It has been observed that , in emergency department staff retention is very less due to stress as result of transforming and dynamic nature of the department. Lower rate of staff retention is also due to the non-cooperation from the management and dissatisfaction in pay scale. Identifying reasons behind poor morale and higher turnover is helpful in finding solutions to prevent higher turnover and to avoid higher burnout of experienced staff members. Poor morale and higher staff turnover directly affects patient care. Incompetent nurses and handling of critical patients are important factors responsible for the higher turnover rate in the emergency and accident department1. Sequential events can occur from poor morale to nurses burnout to the effect on the management of organisation. Nurses burnout lead to nurses turnover to adverse effects on the patient care and finally effect on the management of the hospital. There are varied dimensions for nurse burnout like physical, personal and social2.
Physical environment of the organisation can adversely affects perceived stress and job satisfaction. Environmental aspects in the facility like noise, air quality, light, toxic exposures, temperature, humidity, and aesthetics can affect nurse turnover and patient care3, 4. Physical factors also affects social factors for nurses. Accommodative physical environment gives nurses satisfaction of social support in caring patients. Leadership and collaborative work are the important aspects of the social factors of nurse turnover. Leadership aspects which can lead to poor morale include work scheduling, staffing and promotion opportunities. Collaborative work include support from the all the stakeholders in the hospital. Work/home interface, age and pay scale can be considered as the personal factors responsible for the poor morale and higher nurse turnover5. It has been observed that older nurse leave job more in number as compared to the younger nurses. It has been established that in nursing, professional reasons are predominant than personal reasons for poor morale and higher turnover. In the literature, following are the reasons mentioned with high frequency for nurse turnover in emergency and accident: higher patient-to-nurse ratios, job dissatisfaction, reduced patient safety and adverse perception of the nursing profession. Factors mentioned with comparatively less frequency are : severe sickness of older patients, rude behaviour of patients, low morale, management problems, augmented workload and more amount of work nor related to the nursing profession.
Management should give more focus on improving morale of nurses and stopping nurse turnover because replacement of one nurse can cost huge financial impact on the management. It has been observed that replacement of one nurse can cost management approximately 2.5 % salary of one nurse. Higher turnover can adversely affect patient outcome. There is possibility of increased medical procedure error and medication administration error. Injury may also occur due to falls of the elderly patients. Higher patient-to-nurse ratio can lead to longer duration of wait period and inefficiency of the nurses to provide adequate care to the patients6.
Nurse burnout is one of the prominent reason for poor morale and higher nurse turnover. Burnout may be due to emotional exhaustion, decreased personal accomplishment and depersonalization. Burnout can lead to reduced morale, raised absenteeism as result of sickness, reduced efficiency and productivity, inadequate job performance and patient care. In emergency and accident department, approximately 50 % nurses reach clinical level burnout7.
Needs of the department should be identified. More number of full-time nurses should be recruited as compared to the travel nurses. Orientation strategies should be identified and areas should be identified with requirements of change. Nurses should be given opportunity to develop professionally. Financial aspects, time, management perceptions and staff stigma should be considered in assessing reasons behind poor morale and higher nurse turnover. Staff can reduce turnover by accepting change and working in co-ordination with management, by understanding qualities of good and bad preceptor, by identifying requirements of the department, by making efforts to reduce fatigue, by working in co-operation with other staff members and by not forgetting willingness to help patients to improve their quality of life8,9,10.
Phenomenological approach will be implemented in identifying reasons behind reduced morale of staff. This approach establishes precise, complete, and clear description and understanding of the experiences of the persons11. In this qualitative study, experiences of staff members in the emergency department need to be understood. In this approach, findings emerge from the participants and not imposed by the investigator. It has been well established that emergency department is affected due to high turnover rate of staff members. Gaps need to be understood, in retaining staff members in the emergency department. It is evident that low morale can result in reduced staff retention. Qualitative research based on identification of high turnover rate, will focus on following research questions :
What are the experiences of staff members in the emergency and accident department?
What are the perceptions of staff members ?
What are the perceptions of nurses about facility and management ?
By raising these questions, we aim to know the reasons behind poor morale of the staff members in the emergency department which is responsible for the high turnover. Along with this we aim to identify correlation between poor morale of staff and patient outcome and management role in poor morale. Physical, social and personal reasons are responsible for the low morale of the staff members. It will be helpful in identifying solutions for low morale and higher turnover. Effective training and orientation can be developed to address issue of higher turnover.
In qualitative research, population is a group of people from which data need to be collected. People in the participant population should meet the criteria of the study12. This study will be conducted in the urban hospital comprising of emergency and accident department. This emergency and accident department comprising of 200 beds. This study will be specifically focused on the nurses. This study will incorporate nurses of all age group and both the sexes. In this study, nurses in the emergency department will be specifically focused because it has been observed that nurses in the emergency department experiences more turnover due to poor morale. Hence, relevant data can be obtained from the nurses in the emergency department.
In this study, purposeful sampling method will be implemented for the data collection. In purposeful sampling, data can be collected from all the selected participants and these will be selected based on the inclusion criteria13. This is the most common method of sampling in the qualitative research. Maximum variation sampling is one of the methods of the purposeful sampling and it will be used in this qualitative research of staff of emergency department. Maximum variation sampling can collect data from varied insights of phenomenon by considering varied angles14,15. In this study, 30 nurses will be enrolled. Number of nurses in this hospital are less than standard ratio of 1 : 3 ; nurse : patient ratio in the emergency department. This number participants may vary slightly based on the turnover of the staff. In qualitative studies, number of participants can vary until robust data gathered and saturation point occurred. Hence, in this study, data will be collected and analysed simultaneously to understand progress of the study. Premature saturation can be avoided by improving sampling frame and methodology. It includes selection of suitable population, elimination of biases and analysis of data on regular basis16.
Exclusion criteria :
In this research, most relevant data can be obtained from the ‘hard-to reach’ participants. It is difficult task to involve this population in the research study. Involvement of ‘hard-to reach’ group can be improved by understanding characteristics of the participants. Understanding characteristics of the population is also useful in selecting sampling method for the ‘hard-to reach’ participants 17.
Consideration of ethical issues in the research proved beneficial in protecting human rights. Interaction between the researcher and participant is considered as challenging aspect for researcher in the qualitative studies because researcher should use ethically appropriate language. Hence, ethical guidelines should be established for the conduct of the study. However, there is no requirement of ethical approval in this qualitative research. These guidelines have more importance because there is no statistical analysis in the qualitative studies. Hence, ethical guidelines are useful for accurate data collection and interpretation18. Researcher should maintain anonymity and confidentiality of the participants. In this study, researcher should not make public the personal reasons of participants for poor morale. Hence, these rules should be properly defined in guidelines and protocols of the qualitative study. Researcher may face ethical dilemmas with the participants in the qualitative research in the form of establishment of honest and open interactions, and avoiding misrepresentations. Informed consent is the integral part of the research, however in this study informed consent from the participants is not required19.
Qualitative research is useful in explaining, clarifying and elaborating varied aspects of participants experiences. Hence, researcher can interpret participants experiences. Personal information of the participants can be protected by securing data storage methods, removing identifier components and amendments in the biographical details. Researcher should protect participants from the harmful consequences because it can affect outcome of the research.
30 participant nurses will be selected for the study. Prior to initiation of the study, participants will be informed about the aims and objectives of the study. These participants will be interviewed by the head of the emergency and accident department and administrative officer of the hospital. Interviews will be audio-video recorded for the future references and for the interpretation of the data. Interviews will be conducted in the closed doors with presence of three people comprising of two interviewers and a participant. Interview will last for 1 hour for each participant. Questions related to social, physical and personal reasons for the poor morale will be asked to the participants. After completion of the interviews, training will be provided to the participants for improving morale of the participants. Training will be provided by professional trainers in social life and medical profession. Training will be provided for all the participants at the same time and it will lasts for the period of five days. These training sessions will comprise of theoretical lectures and case studies in the form of videos. All the training programmes will be organised in the English language. Different strategies will be demonstrated in improving morale of the participants. After completion of the training programmes feedback will be collected from the participates. In case, participants remain less educated after completion of the programme, training will be arranged for these participants for the second time.
In mentioned qualitative research, data will be available mainly in the form of subjective expression of the participants. In this type of qualitative research, usually data is subjective20. This data is the expression and experiences of participants in the form of feelings. Data collection can be direct and indirect in qualitative research21. In direct data collection, data can be collected by one to one interaction between interviewer and participant. On the other hand, in indirect data collection data can be collected in a group. In this research on staff of emergency department data related to reasons of poor morale can be collected by direct data collection method. Data related to feedback of the training session can be collected by indirect method of data collection. Interviews are the active interactions between interviewers and participants to get insight of thoughts and feelings of the participants. Interviews can also be useful in getting in-depth understanding of participants authentic experiences. In this qualitative research, experiences of staff members about emergency and accident department need to be collected. Hence, interviews can be most effective method of data collection in this qualitative research.
Interviews will be conducted by two specialist experts. One will from medical field and other from the administrative field. Hence, thoughts and experiences of the participants from all the perspectives can be understood. Validated questionaries’ from the literature will be used in this qualitative research. Based on these questionaries’ interview guidelines will be prepared to conduct interviews. These interview guidelines can serve as guiding tool for the interviewers as a future reference and it will be properly documented in the archives of the organisation. Approval will be taken for interview guidelines form the management of the hospital. Interview guideline will comprise of each topic like physical, personal and social and under each topic 2-3 questions will be mentioned. These questions will be short and in simple English. Open ended questions will encourage participants to express their thoughts and feelings in detail. Closed-ended and leading questions will be avoided in this interview process. Closed-ended questions will allow participants to answer questions in one or two words. Leading questions will force participants to give desired answer. Leading questions can also encourage bias in the qualitative research. As these interviewers are unknown to the participants, there is no question of bias in the data collection. It will also be helpful in maintaining confidentiality. Interview schedule will be decided, after taking approval from both interviewer and participants22.
Semi-structured frame-work of interview will be implemented in this research. In this type frame-work, interviewer can modify structured questions to enable discussion between participants23. Discussion can provide more comfort level during interview and encourage them to express themselves more freely. Topics of the interview can vary based on the different participants. Collected data will be duly signed by both participants and interviewers. This data will be stored in the form of paper and electronic form. Codes will be given for the identification of each participants data. Data will be stored in the archives of the hospital and permission for the access of data will be given upon approval from the management.
In qualitative data, analysis of the data comprises of understanding exact meaning of the collected data and explanation of the thoughts of the participants. Data collection and analysis should run concomitantly in qualitative research. Broadly four steps should be incorporated in the data analysis in the qualitative research like examining, categorising, tabulating and recombining.
In this qualitative research, thematic analysis will be used analysis of the data. Thermatic analysis mainly based on different themes and topics identified in the collected data. Data analysis in qualitative analysis can be completed in the six-steps. Information collected during interview will be transcribed word to word. Field notes collected during interviews will be incorporated in the transcripts. One expert each from medical and administrative field will be appointed to read the transcripts and understand it and discuss among themselves. These experts will be allowed to re-read these transcripts and prepare reflection of content in the transcripts. Collected data will be summarised and segregated in smaller sections. These segregated smaller data will be labelled with specific words or phrases. This process is known as coding and words and phrases are called as codes. Different coding systems like open coding, axial coding and selective coding will be used in the research. Application of different types of coding will be helpful in the arranging the data and interconnecting the data with other topics. In this qualitative research, different factors can influence outcome of other factors. NVivo software will be used make this coding system more clear and effective. In qualitative data analysis, NVivo software can be used to organise, store and code the collected data. After generating codes for every data, verification will be done for accuracy of codes and sub-codes for each topic. These codes will explain data of each topic. Codes and related topics will be reviewed for 2 – 3 times to improve accuracy of the collected data. This data will be documented in tabulated form by using separate table for each code and its respective data. All the collected data will be recombined in one document and final conclusion of the analysis will be written24,25.
Poor morale and higher turnover is associated with different factors like physical, social and personal. Hence, multidimensional study should be designed to address all these factors. Health care administrators should focus on nursing staff retention by promoting leadership qualities in the staff and by implementing comprehensive career development programs. Identifying reasons behind poor morale and high turnover would be helpful in preventing compassion fatigue which is beneficial in reducing higher staff turnover. It would be helpful in maintaining visibility of management, promoting open and respectful communication and encouraging staff involvement in decision making, assessing relation between pay scale and turnover rate and creating optimum orientation programme for new nurses26. Orientation programme would be created based on the nursing education and universal education theory and requirements of the orientees would be considered. Internship and residential programmes would be helpful in increasing retention rate. Discussion among the group members, counselling related to work/home balance and social involvement would be augmented. Productive team spirit and adequate colleague support would be evident in the emergency department. Traumatic events would be dramatically reduced27. Time-out facilities would be developed and support would be provided to the affected nurses. There would be improvement in the self-scheduling and pay scale. Lunch breaks, guaranteed nurse-to-patient ratio and debriefing sessions would be implemented in the identification of reasons behind poor morale and high turnover rate 28.
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