Martha Rogers’ science of unitary human beings in relation to workers health and well-being: A scoping review

2.1Design

This review aimed to broadly map the literature regarding workers health and well-being in relation to the science of unitary human beings. This is an appropriate method to do to prepare for a more comprehensive review [20]. Reporting of the study followed the PRISMA extension for scoping reviews (PRISMA-ScR) checklist for reporting scoping reviews [21], where applicable.

2.2Search methods

The database searches were performed with support from a specialized librarian, to decrease the risk of bias, and were inspired by recommendations from the Cochrane handbook [22], and the PEO framework (Population – Exposure – Outcome) [23]. To identify relevant search terms, initial searches were conducted in PubMed and CINAHL. The articles found were screened for index terms and words in title and abstract. The literature search was then performed in PubMed and CINAHL in May-June 2022. The journals Holistic Nursing Practice and Nursing Science Quarterly were also screened for relevant articles, as were all available issues of Visions: The Journal of Rogerian Scholar Science. Further, PROSPERO was screened for relevant protocols. The search process began with single searches with terms relating to workers and Rogers’ theory. Both free-text and subject headings were used when possible. Then, terms relating to the same concept (e.g., Rogers’ theory) were combined using the Boolean term “OR.” Thus, there was one search block relating to workers and one search block relating to Rogers’ theory. These blocks were then combined with the Boolean term “AND” to direct the search more towards the aim of this review. The search strategy is presented in detail in Tables 1, 2.

2.3Search outcomes and study selection

The inclusion criteria were original studies with qualitative, quantitative, or mixed methods approach, regardless of design. The studies had to have used Rogers’ science of unitary human beings to study workers health and/or well-being in working life. Reviews, theoretical articles (e.g., concept analyses, editorials, columns and discussion papers), case studies, pilot studies, psychometric studies, studies only focusing on patient care, studies with no relation to working life (e.g. studies among workers well-being only in private life), theses, articles in other languages than English, and articles only including other theories than Rogers’ (e.g. middle-range theories derived from Rogers’ theory) were excluded. As the initial search indicated that there was a limited number of articles in the area, no timeframe was chosen. In the first step of the selection process, duplicates were removed. The remaining articles were then screened for eligibility based on the inclusion and exclusion criteria, in a step-wise fashion (see Fig. 1, PRISMA Flow diagram) [21]. Subsequently, the reference lists of the studies that met the inclusion criteria were screened, as well as the article citations in Scopus and Web of Science. However, no additional article was identified in this way. In total, five studies met the inclusion criteria.

Fig. 1

PRISMA 2020 Flow diagram illustrating the selection process.

2.4Data analysis

The first research question was answered using Silva’s [19] classification of theory use, i.e., minimal use, insufficient use, or adequate use of theory. Minimal use means that a theory is briefly summarized in a study but does not really contribute to the research. Insufficient use means that a theory helped the researchers to organize their study, e.g., in choosing instruments for data collection. Adequate use is when a theory is explicitly tested, e.g., that study aims are derived from the theory. Silva described seven criteria for assessing the use of theory, which formed the basis for the assessment. The seven criteria were structured into a table, and the application of the theory in the included studies was analyzed and entered into the table. To answer research question 2, quality assessment of the included studies was performed using the Joanna Briggs Institute’s critical appraisal templates for cross-sectional and qualitative studies [24] and the Mixed Method Appraisal Tool (MMAT) for mixed-method studies [25]. No study was excluded due to quality limitations, as article quality is not the main focus in a review about use of theory [26]. Quality of study methodology and theoretical use are different research areas, meaning that high-quality empirical methods do not necessarily cooccur with adequate use of theories and vice versa [26]. However, quality assessment provides important information about the kind of studies in which a theory has been used. To answer research question 3, a manifest deductive content analysis [27] was performed, based on the aspects of work environment described in Oludeyi’s conceptual review [7]. First, a matrix including the three aspects of work environment was created, and data regarding work environment were extracted from the articles and compiled in a document. Then, the extracted data were interpreted based on if they belonged to the human aspect, the technical aspect, or the organizational aspect, and sorted into the matrix. To answer research question 4, a standardized extraction form, as described by Whittemore and Knafl [28] was used. This is a way to ensure that the same kinds of data were extracted from all studies, so they could be compared. Inspired by Whittemore and Knafl [28], the findings were extracted from the studies and entered into the form. Then, the data were compared across the studies to identify similarities, relationships and differences to create groups/categories, which then were abstracted to create an overall theme.

3.1Study characteristics

Of the five included studies, one was from 2016 [29], one from 2006 [30], one from 2005 [31], one from 1996 [32], and one from 1994 [33]. All studies originated from the United States, but had different authors. Four of the studies had a quantitative (cross-sectional) approach [30–33] and one used a mixed method approach, including a pretest-posttest design [29]. All study populations encompassed nurses. The studies related to working life in different ways, i.e. therapeutic touch at the work place with colleagues [29], nurses’ level of interaction with their nursing environment [30], job satisfaction [31], stress at work [30, 31], measures of work culture and work characteristics [33] and nurses’ social support at work and their willingness to care for AIDS-patients [32]. An overview of the study characteristics is provided in Table 3.

3.2Theory use assessed using Silva’s classification

One of the studies [29] had minimal use of the theory. This meant that the theory was mentioned in the introduction as being related to the exposure in the study, without contributing more to the study. Two studies had insufficient use of the theory [30, 33], i.e. the theory guided data collection but was not tested per se. Two of the studies [31, 32] used the theory adequately, i.e., it shaped the hypotheses and was actually tested. Hence, conclusions could be drawn based on the theory. However, these studies included other theories as well, which contributed to the theoretical framework together with Rogers’ theory. Table 4 gives an overview of how the theory was used in the studies, assessed using Silva’s classification.

3.3The quality of the included studies

The studies were found to have varied quality. One study [32] had no quality flaws according to the assessment tool, while the others had varying degrees of quality. This most often concerned lack of identification of and/or dealing with confounders [31, 33] and lack of clarification whether the variables had been measured in a valid and reliable way [30, 33]. One of the studies [33] had more methodological flaws than the others. For example, participant characteristics were insufficiently described. In another study [31], it was unclear whether objective standard criteria were used for measurement of the condition (if the condition was seen as being a nurse). In the mixed-method study [29], there was no rationale for using a mixed-method design. Hence, the contribution of the design to the knowledge field was unclear. Also, the different components of the study did not adhere to the quality criteria of the tradition of each method used, with the procedure and characteristics of participants insufficiently explained. For example, the time between pre- and posttest occasions and the number of participants in the quantitative part were not described. Overviews of the quality assessments are presented in Tables 5, 6.

3.4Use of the theory-based concept environment in relation to work environment

The deductive qualitative analysis showed that the theory-based concept environment was related to work environment in four of the five included studies [29, 30, 32, 33]. The study that did not include work environment [31] is therefore not represented in this part of this results. The analysis revealed that all aspects of work environment, i.e., human [29, 30, 32, 33], technical and organizational aspects [33] were represented in the studies, but that use of the human aspect was most common. Four of the studies [29, 30, 32, 33] represented the human aspect, but one study represented all three environmental aspect, albeit superficially [33]. The matrix from the deductive analysis is shown in Table 7.

3.5Major findings in the studies

One overarching theme emerged in the analysis: Well-being as an essential phenomenon in working life in all dimensions of existing. This theme reflects that well-being was a relevant matter for the workers (nurses) as a manifestation all the way from the physical to the existential dimension. Four dimensions were identified in the analysis: The physical, the body-mind, the psychological and the existential. The text below describes the findings in relation to these dimensions. For an overview of the major findings, see Table 4.

Well-being in relation to the physical dimension was sparsely described in the studies. However, the study by Bulette Coakley, Barron & Donahue Annese [29] found that therapeutic touch had an impact on physical aspects. Nurses that received the treatment at work had significantly lower respiratory rates after the treatment compared to before the treatment, and one nurse described how his/her back pain eased [29].

All studies addressed aspects of well-being at the body-mind dimension. Nurses providing treatments or care experienced/reported improved well-being related to this [29, 33] in terms of comfort and increased energy levels, peacefulness, relaxation and overall well-being.

The nurses also experienced/reported psychological aspects of well-being, i.e. focus, stress, anxiety, stimulation, work excitement, job satisfaction, frustration and perceived social support. Nurses experienced increased focus and decreased anxiety when providing therapeutic touch to a colleague [29]. Work excitement were positively correlated with being respected for one’s knowledge, having a stimulating work environment and the opportunity to work with other professionals [33]. A study among nurse managers revealed that they were satisfied with their jobs but anyway scored high levels of stress. Stress was however not related to their job satisfaction but with other factors, such as having direct care responsibilities alongside the manager-work [31]. In contrast, the nurses in Lucero and Sousas study [30] perceived stress only sometimes to fairly often. However, the more perceived stress among the nurses, the less engagement they had in their nursing environment. Stress was also present among nurses that provided therapeutic touch to their colleagues [29]. They could feel that it was difficult to relax during the treatment because they were working at a busy unit and couldn’t stop thinking of everything else they needed to do [29]. The feeling of frustration at work was described among nurses due to low staffing, communication problems, and insufficient time to complete work tasks [33]. Regarding perceived social support, Sherman [32] found that this was positively correlated to nurses’ willingness to care for AIDS patients [32].

Two of the studies investigated aspects of well-being at the existential dimension [29, 32], i.e. being a part of a larger context and experiencing death anxiety and spirituality. Nurses in Bulette Coakley, Barron, and Donahue Anneses study [29] felt that they were a part of, and contributed to, an overall healing environment at work when they engaged in therapeutic touch with their colleagues. In Shermans study [32], the nurses’ death anxiety and spirituality (e.g. sense of a mission in life) were associated with their willingness to care for AIDS patients. In other words, a lower level of death anxiety and higher level of spirituality among the nurses were associated with a higher willingness to care for the patients (and vice versa) [32]. For an overview of the dimensions in relation to each other and to the worker, see Fig. 2.

Fig. 2

Dimensions of well-being in relation to the worker.

4.1Methodological considerations

This review is subject to some limitations. First, there is a methodological weakness in that the study selection, analyses, and quality assessments were conducted by a single author. This may increase the risk of bias in the results. According to the Cochrane handbook [23] and PRISMA checklist for reporting systematic reviews [22], it is important to minimize the risk of bias. In this current review, there might be some language bias [23], as several studies was excluded in the selection process due to not being in English. Also, two issues of Visions: The Journal of Rogerian Nursing Science were not available, which means that there might be a so-called location bias [23]. These weaknesses were difficult to prevent. However, a specialized librarian helped with the database searches, which is considered as a strength. A large number of search terms within the same concept was used, which is recommended by the Cochrane handbook [23]. However, health, well-being and working life were not searched for in the data bases but instead selected manually to minimize the risk of missing articles due to a too narrow search strategy. Nevertheless, there is always a risk that some relevant articles were not found because concepts from the theory is not visible in title, abstract and key words. This is a known problem regarding nursing theories [19]. The use of only two data bases is also a limitation, even though the two chosen data bases are highly relevant for nursing research [37]. Furthermore, the exclusion of middle-range theories might have biased the results somewhat. For example, Barrett’s theory of power [18] is closely related to Rogers’ science of unitary human beings and some might therefore argue that the present review does not give an accurate picture of the phenomenon under investigation. However, only the original theory was of interest in this review.

4.2Recommendations for future research

The theory has the potential to be used in future research among workers. More aspects of work environment should be targeted – not least technical aspects, considering the contemporary era. I would also suggest more qualitative research as a basis for quantitative research. Research from other parts of the world than the United States would also be beneficial. Furthermore, the theory should be used in research about treatments other than integrative/complementary interventions, for example palliative care and mental healthcare. Because of the theory’s abstract level and that one of its central concepts is an “energy field,” researchers might believe that the theory belongs within “alternative medicine.” However, the essence of the theory is non-controversial and could be used in almost all kinds of nursing research. The theory was used at the individual level in the included studies. This is appropriate, as the theory described individuals and their integrality with the environment. However, there is also a potential to use it at the group level [17] or the organizational level [38]. For example, organizations are in interaction with the surrounding society, which affects their role in society and how well-functioning they are. This might be another way of using Rogers’ theory in relation to work life. The theory could also be used among other professions than nurses, as it is seen as universal and general [5], i.e., not restricted to a certain context or profession. Since we also live in an era in which research about epigenetics [39] is increasing radically, the human-environment interaction is more relevant than ever. A systematic review could be conducted as well, including more data bases and other sources.