Factors Influencing Job Embeddedness in Emergency Room Nurses: Focus on Positive Psychological Capital, Gratitude, and Anger Expression
Article information
Abstract
Purpose
This study aimed to identify the effects of positive psychological capital, gratitude, and anger on job embeddedness among emergency room nurses.
Methods
A total of 144 participants, nurses with more than 6 months of emergency room work experience, were included. Data collection occurred from July 10 to August 20, 2022. The collected data were subjected to descriptive statistics, t-tests, ANOVA, Scheffé tests, Pearson's correlation coefficient, and multiple regression analysis using the SPSS/WIN 26.0 program.
Results
There were statistically significant differences in job embeddedness according to the general characteristics of the participants in terms of age, position, total experience, positive psychological capital, and gratitude. Job embeddedness and positive psychological capital showed a statistically significant correlation (r=.48, p<.001), and job embeddedness also demonstrated a statistically significant positive correlation with gratitude (r=.38, p<.001). But there was no correlation with anger expression. Multiple regression analysis indicated that positive psychological capital and gratitude were factors influencing job embeddedness, with the independent variables explaining 26.6% of the variance in job embeddedness.
Conclusion
Based on these results, to increase the job embeddedness of emergency room nurses in the future, it is recommended to offer programs aimed at enhancing levels of positive psychological capital and gratitude.
INTRODUCTION
Emergency room (ER) nurses play a crucial role as they need to make appropriate judgments and provide immediate care to patients with various symptoms and degrees of severity [1]. However, due to the unique characteristics and diverse situations in the ER, the burden on nurses is high, leading to a higher turnover rate compared to nurses in other departments [2]. A 2023 report highlights that the national average turnover rate for registered nurses (RNs) is 18.4%, while turnover rates in emergency services and similar high-stress units exceed 29.0%, significantly higher than the rates observed in pediatrics or general wards [3]. The increased turnover rate among ER nurses results in a shortage of nursing staff who need to provide care on-site, and particularly, the absence of experienced nurses negatively impacts the quality of emergency care [2]. To improve the quality of emergency nursing, it is essential not only to increase the retention of ER nurses and reduce their turnover intentions but also to ensure the retention of experienced nurses. Job embeddedness, a concept developed by Mitchell et al. to understand why people stay in their organizations, is relevant here [4]. Most studies related to job embeddedness among clinical nurses focus on its relationships with turnover intention, retention intention, and other organizational factors. But there is an insufficiency of analytical research on the psychological or emotional factors influencing job embeddedness [5].
Positive psychological capital refers to the psychological resources that individuals utilize for personal development, encompassing physical and mental health, and contributing to improved group performance [6]. According to previous studies, Positive Psychological Capital positively affects job embeddedness and individual job-related behaviors, bringing positive changes to the nursing organization [7]. ER nurses experience job stress and emotional labor due to the coexistence of emergency and nonemergency patients and workload, and Positive Psychological Capital can reduce psychological stress and increase job satisfaction, thus being a key factor in enhancing job embeddedness [8].
Gratitude is defined as recognizing the value and meaning of events, people, actions, or objects and feeling a positive connection to them, helping individuals recover and overcome negative situations [9]. ER nurses are exposed to negative factors such as emotional labor, incivility, and violence, which cause them to experience stress, burnout, and anxiety while providing nursing care [10]. Recent studies suggest that gratitude in the workplace enhances job satisfaction, which serves as a crucial factor in reducing turnover intention. Research indicates that gratitude improves job satisfaction and fosters positive work attitudes, thereby increasing job involvement and decreasing the likelihood of leaving an organization [11,12].
ER nurses often face situations where maintaining a cooperative relationship with patients and guardians is challenging, and they frequently experience anger due to assaults by patients or intoxicated individuals [10]. However, due to the nature of their profession, nurses lack the skills to manage and express anger appropriately [13]. This inappropriate anger expression reduces work concentration and efficiency, negatively affecting organizational retention and commitment [14]. This implies that anger increases turnover intentions and indirectly negatively impacts job embeddedness [13]. However, since there is limited research directly linking levels of anger expression to job embeddedness, it is necessary to study the relationship between anger expression and job embeddedness.
Based on the three variables-positive psychological capital, gratitude, and anger expression -that hold significant meaning for the job embeddedness of emergency room nurses, this study aims to examine how these variables influence job embeddedness. It will evaluate the levels of these variables among participants, analyze how they differ based on general characteristics, explore their interrelationships, and identify key factors influencing job embeddedness in ER nurses.
METHODS
1. Study Design
This cross-sectional survey aimed at identifying the levels of Positive Psychological Capital, gratitude, and anger expression among ER nurses, and exploring the impact of these variables on job embeddedness.
2. Participants
Referring to previous research [7], the participants of this study are ER nurses with more than six months of experience, working at university hospitals located in cities D and S, and in province G. The sample size required for regression analysis was calculated using G*Power 3.1.9.4. With a significance level of .05, power of .80, effect size of .15, and 13 predictors, the minimum sample size required for regression analysis was determined to be 131. Considering a 10% dropout rate, questionnaires were distributed to 146 participants, and 144 responses were analyzed after excluding 2 incomplete responses.
3. Instruments
1) General characteristics
The general characteristics included 10 items: gender, age, religion, marital status, education level, position, total experience at the current hospital, total ER experience, total clinical experience, and job turnover experience.
2) Job embeddedness
Job embeddedness was measured using a tool developed by Mitchell et al. [4] and validated and modified by Choi [15]. This tool comprises 17 items divided into four subcategories: organizational fit (7 items), community fit (2 items), benefits (5 items), and team (3 items). Each item is rated on a Likert scale from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating higher job embeddedness. The reliability of this tool in Choi’s study was Cronbach’s ⍺= .85, and in this study, the overall reliability was Cronbach’s ⍺= .83.
3) Positive psychological capital
Positive Psychological Capital was measured using the Psychological Capital Questionnaire (PCQ) developed by Luthans and Youssef [16] and adapted by Kim [17] for the nursing context. This tool consists of 24 items divided into four subcategories: self-efficacy (6 items), hope (6 items), optimism (6 items), and resilience (6 items). Each item is rated on a Likert scale from 1 (strongly disagree) to 5 (strongly agree), with items 3, 8, and 19 reverse scored. Higher scores indicate higher Positive Psychological Capital. The overall reliability of the tool in Luthans et al.'s study was Cronbach’s ⍺= .89, and in this study, it was Cronbach’s ⍺= .91.
4) Gratitude
Gratitude was measured using the Korean version of the Appreciation Scale developed by Adler and Fagley [18] and validated by Noh and Lee [9]. This tool consists of 23 items divided into six subcategories: focus on possessions (5 items), awareness and behavior (4 items), expression (4 items), natural and routine (4 items), downward comparison (3 items), and loss/adversity (3 items). Each item is rated on a Likert scale from 1 (strongly disagree) to 7 (strongly agree), with higher scores indicating higher levels of gratitude. The reliability of this tool in Noh and Lee's study was Cronbach’s ⍺= .95, and in this study, it was Cronbach’s ⍺= .93.
5) Anger expression
Anger was measured using the anger expression scale developed by Spielberger, modified and standardized into the Korean version (STAXI-K) by Jeon et al.[19], and further refined by Kim [20]. This tool consists of 24 items divided into three subcategories: anger-in, anger-out, and anger control, each containing 8 items. Each item is rated on a Likert scale from 1 (strongly disagree) to 4 (strongly agree), with higher scores indicating higher levels of anger expression. The reliability of the anger expression scale in Jeon's study was Cronbach’s ⍺= .90, with a subdomain reliability of .74 for anger expression, .73 for anger suppression, and .81 for anger control. In this study, the overall reliability was Cronbach’s ⍺=.77, with a subdomain reliability of .80 for anger expression, .80 for anger suppression, and .71 for anger control.
4. Data Collection and Ethical Consideration
Data collection occurred from July 10, 2022, to August 20, 2022, using self-report questionnaires. Permission for data collection was obtained from the nursing departments of university hospitals located in cities D and S, and province G. Questionnaires were distributed to participants who voluntarily agreed to participate, with an explanation of the study’s purpose and assurance of anonymity. Participants could withdraw from the study at any time, and only those who provided written consent were included. To protect participants' privacy, completed questionnaires were sealed in individual envelopes and collected by the researcher. This study was conducted following the approval of the Institutional Review Board (IRB) of Eulji University (EUIRB2022-033).
5. Data Analysis
The collected data were analyzed using the SPSS/WIN 26.0 program, and the specific analysis methods were as follows: Descriptive statistics were used to analyze the general characteristics of the participants. The levels of Positive Psychological Capital, gratitude, anger expression, and job embeddedness were calculated using frequencies, percentages, means, and standard deviations. Differences in Positive Psychological Capital, gratitude, anger expression, and job embeddedness according to the general characteristics of the participants were analyzed using t-tests and ANOVA, with Scheffé tests for post hoc analysis. Pearson’s correlation coefficient was used to analyze the relationships between Positive Psychological Capital, gratitude, anger expression, and job embeddedness. Multiple regression analysis was conducted to identify the factors influencing job embeddedness of the participants.
RESULTS
1. General Characteristics of Participants
The general characteristics of the 144 participants are as follows: the average age was 29.31±5.64 years, with 102 participants (70.8%) reporting no religion. The highest level of education for most participants was a bachelor's degree (107 participants, 74.3%), and 129 participants (89.6%) were staff nurses. Regarding their work experience at the current hospital, 68 participants (47.2%) had 3 to 10 years of experience. Fifty percent of the participants had 6 months to less than 3 years of ER experience, and 77 participants (53.5%) had 3 to 11 years of total clinical experience as shown in Table 1.
2. Levels of Positive Psychological Capital, Gratitude, Anger Expression, and Job Embeddedness
The average score for Positive Psychological Capital was 3.43±0.50 out of 5, with the sub-dimensions scoring as shown in Table 2. The average gratitude score was 4.47 ±0.95 out of 7, and the average anger expression score was 2.52±0.29 out of 4. The average job embeddedness score was 2.92±0.48 out of 5, with sub-dimensions scoring as shown in Table 2.
3. Differences in Job Embeddedness, Positive Psychological Capital, Gratitude, and Anger Expression by General Characteristics
The analysis of job embeddedness based on the general characteristics of the participants revealed the following results. For age, individuals aged 30~34 scored 46.93±7.33, while those aged 35 and older scored 54.05±9.40, showing a statistically significant difference (F=3.11, p=.028). Post hoc analysis indicated that the group aged 35 and older had significantly higher scores than the group aged 30~34. In terms of position, nurse managers scored 61.20±12.21, which was statistically significantly higher than staff nurses, who scored 49.08±7.65, and charge nurses, who scored 50.70±8.12 (F=5.83, p=.004). Regarding total clinical experience at the current hospital, those with 11 years or more scored 53.50±10.27, which was significantly higher than those with 6 months to 3 years of experience, who scored 50.54±8.19 (F=3.53, p=.032).
The differences in positive psychological capital by general characteristics were as follows. For age, individuals aged 35 and older scored 90.61±13.32, significantly higher than those aged 24 and younger, who scored 77.93±8.42, and those aged 25~29, who scored 80.87±12.20 (F=4.40, p=.005). In terms of education, those with a master’s degree or higher scored 93.56±9.39, significantly higher than those with an associate's degree, who scored 79.58±7.03, and those with a bachelor's degree, who scored 80.00±11.41 (F=16.33, p<.001). For position, nurse managers scored 100.6±9.15, significantly higher than staff nurses, who scored 81.03±11.50 (F=9.63, p<.001). Concerning clinical experience at the current hospital, those with 11 years or more scored 92.0±12.41, significantly higher than those with 6 months to 3 years of experience, who scored 79.90±12.36, and those with 3-11 years of experience, who scored 82.51±10.43 (F=6.34, p=.002). For ER clinical experience, those with 11 years or more scored 93.85±8.82, significantly higher than those with 6 months to 3 years of experience, who scored 80.63±12.08, and those with 3~11 years of experience, who scored 82.95±11.39 (F=4.27, p=.016).
The differences in gratitude by general characteristics were as follows. For age, those aged 35 and older scored 124.33±23.56, showing a statistically significant difference (F=8.14, p<.001). Married individuals scored 114.11±23.32, significantly higher than unmarried individuals, who scored 101.19±21.20 (p=.006). In terms of education, those with a master's degree or higher scored 119.96±19.33, significantly higher than those with an associate's degree, who scored 107.58±22.39 (F=9.27, p<.001). For position, nurse managers scored 137.00±8.66, significantly higher than staff nurses, who scored 100.25±20.80 (F= 10.52, p<.001. For ER clinical experience, those with 11 years or more scored 129.57±4.89, significantly higher than those with 6 months to 3 years of experience, who scored 102.12±20.19, and those with 3-11 years of experience, who scored 100.49±22.83 (F=6.09, p=.003). Finally, for total clinical experience, those with 11 years or more scored 121.81±25.60, significantly higher than those with 6 months to 3 years of experience, who scored 98.80±19.56, and those with 3-11 years of experience, who scored 101.35±20.56 (F=7.79, p=.001). There were no statistically significant differences in anger expression based on the general characteristics of the participants (Table 3).
4. Correlation between Positive Psychological Capital, Gratitude, Anger Expression, and Job Embeddedness
The correlation analysis revealed statistically significant positive relationships between Positive Psychological Capital and job embeddedness (r=.48, p<.001) as well as between gratitude and job embeddedness (r=.38, p<.001). These findings suggest that greater levels of Positive Psychological Capital and gratitude are linked to higher levels of job embeddedness. anger expression was found to have no correlation with job embeddedness (r=-.05, p=.560) (Table 4).
5. Factors Influencing Job Embeddedness among ER Nurses
Multiple regression analysis was conducted to identify factors influencing job embeddedness, including age and marital status (converted to a dummy variable) as independent variables. The regression model indicated that Positive Psychological Capital and gratitude significantly influenced job embeddedness, with the regression model being significant (F=13.96, p<.001). The independent variables explained 26.6% of the variance in job embeddedness. Specifically, the factors influencing job embeddedness were Positive Psychological Capital (β=.42, p<.001), age (β=-.18, p=.034), marital status (β=.17, p=.038), and gratitude (β=.18, p=.045). The variance inflation factor (VIF) values ranged from 1.24 to 1.45, indicating no multicollinearity, and the Durbin-Watson statistic was 1.64, indicating no autocorrelation (Table 5).
DISCUSSION
The level of job embeddedness among emergency room nurses in this study was found to be lower compared to nurses in general wards or long-term care facilities, as indicated by previous research [21,22]. This difference may be attributed to the higher psychological stress experienced by emergency room nurses, which can negatively affect their sense of job attachment and engagement. Recent studies indicate that stress among nurses significantly impacts their job embeddedness, with high stress levels often leading to reduced organizational commitment and weaker interpersonal connections within the workplace [23]. ER nurses maintain a constant state of tension due to interactions with other departments based on the urgency of emergency patients and the pressure to administer quick treatment [24]. This excessive psychological stress likely results in relatively low job embeddedness scores among ER nurses.
Among the subdomains, organizational fit scored the highest. This suggests that job embeddedness is positively influenced when individuals feel that their colleagues and work environment align with their personal goals rather than the benefits obtained from the organization [7]. Particularly in the ER, where frequent cooperation and interaction with various departments are essential [24], high scores in fit and linkage can be understood. However, in the sacrifice domain, which refers to the benefits of staying, lower scores were observed compared to fit and linkage. Previous studies have also found low scores in the sacrifice domain [7,22], suggesting that ER nurses, due to frequent exposure to sudden emergencies, verbal abuse, and physical conflicts, experience higher frustration and desire to escape [24], negatively impacting the sacrifice domain.
The level of positive psychological capital in this study was relatively high compared to studies [7]. The high scores in the “hope” dimension of positive psychological capital among emergency nurses likely reflect their belief in the potential for improvement in patient conditions, which motivates them to create effective nursing plans, even in complex situations. A recent study supports this idea, emphasizing that positive psychological capital, including hope, is crucial for maintaining performance under stressful conditions and mediates the impact of burnout on nursing outcomes [25]. The level of gratitude was found to be lower compared to studies conducted on general nurses [26], and the expression subdomain scoring the highest. The high score in the expression subdomain may be because ER nurses frequently interact with other departments and various people, creating many situations where they need to express gratitude.
The anger expression subdimension showed the highest level among the subdimensions of anger. This suggests that individuals make significant efforts to control their anger expression [19]. ER nurses encounter many situations that provoke anger due to interactions with various departments and patients. Instead of expressing or suppressing their anger, they make considerable efforts to control it. Additionally, controlling and managing anger to provide high-quality nursing services [14] explains their high score in anger control.
Job embeddedness varied by demographic characteristics, being higher among older, married nurses with higher positions and clinical experience. This finding aligns with previous research [27]. As age and experience increase, so does job proficiency, which can lead to promotions and increased organizational benefits, resulting in higher job embeddedness. However, job embeddedness was lowest among nurses aged 26~35. This age group often experiences career stagnation, repeating familiar tasks rather than taking on new ones, leading to uncertainty about their position and future. This uncertainty can increase interest in new fields or organizations, raising turnover intentions [4]. Strategies to improve job embeddedness for this age group are necessary. Married nurses showed higher job embeddedness, possibly due to the responsibility and stability family life provides [7].
Positive psychological capital was higher among older, more educated, higher-ranking, experienced, and non-religious nurses. Increased age, experience, and education may lead to greater confidence in handling emergencies and higher job satisfaction, enhancing positive psychological capital. The achievement and willingness to learn gained through professional knowledge acquisition positively impact nursing performance [14], suggesting the need for programs that motivate learning and apply acquired knowledge in clinical practice to enhance positive psychological capital.
Gratitude was higher among older, more educated, higher-ranking, experienced, religious, and married nurses. Gratitude can develop through training and learning [28], and higher age, education, position, and experience contribute to its enhancement over time. Implementing gratitude expression training programs could improve nurses' levels of gratitude.
No significant differences in anger expression were found based on demographic characteristics. This result is similar to studies on ER nurses [14]. The frequent interactions with various job types, patients, and guardians in the ER lead to many situations provoking dissatisfaction, verbal abuse, and violence [24]. Therefore, efforts are made to control and resolve anger rather than expressing it based on demographic characteristics [14]. Due to the frequent anger-inducing situations in the ER, interventions such as emotional control and appropriate communication training are necessary [14].
Correlation analysis showed significant positive correlations between job embeddedness and positive psychological capital and gratitude. Positive psychological capital had the strongest positive correlation, consistent with studies on clinical nurses [25]. This suggests that ER nurses seek positive strategies and work attitudes in various situations, overcoming challenges and achieving higher satisfaction, which enhances job embeddedness. Although direct comparisons are difficult due to a lack of studies on gratitude and job embeddedness, gratitude also showed a positive correlation. Gratitude helps regulate emotions and recover in difficult situations, fostering a proactive attitude toward problem-solving [9]. This positive impact of gratitude helps ER nurses find meaning in stressful situations [24], positively influencing job embeddedness.
Although no significant correlation between anger expression and job embeddedness was found, studies on ER and general hospital nurses suggest that appropriate anger expression and control are related to job performance and organizational commitment [13,14]. This indirectly indicates a correlation between appropriate anger expression and job embeddedness. The lack of correlation in this study may be due to ER nurses’ need to control emotions and provide quick judgment and care rather than react to anger-inducing situations.
Multiple linear regression analysis identified positive psychological capital as the most significant factor influencing job embeddedness. This finding supports research on trauma center nurses [7], which also highlighted the importance of developing and enhancing positive psychological capital. Positive psychological capital helps individuals cope with complex and diverse environments, developing their abilities [6]. In the ER, with its dynamic work characteristics, positive psychological capital enhances ER nurses’ coping abilities and potential [7]. Implementing simulation or stress management programs for handling emergencies could improve coping abilities and hope [24]. Further research is needed to verify the impact of such programs on positive psychological capital.
Other factors influencing job embeddedness included age and marital status, supporting findings from studies on trauma center and long-term care hospital nurses [7]. Increased age correlates with accumulated experience and proficiency, enhancing understanding and response to emergencies, positively impacting job embeddedness. Marital status suggests a tendency to settle in one place, also positively influencing job embeddedness [7].
The last factor influencing job embeddedness was gratitude, indicating that higher levels of gratitude among emergency room (ER) nurses correlate with higher job embeddedness. A study on clinical nurses confirmed that higher gratitude levels positively affect happiness and psychological well-being [29]. This suggests that when gratitude levels are high, emotional stability improves, positively impacting job embeddedness. ER nurses experience high psychological instability due to heavy workloads and emotional labor [24], necessitating the provision of emotional management programs to increase gratitude levels. Individually, it is essential to incorporate meditation, prayer, and contemplation, providing time for self-reflection and expressing gratitude in life. Previous studies have developed and applied programs to increase gratitude levels, proving that gratitude can be enhanced through education and training [28]. Based on this, follow-up research is needed to understand ER nurses' psychological states and apply programs to increase their gratitude levels, confirming the improvement post-application. A limitation of this study is that data were collected only from emergency room nurses at university hospitals in three regions, so caution should be exercised when generalizing the findings.
The nursing implications of this study are as follows:
First, this study academically highlights the significance of emotional and psychological factors, such as positive psychological capital, gratitude, and anger expression, as influential variables on job embeddedness, which have been overlooked in previous research. This contributes to a deeper understanding of job embeddedness and highlights the need for a multidimensional approach in nursing research. Furthermore, by analyzing the unique impacts of job embeddedness in high-risk, high-stress environments such as emergency rooms, this study expands the scope of research on job embeddedness across diverse nursing settings. Notably, exploring negative emotions such as anger as a key variable of job embeddedness provides a differentiated academic contribution compared to previous studies.
Second, in terms of practical implications, the findings of this study provide a basis for developing practical intervention programs aimed at enhancing positive psychological capital and gratitude among emergency room nurses. Additionally, based on the study results, nursing managers can establish nurse retention strategies, such as stress reduction programs, emotional support systems, and professional development initiatives, which will contribute to improving the quality of emergency medical services.
CONCLUSION
This study found significant positive correlations between positive psychological capital, gratitude, and job embeddedness. The main factors influencing job embeddedness among ER nurses were identified as positive psychological capital, gratitude, and marital status. Based on these findings, exploring ways to enhance positive psychological capital and gratitude levels is essential to improve ER nurses’ job embeddedness. There were significant differences in clinical experience and job position regarding positive psychological capital and gratitude, which influence job embeddedness. Therefore, when providing programs to enhance job embeddedness among ER nurses, education should be tailored according to their experience and position. Moreover, when developing educational programs, positive psychological capital and gratitude are emotional aspects, so practical applications should be included
This study provides nursing significance by examining the relationship between positive psychological capital, gratitude, anger expression, and job embeddedness among ER nurses and can serve as foundational data for improving job embeddedness among ER nurses. However, further research is needed due to the lack of studies examining the relationship between gratitude, anger expression, and job embeddedness. Additionally, research on the positive effects of anger expression, often viewed negatively, and the tools to measure anger expression among nurses is insufficient, necessitating repetitive studies. Based on these results, developing programs to enhance positive psychological capital and appropriate gratitute methods, and exploring and verifying their effects, is needed to improve job embeddedness among ER nurses.
Notes
The authors declared no conflicts of interest.
AUTHOR CONTRIBUTIONS
Conceptualization or/and Methodology: Joo, SR & Kang, M-J
Data curation or/and Analysis: Joo, SR & Kang, M-J
Investigation: Joo, SR
Project administration or/and Supervision: Kang, M-J
Resources or/and Software: Joo, SR
Validation: Joo, SR & Kang, M-J
Visualization: Joo, SR & Kang, M-J
Writing: original draft or/and review & editing: Joo, SR & Kang, M-J