Job satisfaction among the nurses is a significant issue in any health care organization to provide a high quality of care and best patients outcomes. However, there is a strong relationship between the job dissatisfaction, turnover rate, and the quality of the performance. Nursing satisfaction studies aimed to identify the influencing factors in order to improve the quality of the provided care and reduce the turnover rate (AL-Hussami, 2008). Nowadays, increase the level of nursing satisfaction has been recognized by achieving specific criteria which measures the level of job performance in any health care organization. It might be a challenge for the health care systems to follow these criteria as it considered as a change in the organization (Sommer and Merritt, 1994).
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As a nursing demonstrator at the university and acting as a clinical instructor in the university hospital in Saudi Arabia with regard to nursing management, and as a result of high rate of incidence reports o nursing error which have been documented in this hospital, I have a professional interest to enhancing the quality of nursing care by identifying the promoting factors that can increase the level of job satisfaction and the quality of nursing performance. As the Quality management is used to recognize and identify the factors affecting the level of nursing performance, improve the quality of care, and also it considers the patient safety (Mark, Hughes and Jones, 2004).
Quality of care has been examined, explained, and defined through the literature during the past few decades by a number of researchers. Numerous studies have demonstrated that there is a connection between the nursing satisfaction and the quality of provided care. To some extent, the nurses dissatisfied with their job will lead to the higher rate of patient's harmful outcomes (Stanton, 2004). Moreover, it found that nursing satisfaction is creating a chain, as high level of nursing satisfaction lead to high quality of care and this can result in patient satisfaction within the care. Thus; High level of job performance has great potential to improve the quality of nursing care and to provide an excellent patient's outcomes.
The intend of this paper is to enable me to have a thorough understanding of developing a specific research question focused on identifying the promoting factors that can increase nursing satisfaction and its impact on the quality of nursing care based on some evidence. Firstly, I will identify what the literature says and review the literature about this topic area. Following this, I will propose my research question and critically evaluate the methodology and methods that could be used to answer the research question. Finally, my recommendation will be stated in the conclusion.
It demonstrated that nursing research is a significant approach to expand and generate nursing knowledge that used in clinical area to guide the staff, and improve the quality of care. Nursing research is essential in advanced nursing practice by applying evidence based practice which is generally defined as using the best clinical evidence in making a decision (Manley, 1997). In this section, I will discuss the literature around factors of nursing satisfaction and its impact on the quality of care.
Several studies have evident that low job satisfaction will affect on the quality of care and raise the plan to leave the career among nurses. However, the issue of nursing shortage and burnout are considered as a challenge which facing the health care organizations. Nursing turnover is defined as nursing leaving their work as a result of different factors. Georgia department of public health at the United State found that the turnover rate for nurses has increased from 17.7% in 2004 to 19.4% in 2005, where as in the United Kingdom a review is conducted and it has shown that the turnover rate in England and Wales was approximately about 10 percent. However, Al-Momani (2008) reported that the rate at which nurses are leaving the profession in the Middle East was 18.4% in 1996 and rising to 40% in 2008.
Many studies have discovered that work related factors play an important role in nursing satisfaction. Based on the review of nine articles Coomber and Barriball (2007) reported that the contributing factors related to the work environment are important with nursing satisfaction and nursing turnover more than the demographic factors such as nurses' salary, managerial support, and nurses' physician relationship. A cross-sectional descriptive study carried out by Al- Momani (2008) with 120 of registered nurses in a teaching hospital, and a conducted questionnaire is used to assess the work related factors of job satisfaction. The results reported that nurse's salary with a percentage of 89.7% is identified as one of the prominent factors of nursing dissatisfaction. However, some finding claimed that nurse's salary do not have any effect on their work (Savery, 1989), while other studies have shown the connection between the salary and burnout as Trembly et al. (2008) have conducted a correlational descriptive study with a sample of 1002 registered nurses. With regard to the result of this self- administered questionnaire they found that the mean of nurses intend to leave is n=39 with P<0.01. Therefore, they argued that the in adequate salary is the main reason for some nurses let them to quit. Consequently, the organization should make a consideration on the importance of the nurses' salary as it seems that most of the nurses are leaving their work and seeking for a further job because of it.
It found that the staff nurse and physician relationship could affect on nursing satisfaction. The impact of nurse-physician relationship on nursing satisfaction is studied by Rosenstein (2002) with a survey that distributed between physicians and nurses (n=1,164). It showed that with regard to the physician awareness of the impact of this relation on nursing satisfaction, the rate of the mean was 5.12 (10= highly aware, SD=2.47), while with respect of nurses support who are in conflict with physicians, the mean response rate was 6.49 (10=highly supportive, SD=2.78). Therefore, according to this it seems that there are no adequate support for nurses who have experience a conflict with physicians, and the physicians are not aware of the importance of the this relationship and its impact on their satisfaction. Jasper (2007) argued that the way of the nurses are solving their conflict with the physicians will affect on the level of stress and job satisfaction. It revealed that the avoidance methods of conflict resolution are associated with high level of stress, whereas looking and combining the methods of solving problems are liked to low level of stress and job satisfaction. In addition, the communication between staff nurse and nurse manager could be a struggle and a reason to leave the job. As a leadership style of the nurse manager is a main role in the communication between the staff and the manager (Gagnon et al., 2006). According to Swearingen (2009) a conducted study has demonstrated that the nurse leaders have an influence on staff satisfaction such as in communication. Moreover, Ribelin (2003) said that "nurses do not leave hospitals, they leave managers". Whereas Rad & YarMohammadian (2004) have revealed that the management support and the recognition of nursing achievement can raise and enhance the job satisfaction. In addition, the result of correlational and cross-sectional study with a self-administered questionnaire in Taiwan indicated that the nurses are satisfied with transformational leadership more than transactional leadership (Chen, Beck and Amos, 2005). Consequently, it appeared that leadership style and support are the major contributing factors in nursing satisfaction.
Despite the fact that there are several factors that can affect on job satisfaction, few studies have evident that there are some factors have an impact on job satisfaction and the quality of care. Several studies have demonstrated that the professional nursing autonomy (as a work content factor) is identified as a critical factor of job satisfaction that can demonstrate an impact on the patient. Nursing autonomy defined as the freedom of practicing decision making based on nursing knowledge, education and experience (Schutzenhofer and Musser, 2007; Yolanda, 2009; Wade, 1999). Varjus, Suominen and Leino-kilpi (2003) have defined nursing autonomy as the rights and responsibilities of decision making with knowledge and action base. They concluded that the intensive care nurses have more autonomy in decision making that demonstrate effective care. A descriptive quantitative pilot study was conducted (n=178) by Finn (2001), to identify the importance of nursing autonomy with registered nurses as a component of job satisfaction. The statistical analysis of this study showed that nursing autonomy is a critical component of higher job satisfaction as it was highly ranked more than professional status, and organizational policies. A further study discovered that higher level of nursing autonomy has a positive impact on the quality of care and higher job satisfaction. Nevertheless, it revealed that higher teamwork score with the involvement in patient care is positively correlated with higher level of autonomy (Rafferty, Ball and Aiken, 2001). Riordan (1987) has measured and assessed the dimensions of job satisfaction and autonomy with a conducted questionnaire which demonstrated that nurses are satisfied with their job and produce an effective nursing care as a result of practicing with autonomy.
To sum up, the literature have identified several factor related to nursing dissatisfaction. Moreover, job satisfaction has a positive impact on the quality of care and patient satisfaction. In terms of nursing autonomy, it found that it could be considered as the important factor for higher job satisfaction and quality of care in contrast to the other factors that did not state its impact on the quality of care.
Clearly, after reviewing the literature, I am particularly interested in a research question of nursing autonomy. Therefore, my research question stated as:
Is nursing autonomy considering an effective component for higher job satisfaction and quality of care?
Following the statement of the research question I will critically discuss the potential research methodology. It is important to consider the appropriate and applicable research design to be desirable and practical.
There are different and numerous approaches to address the research question such as an empirical research, and systematic review of published studies. However, I have to be sure that this approach fit with my research question.
The empirical research is the data that derived from observation or applying experiments (Dempsey, P. and Dempsey, A., 1996). Considering the use of this method, there are two types of empirical research which are qualitative and quantitative designs. Therefore, the key issue to answer the research question is whether researchers have used the best design to answer the question, for instance, the quantitative design is used for comparison between two or more groups and applying experiments, while qualitative design is used to understand the nature of the phenomena (Polit and Beck 2004).
Even though qualitative and quantitative methods have some similarities as both of these methods have the same implementation and generation of knowledge, the main differences remain in philosophical origin, reasoning, basis of knowledge, and theoretical focus (Burns and Grove, 2003). However, over the past few years there has been a huge amount of discussion and debate surrounding the best research method that can be used. As each research method has its strengths and weaknesses. Considering the quantitative research method, it is known as an objective, rigorous and systematic process for creating the knowledge (Whittemore, 2005). It also has a wide range of methods and approaches such as descriptive, correlation, cross-sectional, experimental, and quasi-experimental researches. It starts to collect the data by objective methods that provide the evidence in order to make an effective predictions, comparison, and relation (James P. Key, 1997). It recognized that this method is a perfect way of concluding the results and demonstrate a hypothesis. Moreover, this method has a numerical data, and statistical analysis for the results and a complete answer is achieved and published. Quantitative research includes an experiment which can be influenced with external factors, so with appropriate design the result would not be biased (Shuttleworth, 2008). However, to minimize the risk of self selection bias the Randomized control trial (RCT) is conceptualized as (gold standard) in evidence of effectiveness (Odom et al., 2005). The evidence of quantitative research has a high rate of validity, reliability and it can be generalized (pilot and deck, 2006). Although the quantitative research design has many advantages, there are many disadvantages. It can be evident that quantitative experiment is expensive as it usually has a large sample, complex and it takes a long time to conduct it. Furthermore, this design involves a statistical analysis that could be very complicated.
Conversely, qualitative research is identified as describing and understanding the people's behavior, or the experience of related phenomena. In contrast to quantitative, qualitative research is using a subjective data that is difficult to code into numbers. It emphasizes on feelings, experiences rather than numbers. Therefore, the qualitative research methods which are being used most frequently are ethnography, phenomenology, and grounded theory. Furthermore, through this type of research the data is collected by open end questions, interview, and participant observational methods. This design can provide comprehensive information. However, it is very difficult to avoid the bias. As there are some challenges related to qualitative design such as reliability, validity and generalisability (Neill, 2007; pilot and deck, 2006; key, 1997).
Ethical consideration is a significant issue to conduct a research. According to Polit and Beck (2006) while conducting a research it is important that to respect the ethical consideration. Therefore, the researcher should focus on protecting the patients' rights as a human being by reducing the harm level (Beneficence), consider the privacy, confidentiality and the autonomy of the participants. Moreover, respect the peoples autonomous to consent for participating in the research, and balancing benefits and risks (Driscoll, 2008).
Referring back to my research question, it is important to notice that this question can be answered through qualitative and quantitative designs. Regarding to the qualitative design I could conduct a phenomenological research to describe and understand the lived experiences of nurses' clinical practice with autonomy and work related factors through interviews. On the other hand, quantitative design is used by conducting a questionnaire of descriptive study among registered nurses in hospital composing of two parts: work content factor (autonomy) and work related factors (nurses' salary, nurses' relation and managerial support). In the process of data analysis, statistical techniques would be used as a summary of percentages, mean, and standard deviations would be presented through the tables and figures. Moreover, the statistical analysis will includes correlation, and t-test to identify the impact of the dissatisfaction and the satisfaction on the care.
Further method to be applied to the research question is systematic review. Systematic review is a secondary research that reviews all primary or past researches on a topic of interest. Moreover, it reviews the literature with the same principle and rigor of the primary research through the protocols (The Joanna Briggs Institute, 2001).
Nevertheless, today's systematic reviews (quantitative and qualitative) are being used by the evidenceâ€based practice, specifically, for the best clinical decision and improve the clinical practice (Khan et al., 2001). Within this method of a research, the question can be developed by considering the seriousness of the problem with nursing dissatisfaction. It is therefore a matter of interest for general practice to achieve additional detailed studies.
Systematic review is being used very widely for several reasons. In the medical field, using systematic review through evidence based practice can provide the best clinical decision making for patients (quantitative) and improve the clinical practice (qualitative) (Khan et al., 2001). It conveys the evidence to the practice through answering the research questions. Furthermore, it allows the researcher to get into consolidated studies with a vast of information. Also, it includes clear and obvious processes that allow the reader to identify how the conclusions were achieved. In addition, it can be easy to understand through a visible format. Moreover, it limits the risk of bias and it can be update it (research matters, 2008; Kitchenham, 2004; Mulrow, 1994).
Systematic review can be conducted through several process and phases related to my research question. Formulating a research question is very important by using PICO for quantitative P: Nurses', I: effect of autonomy, O: Job satisfaction and quality of care, or PPC for qualitative design. Then critical analysis to develop the review protocol will be established. Therefore, start to select the appropriate studies which are relevant to my research question by using the specific criteria that are identified in the reviewing protocols such as the inclusion and the exclusion criteria. Once the studies have been selected, the all studies should be criticized to identify the validity and reliability. The next step is to collect the data through data collection tools to certify that the all data are importantly accurate, to reduce the risk of errors, and the possibility of bias. Finally, synthesis all results of studies with meta-analysis (quantitative) or meta- synthesis (qualitative)( The Joanna Briggs Institute, 2001; Hemingway and Brereton, 2009; Kitchenham, 2004 )
To conclude, the main aim of this paper is to develop a research question as an initial step in the research process with the statement of factors promoting nursing satisfaction and its impact on the quality of nursing care. As it found that nursing satisfaction is affected by several factors, Higgins (1999) point out, nurses will have a great sense of satisfaction within the job if they work autonomously, and empowered them self. while work related factors such as workload and stress, clinical supervision, salary, leadership style, and motivation are the most related factors related to job satisfaction among the nurses (Bartram, Joiner, and Stanton; AL-Hussami 2008). After all these evidence from the literature, the research question is stated as Is nursing autonomy considered as effective component for higher job satisfaction and higher quality of care?.
However, through the journey of discussing and examining the methodology of this research question, I noticed that these approaches will demonstrate the well- structured research question that can be examined, and enable me to follow the research process. Furthermore, despite the fact that various methodology can be used which are qualitative (phenomenological study), quantitative (descriptive study), and systematic review, I claimed that I will go through systematic review which the finding of the effectiveness of autonomy as a promoting factor of job satisfaction and high quality of care can be tested. However, it should be noted that this method cannot be answered in relation to nursing autonomy in KAAUH, As KAAUH demonstrate low level of nursing autonomy. However, this would be a particular interest to highlight on different methods that can be applied for future studies related to this research question.
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