Effects on Job Satisfaction amongst ER/ED Nurses (A Middle Eastern Perspective) in Saudi Arabia
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Abstract
Job satisfaction is an imperative component not just among Emergence Room (ER) nurses, but also leads to improved patient outcomes. The purpose of the systematic review was to investigate the effects of jobs satisfaction among ER nurses. The review utilised four practice-oriented questions to highlight the state of job satisfaction, the impact of nurse turnover on the delivery of healthcare services, the role of leadership in creating work environment that assures job satisfaction and how interaction among nurses and independent practice impact job satisfaction. The systematic review based on previous studies about job satisfaction among ER nurses. However, it was guided by Herzberg’s Theory of Motivation-Hygiene Factors. Inclusion and exclusion criteria were used to select relevant articles. Findings indicate low-to-moderate level of job satisfaction among ER nurses. This may be attributed to burnout, work overload and patient congestion in ER. Job specialisation, favourable workplace and supportive management lead to job satisfaction. Though systematic review was applied, grey areas were never incorporated. Hence, future studies should explore the relationship between job satisfaction and burnout.
Table of Contents
Abstract 2
1.0 Introduction 4
1.1 Problem Statement 6
1.2 Significance of the study 7
1.3 Research questions 7
1.4 Research objectives 8
2.0 Literature Review 8
2.1 Theoretical framework 8
2.2 Job Satisfaction 11
2.3 Leadership Behaviours 16
2.4 Nurse Independence 18
2.5 Negative Staff Interaction and Relationships 19
3.0 Methodology 20
3.1 Brief summary of the literature 20
3.2 Systematic review vs literature review 20
3.3 Search strategy 21
3.4 Inclusion and exclusion criteria 22
3.5 Methodological quality assessment and data extraction 24
4.0 Results 24
4.1 Levels of job satisfaction 26
4.2 Factors that positively influence job satisfaction 26
4.3 Factors that adversely affect job satisfaction 27
5.0 Discussion 29
5.1 Comparison of systematic review and past literature 29
5.2 Job satisfaction among ED nurses 31
5.3 Implication in nursing practice 32
6.0 Limitations 32
7.0 Conclusion and recommendations 33
8.0 References 35
1.0 Introduction
Reforms in healthcare have contributed to increased demand for healthcare services while increasing nursing turnover and shortages. According to Asegid, Belachew and Yimam (2014), job satisfaction is considered as a crucial competent issue for nurses’ retention. Nursing shortage is not only a recurring issue for healthcare organisations but also marked with significant costs, safety and reduced level of satisfaction for nurses and patients (Suárez, Asenjo and Sánchez 2017). Furthermore, nursing turnover continues to increase in healthcare sector. The National Healthcare and Registered Nurse Retention Report indicate that the rate of nursing turnover for bedside nurses is 17.2% (National Solution Inc. 2019). Furthermore, the turnover rate for emergency department (ED) is about 101.1%. The high rate of ED nurse turnover is attributed to inadequate role clarity, poor communication, and lack of collaboration, insufficient development opportunities, overload and burnout. The problem of nursing turnover is prevalent in industrialised nations and continues to increase. Evidence shows that by 2020, there would be a nursing shortage of approximately one million nurses (Cox, Willis and Coustasse 2014). The crisis if nursing shortages is adversely affecting the ED compared to other nursing areas. The reduced supply of registered nurses (RNs) has widely been investigated and consists of retention challenges, aging population and low enrolment in nursing schools (Haddad and Toney-Butler 2019). The ED is a unique workplace setting, and yet inadequate staffing leads to inadequate patient care loads, and increased patient-nurse ratio owing to overload (Suárez, Asenjo and Sánchez 2017). Besides, there is considerable risk of violence related to working in ED. For instance, a study by Sawatzky, Enns and Legare (2015) found that 82% of RD nurses have been assaulted at some point in their professional practice. From 1992 to 2002, the ED visit increased with high rate of acuity levels (Sawatzky, Enns and Legare 2015). This contributed to a high demand for nurses whilst reducing the supply of ED nurses. In addition, Eds with high levels of nursing shortages are overcrowded, long wait times and many patients leaving without being attended to. Nursing turnover has a significant effect on the quality of care. In contrast, healthcare institutions with high nursing turnover have considerable rate of mortality as well as lengthy hospital stay (Antwi and Bowblis 2018). Additionally, high turnover is associated with low job satisfaction among nurses. Conversely, nursing shortages result to reduced cohesion and low patient fulfillment. The loss of one nurse can cost a facility the annual cost of ED nurse. For instance, Hairr et al. (2014) allege that retraining an ED nurse can cost the hospital about USD 80,000 while the cost of retaining is USD 140,000. The amount of savings associated with retaining one nurse is important to investigate nurse retention through increased job satisfaction. The nursing shortage adversely affects financial stability of the hospital and the staff. Ramoo, Abdullah and Piaw (2013) argue that existing staff can experience high workload resulting to burnout and reduce job fulfilment. The low job satisfaction worsens the adverse effects of turnover on the entire healthcare organization such as low patient fulfilment, high nurse workload and quality of care. Job contentment has been viewed as the most practical factor that determines whether nurses stay or quit job (Liu et al. 2012). According to Liu et al. (2012), job satisfaction is the emotional state that a person has towards their job. On the other hand, Wang et al. (2012), indicates that job satisfaction is the intensity of positive effect a staff has towards place of work or placement. Source shows that while many findings report positive associations between contentment and the resolve to stay, there is a dearth of data on job satisfaction on the ERs. The current study will inform healthcare organization in formulating strategies that help to curtail ERs. Ramoo et al. (2013) assert that job satisfaction is a complex theory and may be construed differently by different people. Moreover, Ramoo et al. goes ahead to suggest how job satisfaction is a subjective indicator that is dependent on the nature of the job and what the employee anticipates out of it. Because job satisfaction is embedded on a person’s expectations, demographic variables are critical when evaluating how job contentment is shaped. Tarcan et al. (2018) affirm that age, academic level, work experience and gender are associated with job contentment. In this respect, the study examined job satisfaction based on demographic factors.
1.1 Problem Statement
Many healthcare systems around the world, whether from developed or developing nations, grapple with the issue of nurse high turnover. Saudi Arabia is not an exception. According to Alhossaini (2006), Saudi Arabia has been experiencing a high nurse turnover owing to massive resignation among Saudi female nurses. High nurse turnover is a serious peril that calls for an urgent solution to address the shortage of nurses. While nurse turnover strain the healthcare sector because of the extra cost related to recruitment as well as training, it also leads to nurse burnout and poor patient outcomes. Moreover, fewer nurses are often overwhelmed with patients, which affect the quality of care. As such, nurse turnover, is an issue of concern because of the negative effects that come with it. Although ERs are unique work environments, they are also characterised by increased nurse turnover rates as well as high nurse vacancy rates that have a negative bearing on patients and healthcare providers. Based on the 2014 National Healthcare & RN Retention Report, the nurse turnover among ERs is above twenty percent and has been increasing progressively over the past several years. Sawatzky & Enns (2012) contends that owing to the high number of patients visiting ERs every day, the nurse turnover issue should be addressed. According to Liu et al. (2012), high nurse turnover is associated with job dissatisfaction.
1.2 Significance of the study
While many studies have concentrated on job satisfaction wholesome, fewer studies have addressed job satisfaction among ER nurses in Saudi Arabia. Moreover, data on job satisfaction of existing care providers in ERs and reasons of discontent could be instrumental to nursing leaders in terms of finding a lasting solution to scale down the high nurse turnover and ensure ERs have adequate personnel, to enhance the quality of care. In addition, outcomes of this systematic review will enable Healthcare facilities in Saudi Arabia to work in concert with employees in addressing stressors and by ensuring nurses are not only happy but rather deliver quality work. When nurses are motivated, they do not work under pressure but rather because they want to impact the healthcare industry positively. The study results will equally help healthcare facilities and policy makers develop a framework that assures job satisfaction hence reduce nurse turnover. The ripple effect on the healthcare industry will be high productivity, increased revenue, reduced operational costs and improved patient outcomes.
1.3 Research questions
1. What is the state of job satisfaction among nurses working in Emergency Rooms in Saudi Arabia?
2. How does nurse turnover impact the delivery of healthcare services?
3. What is the role of leadership in creating work environment that assures job satisfaction?
4. How does the interaction among nurses and independent practice impact job satisfaction?
1.4 Research objectives
• To establish the current state of job satisfaction among ERs nurses in Saudi Arabia
• To determine how job dissatisfaction affect healthcare delivery
• To examine how leadership can create an enabling workplace setting to attain job satisfaction
2.0 Literature Review
2.1 Theoretical framework
The systematic review is guided by Herzberg’s Theory of Motivation-Hygiene Factors (1959). The theory of Motivation-Hygiene Factors is also called the dual-factor. The theory highlights aspects in workplace setting that contribute to dissatisfaction or satisfaction. Based on the Herzberg’s theory, effective management of hygiene factors can help in preventing employee dissatisfaction. Nevertheless, the hygiene factors cannot be utilized as the basis for satisfaction. While good work place conditions, for example can assist organisations in retaining workers; however, it cannot motivate them to be productive. On the contrary, poor working conditions that are dissatisfying to workers encourage turnover. In reference to the theory of Motivation-Hygiene Factors, organisations can increase employee satisfaction by concentrating on motivating components or satisfiers. Organisations with satisfiers can motivate employees, offer job fulfilment and increase productivity, similalry, lack of job satisfiers does contribute to dissatisfaction and low performance. Therefore, Herzberg theory allege that hygiene factors are basic requirements including supervision, organisational, policies, interpersonal association, job security, working condition, benefits and salary. The hygiene factors are essential in preventing dissatisfaction. Even though hygiene factors are not satisfiers or motivation factors, their absence contributes staff dissatisfaction. Conversely, the theory shows that intrinsic factors are satisfiers that are correlated with job satisfaction. Some of the intrinsic factors are professional growth, accountability, recognition and attainment (Pasaron 2013). Whereas hygiene factors focus on workplace conditions, motivation factors highlight how the job is performed. Previous study by Suárez, Asenjo and Sánchez (2017) demonstrates that ED is a stressful environment and the major cause of job fulfillment. Furthermore, job satisfaction is an important component used for determining individuals’ attitude towards their work. Moreover, attitude influences the quality but also the quantity of work and variables such as rotation and absenteeism Sawatzky & Enns (2012). Clinical studies have emphasised on evaluating job satisfaction and analysis of its components. High hygiene and high motivation means that workers are motivated to work and do not have any complains (Son, Lu and Kim, 2015). On the other hand, high hygiene and low motivation, employees not only complain but also not motivated and consider their jobs as a pay check. When hygiene factors are low and high motivation, workers are very motivated to work yet, they have complaints about working condition. When both motivation and hygiene factors are low, the workers are not motivated and have numerous complaints. Any adjustments on the hygiene factors have temporary impact on job satisfaction. In contrast, adjusting the motivation factors has a long-term influence on performance. Herzberg’s theory identifies unidirectional factors that influence about job, which implies that dissatisfaction and satisfaction are not opposite. Instead, they are influenced by various factors and must be evaluated in a different manner (Pasaron 2013). Herzberg’s theory is appropriate for this study because it offers a platform for identifying factors that affect job satisfaction among ED nurses. Furthermore, the motivation and hygiene factors of the theory are essential in recognising elements to address in determining job fulfilment. Even though Herzberg’s theory is preferred for this systematic review, due to its increased productivity, individuals are inclined to external factors (Shinde 2015). However, productivity greatly relies on external factors. Equally, Herzberg’s theory is selected for this study since hygiene factors can lead to the dissatisfaction of the ED nurses. Equally, motivation factors can increase job satisfaction of ED nurses. Both hygiene and motivation factors can lead to job satisfaction of ED nurses since they highlight the aspects of appreciation, development opportunities, and responsibility (Son, Lu and Kim, M.Y. 2015). Dealing with dissatisfaction cannot satisfy ED nurses rather it is vital to focus on hygiene factors them motivation factors as illustrated below;
Source: (Shinde 2015)
2.2 Job Satisfaction
Job contentment is a critical variable in the preservation of nurses. This is particularly paramount when emphasising the high nurse turnover in ERs. Specialty areas such as emergence rooms are the worst hit in terms of high turnover as opposed to other nursing units. Comprehending variables that lead to job contentment is fundamental in aiding the management at ERs to scale down the issue of high nurse turnover and retain nurses. Yen-Ju Lin et al. (2012) carried out a survey to determine employee satisfaction using a sample size of 442 medics and 119 nurses working in ERs in Taiwan. The study which aimed at comparing the ER culture in relation to job contentment and the goal to leave, established that culture does not influence nurses intent to quite work, however, it has a bearing on job contentment. Furthermore, the study determined that most ERs are flooded with pecking order and market culture that does not auger well with nurses, which leads to job dissatisfaction. The previous study is corroborated by Hairr et al. (2014), which sought to examine the linkage between nurse staffing, job contentment and nurse retention, correspondingly, the authors established a weak association between workload and job contentment. The study also determined an inverse association between job gratification and retention. Just like the outcomes of Yen-Ju Lin et al. (2012), the aspect of lower job satisfaction was also linked to turnover in Hairr et al. (2014). Gaki, Kontodimopoulous and Niakas (2013) undertook a study to establish how demographics and work-related variables influence motivation among healthcare practitioners. Moreover, with a sample of 152 nurses from a varsity hospital in Greece, the authors examined the linkage between job contentment and triggers using Maslow and Herzberg’s concepts. The study found that nurses are motivated as they progress up the longer and the more experienced they get. In this respect, satisfaction also comes with old age. However, poor remuneration and restricted career advancement were associated with low contentment among healthcare providers. In addition, a study El-Jardali et al. (2009), which examined the effect of job contentment and the intention to quit utilising a sample size of 1739 nurses in 69 healthcare facilities in Lebanon is in tandem with (Gaki, Kontodimopoulous and Niakas 2013). About 67.5% of nurses surveyed indicated the likelihood to quit their current job in less than 3 years, while 29.4% intended to quit nursing as a profession. Moreover, just like Gaki, Kontodimopoulous and Niakas (2013), findings by El-Jardali et al. (2009) indicate that external motivations were reasons for the nurse willingness to quit their jobs. Both studies project a single denominator which is, poor remuneration is therefore a critical variable that compel nurses to leave their current placement. Moreover, in a bid to evaluate job satisfaction using a sample of 109 nurses in a hospital in South Africa, Petersen (2005) employed Herzberg’s theory to examine external and internal variables that impact job contentment. In optimizing the Job Satisfaction Questionnaire (JSQ), the author evaluated the attitude of job satisfaction and came up with results where more than 50% of participants were not satisfied with their jobs. What becomes evident with Petersen (2005) that is synonymous to previous studies by Gaki, Kontodimopoulous and Niakas (2013), El-Jardali et al. (2009) is that most respondents were dissatisfied with external factors. According to Bakotic (2014), job satisfaction is staff attitude towards their job and the degree of contentment. As such, an analysis of factors that affect job satisfaction is essential. The view is supported by Tomaževičet, Seljak and Aristovnik (2014), who demonstrate that some of these factors include stressful workplace, working conditions, nurses’ well-being and supervision at workplace. On the other hand, a study by Dinis & Fronteira (2015), which approaches job satisfaction from an economic perspective, shows that job satisfaction plays an important role of increasing organisational performance. In healthcare organisations, job satisfaction is characterised with increased performance and improved quality of care. Based on the importance of ED nurses, their job contentment is important for healthcare institutions. As shown by Kovner et al. (2014), high job satisfaction among ED nurses is related to retention while low satisfaction is characterised by high turnover. The findings are supported by past research which demonstrates that nurses’ turnover is determined by job dissatisfaction. Furthermore, while job dissatisfaction has adverse effects on nurses’ retention, it leads to loss of profit margin for healthcare organization. Moreover, this demonstrates that a suitable workplace is necessary in the provision of quality care and staff retention. Subsequently, unlike, Kovner et al. (2014), Bakotic (2014), Tomaževičet, Seljak and Aristovnik (2014), El-Jardali et al. (2019), Gaki, Kontodimopoulous and Niakas (2013), El-Jardali et al. (2009), a study by Mehrad and Fallahi (2014) illustrate that leadership style is crucial in job satisfaction because it acts as external factors for enhancing employee dedication towards the organisation. Essentially, positive leadership contributes to improve job satisfaction and workplace setting. However, Skogstad et al. (2014) upholds the views of Mehrad and Fallahi (2014) is suggesting that tyrannical leadership results in job dissatisfaction. Authentic leadership style positively affects ER nurses empowerment that enhances job satisfaction as well as performance. Similar to Skogstad et al. (2014), Mehrad and Fallahi (2014), Hocine et al. (2014), demonstrate that employees with supportive leaders have a high job compared to those with unsupportive leaders. Fundamentally, supportive leadership has a direct impact on workers’ job fulfilment. Additionally, there is a strong correlation between employee turnover and job satisfaction. For instance, Skogstadet al. (2014) found that nurse’ views about workplace increased job satisfaction and retention. This is supported by Hocine et al. (2014) who demonstrated that group cohesion was a vital indicator of job satisfaction. Nonetheless, Björn et al. (2015) discovered that nurses’ retention was related to job satisfaction. The view is also shared by Tavakoli et al. (2018) who contend that ER is a stressful workplace marked with workload, long shifts, and physical pressure, which leads to job burnout. The burnout leads to reduced job satisfaction and ER nurses and eventually forced to leave their jobs. Furthermore, nurse turnover is associated with high financial costs and in turn contribute to adverse patient outcomes. Whereas the study by Tavakoli et al. (2018) demonstrate that job satisfaction is crucial in moderating the impacts of job burnout amongst ER nurses, however, Tarcan et al. (2017) posit that the salient drivers between job satisfaction and burnout are unclear. Likewise, in both studies, Tavakoli et al. (2018) and Tarcan et al. (2017) present insights on how healthcare organisations should adopt tools to enhance job satisfaction while reducing job dissatisfaction. In another study, overcrowding in ERs was associated with job dissatisfaction, burnout and long hospital stays (Shamsi et al. 2016). Nonetheless, whereas ERs are satisfied with their jobs, they continue to increase. According to Shamsi et al. (2016), ER is the heart of any healthcare organisation. As well, ER experiences various challenges such as crowdedness, which leads to job satisfaction among nurses. Employee contentment is one of the contributors of efficiency and performance. Furthermore, in nursing job satisfaction is important is directly related to quality of care. On the contrary, job dissatisfaction among nurses contributes to turnover, burnout, and high patient mortality. Thus far, Shamsi et al. (2016) and Tarcan et al. (2017) share a common denominator in their arguments on how burnout among healthcare professionals adversely affects job performance as well as satisfaction resulting to mental health conditions. Furthermore, Shamsi et al. (2016) analogous to Tarcan et al. (2017) suggest that burnout among providers is integral in individual wellness, health and the quality of services. In this case, burnout and job dissatisfaction leads to negative health outcomes including increased medical errors, reduced patient satisfaction, lower quality care and long recovery time. In particular, ER nurses experience burnout that contributes to low job satisfaction. Even though there is association between job contentment and burnout, there is inadequate research about two variables among ER nurses. Gaps in literature indicate that further investigations are required to illustrate and describe the impacts of job burnout on satisfaction of ER providers. Due to congestion and long hospital stays, stabilisation model increase satisfaction among ER nurses. Essentially, stabilisation model can eliminate the congestion and poor management in ER (Shamsi et al. 2016). Evidence shows that human capital outcomes are essential on the performance of the organisation whereas job fulfillment determined workforce performance that is correlated with organisational performance (Tarcan et al. 2017). In retrospect, Tavakoli et al. (2018) adds weights to the previous argument by Tarcan et al. (2017) in citing that Job satisfaction is seen as individual attitude that stems from their perceptions about the career. Other scholars allege that job satisfaction is the emotional reaction to value judgement by an employee, if they perceive that their job value are met them they are fulfilled. Kalleberg theory of job satisfaction provides an understanding between fulfillment and elements of work (Kallebergy 1977). Similarly, Herzberg’s Theory of Motivation-Hygiene Factors (1959) indicates that employee satisfaction is determined by hygiene and motivation aspects. Specifically, even though hygiene factors prevent job dissatisfaction, they do not facilitate satisfaction. In any case, hygiene factors important in preventing negative feelings about work. Motivation factors on the other hand are elements that motivate employees. Therefore, based on Herzberg’s theory, employees satisfied with hygiene and motivator factors are good performers. As an emotional reaction, job satisfaction is accompanied with thoughts associated with work while motivation is a procedure that stimulates behaviour (Alshmemri, Shahwan-Akl and Maude 2017). Furthermore, since satisfaction is an attitude there is a likelihood that an employee might be satisfied with work but not motivated. Inasmuch as job contentment is a unitary aspect, it could multidimensional in nature and should not be ignored. For instance, factors that positively influence job satisfaction are workplace conditions, empowerment, organisational policies, salary, work-related stress, professional and individual development. Not all dissatisfied employees leave their work however dissatisfaction can affect the quality of care and co-workers’. In most cases, dissatisfied nurses present signs of tardiness and violent towards colleagues. While job dissatisfaction is linked to low quality of patient care and safety, highly satisfied nurses’ deliver quality care.
2.3 Leadership Behaviours
While leadership remains paramount, there is need to monitor nurse supervisors to enhance patient care and curtail the high turnover of novice nurses. Coomber and Barriball (2007) contend that transformational leadership may accelerate high quality care and curtail nurses from quitting their current placement. The views on leadership by Coomber and Barriball (2007) are underpinned by Lavoie et al. (2016), who suggest that offensive leadership approaches such as victimization and partiality cannot just have a negative impact on patient outcome, but may also trigger a high nurse turnover. Effective leadership approaches among nurse managers is linked to nurse job contentment and retention. Nevertheless, Unlike Coomber and Barriball who attach more emphasis on transformational leadership, Kleinman (2014) indicates that transactional and transformational leadership approaches are quite effective when it comes to employee satisfaction. While investigating the perception of managers and nurses on the linkage between high turnover and leadership approaches, the study found that different leadership styles and variables lead to effective communication and job contentment in nurses. The conclusion was arrived at using a correlational study that included 79 staff nurses as well as 10 nurse supervisors at a 465-bed community health facility in the North-eastern United States. Leadership is correlated to job satisfaction since it encourages transformation leadership. Yang (2016) alleges that transformational leaders have a positive impact on job fulfillment. Therefore, transformational nurse leaders can influence job satisfaction of ER nurses. The perception by Yang (2016) are consistent with Mulki, Caemmerer and Heggde (2015) who suggest that transformational leadership empowers the staff which then leads to job contentment. However, Yang (2016) discovered that irrespective of leadership style, ethical leaders are instrumental in influencing workers. In addition, nurses’ roles are highly specialised and as a result they require independence. De Poel, Stoker and van der Zee (2014) indicate that employee empowerment comes with independence, creativity, information and responsibility associated with job satisfaction. In their study the authors highlight that nurses with a high degree of autonomy were highly satisfied with their job. Additionally, autonomy is crucial following the technological development in healthcare. In reality, nurses who have influence in their roles feel empowered and contented with their work. The study by De Poel, Stoker and van der Zee (2014) resonates with the perception of Cho and Song (2017) in demonstrating that autonomy and support enhances organisational trust, which in turn lowers turnover. A previous study found that teams with transformational leadership portrayed increased corporate dedication, creativity and highly satisfied with their job (De Poel, Stoker and van der Zee 2014). The follower-leader discussion indicated connectedness and diversity that positively influence job satisfaction via inclusion while reducing intensions to leave. Communication is an important aspect of follower-leader discussion. According to Vidyarthi et al. (2014), the rate of communication affects job satisfaction in low leadership connections. Nonetheless, the authors went ahead to show that a high job satisfaction was noted in cases where there are direct supervision and concrete feedback compared to hierarchically distant leaders (Vidyarthi et al. 2014). These findings demonstrate that leaders have an important influence on job satisfaction, hence, healthcare organisations should offer nurses with leadership training programs. Moreover, leaders are useful in terms of preventing workforce turnover due to their actions. A cross-sectional study by Chen et al. (2015), for instance, infers that nurse leaders who adopted rotation programs achieved higher job satisfaction and enhanced retention of nurses. Just like Chen et al. (2015), Morris and Laipple (2015) indicate that leadership training programs can also present nurse leaders with the basis to encourage wellness behaviour among nursing staff. In the words of Yang (2016), transformational leaders can also ensure a favorable workplace to reduce burnout while enhancing job satisfaction. However, burnout affects the degree of job satisfaction whilst increasing dissatisfaction. In turn, job dissatisfaction leads to turnover.
2.4 Nurse Independence
According to Varjus, Leino-Kilpi, and Suominen (2011), the perception of staff nurses concerning independent practice, role alignment, and work stress are not only responsible for burnout, but rather lead to high turnover. Though suggestions by the previous authors are echoed by Kutne-Lee, Wu, Sloane, and Aiken (2013), the aspect of leadership presented by Yang (2016) finds solace in their arguments. Essentially, all these authors contend that healthcare organizations can enhance recruitment and retention through transformational leadership where everyone is valued. Furthermore, Creswell (2009) indicates that the environment in which nurses work has a direct connection to patient and nurse outcome. The perception on the ecological setting has been advanced by De Gieter, Hofmans and Pepermans (2011) in suggesting that when the retention of nurses is optimum, the morale of current nurses goes up; on the other hand, high nurse turnover has a ripple effect on the remaining staff. In a bid to explore how nurse turnover impact team activities across the organization, Bae et al. (2010) established a negative bearing on patient outcomes. While Esnard, Bordel and Somat (2013) determined that unhappy nurses tend to leave their job they simply submitted to the views by Bae et al. (2010) on the issue of high nurse turnover and how it leads to burnout. In the same breadth, the sentiments by Bae et al. (2010), Esnard, Bordel and Somat (2013), are recounted by Esnard et al. (2013) by stating that high turnover leads to burnout because healthcare facilities struggle to meet the high demand of services; hence nurses are often required to work in places they are not familiar with. In the long run, this affects group dynamics because the moral and productivity drops while also impacting patient outcomes negatively. According to Milliken, Clements, and Tillman (2007), when the workforce is stressed up or fatigued, it often degenerates into other innumerable health-associated anomalies that impair corporate productivity. The previous narrative is espoused by Martin (2015) who implies that high nurse turnover may not only impact patient outcomes, but also revenue, which puts at stake the future of healthcare, patient care and the wellbeing of nurses. When the healthcare facility has poor patient outcomes, the facility may fail to obtain reimbursement payments an aspect that may hamper service delivery. Healthcare facilities with compromised quality may also experience the disappearance of patients that may shop around for healthcare utilizing quality data.
2.5 Negative Staff Interaction and Relationships
A shared working affiliation of nurses and other medics is a vital component that may have a direct impact on nurse job contentment and the quality of care afforded to patients. In most cases, Abbott, De La Garza, Krantz and Mahvi (2011) suggest the quality of care and patient outcome is worst hit, especially when nurses become hesitant to engage physicians in collaborative care. While it is the prerogative of nurses to champion for quality care, medics whose behaviour is disruptive or demeaning is more likely to leave nurses demoralised hence impact patient outcome negatively. Though Kutne-Lee et. (2013) reaffirms the views by Abbott, De La Garza, Krantz and Mahvi (2011), the authors equally reiterate that when the relationship between the nurse and physician is positive, job satisfaction among the nurses is not just enhanced but the willingness to stay within the firm as well. Moreover, Kutne-Lee et al. (2013), contend that certain factors including time exposure to occupants and working in acute areas are linked with negative energy that may influence job satisfaction among novice nurses. On the contrary, Laschinger, Wong, and Grau (2013) posit that burnout is a transitional reaction to negative working circumstances. By and large, it is also an indicator of job discontent, which culminates to high turnover. Increased workload, lack of control over responsibilities, poor remunerations and working relations across the organization may lead to emotional exhaustion hence nurse burnout.
3.0 Methodology
3.1 Brief summary of the literature
The study demonstrates that job satisfaction and turnover is a serious problem among nurses. There is inadequate information on the effects of job satisfaction among ER nurses. In the literature review, about 6 studies focused on the impacts of job satisfaction in ER nurses. For instance, Suárez, Asenjo and Sánchez (2017) found that job satisfaction was lower among ER nurses due to work related stress. Nevertheless, Hairr et al. (2014) gathered data from 70 providers out of 9 ER nurses and discovered a weak relationship between job satisfaction and workload. This suggests an inverse association between job relationship and retention. This implies that lower job satisfaction among ER nurses contributes to the high turnover rate. Nevertheless, Tavakoli et al. (2018) moderate degree of job satisfaction, stress and burnout among ER nurses. In particular, the authors discovered that there is indirect correlation between job burnout and job satisfaction. These findings are echoed by Tarcan et al. (2017) who suggested that job satisfaction among ER nurses is important because it is a driver of performance. Furthermore, job satisfaction is associated with healthcare providers’ stress, burnout, turnover, intentions to leave and motivation. Nevertheless, Shamsi et al. (2016) found that besides hygiene and motivation factors, job specialization can reduce patients’ length of stay in ER while increasing nurses’ satisfaction. Kontogeorgou et al. (2017) shows that even though ERs nurses are fulfilled with their job, they continue to leave their careers.
3.2 Systematic review vs literature review
According to Bettany-Saltikov (2010), a systematic review employs a rigorous methodology to reduce bias. On the other hand, Bettany-Satikov and McSherry (2016) allege that a systematic review focuses on appraising relevant studies and avoid summary using a scientific approach. This suggests that systematic reviews use a clear question to generate evidence underpinning a given research. This study used systematic review because it puts emphasis on a single question based on a peer-review plan. While literature review does define the procedure for choosing articles, systematic reviews present a clear guideline on how the articles were selected. Furthermore, systematic reviews are beneficial than literature review since a detailed search is performed and assess the study quality. Thus far, the technique used in data collection allowed the researcher to search different databases using specified keywords to get relevant data. Systematic reviews responds to a specific PICO question to reduce bias (Robinson and Lowe 2015). In addition, a systematic review is advantageous since inclusion and exclusion criteria are provided prior to performing the review (Bettany-Saltikov 2010). Fundamentally, Robinson and Lowe (2015) allege that a systematic review can generate results that oppose the common philosophies. Search strategy was conducted from several repositories including PubMed, WOL and PMC
3.3 Search strategy
A systematic search was performed from various databases including PubMed; Wiley Online Library and PMC. Furthermore, articles published from 2014-2019 were searched. The search strategy used key words to gather information from previous literature related to the topic and research questions. In the search strategy, various key words were used such as job satisfaction, emergency room nurses, and emergency department nurses. From the initial search, a total of 2000 papers were retrieved. To get relevant articles, the Boolean string was integrated in the search strategy. The key words were refined as follows; job satisfaction AND emergency department nurses; effects OF job satisfaction on emergency department nurses; turnover AND job satisfaction.
3.4 Inclusion and exclusion criteria
Qualitative and quantitative studies published in English between 2014 and 2019 in relation to the research topic included in the systematic reviews. Another inclusion criteria was peer reviews, full text and focused on ED setting (Table 1). However, abstracts, thesis, not primary studies were excluded. After eliminating the duplicates, the articles were screened for inclusion criteria in three phases. During the first phase, the articles were screened using their titles and abstract to determine if they meet the inclusion requirements. Articles considered relevant were retained. In the second phase, the retained full text articles were evaluated and verified.
Inclusion criteria Exclusion criteria
Dependent variable Job satisfaction
Job dissatisfaction
Staff satisfaction
Nurse satisfaction
Nurse dissatisfaction
Compassion satisfaction
Studies Peer-reviewed
Qualitative studies
Quantitative studies
Cross sectional studies Duplicates
Abstracts
Dissertation/thesis
Reviews
Date Studies published between 2014 to 2019 Research studies published before 2012
Language English Other languages apart from English
Participants ED/ER nurses Non-ED health workers
Context Emergency department
Emergency room Speciality departments
Dialysis
Oncology
Telehealth
Table 1: Eligibility Criteria
The search generated 2000 articles out of which 1,103 duplicates were removed. The remaining 897 articles were screened for eligibility. During the initial screening, a total of 801 were removed because they failed to meet the inclusion criteria. The remaining 96 articles were further screened and 90 removed because they were not relevant to the research topic, not primary studies, abstracts dissertations/thesis, not conducted in ED setting and reviews (Figure 1).
Figure 1: PRISM Flow Diagram
3.5 Methodological quality assessment and data extraction
The methodological quality of the selected studies was assessed using Higgins (2018) guidelines. Quality Assessment and Validity Tool was used because it is suitable for identifying research goals, sample, outcome variable and statistical analysis. The Quality Assessment and Validity Tool has a score of 16 points and was used to evaluate studies in three methodological areas including sampling (8 points); measurement (4 points); and statistical analysis (4 points).
To get the final score for the included articles, the total point scored was divided by 16 and subtracted the inapplicable points for every article. The obtained score for every article was categorised in one of the methodological qualities; weak (less than 0.05)’; low to moderate (0.51-0.65); moderate-high (0.66-0.76) strong more than 0.80. This type of rating has been used previously, for instance, in a systematic review by Squires et al. (2015).On the other hand, data from the included studies was extracted in Excel and verified for accuracy. Any discrepancies in the data extraction were addressed by the study committee members. The extracted data comprised of study characteristics including authors; publication year, journal, study design; healthcare setting, year of data collection, statistical analysis and sample size (Table 3). Moreover, data on job satisfaction, theoretical framework, conceptual definition of job satisfaction, effects of turnover, burnout on job satisfaction was extracted.
4.0 Results
About 2000 studies were retrieved out of which 6 met the inclusion criteria. 1994 studies were excluded because they were abstract, duplicates, not-full texts, irrelevant, not primary studies, thesis and dissertations and some were not based on the ER setting. Of the 6 included studies (Table 3), 5 were quantitative studies while 1 was before and after quasi-experiment study. In addition, the included studies recruited physicians and nurses working in ERs. Again, the articles highlighted the issue of job satisfaction among ER nurses. One study focused on the correlation between nursing staffing on retention and job satisfaction (Hairr et al. 2014). Another study explored the impacts of ER nurse job specialisation on job satisfaction and length of hospitalisation in the ER (Shamsi et al. 2016). Two studies solely focused on the job satisfaction among ER nurses (Kontogeorgou et al. 2017; Suárez, Asenjo and Sánchez 2017). Conversely, a study by Tavakoli et al. (2018) and Tarcan et al. (2017) explored career burnout and the level of job satisfaction of ER nurses. The common themes in the included articles were job satisfaction, factors the improve job satisfaction, and factors that reduce job satisfaction.
Authors, Journal, Year of publication Sample size Unit Study design
Hairr et al. 2014
Journal of Nursing Economics 70 ER Correlational design
Kontogeorgou et al.2017
Journal of Perioperative Nursing 151 ER and ICU Quantitative research design
Shamsi et al. 2016
Trauma Monthly Journal
70 ER Before and after quasi experiment design
Suárez et al. 2017
Australasian Emergency Nursing Journal
52 ER Cross-sectional design
Tarcan et al. 2017 Applied Nursing Research Journal 250 ER Cross-sectional design
Tavakoli et al. 2018
Emergency Journal
788 ER Cross-sectional design
Table 3: PRISMA Table
4.1 Levels of job satisfaction
While the level of job fulfilment was one of the main themes, the variations of participants’ characteristics make comparisons challenging. The studies used different measures to assess the level of job satisfaction. For instance, Hairr et al. (2014) and Kontogeorgou et al. (2017) study quantitatively evaluated job satisfaction using Likert Scale. And yet, Kontogeorgou et al. (2017) used a Likert scale five items including very satisfied; satisfied; neither satisfied nor dissatisfied; dissatisfied, very dissatisfied. On the other hand, Hairr et al. (2014) used four Likert scale of strongly agree; agree; disagree and strongly disagree. On the other hand, one study used the Mohr man-Cooke-Mohr man job satisfaction scale (MCMJSS) to investigate the ER nurses level of job satisfaction (Shamsi et al. 2016). On the other, Suárez, Asenjo and Sánchez (2017) and Tavakoli et al. (2018) used questionnaire to assess the level of ER nurses’ job satisfaction. In this study, there were varied levels of satisfaction. For example, ER was satisfied with their job because of job specialisation (Shamsi et al. 2016). Nonetheless, Kontogeorgou et al. (2017) and Suárez, Asenjo and Sánchez (2017) studies found that the level of job satisfaction in ER nurses was low. But, Hairr et al. (2014 and Tavakoli et al. (2018) found moderate level of job satisfaction of ER nurses.
4.2 Factors that positively influence job satisfaction
The study by Shamsi et al. (2016) found that ER nurses’ job specialisation was characterised by increased job satisfaction from 62.5% to 72.7%. In addition, specialisation contributed to empowerment, which resulted in enhanced nurse satisfaction. In this respect, job specialisation can reduce or enhance patients’ length of stay in the ER while improving job satisfaction. Consequently, job specialisation cannot only reduce congestion in the ER but can also be utilized as an intervention to enhance the quality of emergency care. Similarly, Hairr et al. (2014) reported that adequate level of nursing staff leads to increased job satisfaction. This is supported by Suárez, Asenjo and Sánchez (2017) who found that a favorable workplace was associated with enhanced job satisfaction. Additionally, job rotation and interpersonal relationships resulted to greater job satisfaction. Tavakoli et al. (2018) and Tarcan et al. (2018) argue that high job satisfaction is positively related to increased quality care, staff retention and health outcomes. Another factor that increases job satisfaction is age. For example, work satisfaction increase with an increase in nurses’ age. This indicates an inverse correlation between works related stress and job satisfaction. Irrespectively, it is evident that household income and annual income positively leads to a higher work satisfaction. Therefore, Tarcan et al. (2018) recommends that healthcare organisations can create programs for increasing job satisfaction while reducing burnout among nurses. Moreover, Kontogeorgou et al. (2017) discovered that job satisfaction among ER nurses’ is based on professional development opportunities, working hours, interests, workplace conditions and supportive management. Support and cooperation from the management and co-workers are not only important in reducing dissatisfaction but also increasing job satisfaction.
4.3 Factors that adversely affect job satisfaction
The studies found considerable consistency of factors that affect job satisfaction. According to Hairr et al. (2014), economic environment and overload affected ER nurse leading to dissatisfaction. As a result, there was an inverse association between nurse retention as well as job satisfaction. Another important factor that was evident in included studies was linked to burnout, stress and workload (Hairr et al. 2014; Shamsi et al. 2016; Tavakoli et al. 2018; Tarcan et al. 2018). Essentially, Shamsi et al. (2016) indicated that prolonged hospitalisation and congestion in the ER lead to nurses’ job dissatisfaction. In turn, dissatisfaction is associated with nurses’ burnout, sense of inefficiency, emotional breakdown, increased mortality and turnover. Suárez, Asenjo and Sánchez (2017) demonstrate that factors such as work related stress as well as pressure contributed to job dissatisfaction. In particular, the ER setting is overcrowded and sometimes hostile. Again, the constant congestion witnessed in the ER and inadequate resources contribute to psychological and physical distress of nurses, which ultimately result in work dissatisfaction and burnout. This is consistent with Tavakoli et al. (2018) who determined that stress and job burnout affect ED nurses negatively, an aspect that impact job satisfaction. In this study, Tavakoli et al allege that ER is a fast paced environment characterised with physical and mental challenges that lead to job burnout and turnover. Nurse turnover adversely affects patient safety and lower quality of care. Again, work stress such as violent workplace and aggression considerably lowers job satisfaction. While job burnout negatively affect job satisfaction, Tavakoli et al. found that majority of nurses had low to moderate burnout. Specifically, Tavakoli et al. (2018) allude that job satisfaction is necessary in reducing the impact of stress that lead to burnout. As such, the study found an inverse association between job satisfaction and burnout among ER nurses in that if burnout increases there is a decrease in satisfaction. Tarcan et al. (2018) reported that burnout is prevalent among ER nurses leading to job dissatisfaction, performance resulting in psychological health problems such as depression, anxiety and depression. This is echoed by, Kontogeorgou et al. (2017) who uncovered that stress; age, working hours, experience and communication with co-workers affect job satisfaction. The long working shifts can be attributed to low staffing levels.
5.0 Discussion
The chapter provides the findings of the review while comparing with previous literature and implications to nursing practice. The systematic review highlighted the available evidence on the effects of job satisfaction among ER nurses. The findings demonstrated that varied measures assess the ER nurses degree of satisfaction and factors affecting work satisfaction were not consistent. The literature demonstrated that the level of job satisfaction in ER nurses was low and not consistent. For instance, one study reported ER nurses were satisfied (Shamsi et al. 2016); two studies found lower levels of satisfaction (Kontogeorgou et al. 2017 and Suárez, Asenjo and Sánchez 2017); while 3 studies demonstrated moderate level of satisfaction (Hairr et al. 2014; Tavakoli et al. 2018; and Tarcan et al. 2018). Different factors emerged as the correlated to job satisfaction including burnout, work stress, job specialisation, level of nursing, age, workplace conditions, working hours and patient congestion in the ER.
5.1 Comparison of systematic review and past literature
The systematic review showed that work related stress and burnout has a negative impact on the level of job satisfaction. Essentially, four of the included studies found that burnout was characterised with job dissatisfaction in ER nurses. This is consistent with, Abdullah and Piaw (2013) who allege that burnout among nurses adversely affect job satisfaction, which results in workloads and quality healthcare delivery. Based on the findings and previous literature, job dissatisfaction and burnout contribute to adverse outcomes including low patients’ fulfillment, increased cases of medical errors and low quality of emergency care. While there is a direct association between job satisfaction and burnout, future studies should put emphasis on investigating the effects of these variables in ER health workers. Similarly, Laschinger, Wong and Grau (2013) found that burnout is a result of poor workplace environment such as long shifts, workload or poor remuneration and directly related to job dissatisfaction leading to nurse turnover. In turn, nurse turnover contributes to burnout because the available staffs have to meet the demands of service delivery affecting team work, efficiency and health outcomes (Esnard, Bordel and Somat 2013). Nonetheless, Morris and Laipple (2015) allege that healthcare leaders can create good workplace environments to reduce burnout while increasing job satisfaction. Apparently, the review found that work stress was related to nurses’ satisfaction. This finding is supported by previous literature demonstrating that stress in a workplace environment, and nurses’ wellbeing leads to job discontent (Tomaževičet, Seljak and Aristovnik 2014). Furthermore, one of the six studies reported that economic conditions are not only associated with lower job satisfaction but impacts financial stability of healthcare institutions (Hairr et al. 2014). Specifically, poor remuneration encourages turnover, which implies more investments to recruit and hire nurses. A study by Kovner et al. (2014) demonstrates that as a result of job dissatisfaction, retention of nurses becomes challenging; hence contributing to loss of profitability in healthcare organisations. Specifically, Dinis and Fronteira (2015) established that from an economic standpoint, job satisfaction is associated with improved organisational performance as well as quality care. On the other hand, the review found a positive correlation between workplace setting and satisfaction. In particular, a helpful workplace environment contributes to improved health outcomes, staff retention and quality emergency care. Similarly, Alshmemri, Shahwan-Akl and Maude (2017) found that job satisfactions is positively influenced by workplace setting, salary, job stress, professional development, organisational policies and procedures. Nevertheless, Alshmemri, Shahwan-Akl and Maude (2017) contend that it is not a guarantee that dissatisfied nurses will leave the organisation instead they would affect the quality of care and colleagues negatively. Essentially, dissatisfied nurses are violent towards co-workers.
5.2 Job satisfaction among ED nurses
Based on the systematic review, ER nurses are moderately satisfied with their jobs. The findings found negative changes, for instance, ER nurses were previously satisfied with their jobs compared to present times. While it is expected for job satisfaction to fluctuate with time, precisely, it is assumed that ER nurses fulfilment will certainly be higher than previous decades as a result of technological developments and professional developments in nursing practice. To comprehend this finding, 6 articles were explored and found different measures for assessing job satisfaction. Interestingly, it was evident that researchers have failed to present an operational description and measures of job fulfilment of ER nurses in a consistent manner. The inconsistency makes it challenging to recognise the validity as well as reliability of job satisfaction score. Other reasonable explanations include low methodological quality and inconsistent and unreliable job satisfaction measures. This suggests that further studies should investigate the level of job satisfaction among ER nurses using reliable and consistency measures. Besides, the review discovered that organisational factors like support from management and workplace environment influenced satisfaction. In the review, support from leadership was found to increase job satisfaction whilst minimising dissatisfaction and turnover (Kontogeorgou et al. 2017). Apparently, further studies should investigate organisational factors including supportive leadership and how they impact job satisfaction. Again, failure to accept scores of job satisfaction and issues of inconsistency when exploring the effects of job satisfaction demonstrates significant developments in nursing research.
5.3 Implication in nursing practice
Based on the review, ER nurses are not satisfied with their current job. This implies the need to enhance job satisfaction among specialized nurses to guarantee retention but also improve the delivery of quality emergency care. Moreover, the review highlighted important factors such as communication, experience and staffing levels that can help nurse leaders to improve the level of satisfaction among ER nurses. In particular, if nurse managers ensure adequate staffing of the ER and foster open communication it would increase job satisfaction. Moreover, the findings from the systematic review will present nurse leaders with insights in monitoring job stress and burnout because they have adverse effects on work satisfaction. Based on the findings, future studies need to explore consistency in conceptualising job satisfaction; use theories to guide the manner in which job contentment is defined; consistent measures for assessing job satisfaction to guide in comparing results and the need for rigorous research on job satisfaction among ED nurses.
6.0 Limitations
Even though rigorous techniques were adopted to perform the systematic review, there are certain limitations. The literature search was systematically performed; still, grey literature was not used. This is an indication that the systematic review failed to integrate all the relevant literature highlighting the effects of ER nurses’ job satisfaction. Moreover, the included studies did not describe the theory for conceptualising job satisfaction. Conceptual precision and reliability could be associated with how job satisfaction is measured and recognised. For that reason, researchers must be consistent with the description and related factors for predicting job satisfaction. Further studies must explore detailed conceptualisation of nurses’ job satisfaction and associated factors. Another limitation is that even though the systematic review used a synthesis of available and relevant studies, the different measures of level of job satisfaction made comparisons hard.
7.0 Conclusion and recommendations
The systematic review was carried to explore the effects of job satisfaction of ER nurses in Saudi Arabia. The included studies indicated that job satisfaction is an important indicator of retention, investigating the associated factors is important. The findings of the system review demonstrate that job satisfaction among ER ranges from low to moderate. This level of satisfaction is a result of numerous factors including job stress, burnout, working hours, staffing level, workload and congestion are crucial for ER nurses’ job satisfaction. Due to the current problem of nurse shortages, providing a favourable workplace setting is necessary to retaining specialised nurses in the ER. Also, job satisfaction is an important component for nurse retention. Therefore, identification and recognition job satisfaction presents opportunities for successful retention programs for ER nurses. Retention programs are important since they can help healthcare organisations in retaining skilled and experienced nurses and patients that depend on ER for quality care. Again, it is for healthcare organisations to recognise the effects and associations of identified factors and initiate measures for empowering and retaining ER nurses. Based on the significance of job satisfaction and delivery of quality care, nurse leaders should enhance staff engagement that leads to job fulfilment. Theoretically, engagement is related to job satisfaction, commitment, involvement and empowerment. Engaged nurses in their practice exhibit dedication, passion and always read to help the organisation realize its success. Furthermore, engagement is an important variable for differentiating healthcare institutions; however organisation culture can be challenging to change. Professional development opportunities and leadership impact work stress and engagement. Hence, effective leaders can play a huge role in realizing a highly engaged workforce. Furthermore, healthcare organisations should create conducive work environments to increase retention. Healthcare leaders should ensure a positive workplace where employees perform their studies comfortably. A safe workplace setting enhances satisfaction, collaboration and teamwork. Additionally, due to the significance of workplace environment, healthcare organisations should implement strategies for improving adjustable workplace factors.
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