Job performance and associated factors among nurses working in adult emergency departments at selected public hospitals in Ethiopia: a facility-based cross-sectional study

The study was conducted in the emergency departments (EDs) of public hospitals in Addis Ababa, Ethiopia, from March 25 to April 25, 2023. Addis Ababa is the capital city of Ethiopia, which is located in the central part of Ethiopia. There are a total of 12 public hospitals in Addis Ababa [31]. The study was conducted in five randomly selected public hospitals found in Addis Ababa, namely Tikur Anbessa Specialized Hospital (TASH), St. Paulo’s Specialized Hospital, AaBET Hospital, St. Peter’s Referral Hospital, and Alert Referral Hospital.

St. Paul’s Specialized Hospital has 72 nurses working in the adult ED; AaBET Hospital has 98 nurses working in the adult ED; TASH has 42 nurses working in the adult ED; St. Peter’s Referral Hospital has 28 nurses working in the adult ED; and Alert Referral Hospital has 52 nurses working in the adult ED [32]. Hence, a total of 292 nurses were working in the adult EDs of selected public hospitals in Addis Ababa during the survey.

A facility-based cross-sectional study design was conducted among nurses working in the adult EDs of selected public hospitals in Addis Ababa, Ethiopia. All nurses working in the adult emergency department of each public hospital were invited to take part in the study. Nurses who were on maternity leave, annual leave, sick leave, or severely sick were excluded.

The sample size required for the study was determined by using a single population proportion formula considering a 67.8% proportion of nurses’ performance (P) taken from the study conducted at Jimma University Specialized Hospital, Ethiopia [5], a 95% confidence interval, a 5% margin of error, and a 10% non-response rate.

Since the total study population from five selected public hospitals (N = 292) is less than 10,000, a correction formula was applied to get the final sample size (nf) as follows.

Then, after adding a 10% non-response rate, the final sample size required for the study was 172.

First, five hospitals (TASH, St. Paul’s Specialized Hospital, AaBET Hospital, St. Peter’s Referral Hospital, and Alert Referral Hospital) were randomly selected (by lottery method) from 12 public hospitals found in Addis Ababa. Then, the total number of nurses working in the adult emergency departments of selected public hospitals was determined by the ward nurse managers. The participants were then allocated from selected five hospitals in proportion to the number of nurses working in the adult ED. Finally, the study participants were selected using a simple random sampling technique (Fig. 1).

The outcome variable for this study was nurses’ job performance. Independent variables include socio-demographic characteristics (age, sex, marital status, education level, work experience), in-service training, resource availability, organizational factors such as feedback, remuneration, recognition, and rewards, and personal factors such as motivation, job satisfaction, interpersonal relationships, knowledge and skills, clinical competency, and related variables.

A pretested self-administered structured questionnaire adapted with slight modifications from previous studies [5, 27, 33] was used to collect data on the performance of nurses. The questionnaires consisted of socio-demographic data, performance measurement tool, questions on job satisfaction, and organizational related factors. Nurses’ performance was measured by nine items that are self-rated on a five-point Likert scale (1 = very poor, 2 = poor, 3 = good, 4 = very good, and 5 = excellent). The scores were averaged so as to show each participant’s job performance level, ranging from 9 to 45 [27, 33]. Respondents were categorized as having “good job performance” if their average job performance score was greater than or equal to the computed overall mean value of job performance (mean ≥ 3.56), and “poor job performance” if their average job performance score was less than the computed overall mean value of job performance (mean < 3.56) [33, 34]. The Cronbach alpha coefficient value was 0.72, showing the performance measure was reliable. Nurses’ Job satisfaction was measured by eleven items on a five-point Likert scale (1 = strongly dissatisfied, 2 = dissatisfied, 3 = average, 4 = satisfied, and 5 = very satisfied). The scores were averaged so as to show each respondent’s satisfaction level, ranging from 11 to 55. Respondents with an average score less than the mean value were classified as dissatisfied, and those with an average score of the mean value and above were considered satisfied. The Cronbach alpha coefficient was 0.839, showing the job satisfaction measure was reliable. Organizational related factors were measured by eight items using a Likert scale with five responses (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree). Data were collected by trained data collectors and supervisors using pretested self-administered questionnaires.

A pretested and validated self-administered structured data collection tool was used to ensure data quality. Two days training were given to the data collectors and supervisors on the objectives of the study, the contents of the data collection tool, and other related issues. A pretest was done on 10% of the sample size at Yekatit 12 Referral Hospital before the actual data collection period to check for the reliability and validity of the data collection tools. The questionnaires were reviewed and checked for incompleteness and inconsistency, and necessary amendments were made based on the pretest results. The collected data were carefully checked for completeness, accuracy, and consistency by supervisors and the principal investigator on a daily basis.

The study was conducted following the principles of the Helsinki Declaration. Ethical clearance was obtained from Addis Ababa University’s, College of Health Science’s Institutional Health Research and Ethics Review Committee (IHRERC) under Ref. No. PM 23/661. After ethics approval, a written official letter of cooperation was submitted to each hospital before the commencement of the data collection to obtain administrative permission. Informed voluntary, written, and signed consent was obtained from the study participants after they were informed of the aim, purpose, and benefits of the study. The confidentiality of the information was ensured throughout the data collection and dissemination processes.

A total of 166 study participants completed and returned the questionnaires, yielding a response rate of 96.5%. The mean (±SD) age of the study participants was 29 (±6.23) years. Among the respondents, the majority (58.4%) were aged 26 to 33 years, more than half (57.8%) were female, and 85 (51.2%) were single in marital status. Regarding their education status, more than two-thirds (64.5%) of the respondents had a BSc in Nursing, and 51 (30.7%) of them had 2–3 years of work experience in the emergency departments (Table 1).

The self-rated performance assessment of nurses was calculated using total measures of performance assessment items such as sick and emergency leave, attendance and punctuality, optimizing personal skills, relationships with patients and coworkers, quality of work, relationships with supervisors, improving work methods, and overall performance compared to co-workers. The overall self-rated job performance of nurses was 70.5% (95% CI: 63.7–77.3). The overall self-rated job performance showed that the majority of nurses, 117 (70.5%), working in the adult EDs of selected public hospitals in Addis Ababa had good job performance, while 49 (29.5%) had poor job performance (Fig. 2).

The majority of respondents rated their knowledge and skills satisfactory, as indicated by the mean score of different items that assessed their knowledge and skills. About 79.6% of respondents thought that they had good interpersonal relationship skills, with a mean score of 3.98, followed by time management (78.6%), applying a nursing care plan (78.2%), and work quality (77.8%). The respondents rated themselves as having an average level of knowledge and skills in providing health education (72.8%) and relationships with their supervisors (72.2%) (Table 2).

Sixty-two (37.3%) of the respondents reported that their performance was reviewed on a regular schedule and under a formal method of appraisal, which included a review of prior performance and the setting of objectives; 53 (31.9%) stated that their performance was reviewed informally, but with regular assessments that included a discussion of past performance and agreed with future action; and 33 (19.9%) reported that their performance was reviewed informally with a specific review when there was a performance problem (Fig. 3). The majority of respondents, 43 (25.9%), 61 (36.7%), and 35 (21.1%), said the results of performance appraisals were used for training, rotation, and promotion, respectively (Fig. 4).

The mean score of different items showed that the majority of respondents were not satisfied with the performance appraisal system and its utilization. The majority, 84 (50.6%) and 75 (45.2%), of them were uncertain with performance standards expected from staff being clear and understood by all and objectives to be achieved known by individuals, with mean scores of 3.27 and 3.23, respectively. Seventy-eight (47.6%) disagreed that feedback on how staff were performing was provided throughout the year, with a mean score of 2.97. While 48 (28.9%) of them disagreed with staff that they were given the opportunity to comment on the result of their performance, with a mean score of 2.81 (Table 3).

Most of the nurses working in the adult EDs of selected public hospitals in Addis Ababa were not satisfied with the remuneration, benefits, and recognition they received from the institution. The majority of them disagreed that remuneration was competitive with other similar organizations and given according to their responsibility, with mean scores of 3.25 and 3.04, respectively. Sixty-one (36.8%) were unaware of their fringe benefits, and almost half (49.4%) disagreed that hardworking nurses were being recognized, with mean scores of 3.07 and 2.78, respectively. Similarly, 54 (32.6%) of nurses disagreed with the statement that remuneration was based on their level of experience, with a mean score of 3.19, and 67 (40.4%) disagreed with the statement that there is an opportunity for career advancement, with a mean score of 2.95 (Table 4).

The results of this study indicated that almost half (49.4%) of the respondents disagreed with the fairness of the overall work schedule with a mean score of 2.73, and most respondents disagreed that they had the opportunity to make inputs into staffing policies and procedures with a mean score of 2.66. The majority (62.1%) of the respondents disagreed that the allocated staff in their unit are adequate to cover the current workload, with a mean score of 2.55 (Table 5).

The study showed that more than half (61.5%) of the respondents were dissatisfied with job-specific refresher courses, and the in-service training filled the skill gap with mean scores of 2.45 and 2.54, respectively. Half (50%) and 90 (54.2%) of respondents disagreed with the opportunity for advancing in the organization and the availability of opportunities for continuing education, with mean scores of 3.26 and 3.10, respectively. The majority (75.5%) felt that they were not given the necessary training to ensure job effectiveness, with a mean score of 2.62 (Table 6).

Nurses working in the adult EDs of selected public hospitals in Addis Ababa were dissatisfied with the workspace and environment. Respondents disagreed with the availability of necessary instruments, materials and supplements, working instruments, guidelines for infection control strategy, and whether the work environment is safe and free from environmental hazards, with mean scores of 2.77, 2.43, 2.74, 2.83, and 2.59, respectively (Table 7).

In the multivariable logistic analysis, workload, remuneration, rewards, objectives to be achieved, and feedback on performance appraisals were identified as significantly associated with nurses’ performance. Nurses who had a light workload were 1.7 times [AOR = 1.70 (95% CI: 1.19–2.44)] more likely to have good performance than those who had a heavy workload. Nurses who had good remuneration were 1.89 times [AOR = 1.89 (95% CI: 1.35–2.67)] more likely to have good performance than nurses who had poor remuneration. Nurses who had rewards for their work were 1.5 times [AOR = 1.50 (95% CI: 1.01–2.23)] more likely to have good performance than nurses who did not. Moreover, nurses who knew the objectives to be achieved were 1.88 times [AOR = 1.88 (95% CI: 1.32–2.67)] more likely to have good performance than nurses who did not. Nurses who perceived feedback on performance appraisals were 1.65 times [AOR = 1.65 (95% CI: 1.17–2.33)] more likely to have good performance than nurses who did not (Table 8).

This study provides relevant research-based data on nurses’ performance levels and identifies factors that influence their performance, which could help stakeholders design evidence-based interventions. This study had the following limitations: First, due to the nature of the cross-sectional study, it was difficult to establish the cause-effect relationship between variables. Second, the small sample size used in the study may not represent a larger population. In addition, respondents may have been biased in their self-reports of job performance. Another limitation of this study is that an observation checklist was not used. This study asks respondents about their perceived knowledge and skills, and measuring performance through self-report is not the best way to gather information. The study did not include primary healthcare facilities and private clinics, so no comparison was made between public and private clinics, which may also be a limitation of this study.