ED Nurse Job Satisfaction and Morale: A Research Prospectus

Introduction to the Problem

Job-related stress is a substantive variable in the overall personnel costs of any industry. In the literature, the relationship between job stress and the costs associated with increased rates of attrition, the provision of mental health supports, and expanded healthcare programs is well established. When employees experience job-related stress, companies must invariably allocate and spend resources in mitigation efforts. Concerns about job stress in medical and healthcare workers extend beyond fiscal concerns to broader issues related to patient care. The literature on patient care indicates that the quality of care provided by overly stressed medical and healthcare personnel may differ in substantive ways from the quality of care provided in similar environments where workers report experiencing less job-related stress (Roche & Duffield, 2010).

Two distinct fields of inquiry are emerging with respect to the study of job-related stress in medical and healthcare workers. Some inquiries are directed toward administrative risks and costs associated with job stress and low staff morale (Kellagher et al., 2010). Other lines of research focus on the provision and quality of patient care. The two areas of research are related: poor patient care from overly stressed care and treatment staff can result in loss of income from patients, which is solidly an administrative concern. However, in order to best understand how to address high levels of job-related stress, it is important to focus on the care provider as a unit of analysis. From a research methods perspective, for example, simply knowing the numbers of caregivers who have left hospital positions due to job-related stress or low morale provides very little useful information for constructing solutions to the attrition problem. It is essential to understand the types and mechanisms of job-related stress variables and the dynamics by which they operate in order to generate theories that can be tested through applied research.

Moreover, the dynamics of job-related stress variables may differ across environments. For these reasons, it is imperative that research outcomes intended to be useful in medical settings must result from study in specific environments with appropriately identified and selected research participants. The proposed research has as its objective a greater understanding of job-related stress, and associated low levels of morale, as it occurs in the emergency departments of American hospitals. This research differs from the corpus of literature on job-related stress in hospitals in two major regards: (1) the category of workers in this investigation is narrow — the subjects in this study will be nurses working in emergency rooms; and (2) the nurses who will participate in this study must be serving in American hospitals.

Literature on the job-related stress of workers in American hospital emergency departments has focused on two main categories of workers: physicians and emergency response workers, such as firefighters, emergency medical technicians, and police. The literature has demonstrated that the experiences of physicians and nurses within the same care setting are quite different (Moskop et al., 2009), and the experience of nurses working in emergency rooms varies considerably from the experiences of emergency response workers. In order to generate data that is highly specific, this inquiry will focus on the experiences of nurses employed in emergency rooms.

Furthermore, a preponderance of research has examined job stress and job satisfaction of workers in specialty medical areas such as acute care and hemodialysis. The set of challenges that working in an emergency department poses to nurses is considered to be distinct from that of other types of nursing care provided in hospitals (Adriaenssens, De Gucht, Van Der Doef, & Maes, 2011). Attributes that exacerbate job stress, burnout, low morale, and absenteeism are prevalent in hospital emergency departments (Davey, Cummings, Newburn-Cook, & Lo, 2009). The literature provides a considerable body of work on promising recommendations for amelioration of worker job stress by medical team leaders and hospital administrators (Malloy & Penprase, 2010). This research is limited by an absence of comparative cross-cultural studies on the impact of implementing these recommendations. The influence of relevant factors — such as worksite culture, employee labor organizations, economics, institutional fiscal models, and supervision structures — on the implementation of corrective activity and policy responses has not been ascertained. Research on job stress issues of nursing staff in foreign hospitals is also more prevalent than studies on those topics for nurses in American hospitals.

Caregiving practices and medical policies vary across hospitals by size and type according to where they are located (Kalisch et al., 2010). This is particularly true when comparisons are constructed between hospitals in different countries. The purpose of this study is not to make comparisons between domestic and foreign hospitals, but rather to consider what relevant variables might impact job-related stress in American hospitals. The literature indicates that job satisfaction and worker morale are related to workload variables and obstacles that are best analyzed at specific levels: the unit level, the job level, the patient level, and the situational level (Gurses, Carayon, & Wall, 2009). These factors related to job satisfaction of emergency department nurses may vary, for instance, by country or regional location, by the fiscal model adopted by the institution, or by labor regulations that govern employment in hospitals. Knowing what increases or decreases job satisfaction within the emergency department can assist nursing administration and management in retaining nurses and decreasing the stress associated with working in a critical care unit (Gurses et al., 2009).

Much of the research on job satisfaction and job stress has focused on emergency room physicians, emergency response workers such as firefighters and members of the police force, specialty areas of hospitals such as acute care and hemodialysis, and emergency room staff in hospitals in foreign countries. The literature on job-related stress of emergency room nurses in American hospitals is scant. The ways in which the experiences of emergency room nurses differ from nurses in other caregiving and treatment environments are not well understood. Moreover, there may be particular attributes of emergency rooms in American hospitals that exacerbate stress, burnout, and low morale for emergency room nurses. Wide variation in approaches to healthcare is seen when country-by-country comparisons are conducted, and the various governing structures and for-profit or non-profit configurations result in a wide array of staff supports and job-stress-mitigating arrangements.

Variables that contribute to job stress and low morale for nurses working in emergency rooms may differ depending on hospital attributes, such as size and location, and on management or administrative practices, such as staffing ratios and shift scheduling. The literature has primarily considered these hospital attributes and management or administrative practices when researching the experiences of nurses who provide services in acute care or dialysis settings. This research will extend the literature on hospital structures, care management practices, and hospital administration to the emergency room setting. Although the literature indicates that the actions carried out and the supports provided by medical team leaders and hospital administrators can positively impact the morale of nurses working in emergency room settings, the research in this area remains limited. This research will inform the literature on job satisfaction variables that show promise for positively impacting the emergency room nursing environment, and will add to the literature that makes distinctions between various nursing contexts with regard to staff morale.

Literature Review

This literature review seeks to explore factors that contribute to job satisfaction and morale of emergency care nursing staff. The review includes a search for studies that differentiated between hospital acute care nursing staff and the more specialized nursing staff in emergency departments. Studies addressing staff morale and job satisfaction in hospital acute care settings were relatively common and generally rigorous. However, many of these studies subsumed emergency department nurses under the larger category of general hospital staff. As a result, very little differentiation has occurred, and when it has, the distinctions have predominantly been made with regard to emergency room physicians and general hospital physicians.

This lack of differentiation was a substantive consideration with respect to the initial research topic. The literature appeared to largely overlook the particular difficulties of emergency room nursing care and the jeopardy to morale and job satisfaction that was an aspect of the daily work demands in emergency room settings. The exigencies of emergency room nursing care ranged from treating people whose lives were in immediate jeopardy, treating people who were in need of routine medical care for common though uncomfortable conditions, and managing patients who were violent toward those trying to care for them. In addition, there are few studies on emergency room nursing set in American contexts.

Searches were completed using PubMed, Medline, and Google, in addition to a federated search engine, to locate articles addressing topics related to emergency care and emergency room care. Key words used in the search included emergency rooms, emergency staff, emergency nurse, job satisfaction, psychosomatic symptoms, burnout, job stress, job distress, job fatigue, job turnover, workload, work engagement, and American hospital emergency rooms. During the course of conducting the literature review, variables that were not initially viewed as contributing factors became salient. This dynamic resulted in a broader and deeper perspective about factors that impact the job satisfaction and morale of emergency room nurses, and that have the potential to indirectly impact the quality of patient care. The search included original research and literature reviews in professional, peer-reviewed journals. Industry papers and periodicals were included in order to address currency. Gradually, a mosaic of literature was compiled that illustrated the need for more research on job satisfaction and staff morale in nurses who practice in the emergency rooms of American hospitals.

The reasons for staff morale and job satisfaction among nurses working in the emergency rooms of American hospitals are not entirely clear. A considerable degree of generalization has occurred from nursing staff providing different types of care in a variety of settings to staff providing emergency room nursing care. Sweeping assumptions have been made about staff morale and job satisfaction of nurses, which have tended to disregard the very different types of work that these nurses do and the different types of practice demands they face in these several and distinct settings.

Bechtel (2009) conducted a qualitative descriptive study about emergency room nurses' experiences with critical incidents and identified strategies that may be useful in the management of those incidents. The common definition of a critical incident is an event — such as a death or serious injury — that results in a strong emotional reaction in nursing staff that may overwhelm typical coping skills (Bechtel, 2009). In this research, 19 nurses working in one of two community-based emergency departments in Massachusetts were interviewed about critical incidents they had experienced in their nursing careers (Bechtel, 2009). Critically, the incidents were limited to events involving children, patient deaths, and interactions with patients' families — a departure from prior research, which commonly included incidents involving violence, multiple casualties, or mutilating injuries (Bechtel, 2009). Two primary themes emerged from the data: critical incidents and their aftermath, with five subthemes — connections, lasting effects, workplace culture, responses, and strategies (Bechtel, 2009). This research probes the psychological reactions of nurses to critical events and relates the findings to burnout. The subthemes, particularly, illuminate the influence of several contextual factors on stress reactions in emergency room nurses, including workplace culture, connections to patients, and formal strategies to employ in the aftermath of a critical event (Bechtel, 2009).

A cross-sectional study that surveyed 423 Swedish healthcare staff employed a battery of standardized instruments to measure variables that contribute to burnout (Glasberg, Eriksson, & Norberg, 2007). The questionnaires employed included the Maslach Burnout Inventory, the Perception of Conscience Questionnaire, the Stress of Conscience Questionnaire, the Social Interactions Scale, the Resilience Scale, and a demographic form related to work and personal attributes (Glasberg et al., 2007). A regression analysis of the data accounted for roughly 59% of the total variation in emotional exhaustion (Glasberg et al., 2007). A secondary finding was that 30% of the variation could be explained by depersonalization and being a physician (Glasberg et al., 2007). Perceptions of healthcare staff related to unsatisfactory implementation of their duties and responsibilities were manifested by lack of time to provide needed care, demanding work that impacts home life, the inability to live up to the expectations of others, and having to suppress one's conscience (Glasberg et al., 2007). This research is relevant to the proposed study since it presented findings against a background of healthcare as a moral endeavor, which, when perceived to be unsatisfactorily implemented, can generate moral strain and a troubled conscience (Glasberg et al., 2007).

Nurses working in emergency departments in hospitals in Ireland participated in a quantitative survey on burnout as related to aspects of their work environment (O'Mahony, 2011). Of those participating, 52 percent reported high levels of depersonalization and emotional exhaustion significantly related to their work environment (O'Mahony, 2011). O'Mahony (2011) reviewed the study findings against a backdrop of Magnet hospitals, which are seen to attract and retain nurses at rates superior to those of other hospitals.

Zuzelo (2007) surveyed 100 registered nurses about moral distress and assessed the frequency of morally distressing events at an urban medical center. Instrumentation included the Moral Distress Scale and an open-ended questionnaire (Zuzelo, 2007). Direct-care-providing nurses identified the following as morally distressing circumstances: working at "unsafe" staffing levels, conflict over patient care plans with families — including life support maintenance — and unnecessary treatments and tests (Zuzelo, 2007). The findings suggest that nurses undergoing moral distress tend to seek support and information from colleagues, chaplaincy, and nurse managers (Kalisch, Hyunhwa, & Rochman, 2010; Zuzelo, 2007). Nurses in this survey requested information about biomedical ethics and asked for non-punitive environments for ethics committee consultations and ethics rounds (Zuzelo, 2007). Zuzelo's (2007) research adds relevant instrumentation for assessing the perceptions of registered nurses with respect to morally distressing circumstances and associates moral distress with job satisfaction and job retention. This association has been confirmed by additional research (Burtson & Stichler, 2010; Callaghan, 2003; Gurses et al., 2009).

In an effort to understand nurses' perceptions of ideal and ethical climates, Goldman and Tabak (2010) surveyed 95 nurses working in internal medicine wards of a central Israeli hospital. Using analysis of variance, multiple linear regressions, and Pearson's correlation coefficient, the results of three sub-questionnaires were analyzed to determine relationships between demographic characteristics and perceptions about an ideal ethical climate (Goldman & Tabak, 2010). Survey respondents with perceptions of "caring" and "independence" were associated with a decline in job satisfaction, while those with perceptions of "caring" and "service" were positively influenced across all aspects of job satisfaction (Goldman & Tabak, 2010). The relevance of this study to the research topic is underscored by the association between job satisfaction and administrative or leadership action with regard to establishing a positive work climate (Hu, Chen, Chiu, Shen, & Chang, 2010; Lee & Cummings, 2008; Malloy & Penprase, 2010).

Gombor (2009) studied burnout in Swedish and Hungarian emergency room nurses with respect to demographic variables, work-related factors, social support, personality, and life satisfaction. Gombor (2009) found that Hungarian nurses suffered significantly higher levels of burnout and more work-related stress in general than did Swedish nurses. The Swedish nurses scored higher on life satisfaction; however, life satisfaction was not found to influence burnout even when nationality was taken into account (Gombor, 2009). The Swedish nurses were found to have higher levels of psychological immunity, a factor associated with lower levels of burnout (Gombor, 2009). Social support was not found to differ between Swedish and Hungarian nurses. Married nurses were found to have lower levels of burnout (Gombor, 2009). Overall, the research findings indicated that psychological immunity, marital status, and Swedish nationality served as protective factors against burnout, with psychological immunity having the strongest association to reduced levels of burnout (Gombor, 2009).

A qualitative study focused on the issue of nurse turnover in Canadian hospitals was conducted by O'Brien-Pallas, Murphy, Shamian, Li, and Hayes (2010). The high rate of nurse turnover in Canadian hospitals, with a mean turnover rate of 19.9 percent at the time of the study, was associated with higher levels of role conflict, role ambiguity, and job dissatisfaction (O'Brien-Pallas et al., 2010). Importantly, high rates of nurse turnover were associated with an alarming increase in the probability of medical error (O'Brien-Pallas et al., 2010).

Adriaenssens et al. (2011) found that emergency room nurses in 15 Belgian hospitals experience profound differences in their practice compared with nurses who work in general hospital settings. The differences are particularly evident with regard to the physical demands and time pressure of emergency work (Adriaenssens et al., 2011). In addition, the varying demands of emergency work can result in procedures that are less clearly defined — which can provide opportunities for discretion with regard to the skills employed — and are characterized by a reduced ability to exercise authority (Adriaenssens et al., 2011). Even though social and collegial support is higher for emergency nurses, the work overall feels less rewarding. According to Adriaenssens et al. (2011), the overriding determinant for fatigue and physical complaints by emergency nurses was identified as the inherent time demands and work demands of the nature of the work. The study underscores the importance of a number of job attributes and aspects that influence emergency nurses' engagement in their work, their satisfaction with their jobs, and their level of turnover intention. These attributes and aspects include social support from supervisors, discretion in the application of skills, the level at which work-derived reward is perceived, the adequacy of procedures used in emergency care, and the level of decision authority that can be exercised (Adriaenssens et al., 2011; Kellagher, Simpson, Flynn, & Armstrong, 2010; Lang, Hodge, Olson, Romano, & Kravitz, 2004; Lauer, 2002).

One of the primary differences between emergency room care and acute care in the general hospital context is the availability of physician specialists (Glabman, 2005). A number of variables impact the availability of specialists for emergency room care, not the least of which is the rising rate of medical liability insurance in concert with a growing number of uninsured patients (Glabman, 2005). There is also a federal mandate for U.S. hospitals to provide the same services in their emergency departments that they do on their upper floors. An infraction in the emergency room can cost the hospital $50,000, a violation of Emergency Medical Treatment and Active Labor Act (EMTALA) laws can result in license revocation, and an end to Medicare and Medicaid provider agreements (Glabman, 2005).

In a study that focused on patient-to-nurse ratios, patient mortality, and failure-to-rescue deaths among surgical patients, Aiken, Clarke, Sloane, Sochalski, and Silber (2002) found that nurses are more likely to experience burnout and job dissatisfaction in hospital settings associated with these issues. Specifically, job burnout risk and job dissatisfaction risk increased in hospitals with high patient-to-nurse ratios, with high failure-to-rescue rates, and where surgical patients experienced greater mortality (Aiken et al., 2002). The State of California mandated minimum nurse-to-patient ratios for acute care hospitals in 1999, and research indicates that the outcomes of this legislation are mixed (S. A. Chapman et al., 2009). The challenge of meeting the staffing ratios in all units at all times led to a backlog of patients in the emergency department and a decrease in the number of ancillary staff (S. A. Chapman et al., 2009). Registered nurses in this study reported improvement in job satisfaction related to workload, but decreased job satisfaction about decision-making regarding scheduling (S. A. Chapman et al., 2009).

Moskop, Sklar, Geiderman, Schears, and Bookman (2009) studied the causes and impact that crowding in emergency rooms has on the quality of patient care. The most relevant aspect of this research to the proposed study is the portrayal of the changing medical facilities landscape in America (Moskop et al., 2009). Two forces are in direct opposition in American medical facilities: there is an increasing demand for and growth in the provision of emergency department care, and there has been a marked decrease in the number of health care facilities available to diagnose and treat medical emergencies (Cowan & Trzeciak, 2005; Moskop et al., 2009). The number of visits made annually to emergency rooms in the U.S. increased from 96.5 million in 1995 to 115.3 million in 2005 (Moskop et al., 2009). This 20 percent increase in use of emergency room facilities and care occurred at the same time that the number of emergency rooms in the U.S. fell by 381, the number of hospitals shrank by 535, and the number of hospital beds diminished by 134,000 (Moskop et al., 2009).

Greater longevity in the American population, coupled with increased immigration and a burgeoning number of underinsured and uninsured people, has doubtless contributed to emergency room crowding (Moskop et al., 2009). The research indicates that the use of emergency rooms for non-emergency care is not a predominant reason for the crowding in emergency rooms, despite the appeal of this argument to the general public and the press (Lee & Cummings, 2008; Moskop et al., 2009). Rather, Moskop et al. (2009) argue that crowding in the emergency room is a symptom of crowding in the hospital proper. Crowding in the emergency room takes place as a result of the inability to find beds within the hospital for patients who have been evaluated and admitted by emergency room physicians (Moskop et al., 2009). Research has confirmed that hospital occupancy rates are strongly correlated with the duration of patient stays in the emergency rooms (Moskop et al., 2009). In fact, fiscal cuts in hospital budgets that result in fewer beds, fewer wards, and constrained service are a fast track to low staff morale (Cowan & Trzeciak, 2005; "Staff morale at trust plummets as ward closes and beds are cut," 2011).

One other study related to specialty nursing — that of hemodialysis nursing — was identified. The nature of hemodialysis nursing is best illustrated by the intense and prolonged interactions between patients and nursing staff, which are necessitated by the complexity of care. Renal patients with chronic kidney disease often have concurrent medical conditions, such that the two health aspects contribute to protracted and complex medical care.

Hayes and Bonner (2010) found job satisfaction in hemodialysis nursing to be influenced by organizational variables, nurses' individual backgrounds, and aspects of patient care. The length of time working in hemodialysis was associated with job satisfaction, such that nurses with three to eight years in renal care experienced more job satisfaction and felt more personal accomplishment. Ross, Jones, Callaghan, Eales, and Ashman (2009) found older hemodialysis nurses to be more satisfied with their jobs, while Arikan, Köksal, and Gökçe (2007) reported that younger hemodialysis nurses had higher levels of job satisfaction. A dominant factor in the job satisfaction of hemodialysis nurses was the ability to avoid night shifts. Unlike their peers in intensive care units, in general hospital wards, and in emergency rooms, hemodialysis nurses were able to maintain typical family life and lifestyles (Brokalaki et al., 2001). Research has shown that nurses with high workloads experienced burnout at a rate five times that of nurses with lower workloads (Flynn, Kellagher, & Simpson, 2010; Freeman & O'Brien-Pallas, 1998). The critical variable, according to Flynn et al. (2010), appears to be the inability to meet patient needs under conditions of high workload.

Research on home healthcare specialists indicates that control over practice decisions and control over the choice of practice settings are significant predictors of job satisfaction (Tullai-McGuinness, 2008). Moreover, the number of years providing home healthcare was negatively associated with job satisfaction (Tullai-McGuinness, 2008). This research is relevant to the topic as it underscores the importance of shared decision-making on the job satisfaction of nurses across different care settings. Research has also shown that there is a difference in work environments between mental health and medical/surgical units (Roche & Duffield, 2010), and that different work environments have their own particular set of stress inducers (Casey, Saunders, & O'Hara, 2010). Research, however, is lacking when applying this hypothesis to the emergency department.

The literature points to the critical element of contamination risk and patient death as patient care stressors (Brokalaki et al., 2001; Murphy, 2004). Exposure to bloodborne pathogens, such as hepatitis or HIV, and patients who were verbally aggressive or physically violent were found to increase job stress — problems commonly encountered in emergency rooms. Nurses report feeling unsupported by nursing and hospital management when dealing with aggressive, abusive, and violent patients (Hayes & Bonner, 2010; Murphy, 2004; Tomey, 2009). The ramifications of dealing with abusive and violent patients include emotional upset and stress — sometimes to the point of post-traumatic stress syndrome — physical injuries, decreased job performance and job satisfaction, and avoidance of contact with patients (Chapman, Perry, Styles, & Combs, 2009).

Critical incidents — which are fairly common for Emergency Medical Technicians (EMTs) and others who provide emergency care — are those events that overwhelm emergency care workers (Caroline, 2010; Jui-Chu, Pi-Hsia, Yuh-Cheng, & Wen-Yin, 2009). The sense of being overwhelmed can occur at the scene of the emergency or much later (Caroline, 2010). Critical Incident Stress Debriefings (CISD) are commonly used to help emergency personnel deal with the stress and trauma of critical incidents (Caroline, 2010). The literature points to substantive similarities between the stress-invoking practice demands of emergency medical technicians and emergency department nurses (Caroline, 2010).

Davey et al. (2009) studied the relationship between organizational attributes and the characteristics of individual nurses with regard to absenteeism. Their research indicates that conclusive evidence regarding the predictors of absenteeism in nursing staff is not currently available (Davey et al., 2009). The research does show a relationship between job stress, burnout, and absenteeism (Davey et al., 2009). Retention factors that tend to reduce absenteeism and burnout include commitment to the hospital or healthcare organization, involvement in the work, prior attendance records, and general work attitudes (Davey et al., 2009).

The relation between hospital climate and job satisfaction was an unexpected finding in the literature. Of the several attributes associated with hospital climate, the standout was having the opportunity for professional development. Some of the job dissatisfaction was expressed by CNAs and LPNs who do not experience many opportunities or avenues for professional betterment. An important aside was that registered nurses often expressed dissatisfaction with not being able to spend more time caring for patients, while LPNs and CNAs felt they were spending too much time on patient care with very few other alternatives, particularly opportunities for staff development (Adler & Matthews, 1994; Cowan & Trzeciak, 2005). Experience with emergency room nursing care and the accuracy of concomitant work expectations led to higher job satisfaction. In other words, nurses who did not have accurate ideas about what emergency room nursing entailed were more likely to be dissatisfied with their jobs and to experience lower morale.

The work climate or work environment of a hospital-based emergency room can have a substantive impact on the job satisfaction of emergency physicians and emergency nurses (Lin et al., 2008). Lin et al. (2008) argue that the educational levels of emergency nurses can have a contradictory influence on job satisfaction. Emergency nurses with higher education levels were more sensitive to hospital regulations and policies and to aspects of emergency department management (Cowan & Trzeciak, 2005; Lin et al., 2008). The authors attribute this to expectations held by the emergency nurses that were not in alignment with the limitations of the work context or their job positions (Lin et al., 2008). Several studies have shown that older nurses experience the emergency and other critical care department context differently than do younger, less experienced nurses (Gurses et al., 2009; Lin et al., 2008). Older nurses demonstrated higher levels of job satisfaction that appeared to be related to their perceived greater flexibility in their roles and more opportunities for autonomy and professional growth, which were in turn associated with more productivity and commitment to the organization (Lin et al., 2008).

Together, the research of Day, Minichiello, and Madison (2007) and Lin et al. (2008) casts an interesting light on the resilience and efficiency of older emergency department nurses. A study of Australian nurses found that those who could withstand the rigors of their jobs had higher morale and greater job satisfaction (Day et al., 2007). The capacity to enjoy other activities at the end of a working day was a marker for higher morale as it indicated better levels of work management (Day et al., 2007). Deeper experience and strong skill development on the part of emergency nursing staff resulted in higher levels of job satisfaction and associated levels of high personal morale.

The Wisdom at Work initiative in the U.S. promotes innovative staffing approaches and opportunities for staff development and training for veteran nurses (Hatcher et al., 2006). Using the American Association of Retired Persons (AARP) Best Employers for Workers Over 50 best practices criteria, the Wisdom at Work initiative identified the benefits that have the most positive influence on job satisfaction. Opportunities for employee development topped the list, followed by healthcare benefits. Alternative scheduling, work arrangements, and time away from the job were ranked highly, as were pensions and retirement benefits (Hatcher et al., 2006). Trossman (2011) reports that the age of nurses in acute and emergency care is increasing, presumably related to the larger phenomenon of people postponing their retirement. According to Trossman (2011), the field of nursing is seeking ways to retain older nurses by establishing different roles and positions — such as a super-user of new medical electronic documentation software — and ways to catalog their unit-based and system-wide wisdom.

It does little good to simply catalog the many variables that contribute to nurse turnover, low job satisfaction, and low nursing staff morale. The studies delineated and discussed in this paper have demonstrated that both qualitative and quantitative research approaches result in theoretical support and confirmation of important factors in job satisfaction and the morale of nurses in general — and, in many studies, of emergency room nursing staff as well. The line of research that examines the influence of nurse managers, hospital administrators, and leaders in the field of nursing provides literature that is highly relevant to the study of nurse turnover and retention (Lee & Cummings, 2008).

Hayes, Bonner, and Pryor (2010) argue that nurse managers need to promote and implement strategies from each of the factor categories that contribute to the job satisfaction of nurses. These factor categories are those that occur between persons, those that occur within individuals, and those that take place outside of people, collectively or individually (Hayes & Bonner, 2010). Variables within each of these categories are believed to contribute to job satisfaction and the retention of nurses (Hayes et al., 2010). Indeed, Hayes et al. (2010) suggest that nurse managers regularly employ staff satisfaction surveys as a means of keeping a finger on the pulse of the job-related wellbeing of nurses under their supervision. The role of nurse managers and hospital leadership in improving the job satisfaction of nurses should be emphasized (Hayes & Bonner, 2010; Tomey, 2009). Nurse managers can contribute to a positive work environment and culture by attending to workload problems and inter-collegial communication and relationships (Hayes & Bonner, 2010; Tomey, 2009). In addition, the quality of patient care and patient safety has been shown to have a profound influence on job satisfaction of nurses (Hayes & Bonner, 2010; Tomey, 2009).

Curtis and O'Connell (2011) assert that there are a number of viable leadership strategies available to nurse managers that have the potential to influence employee morale and motivation. With an emphasis on transformational leadership, training of junior staff, shared decision-making, and aligning changes to practice, their study provides practical approaches for staff empowerment and the achievement of work-life balance (Curtis & O'Connell, 2011).

Research Design and Purpose

The literature suggests that, in addition to quantitative analysis, qualitative research is particularly relevant for the study of job satisfaction. The number of variables influencing job satisfaction in emergency department settings is sufficiently large that quantitative data alone could obscure important differences in the perceptions and experiences of emergency department nurses. Techniques such as structural equation modeling can help to pinpoint causal relationships between the predictors of job satisfaction, individual attributes of nursing staff members, organizational aspects, and job demand features. This author contends that further research should be completed in the target setting: an American emergency department. Both qualitative and quantitative studies in the emergency department setting should be conducted with a focus on nurse perceptions. Data acquisition instruments such as questionnaires and open-ended interviews with emergency department staff would help to achieve the research objectives, as these instruments have been shown to be effective in qualitative studies on this general topic.

The evidence-based research in hospital leadership and nursing management indicates that administrators can have a profound impact on the job satisfaction of emergency nurses (Sellgren, Ekvall, & Tomson, 2008). Transformational leadership styles go a long way toward accomplishing participative management in which patient quality of care and patient satisfaction are the focus (Sellgren et al., 2008). Healthy workplace environments are correlated with personnel wellbeing and healthy patients (Sellgren et al., 2008). Accomplishing healthy work environments and cultures in emergency departments is a complex task that is continually constrained by resource limitations. Yet the research indicates that much can be done to achieve substantive improvements in these emergency care work environments and cultures of leadership.

Research on emotional intelligence is more frequently seen in the nursing leadership journals today, having moved outside the bounds of psychology, management, and supervision literature. Feather (2009) conducted an extensive literature review on the development of emotional intelligence and the level of study with regard to nursing leadership. Feather (2009) suggested that educating leaders in the field of nursing about emotional intelligence, with the aim of increasing their practicing levels of emotional intelligence, could have a positive influence on staff turnover and the problem of nursing shortages. In light of the findings in neurobehavioral research involving the limbic system, Feather (2009) asserts that emotional intelligence can be learned through educational programs. Feather's (2009) research identifies several areas in which future research could potentially enhance nurse leadership preparation and in-service training for hospital administrators and emergency department administrators.

Because of the lack of literature that narrowly focuses on emergency room nurses, the purpose of this research study is to explore the variables of staff job satisfaction in the setting of an emergency department in an American hospital. The mixed-methods research approach used in this study will be conducted in the context of an emergency department with a focus on the perceptions of emergency room nurses. Surveys and open-ended interviews with emergency department staff will be used to collect data about the perceptions of emergency room nurses regarding their job-related morale (Glesne & Peskin, 1992). The goal of this research is to clearly answer the following research questions and to fill a gap in the research literature.

Both qualitative research methods and quantitative research methods are proposed for this inquiry in a mixed-methods approach (Coffey & Atkinson, 1996). Quantitative research methods will be used in this study, and the research draws from phenomenology theory, which holds personal accounts to be legitimate sources of data (Coffey & Atkinson, 1996). The qualitative component of this mixed-methods research will consist of in-depth interviews using a protocol of open-ended questions. The quantitative component will consist of a survey questionnaire.

The following hypotheses apply to the quantitative methods used in this mixed-methods research:

1. Higher job satisfaction scores will positively correlate with more years of service.

2. Higher job satisfaction scores will positively correlate with more highly educated nurses.

A Likert-scale survey approach is appropriate for gaining quantitative results on the survey questionnaire. The questionnaire used in the quantitative component will consist of approximately 30 Likert-scale questions. Since responses will be recorded by marking Likert scales, the data collected will be quantitative. The survey questionnaire will also contain a section of approximately 15 basic demographic questions that address participants' age, gender, educational attainment, experience working in different hospital care units, location of hospital, type of hospital, and size of hospital. These questions will be developed and pilot-tested according to the procedures outlined by Gurses et al. (2009). The questionnaire will be designed to measure job demands related to workload, shift work, staff communication, training, quality of patient care, safety of patient care, quality of working life constructs, and demographic and background variables of the study participants. In addition to the survey questionnaire, there will be three interview questions that will seek to elicit qualitative responses regarding participants' feelings about job satisfaction.

Research on job satisfaction, job stress, burnout, and staff morale tends to rely on self-report instrumentation that results in qualitative data. Additionally, the methodology includes the use of survey interviews that provide study participants an opportunity to generate personal accounts or narratives of their nursing experiences and perceptions. The literature suggests that qualitative research is particularly relevant for the study of staff morale (Dye, Schatz, Rosenberg, & Coleman, 2000). The reason that qualitative research methods were selected for this study is that thick, rich accounts are likely to be generated through the survey and interview processes. These personal narratives will reflect the job-related perceptions and attitudes of the research participants (Lincoln & Guba, 1985).

Building on the Gurses et al. (2009) categorical analysis of workload variables associated with staff morale, the research questions are structured to address workload variables at the unit level, the job level, the patient level, and the situational level. Hypotheses are not needed for the qualitative component since it is derived from grounded theory — a research approach that relies on emerging patterns and the development of themes rather than on hypothesis-testing formats based in positivist theory. The qualitative component will use in-depth interviews consisting of three open-ended questions derived from the research questions:

Research Question 1. What contextual variables unique to emergency room settings appear to depress the morale of emergency room nurses?

Research Question 2. What contextual variables unique to emergency room settings appear to heighten the morale of emergency room nurses?

Conclusion and Future Directions

As has been outlined, there is a wealth of literature that identifies the variables that contribute to job stress for acute care nursing staff, but there is a complete lack of research when narrowly focused on an emergency department nursing staff. There are several research questions that need to be answered fully in order to provide hospital administration and management the tools to increase morale and minimize stress of emergency department nursing staff. This research will be a start and will examine the perceptions of nursing staff in a relatively small area, but research needs to be continued and expanded to get a rich view of nursing staff perceptions. This researcher would next turn his attention toward a study that examines the impact of implementing recommendations for contextual changes in the work environment of an emergency department in an American hospital.