Factors Influencing Job Satisfaction in a Population of Critical Care and Emergency Nurses

Submitted by Skip Morelock PhD, RN, NEA-BC

Tags: critical care emergency emergency department Emergency Nurses Job Satisfaction night shift nursing leadership recruiting work environment

Factors Influencing Job Satisfaction in a Population of Critical Care and Emergency Nurses

Patient satisfaction for the past several years has become increasingly important as hospital compete for a finite amount of health care dollars. This competition for improving and maintaining patient satisfaction has fostered a belief, whether imagined or not, that nurse satisfaction plays a lesser role or is at least of diminished importance in the health care world. What we know is that the demand for critical care nurses has not diminished, even though there are indications that the overall nursing shortage may be temporarily easing. It is imperative that these nurses remain productive and engaged. This can only be assured with a careful analysis of the factors which impact nurse job satisfaction.

Review of Literature

Nursing job satisfaction is becoming increasingly important today. For many years the focus has been on patient satisfaction. This is not surprising since insurance reimbursements are sometimes calibrated based on a facility’s patient satisfaction scores. Despite this emphasis on patient satisfaction, nurses represent the centerpoint for a patient’s overall clinical experience. Ensuring that the nurses are engaged and satisfied with their work environment might go a long way in ensuring that the patient has an equally satisfying care experience. Additionally, it can be prohibitively expensive to recruit, train, and fully orient a critical care or emergency department registered nurse. Estimates range from $16,000 to 80,000 per nurse depending on specialty, and this cost does not include advertising and several weeks of reduced productivity while these nurses are onboarding (Hatler, Stoffers, Kelly, Redding, & Carr, 2011). Multiply this by several nurses over several departments, and replacement of dissatisfied nurses can represent a significant expense to a facility’s operating budget.

Nurse turnover and decreased staffing levels have been shown to be a significant predictor for higher mortality, higher ‘failure to rescue’ incidents, and increased hiring costs (Jayawardhana, Welton, & Lindrooth, 2014; McHugh, Kelly, Smith, Wu, Vanak & Aiken, 2012). In terms of what nurse’s want, certainly adequate staffing is close to the top of any list. Defining what adequate staffing is can be somewhat more complex. It comes down to more than simple numbers. The recent downturn in world economies has placed increasing pressure on the healthcare sector to manage and even reduce costs. Nursing labor costs comprise a significant percentage of a hospitals operating budget and is, logically, one of the first areas that is examined for possible savings opportunities either in the form of job cuts or the adoption of more efficient means of delivering health care. Unfortunately, the reduction of nursing presence has shown to have an opposite effect. Twigg, Geelhoed, Bremmer & Duffield et al (2013) found that higher nursing staff levels are associated with a decrease in mortality and in nurse-sensitive outcomes such as surgical wound infections, code blues, and failures to rescue. Similar findings by Kutney-Lee, Stimpfel, Witkoski, Sloane, Cimiotti et al (2015) validated these findings by examining Magnet, and Magnet-pathway hospitals versus non-Magnet facilities. Nurses want adequate staffing to ensure adequate surveillance of the patients under their care. This author prefers the term sustained vigilance as it implies an ever ready state of recognition, readiness and responsiveness. Nowhere is this more important than in the emergency and critical care environments.

Nurses also want a sense of workplace empowerment, the ability to influence how they practice and meaningful participation in decisions that impact their practice. Empowerment is closely tied to self-determination. Kanter’s (1977) seminal work on organizational empowerment for registered nurse focused on four pillars – access to power, adequate resources, support, and opportunities. Cicolini, Comparcini & Valentina (2014) found that when these forces are combined, nurses not only feel empowered, but they are able to then empower their patients to help sustain positive and efficacious outcomes. Orgambidez-Ramos & Borrego-Ales (2014) further refined these constructs and found that empowerment characteristics are crucial for employee engagement, initiative and enhanced organizational effectiveness. Transformative nursing leadership is also highly influential in the sense of empowerment that is perceived by the nurse. This is especially true in nurses with less than 5 years of experience (Bormann & Abrahamson, 2014).

We know from the work of Jane Ryan (2002) that generational differences on the nursing unit may be playing a significant role in nurse satisfaction and retention. The expectation of those in leadership positions and styles of communication may vary widely depending on which generational group is being examined. Baby Boomers tend to be competitive and enjoy recognition for their work while Generation X’ers (Gen X) and Generation Y’ers (Gen Y) may display less competitive tendencies, but do appreciate immediate feedback on performance (Douglas, Howell, Nelson, Pilkington & Salinas, 2015). The differing ways that the generations approach the job milieu creates a challenging environment for a nursing administrator or manager who is expected to appease all three groups to some extent.

When studying nurses and nursing satisfaction, it can be difficult to effectively capture meaningful results using only quantitative measures. Therefore this study, in addition to utilizing quantitative techniques, also factors in a purely qualitative question in an effort to encourage nurses to verbalize what makes a nursing job satisfactory to them and what would improve overall job satisfaction. Recent studies provide ample evidence linking job satisfaction to variables such as healthy work environments, authentic nursing leadership, and structural empowerment (Lambrou, Merkouris, Middleton, & Papastavro, 2014). Improved job satisfaction may also incur other benefits. Rathert & May (2007) offer compelling evidence that improving a nurse’s work environment may have the effect of reducing the commission of medication errors. This article will explore the factors that influence job satisfaction in nurses.

Sampling and Methods

This research is best characterized as an exploratory study. The research questions are what factors influence nurse job satisfaction and are there generational differences in job satisfaction?

The research relies on three well-validated instruments and an instrument developed by the author. Aiken and Patrician (2000) developed the NWRI as a battery of questions to better define how to measure the work that a nurse does. A subscale of this instrument is comprised of seven questions designed to quantify a nurses’ Control of the Practice. It is this subscale that was used in this research. The alpha for the entire instrument is reported to be .96; and the alpha for the Control of the Practice subscale is reported as .84. Work Overload was also measured. A four question assessment developed and validated by Spector and Jex (1998) was employed to quantify the perceived overload of nurses related to their work. The reported Cronbach’s alpha is 78. The final instrument used was developed by the author and is called the Morelock Practice Risk Assessment. It has not yet been utilized in a published study, but has shown excellent test-retest reliability over 16 pilot studies using critical care and emergency department nurses (r = 0.71). This test is composed of 3 items measured with a five-point Likert scale from “Always to Never”. It is proposed that a compounded effect would ensue from perceiving higher levels of risk in a critical care environment. The cumulative score is then obtained by adding the total of the three items to arrive as a practice risk score.

Since the outcome variable is Job Satisfaction, finding an instrument that would measure the various elements of the motivation was key. The outcome variable of Job Satisfaction was measured by the Wieck Nurse Job Satisfaction Index (Wieck, Dols, & Northam, 2009). The reported alpha for this instrument is .85.

The research participants were composed exclusively of registered nurses. The study was conducted in five critical care units and two emergency departments from two hospitals with similar service lines and patient demographics. Sample size was estimated using G-Power 3.1.0 online program (Faul, Erdfelder, Buchner, & Lang, 2009). A priori analysis using a medium effect size f=.15, power of .80, and α=0.05 yielded a desired sample size estimate of 77. A medium effect size was chosen based on Cohen’s (1992) advice about effect size indices for multiple and partial correlations with between two and eight independent variables. This study has four variables when all are included.

The research participants exclusively work their productive hours in either critical care or the emergency areas. All nurses in the research facilities work twelve hour shifts. The study hospitals each have emergency departments and an array of specialized critical care units. Expedited Review status was granted by the hospital system’s Institutional Review Board (IRB).

The research tool was a questionnaire and was administered via the Qualtrics platform. Basic demographic information was captured as well as the length of experience as a registered nurse. Because of known generational differences between work ethics and job expectations, the age of the nurse was converted to a generational group using the generally accepted labels and birth ranges of Baby Boomers, Generation X and Generation Y. This makes it possible to later test and compare the different generations with job satisfaction variables.

The inclusion criteria consisted of critical care nurses who were permanently assigned to work in one of the intensive care units or emergency departments in the research facilities. No external or agency nurses were invited to participate in the study. Demographic information was used to determine eligibility for inclusion. Any respondents who did not work in intensive care or the emergency department were not included in the study.

All interested participants were fully informed about the project including benefits and risks. The instruction and recruitment processes were managed by the principle investigator. Recruitment for the research study was conducted by the use of posters in the various intensive care and emergency departments. There were also announcements about the research in staff meetings and in the various unit-based councils. A link to the survey was distributed by email and instructions signified that completion and submission of the anonymous survey implied consent to participate in the study. The survey was completely anonymous and neither hospital management nor the principal investigator was aware of who participated and who did not.

The total number of registered nurses who were eligible for participation in the research was 321. This group was invited to participate in the study. The initial examination of the raw data showed that 81 surveys were at least started. Twenty-six surveys were not included in analysis based on factors ranging from failure to complete critical elements/instruments of the survey to not finishing or ‘timing out’ of the survey. The final yield was 55 fully completed surveys. These surveys were used for the final data analysis.

Results and Discussion

Of the 55 surveys completed, 38.2% were male and 61.8% were female. Of the 73 eligible male nurses in the research units, 28% participated while only 13.7% of eligible female nurses participated. In other words, male nurses contributed significantly and disproportionately to the final dataset. This was unexpected since the number of male RN’s in the research units comprises only 22% of the total number of nurses. It is unknown why so many more male nurses chose to participate in this survey. It seems, at least anecdotally, that male nurses tend to gravitate towards the niche nursing areas such as critical care, emergency care, nurse anesthesia, and flight nursing. This could be a plausible reason why the number of male nurses in the critical care areas studied represents so much of the total, far higher than the current estimated 7.0% male nurses in the current nursing work force (American Association of Colleges of Nursing, 2013). The nurses working the night shift also responded to the survey in a higher number than their day shift counterparts. Complete demographic information is displayed in Table 1.

Testing proceeded using the Statistical Package for the Social Sciences (SPSS, ed. 2011) statistical software. Tests of normality and required assumptions were not met in any test variable with the exception of Practice Risk. Analysis proceeded using the non-parametric Spearman’s rho. Results are displayed below in Tables 2 and 3.

The results of the analysis reveal some interesting results and should provide a stepping point for further research into these areas. Job satisfaction showed a statistically significant correlation with Control of the Practice (r = .413 p= .002) and Practice Risk (r = .368 p=.006). The author had surmised that job satisfaction would show a positive relationship with control of the practice environment. This was not unexpected since recent research by Bogaert, Timmermans, Weeks, van Heusdan, Wouters, and Franck (2014) showed that the more the nurse can control the care environment or have input into the framing of their practice, the more satisfied they are with their jobs. This makes sense in that the ability to influence one’s working environment has also been found to increase job satisfaction in the non-nursing world (Tsai, 2011) as well as the healthcare world (Weston, 2010). While it might seem that nurses would be quite limited in their ability to actually change the practice culture in an individual unit, with the growth and increasing influence of unit-based councils and the adoption of shared governance models, hospitals are more likely to incorporate suggested changes in an effort to increase job satisfaction, retain high quality nurses and to make nurses happier. An added benefit to keeping nurses happy might be a decrease in unit erosion and nursing turnover.

Somewhat surprising is that higher Job Satisfaction is correlated with higher Practice Risk. Granted, the correlation is not especially strong (r = .368, p = .006), but it does lend some credence to the thought that some nurses enter critical care and emergency department nursing because of the adrenaline rush associated with the frequently rapid pace of these areas in combination with managing acute and sometimes desperately ill patients. Perhaps these nurses recognize that a rapid and chaotic pace sometime courts risk, both in environment and in practice.

Also noteworthy were significant correlations seen within the other variables. An especially strong correlation (r = -.541, p= .000) was seen when Work Overload and Control of the Practice Environment was compared. In this instance it was a negative correlation, when Work Overload decreased, the Control of the Practice variable increased. Perhaps this suggests that that critical care and emergency nurses are well aware that much of what nurses do can be termed ‘busy work’ and does not represent quality nursing care time or time spent with the patient. As the workload decreases, the nurse can spend more time with their patients. Since the widespread implementation of electronic charting systems, there is a prevailing belief that nurses are spending significant time negotiating the electronic chart and trying insuring that certain quality metrics and required elements are captured. While these activities are certainly important when viewed through a regulatory lens, it does take valuable time away from patients. Other less impressive correlations were seen in Practice Risk and Control of the Practice (r = .365, p=.006) and Practice Risk and Work Overload (r = -.383, p=.004). Regarding Practice Risk and Work Overload, this also shows a negative correlation as the perception of Practice Risk decreased, Work Overload increased. This finding was unexpected and no research could be found that supported this result.

Generational differences in the workforce of these critical care and emergency departments were also analyzed (Table 3). Baby Boomers (age 52–70) made up 21.8% of the research sample, Generation X (age 34–51) comprised 38.2% and Generation Y (age 16-33) was the largest cohort at 40% of the research sample. For Job Satisfaction, none of the factors seemed to be generationally influenced as there were no statistically significant results for control of the practice, work overload or practice risk when the statistical analysis was isolated to specific generational cohorts.

There were some interesting generational differences when other variables were analyzed however. Practice Risk was correlated with Control of the Practice Environment (r = .566, p = .008) in the Gen X’ers. Generation Y and Generation X showed a statistically significant correlation with Control of the Practice and Work Overload. This was interesting since it seems to indicate that, at least in this sample, in the Generation X cohort, as the Control of the Practice Environment decreased, the Work Overload increased (r = -.612, p = .003). The opposite effect was noted among the Generation Y cohort which showed as Work Overload decreased, the Control of the Practice Environment increased (r = -.687, p = .000). Extant literature measuring intergenerational differences with these variables could not be located so it is unknown if this is a true generational difference or a statistical artifact.

The research instrument also included an open-ended qualitative question “what would make your nursing job more satisfying?” A majority of the research subjects (87%) answered this question and the answers given were highly variable. After compiling the answers and identifying recurring themes, there were 3 answers that were given collectively by more than 65% of the respondents. The first for all generation labels was availability and visibility of the immediate supervisor or clinical manager. Nursing leaders should not underestimate the importance of frequent and purposeful staff rounding. The transformational manager should always know the ‘barometer’ of their units and be in a position to intervene on behalf of their staff. The second most popular answer among the Generation X and second in the Baby Boomers category was the perceived lack of physician respect. While this issue has its roots embedded in nursing’s history, contemporary healthcare delivery should function as a team and not be reliant on a pedestaled and unapproachable leader. Nurses can go a long way toward gaining physician respect by knowing their patients, being confident and knowledgeable in their care delivery and engaging the physician when questions or clarifications are needed. Conversely, nursing leadership must be in a position to intervene swiftly if physician bullying of a nurse is observed or reported. The third most common response called for increased staffing especially when the intensity of care required is above the unit norm or the census is higher than usual. Hospitals have been fighting this battle for decades. No matter what predictor is utilized to project staffing needs, they can only generalize based on historical trends. They simply do not possess the granularity of function which is needed to safely and effectively staff a critical care unit or emergency department hour by hour. Many hospitals as well as health systems have created pools of qualified critical care and emergency nurses. They are usually compensated at a higher rate than other registered nurses because of the need to possess skill sets which enable them to function in a variety of clinical situations. Despite this, other studies are still showing the perception that critical care and emergency department areas remain understaffed- sometimes dangerously so (AACN). Staffing needs will likely continue to dominate nursing conversation at all levels. The remainder of the responses was varied, but several wished for more rigorous education for inexperienced nurses, and some lamented the lack of time to properly orient, educate, and assess new nurses critical care skillsets. Other recommendations were for there to be fewer novice nurses placed on the night shift and the tripling of intensive care level patients was also mentioned as a strong negative and a detriment to providing safe care. Some of these recommendations seem to be eternal. In 1958, Grivest found that 63% of the 132 staff nurses surveyed reported annoyances in their work situation. They felt that management took only perfunctory measures to correct the hazards leading to accidents and were particularly dissatisfied with rotation to evening and night shifts. It is interesting that many of the staff nurse concerns have not changed that much over the past sixty years. The current study demonstrates the importance of continually assessing the work environment of nurses to try to improve the care delivery process and patient outcomes.

Strengths and Limitations

This study is an exploratory look into what critical care and emergency department nurses want in their environment in order to achieve job satisfaction. The research contributes to the body of nursing knowledge by demonstrating that nursing job satisfaction may be impacted by workload, practice risk, and practice environment. It should help catalyze further research into these areas. The research is also strengthened by the fact that the parameters examined could be quantitatively assessed and that minimal personal information was required in order to participate. The statistics used to measure the findings were non-parametric and as such, there is some compromise of robustness. The response rate was also less than optimal. Possibly contributing to this was the lengthy survey instrument. Additionally, the research cohort consisted of a convenience sample rather than a true random sample. These factors require that the applicability or inference of the findings to a more general population of nurses be approached cautiously. Additionally, nuances between the different generations of nurses were not fully explored in this article. Finally, the statistical data that was obtained when the generations of nurses were compared were based on small sample sizes within the research cohort and are of questionable value.

Conclusions and Recommendations

The primary recommendation includes examining the root causes of nurse job dissatisfaction and proactively seeking ways to eliminate or control those causes. Recruiting, hiring, and onboarding a critical care nurse or emergency department nurse involves significant expense both monetarily and in time resources. Identifying causes of job dissatisfaction and eliminating or modifying them may help reduce unit erosion and increase retention and encourage qualified nurses to remain engaged and active on their units. Permitting nurses to have greater control of their practice environment seems to be a relatively easy solution, especially since Magnet and Pathways to Excellence designations depend on the nurses’ perception that they can influence and tailor their nursing environment to best suit their practice and their patients.

Nursing and administrative leaders should be responsive to nursing demands. There are far more opportunities for nurses now than there were a generation ago and the hospital is not always the first choice of graduating nurses. While the projected nursing shortage has thus far failed to fully materialize, the numbers are sobering. Even in this study, almost 22% of the respondents are Baby Boomers and would be expected to retire over the next 10 years. Hospitals should be aggressively reaching out to recruit and retain high quality nurses. Money should be allocated, legislatively if necessary, to ensure adequate numbers of qualified faculty are available to teach the incoming cohorts of nursing students. Finally, the model of shared governance should be incorporated into all aspects of hospital and nursing administration, from recruiting, to budgeting, allocation of capital expenses, and personal scheduling. The professional nurse of today is demanding a flexible, responsive, and well-compensated work environment. Adaptation will be key if hospitals are to survive in this era of rapidly metamorphosing health care.

References

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Table 1

Demographics

Gender		Frequency	Percent
	Male	21	38.2
	Female	34	61.8

Ethnicity
	African-American	4	7.3
	Alaskan Native/Native American	0	0.0
	Asian	5	9.1
	Caucasian	44	80.0
	Hispanic/Latin	1	1.8
	Pacific-Islander	1	1.8

Level of Nursing Education
	Associates	9	16.4
	BSN	44	80.0
	MSN	1	1.8
	Post Masters	1	1.8

Generation
	Baby Boomer	12	21.8
	Generation X	21	38.2
	Generation Y	22	40.0

Shift Worked
	AM	23	41.8
	PM	32	58.2

Table 2

Correlation using Spearman’s rho (Entire Cohort)

	Practice Risk	Job Satisfaction	Control of Practice	Work Overload
Practice Risk	r = 1.000	r= .368 p = .006	r = .365 p = .006	r = -.383 p = .004
Job Satisfaction	r = .368 p = .006	r = 1.000	r = .413 p = .002	r = -.158 p = .249
Control of Practice	r = .365 p = .006	r = .413 p = .002	r = 1.000	r = -.541 p = .000
Work Overload	r = - . 383 p = .004	r = -.158 p = .249	r = -.541 p = .000	r = 1.000

Table 3

Correlation using Spearman’s rho (Generational)

Baby Boomers (n=12)
	Practice Risk	Job Satisfaction	Control of Practice	Work Overload
Practice Risk	r = 1.000	r = .275 p = .368	r = .186 p = .607	r = .669 p = .017
Job Satisfaction	r = .275 p = .368	r = 1.000	r = .538 p = .071	r = -.196 p = .537
Control of Practice	r = .186 p = .607	r = .538 p= .071	r = 1.000	r = -.187 p = .560
Work Overload	r =.669 p = .017	r = -.196 p = .537	r = -.187 p = .500	r = 1.000

Gen X (n = 21)
	Practice Risk	Job Satisfaction	Control of Practice	Work Overload
Practice Risk	r = 1.000	r = .370 p = .098	r = .566 p = .008	r = -.428 p = .053
Job Satisfaction	r = .370 p = .098	r = 1.000	r = -.413 p = .062	r = -.241 p = .293
Control of Practice	r = .566 p= .008	r = .413 p = .062	r = 1.000	r = -.612 p = .003
Work Overload	r = -.428 p = .053	r = -.241 p = .293	r = -.612 p = .003	r = 1.000

Gen Y (n = 22)
	Practice Risk	Job Satisfaction	Control of Practice	Work Overload
Practice Risk	r = 1.000	r = .351 p = .109	r = .190 p = .397	r = -.126 p = .577
Job Satisfaction	r = .351 p = .109	r = 1.000	r = .263 p = .238	r = -.093 p = .682
Control of Practice	r = .190 p = .397	r = .263 p = .238	r = 1.000	r = -.687 p = .000
Work Overload	r = -.126 p = .577	r = -.093 p = .682	r = -.687 p = .000	r = 1.000

Table 4

Responses to the Question “What would make your nursing job more satisfying?”

	Baby Boomers	Gen X	Gen Y
Availability of Management	95%	100%	47%
More MD Respect	95%	59%	42%
Increased Staffing	42%	57%	46%
More Educational Opportunities	10%	16%	71%
Fewer Night Shift Novice Nurses	16%	9%	2%
Less Tripling of ICU Patients	27%	17%	21%
More Support Staff	16%	8%	9%