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Integrative Review of Literature

Zoë Raine

Bon Secours Memorial College of Nursing

NUR 4322

Dr. Karen Mellott

November 21, 2020

“I pledge”
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Abstract

Purpose: The purpose of this integrative review is to research the basis of nurse’s satisfaction

or dissatisfaction with their position in an acute care role. Nurse’s perception of job satisfaction

affects turnover rate which is an issue in the profession as it adds to the nursing shortage.

Background: A nurse endures many obstacles and emotional and physical stressors in their

work day, therefore it is important to identify factors that affect satisfaction in order to reduce

burnout and improve work environment. Design and Search Method: The research design is

an integrative review of literature. EBSCOhost resources complete search engine was used to

find articles for review. If full articles were not immediately available a request was granted by

the college librarian and article PDFs were obtained. Results and Findings: Results from a

review of the articles concluded that nurses enjoy the patient-centered care portion of the work

itself. The research shows that their work stress and dissatisfaction stems from managerial

decisions, (unrealistic) expectations, and work environment. Limitations: This is the first

literature review done by the researcher; therefore, the researcher lacks experience and

knowledge pertaining to this. Implications for Practice: Open communication between staff

and manager, practical expectations, and positive work environment should be implemented

and monitored to ensure high levels of job satisfaction. Recommendations for Future

Research: Future research should incorporate more male participants as the male voice was

finite compared to ratio of men in the nursing field.

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Integrative Review of Literature

The intention of this integrative review of literature is to discover the reasons nurse’s find

satisfaction or dissatisfaction in their jobs. Nurse’s play a substantial role in patient care as well

as the success of healthcare as a whole system. The shortage of nurses continues (Loft &

Jensen, 2019) due to current workforce aging out and fewer youth choosing nursing as a career

path. The increase in difficulty of care and higher education requirements demand individuals

with dedication and drive. Dissatisfactory work environment should not be an additive reasoning

for not staying in the nursing career, as this is something that, with comprehension of the

issues, can be evolved.

It is clear that nursing is a challenging job. There are many factors one could identify that

may affect satisfaction a nurse feels. It is not so much the loss of patient or the difficulty in their

care but the supporting components of the job that provide satisfaction or not. It is important to

identify areas of improvement to attempt to decrease that rate of turnover and narrow the

shortage of nurses in acute care. The aim of this investigation is to find those areas in which

satisfy the PICOT question: How do nurse s(P) who work in acute care settings (I) perceive job

satisfaction (O) during their work hours(T)?

Designs and Methods

The research design is a combined review of literatures. EBSCOhost resources

complete, a computerized search engine, was used to find articles relating to the topic. The full

texts of these articles were requested and granted through the college’s library. The terms and

phrases used to pinpoint the question being searched were ‘job satisfaction’, ‘nurses or nursing’,

and ‘qualitative research’. Before setting these specific filters the search yielded thousands of

articles, therefore the choice pool needed to be narrowed. The search produced 91 articles and

was refined to full peer reviewed journal articles studying mostly qualitative research published

between 2018 and 2020. The articles were relevant to the PICOT question of how do nurses

who work in acute care settings perceive job satisfaction during their work hours?
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Upon review, the articles were chosen based on the work satisfaction or dissatisfaction

in the title. Articles were further narrowed and chosen based on a set of criteria. The participants

had to be registered nurses working in the field or just recently leaving the field. The article

needed to mention some qualitative research method or mixed method structure in the abstract

as well as having an acute care, hospital, or clinical setting. Many articles were examined before

the five utilized here were chosen.

Findings and Results

The findings and results of the five reviewed articles suggest many nurses feel changes

need to be made for them to feel higher levels of job satisfaction. The articles reviewed (Gulsen

& Ozmen, 2020; Karlsson, et al., 2020; Loft & Jensen, 2020; Senek, et al., 2020; Waltz, et al.,

2019) are summarized in Appendix 1. A nurse’s main objective is to provide complete patient-

centered and quality care. Circumstances that obstruct the achievement of this objective

retracts from overall job satisfaction because nurse’s feel they are not able to do their job

effectively and efficiently. The researcher has compiled three major themes from the articles:

leadership support, workload and staffing, and relationships with coworkers.

Leadership support

The researcher pulled this overall theme from mentions of relationship with leaders and

managers. The experiences nurses have with their unit managers, clinical care leads, or charge

nurses heavily impacts satisfaction in their profession. Articles by Loft and Jensen, Waltz et al.,

Gulsen and Ozmen, and Senek et al. agreed that having a good leader promotes satisfaction. A

leader that listens, encourages feedback, and is knowledgeable creates satisfaction at work. If

there is a high turnover rate for nurse leaders that can impede team morale and take away from

a satisfactory work environment. Nurse’s want constructive criticism as well as educational

opportunities order to grow and improve in their profession.

Just as nurses are advocates for their patients a nurse manager is an advocate of their

employees to the higher levels in the health system. A leader who does not take into
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consideration, and action, what his team is revealing and expressing is not advantageous to

said team. Leaders who are aware of how their nurses feel and what their nurses need are able

to provide those things and create a healthy and positive work environment. Nurses who do not

receive support from upper management have a difficult time fulfilling staffing needs and

therefore struggle with providing safe and quality care to patients.

Workload and staffing

Articles by Senek et al, Loft and Jensen, Karlsson, and Waltz et al. concur about the

importance of having a reasonable workload and adequate staffing. High patient-to nurse ratios,

high patient acuity levels, and increasing tasks required of nurses hinder a nurse’s ability to

provide quality care. The increase in administrative type work put under the responsibility of the

nurse is another example of excess work taking away from patient care. In the article by

Karlsson it is mentioned that “although RNs enjoyed a challenging workload, and overly high

workload reduced their sense of control”. Failing to perform tasks to safety standards and

according to evidenced based standards is upsetting and takes away from the satisfaction of

doing that job (Karlsson, et al. 2020). One article mentions the necessity of patient care

associates (Waltz et al., 2019). These employees can help with more fundamental tasks like

vital signs, taking blood sugars, and other routine checks. Without these assistants, the number

of tasks a nurse is responsible for is impractical and they will likely not be able to stick to

schedule for the entire shift. This can be very overwhelming for the nurse and can be harmful for

them and their patients.

This issue is not just due to a specific unit manager or situation but the hospital as a

whole. Leaving essential work undone is an overall concept in all of the articles. When this

happens it is very disappointing and dissatisfying for a nurse as the work is then put on the next

shift. This can add to the stress of the job and make it more challenging. Patient needs can be

unpredictable a lot of the time, so that better safe than sorry cliché comes to fruition here. If
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there is enough help on a unit this is not as likely to happen, therefore eliminating that negative

factor.

Relationship with Coworkers

As patient assistants are helpful to a nurse during their shift, other nurses and staff can

be as well. The importance of having positive relationships at work was discussed in the themes

of these studies. One article focused on millennial nurses and those participants said the

generational differences can make communication challenging at times (Waltz et al., 2019).

Creating friendships and being able to rely on coworkers changes the work environment

entirely. If a nurse looks forward to going to work because they like those they work with it is

less likely they will want to leave, even if some conditions are substandard.

When one unit is adequately staffed but another unit is understaffed a staff member from

the staffed unit will be pulled. Not only does the hurt the nurse’s home unit but requires that

nurse to go to an unfamiliar unit and work under a variety of conditions and new people (Senek

et al., 2020). If nurses are consistently pulled to a different unit they are not able to form

relationships with coworkers. If a nurse is uncertain of the capabilities of their colleagues this

can make the job more difficult, as they may not ask for help to ensure their patients get the

care they know will be quality.

Discussion and Implications

It is understood that the nursing profession is a challenging one, but the intrinsic

challenge is what is exciting for most nurses. It is the opposing factors, within the system, that a

nurse cannot control, that pose unnecessary challenges that may risk a nurse leaving. Nurse’s

desperately want to provide complete and quality care to their patients and when this is

interfered with, they feel dissatisfied. It is advantageous to regularly evaluate the emotional

labor and job satisfaction of nurses in order to construct strategies for improvement and

eventually make systematic changes.

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The implications are enlightening as to how relationships at work, the work environment,

staffing, etc. can be improved to subsequently improve satisfaction. The health care system

needs to ensure they are employing competent leaders and providing rules for a health and safe

work environment. If their nurses are working under over-demanding, taxing, and unrealistic

regulations then this puts all the patients at risk. This is important as the shortage of nurses

worldwide is detrimental to the health care system and patient care. It is important that nurses

want to stay in the clinical setting because that is where they are needed most.

Limitations

This integrative review of literature has its own limitations. The researcher is not

experienced in literature review so there may be missed opportunities in analyzation of

literature. There are only five articles being reviewed therefore this is not a fully comprehensive

evaluation of the possible literature. These articles were all from the past 2-3 years so the

information may only be pertinent to the current time.

When reading through articles under review the researcher noticed some limiting factors.

One study took information via focus groups and the worry is that this influenced answered or

hindered honesty of participants (Waltz, et al., 2019). One study notes a limitation is the design

used and mentions that a mixed-methods approach would have allowed for more information

(Gulsen & Ozmen, 2020). Another study did not collect demographic data about participants,

therefore they cannot promise transferability among differing demographics (Senek, et al.,

2020.) Most studies underrepresent the males in the workforce as few participants are males.

Conclusion

As mentioned, the work itself is not the issue. Most nurses report liking the challenge of

the profession but “the positive feeling of challenge could be replaced by frustration and feelings

of insufficiency” (Karlsson, et al., 2020). Overall, it is not the actual nursing profession that

creates a dissatisfactory work environment for nurses but, rather, the independent variables that

can take away from the work at hand. The leaders of the clinical or health care setting, the
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number of nurses working a particular shift, and the comradery and reliability of their coworkers

impact a nurse’s workday and work environment. Depending on whether the impacts of these

respective variables is positive or negative decides how satisfied or dissatisfied a nurse can

feel.

Changes to improve the themes of management support, workload and staffing, and

relationship to coworkers, pulled from this literature review, can provide a safer space for nurses

and patients. In the end these conditions all affect the safety of patients as nurses are the ones

providing the majority of their care. Individuals that become nurses are built to handle

challenges, emotional and physical, but none of which should be imposed on them by a lack in

supportive measures. New legal restrictions should be input to secure lower patient to nurse

ratios and assure a certain number of certified personnel, of varying levels, on a unit at any

time.
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References

Gulsen, M., & Ozmen, Dilek. (2020). Relationship between emotional labour and job satisfaction

in nursing. International Nursing Review 67, 145-154. https://doi.org/10.1111/INR.12559.

Karlsson, A., Gunningberg, L., Bäckström, J., & Pöder, U.(2018). Registered nurses’

perspective of work satisfaction, patient safety, and intention to stay – a double-edge

sword. J Nurse Manag. 27(7). 1359-1365. https://doi.org/10.1111/jonm.12816

Loft, M., & Jensen, C. (2020). What makes experienced nurses stay in their position? A

qualitative interview study. J Nurse Manag. 28: 1305-1316.

https://doi.org/10.1111/JONM.13082

Senek, M., Robertson, S., Ryan, T., King, R., Wood, E., Taylor, B., & Tod, A. (2020).

Determinants of nurse job dissatisfaction – findings from a cross-sectional survey

analysis in the UK. BMC Nursing 19:88. https://doi.org/10.1186/s12912-020-00481-3

Waltz, L., Muñoz, L., Johnson, H., & Rodriguez, T. (2019). Exploring job satisfaction and

workplace engagement in millennial nurses. J Nurse Manag. 28: 673-681.

https://doi.org/10.1111/JONM.12981
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Appendix 1: Summary of Literature Table

APA Citation Author APA Citation: Karlsson, A., Gunningberg, L., Bäckström, J., & Pöder, U.(2018). Registered nurses’
Qualifications perspective of work satisfaction, patient safety, and intention to stay – a double-edge sword. J
Nurse Manag. 27(7). 1359-1365. DOI: 10.1111/jonm.12816
 Karlsson (2018) – Department of Public Health and Caring Sciences, Uppsala University,
Uppsala, Sweden
 Gunningberg (2018) – Department of Public Health and Caring Sciences, Uppsala
University, Uppsala, Sweden
 Bäckström (2018) – Department of Public Health and Caring Sciences, Department of
Neuroscience, Psychiatry Uppsala University, Uppsala, Sweden
- Division of Nursing, Department of Neurobiology, Care Sciences and Society,
Karolinska Institutet, Huddinge, Sweden
 Pöder (2018) - Department of Public Health and Caring Sciences, Uppsala University,
Uppsala, Sweden
Background/Problem  To examine nurse’s job satisfaction, their intention to stay in current workplace or
Statement profession, and patient safety in relation to the two
 Nurse turnover presents a challenge in health care that could be predicted with factors
related to work environment
Conceptual/theoretical  No conceptual or theoretical framework identified, use of thematic framework.
Framework  No specified literature review although other literature mentioned in background
Design/  Descriptive design with qualitative interviews
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical  25 medical/surgical bedside registered nurses in Sweden
Considerations  One (1000 bed) university hospital and one (160 bed) county hospital from two different
regions in Sweden
 Written consent obtained and participants were there voluntarily. Confidentiality assured.
 Approval obtained from Regional Ethical Review Board Uppsala, Sweden
Major Variables Studied  Nurses are the independent variable
(and their definition), if  Themes identified in article are dependent variable
appropriate
Measurement Tool/Data  Semi-structured interview
Collection Method  Probing questions used with main interview questions
 Interview took place 1 time and elapsed 25-56 minutes
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 Audio-recorded with verbatim transcription describing emotional expressions

 Data collected over a year May 2016 to May 2017
Data Analysis  Systematic text condensation based on Giorgi’s psychological phenomenology
 Identified preliminary themes, sorted themes, created code groups
 Authors discussed code groups and reached consensus
 Synthetization of code groups
Findings/Discussion  Themes:
o RN feel satisfied when providing patient centered care
o RN enjoy variability of nursing job, but want control
o RN feel frustrated when care is put on hold or left undone
o RN are dependent on team collaboration and work environment to assure patient
safety
o Intention to stay depends on work environment and a chance for renewal
Appraisal/Worth to practice  Focuses on aspects that affect job satisfaction of RNs
 Ultimately improves patient safety

APA Citation Author APA Citation: Waltz, L., Muñoz, L., Johnson, H., & Rodriguez, T. (2019). Exploring job
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Qualifications satisfaction and workplace engagement in millennial nurses. J Nurse Manag. 28: 673-681. DOI:
10.1111/jonm.12981
 Waltz (2019) – University of the Incarnate Word, San Antonio, Texas
 Muñoz (2019) – University of the Incarnate Word, San Antonio, Texas
 Johnson (2019) – Northeast Methodist Hospital, San Antonio, Texas
 Rodriguez (2019) – University of the Incarnate Word, San Antonio, Texas
Background/Problem  To examine job satisfaction and workplace engagement of millennial nurses
Statement  rapid growth of millennial nurses in workforce and they are less satisfied in their job
compared to nurses from other generations
Conceptual/theoretical  Thematic framework utilized.
Framework  Literature review done to explore definition of millennial generation and components
affecting job satisfaction of new nurses
Design/  Exploratory-descriptive design with qualitative approach
Method/Philosophical  Split into 9 focus groups
Underpinnings
Sample/ Setting/Ethical  33 millennial nurses in 9 focus groups
Considerations  179 bed private hospital in large metropolitan area of southwest region of U.S.
 Written consent obtained and anonymity and confidentiality assured
 Study approval obtained from Methodist Healthcare System Institutional Review Board,
San Antonio, Texas
Major Variables Studied (and  Millennial nurses are the independent variables
their definition), if  Workplace engagement and job satisfaction are the dependent
appropriate
Measurement Tool/Data  Focus groups audio recorded and field notes taken by researchers
Collection Method  Saturation of data determined when data became redundant
 Doctorally prepared nurse researchers conducted interviews
 Semi-structured interview questions
 Questioned developed with nursing administration to build on previously gathered data
Data Analysis  Descriptive statistics used for demographic data
 Inductive thematic approach to analyze data from focus groups
 Analyzed individually and then compared findings
Findings/Discussion  Themes:
o Professional relationships
o Rewards
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o Communication
o Professional development
o Workload/staffing
Appraisal/Worth to practice  Millennial RNs workplace engagement and job satisfaction
 Tailoring the work environment to suite the new force of workers
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APA Citation Author APA Citation: Loft, M., & Jensen, C. (2020). What makes experienced nurses stay in their
Qualifications position? A qualitative interview study. J Nurse Manag. 28: 1305-1316. DOI: 10.1111/jonm.13082
 Loft – Department of Neurology, Rigshospitalet, Glostrup, Denmark
 Jensen – Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital,
Aarhus N, Denmark
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus N,
Denmark
- Department of Clinical Medicine, Aarhus University, Health, Aarhus N, Denmark
Background/Problem  Explore factors that are important to experienced nurses’ intention to stay in clinical
Statement setting and learn what factors affect their job satisfaction
 nurse turnover is a challenge in healthcare and keep nurses at the bedside is important,
therefore we need to understand why nurses stay at place of employment in clinical
setting
Conceptual/theoretical  Thematic framework
Framework
Design/  qualitative descriptive design
Method/Philosophical  inductive content analysis
Underpinnings
Sample/ Setting/Ethical  28 nurses from neurology, pediatrics, surgical, hemodialysis, intermediary units
Considerations  Nurse with at least three years of experience in current position
 Six hospitals (two university hospitals) in Capital Region of Denmark and Central
Denmark Region
 Oral and written consent obtained
 Study registered with Danish Protection Agency
 According to the Danish National Committee on Health Research Ethics, only studies
defined as bio- medical research studies must be approved. Therefore, this study was not
registered under the committee act
 ethical principles of the Declaration of Helsinki were followed, as were the Ethical
Guideline for Nursing Research in the Nordic Countries
Major Variables Studied (and  acute care nurses are the independent variable
their definition), if  what makes them stay in their positions is the dependent
appropriate
Measurement Tool/Data  qualitative interviews inspired by Kvale and Brinkmann
Collection Method  obtained from September 2018-April 2019
 semi-structured interviews
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 experienced interviewer
 audio-recorded and transcribed verbatim
 interviews were 20-60 minutes
 28 interviews provided data saturation
Data Analysis  Inductive content analysis
 Multiple readings of recordings
 Divided into domains
 Divided into meaning units
 Condensation of units and labeled with codes
 Themes abstracted
 Authors did this individually and then compared
Findings/Discussion  Themes:
o Being an experienced nurse
o The importance of the speciality
o Management
o Professional challenges
o Good colleagues
o Balancing family and work-life
o Changes in work organization
Appraisal/Worth to practice  Above themes affect job satisfaction as well as intention to stay in position
 Comprehension of what nurses need to stay can help lessen turnover and narrow the gap
of shortage
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APA Citation Author APA Citation: Senek, M., Robertson, S., Ryan, T., King, R., Wood, E., Taylor, B., & Tod, A.
Qualifications (2020). Determinants of nurse job dissatisfaction – findings from a cross-sectional survey analysis
in the UK. BMC Nursing 19:88. https://doi.org/10.1186/s12912-020-00481-3
 Senek (2020) – Division of Nursing & Midwifery, Department of Health Sciences,
University of Sheffield, Sheffield, UK
 Robertson – Division of Nursing & Midwifery, Department of Health Sciences, University
of Sheffield, Sheffield, UK
 Ryan – Division of Nursing & Midwifery, Department of Health Sciences, University of
Sheffield, Sheffield, UK
 King – Division of Nursing & Midwifery, Department of Health Sciences, University of
Sheffield, Sheffield, UK
 Wood – Division of Nursing & Midwifery, Department of Health Sciences, University of
Sheffield, Sheffield, UK
 Taylor – Division of Nursing & Midwifery, Department of Health Sciences, University of
Sheffield, Sheffield, UK
 Tod – Division of Nursing & Midwifery, Department of Health Sciences, University of
Sheffield, Sheffield, UK
Background/Problem  Lower recruitment and high turnover rate of registered nurses creates a global shortage
Statement  Intention to leave rates are between 30 and 50% showing a high level of job
dissatisfaction
Conceptual/theoretical  Thematic framework utilized to organize information
Framework  Thematic framework analysis of qualitative data
Design/  Secondary analysis of an online-based cross-sectional survey or registered nurses
Method/Philosophical  Explanatory mixed methods study design
Underpinnings
Sample/ Setting/Ethical  RN’s from Royal College of Nursing
Considerations  7040 RNs in acute care
 368 respondents represented qualitative data
 Data anonymized
 Ethical approval was obtained on 27/08/2019 from the University of Sheffield
Major Variables Studied (and  RN’s are independent variable
their definition), if  Determinants of job dissatisfaction are the dependent variables
appropriate
Measurement Tool/Data  Secondary analysis of an online-based cross-sectional survey or registered nurse
Collection Method  multivariate logistic regression modelling
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 abductive reasoning
Data Analysis  Explanatory analysis to draw conclusion
 Univariate analysis with independent variables
 Normality test
 Backward logistic regression
 Qualitative data coded into themes and subthemes
 Integrated data sets
Findings/Discussion  Themes:
o Staffing issues
o Lack of support
o Risk to self or others
o Personal impact

Appraisal/Worth to practice  Just as learning what makes a satisfying environment knowing what isn’t working can be
helpful is eliminating these things and changing for the better

APA Citation Author APA Citation: Gulsen, M., & Ozmen, Dilek. (2020). Relationship between emotional labour and
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Qualifications job satisfaction in nursing. International Nursing Review 67, 145-154.

https://doi.org/10.1111/INR.12559.
 Gulsen – Associate Professor, Public Health Nursing Department, Faculty of Health
Science, Manisa Celal Bayar University, Manisa, Turkey
 Ozmen – Research assistant, Nursing Management Department
Background/Problem  To investigate relationship between emotional labour and job satisfaction
Statement  Nurses experience a lot of emotional labour, the relationship between this and job
satisfaction have different consequences in nursing
Conceptual/theoretical
Framework

Design/  Cross-sectional descriptive design

Method/Philosophical  Personal information form, emotional labour scale and Minnesota Satisfaction
Underpinnings Questionnaire
 Descriptive statistics
Sample/ Setting/Ethical  281 nurses in Turkey
Considerations  One university hospital and three public hospitals in Manisa, Turkey
 Consent taken via informed consent form and confidentiality promised by making survey
anonymous
 Approval obtained from Ethics Committee of the Faculty of Medicine, Manisa Celal Bayar
University
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data  Personal information form, emotional labour scale and Minnesota Satisfaction
Collection Method Questionnaire
 Collected from April – June 2016
 Questionnaire given during shift and collected same day
 Incomplete questionnaire excluded
Data Analysis  BM SPSS statistics software 23.0 (IBM SPSS, Armonk, NY, USA) was used for data
analysis.

Findings/Discussion  Results contribute to knowledge about emotional labor and job satisfaction
 A mixed method designs may have been more useful
Appraisal/Worth to practice  Focuses on RN
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 Defines and discusses emotional labour and its affect on job satisfaction
 This is important information from a managerial standpoint
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