environments,
workplace support and challenges, and Hawaii’s beliefs, values, and laws. By applying
Bronfenbrenner’s (1979) EST, this survey explored how these key concepts contributed to the
nurses’ desire to remain at the bedside in the acute care setting or move away from direct patient
care. Specifically, Bronfenbrenner’s microsystem, exosystem, and macrosystem constructed a
framework from which the specific experiences of the nurse affected their positionality in and
attitude toward nursing.
Section two was a voluntary demographics section. This section gathered information on
participants’ license length and location, employment status during the survey period, and
residency status (whether they are a resident of Hawaii). Participation in this demographics
section was optional, and all responses were treated confidentially.
Data Collection Procedures
This study employed a primary quantitative survey design, and the data collection
process was managed using electronic procedures. Data collection was accomplished by
distributing a survey to registered nurses in Hawaii. This survey was administered using
Qualtrics, a popular platform known for its efficiency and reliability in gathering and managing
survey responses (Sax et al., 2003). A unique feature of Qualtrics is its ability to handle multiple
respondents concurrently, allowing a reach to many nurses within a short period and providing
an easy, user-friendly interface for survey respondents.
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The survey distribution occurred electronically via email and through the HI American
Nurses Association newsletter. The survey was estimated to take between 15 to 30 minutes to
complete. This time estimation was informed by the scope of the survey questions, ensuring that
respondents could provide thorough answers without feeling overly burdened (Dillman et al.,
2014). To ensure the survey’s integrity, each participant could only take the survey once from
any IP address to prevent multiple responses from the same individual.
Data Analysis
This study implemented quantitative data analysis methods using Qualtrics software,
given that the data collected was numerical (Field, 2018). Open-ended qualitative answers were
coded numerically as positive, neutral, and negative. The analysis procedure was conducted in
several stages. The combination of the following analysis methods provided a holistic
understanding of the data gathered from the survey, offering insights into the factors influencing
nurses’ decisions to reduce working hours, remain in or leave their bedside roles in acute care
settings, or leave the field.
Descriptive statistics
Descriptive statistics were first utilized to give an overview of the collected data. This
step included calculating the mean, median, standard deviation, and ranges for the different
variables under study, particularly the scores from the Likert-style survey questions (Field,
2018). It provided a summary of the central tendency and dispersion of the variables (Pallant,
2020), allowing for an initial understanding of the nurses’ responses.
Inferential Statistics
Inferential statistics were performed following the descriptive statistics. The review
employed independent-sample t-tests to determine the statistical significance between the
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relationships between the variables (such as burnout and workplace support or family
environment) and the decision to remain in or leave the bedside role in acute care settings (Field,
2018). The chosen tests were based on the type and nature of the data collected from the Likert
scale and yes/no questions.
Thematic Analysis
In addition to the quantitative analysis, responses to the five open-ended questions about
Hawaii’s culture were analyzed using a thematic analysis approach. This method involved
identifying, analyzing, and reporting themes within the data (Braun & Clarke, 2006). While this
form of qualitative analysis may seem counterintuitive in a predominantly quantitative study, it
provided an opportunity to understand nurses’ subjective experiences and perspectives that may
not have been captured in the numerical data (Braun & Clarke, 2006).
Validity and Reliability
The survey instrument underwent revisions from its original form to enhance its construct
validity, particularly concerning the temporal scope it encompasses. Initially, the survey aimed to
gather information spanning 3 years; however, capturing comprehensive and accurate data across
such an extensive period can be challenging (Field, 2018). Therefore, the survey span was
refined to 2 years, focusing on the height of reported burnout, which significantly increased in
2021 (Ge et al., 2023) and worsened in 2022 (Martin et al., 2023). While a broader study could
consider data from 2020 through 2023, the survey instrument for this research was meticulously
crafted to capture data from the outset of COVID-19 until testing, treatment, and vaccinations
were readily available (The White House, 2022), thus enhancing its construct validity (Pallant,
2020).
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Specific participant selection criteria and standardized instructions were implemented to
augment the reliability of this study. This research only included registered nurses who provided
bedside care in an acute care facility in Hawaii within the defined time frame. Regarding
interrater reliability, as defined by Salkind (2013; 2018), high similarity across participants’
responses concerning their work environment was anticipated. This similarity extended to the
well-being section, fostering consistency and reliability in the data (Field, 2018). Incorporating
open- and closed-ended questions within the survey instrument enhanced its content validity,
capturing a more holistic picture of the nurses’ experiences (Braun & Clarke, 2006).
Ethics
The ethical protocols in this research were strictly adhered to throughout the process.
Participants were contacted via email or could scan a provided QR code, accompanied by a
comprehensive confidentiality preamble outlining their rights, the study’s intent, and their option
to participate voluntarily (Dillman et al., 2014). A unique link was provided to submit their
anonymous responses, ensuring their privacy and confidentiality (Braun & Clarke, 2006). This
approach aligns with the ethics of respect for persons, ensuring that potential participants know
what participation entails and that consent is informed and voluntary (Resnik, 2020).
The survey results will be shared on the University of California website and made
accessible to the public, adhering to the principle of transparency and promoting the value of
available research (Resnik, 2020). All data published is aggregated, further maintaining
participant anonymity and upholding privacy standards (Field, 2018). Stringent data protection
measures were applied to prevent unauthorized access to individual responses, ensuring
compliance with privacy regulations and institutional guidelines.
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Stakeholders impacted by this study include Hawaii State registered nurses, Hawaii
hospitals, hospital leadership, and the broader population of the State of Hawaii. Each
stakeholder group stands to gain unique insights from the study’s findings. Hawaii RNs stand to
benefit if the publication of the results drives changes in their work environment, making it more
appealing. Hawaii hospitals may utilize these results to enhance their nursing recruitment and
retention efforts.
Hospital leadership and systems may encounter financial and operational challenges if
the survey results necessitate a systemic change to mitigate workforce reduction and attract new
talent. However, these potential burdens must be weighed against the overarching objective of
improved healthcare outcomes for Hawaii’s people. If changes to nursing workspace, hours,
conditions, salaries, or other factors are identified and implemented based on the study’s
recommendations, the outcome may lead to decreased nursing attrition and increased healthcare
access and resources for Hawaii’s population. The principle of beneficence, aiming for a positive
impact on society, underpins these potential actions and outcomes (Resnik, 2020).
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Chapter Four: Findings and Results
The primary objective of this research study was to determine the degree, if any, to which
the nurses’ home, work, social, and cultural interactions affected their consideration to remain at
or leave acute care bedside nursing in Hawaii during the COVID-19 pandemic. This chapter
thoroughly analyzes and explains the data collected by the quantitative survey instrument. This
chapter is a comprehensive examination of the methods used to gather data, the techniques
employed to analyze the data, some demographics of the participants involved in the study, and a
presentation of the research findings, all of which are strongly related to the main research
questions.
The survey’s central inquiry focused on Instrument Question 3, which inquired whether
the participant contemplated departing from direct patient care in the acute care setting from
March 2020 to March 2022. The study examined the individuals’ self-perception using
Questions 12 to 20, which assessed their general well-being from March 2020 to March 2022.
The microsystem was explored in two sections spanning Questions 21–30. Specifically, the
participant was asked questions that addressed interactions and support with family and social
circles. Questions 31–35 focused on the assistance and policies of the participants’ hospital to
examine relevant components of the exosystem. The instrument polled for data around the
macrosystem in Section 7 through Likert-style Questions 36–41 and open-ended Questions 42–
46. The former was around restrictions enforced by the state of Hawaii during COVID-19, like
masking requirements, testing requirements, and social distancing. The open-ended questions
asked about specific cultural aspects of Hawaii, aloha, mālama, kuleana, ho’oponopono, and
lōkahi to determine if these cultural components weighed on the consideration of staying at or
leaving acute care bedside work. The instrument asked the participant for some demographic
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information, all optional, to determine if longevity in geographic location or work influenced the
nurses’ decision-making process around bedside care.
Survey data was analyzed by utilizing the Qualtrics platform. This system can describe
aggregated answers to survey questions and provide relational statistical significance between
variables. The qualitative data in the last five questions was coded as positive, neutral, and
negative as it pertained to the question. It was evaluated for statistical significance to whether the
participant thought about leaving direct patient care in the acute care setting between March
2020 and March 2022.
Participants
The sample population for the research study was registered nurses who worked at the
bedside in an acute care hospital in the State of Hawaii between March 2020 and March 2022.
The State of Hawaii has 2950 licensed beds in acute care hospitals, including critical access
hospitals (State of Hawaii, 2022). Not all licensed beds are 24-hour, for example, perioperative
and observation beds, and not all licensed beds are staffed 100% of the time. Extrapolating from
known data of one hospital with a licensed bed count to FTE ratio of 1:1.91, the estimated N for
this study was 5634.5 registered nurses in the State of Hawaii when the study was conducted. A
survey conducted by the Hawai’i State Center for Nursing (2023) received 14,545 registered
nurse respondents, of which 6,975 identified they worked in an acute care hospital. Not all
registered nurses in an acute care hospital provide bedside care, supporting the estimated N of
5634.5.
The sample population was calculated using an online Raosoft sample size calculator,
producing an ideal sample size of 80 participants with an 8% margin of error, 85% confidence
level, and a response distribution of 50%. A sample size of 83 was produced using a Qualtrics
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online sample size calculator with a confidence level of 90% and a margin of error of 9%.
Seventy-five participants started the survey and of those, 70 completed it. Twenty-nine
participants accessed the survey by the provided QR code on the flyer, while 46 typed the
hyperlink into a browser. No identifiable information was requested from the participants, but
demographic information relating to their licensure, time in service, and work departments were
asked. This data was voluntary, and 70 of the 70 participants who completed the survey provided
this information.
Participation in the survey was incentivized. After completing the survey, participants
received a prompt to enter a randomized raffle for one of 25 Starbucks cards for USD 10.00
each. The raffle was not associated with their survey answers and was held at the end of the
survey period. Raffle entries were randomized via random.org, and e-cards were distributed to
the first 25 on the list.
Table 2 outlines participants’ self-reported demographic data and information about the
participants’ longevity in nursing and work location during the pandemic. Data is displayed for
those who completed the survey (N = 70). The five individuals who started but did not finish the
survey are not included in the summary and results.
A lens this study wanted to look through was the number of years participants were
licensed as a nurse, where they were licensed, and their employment history. This frame intended
to identify whether longevity or employment consistency affected the participants’ opinions
about bedside work. All respondents (n = 70) identified that they are currently employed as
nurses, as displayed in Table 2. Most respondents (94.3%) reported they are employed at the
same organization at the time of the survey as they were during the pandemic.
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A review of respondents’ primary work location in acute care during the pandemic is
provided in Table 3. Acute care bedside departments were identified as medical/surgical and
telemetry floors, step-down units, clinical decision units, and similar spaces where patients are
admitted for general medicine. Intensive care units for both adult and neonates were provided
their own category, as the work is higher acuity and requires different resources. The same
applies to emergency/trauma, perioperative, and maternal/child services. As the stressors differed
for each work location, the survey intended to investigate if these locations contributed to the
nurses’ consideration of bedside work in a meaningful way. Notably, the population size for each
of these categories is aligned with the broader employment location distribution in the State of
Hawaii (Hawai’i State Center for Nursing, 2023), providing greater survey reliability.
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Table 2
Participant Self-Reported Demographics (N = 70)
Participant demographics n Percent
Were you born in Hawaii?
Yes 33 47.1
No 37 52.9
Total years claimed Hawaii as primary residence
1–5 years 7 10
6–10 years 7 10
11–15 years 6 8.6
16–20 years 3 4.3
> 20 years 47 67.1
Total years licensed as an RN in any state
1–5 years 14 20
6–10 years 12 17.1
11–15 years 17 24.3
16–20 years 7 10
> 20 years 14 20
Total years licensed as an RN in Hawaii
1–5 years 18 25.7
6–10 years 16 22.9
11–15 years 16 22.9
16–20 years 10 14.3
> 20 years 10 14.3
Prefer not to answer 6 8.6
Currently employed as an RN
Yes 70 100
No 0 0
Retired 0 0
Total years at current employer
1–5 years 21 30
6–10 years 18 25.7
11–15 years 14 20
16–20 years 8 11.4
> 20 years 9 12.9
Employed at the same organization as during the pandemic?
Yes 66 94.3
No 4 5.7
Note. Some of the data was not mandatory for the survey to be completed. Respondents could
choose “prefer not to answer” in lieu of provided list choices.
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Table 3
Participant Self-Reported Work Location as a Registered Nurse (N = 70)
Work location (at the time of survey) n Percent
Acute care (medsurg, tele, SDU, clinical decision unit, etc.) 45 64.3
Emergency/trauma services 14 20.0
Critical care (Any except NICU) 11 15.7
Neonatal intensive care unit (NICU) 7 10
Perioperative services (OR, same-day surgery, PACU, etc.) 6 8.6
Maternal child (L&D, antepartum, mother-baby, etc.) 5 7.1
Pediatrics 4 5.7
To the heart of the study is the inquiry around whether the nurse considered leaving acute
care bedside care between March 2020 and March 2022. Table 4 provides data that 60% (n = 42)
of nurses considered leaving bedside care during the pandemic, while the remaining 40% (n =
28) did not. Data is provided in Table 5, highlighting how individuals acted on their
consideration of leaving direct bedside care in the acute care setting. Of the 60% that considered
leaving bedside care, 69% (n = 29) continued to provide direct patient care in the acute care
setting. Fourteen point three percent (n = 6) continued to provide direct patient care outside of
acute care, such as in a clinic, outpatient setting, school, et cetera, while 16.7% (n = 7) left direct
patient care and entered administrative roles. All respondents (N = 70) reported they remained
employed as a nurse; as such, none reported they left healthcare altogether.
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Table 4
Participant Self-Reported Consideration to Work Direct Bedside, Acute Care Between March
2020 and March 2022 (N = 70)
Consideration to leave bedside care n Percent
Considered leaving bedside care 42 60
Did not consider leaving bedside care 28 40
Table 5
Participant Self-Reported Outcome After Consideration to Leave Direct Bedside Care (N = 42)
Outcome after consideration n Percent
Continued to provide direct patient care in acute care setting 29 69.0
Left acute care, but provided indirect patient care (administration,
quality, education, etc.)
7 16.7
Left acute care, but provided direct patient care in a different
setting (clinic, outpatient, school, etc.)
6 14.3
Note. Respondents include only those who considered leaving bedside care.
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Research Question 1: Nurses’ Environment on Acute Care Bedside Work
This research question and its corresponding items on the survey instrument were
intended to explore the self, and Bronfenbrenner’s (1979) microsystem and exosystem.
Specifically, the intent is to look at how the overall well-being of the participant factored into
their consideration of their work at the acute care bedside. Survey items were created to inquire
about the participants’ interaction and support with family, social circles, and work. Each
question in the instrument has been evaluated for its specific relationship to Instrument Question
3 to determine the statistical significance between itself and whether the participant considered
leaving the acute care bedside during the pandemic. All survey items addressing this research
question are Likert-style items with no open-ended questions.
Each subsection will provide the raw data for its survey items, providing the overall N
and response (n) for each answer option per item. Available answers for each item were “never,”
“sometimes,” “about half the time,” “most of the time,” “always,” and “pefer not to answer.”
Data is also provided as a percentage of the total (N = 70) for each answer option. The
discussion after the results from each section will focus on questions that were calculated as
statistically significant for “I considered leaving direct patient care” and “I did not consider
leaving direct patient care.” One hundred percent of respondents (N = 70) selected a measured
response or chose “prefer not to answer.” Those who did not answer were excluded from the data
set. Each category has a table that provides the total count, mean, and median as distributed by
the respondents’ corresponding answer to survey item three: “I considered leaving direct patient
care” and “I did not consider leaving direct patient care.”
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Overall Well-Being
The first data collected after demographic information pertains to the participants’ overall
well-being between March 2020 and March 2022. This set of instrument items asks the
participant about how they felt generally during work hours, off work hours, and work-life
balance and stress in Questions 12–20. This data provides a grounded understanding of how the
participant felt and is centered at the core (self or individual) of Bronfenbrenner’s (1979) EST.
Table 6 provides all nine section items’ (n) and percentage results. Instrument items have been
labeled as “W#” as coded during data analysis.
Most respondents reported feeling physically drained after a workday as noted in Table 6,
with 31.4% indicating this feeling most of the time and 47.1% always experiencing it. Mental
exhaustion was also prevalent, with 24.3% feeling mentally exhausted most of the time and
38.6% always feeling this way. Difficulty disconnecting from work-related thoughts during off
hours was another notable issue, with 34.3% experiencing this most of the time and 18.6%
always having this difficulty. These findings suggest a substantial burden of physical and mental
strain among RNs, which may contribute to their overall well-being.
Statistically significant data for considering leaving acute care bedside work secondary to
overall well-being is provided in Table 7 in questions W3, W5, and W9. Difficulty disconnecting
from work-related thoughts had a p-value of 0.00465 and an effect size (Cohen’s d) of 0.739,
indicating this factor had a moderate to large effect on the consideration of leading the bedside.
Similarly, trouble sleeping due to work-related stress (p = 0.00831, d = 0.674) and mental
exhaustion (p = 0.00218, d = 0.829) showed a statistically significant correlation to a
consideration around leaving the bedside. These findings underscore the significant impact of
job-related stressors on RNs contemplating leaving direct patient care.
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Table 8 provides statistically significant data for factors around the participants’ overall
well-being and not considering leaving the bedside. Questions W6, W7, and W8 highlight the
factors that made those not considering leaving direct patient care fare better. Mental health
support for job demands had a p-value of 0.00526 and an effect size (Cohen’s d) of 0.716,
indicating a significant difference. Participants who found their work meaningful and fulfilling
(p = 0.00228, d = 0.754) and those who maintained a work-life balance (p = 0.0135, d = 0.637)
were notable factors in those not considering leaving acute care bedside work.
Overall well-being analysis revealed factors influencing participants’ decision to leave
direct patient care. Job-related physical and mental pressures significantly affected participants’
well-being and their decision to leave or stay in direct patient care. Higher exhaustion and
difficulty managing work-related stress were associated with higher consideration of leaving,
while participants who did not consider leaving reported better mental health resilience and a
better work-life balance.
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Table 6
Results From Research Question 1 of RN Overall Well-Being (N = 70)
Well-being factor Never Sometimes About half
the time
Most of the
time
Always
n % n % n % n % n %
(W1) I felt a sense of satisfaction from my workload. 10 14.7 23 33.8 13 19.1 20 29.4 2 2.9
(W2) I was physically drained after a workday. — — 7 10.0 8 11.4 22 31.4 33 47.1
(W3) I found it difficult to disconnect from work-related
thoughts during off hours.
1 1.4 22 31.4 10 14.3 24 34.3 13 18.6
(W4) I had the stamina to perform my work duties
efficiently.
2 2.9 10 14.3 17 24.3 32 45.7 9 12.9
(W5) I had trouble sleeping due to work-related stress. 7 10.0 28 40.0 8 11.4 14 20.0 13 18.6
(W6) My mental health was able to support the demands of
my job.
2 2.9 23 32.9 10 14.3 20 28.6 15 21.4
(W7) My work was meaningful and fulfilling. 2 2.9 20 28.6 8 11.4 26 37.1 14 20.0
(W8) I was able to maintain a work-life balance. 4 5.7 27 38.6 15 21.4 20 28.6 4 5.7
(W9) I felt mentally exhausted after a workday. 1 1.4 15 21.4 10 14.3 17 24.3 27 38.6
Note. The data was not mandatory to complete the survey. Respondents could choose “prefer not to answer” in lieu of Likert choices.
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Table 7
Statistical Significance of Consideration to Leave (Yes)—Overall Well-Being (N = 70)
Well-being factor T-Test
P-value Effect size
(Cohen’s d)
Difference
between
averages
Confidence of
interval
difference
(W3) I found it difficult to disconnect from work-related
thoughts during off hours.
0.00465 0.739 0.798 0.256 to 1.34
(W5) I had trouble sleeping due to work-related stress. 0.00831 0.674 0.845 0.226 to 1.46
(W9) I felt mentally exhausted after a workday. 0.00218 0.829 0.929 0.351 to 1.51
Note. Table includes statistically significant questions only for overall well-being and “I considered leaving direct patient care.”
Table 8
Statistical Significance of Consideration to Leave (No)—Overall Well-Being (N = 70)
Well-being factor T-Test
P-value Effect size
(Cohen’s d)
Difference
between
averages
Confidence of
interval
difference
(W6) My mental health was able to support the demands of
my job.
0.00526 0.716 –0.821 –1.39 to –0.254
(W7) My work was meaningful and fulfilling. 0.00228 0.754 –0.833 –1.36 to –0.309
(W8) I was able to maintain a work-life balance. 0.0135 0.637 –0.643 –1.15 to –0.138
Note. Table includes statistically significant questions only for overall well-being and “I did not consider leaving direct patient care.”
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Interaction and Support With Family
Bronfenbrenner’s (1979) microsystem evaluates the support and interactions of
individuals with their families. Table 9 provides Questions 21–25 of the instrument, labeled as
“F#,” as coded during analysis, which explored the impact of family interaction and support on
the participants’ consideration to leave acute care bedside care. This section’s responses were
evaluated in relation to the participants’ thoughts on leaving direct patient care. The results are
detailed in two primary tables, each addressing different aspects of the inquiry.
The frequency distribution of familial factors, such as whether the family understood the
demands of the participant’s job, the family expressed concern about the participant’s exposure
to COVID-19, and how the family support affected the participant’s job performance, is outlined
in Table 9. While no data point was statistically significant for a consideration to remain in direct
patient care, Table 10 presents two points of positive statistical significance of the familial
factors for those who considered leaving direct patient care. Family health and well-being
affecting job performance (F4) had a p-value of 0.00905, an effect size of 0.683, a difference in
averages of 0.811, and a confidence interval difference between 0.211 to 1.41. Strained family
relationships due to work demands (F5) had a p-value of 0.0287, an effect size of 0.575, a
difference in averages of 0.593, and a confidence interval difference between 0.0640 to 1.12.
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Table 9
Results From Research Question 1 of RN Interaction and Support With Family (N = 70)
Familial factor Never Sometimes About half
the time
Most of the
time
Always
n % n % n % n % n %
(F1) My family understood the demands of my job. 2 2.9 16 23.2 10 14.5 18 26.1 23 33.3
(F2) My family expressed concern about my exposure to
COVID-19 at work.
3 4.3 20 29.0 6 8.7 15 21.7 25 36.2
(F3) My family’s emotional support helped me cope with
work-related stress.
2 2.9 19 27.5 6 8.7 15 21.7 27 39.1
(F4) My family’s health and well-being affected my job
performance.
7 10.3 31 45.6 7 10.3 14 20.6 9 13.2
(F5) My family relationships were strained due to my work
demands.
11 15.9 35 50.7 7 10.1 14 20.3 2 2.9
Note. The data was not mandatory to complete the survey. Respondents could choose “prefer not to answer” in lieu of Likert choices.
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Table 10
Statistical Significance of Consideration to Leave (Yes)—Family (N = 70)
Familial factor T-Test
P-value Effect size
(Cohen’s d)
Difference
between
averages
Confidence of
interval
difference
(F4) My family’s health and well-being affected my job
performance.
0.00905 0.683 0.811 0.211 to 1.41
(F5) My family relationships were strained due to my work
demands.
0.0287 0.575 0.593 0.0640 to 1.12
Note. Table includes statistically significant questions only for family and “I considered leaving direct patient care.”
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Interaction and Support With Social Circles
Continuing in Bronfenbrenner’s (1979) microsystem, the instrument assigned Questions
26–30, labeled “S#,” as coded during analysis, to explore the interaction and support among
participants with their social circles (N = 70) during March 2020 and March 2022. While nursing
is a social occupation, this section probed into the participants’ social interactions outside work.
These social connections were subsequently evaluated in relation to the participants’
consideration of leaving or remaining in acute care bedside work.
Several social factors are detailed in Table 11, which provides information on the
frequency and nature of these interactions. Notably, 20.3% of participants reported never being
able to meet friends or social groups in person regularly, while 60.9% could do so sometimes,
11.6% about half the time, 5.8% most of the time, and only 1.4% always had this opportunity.
When asked about limiting social interactions to prevent the spread of COVID-19, no
participants reported “never” having to limit their interactions. Instead, 21.4% limited
interactions sometimes, 8.6% about half the time, 37.1% most of the time, and 32.9% always had
to limit social interactions.
In today’s age, and during COVID-19, the reliance on online platforms for social
interaction was prevalent (Hwang et al., 2020; Kenyon et al., 2023; Spassiani et al., 2022).
Participants in this study varied in their use of such platforms, with 7.1% of participants never
relying on online social sites, 40% sometimes relying on them, 11.4% about half the time, 31.4%
most of the time, and 10% always relying on online platforms. Despite the social nature of
nursing work, 47.1% sometimes felt socially isolated due to the nature of their work, and 22.9%
felt isolated most of the time. Only 11.4% of participants never felt socially isolated due to the
nature of their work, 10% felt isolated about half the time, and 8.6% always experienced social
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isolation. When assessing the role of social connections in coping with work-related stress, 4.3%
never found them helpful, 52.9% sometimes found them helpful, 15.7% about half the time,
21.4% most of the time, and 5.7% always relied on their social connections for stress relief.
These findings are statistically significant on two points, one significant of consideration
to leave and the other not. For those considering leaving direct patient care, Table 12 shows that
the feeling of social isolation due to the nature of work (S4) was statistically significant with a pvalue of 0.00587, an effect size (Cohen’s d) of 0.723, and a difference between averages of
0.810, within a confidence interval difference ranging from 0.244 to 1.38. On the other hand, for
participants not considering leaving, Table 13 displays the role of social connections in helping
cope with work-related stress (S5) was statistically significant with a p-value of 0.0143, an effect
size (Cohen’s d) of 0.669, and a difference between averages of –0.655, within a confidence
interval difference of –1.17 to –0.137.
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Table 11
Results From Research Question 1 of RN Interaction and Support With Social Circles (N = 70)
Social factor Never Sometimes About half
the time
Most of the
time
Always
n % n % n % n % n %
(S1) I was able to regularly meet with friends or social
groups in person.
14 20.3 42 60.9 8 11.6 4 5.8 1 1.4
(S2) I had to limit my social interactions to prevent
spreading COVID-19.
— — 15 21.4 6 8.6 26 37.1 23 32.9
(S3) I relied on online platforms to interact with my social
circles.
5 7.1 28 40.0 8 11.4 22 31.4 7 10.0
(S4) I felt socially isolated due to the nature of my work. 8 11.4 33 47.1 7 10.0 16 22.9 6 8.6
(S5) My social connections helped me cope with workrelated stress.
3 4.3 37 52.9 11 15.7 15 21.4 4 5.7
Note. The data was not mandatory to complete the survey. Respondents could choose “prefer not to answer” in lieu of Likert choices.
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Table 12
Statistical Significance of Consideration to Leave (Yes)—Social (N = 70)
Social factor T-Test
P-value Effect size
(Cohen’s d)
Difference
between
averages
Confidence of
interval
difference
(S4) I felt socially isolated due to the nature of my work. 0.00587 0.723 0.810 0.244 to 1.38
Note. Table includes statistically significant questions only for social and “I considered leaving direct patient care.”
Table 13
Statistical Significance of Consideration to Leave (No)—Social (N = 70)
Social factor T-Test
P-value Effect size
(Cohen’s d)
Difference
between
averages
Confidence of
interval
difference
(S5) My social connections helped me cope with workrelated stress.
0.0143 0.669 –0.655 –1.17 to –0.137
Note. Table includes statistically significant questions only for social and “I did not consider leaving direct patient care.”
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Interaction and Support at Work
Leadership in healthcare during COVID-19 had a strong correlation to the frontline
nurses’ overall well-being and desire to remain at the bedside (ANA Nursing Resources Hub,
2023; Aquilia et al., 2020). Questions 31–35, labeled “J#” as coded during analysis, spanned the
microsystem and exosystem in Bronfenbrenner’s (1979) EST. The microsystem is addressed in
questions that pertain to the participant’s direct work relationship and leadership. Hospitals were
heavily influenced by the local government (Fontenot et al., 2021) and Centers for Disease
Control and Prevention (2021) during the COVID-19 pandemic, which, along with supply
shortages of personal protective equipment (PPE) (Cohen & Rodgers, 2020; Ranney et al.,
2020), were out the hospital’s direct control and affected the participant in the exosystem.
Table 14 provides a frequency distribution dataset for the questions in this section. A
moderate proportion of participants felt supported by their co-workers (J1), with 35.7% feeling
supported most of the time and 27.1% always feeling supported. Participants felt managerial
support (J2) less, with a notable 18.8% never feeling supported and 33.3% only feeling
supported sometimes. A mere 14.5% always felt supported by their direct manager. Adequate
PPE (J3) availability was reported with relatively balanced results, many participants (34.3%)
feeling the company did the best they could to provide PPE most of the time. 25.7% of
participants felt they sometimes lacked adequate PPE, which suggests that the intermittent
supply issues could have contributed to job dissatisfaction. Nurse workload directly correlates to
satisfaction and burnout (Chen et al., 2019; Ebrahimi et al., 2021). Most participants in this study
reported feeling overwhelmed by the number of patients they were responsible for (J4), with
50% of participants sometimes feeling overwhelmed and 21.4% always feeling overwhelmed.
The perception of whether nurses’ opinions were heard and respected by hospital leadership (J5)
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was predominantly negative, with 47.8% feeling this was only sometimes the case and 25.4%
never feeling heard. This lack of perceived respect and acknowledgment from leadership could
be a significant factor driving nurses to consider leaving their roles.
An analysis for statistical significance in Table 15 provides a lens that feeling supported
by co-workers (p = 0.0148, effect size = 0.610), managers (p = 0.0472, effect size = 0.509), and
the availability of PPE (p = 0.0167, effect size = 0.580) were all significant factors associated
with the consideration not to leave. These findings suggest that peer and manager support,
ensuring consistent PPE provision, and addressing workload issues are critical strategies to
improve nurse retention.
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Table 14
Results From Research Question 1 of RN Interaction and Support at Work (N = 70)
Work (job) factor Never Sometimes About half
the time
Most of the
time
Always
n % n % n % n % n %
(J1) I felt supported on my unit by my co-workers (peers). 1 1.4 17 24.3 8 11.4 25 35.7 19 27.1
(J2) I felt supported on my unit by my manager. 13 18.8 23 33.3 9 13.0 14 20.3 10 14.5
(J3) The company I worked for did the best they could to
provide adequate PPE.
4 5.7 18 25.7 13 18.6 24 34.3 11 15.7
(J4) I was overwhelmed by the number of patients I was
responsible for.
3 4.3 35 50.0 10 14.3 7 10.0 15 21.4
(J5) My opinions were heard and respected by hospital
leadership.
17 25.4 32 47.8 4 6.0 12 17.9 2 3.0
Note. The data was not mandatory to complete the survey. Respondents could choose “prefer not to answer” in lieu of Likert choices.
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Table 15
Statistical Significance of Consideration to Leave (No)—Work (N = 70)
Work (job) factor T-Test
P-value Effect size
(Cohen’s d)
Difference
between
averages
Confidence of
interval
difference
(J1) I felt supported on my unit by my co-workers (peers). 0.0148 0.610 –0.679 –1.22 to –0.137
(J2) I felt supported on my unit by my manager. 0.0472 0.509 –0.666 –1.32 to
–0.00851
(J3) The company I worked for did the best they could to
provide adequate PPE.
0.0167 0.580 –0.655 –1.19 to –0.122
Note. Table includes statistically significant questions only for work and “I did not consider leaving direct patient care.”
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Research Question 2: Hawaii’s Culture on Nurses’ Acute Care Bedside Work
The study’s second research question, “How did Hawaii’s culture impact Hawaii’s
registered nurses’ decision to work at the bedside in the acute care setting during COVID-19?”
provided an opportunity to inquire about several significant components of the culture. In
Bronfenbrenner’s (1979) EST, the exosystem encompasses laws and regulations the individual
must adhere to established by local governments. Through this lens, the study inquires about the
participant’s perception of Hawaii’s laws and regulations created during COVID-19. The
macrosystem provides a broader lens of cultural beliefs, norms, and attitudes, and it is here that
the study elicits the participant’s feelings on Hawaiian concepts like aloha, mālama, kuleana,
ho’oponopono, and lōkahi. As in previous sections, the data is scrutinized against its statistical
significance regarding whether it affected the participants’ consideration to remain at the bedside
in the acute care setting.
Hawaii’s Regulations and Laws During COVID-19
While Hawaii followed the CDC and World Health Organization’s guidance on masking
(Gostin et al., 2020), stay-at-home requirements (Fowler et al., 2021), and social distancing
(Kamga & Eickemeyer, 2021), it was unique in its response to COVID-19 pandemic by way of
geography. Hawaii was able to significantly reduce who could circulate in the general population
by all but halting tourism and requiring strict regulations on those who did come to the island
chain (Guo et al., 2021). Honolulu, Maui, and Hawai’i counties also implemented vaccine
passport mandates for select industries when they began to open, like bars, restaurants, and gyms
(Juarez et al., 2022). This section of the study was designed to investigate whether Hawaii’s
beliefs, values, and laws influenced registered nurses (RNs) in their decision to leave acute care
bedside positions. This was analyzed through two lenses. The first assessed the degree of
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comfort participants felt in response to various Hawaii-specific factors, while the second
evaluated whether these factors led RNs to consider leaving direct patient care.
Questions 36–41, labeled “H#” as coded during analysis, queried whether Hawaii’s
beliefs, values, and laws influenced participants’ decision to leave acute care bedside positions.
The respondents were asked to state whether the conditions listed “provided no comfort,”
“provided some comfort,” or “provided great comfort.” An option to select “prefer not to
answer” was available, and this data is included in Table 16’s frequency distribution. Notably,
for all six inquiries into the regulations imposed and attitudes of Hawaii’s people, most
participants indicated they felt either some comfort or great comfort with the steps the State had
taken for their protection.
The most impactful measure was the reduction in tourism (H3), with 52.9% of
respondents stating they felt great comfort from the steps to reduce outside visitors. Most
participants reported some comfort (52.9%) or great comfort (31.4%) when polled about
Hawaii’s masking requirements (H1) and the community’s attitude toward healthcare
professionals (H6) followed closely with 47.1% and 32.9%. Social distancing (H5) had an equal
number of participants who indicated they felt some or great comfort from the measure at 38.6%
respectively. The categories that provided no comfort to at least 20% of the participants were
Hawaii’s stay-at-home requirements (H2) at 20%, and COVID-19 testing requirements (H4) and
social distancing (H5) at 21.4%.
The findings did not provide statistical significance to support an assertion that the
beliefs, values, and laws queried in this survey influenced the participants’ consideration of acute
care bedside work. Rather, they indicate that Hawaii’s beliefs, values, and laws had a nuanced
impact on the participants. While these factors provided varying levels of comfort, they did not
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statistically influence the consideration of leaving or staying at the bedside. The consistency in
the distribution of comfort levels and measures of central tendency across both groups highlights
the complexity of these influences on participant decisions.
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Table 16
Results From Research Question 2 of Hawaii’s Regulations and Laws and RN Overall Well-Being (N = 70)
Hawaii factor Provided no
comfort
Provided some
comfort
Provided great
comfort
Prefer not to
answer
n % n % n % n %
(H1) Hawaii’s masking requirements 10 14.3 37 52.9 22 31.4 1 1.4
(H2) Hawaii’s stay-at-home requirements 14 20.0 31 44.3 24 34.3 1 1.4
(H3) Hawaii’s reduction in tourism 10 14.3 20 28.6 37 52.9 3 4.3
(H4) Hawaii’s COVID-19 testing requirements 15 21.4 31 44.3 24 34.3 — —
(H5) Hawaii’s laws about social distancing in public
spaces
15 21.4 27 38.6 27 38.6 1 1.4
(H6) Hawaii’s community attitudes toward healthcare
professionals
13 18.6 33 47.1 23 32.9 1 1.4
Note. The data was not mandatory to complete the survey. Respondents could choose “prefer not to answer” in lieu of Likert choices.
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Hawaiian Beliefs, Values, and Traditions
The culture of Hawaii is known to be a strong driver in how its people approach their
daily lives and work. Questions 42–46, labeled “C#” as coded during analysis, looked at five
specific tenets known to be at the core of the culture. Responses provided by participants were
evaluated based on the positive, neutral, or negative sentiment regarding the influence of aloha,
kuleana, mālama, ho’oponopono, and lōkahi and their desire to remain at or leave the bedside
between March 2020 and March 2022. Each cultural factor’s effect was measured concerning the
participants’ desire to either stay or leave bedside care, with responses categorized as 1
(negative), 2 (neutral/no effect), or 3 (positive). Answers such as “no effect,” “it didn’t,” or “not
at all” were evaluated as neutral sentiments. Answers that did not provide a positive, neutral, or
negative tenor, such as answering with a “yes” or “no,” were excluded from the data evaluation,
as the researcher cannot assume the intent of the participant. Participation in this survey question
was voluntary, resulting in varying sample sizes for each cultural factor. Appendix B provides
the responses as coded during analysis for each value and belief noted above.
Each cultural factor is analyzed in Table 17 based on its mean, median, confidence
interval (CI) of the average, and standard deviation. All five cultural factors had a mean of 2.5 to
2.8, indicating a generally positive influence of the factor on their consideration of bedside care.
The sample sizes range from n = 22 on the low end with ho’oponopono to n = 40 with kuleana.
These findings demonstrate the participants’ perceptions and experiences. While no
factor was statistically significant in its relationship to the participants’ consideration to leave or
remain at the bedside, an evaluation of the qualitative content of the participants’ sentiments and
coding mechanisms provided a richer understanding of how the values, beliefs, and traditions
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provided some support positively for nurses to remain at the bedside. This evaluation provided a
critical lens into the nuances of Hawaiian culture as it relates to the participants’ work.
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Table 17
Results for Research Question 2 of Hawaii’s Beliefs, Values, and Traditions (N = 70)
Cultural factor Sample size
(n =)
Mean Median CI of
average
Standard
deviation
(C1) Aloha (love) 39 2.6 3 2.40 to 2.83 0.7
(C2) Kuleana (responsibility for others, rules, and self) 40 2.6 3 2.39 to 2.81 0.7
(C3) Mālama (caring for others) 38 2.8 3 2.63 to 2.95 0.5
(C4) Ho’oponopono (making things right) 22 2.5 2.5 1.97 to 2.66 0.8
(C5) Lōkahi (unity, harmony) 32 2.6 3 2.35 to 2.83 0.7
Note. Each cultural factor was asked about in relation to its effect on the participants’ desire to remain or leave the bedside between
March 2020 and March 2022. Answers were coded as 1 (negative), 2 (neutral/no effect), or 3 (positive). This question was not
requisite to complete the survey and the sample size for each factor varies.
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Aloha
Question 42 (C1) on the instrument asked, “How did the Hawaiian value of aloha (love)
affect your desire to remain at that bedside during COVID?” and received 42 data point entries.
Some of these entries were screened out of the evaluation as the participant did not provide any
answer, wrote “N/A,” or did not address the question with answers like “The state of Hawaii
needs better planning, structure, and organization.” Positive sentiments were reported by 71.8%
(n = 27) of respondents, while only 10.3% (n = 4) were negative. Seventeen point nine percent
(n = 7) of respondents reported that aloha did not affect their consideration of bedside care.
The majority of respondents indicated that the value of aloha was motivating and had a
sustaining positive impact on their professional decisions around bedside care during COVID-19.
Several participants emphasized how aloha helped them continue providing care and
underscored their intrinsic motivation from this cultural value. One participant commented that
The spirit of Aloha helped sustain me through the pandemic as I strived to provide
loving, compassionate care to my patients, holding their hands, providing emotional
support, and taking the place of families and friends who were prohibited from visiting.
The quiet moments in nursing, one-on-one with patients, helped sustain me in working
bedside.
Many participants highlighted their commitment to patient care and dedication to their work,
increasing their desire to help their community during this time as a “duty to the people of the
islands.” Another highlighted that the respect for each other in their work unit, grounded in
aloha, was instrumental in their decision to remain in their role. They wrote that they “probably
stood longer working on my old unit which was a covid unit because I felt the Aloha for my coworkers rather than the job itself.”
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Seven participants were neutral about the concept of aloha, indicating that it did not
significantly influence their decision-making. One individual wrote that aloha did not influence
their decision; their core values as a nurse kept them going. It could be argued that love (and
other definitions of cultural values) are the core values of nursing. Nonetheless, this comment
was coded as neutral. The neutral stance highlights a diversity of personal and professional
priorities among participants.
Of the four participants who conveyed a negative sentiment regarding the influence of
aloha, the primary thread was around their perception of a reduction in aloha. One participant
highlighted how aloha from patients made them want to stay at the bedside but noted that those
from the island did not always show it, creating frustration. They wrote that they felt “stressed
and feeling unappreciated by certain patient populations, demanding [patients], etc [sic].” One
participant noted that aloha decreased because “more families are now rude to bedside nurses.”
Two of these participants expressed that the aloha they had for their job was not strong enough
for them to remain at bedside, with one being concerned about getting ill and the other declaring
they “wanted to leave bedside due to seeing family saying their last good byes thru video call.”
The overall data received from C1 reveals a predominantly positive impact of the
Hawaiian value of aloha on the participants’ decision to remain in acute care roles during the
COVID-19 pandemic. However, neutral and negative sentiments underscore the complex
interplay between cultural values and external factors in stressful times. This instrument item
highlighted the profound personal significance of aloha for many while acknowledging the
challenges presented during a crisis.
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Kuleana
Data collected from participants around the impact of the Hawaiian belief in kuleana
(responsibility for others, rules, and self) on their desire to remain or leave the bedside in acute
care between March 2020 and March 2022 provided a nuanced lens through which they
perceived that responsibility. Question 43 (C2) had 40 responses that were coded, with 70% (n =
28) being positive, 20% (n = 8) neutral, and 10% (n = 4) negative.
Several respondents reported a positive sentiment around kuleana regarding their
responsibility to patients and their loved ones. One participant wrote that it was their kuleana “to
ensure that the decades of medical training that I have received from mentors, colleagues, and
patients be utilized to continue to improve the healthcare for our state.” This Hawaiian value is
shown through a sense of community and a responsibility to each other. While some participants
clarified that this value helped them stay at the bedside, one wrote, “It helped me to see my
purpose.” Another respondent felt kuleana towards their co-workers, stating “I felt as a
healthcare provider that I wanted to support my peers and my patients so they could get optimal
care.” These responses reflect a positive outlook, emphasizing the role of kuleana and fostering a
sense of duty and protection towards co-workers and patients.
Some responses were neutral, indicating that cooling on a had no impact on their desire to
remain or leave at the bedside. Most of these responses were recorded as either “it did not,” “no
effect,” “or none at all.” The participant who pointed to their values as a nurse as the driver to
remain at the bedside instead of kuleana, stating “my core values as a nurse influenced my
decision” was identified in this answer, and the same correlation to nursing values can be made.
A participant who wrote that others who did not feel the level of kuleana as them created
a desire to leave the bedside, reflecting a sense of isolation and frustration. One participant spoke
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about this value as it pertains to COVID-19 vaccinations, stating “the patients that were against
covid vaccinations, then suffering with covid and taking care of them was very frustrating.” Of
note, one participant declared that their kuleana to themselves and their families made them
reconsider bedside work. While the sentiment is not directly negative, the participant wrote, “I
started to put myself and my families well being and being at bed side was not healthy.” These
responses underscore the significant strain on healthcare workers and how it can diminish the
influence of even deeply held beliefs.
These findings suggest that the belief in kuleana mostly positively impacted the
participants’ decisions regarding their roles in acute care bedside care during the pandemic. The
positive responses highlight how kuleana reinforced their commitment, provided focus, and
motivated them to continue their work despite the challenges. The presence of neutral and
negative experiences reflects the diverse and multifaceted nature of how individuals respond to
cultural values during a crisis. The neutral responses suggest that other factors for some guided
professional decisions. In contrast, the negative responses highlight the challenges of
maintaining cultural values under extreme stress and differing workplace dynamics.
Mālama
Mālama (caring for others) is a core Hawaiian value and one of the leading values of
nursing. Responses to question 44 (C3) on how mālama influenced participants’ considerations
of leaving or remaining at the bedside were overwhelmingly positive at 81.6% (n = 31). Only
2.6% (n = 1) of participants expressed a negative sentiment around mālama, which was attributed
to their perception that their employer did not care for the employees. Fifteen point eight percent
(n = 6) provided responses coded neutral and aligned with the neutral responses for aloha and
kuleana.
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Most participants’ responses were coded with a positive sentiment toward mālama and
highlighted how the value reinforced their commitment to nursing. Many expressed mālama was
the reason they entered nursing in the first place. “The response to this question goes along with
why most of us become nurses, we want to care for others. During Covid we put the needs of
others before that of our families.” These participants expressed that caring for others was
integral to their role, describing nursing as a fulfilling and rewarding experience. One participant
wrote, “there is a strong sense of Malama on my unit which helped me learn and stay at the
bedside.” Through tragedy, once participant was influenced to remain at bedside as they describe
how “seeing people in our community pass made it more important for me to stay in the acute
care setting.” For one participant, it was how they received mālama that prompted them to stay.
“The way some of the community, Malama’d our staff encouraged me especially when they
were generous and giving during their own troubled times.” Several responses were coded as
positive even though the participants denoted they left the bedside because they clarified that
their new work allowed them to show mālama in a different role.
Mālama significantly influenced participants’ roles and acute care bedside nursing
decisions. An overwhelming 81.6% expressed positive sentiments, reinforcing how mālama
impacted their commitment to nursing and underscored the fulfillment they derive from caring
for others. The negative responses were negligible and were attributed to perceived employer
shortcomings. For example, one respondent wrote, “I have no problem caring for others, but
when you are not taken cared [sic] of by your employer then you moral [sic] goes down.” The
impact of mālama highlights its essential role in Hawaii’s personal and professional realms and
emphasizes the connection between cultural values and professional dedication. These findings
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reinforce the importance of integrating core values into healthcare practices to foster supportive
and fulfilling work environments.
Ho’oponopono
The response rate for question 45 (C4) reviewing the Hawaiian value of ho’oponopono
(making things right) was the lowest of all cultural factor questions, garnering only 22 data point
entries. The sentiment around making things right during the COVID-19 pandemic is profoundly
layered and may contribute to reduced respondent entries and lower positive sentiment. 50% (n =
11) of the respondents had a positive sentiment around ho’oponopono, with 31.8% (n = 7) as
neutral and 18.2% (n = 4) as negative.
One participant with a positive sentiment around ho’oponopono saw it as an opportunity
to adjust how they approached the crisis, stating, “[I] just had to adjust how I make things right.”
Another participant wrote they had a positive experience around the value when they “discussed
with my manager what I wanted to be as a nurse and she helped make that happen.” Positive
sentiments were expressed by respondents who identified “a strong sense of Ho’oponopono on
my unit, and of doing the right thing all of the time, which can be a lot of work but gives a sense
of fulfillment.” Like mālama, some respondents viewed ho’oponopono as an internal need to
make things right, leading them to leave the bedside in acute care but continue their work as
nurses. One respondent remained in acute care but felt “like I needed to make it right for my
mental health by leaving a unit that was strictly Covid patients.”
Negative sentiments around ho’oponopono were expressed by one participant who
expressed frustration by not being involved in decisions that were being made. They wrote
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There was no process to be heard or talk through what was going on. No one involved us
bedside workers in any decisions that were being made. We were just told what to do. No
concern for our beliefs/concerns/opinions, etc [sic].
A similar response indicated that their hospital “had zero empathy for us bedside nurses and our
safety.” One participant wrote, “I strongly felt the organization did not make things right for their
nurses and staff, which influenced my decision to become part-time.” These responses show that
involving those involved in the work is seen as valuable and ensures that hospital administrators
show ho’oponopono and make things right.
The data regarding the Hawaiian value of ho’oponopono in the context of the COVID-19
pandemic revealed a complex response. Despite the lower response rate for question 45 (C4),
which may reflect nuances around making things right during such a challenging period, the
responses provided valuable insights. Positive responses emphasized how the value influenced
their approach to crisis management and dedication to delivering quality care. The negative
responses highlighted frustrations related to exclusion from decision-making processes and a
perceived lack of empathy from hospital administrators. These responses show the importance of
involving staff and decisions and embodying the principles of ho’oponopono to support and
retain healthcare workers. The findings emphasized the need for hospital administrators to
engage and support their staff genuinely.
Lōkahi
Lōkahi (unity, harmony) was the Hawaiian value explored in question 46 (C5) in this
instrument. Many respondents (68.8%, n = 22) were coded with positive sentiments around unity
and harmony. Only 9.4% (n = 3) were coded negative, and 21.9% (n = 7) as neutral. Neutral
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responses held the same content as previous sections and indicated the value was not used in the
participant’s consideration to remain at or leave the bedside in acute care.
Positive sentiments highlighted a recognition and appreciation of lōkahi in the healthcare
environment as evidenced by responses like, “community partnership helped me a great deal”
and “working as one helped us go thru [sic] it all together.” Individuals who expressed positive
experiences perceived a supportive and harmonious work environment. For example, one
individual wrote, “if my team was going into the trenches, I was going to be there with them.”
For one participant, their sense of harmony increased “once I moved to a non covid [sic] unit
because I could literally feel a sense of relief knowing that myself and family would be at a
Lower risk of contracting the illness.” Several respondents acknowledge leadership practices in
fostering lōkahi by stating that “unity and harmony is valued if you are under great leadership.”
This leadership, embedded in cultural practices, is essential to organizational culture. The
positive impact of lōkahi for these respondents suggests that when unity and harmony are
actively promoted and valued, they can contribute significantly to job satisfaction and retention.
The smaller percentage of participants whose responses were coded as negative related to
lōkahi were supported by descriptions of an absence of unity and harmony. One participant
enthusiastically wrote, “Zero lokahi at the hospital I worked at…!!!” This participant named the
hospital, which has been redacted. One participant wrote that they were conflicted because “there
wasn’t a great deal of lokahi amongst our leaders at the time.” The negative experience
highlighted critical gaps in leadership and staffing with one individual expressing, “I felt like
being short staffed caused a negatively strain as unit and affected harmnious [sic] work
environment.” These responses indicate that in environments where lōkahi is not upheld, adverse
effects on morale and retention can be seen.
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Evaluating the Hawaiian value of lōkahi provides a critical lens on how unity and
harmony can affect a healthcare provider’s consideration to remain at or leave acute care bedside
work. When leadership focuses on inclusivity, a platform is created to discuss the potential
benefits of integrating unity and harmony into workplace practices. These positive responses
suggest that fostering lōkahi can positively influence staff retention. The negative responses,
though fewer, emphasize the importance of ensuring cultural values are upheld to avoid
disconnection, dissatisfaction, and turnover.
Summary
Chapter Four provides a comprehensive data analysis of the results gathered from this
research study to answer the primary research questions, which focus on Hawaii’s registered
nurses’ environment and the culture of Hawaii as they pertain to the participants’ impact on their
decision to work at the bedside in the acute care setting between March 2020 and March 2022.
Through the 46-item instrument, participants expressed strong opinions and diverse perspectives
in response to the items. Bronfenbrenner’s (1979) EST provided a platform to highlight these
perspectives and beliefs in the microsystem, exosystem, and macrosystem.
Participant characteristics and demographics were gathered in the form of their work
department, longevity in the profession, and residence. Each participant self-reported their
consideration of leaving or remaining at the bedside. A follow-up component was asked about
the outcome for those considering leaving acute care bedside work.
Overall well-being weighed heavily on some participants, with those feeling well more
likely to stay at the bedside. Individuals considered leaving the bedside when they felt their
family’s health was at risk or their relationships with their families were stressed. Isolation from
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social circles was correlated with the consideration to leave. When participants felt supported at
work by their co-workers and managers, they were likelier to remain at the bedside.
Hawaii’s cultural impacts, including laws and regulations, do not produce a statistically
significant relationship for the participants’ consideration to leave or remain at the bedside. That
said, the nuances of the culture of Hawaii were at the forefront, positively impacting the
participants’ consideration of remaining at the bedside in the open-ended questions (42–46).
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Chapter Five: Discussion
This chapter discusses the study’s findings and recommendations for practice and future
research. The focus is on the factors influencing Hawaii’s registered nurses’ decisions to stay in
or leave bedside care during the COVID-19 pandemic. Guided by the research questions, this
analysis explores the interplay between environmental, cultural, and organizational elements that
shaped nurse burnout and retention. Bronfenbrenner’s (1979) EST is the foundation for
understanding these interactions, offering a comprehensive view of how personal, familial,
social, and cultural factors intersected during this challenging period.
The study’s first research question sought to understand how Hawaii’s unique
environment, including the specific conditions nurses faced in their personal and professional
lives, impacted their bedside care decisions. This inquiry extends beyond the individual to
consider the broader social circles and organizational dynamics that influence nurses’ well-being.
The study also explored the role of Hawaii’s cultural values in shaping nurses’ decisions. The
second research question centered on how cultural elements, such as the values of aloha,
mālama, kuleana, ho’oponopono, and lōkahi influenced nurses’ professional commitments.
These cultural aspects are deeply embedded in Hawaii’s societal fabric and significantly
reinforce, or challenge nurses’ resolve to remain in bedside care. The findings reveal how these
cultural supports helped sustain nurses during intense professional and personal strain when
aligned with a positive work environment.
Research Question 1
The findings of this section address the research question of how the environment of
Hawaii’s registered nurses impacted their decision to work at the bedside in the acute care setting
during COVID. This action analyzes environmental factors such as personal well-being, family
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and social circles, workplace dynamics, and broader social influences. The section applies
Bronfenbrenner’s (1979) EST and looks at how individual stressors within the microsystem,
ecosystem, and macrosystem shaped the nurses’ experiences and decisions around bedside care.
The findings align with existing literature on stress and burnout and offer a nuanced
understanding of how the unique social-cultural context of Hawaii affected these pressures
during the COVID-19 pandemic.
Overall Well-Being
The problem of practice of the study looks at increased stress and burnout among acute
care nurses in Hawaii during COVID-19, which led to high turnover and subsequent staffing
shortages. The findings of this study directly addressed the problem by providing evidence that
nurses’ decisions around remaining at the bedside were affected by specific stressors. Physical
and mental exhaustion, difficulty disconnecting from work-related feelings and thoughts, and
trouble sleeping were some factors borne out in the data from these stressors, which had a direct
correlation to considering leaving the bedside in the acute care space.
The study uncovered that the immediate environment of the nurses, including their
physical and mental health, played a significant role in their overall well-being. Nurses who
reported that they experience consistent physical and mental exhaustion, difficulty disconnecting
from work, and trouble sleeping due to work-related stress highlight the core components of
burnout as emotional exhaustion, lack of accomplishment, and cynicism (Kowalski et al., 2010;
Leiter & Maslach, 2009; Maslach & Jackson, 1981).
Nurses who found their work meaningful reported better overall well-being and were less
likely to consider leaving, which aligns with research emphasizing the importance of
organizational support in mitigating burnout (Laschinger et al., 2014; Leiter & Maslach, 2009).
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Effective leadership, adequate staffing, and access to mental health resources foster a supportive
work environment and reduce burnout rates (Cooper, 2000; Cox et al., 2018).
Sociocultural dimensions specific to Hawaii emphasize community and family. While
these cultural factors could sometimes provide resilience in the laws and regulations around
tourism and masking requirements, they also added to the stress due to the fear of infecting loved
ones. The literature highlights how societal factors, such as public perception and social support,
significantly impact healthcare workers’ mental health (Juraschek et al., 2011; Kim & Lee, 2021;
Laschinger et al., 2001).
Interaction and Support With Family
The findings highlight the influence of family interactions and support on Hawaii’s acute
care nurses’ well-being and professional decisions. The data suggests that familial understanding
and emotional support reduced their considerations of leaving bedside care. However, when
nurses were concerned about family health and strained relationships due to work demands, there
was an increase in the number of considerations for leaving.
The data revealed that when the nurse’s microsystem of home and family understood
their job demands and provided consistent emotional support, there was less inclination to leave
the bedside. McCubbin (2007) emphasized the importance of a supportive home environment in
mitigating job-related stress and burnout. The findings also reveal significant statistical
correlations between family health concerns and strained relationships with the likelihood of
nurses considering leaving direct patient care. These results align with previous studies (Henshall
et al., 2020) that identified family well-being as a critical factor in healthcare professionals’ job
satisfaction and retention.
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Interaction and Support With Social Circles
The data provided clarity around social isolation, showing that work and reliance on
online platforms significantly influenced the nurses’ well-being. The problem of practice around
burnout and the nursing shortage is directly tied to social circles, especially in Hawaii, where
family and friends are at the center. For example, social isolation was statistically significant for
those who considered leaving direct patient care, while social connection helped nurses cope
with work-related stress and did not consider leaving.
Nurses who responded to this survey provided input that their social circles, including
family and friends, served as a buffer against stress and contributed to stress, depending on the
relationships. The study findings reveal that a significant proportion of respondents experienced
social isolation despite the inherently social nature of their profession. The inability to regularly
meet with friends or social groups increased feelings of isolation, which aligns with literature
indicating that social support is a crucial factor in mitigating burnout (Dyrbye et al., 2019;
Shechter et al., 2020).
Respondents in this study indicated that societal norms around infection prevention led to
limited social interactions. This isolationism reflected a broader community role in shaping
individual behaviors and stress levels. Previous research indicates that community attitudes and
societal recognition of healthcare professionals can significantly impact job satisfaction and
healthcare provider retention (Kim & Lee, 2021). A necessary adaptation to the isolation was
increased reliance on online platforms for social interaction. Even so, it did not fully substitute
the benefits of in-person connections, highlighted in Bronfenbrenner’s (1979) exosystem
influence.
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The broader sociocultural context of Hawaii, identified as Bronfenbrenner’s (1979)
macrosystem, supported and challenged nurses. The cultural emphasis on family and community
provided a source of resilience, consistent with McElfish et al. (2019), who highlighted the
importance of communal support in Hawaiian culture. Conversely, heightened anxiety around
infection spread within close-knit communities and multigenerational homes added a layer of
stress, as documented by Brewer et al. (2023) and Davide et al. (2022).
Interactions and Support at Work
This study’s findings emphasize that support from co-workers and managers played a
critical role in the nurses’ decisions around direct patient care. Increased support by co-workers
and managers and having adequate personal protection equipment (PPE) were statistically
significant for those not considering leaving patient care. These findings support the assessment
that improving managerial support, ensuring consistent PPE, and addressing workload issues can
enhance nurse retention.
Bronfenbrenner’s (1979) microsystem provides a lens through which to examine direct
work relationships and immediate environmental factors. Consistent with Aiken et al. (2002) and
Brooks Carthon et al. (2019), this study found that supportive work relationships and adequate
resources are vital for job satisfaction and retention. The findings showed that a significant
proportion of nurses felt unsupported by their managers and overwhelmed by their workloads,
similar to the stress and burnout reported in other studies (Chen, Liang, et al., 2020; Chen, Sun,
et al., 2020; Lai et al., 2020), producing similar dissatisfaction.
Research Question 2
Hawaii’s regulations, laws, and culture impacted its nurses’ decisions around continuing
to work at the bedside during COVID-19. This section looks at findings from the study and
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focuses on Hawaii’s unique cultural and regulatory environment in the context of the nurses’
professional decisions. Bronfenbrenner’s (1979) EST examines these influences across various
levels, from individual experiences within the nurse’s immediate work and family environments
to broader societal contexts shaped by Hawaiian cultural values. Regulatory measures during the
pandemic comforted nurses, but the cultural elements, such as aloha and communal values, were
significant in shaping resilience and decision-making processes. The findings reveal that while
Hawaii’s regulations alone did not decisively influence nurses’ decisions to remain at the
bedside, the cultural context played a critical role in reinforcing or undermining professional
commitment.
Hawaii’s Regulations and Laws During COVID-19
The COVID-19 pandemic necessitated extraordinary measures globally, with Hawaii
implementing unique strategies due to its geographical isolation and reliance on tourism.
Hawaii’s regulatory response to the COVID-19 pandemic, characterized by stringent measures
such as tourism reduction, mask mandates, and vaccine passports, created a distinct environment
for acute care nurses. Hawaii’s cultural values and regulations provided different levels of
comfort to nurses during the pandemic.
The problem of practice identified the significant impact of the pandemic on nurse
burnout and turnover. While Hawaii’s regulations provided varying degrees of comfort, the
statistical analysis did not conclusively show that these measures influenced the decision to leave
bedside positions. However, the nuanced impact on comfort levels suggests that while regulatory
measures alone may not determine job retention, they contribute to a supportive environment
crucial for nurse resilience.
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Hawaiian Beliefs, Values, and Traditions
The COVID-19 pandemic exacerbated existing stressors within healthcare systems
globally and brought about previously undiscovered ones, significantly impacting the nursing
workforce. This study examined acute care nurses’ experiences in Hawaii, employing
Bronfenbrenner’s (1979) EST to understand how the nurses’ environment and culture of Hawaii
influenced the nurses’ attitudes around acute care bedside work during COVID-19. Hawaiian
cultural values, beliefs, and traditions, such as the aloha spirit, mālama, kuleana, ho’oponopono,
and lōkahi, were central to this examination, given their profound influence on the nurses’
resilience and responses during the pandemic.
Hawaiian cultural values influenced nurses’ professional decisions and overall wellbeing. Positive sentiments around aloha, kuleana, mālama, ho’oponopono, and lōkahi emphasize
the deep-rooted cultural motivations that sustained nurses during the pandemic. However, neutral
and negative responses indicate that the challenging work environment and lack of inclusivity in
decision-making can undermine these cultural supports. Ensuring that cultural values are upheld
and integrated into healthcare practices can enhance nurse job satisfaction and retention.
Bronfenbrenner’s (1979) EST, which explores individual, organizational, and societal
influences, aligns with the multifaceted nature of the findings. The microsystem, encompassing
immediate environments like family and workplace interactions, played a crucial role in the
nurses’ adherence to aloha. The exosystem, representing broader organizational contexts and
external environments, was reflected in the cultural practices within healthcare institutions. The
Hawaiian values of mālama and lōkahi were particularly noticeable in fostering a supportive and
harmonious work environment. Positive sentiments around these values indicated that when
healthcare settings actively promoted care and unity, they significantly contributed to a desire to
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remain at the bedside. However, negative experiences highlighted gaps in leadership and
organizational support, emphasizing the need for institutional practices that align with these
cultural values to mitigate burnout.
At the macrosystem level, encompassing societal and cultural contexts, the aloha spirit
and principles of kuleana and ho’oponopono were central. These values influenced individual
behaviors and framed broader societal expectations and norms. The aloha spirit, embodying love
and compassion, motivated many nurses to continue bedside care despite the challenges,
illustrating how societal values can reinforce professional dedication. Conversely, the lack of
perceived aloha from some patient populations led to frustration and reconsidering professional
roles, demonstrating the macrosystem’s dual capacity to support and strain healthcare providers.
The findings of this study align with the literature on cultural resilience and professional
commitment (Brewer et al., 2023; Henshall et al., 2020; Jackson et al., 2007). The emphasis on
cultural values such as the aloha spirit and mālama reflects the broader understanding that
cultural and professional values are linked, especially in high-stress environments like healthcare
during a pandemic. These values provided a framework for understanding the resilience and
dedication of Hawaiian nurses, supporting the notion that cultural context is crucial in
interpreting healthcare professionals’ responses to crises.
Recommendations for Practice
The recommendations for practice are designed to address the well-being of acute care
nurses and are grounded in Bronfenbrenner’s (1979) ecological systems theory. These
recommendations are developed from the study results and highlight a critical need for targeted
interventions to mitigate burnout and increase nurse retention. Recommendations are provided
for research question one, which is about the nurses’ immediate environment, and research
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question two, which is about the culture of Hawaii. These strategies address immediate
environmental stressors and consider broader organizational and societal influences impacting
nurses’ well-being. The proposed interventions are supported by research and are intended to
create a holistic and supportive work environment that fosters resilience amongst nursing staff.
Overall Well-Being
Based on the findings and the application of Bronfenbrenner’s (1979) EST, the following
recommendations are proposed to address the well-being of acute care nurses and mitigate
burnout. These strategies can effectively address the problem of practice of nurse burnout and
turnover.
Implement Comprehensive Stress Management Programs
Comprehensive stress management programs should be implemented to enhance nurse
well-being. Data from the study shows high levels of physical and mental exhaustion among
nurses, with significant difficulty and disconnecting from work-related thoughts, which
underlines the need for targeted stress management interventions. Research supports this
approach, showing that stress management programs reduce emotional exhaustion and improve
job satisfaction (Kowalski et al., 2010; Leiter & Maslach, 2004). Techniques such as
mindfulness, cognitive-behavioral strategies, and resilience training have proven effective in
helping nurses manage stress (Henshall et al., 2020; Rink et al., 2021). The recommendation
aligns with the microsystem of Bronfenbrenner’s (1979) framework by addressing stressors in
the immediate environment of nurses and providing direct support to these individuals.
Healthcare institutions should develop comprehensive burnout prevention programs that
incorporate the findings of this study, like the positive influence that the culture of Hawaii had
on its nurses. These programs should address the various ecological systems influencing their
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burnout, providing resources and interventions at individual, organizational, and societal levels.
A holistic approach can effectively mitigate burnout and enhance resilience among nurses.
Research by Halbesleben and Rathert (2008a) highlights the importance of comprehensive,
multi-level interventions in preventing burnout and improving overall healthcare outcomes.
Provide Accessible Mental Health Resources
It is crucial to provide accessible mental health resources to enhance nurses’ overall wellbeing. The findings indicate that nurses with access to mental health support reported better
overall well-being and were less likely to consider leaving their positions. Cox et al. (2018) and
Melnyk et al. (2021) demonstrated that access to mental health services, including counseling
and support groups, significantly reduces symptoms of burnout and improves mental health
outcomes.
Integrating this recommendation into practice involves both the microsystem and
exosystem levels of Bronfenbrenner’s (1979) EST. Direct support to individuals is essential
(microsystem), while organizational structures must facilitate easy access to these resources
(exosystem). This recommendation establishes accessible mental health resources such as on-site
counseling, peer support groups, and mental health hotlines. It is vital to normalize everyone’s
emotions and feelings and the pursuit of mental health support through organizational policies
and leadership endorsements. This recommendation addresses immediate mental health needs
and fosters a supportive work environment that prioritizes the well-being of nursing staff.
Specific steps would need to be taken at both the organizational and leadership levels to
ensure the successful implementation of this recommendation. Nurse managers and human
resources departments must collaborate to identify and establish partnerships with mental health
professionals to provide on-site counseling services. Additionally, nurse managers would be
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responsible for coordinating regular peer support group sessions. Hospital leadership and the
human resources department will work together to establish and promote a mental health hotline,
ensuring 24/7 accessibility. Hospital executives would need to formalize this initiative through
clear policy directives prioritizing mental health support and creating an open, stigma-free
culture around utilizing these services. The nursing leadership team would also be accountable
for consistently promoting these resources and monitoring their impact on staff well-being
through regular feedback mechanisms.
Interaction and Support With Family
The findings of this study underscore the importance of family interaction and support in
influencing acute care nurses’ decisions to remain in bedside care during the COVID-19
pandemic. The following recommendations are proposed to address the identified issues and
enhance nurse retention. Each recommendation aligns with the study’s findings, existing
research, Bronfenbrenner’s (1979) EST, and Bronfenbrenner’s (1986) work around the family as
a context for human development.
Enhance Family Support Programs for Nurses
Family support programs designed for nurses should be implemented to enhance nurse
interaction and support with family. These programs should encompass resources such as
counseling services, family wellness workshops, and support groups tailored to address the
unique challenges nurses, and their families face during pandemics and other crises. The findings
of this study reveal that emotional support from family significantly influences nurses’ decisions
to remain in bedside care. Nurses who consistently received family support reported lower levels
of job-related stress and were less inclined to consider leaving their positions.
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Supporting research underscores family support’s critical role in mitigating job-related
stress and burnout (Aquilia et al., 2020), especially in Hawaii (McCubbin, 2007). Studies by
DeBaryshe et al. (2006) and Henshall et al. (2020) indicate that robust family support networks
can enhance resilience among healthcare workers. By fostering programs that reinforce family
support, healthcare organizations can help nurses manage stress and reduce burnout and
turnover, addressing the problem of practice of this study. This recommendation aligns with
Bronfenbrenner’s (1979) microsystem within the conceptual framework, emphasizing the
immediate environment surrounding an individual.
To effectively implement this recommendation, healthcare organizations should develop
and roll out specific family support initiatives, such as on-site family counseling sessions and
virtual wellness workshops. Human resources, in collaboration with the wellness and employee
assistance program (EAP) teams, would be responsible for the design and execution of these
programs. Nurse managers would facilitate regular communication about available family
support resources, ensuring that nurses are aware of and encouraged to utilize these services.
This structured approach would ensure that the family support programs are tailored to the
nursing staff’s and their families’ needs, aligning with the broader organizational goals of
workforce retention and well-being.
Provide Comprehensive Infection Control Training and Resources
Comprehensive infection control training and resource allocation will improve nurse
interaction and support with their families. The study identified significant stressors among
nurses concerning the potential exposure of their family members to COVID-19. Providing
regular updates on best practices around infection prevention, ensuring access to PPE, and
offering resources for managing infection control within the home will reduce familial stressors.
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By establishing robust infection control measures, hospitals can help alleviate these concerns and
subsequently reduce stress levels among nurses.
Supporting research underscores the necessity of effective infection control training and
resources in safeguarding healthcare workers and their families, which, in turn, diminishes
anxiety and burnout (Cai et al., 2020; Sun et al., 2020). This recommendation aligns with
Bronfenbrenner’s (1979) mesosystem, which focuses on the interplay between the work and
home environments. Ensuring nurses are confident in managing infection risks at home can
significantly enhance their overall well-being and commitment to their professional roles. This
training should be supplemented with access to PPE and guidance on its appropriate use in
clinical settings and at home. Additionally, hospitals should develop infection control resource
kits for home use, which could be distributed to nurses to support safe practices outside of work
further.
The nursing leadership team would ensure that infection control workshops are attended,
while the infection prevention department would maintain and update educational content.
Operations teams must coordinate the timely distribution of PPE and home resource kits. By
establishing these robust infection control measures, hospitals can help alleviate familial
exposure concerns, reducing nurses’ stress levels.
Interaction and Support With Social Circles
Based on the findings, their alignment with Bronfenbrenner’s (1979) EST, and the
reviewed literature, several recommendations for practice around the interaction and support
with social circles can be made to address nurse burnout and improve retention among acute care
nurses in Hawaii. These recommendations aim to enhance the social support systems at various
levels of influence—microsystem, exosystem, and macrosystem.
128
Enhance Social Support Within the Workplace
Fostering a supportive work environment is essential to mitigate feelings of social
isolation and support nurses in coping with work-related stress. Regular opportunities for social
interaction should be established to enhance social support in the workplace. These can include
team-building activities, peer support groups, and wellness programs. These initiatives
significantly impact nurses’ well-being by promoting a sense of community and belonging
(McElfish et al., 2019). During periods of forced isolation, as seen during COVID-19, healthcare
systems should look to set up virtual opportunities for interaction.
The findings from the study indicate that social isolation is a critical factor contributing to
nurses’ consideration of leaving bedside care. Research by Dyrbye et al. (2019) supports that
strong social support networks within the workplace can reduce burnout and improve job
satisfaction. By enhancing social support within the microsystem, healthcare organizations can
provide immediate relief and support to nurses, ultimately improving retention rates and job
satisfaction. Creating a culture that values and promotes social support can lead to a more
resilient and engaged nursing workforce.
Specific tasks and accountability are essential to ensure actionable steps for enhancing
social support. Nurse managers could organize monthly team-building activities to strengthen
relationships across shifts, including bi-weekly peer support groups. Human resources, with the
wellness committee, should develop a wellness program focused on mental health and regular
debriefing sessions. Information technology could collaborate with nursing leadership during
forced isolation to create virtual social spaces, such as online lounges and peer meetings.
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Leverage Online Platforms for Social Interaction
Especially during times of isolation, healthcare organizations should leverage online
platforms for social interaction. Increasingly, there is a reliance on online tools for social
engagement, and this was evident during the pandemic. Virtual social events, online support
groups, and digital forums can offer alternatives for social support, particularly when in-person
interactions are limited.
The findings of this research underscore the importance of online platforms as a critical
medium for social interaction among nurses during the pandemic. Studies have shown that online
support groups effectively reduce feelings of isolation and foster social connectedness (Hwang et
al., 2020; Spassiani et al., 2022). This aligns with the need to sustain social connections within
the microsystem of nursing practice. By maintaining and enhancing these online interactions,
healthcare organizations can ensure that nurses receive the necessary social support, improving
their overall well-being and job satisfaction.
To implement this recommendation, healthcare organizations should designate a task
force, including information technology specialists, nurse managers, and human resource
personnel, to develop and maintain dedicated virtual platforms for social support. This team
would organize and schedule regular virtual social events, create accessible online support
groups, and facilitate nurse participation in digital forums. Each nurse unit should assign a social
liaison to promote engagement within their respective teams. These steps will ensure sustained
online interaction and support, particularly when in-person contact is not feasible.
Interaction and Support at Work
The following recommendation is proposed to address the organizational responsibilities
centered around burnout and improving retention among acute care nurses in Hawaii. This
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recommendation is based on the study’s findings, the application of Bronfenbrenner’s (1979)
EST, and relevant previous research. Supporting leadership and training them around high
reliability and a speak-up culture will enhance the support leadership can provide to the front line
and improve organizational culture.
Programs like TeamSTEPPS, critical event team training (CETT), and Just Culture
education provide a platform for this discussion. Research indicates that a positive organizational
culture values staff well-being and is linked to lower burnout rates and higher job satisfaction
(Halbesleben & Rathert, 2008a). Aligning this recommendation with the findings, nurses who
reported meaningful interactions with their managers were less likely to consider leaving bedside
care. The study showed, however, that a substantial proportion of nurses felt unsupported by
their managers. This lack of support contributed to their burnout and consideration of leaving
their positions.
The research underscores the importance of effective leadership and a positive
organizational culture in reducing burnout and improving nurse retention. Studies by Laschinger
et al. (2014) and Leiter and Maslach (2009) emphasize that leaders who provide emotional
support and foster a sense of community can significantly mitigate the effects of workplace
stress. Interventions at the organizational level resonate with Bronfenbrenner’s (1979) EST,
emphasizing how indirect environmental influences shape individual experiences. Executive
leaders and mentors are responsible for building supportive managerial relationships, which is
crucial in reducing stress and increasing job satisfaction, as evidenced by Aquilia et al. (2020)
and Brewer et al. (2023). Developing and implementing comprehensive leadership training
programs that focus on emotional intelligence, supportive communication, and team building by
organizational and leadership development personnel will encourage leaders to create an
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inclusive and supportive work environment where nurses feel valued and understood is
paramount.
Hawaii’s Regulations and Laws During COVID-19
The following recommendation speak to Hawaii’s regulations and laws and indicate
changes that can support a more robust nursing workforce. This recommendation is grounded in
the exosystem and macrosystem of Bronfenbrenner’s (1979) EST and supported by current
literature. Healthcare organizations in Hawaii must strengthen community support and
engagement to enhance the well-being of nurses after COVID-19. Executive leaders’
collaboration with community leaders and cultural organizations can create programs
emphasizing family and community involvement. This approach aligns with findings indicating
that broader societal and cultural contexts significantly influence nurses’ well-being. Addressing
these factors through community support can enhance resilience and provide additional layers of
support for nurses.
Research supports the importance of community and societal support in mitigating stress
and promoting well-being among healthcare workers (Kim & Lee, 2021; Shechter et al., 2020).
This recommendation also connects to the theoretical framework by addressing the macrosystem,
which emphasizes the role of societal and cultural support structures in shaping individual
experiences. Hospital leadership and government relations should engage with community
organizations and policymakers to raise awareness about nurses’ challenges. Developing
community support programs such as childcare services, financial assistance, and public
appreciation campaigns can alleviate external stressors and enhance societal support for
healthcare professionals.
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The aloha spirit and ohana were significant cultural factors influencing nurses’
experiences. By integrating community and cultural support into the macrosystem, healthcare
organizations can strengthen the overall support network for nurses. Engaging with the
community and broader societal groups to foster support and appreciation for nurses is vital. The
cultural context in Hawaii, which emphasizes community support, bolstered nurses’ resilience
during the pandemic. Initiatives that involve the community in supporting healthcare workers
can enhance nurses’ sense of value and commitment (Davide et al., 2022).
Hawaiian Beliefs, Values, and Traditions
To build a system of inclusivity and understanding, the following recommendations
review the study’s findings and guide programs and initiatives that can bring cultural sensitivity
to the practices in Hawaii. The macrosystem is referred to as the guiding theoretical framework
here. Research is provided around cultural competence training, sensitivity, and support.
Foster a Culturally Supportive Environment
Healthcare institutions should actively foster a culturally supportive environment that
aligns with the values of aloha, mālama, and lōkahi. Recent findings indicate that these values
significantly contribute to job satisfaction and professional dedication. aloha, embodying love,
compassion, and kindness, fosters a sense of community and mutual respect among healthcare
workers, patients, and their families. Mālama, which signifies caring for and protecting,
promotes a culture of care that extends beyond the immediate physical needs of patients to
include emotional and spiritual well-being. Lōkahi, representing unity and harmony, encourages
teamwork and collaboration, which is essential for a cohesive and supportive healthcare
environment.
133
Integrating these values into organizational policies involves creating protocols and
guidelines that reflect the principles of aloha, mālama, and lōkahi. For example, compliance and
legal should write policies that mandate the inclusion of family and community in care decisions,
reflecting the collectivist nature of Hawaiian culture. The physical environment of healthcare
facilities can be designed to incorporate elements of Hawaiian culture, such as natural elements
and spaces for reflection and prayer, which can provide comfort and a sense of familiarity to
staff and patients.
This approach aligns with Bronfenbrenner’s (1979) microsystem and exosystem levels,
where immediate environments and broader organizational practices influence individual
experiences. The microsystem, which includes the direct environment where nurses interact,
such as their workplace, can be enriched by fostering supportive relationships and a nurturing
atmosphere based on Hawaiian values. The exosystem, encompassing the larger organizational
structures and policies, can support these microsystem changes by institutionalizing culturally
supportive practices and providing the necessary resources for their implementation.
Research by Pukui et al. (1976) shows that a culturally supportive environment can
enhance commitment and reduce stress among healthcare professionals. This type of
environment is particularly relevant in Hawaii, where integrating cultural values into healthcare
practices can bridge the gap between modern medical practices and traditional Hawaiian healing
practices. By aligning healthcare practices with cultural values, institutions can create a more
resilient and dedicated workforce, ultimately leading to better patient outcomes and a more
harmonious work environment. This approach honors the rich cultural heritage of Hawaii and
contributes to the overall well-being and effectiveness of the healthcare system.
Encourage Reflective Practices and Continuous Improvement
134
Integrating reflective practices and continuous improvement into the nursing profession is
essential to provide a recommendation for practice around Hawaiian beliefs, values, and
traditions. When leaders encourage nurses to engage in regular reflection, peer discussions, and
feedback sessions, they can enhance a sense of ho’oponopono (a Hawaiian practice of
reconciliation and forgiveness) and lōkahi (harmony and unity). These practices foster a culture
of continuous learning and improvement, which is particularly crucial in navigating the
challenges posed by the pandemic and beyond. Integrating these practices into the nursing
workflow aligns with Hawaiian cultural values and promotes a supportive and cohesive work
environment.
Reflective practices allow nurses to critically assess their experiences, identify areas for
improvement, and develop strategies to enhance their performance. In Bronfenbrenner’s (1979)
microsystem, immediate social and professional interactions influence individual practices.
According to Meyer (1995), reflective practices significantly contribute to job satisfaction and
professional growth, supporting the idea that continuous reflection and peer engagement are
beneficial.
Limitations and Delimitations
Like all research endeavors, this study has limitations and delimitations that shape its
scope and the interpretation of its findings. In this section, the limitations and delimitations of the
study are discussed to provide a clear understanding of the scope and boundaries of the research.
Limitations refer to potential weaknesses or constraints that may affect the findings’ validity,
reliability, or generalizability, often due to factors beyond the researcher’s control. Delimitations,
on the other hand, are the intentional choices made by the researcher to narrow the focus of the
study, such as the specific population, timeframe, or variables examined.
135
Limitations
One limitation of this study was the potential for response bias inherent in self-reported
survey data (Field, 2018). Participants may have responded to survey questions in ways they
perceive as socially desirable, thereby introducing bias into the data (Dillman et al., 2014).
Additionally, recall bias might have affected the responses, as the participants were asked to
remember experiences from 2020 through 2022 (Braun & Clarke, 2006).
Recall bias, also known as recall error, was positioned as a potential limitation of this
study due to the length of time between the study timeline and survey distribution. Recall bias is
a systematic error that occurs when participants do not remember past events or experiences
accurately or when there is a differential recall accuracy between two groups being compared.
This type of bias can significantly influence the results of retrospective studies where subjects
are asked to recall past events (Porta, 2014), particularly when the events are associated with
anxiety and depression (Hakamata et al., 2022).
Despite the suggested vividness of traumatic memories, questions regarding their
accuracy have been raised. Researchers like Erdelyi (2006) and Loftus (1993; 1994) argued that
the mind’s susceptibility to external influence might lead to the integration of false elements into
genuine memories or the creation of entirely false memories. This phenomenon and the distress
accompanying traumatic memories can affect the memories’ clarity and reliability over time
(Loftus, 1997; Patihis et al., 2013; Patihis et al., 2014). The dichotomy between the vividness
and potential inaccuracy of traumatic memories underlines the complexity of the brain’s
response to traumatic stress and necessitates further research.
In the realm of cognitive psychology and neuroscience, the retention and recall of
memories associated with prolonged traumatic events have been subjects of significant scrutiny.
136
Previous research proposes that due to their emotionally charged nature and induced severe
stress, traumatic events are more vividly encoded and later retrieved compared to non-traumatic
experiences (Azarian, 2022; McGaugh, 2004; Schwabe et al., 2022). Traumatic recall is
particularly apparent in instances of sustained traumatic events, where the consistent stress
source fortifies the memory encoding process (Horowitz, 1975; Read & Lindsay, 1997; 2013).
Delimitations
The study was geographically constrained, focusing solely on registered nurses who
worked bedside in acute care settings in Hawaii. This delimitation intentionally narrowed the
scope of the research to understand this group’s unique experiences and challenges during a
global health emergency. However, focusing on a specific geographic location limited the
study’s generalizability to nurses in different regions or healthcare settings (Creswell &
Creswell, 2018).
A further delimitation is the study’s high reliance on quantitative data. This approach was
chosen to accumulate data from a large sample. The study has a qualitative component intended
to capture more depth of participants’ experiences or the subtleties of their perceptions and
attitudes. However, a broader mixed-methods study, integrating qualitative data, could provide a
more comprehensive understanding of the phenomena under investigation (Creswell & Plano
Clark, 2017).
Recommendations for Future Research
Based on the findings of this study, several areas warrant further investigation to address
the problem of nurse burnout and turnover in Hawaii’s acute care settings. Future research
should focus on the long-term impact of family dynamics on nurses’ well-being and career
decisions and the effectiveness of culturally tailored interventions that integrate Hawaiian values
137
into healthcare practices. Examining these aspects over time can provide deeper insights into
supporting nurse resilience and improving job satisfaction.
Additionally, research should investigate the impact of specific organizational policies
and mental health support programs on nurse retention. Comparative studies between institutions
with varying levels of support systems can identify best practices for creating a supportive work
environment. Exploring technological solutions that enhance social connectivity among nurses,
such as virtual support groups and online wellness programs, could help mitigate feelings of
isolation and strengthen social support networks. Addressing these areas can contribute to a more
supportive and sustainable work environment for nurses, ultimately improving retention rates
and healthcare outcomes.
Conclusion
The findings of this study illuminate the complex interaction of factors influencing the
decisions of Hawaii’s registered nurses to remain in bedside care during the COVID-19
pandemic. The analysis reaffirms the significance of personal, familial, social, and cultural
environments in shaping these decisions by revisiting the research questions. The application of
Bronfenbrenner’s (1979) EST provided a robust framework to understand the multi-layered
influences on nurse burnout and retention.
The findings demonstrated that supportive family interactions and social connections are
critical in mitigating stress and encouraging nurses to continue their bedside roles. Conversely,
social isolation, overwhelming workloads, and perceived disrespect from leadership significantly
contribute to burnout and considering leaving the profession. Hawaii’s cultural values emerged
as powerful motivators that reinforced nurses’ commitment to patient care, although challenges
138
related to inclusivity and decision-making processes within the work environment sometimes
undermined these cultural supports.
These insights emphasize the need for targeted interventions addressing the specific
environmental and cultural factors impacting nurse well-being. Integrating individual,
organizational, and societal strategies is crucial in fostering a supportive and sustainable work
environment for nurses. The study’s findings contribute to the broader discourse on healthcare
workforce sustainability, highlighting the importance of culturally sensitive and contextually
relevant approaches in addressing the problem of nurse burnout and turnover in Hawaii.
This study revealed the relationship between personal resolve, cultural ethos, and
systemic forces that shaped Hawaii’s nurses’ commitment during the recent COVID-19
pandemic, an era of unparalleled adversity. It highlighted how the tenets of Hawaii’s culture
supported these nurses so that they could become a beacon of hope for the community. With
overwhelming workloads, social isolation, and organizational challenges, Hawaii’s nurses stood
as pillars of strength, upholding a social and cultural mission far beyond mere professional duty.
Their stories are a reminder that nurses are the heartbeat of healthcare. They are a lifeline
that sustains the well-being of Hawaii’s most vulnerable. This study amplifies their voices and
issues a call to action: honor their actions by fostering environments that respect and nurture
their well-being to ensure that the compassion and resilience they exemplify continue to inspire
and heal.
139
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Appendix A: Survey Questions
Question Open or
closed?
Level of
measurement
Response options
(if close-ended)
RQ Concept being
measured
Questions 1–4 are inclusionary questions. These will ensure participants meet the minimum participant qualifications
1. I provided direct patient care in an acute
care hospital in Hawaii as a registered
nurse between March 2020 and March
2022.
Closed Nominal Yes (1)
No (2)
(End survey)
None—inclusion criteria
2. What unit(s) did you work on in the
hospital between March 2020 and March
2022?
Open Nominal
3. I thought about leaving direct patient care
in the acute care setting between March
2020 and March 2022.
Closed Nominal Yes (1)
No (2)
RQ
1,2
None—
identifying
criteria
4. I left direct patient care in the acute care
setting between March 2020 and March
2022.
Closed Nominal Yes (1)
No (2)
Questions 5–11 are demographic questions.
5. Were you born in Hawaii? Closed Nominal Yes (1)
No (2)
None—demographic
information
6. What are the total number of years that
you claimed Hawaii as your primary
residence?
Closed Nominal 1–5 years
6–10 years
10–15 years
15–20 years
> 20 years
7. What are the total number of years you
held a registered nurse license in ANY
State?
Closed Nominal 1–5 years
6–10 years
10–15 years
15–20 years
>20 years
8. What are the total number of years you
held a registered nurse license in Hawaii?
Closed Nominal 1–5 years
6–10 years
184
Question Open or
closed?
Level of
measurement
Response options
(if close-ended)
RQ Concept being
measured
10–15 years
15–20 years
> 20 years
9. Are you currently employed as a
registered nurse?
Closed Nominal Yes (1)
No (2)
10. How long have you worked at your
current employer?
Closed Nominal 1–5 years
6–10 years
10–15 years
15–20 years
> 20 years
11. Are you at the same organization you
were at during the pandemic?
Closed Nominal Yes (1)
No (2)
Questions 12–20 address your overall well-being between March 2020 and March 2022
5-point Likert-style survey from 1 (never) to 5 (always). Coded W#.
12. I felt a sense of satisfaction from my
workload.
Closed Ordinal
Never (1)
Sometimes (2)
About half the time (3)
Most of the time (4)
Always (5)
RQ
1,2
Burnout
13. I was physically drained after most
workdays.
Burnout
14. I found it difficult to disconnect from
work-related thoughts during off hours.
Resilience
15. I had the stamina to perform my work
duties efficiently.
Burnout
16. I had trouble sleeping due to work-related
stress.
Resilience
17. My mental health was able to support the
demands of my job.
Resilience
18. My work was meaningful and fulfilling. Resilience
19. I was able to maintain a work-life balance. Resilience
20. I felt mentally exhausted after a workday. Burnout
Questions 21–25 address your interactions and support with your family between March 2020 and March 2022.
5-point Likert-style survey from 1 (never) to 5 (always). Coded F#.
185
Question Open or
closed?
Level of
measurement
Response options
(if close-ended)
RQ Concept being
measured
21. My family understood the demands of my
job.
Closed Ordinal 1 (never)
2 (sometimes)
3 (about half the time)
4 (most of the time)
5 (always)
RQ1 Bronfenbrenner
microsystem
22. My family expressed concern about my
exposure to COVID-19 at work.
23. My family’s emotional support helped me
cope with work-related stress.
24. My family’s health and well-being
affected my job performance.
25. My family relationships were strained due
to my work demands.
Questions 26–30 address your interactions and support with your social circles between March 2020 and March 2022.
5-point Likert-style survey from 1 (never) to 5 (always). Coded S#.
26. I was able to regularly meet with my
friends or social groups in person.
Closed Ordinal 1 (never)
2 (sometimes)
3 (about half the time)
4 (most of the time)
5 (always)
RQ1 Bronfenbrenner
microsystem
27. I had to limit my social interactions to
prevent spreading COVID-19.
28. I relied on online platforms to interact
with my social circles.
29. I felt socially isolated due to the nature of
my work.
30. My social connections helped me cope
with work-related stress.
Questions 31–35 address your interactions and support with the hospital I worked at between March 2020 and March 2022.
5-point Likert-style survey from 1 (never) to 5 (always). Coded J#.
31. I felt supported on my unit by my coworkers.
Closed Ordinal 1 (never)
2 (sometimes)
3 (about half the time)
4 (most of the time)
5 (always)
RQ1 Bronfenbrenner
exosystem
32. I felt supported on my unit by my
manager.
33. The company I worked for did the best
they could to provide adequate PPE.
186
Question Open or
closed?
Level of
measurement
Response options
(if close-ended)
RQ Concept being
measured
34. I was overwhelmed by the number of
patients I was responsible for.
35. My opinions were heard and respected by
hospital leadership.
Questions 36–46 address how Hawaii’s beliefs, values, and laws affected your desire to remain at the bedside between March 2020
and March 2022.
3-point Likert-style survey from 1 (provided no comfort) to 3 (provided great comfort)
Questions 36–41 coded H#. Questions 42–46 coded C#.
36. Hawaii’s masking requirements Closed Ordinal 1 (provided no
comfort)
2 (provided some
comfort)
3 (provided great
comfort)
RQ2 Bronfenbrenner
37. Hawaii’s stay at home requirements macrosystem
38. Hawaii’s reduction in tourism
39. Hawaii’s COVID-19 testing requirements
40. Hawaii’s laws about social distancing in
public spaces
41. Hawaii’s community attitudes toward
healthcare professionals
42. How did the Hawaiian value of Aloha
(love) affect your desire to remain at the
bedside during Covid?
Open
43. How did the Hawaiian belief in Kuleana
(responsibility for others, rules, and self)
affect your desire to remain at the bedside
during Covid?
44. How did the local emphasis on Mālama
(caring for others) influence your
professional dedication to the crisis?
45. Can you provide examples of how the
local tradition of Ho’oponopono (making
things right) resonated with you as a
healthcare worker?
187
Question Open or
closed?
Level of
measurement
Response options
(if close-ended)
RQ Concept being
measured
46. How did the local value of Lōkahi (unity,
harmony) contribute to your decision
around remaining or transitioning away
from the bedside during Covid?
188
Appendix B: Responses to Open-Ended Questions
C1: How did the Hawaiian value of Aloha (love) affect your desire to remain or leave the
bedside between March 2020 and March 2022?
C1: Coded 1 (negative)
Aloha decreased. More families are now rude to bedside nurses.
I loved being a nurse, but didn’t want to die from being a nurse
Stressed and feeling unappreciated by certain patient populations, demanding pts, etc.
unfairness on pay compared to mainland kaisers
Wanted to leave bedside due to seeing family saying their last good byes thru video
call
C1: Coded 2 (neutral/no effect)
Didn’t influence my decision. My core values as a nurse kept me going.
It did not.
It didn’t.
no affect
none
not at all
C1: Coded 3 (positive)
Affected a lot—I stayed.
Affected me to stay at bedside.
Aloha means no one gets left behind.
Appreciation from patients made me want to stay at bedside.
189
As a nurse during the COVID-19 pandemic, I was almost exclusively assigned to the
COVID-19 nursing unit. I cared for many patients as they struggled to breathe and
had no family at the bedside to give them comfort. The spirit of Aloha helped sustain
me through the pandemic as I strived to provide loving, compassionate care to my
patients, holding their hands, providing emotional support, and taking the place of
families and friends who were prohibited from visiting. The quiet moments in
nursing, one-on-one with patients, helped sustain me in working bedside.
Big factor: Aloha is Hawaii.
duty to the people of the islands
I couldn’t leave nursing.
I decided to stay at bedside to support my team members who dealt with the constant
change of protocols and procedures during covid and support our patient population
who were not able to see their families.
I feel that it played a big role in why I continued to work as a bedside nurse
I never thought of leaving the bedside. I remained for financial reasons as well as the
love for my job.
I probably stood longer working on my old unit which was an all covid unit because I
felt the Aloha for my co-workers rather than the job itself.
I still feel connected to my community and providing the care they need.
It always made me lean more on the side of staying. It was the overwhelming senior
leader (not direct manager) disconnect and lack of support that made me want to
leave.
It helped me stay.
190
Moderately affected bc I still wanted to provide some support for pts.
My Aloha is not organizational focused, but more for all those in our state.
My dedication to my work and desired to help my community during those times.
Overall, I do love many aspects of my job. There are certain aspects such as quantity
vs quality of life ethics that I sometimes debate internally.
strong desire to remain at bedside
Taking care of ppl is what we vow to do as nurses and during this desperate time of
need that is what we had to do. The love of each other to take care of ppl as your
family has always been the way of life in hawaii.
The Aloha I felt amongst my co-workers and even some grateful patients helped me
stay at the bedside.
The Aloha stayed but the outside hawaii people had no aloha to the locals
The feeling that if I didnt do this job, who would. I wouldnt want to put someone else
in my position.
The respect for each other was profound during these years and beyond.
The value of Aloha affected my desire to remain at the bedside during Covid is
because I love my job, I love being an RN.
Wanted to continue to take care of Hawaii’s people especially during such a new and
scary time.
C2: How did the Hawaiian belief in Kuleana (responsibility for others, rules, and self)
affect your desire to remain or leave the bedside between March 2020 and March 2022?
C2: Coded 1 (negative)
I had a desire to leave bedside due to how bad the situation to everyone.
191
I started to put myself and my families well being and being at bed side was not
healthy.
The patients that were against covid vaccinations, then suffering with covid and
taking care of them was very frustrating.
When others didn’t feel the same it supported my wanted tonorave [to leave].
C2: Coded 2 (neutral/no effect)
Didn’t influence my decision. My core values as a nurse influenced my decision.
It did not.
It did not.
It didn’t.
no affect
no affect
none
not at all
C2: Coded 3 (positive)
Affected in a positive way.
Affected me to stay at bedside.
As a nurse to the best of our ability we do what we can when it’s needed to meet the
path we took to take care of other.
As an RN, I have a responsibility to my community.
Big factor: Kuleana means respect.
192
Every year the struggle to live and thrive in Hawaii grows. It is my Kuleana to
provide for my family, that was my driving desire to remain at bedsied during Covid.
I love my job, but I also like that I get paid to do this :o).
Helped with respecting Covid restrictions.
I felt a responsibility to care for my loved ones and others in the community.
I felt a responsibility to my patients.
I felt as a healthcare provider that I wanted to support my peers and my patients so
they could get optimal care.
I felt it was my Kuleana to help care for the sick patients who had COVID-19 despite
the uncertainty of how it would affect myself and the increased risk of exposure for
myself and family.
I felt like it was my responsibility as a nurse to care for COVID patients the same as I
would any other patient. I also felt like it was my Kuleana in my profession to keep
working and caring for all during the pandemic.
I took the role as being in the health profession a great deal and responsibility to serve
my community no matter what.
I wanted to remain at beside to help educate and take care of the sick.
It affected it in that I felt as though I had to stay at the bedside to care for our families
because no one else could.
It helped me stay.
It helped me to see my purpose.
193
It is my kuleana to ensure that the decades of medical training that I have received
from mentors, colleagues, and patients be utilized to continue to improve the
healthcare of our state.
It’s my responsibility to help.
Kuleana kept me coming to work to support my family, while being safe of course,
and kept me coming to work to help support my co-workers and give care to those
who needed it.
Kuleana made me realize that staying would help the greater good.
Kuleana means taking care not only of others but also of our own family and those
close to us. A critical question nurses and all frontline healthcare providers faced was
our responsibility to our families and ourselves. Do we value our health, safety, and
well-being? If we don’t care for ourselves, who will? What is our Kuleana and
responsibility if we incidentally expose our loved ones to COVID-19 and they get
sick? I believe the pandemic provided much-needed reflection and clarity for nurses
and helped us prioritize ourselves and our families over work. I ultimately decided to
take another position in the hospital with fewer hours but still at the bedside.
strong desire to remain at bedside
This was my job and my kuleana. Shut up and show up and do your job. Thats how i
felt. I also felt those who made excuses were selfish.
This was my main value that kept me at the bedside, I felt like as a nurse who was
young and healthy I needed to stay.
We always tried to maintain a satisfactory obligation to our kuleana.
194
C3: How did the Hawaiian belief in Mālama (caring for others) affect your desire to
remain or leave the bedside between March 2020 and March 2022?
C3: Coded 1 (negative)
I have no problem caring for others, but when you are not taken cared of by your
employer then you moral goes down.
C3: Coded 2 (neutral/no effect)
Didn’t influence my decision. My core nursing values was the deciding factor.
It did not.
It didn’t.
no affect
This did not impact my care.
C3: Coded 3 (positive)
affected me to stay
As a kamaaina I feel a sense of responsibility to Mālama the most vulnerable.
As a nurse, Malama is engrained in our DNA. Nurses are built to care for others, even
above themselves. The unknowns and stressors of working during a global pandemic
put a strain on nurses, and we found ourselves in a stark reality with no one caring for
us. But when we are taught to put patients above everything, walking away from the
bedside is difficult—especially living in a close-knit community where you most
likely know patients outside the hospital setting. The responsibility to Malama and
care for your neighbors, friends, and families were factors in choosing to stay at the
bedside.
Big factor: Malama is innate to nurses.
195
encouraged me to stay when I wanted to leave
I love caring for others, but being irresponsible by not getting vaccinated and social
distancing was hard to deal with.
I love what I do. I went into the field of nursing to help others.
I love working with patients but i felt like i could help patients in different
environment.
I still wanted to continue to live my dream of caring for others.
I wanted to care for others as best as I could but the way the hospital administrators
and community’s attitude sometimes made that choice difficult. However the way
some of the community, Malama’d our staff encouraged me especially when they
were generous and giving during their own troubled times.
I wanted to continue to take care of the Hawaii patients.
I went into nursing to serve others. It is a calling.
It helped me stay.
It helped me to connect my values & purpose to care for others.
It’s all pure love of what you doing.
It’s my job.
It’s part of my job.
Just had to change how I was caring for others.
Leaving the bedside was a tough decision. Transitioning into this new journey allows
me to continue to reach patient care but on a more global scale.
Seeing people in our community pass made it more important for me to stay in the
acute care setting.
196
strong desire to remain at bedside
The Aloha Spirit is strong and engrained in our culture that it is a natural response
throughout the island to care for others.
The response to this question goes along with why most of us become nurses, we
want to care for others. During Covid we put the needs of others before that of our
families. I would have to answer that to show Malama to others was greatly affected
my desire to remail at bedside nursing during Covid.
The spirit of malama gave me the strength and determination to continue my work at
the bedside and care for those who needed it.i try.
There is a strong sense of Malama on my unit which helped me learn and stay at the
bedside.
This is our job this is what we do and how we did it never was recognized but helping
others as our own family was always was the greatest reward.
wanted to remain at bedside
We are in this job to malama everyone that nees our help. It was hard to see people
disregard the rules for selfish reasons.
We supported each other.
We will always malama our friends and family.
C4: How did the Hawaiian belief in Ho’oponopono (making things right) affect your
desire to remain or leave the bedside between March 2020 and March 2022?
C4: Coded 1 (negative)
197
It didnt. There was no process to be heard or talk through what was going on. No one
involved us bedside workers in any decisions that were being made. We were just
told what to do. no concern for our beliefs/concerns/opinions/etc.
The hospital I worked for during covid had zero empathy for us bedside nurses and
our safety, I was so grateful for the fema nurses.
The traditional practice of Ho’oponopono helps forgive past wrongs, conflicts, and
misunderstandings. I took a step away from the bedside by becoming part-time to
overcome my helplessness with the pandemic and inability to enact organizational
change to improve my and fellow nurses’ working conditions. I strongly felt that the
organization did not make things right for their nurses and staff, which influenced my
decision to become part-time.
C4: Coded 2 (neutral/no effect)
Didn’t influence my decision.
It did not.
It didn’t.
no affect
no affect
none
This did not affect my care as it is incorporated into my daily nursing values.
C4: Coded 3 (positive)
affected me to stay
198
Ho’oponopono is often used to describe dissolving a conflict amongst parties. In my
case, I needed to resolve the work-life balance as I was quickly if not already
approaching “burn out.”
I continued to take care of our Hawaii community to make it right.
I discussed with my manager what i wanted to be as nurse and she helped make that
happen.
I feel like I needed to make it right for my mental health by leaving a unit that was
strictly Covid patients.
I try to i still ho’oponopono in my everyday life and that included preforming the best
qualitly if care i could during these trying time between 2020–2022. I gave more of
myself as a nurse to get through the pandemic and love my family for all the support
one person can have.
It’s part of our jobs.
Just had to adjust how I make things right.
staying to keep pushing to provide adequate care
strong desire to remain at bedside
There’s also a strong sense of Ho’oponopono on my unit, and of doing the right thing
all of the time, which can be a lot of work but gives a sense of fulfillment.
C5: How did the Hawaiian belief in Lōkahi (unity, harmony) affect your desire to remain
or leave the bedside between March 2020 and March 2022?
C5: Coded 1 (negative)
I felt like being short staff caused a negatively strain as unit and affected harmnious
work environment.
199
I was conflicted. There wasn’t a great deal of lokahi amongst our leaders at the time.
Zero lokahi at the hospital I worked at (kuakini hospital)!!!
C5: Coded 2 (neutral/no effect)
Did not affect it.
Didn’t influenced my decision. My core nursing values played an important part in
my desire to remain in the field.
It didn’t.
no affect
none
Not used to evaluate my care.
C5: Coded 3 (positive)
affected me to stay
As COVID came out, I felt closer to our team and wanted to help take care of our
members.
Community partnership helped me a great deal.
for the goods of every one
I embraced the value of Lokahi when I dropped down to part-time. By stepping back
from the stress of work and the pandemic, I chose a more balanced and healthier
lifestyle, striving for a more harmonious existence physically, mentally, and
spiritually.
I felt a sense of harmony once I moved to a non covid unit because I could literally
feel a sense of relief knowing that myself and family would be at a Lower risk of
contracting the illness.
200
I felt lokahi on my unit as well which created a strong sense of teamwork that greatly
helped me stay at bedside.
I’m a son of Hawaii and will forever be a guardian and practicioner of practices that
help improve the community.
I’m fortunate to work with SOME nurses that have good work ethic, we help each
other and work as a team. If I/they did not share this value of Lokahi, I would have
felt more compelled to leave bedside nursing during Covid.
If my team was going into the trenches, I was going to be there with them.
It helped me stay.
It’s Hawaiian way.
My co-workers got me through the hard times and kept me going.
Our unit has always worked together well, and it’s nice to see a community effort and
be a part of that community.
strong desire to remain at bedside
Those of us that stayed in our positions and worked along side each other became
closer. The pandemic definitely highlighted the negative and positive attributes in
people we worked with.
together as a whole nursing community working together always go us thru the hard
days
Unity and harmony is valued if you are under great leadership.
We all worked together for each other and supported one another to make sure we
provided the care in a safe manner so we all could come back and continue to care for
our patients who always deserve the best quality iof care from Kaiser Permanente.m y
201
Working as one helped us go thru it all together.
You showed up to work to be an integral part of a team. Overall, co-workers took
care of each other.
Abstract (if available)
Abstract
The COVID-19 pandemic presented unprecedented challenges to healthcare systems, significantly increasing stress, anxiety, and burnout among acute care nurses in Hawaii. This study investigated the determinants of burnout during the period from March 2020 to March 2022, with a particular focus on those nurses who were considering reducing their work hours, exploring alternative employment opportunities, or leaving the profession altogether. Grounded in Bronfenbrenner’s (1979) ecological systems theory framework, the research examined a range of individual, organizational, and societal factors that contributed to nurse well-being and burnout during the pandemic. The study uncovered how the interaction between personal and work environments, coupled with Hawaii’s unique cultural norms, influenced nurses’ intentions to remain in their roles amidst the crisis. It highlighted how the pandemic exacerbated preexisting healthcare disparities, leading to intensified nursing shortages and compromised care quality, especially in marginalized communities. The insights gained from this research were intended to inform interventions and policy measures aimed at mitigating burnout, enhancing the well-being of nurses, and improving the overall quality of patient care. Ultimately, this study contributed valuable knowledge to the growing body of literature on healthcare professional burnout during crises, offering strategies to bolster the resilience of the healthcare system in Hawaii and beyond.
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Asset Metadata
Creator
Weldon, Erich Matthew
(author)
Core Title
Navigating the storm: the impact of Hawaiian culture on stress, burnout, and retention of Hawaii’s acute care nurses during the COVID-19 pandemic (2020–2022)
School
Rossier School of Education
Degree
Doctor of Education
Degree Program
Organizational Change and Leadership (On Line)
Degree Conferral Date
2024-12
Publication Date
12/17/2024
Defense Date
10/30/2024
Publisher
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Tag
aloha,Bronfenbrenner’s ecology of human development,Burnout,COVID-19,critical incident stress,Hawaii registered nurse,ho’oponopono,kuleana,lōkahi,mālama,OAI-PMH Harvest,pandemic
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Tags
aloha
Bronfenbrenner’s ecology of human development
COVID-19
critical incident stress
Hawaii registered nurse
ho’oponopono
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pandemic