Middle Range Nursing Theories for Emergency Department Staff Satisfaction

Introduction

As a profession, nursing presents many challenges. It is one of the most stress-inducing jobs in the world, not only in terms of the physical toll and long hours, but also because of the emotionally exhausting nature of the work. For this reason, personnel turnover tends to be high and there is a general shortage of nursing staff at hospitals. Because of the vital importance of the profession to the healthcare field and to humanity in general, many researchers have addressed the problem of high personnel turnover in nursing, as well as factors such as leadership, work efficiency, and interpersonal relationships.

Of all the work environments within the nursing profession, the emergency department is probably the most stressful, which also contributes to high personnel turnover. One approach toward a resolution is to find ways of enhancing nursing staff satisfaction. Increased satisfaction at work leads to greater commitment and a lower tendency to leave the workplace. As such, two middle range theories will be evaluated for their applicability to improving nursing staff satisfaction in the emergency department: Harry Stack Sullivan's interpersonal theory and Carl Rogers' person-centered theory.

Description of Clinical Practice Problem

Burnout is one of the most common problems faced by nurses today. This is a particular challenge in the emergency department, where patient overcrowding, leadership challenges, logistical problems, and a basic lack of satisfaction among both personnel and patients tend to be part and parcel of the workday. For this reason, leadership is one of the most important components in the medical profession, and particularly in high-stress environments like the emergency room.

According to Lin et al. (2011, p. 239), leadership has an effect on every aspect of nursing, including work attendance, productivity, performance, and job satisfaction. Good leadership leads to good nursing outcomes, whereas poor leadership necessarily increases stress factors such as poor job satisfaction. The authors go as far as noting that leadership could affect not only the performance but the very survival of the organization. As such, a leader in such a role must recognize that his or her function is no longer solely medical, but encompasses all the components of organizational leadership — including ensuring that personnel are satisfied and committed to their work.

A particular challenge in the emergency department is that the nature of the work is not only continuously changing; it also entails a high velocity of actions during critical care within a complex mixture of relationships among staff members, leadership, and patients. Effective leadership is therefore vital to ensure the smooth operation of such a frequently volatile environment.

A well-functioning emergency department is the result not only of the experience and technical skills of the leader, but also of his or her behavior and interpersonal skills. Without the effective management of relationships, leaders in the emergency environment cannot operate effectively.

Effective leadership also influences the commitment that employees display in the workplace. Without a committed workforce, the emergency department would struggle to maintain a consistent level of excellence in care. Meyer and Maltin (2010, p. 334) emphasize the importance of employee commitment and the benefits this holds not only for employers but for the workforce itself. According to the authors, a high level of employee commitment has been shown to correlate with employee satisfaction. This applies particularly to the emergency environment, where high commitment also relates to lower stress levels and a greater sense of meaning in the workplace.

One factor that contributes significantly to stress among emergency department employees is patient overcrowding. This creates a sense of urgency as employees struggle to meet the needs of all patients arriving in the emergency room. The resulting stress detracts from effective employee-employer relationships as well as the quality of patient care provided. Rowe et al. (2011) suggest that operational processes can be used to remedy this problem — and again, effective relationships among team members and employers are essential to implement and manage such logistical changes successfully.

Hwang, Younsuk, and Hojung (2011) similarly emphasize the importance of physical structure and process management for improving the quality of healthcare. They suggest that critical pathways play a vital role in ensuring the effective functioning of multidisciplinary teams within healthcare settings.

In short, staff satisfaction should begin with effective interpersonal relationships, which in turn shape behavioral patterns. There are many types of relationships within emergency departments, including leader-follower relationships, relationships among colleagues, those among team members, and those between team members and team leaders. These should be managed effectively, with communication structures that allow concerns to be openly discussed, suggestions made, and changes implemented as needed.

When effective communication and relationships are in place, more practical concerns such as process issues and patient flow can be handled effectively as well. Two middle range theories relevant to the enhancement of staff satisfaction in the emergency department are Harry Stack Sullivan's interpersonal theory and Carl Rogers' person-centered theory.

Interpersonal Theory

Harry Stack Sullivan's theory was rooted in developmental theory. His central premise was that every person exists as part of a relational network with other people (Penckofer et al., 2011). It is impossible to exist without at least some influence from these relationships. When an individual is a young child, for example, there is a particular dependence upon interpersonal relationships — a dependence that continues throughout the human lifespan.

In terms of nursing theory, Sullivan's work gave rise to Peplau's nursing theory, in which Peplau extended Sullivan's concept of anxiety in interpersonal relationships by describing four levels: mild, moderate, severe, and panic (Penckofer et al., 2011). Nurses use these levels as a means of assessing anxiety among patients. Once the anxiety level has been assessed, the nurse's task is to assist patients in managing their anxiety by channeling it into constructive action. The nurse functions as an effective component within the patient's interpersonal experience, and this relationship is used to create a supportive environment for the patient.

Evaluation

By naming and articulating it, both Sullivan and Peplau created an explicit middle range theory. The social significance of the theory relates to the condition of anxiety experienced by a large number of patients when entering the emergency department. Most such patients have experienced an unforeseen trauma and their anxiety level tends to be high. The theoretical significance of the theory lies in its precise explanation of patients' psychological condition and how nursing staff can manage it. Concepts such as interpersonal relationships, dynamism, and anxiety are clearly defined, ensuring the internal validity of the theory and consistency in its definitions and terms.

The reasoning underlying the theory is appropriate. Deductive reasoning is used to arrive at a theory of interpersonal relationships. Observing that people are continually dependent upon and influenced by one another throughout the lifespan, Peplau deduced that this dependency could be used to reduce anxiety and other negative experiences within the clinical setting. Various studies support this theory, making it empirically viable, particularly in the field of psychology. The concept of the participant-observer indicates that patients must participate actively in their own healing process — a vital element in eliminating negative emotions such as anxiety and fear and directing them toward recovery.

Applicability

While the interpersonal theory traditionally applies to the nurse-patient relationship, it can also apply to the clinical setting in the emergency department and to interpersonal relationships among staff. First, the theory supports the ideal of effectiveness. When a nurse interacts effectively with a patient, he or she experiences the satisfaction of alleviating anxiety and helping the patient cope better with a stress-inducing injury. The same is true of interactions with family members who have entered the facility.

A second dimension is the leader-follower relationship. Here, the participant-observer paradigm is applicable. While leaders identify the actions and logistics within the department, nurses must be part of the process by actively contributing suggestions and improvements. An open communication channel between nursing staff and their leaders is essential.

Finally, teamwork applies in terms of both anxiety reduction and the participant-observer paradigm. Anxiety can be significantly reduced when nursing staff work in teams, since this distributes the workload while also providing colleagues who collaborate on similar challenges. The psychological sense of support is important for reducing stress among nursing staff and increasing satisfaction. This relates closely to the participant-observer paradigm, in which nursing staff function as a creative team developing solutions for managing a high volume of patients in a stressful environment.

In these ways, effective individual patient care, good leadership, and interactive teamwork all conform to the principles of the interpersonal theory and support nursing staff satisfaction in the emergency department.

Conclusion

On the strength of the above discussion, it can be concluded that the interpersonal theory, as developed by Sullivan and Peplau, is most applicable to nursing staff satisfaction in the emergency department. The reason is that it applies to all kinds of interpersonal relationships, including those found in the emergency room. Rogers' theory, by contrast, is far more focused on the individual and the relationship of one person to another. The way in which this functions is less well-suited to the fast-paced, busy environment of the emergency room. In a work environment where many individuals and teams work together on a rotational basis, it is simply more practical to apply a collective interpersonal theory than an individualistic person-centered one.

In terms of the nurse's relationship with patients, nurses can work to reduce patient anxiety and help empower patients to participate in their own healing and manage their stress. In terms of the leader-follower relationship, leaders can help nurses become partners in improving the effectiveness and efficiency of the department through open, two-way communication. In terms of teamwork, nurses can work together to reduce general anxiety and stress while functioning as partners who communicate and help ensure the smooth operation of the emergency department — collectively reducing the pressure created by patient overload and work-related burnout.

This is not to say, however, that Rogers' theory has no place in the emergency department. In the context of teamwork, for example, leaders can focus on individual team members, identify each person's unique qualities, and use these to assess the strengths and weaknesses each individual brings to the workplace. These insights can then be used to help each individual actualize his or her potential for the benefit of patients and the organization as a whole.

To conclude, both Sullivan and Rogers offer valid perspectives for enhancing nursing staff satisfaction in the emergency department. When it comes to the collective paradigm of leadership, teamwork, and nurse-patient relationships in this busy environment, however, Sullivan's work bears more relevance because both nurses and leaders must operate in a fast-paced and often overcrowded setting. Individual, person-centered attention is not always possible in such conditions.

Rogers' person-centered theory is more viable in environments that include relatively small teams with a team leader who has the time to recognize uniqueness and encourage self-actualization. In a collective setup, however, self-actualization can be encouraged by offering nurses the means and motivation to take personal responsibility for self-regard, growth, and actualization.

Finally, by increasing staff satisfaction in the emergency department, leaders can ensure lower rates of staff turnover, better quality of patient care, and often the very survival of the clinical organization. These are critical considerations in the vital field of healthcare.

References

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Lin, B. Y-J., Hsu, C-P. C., Juan, C-W., Lin, C-C., Lin, H-J., & Chen, J-H. (2011). The role of leader behaviors in hospital-based emergency departments' unit performance and employee work satisfaction. Social Science & Medicine, 72.

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