Heavy workloads, exposure to violence and conflict, and high-acuity patients contribute to a challenging work environment for ED nurses globally.1,2 Efforts should be undertaken to improve the ED work environment to maintain patient safety; for example, by addressing nursing job satisfaction. It's known that increasing nurses' job satisfaction can increase patient safety and quality of care, decrease nursing absenteeism and turnover, and positively influence the health of nurses.2-5 Addressing nursing job satisfaction is also known to be a cost-effective way to positively influence the work environment, which is important in countries facing increasing healthcare-related budgetary constraints such as Canada.3,6 However, EDs around the world are reporting low levels of nursing job satisfaction and high levels of burnout.7-9 Little is known about the challenges and barriers to implementing job satisfaction interventions for ED nurses.
The aim of this research study was to addresses this knowledge gap by determining the challenges and barriers to implementing interventions that increase the job satisfaction of ED nurses, with a focus on the practical implications of the research results to translate findings into practice and increase real-world application.10-12 This study was conducted before the global COVID-19 pandemic, yet the results are even more relevant in the current pandemic climate. The COVID-19 pandemic has dramatically increased the physical and mental stressors endured by ED nurses and further emphasizes the need to address work environments to ensure patient safety and the sustainability of the essential nursing workforce.
Methods
Purposeful maximum variation sampling was used to select participants from across Ontario, Canada.13 Participants held a current or recent (within the past 6 months) ED management position at a hospital and were included if they were able to complete a survey and a 60-minuteinterview. The application of maximum variation sampling decreases the risk of selection bias by ensuring that the sample is as close to an accurate representation of the population of ED managers as possible.14 Variety of this type encourages a holistic understanding of a phenomenon and brings value to qualitative research.15
Each hospital in Ontario can be placed into four categories based on population density: large urban population centers (population greater than 100,000 people), medium population centers (30,000 to 99,999 people), small population centers (1,000 to 29,999 people), and rural areas (all other areas).16 The 2016 Statistics Canada Population Center and Rural Area Classification document was used to determine the category of each participant's workplace.17 Hospitals were chosen from each of the four population density categories and from a well-distributed geographic location. Only one hospital was chosen from each geographic area. All selected hospitals had an ED. No ED managers who had an existing relationship with the investigator participated in the study. A minimum of two managers from each population density category were selected.18 This study was approved by the investigator's university research ethics board.
A mixed methods research approach was used to deepen the understanding of real-world barriers. A short quantitative descriptive survey was designed, as well as a semistructured qualitative descriptive interview based on the literature review.19 Qualitative descriptive studies produce findings that have rich descriptions, and the results of these studies increase the depth of knowledge about both clinical situations and participants' experiences.20 The semistructured format allows the same general information to be collected for all participants while simultaneously ensuring full expression of the participants' viewpoints and decreasing researcher bias.21 A pilot study was conducted to decrease measurement bias; the pilot study results weren't used in the data analysis.14,21
Quantitative data were entered into statistical software and descriptive and frequency statistics were calculated. Qualitative data from the interviews were analyzed iteratively using the six-phase model of thematic analysis.22 Data collection and analysis occurred concurrently. To protect the privacy and confidentiality of participants, the ED managers are referred to by the gender-neutral third person pronouns they, them, and their.
Quantitative results
Out of the 18 ED managers contacted, a total of nine participants completed both the survey and the interview and were included in data analysis. (See Table 1.) Every population center category had two participants (22%), except for the medium population center category for which there were three participants (34%). Just under half of the participants identified as female (44%) and the others identified as male (56%). The majority of participants were ages 31 to 50 (78%). All managers had a nursing background, and most participating managers (78%) had less than 5 years of experience as ED managers.
Participants demonstrated a strong knowledge of the known correlation between nursing job satisfaction and patient safety, nursing staff turnover, absenteeism, and nurse health, with all nine participants either strongly agreeing or agreeing with these correlational statements. All nine participants strongly agreed that job satisfaction is correlated with staff absenteeism. Questions regarding measurement of job satisfaction produced the most variation in participant responses. Thirty-three percent responded that they neither agreed nor disagreed that job satisfaction measurement tools exist, 45% neither agreed nor disagreed that accurate tools exist, and 78% neither agreed nor disagreed that cost-effective tools exist. One participant disagreed that job satisfaction measurement tools and cost-effective tools exist, and two participants disagreed that accurate tools exist.
Questions regarding the implementation of interventions produced unanimous results, indicating managers believe that job satisfaction interventions, including cost-effective ones, exist. Only one participant indicated that they neither agreed nor disagreed that cost-effective interventions exist. Participants also unanimously agreed that job satisfaction, job satisfaction measurement, and job satisfaction interventions are important in the ED, with all participants either agreeing or strongly agreeing with this statement.
Participants were asked to rank the importance of issues (requiring immediate attention) in the ED, with 1 indicating the least important issue and 10 indicating the most important issue. Managers ranked the importance of addressing job satisfaction (M = 9.22) and creating job satisfaction interventions (M = 9.33) as being of utmost importance (requiring almost immediate attention), whereas measuring job satisfaction (M = 8.00) remained important but less urgent than creating job satisfaction. Variability existed in participant responses when they were asked if the organization believes job satisfaction to be an important issue in the ED. Two participants (22%) strongly agreed, five (56%) agreed, one neither agreed nor disagreed, and one disagreed. This was reflected in the ranking questions where participants indicated that the organization places less importance and immediacy on the issue of job satisfaction (M = 7.78) than managers do (M = 9.22).
Qualitative results
Three main themes emerged from analysis of the interviews: lack of control, lack of time, and lack of tools. The themes highlighted the differences in barriers faced by managers working in smaller and more isolated hospitals versus those working in larger urban centers. (See Table 2.)
Lack of control
Managers of smaller and more isolated hospitals noted that many factors influencing job satisfaction were outside of their locus of control. They felt that these factors acted as barriers to increasing nursing job satisfaction because the managers felt powerless to change them. ED managers working in larger urban centers also reported many factors that were outside of their locus of control, but the factors differed slightly from those described by managers of smaller hospitals.
Specific areas where managers of smaller and more isolated hospitals indicated lack of control included:
* community infrastructure. One manager of a multisite organization stated, "A lot of times, because the towns are small...they don't have the infrastructure for people to find sufficient work and housing. This is an issue up here, too. So even when we can recruit new grads...sometimes we have trouble finding housing for them." Two other managers cited a lack of day-care availability and a lack of adequate education for children due to understaffed schools as major barriers to increasing job satisfaction and retention of ED staff members with families. The lack of adequate schools also influenced the ability to recruit homegrown nurses because the level of education that local students can access in smaller communities didn't prepare them to gain acceptance to nursing programs after high school. Consequently, the smaller, isolated hospitals were staffed primarily by nurses who didn't have existing ties to the community. Retention of these nurses was also an issue.
* community members' respect for, and understanding of, the nursing profession. One manager reported that in their community, "nurses aren't respected the way we used to be." The manager stated that patients expected nurses to be "subservient to the community" versus just "doing their job," indicating a disconnect between expectations and the reality of care provided in the hospital. This attitude influenced the way patients treated nurses, and the manager stated that it significantly decreased nursing job satisfaction.
* external hospitals and transportation services. Smaller hospitals frequently must transfer patients to other facilities due to lack of specialty services or equipment, and the time waiting for transfers can drastically increase ED nurses' workload and stress. One manager described waiting for 4 days for an evacuation of a patient with mental health issues. In facilities where there was one RN in charge of the entire hospital, including the ED, the manager stated that having a patient who required 1:1 care in the ED for a few days dramatically changed the hospital's staffing needs. Staffing requirements were frequently unmet due to a lack of available nursing staff in the community. These stressful situations contributed to nurse dissatisfaction, yet the ED managers expressed that they had no control over them.
* natural environment. Rural communities often face environmental challenges, such as ice break up, flooding, and inclement weather, that influence hospital functioning. These environmental factors can acutely change hospital staffing needs, are largely unpredictable, and can't be controlled. Nurses who are present in the community are heavily relied on, and one manager reported that nurses are frequently called into work (even after having just finishing a shift) at undefined times. These nurses often come into work out of obligation to the team and community. The manager stated that this dynamic creates a poor quality of life for nurses because they feel they can't make plans due to feelings of guilt associated with not being present when needs arise.
The main areas of concern for managers of larger hospitals in more populated areas included:
* admitted patients remaining in the ED. One manager explained that an increase in the number of admitted patients staying in the ED who have no assigned bed on other units (due to capacity issues in the rest of the hospital) resulted in fewer beds available for emergency patients. Fewer available ED beds decreased patient flow in the department, causing increased wait times, higher volumes of patients in waiting rooms, and increased stress on staff due to decreased ability to provide safe and timely care.
* violence and abuse. Managers reported an increasing frequency and intensity of violence and aggression toward nurses from both patients and family members, which decreased nursing job satisfaction. Managers of medium-sized population centers especially reported frustration from a lack of control over being able to provide staff with the infrastructure needed to assist violent patients who needed isolation due to safety concerns. Managers stated that infrastructure and staffing changes, which could be achieved by adding more isolation rooms or around-the-clock security personnel, weren't seen as priorities by the organization's administrators due to the large monetary investment required.
Lack of time
All managers expressed at some point in the interview that they had limited time and being constantly busy was a part of their everyday work life. All participants reported that adequate time was needed for them to be able to positively influence nursing job satisfaction. They noted that time was required for them to access what was happening within their departments, with the goal of understanding the dynamics and needs of the ED and staff. They said it took time to find or create interventions to influence the areas in need of improvement and follow-up and evaluate the effectiveness of interventions.
All managers reported that they determined the amount of time and attention they gave to issues based on their priority. High-priority issues took up most of the managers' time because they required immediate attention and included urgent issues (such as attending an assaulted triage nurse, filling gaps in the schedule due to sick calls, addressing performance issues like documentation errors, and responding to reports of bullying) and the time-defined priorities dictated by the organizational administrators (such as implementation of electronic documentation).
One manager stated, "It's overwhelming sometimes, the sheer volume of [tasks]... you can get really stuck in really just trying to put out the fire that's in front of you and not manage something that's sort of smoldering off to the side." No manager reported that job satisfaction initiatives had any definitive time line, and managers reported that although the organizational leaders placed value on the idea of job satisfaction, this value was not translated into a priority.
Managers of smaller and more isolated hospitals reported challenges with:
* recruitment. ED managers in smaller hospitals reported that recruiting new nursing staff took a large amount of their time and prevented them from being able to focus on nursing job satisfaction issues. One manager reported spending 3 to 5 hours per week on telephone interviews for nursing recruitment.
* managing multiple departments. Smaller hospital managers were also more likely to be in charge of multiple departments, or even the entire hospital (in rural locations). Managers described this as being very time-consuming, requiring them to "wear many hats" and perform many duties outside of managing the ED. One manager stated that frequent changes between the two departments in their portfolio caused their nurses increased stress because there was no second layer of leadership for staff to rely on. One manager described the inherent risk of having only one layer of leadership at the hospital by stating, "If something happened to me...there's nobody here who can just walk in and carry on."
* protocols, policies, and accreditation. One manager in charge of the entire hospital expressed their frustration regarding the amount of time spent on accreditation for long-term care, citing that they're "plagued" with this process, which alone is a full-time job. Another barrier identified by managers was the time required to write new policies and protocols for their ED. The managers stated that although these policies and protocols did contribute to a better work environment, they also resulted in time away from focusing on job satisfaction initiatives.
Managers of larger hospitals in more populated areas noted the following challenges:
* large numbers of nursing staff and differences in generational needs. Managers felt like they weren't able to dedicate enough time to being present in the department or getting to know the diverse needs of their staff. With increasing staff numbers, the issue of generational differences was accentuated. Although one manager of a rural hospital commented on a perceived lack of self-direction among some younger nurses, these issues were amplified in larger hospitals due to the number of staff members. One manager reported that several younger nurses were less resilient, had fewer coping strategies, and expressed a different sense of accountability compared with their older nurse counterparts. Two other managers stated that the younger generation of nurses had very different needs compared with older nurses, citing specifically that the younger nurses expressed an increased desire for work-life balance. Three managers in larger population centers stated that older nurses were more resistant to departmental changes, especially large-scale changes. One manager felt the need to create different types of job satisfaction interventions based on generational characteristics. Considering these differences in staff needs requires a huge investment of time and can increase the complexity of implementing job satisfaction interventions.
* policy and procedure. Although ED managers from both larger and smaller hospitals reported that any change takes a long time, effectively implementing changes in larger hospitals took longer due to the layers of bureaucracy that exist.
Lack of tools
All managers indicated that a significant barrier to increasing job satisfaction was the lack of readily available, accurate, and cost-effective tools for measuring job satisfaction and implementing interventions to increase it. All nine managers stated that their organization had some variation of a worker satisfaction survey administered by the human resources department or an external organization. Even though hospitals put a lot of time, money, and good intention into implementing these surveys, all of the managers reported that the surveys didn't produce useful or useable results.
Managers described these surveys as being too generic and closed-ended, not specific to the ED, and unable to provide real-time information or information that could be used for real departmental change (especially concerning job satisfaction). One manager noted that when too many surveys are distributed to staff, survey fatigue can influence the reliability of results. Additionally, managers of smaller hospitals reported that the smaller number of staff completing worker satisfaction surveys inaccurately skewed the results. Many managers mentioned the ubiquitous "bad egg" worker who had an unwavering negative attitude that could influence survey results yet was rarely taken into consideration.
Some managers from both large and small organizations made explicit that in the staff satisfaction surveys, what staff members say they want isn't always what managers think they need. There were certain issues, such as workplace bullying and performance issues, that managers recognized as being important influencers of job satisfaction, but these issues were less likely to be reflected in satisfaction surveys. Managers stressed the importance of involving staff in the process of identifying areas for job satisfaction improvement, but not allowing this to overshadow the system perspective regarding important issues brought by departmental leaders.
Most managers reported relying on their nursing background, intuition, and communication skills to feel the pulse and morale of the department and not needing tools to measure satisfaction. One stated, "I don't need an organization to let me know that my staff [is] not thrilled." Regarding their staff members' job satisfaction, managers reported that they can "just know or feel it" and "it's one of those palpable things." There was a general sentiment that it took too much time to research evidence-based measurement tools and interventions because these resources weren't readily available.
Managers also noted the importance of being able to act on information when it's collected; however, although all nine managers reported that their organizations implemented surveys, only one manager indicated an action plan was developed based on survey information. Most managers lamented the fact that they didn't have any efficient means of communicating with other ED managers and no effective communication platform to exchange ideas regarding job satisfaction in the ED environment.
Discussion
Many managers stated that they went out of their way to participate in this study because they believed in the importance of the topic and wanted to contribute to building collective knowledge about the issue. Both methods of data collection revealed that managers had a high level of knowledge regarding job satisfaction and they understood the benefits of high nursing job satisfaction and the detriments of low job satisfaction in their departments. However, data revealed that managers lacked concrete, easy-to-use, and cost-effective ways of measuring job satisfaction; easy access to evidence-based interventions known to influence job satisfaction; and ways to measure the impact and success of these interventions. It was clear that these barriers were a source of frustration for managers. The desire to improve nursing job satisfaction was present, but the tools to do so weren't.
Overcoming lack of control
Lack of control is one of the most difficult barriers to overcome. Creative solutions are required, and further research is needed to find larger systemic solutions. Especially with issues that can't be controlled, communication is essential to make departmental needs known and promote external action and change.
For smaller and more isolated hospitals, effective communication with the community is imperative. If possible, the community needs to understand the causal mechanism of a lack of nurses and the consequences they'll feel as healthcare system users. For example, if housing isn't provided or maintained properly, nurses won't feel comfortable in the area and will have less incentive to stay and work, which decreases their ability to provide the care that the community needs.
For larger hospitals in more populated areas, it's essential that there's effective communication between departments. Some managers reported that cross-training nurses where possible is a way to create an understanding and empathy of difficulties faced by nurses from other units. When cross-training isn't possible, providing opportunities for both nurses and leaders to physically spend time in different departments to get to know their processes may lead to insights and show how pitfalls in patient flow influence various departments.
Overcoming lack of time
Even though this barrier is technically manipulatable, overcoming it is more complicated than simply providing managers with more time. Time is also related to funding distribution, which most managers only partially control. This lack of total control over resources adds an additional layer of complexity. The most important change that can be made with respect to time is the transition of job satisfaction from an important issue to an issue that has a time-defined priority within the entire organization.
One problem with this approach is that job satisfaction is never technically solved. Maintaining nursing job satisfaction is an ongoing process that needs to be reevaluated and recalculated constantly depending on staff and department needs. One manager stated that the problem with undefined issues is "when everything is a priority, nothing is a priority." Time-stamping job satisfaction measurement, intervention implementation, and reevaluation has the potential to move the issue from the sidelines to the playing field. However, this change of priority can't be done without acknowledging the required investment of time and money by managers.
Smaller and more isolated hospital managers who spend a large amount of their time on recruitment may benefit from investing in an external recruiting firm or agency to fulfill this role. Although such an approach requires an initial investment, it can increase departmental efficiency and free up the manager to spend time improving the work environment. Employing a professional recruiter can save money if nurses are retained, which means less needs to be spent on recruiting and training staff.
Another area where smaller hospitals can save time is to collaborate with bigger hospitals when writing policies and procedures to improve work environments. One manager reported saving a large amount of time by using another hospital's naloxone distribution protocol as a template. Additionally, using another facility's protocol opened communication channels between managers in the two locations and created a platform where they could exchange ideas and promote knowledge sharing about successful interventions.
Managers who have a larger number of nurses to oversee can benefit from appointing an employee (perhaps part time) to specifically focus on issues involving the work environment, staffing, and job satisfaction. This approach requires an up-front investment, but the amount of money spent on training new nurses indicates the need for more investment in retention strategies. Under the current model, ED managers can't invest adequate time in creating appropriate interventions to address these issues without assistance. One manager described their experience with such a dedicated position in their department. Although no formal data were collected at the time of the interview, they reported that the position was an immense help in enhancing work environments and increasing staff satisfaction.
Another barrier in larger hospitals related to the large number of staff was the time required to implement interventions for different generations of nurses. Managers reported issues of resiliency and coping mechanisms in newer nurses and resistance to change in older nurses. One option for improving resiliency and coping is to mandate nursing programs address new and emerging issues in the curriculum. Nursing curricula need to adapt to the changing needs of the new generation of nurses and also the changing needs of the hospitals where they'll work. Providing resiliency training during nursing education may increase the ability of new grads to cope with the changing patient environment, improving job satisfaction.
Larger hospitals also need to determine how to streamline their decision-making and approval procedures, creating more efficient ways to implement interventions related to the ED work environment. If an intervention takes multiple years to pass through the many levels of bureaucracy before it can be implemented, chances are that departmental needs may have already changed, resulting in a waste of time and money.
Overcoming lack of tools
It's clear that organizations are placing a high value on staff satisfaction and they understand how it influences staff retention. The value of job satisfaction is reflected in the fact that the participants' organizations deploy some form of staff satisfaction survey every few years. However, the lack of action reported by managers in response to these surveys indicates the need to increase the usability of this tool in practice. If these surveys are to be useful, they need to be changed to reflect managers' needs, such as making them more ED-specific, including more open-ended questions so issues can be raised, focusing questions on the needs of specific departments, and allowing opportunities for different generations of nurses to express their needs. The point of these surveys shouldn't be to see what the levels of job satisfaction are, which was said to be largely useless for managers, but rather a way to explore where improvements can be made and why these are the areas that need to be addressed.
Process transparency and staff involvement are essential when ED managers implement interventions focused on increasing job satisfaction. Getting staff members involved increases the potential for producing real and useable change because it's based in their reality. However, as many managers voiced, interventions shouldn't be based solely on staff feedback. The perspectives of organizational and ED leaders should also be considered due to their ability to see the whole system.
One manager reported using the results of the staff satisfaction survey to introduce changes in the department by allowing staff to choose a few topics that needed improvement and combining these choices with topics chosen as priorities by ED managers and the organization. This balances staff and organizational perspectives and increases the chance for meaningful change to occur.
In smaller departments, organizations and leaders need to be aware of the bias that can be introduced by smaller numbers of staff. The results of staff satisfaction surveys should be less focused on quantitative results and more focused on the dialogue that surveys can create from qualitative data. This type of dialogue would be more helpful in reflecting nurses' reality because statistical analysis on small sample sizes can produce biased results.
Many managers preferred a satisfaction tool that included a list of specific evidence-based interventions that they could refer to. Managers often asked the researcher what other managers were doing, what the situation was in other departments, and if they had similar issues or any novel solutions. Currently, there's no practice community where ED managers can communicate with each other to share this valuable information. Managers may benefit from having a communication platform to share ideas and give recommendations to one another.
Managers are clearly experiencing similarities in their challenges to increasing job satisfaction, and issues are different based on hospital size and the community they're based in. The ability of ED managers to share practical experiences may increase the translation of knowledge into practice and result in more timely departmental changes. However, it shouldn't be assumed that there's a one-size-fits-all solution to increasing ED nurses' job satisfaction. Interventions to increase job satisfaction should be tailored to departmental needs and all barriers considered to increase success.
Limitations
There's a risk of selection bias in the participants who took part in this study. The managers who didn't return calls and those who couldn't commit to the 60-minute interview may have had more stress than the managers who participated, which could influence the results. Reflexive and methodological journals detailing the researcher's thoughts and processes, as well as a clear audit trail, minimized researcher bias.
Take action
Although it's clear that managers and administrators have a high level of knowledge about the issue of job satisfaction and see it as important, there needs to be an investment from all levels of stakeholders to overcome the specific challenges related to ED managers lacking the control, time, and tools necessary to improve nursing job satisfaction.
Nursing schools need to update their curricula to reflect the changes in realities faced by new nurses and prepare nurses for extended scope of practice, as well as providing resilience training to help new nurses cope with real-world stressors. Organizational leaders need to redistribute priorities and funds and promote forward-thinking long-term prevention strategies versus band-aid solutions, which ignore the root of the problem and increase long-term costs for the hospital. ED managers need to advocate for departmental needs and ensure constant communication with staff and organizational administrators regarding the issues that are preventing them from improving job satisfaction. ED nurses need to take initiative by involving themselves in their work environment, maintaining constant communication with their leaders, and advocating for the needs of their patients. Researchers need to create useable, practical, evidence-based resources addressing job satisfaction that are specific to the ED and take into consideration the variety of barriers faced by hospitals in different population densities.
Only when all stakeholders take action on this issue and invest time, money, and energy will true practical and sustainable change occur to create safer and healthier EDs for patients and nurses.
INSTRUCTIONS Emergency nursing job satisfaction: Challenges and solutions
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REFERENCES