“ We are all a family ” Staff Experiences of Working in Children's Blood and Cancer Centers in New Zealand—A Constructivist Grounded Theory

Care of Children With Cancer and Blood Disorders in New Zealand

Internationally, care of children with cancer has evolved significantly over recent years, with most cancers now being highly curable if identified at an early stage and the child lives in a developed country (Ward et al., 2014). However, advances in treatment have meant an increase in intensity and complexity of treatment for some cancers. The complexity of nursing and medical care children require has an impact on the roles and responsibilities of staff.

New Zealand has access to world-class treatment and New Zealand children receive care comparable to those in large international centers (Children’s Oncology Group, 2019). However, New Zealand faces unique challenges with a small (4.9 million people) and geographically dispersed population (Stats NZ, 2020). As a result, child cancer care is centralized to two specialist centers, in Auckland (North Island) and Christchurch (South Island). Both specialist centers have multidisciplinary teams, including but not limited to, nursing, medical, social work, play specialist, physiotherapy, occupational therapy, cultural and spiritual support, and child liaison psychiatry support (Starship Blood & Cancer Centre, 2019). This multidisciplinary focus was important in considering the study aims and design.

Study Aim

The purpose of this study was to explore staff experiences of working in a children's blood and cancer center, with a focus on how staff maintain resilience in their work and sustain working in this area. A constructivist grounded theory (GT) design was chosen by the authors to explore this phenomenon.

Methodology

This study used constructivist GT methods, described by Charmaz (2014a). Key to constructivist GT is the acknowledgment of the role of the researcher. The researcher is integral to the research process and a critical part of the construction of the final GT. This differs somewhat to Glaser and Strauss's initial GT approach, where the researcher was seen to be an outside observer (Glaser & Strauss, 1967).

Finding Attachment

On the first day when a new staff member starts in the unit, they instantly become part of a child cancer community. This is a community that incorporates all staff who work in the area, organizations that support children with cancer, the wider child health community across New Zealand, and children with a cancer diagnosis, and their families. Although they are instantly part of a community, staff transition from being new in the team and forming early attachments with colleagues to becoming secure in the knowledge that they feel part of the work family. This is explained by the following participant:

During this early period of finding attachment and being new, staff highlighted the need for a good support system outside of work. Having supportive family and friends, and someone within their home environment that they can talk to and share some of their distress, helps the staff member adjust to their new role and find their place in the “work family.”

Being new in the team and being overwhelmed is a critical part of the process. This is recognized as the period of greatest vulnerability. Staff grapple with the challenging work, trying to assimilate the complexity of care and the acuity of the work, while facing the harsh realities that at times are part of working in children's oncology:

The first attachment is usually made with either the clinical director or nurse unit manager, depending on the role of the new staff member. This person is an authority figure and will likely be their manager for the remainder of their time working in the unit. Participants highlight this person as being a parental figure throughout their career. For example, participant 25 explained her relationship with the nurse manager as follows:

A memo recorded shortly after interviewing a manager, participant 23, also highlighted the maternal role managers hold in this area:

Managers also see this as a reciprocal situation where they are equally being supported and nurtured by their team; this is further described by a senior leader, participant 23:

Concurrent to the attachment being formed with the manager, an attachment is also developed with an informally selected or formally identified mentor (often identified by the parental figure). Having a mentor with whom you have a good relationship with, and can share and talk with openly and honestly, is essential to being able to form an attachment to the family or work team. A participant in focus group one highlights this:

In professions where there are multiple staff members, the attachment or mentor relationship often naturally occurs within the individual discipline—for example, nurses attach to nurses. However, when the staff member may be from a smaller or single professional group, these staff will attach to someone they work closely with on a regular basis. For example, the new cleaner may attach to the health care assistant or hospital aide, as highlighted below:

Regardless of profession, this attachment could be compared to the role of an aunty or uncle. An aunty or uncle is someone who provides support, guidance, and advice both on a regular basis and in the midst of a crisis. This aligns with how staff described their mentors. Further attachments are then able to be developed with colleagues of the same profession, who are like the siblings within a family, and with other members of the multidisciplinary team, who are identified as being similar to cousins—these are further explored in the context of belonging to a work family. To enable staff to have a high level of secure attachment to the wider team, social connectedness is vital.

Social connectedness. Staff who are connected socially within the work environment and have the opportunity to share their own successes and challenges both within their work and on a personal level, tend to have stronger levels of attachment and thrive in the work environment. Staff acknowledged the social connection with their work colleagues as being different from their peers who worked in other environments:

Knowing each other can also lead to a more cohesive and well-functioning team. Encouraging social connectedness through social activities both at work and outside work means staff can get to know each other on a more personal level. These activities could include coming together during the day to share morning tea or cake or socializing together over dinner or a social outing. Team building activities or adventures where all staff can attend and be together were recognized as helpful strategies in ensuring secure attachment to colleagues and the wider work “family”:

When staff do not know each other well, this can contribute to a sense of discomfort or unease, which can then impact on their ability to work together and provide good quality care to children and families; for example, see the quote below:

Staff articulated the value of collegial support and being socially connected to colleagues, as a key marker of their resilience. Although they were all aware of formal supports, such as the employee assistance program (EAP), no participants had accessed this support and all felt support from colleagues within the unit met their needs on both a regular basis and in times of crisis:

Having social areas to meet and gather at work away from the unit has also been identified as helpful to enable social connectedness around the workplace—a medical participant alludes to this:

Once staff have found attachment, and have begun to socially connect with colleagues, they begin to become part of the work family. In situations where staff are unable to connect to the work family, or where connections become broken, staff tend to carry both the emotional and physical burden of the work alone. This is demonstrated in the quote from a participant who had left the unit. While this participant identified their partner as a key support, they felt alone and unable to talk about their struggles with work colleagues:

Becoming a Work Family

Participants referred to the notion of family throughout the focus groups and individual interviews. The work family can be aligned to a traditional family model including roles of parents, children, aunties, and uncles as discussed in the process of finding attachment. Colleagues who are most like the staff member, for example, other nursing colleagues for a new nurse, align to being the nurse's siblings. Siblings hold an important role in supporting and nurturing the new staff member, while they “learn the ropes.” Once the staff member feels attached to and comfortable with their siblings, they begin to develop stronger relationships with other members of the multidisciplinary team or their cousins. Although there may be defined roles within the family, each individual staff member will formulate their own sense of how they fit into the family unit. The following quote from a participant highlights that she sees herself very proudly within the unit as Grandma; she also identifies who she sees as her children:

Being a team and being able to share the success and burden were critical components staff highlighted of being a work family. While the sense of camaraderie and teamwork was prominent, participants also identified that they were more than a traditional team:

This level of dysfunction and irritability with each other can reflect the realistic nature of being a family, and could also be reflective of how comfortable staff feel around each other. Nevertheless, the core of being a team was central to the notion of family life in the staff of a children's blood and cancer center.

Being a Team. To become a successful team member, an individual must have an acknowledged role with responsibilities. The ultimate aim of the team is the common goal of providing quality care for children and families. Initially, the team can appear very strong and together, with a sense of being very “cliquey.” At times, it can be perceived as difficult to become part of the team. The reality is that once the new staff member has proven they are there to work toward the common goal and have demonstrated they have something to offer, they are welcomed into the team. Participants from an early focus group offer two different perspectives on being new to the team:

After a period of settling in, when attachments are formed, being part of the team can be likened to being a family. This means the full multidisciplinary team can be considered as the extended family, with smaller family groups within, that are discipline and function focused, for example, the nursing family or the administration family. Being a team and being part of a family unit is of great value to staff and something they begin to really treasure:

Sharing Success and Burden. The above quote also shows that as a family, the highs and rewards, on both a work and personal level are shared and celebrated. Each staff member is supported, encouraged, and nurtured through their work by other members of the family and by their parental figure (manager or leader). Participants also highlighted the ability of the team to share the load and do what is needed to get through together:

Critical to being able to share the burden and load of the job is having the time and space to sit and talk with colleagues and socially connect. Staff all identify the value of there being a forum to have informal conversations as a team. This is encapsulated in the following comment:

Managing these moments means team members' individual unique needs and personalities need to be recognized and acknowledged. There is a need for staff to be tolerant of others and aware that others may have differing needs on different days or depending on what is happening in other aspects of their life, as well as what is happening for them at work. Having an understanding of other's needs means individuals can work together more collaboratively, appreciating the vulnerabilities of individuals and their family:

Having Core Work Family Values. Ultimately understanding each other's needs is about recognizing each individual for who they are and respecting their differences. Respect for each other was highlighted by staff as a core value of the work family. Respect is not only important within the work family, but also within the wider community—with all stakeholders, including the children and families.

Core work family values were identified and constructed throughout focus groups and individual interviews. It was apparent that all staff share the core work family values of not only respect, but also trust, loyalty, honesty, and mutual guidance and support. When these values are challenged, this can compromise attachment to the family, leading to isolation of the staff member. This seems particularly pertinent when mutual support and guidance of a staff member is lacking—either they do not have the capacity to care for others in the team, or they are not being adequately cared for within the team. This can be seen in the memo following an individual interview, which was with a staff member who had left the unit prior to participating in the study:

Although the family of a New Zealand children's blood and cancer center is clearly defined by their values and shared goal, each staff member develops their own identity, with their own role and responsibilities within the family, as can be seen from the following quote:

To be able to have an identity as a professional within the work family, staff need to have the common goal of providing quality care to children and families at the heart of everything they do.

Having an Identity

Over time staff working in the unit develop a clear identity of themselves that closely relates to their professional role. This identity is about how they see themselves as an individual within the wider family, but also how they see themselves outside of the workplace. For example, a participant who has been a long serving staff member saw his work as identifying and defining who he was as an individual:

Leaders and managers fulfill an important role within the family. They are important in providing support and guidance in the midst of a crisis. The senior leaders identify themselves as being parental figures in the team with a clear responsibility to nurture and care for younger and newer staff. They can be seen as the head of the family who bring the team together and set expectations, family rules, and boundaries.

All team members identify with their work being important and meaningful. They relate to the work and environment being different from other areas of health care, and almost have a sense of “being special” or unique.

Being Special. Staff recognize their role as critically important and acknowledge that it is a highly specialized area to work in. They feel not just any person could do their job:

Staff recognize that their work is glorified and made glamorous by the media. This can make it difficult for staff to identify themselves when asked where they work or what they do for a job. They feel the reality of their work is very different from the picture portrayed to the public, namely, that all children with cancer will die. Some take the opportunity to educate people about the reality and the things they enjoy about the job, while others will actively avoid discussion about their work, despite there being real highlights and positives.

Making a Difference. One of the highlights of the job for staff is the ability to make a difference; this is also a huge part of their identity as staff working in this area. The ultimate goal for many is the delivery of treatment and therapies to enable children to be treated effectively, survive their cancer, and return to “normality.” As quoted, staff enjoy celebrating survivorship and achievements of children they have cared for:

For other staff, the perceived simple things can make the biggest difference. For example, supporting a parent, listening to a family member, developing a plan of care to make a child more comfortable, or playing a game:

Being Valued. There is an element of “making a difference” that needs to be supported and affirmed through appreciation from managers, as well as, children and families. Cards and tokens of appreciation such as chocolates, baking, and food are seen as important to staff. Staff find it perplexing to their own values and beliefs when there is a lack of acknowledgment for the work they have done and what they have achieved.

Ultimately staff need to individually feel valued within the work family and within their community. In identifying themselves as a professional working in the area, they need to feel they are appreciated and valued for the personal sacrifices they make, the challenges they face, and the distress they witness in doing this work. The following quote from a participant really summarizes the value of connection and importance of belonging to the work family:

Strengths and Limitations

This study included all members of the health care team and was carried out across both New Zealand children's blood and cancer units. The theory has been shared with a cross section of staff working in both units, including senior leadership teams. The theory strongly resonated with staff and they felt it described how they operated as a collective group. Despite these strengths, it must be acknowledged there are limitations to the study. The study was a small qualitative study that included only 30 staff across the two units. It is recognized that staff who agreed to participate in the study may be those who are naturally more socially minded and therefore feel a greater connection to the work family. Constructions from data were made by GA, KH, and MG, other researchers may have constructed an alternative storyline. Further research is needed to explore whether this concept is universal to all staff working within children's blood and cancer centers in New Zealand.

Implications for Research and Clinical Practice

This study has highlighted the value in considering all staff working in children's blood and cancer centers as one unit. In both clinical practice and research settings staff are often split into disciplines. This study demonstrates that regardless of discipline, all staff experience similar feelings about their work and can develop and enhance their resilience by belonging to a “work family.” Being socially connected has been recognized as the most supportive intervention and was identified as being of greater value than the traditional one-on-one support that is currently encouraged (van Wyk & Pillay-Van Wyk, 2010; Zander & Hutton, 2009).

These findings provide an opportunity for teams to reflect upon how they approach staff support. It is timely to consider how staff that have traditionally not been visible and present as part of team business, are encouraged and included to have a voice and be active participants in discussion and activities. These changes to structure within a workplace may lead to a change in workplace culture and environment and improved communication. Improved workplace culture, environment, and communication may also lead to happier, more engaged staff, and ultimately improved patient and family care, outcomes, and safety (Hume, 2018). Given nursing is the largest group within any children's blood and cancer center, there is potential opportunity for nurses to lead this culture change. This requires further research.

The theory described in this paper of “being a work family” operates within children's blood and cancer centers in New Zealand. The theory may have relevance and be considered useful in other areas of health care, or other workplace environments.