Cardiology in the Young Qualitative assessment of nurse satisfaction in

cambridge.org/cty
the paediatric cardiac ICU
Julie E. Stark1 , Kim Steanson2, Emily R. Cooperstein3, Robert E. Harper4 and
M. Lynne Smith5
Original Article
1
Division of Critical Care Medicine, Department of Pediatrics, Monroe Carell Jr. Children’s Hospital, Nashville,
Cite this article: Stark JE, Steanson K, Tennessee, United States; 2Vanderbilt University School of Nursing, Nashville, Tennessee, United States;
Cooperstein ER, Harper RE, and Smith ML 3
Division of General and Community Pediatrics, Department of Pediatrics, Cincinnati Children’s Hospital Medical
(2023) Qualitative assessment of nurse
satisfaction in the paediatric cardiac ICU. Center, Cincinnati, Ohio, United States of America; 4University of Cincinnati College of Medicine, Division of
Cardiology in the Young 33: 2511–2517. Pediatrics, Cincinnati Children’s Hospital, Division of General and Community Pediatrics, Cincinnati, Ohio,
doi: 10.1017/S1047951123000306 United States of America and 5University of Cincinnati, Cincinnati, Ohio, United States of America

Received: 19 September 2022

Abstract
Revised: 23 January 2023
Accepted: 30 January 2023 The objective of this qualitative assessment, utilising the constant comparative method, was to
First published online: 27 March 2023 identify satisfiers and dissatisfiers that influence paediatric cardiac ICU nurse retention and
Keywords:
recognise areas for improvement. Interviews for this study were performed in a single, large
Nurses; personal satisfaction; paediatrics; ICUs; academic children’s hospital from March of 2020 through July of 2020. Each bedside paediatric
cardiac surgical procedures; grounded theory cardiac ICU nurse underwent a single semi-structured interview. Among 12 interviews, four
satisfiers were identified: paediatric cardiac ICU patient population, paediatric cardiac ICU care
Author for correspondence:
team, personal accomplishment, and respect. Four dissatisfiers were identified: moral distress,
Julie Stark, MD, Med, Doctor’s Office Tower
5118, 2200 Children’s Way, Nashville, fear, poor team dynamics, and disrespect. Through this process of inquiry, grounded theory was
Tennessee 37232, United States of America. developed regarding strategies to improve paediatric cardiac ICU nurse retention. Tactics out-
Tel: (765) 427-0916. lined here should be used to support retention in the unique environment of the paediatric
E-mail: julie.stark@vumc.org cardiac ICU.

The highly anticipated critical nursing shortage is upon us. In 2010, the World Health
Organization reported that 86% of member countries in a global survey were experiencing nurs-
ing shortages.1 Since that time, the global nursing shortage has become so significant that a
research prioritisation exercise conducted in the United States of America and United
Kingdom among healthcare professionals and patient families in 2019 identified it as a top
research priority.2 Shortages continue to increase and are now exacerbated by the emergence
of the SARS-CoV-2 pandemic. Fewer nurses are choosing to stay in bedside nursing their entire
careers, and turnover is particularly high among critical care nurses.3 In a 2015 Canadian study,
24% of critical care nurses reported an intent to leave their current role in the next year.4
Paediatric critical care nurses are highly specialised and require intensive training to provide
high-quality bedside care.5 In 2014, Duffield et al. found that the average cost to train a new
critical care nurse in the United States of America was $20,561.6 Additional costs are incurred
when nurses are paid overtime or when travel nurses must be hired to maintain adequate staff-
ing.7 Nurse staffing models within the paediatric cardiac ICU in the United States of America
vary widely.8 Recent studies within paediatric cardiac ICUs have directly linked patient mortal-
ity to years of bedside nurse clinical experience and patient complications to level of nursing
education.9,10 Thus, retention of paediatric cardiac ICU nurses is paramount as turnover rep-
resents a significant financial burden as well as a loss of crucial clinical expertise.
Nurses are at particularly high risk for job stress and burnout, but studies have shown these
effects can be mitigated.11 New nurses appear to be particularly at risk. Blake et al found an
inverse relationship between years of experience and intent to leave.12 The concept of the
“Healthy Work Environment” is well established, and validated tools have been developed
to measure defined benchmarks.13 A healthy work environment has been linked to staff satis-
faction and retention, and it provides the theoretical framework for this work, which will be
© The Author(s), 2023. Published by Cambridge discussed further in this article.
University Press. This is an Open Access article, Most nursing satisfaction studies to date have focused on adult critical care nurses and have
distributed under the terms of the Creative utilised survey-based quantitative methods to gauge nursing satisfaction. These studies rely on
Commons Attribution licence (https://
creativecommons.org/licenses/by/4.0/), which
predetermined questions and do not allow the same degree of inquiry that is achieved with
permits unrestricted re-use, distribution and qualitative methods. Qualitative methods have been shown to be highly effective in outcomes
reproduction, provided the original article is research in healthcare.14 Qualitative methods seek to “shine a light” on natural phenomena, and
properly cited. researchers must approach each study with as few preconceived ideas as possible.15
Establishing validity is particularly challenging and important in qualitative assessment
because conclusions are drawn and not calculated, as in quantitative assessment.
“Qualitative Research” by Merriam and Tisdell states: “One of the assumptions underlying
qualitative research is that reality is holistic, multidimensional, and ever-changing; it is not a

https://doi.org/10.1017/S1047951123000306 Published online by Cambridge University Press

 2512 J. E. Stark et al.

single, fixed, objective phenomenon waiting to be discovered.” Table 1. Demographics of nurses interviewed
Despite these challenges, rigorous standards of validity were main-
Percent
tained throughout this study, including assessment of internal val- Number of Total
idity based on review by paediatric cardiac ICU nurses and
Gender
triangulation of information from multiple sources (interviews).
The work presented here utilises a qualitative research Male 2 17%
approach to address nursing satisfaction in a single paediatric car- Female 10 83%
diac ICU at a large academic children’s hospital. This work is also
Years of Experience in Nursing
innovative because the primary investigator was a physician who
provides novel perspective, unaffected by prior experience working > 1–< 3 years 3 25%
in a nursing role. Specific aims were 1) to define satisfiers and dis- 3–< 6 years 4 33%
satisfiers which influence retention in the paediatric cardiac ICU
and 2) to identify potential areas in which retention can be posi- ≥ 6 years 5 42%
tively impacted. Years in the Cincinnati Children’s Hospital
Medical Center Paediatric Cardiac ICU

Materials and methods > 1–< 3 years 4 33%

3–< 6 years 4 33%
Study design
≥ 6 years 4 33%
This was a qualitative assessment utilising semi-structured inter-
views of paediatric cardiac ICU nurses at Cincinnati Children’s Shift
Hospital Medical Center from March 2020 through July of Day shift 6 50%
2020. The study was reviewed by the Cincinnati Children’s Night shift 2 17%
Hospital Medical Center Internal Review Board and deemed
IRB exempt. An informed consent form was reviewed and signed Rotating days/nights 3 25%
by each participant prior to his or her interview (Supplemental 1). Other 1 8%

Population and setting

All nurses in the Cincinnati Children’s Hospital Medical Center open coding, all interviews were reviewed and annotated with
paediatric cardiac ICU received an email requesting participation. descriptors related to the study. Using axial coding, these descrip-
Nurses who had worked in the paediatric cardiac ICU for at least a tors were grouped. Selective coding was used to develop categories,
year were accepted in order of response. The goal was to complete or theories, about satisfiers and dissatisfiers. The constant compar-
at least 12 interviews with nurses of various years of experience (1– ative method developed by Glaser and Strauss was utilised to
< 3 years, 3–< 6 years, and 6 or more years) and to ensure repre- develop grounded theories, which were then used to generate
sentation of nurses from dayshift and nightshift. Interim analysis hypotheses regarding paediatric critical care nurse job satisfaction
after 5 interviews demonstrated appropriate variability in level of and retention.17
experience but underrepresentation of nightshift nurses. A second
email was distributed requesting increased recruitment of night-
shift nurses, which was subsequently achieved. (Table 1)
Results
Interviews were conducted until data saturation was achieved,
meaning that subsequent interviews provided no new insight into Four core categories were developed for nurse satisfiers and dissat-
the phenomenon being studied. isfiers (Figure 1). Satisfiers were identified as 1) paediatric cardiac
ICU patient population, 2) paediatric cardiac ICU care team, 3)
Data collection personal accomplishment, and 4) respect. Dissatisfiers were iden-
tified as 1) moral distress, 2) fear, 3) poor team dynamics, and 4)
Interviews were conducted by the primary investigator, in a private
disrespect.
meeting room adjacent to the paediatric cardiac ICU following or
prior to the nurse’s shift. One interview was completed by phone.
Four primary questions were utilised to direct each interview. Satisfier: PCICU patient population
(Table 2) Interviews were audio recorded and transcribed within
72 hours by the primary investigator. Interviews were approxi- The most consistently identified satisfier, cited by 11 out of 12
mately 20 to 30 minutes in length producing 6 to 8 pages of sin- nurses, was the paediatric cardiac ICU patient population. This
gle-spaced transcript per interview. Each participant was assigned core category could further be divided into paediatric cardiac
a unique identification number. All data were securely stored ICU patient potential, paediatric cardiac ICU patient progress,
throughout data collection and analysis. and affinity for the paediatric cardiac patient population in general.
Regarding patient potential, multiple nurses cited seeing pictures
Data analysis of patients at home or in school and reported this to be gratifying.
All interviews were coded by the primary investigator and reviewed “Even though he had every complication under the sun, to see him make it
out of here and then the family sends us pictures of him at home. That is the
by the senior author. Utilising the process of analytical coding,
biggest joy.” CICU02† (†Deidentified nurses designated by “CICU#”)
codes were grouped into core categories which spanned the 12
interviews.15 Three phases of coding (open, axial, and selective) In the paediatric cardiac ICU, daily patient progress, especially
were performed, as described by Corbin and Strauss.16 During immediately postoperative, was also fulfilling:

https://doi.org/10.1017/S1047951123000306 Published online by Cambridge University Press

 Cardiology in the Young 2513

Table 2. Interview questions accomplished when they successfully cared for challenging
patients. A third of nurses specifically cited satisfaction from the
Question Intent
ability to identify decompensating patients before the patient sig-
1. Please, take me through a usual Encourage nurses to nificantly deteriorated. In correlation with the first satisfier, nurses
day at work for you. visualise their work
felt accomplished when they played a role in patient progress.
environment
“Typically, you want to have some sense of accomplishment that you
2. How do you feel when you leave Elicit satisfiers/dissatisfiers
work most days? from recent work actually made either an improvement or that you maintained where they
experiences are so that they can, you know, proceed on the trajectory that everybody has
planned for them.” CICU03†
3. Thinking about the past 6 months, Elicit satisfiers/dissatisfiers
would you say that you are mostly from more distant work On a personal level, nurses in the paediatric cardiac ICU liked to
happy with your current job in the experiences be challenged. They felt motivated to read about their patients out-
paediatric cardiac ICU or mostly side of work and liked being able to teach. Multiple nurses stated
unhappy? Why?
that they felt increasingly confident at work. Nurses also stated that
4. What do you think drives Focus on key drivers for they felt like their work “really matters.” Finally, nurses liked to be
Cincinnati Children’s Hospital retention
identified by others outside the paediatric cardiac ICU as intensive
Medical Center paediatric cardiac
ICU nurses to stay or seek other care nurses who could “handle anything.”
employment? “I think that people here want to be challenged and they kind of like the
stigma of, you know ‘I’m a pediatric cardiac ICU nurse.’” CICU08†

“I just think that part of it is neat: being able to, I mean, even in the short
Satisfier: respect
term, seeing how sick they were, and being able to just send them to the
floor is a big deal.” CICU07† The final category for satisfaction was broadly characterised as
When necessary, nurses defined occurrences of difficult conver- respect, which was further subdivided into being valued and being
sations between patient families and the medical team as “patient empowered. Nurses felt particularly valued when their fellow
progress,” and these were often a relief to the bedside nurse. nurses or the medical team took time to teach them.
“The most important thing is those hard conversations. When we wait and “Having people teach me and sit there with me and walk me through things
wait on them and then they finally happen, and those parents get those and devote their time really made me feel like it was important to them for
answers, that’s the best thing.” CICU05† me to be there and to better myself.” CICU08†

Some nurses simply stated an intrinsic love for children with This category aligned closely with the category of the paediat-
congenital heart disease and felt paediatric cardiac ICUs provided ric cardiac ICU care team. Nurses felt valued and respected when
hope for patients who would otherwise have none. they were able to ask questions without judgement, even when
those questions challenged the current management of the
patient. When nurses felt empowered to question the treatment
Satisfier: paediatric cardiac ICU care team plan, they felt that their professional decision making was
The second category identified as a satisfier for nurses in the paedi- utilised.
atric cardiac ICU was the care team. Multiple nurses stated that “That makes you feel good because then it validates your professional opin-
they stayed in their current role because of affinity for their ion and your personal opinion, and we’re all still people.” CICU05†
colleagues. Even in difficult situations when the patient outcome was likely
“I generally like 90% of the people I work with, so it makes me continue to to be poor, nurses felt increased satisfaction when their experience
love what I do and where I do it.” CICU04† within the patient room was validated by the medical team. As their
Teamwork between nurses, providers, and other staff was a key experience increased, being empowered to teach made nurses feel
element of satisfaction. Approachability and support from man- that their expertise was valued. Finally, acts of appreciation from
agement and the medical team were cited to be of particular impor- administration or nurse committees were gratifying for nurses.
tance. For all nurses, but especially newer nurses, the ability to ask “It speaks towards, “We know it’s been a rough time. Your hard work
questions in a non-intimidating forum and receive answers with- doesn’t go unacknowledged.” CICU03†
out perceived judgement was crucial.
“I can ask them a question about a diagnosis like, ‘I don’t understand this;
Dissatisfier: moral distress
please, explain it to me’ without judgement or without feeling like I failed.”
CICU08† The most consistently identified dissatisfier, cited by 11 out of 12
Between nurse colleagues, nurses appreciated the ability to nurses, was moral distress. Moral distress is defined as “when a
commiserate on difficult days and to celebrate achievements on healthcare provider believes he or she knows the ethically correct
successful ones. The quality nurses most frequently cited as vital action but cannot follow that action due to interpersonal, institu-
were “having each other’s back.” tional, regulatory, or legal constraint.”18 The majority of nurses
reported continuing to care for patients with low likelihood of pos-
itive outcomes in the paediatric cardiac ICU, which was especially
Satisfier: personal accomplishment distressing when minimal progress was seen on a daily basis.
Personal accomplishment was another consistent satisfier. This “The exhausting end of the [spectrum] would be the kids that, across the
category could be further divided into patient care, personal board, the kids that are in multi-system organ failure, and we’re still doing
growth, and outside perception. Regarding patient care, nurses felt all the things.” CICU07†

https://doi.org/10.1017/S1047951123000306 Published online by Cambridge University Press

 2514 J. E. Stark et al.

Figure 1. Satisfiers and dissatisfiers for nurses in the

pediatric cardiac intensive care unit. PCICI = paediatric
cardiac ICU.

Delay in the medical team initiating difficult conversations was “The first year was like really really hard. I felt like I didn’t know anything,
also upsetting and was magnified for nurses who were the ones in and I just was worried every day that I was going to kill somebody.”
the room providing direct patient care. CICU11†

“You’re not in there every, you know, few minutes of every hour. You don’t A third of nurses, all within the two less experienced groups,
know what it’s like, and you don’t see their faces.” CICU02† specifically cited fear of approaching the medical team and nurse
colleagues with questions.
Nurses also reported distress in interacting with patient families
who were in extremis and who were unlikely to fully comprehend “I would never let my personal fear of feeling stupid stop me from doing
the patient’s projected course. Some nurses stated that they wanted something that I felt like I needed to do for the patient, but it’s always a
to focus more on quality over quantity of life. Many felt that the thought in my mind.” CICU12†
paediatric cardiac ICU was a sad place in general and that some Finally, nurses feared being talked about negatively for pulling
nurses left because it was too sad. the code alarm or for asking “stupid” questions.
“For lack of a better word, [it is] just a sad unit to be a part of.” CICU03†
Finally, nurses reported feeling the pressure of supporting fel- Dissatisfier: poor team dynamics
low nurses through difficult patient situations. The third dissatisfier identified was poor team dynamics, which
was divided into interactions between nurses and management,
between nurses and the medical team, and among nurses.
Dissatisfier: fear Regarding management, the findings were mixed. Multiple nurses
Another consistent dissatisfier was categorised as fear, which could reported feeling well supported by their manager, which was a sat-
be divided into fear at the time of patient deterioration and fear of isfier, while others felt like their managers did not understand their
anticipated events. Patterns were noted in this category based on work challenges or were condescending. More consistently, almost
level of seniority. The majority of nurses with 1–3 years of expe- half of the nurses interviewed reported frustration when they felt
rience and all nurses with 3–6 years of experience cited concerns like their concerns were underappreciated or unheard by the medi-
within this category. No nurses with 6 or more years of experience cal team.
cited any dissatisfiers within this category. Nurses felt demoralized “It’s just kind of like a one-way conversation and a one-way decision. And
and feared they “missed something” when patients deteriorated or then, it’s kind of like, well, alright, I’ll just sit back and wait for my orders to
died unexpectedly. This feeling was noted even if the patient do what we need to do.” CICU03†
decompensated in the subsequent shift after the nurse left. Interactions between nurses were the most robustly discussed
Multiple nurses stated that being a new nurse in the paediatric car- interactions within this category. Nurses at all levels of experience
diac ICU was particularly difficult. reported feeling under-supported when they were new. Nurses in
“I think [my] burnout in the past has just been like being tired, being new, the most experienced group reported concern that new nurses are
and not quite comprehending all of this. Like, seeing things go wrong and not receiving adequate training, out of necessity, due to high nurs-
not knowing why they went wrong and how to fix them.” CICU06† ing turnover.
The fear of anticipated events centered around both a fear of “You take those people that got a skeleton version of orientation, and now,
patient events and a fear of appearing incompetent. they have precepted a group of people and also only provided that skeleton

https://doi.org/10.1017/S1047951123000306 Published online by Cambridge University Press

 Cardiology in the Young 2515

version. And now those people are orienting. So what we have is like two or survey item with the largest decline was: “RNs are valued and com-
three generations of newer nurses that don’t know the things that they need mitted partners in making policy, directing and evaluating clinical
to know. But they don’t know that they don’t know it.” CICU07† care, and leading organizational operations.” Not incorporating
This led experienced nurses, who were in charge or in roles nurses into clinical decision making negatively impacts both
helping newer nurses, to feel the pressure of supporting multiple patient care and nurse retention.22 These findings were supported
patients. Only a single nurse expressed that nurses using the paedi- by the nurses interviewed here and provided a theoretical frame-
atric cardiac ICU as a “stepping stone” to further education was a work for our work.
dissatisfier. This study suggests a mandate for a change in paediatric cardiac
ICU culture. While this is the most difficult type of change, it is the
most valuable. It would be easy to say that categories like “respect”
Dissatisfier: disrespect
and “disrespect” suggest that simply being nicer to nurses is suffi-
The final dissatisfier was defined as disrespect. Disrespect was the cient. This study suggests that the issue is more complex. For
least frequently identified dissatisfier, and it contained elements of instance, one key action that reflected respect to nurses was teach-
the other three categories. Multiple nurses stated that, at times, ing. The physiology of the patients in the paediatric cardiac ICU is
they had felt a lack of respect from all levels of the care team: sur- challenging. Nurses and medical trainees are often dismissed
geons, the surgical team, physicians, nurses, patients, and families. because the content is “too difficult.” When given the chance, both
Nurses felt particularly disrespected when time was not taken to groups rise to the challenge. As self-confidence increases, empow-
teach them. Regarding her preceptor, one nurse stated: erment increases.23 As leaders on the team, physicians and other
“She didn’t want to teach. And so I, you know, you can just feel that, and [it]
providers must work to empower and educate those around us
doesn’t make you want to be here.” CICU11† while creating an environment that is conducive to learning.
Physicians must also recognise that we are fallible and welcome
One newer nurse described feeling like it was difficult for her to discussion and questioning of the plan by our nursing colleagues.
prove that she should be taking more critically ill patients, while a When plans are made as a team, nurses are respected and utilise
more experienced nurse stated she felt like older nurses were their expertise to the fullest degree. A recent qualitative assessment
phased out of patient care in various ways, including being of stressors in senior paediatric nurses found that nurses feel
assigned to less complex patients. “powerless to provide quality care” when the medical team does
not seek or acknowledge their opinions.24 In contrast, nurses
who are allowed to share their concerns and opinions are less likely
Discussion
to leave their current position.25,26 These conversations must be
The findings explored here are part of a larger discussion about had respectfully and in forums that do not detract from patient-
nursing retention. In the paediatric cardiac ICU, there exists a centered care, but they are of utmost importance both to patient
baseline level of nurse turnover for positive reasons such as oppor- care and in enhancing nurse satisfaction.
tunities for continuing education and advancement. As new com- Moral distress was identified as the most consistent dissatisfier
peting factors like the role of travel nursing develop; however, in this study, and it has been strongly linked to nurse burnout.27
stakeholders in the paediatric cardiac ICU must develop ways to The paediatric cardiac ICU pushes the boundaries of viability in
aggressively retain our current paediatric cardiac ICU nurses. an extremely challenging patient population, which often leads
These nurses have chosen to work in the paediatric cardiac ICU to moral distress for nurses at the bedside. We are called to limit
for many of the reasons identified here, and they are among our suffering whenever possible, but nurses in the paediatric cardiac
most valuable resources. ICU will continue to be asked to care for patients with poor prog-
Previous studies have suggested that nursing managers are the noses. In these situations, nurses reported relief when physicians
key to retaining nurses. Blake et al wrote, “Nurses do not leave and other team members validated their experiences. Nurses
organizations, they leave their managers.”12 Interestingly, that saw difficult conversations with families as a form of patient
was not seen in this study. Multiple nurses here reported significant progress, which was a satisfier for nurses. Based on findings here,
satisfaction with their nursing manager, which did not coincide we should have these discussions early and often. Conferring with
with overall job satisfaction. Burke and colleagues completed a nurses on how best to approach patient families will benefit fam-
qualitative analysis of successful nursing directors.19 They stated ilies and nurse satisfaction.
that successful directors empower their nurses and enhance their In the literature, moral distress in nursing is also caused by pres-
autonomy. They also balance autonomy with support in a non- sure from administrators or insurers to reduce costs, leaving nurses
judgemental environment. Many of these findings were supported with inadequate resources to provide optimal patient care.28 This
here, but they were not specific to nursing directors. Findings of was exemplified in our study by senior nurses being concerned
this study reflect that nursing satisfaction and retention are the about inadequate training in junior nurses. This led senior nurses
responsibility of everyone in the paediatric cardiac ICU. Fellow in our study to feel the pressure of supporting the entire unit.
nurses and nurse managers play key roles, but so do physicians Another critical finding of this study is that many nurses in the
and other providers in particular. paediatric cardiac ICU feel fear daily. They appropriately fear
In 2005, the American Association of Critical-Care Nurses pub- patient deterioration, but they also expend considerable energy
lished their landmark six standards for a “Healthy Work fearing judgement from their nursing and medical colleagues.
Environment”: skilled communication, true collaboration, effec- This is particularly true of newer nurses who are at the highest risk
tive decision making, appropriate staffing, meaningful recognition, for burn out and lack of retention.29,30 Since critical care nurses
and authentic leadership.20 These standards seek to support excel- tend to be a young cohort of nurses, the paediatric cardiac ICU
lent patient care as well as nursing retention. Despite the recogni- can become a revolving door.4
tion of these standards, a 2013 follow-up survey demonstrated a This study demonstrated that senior nurses seem to have largely
decrease in healthy work environments for nurses.21 The single overcome the inappropriate fear of judgement. We must continue

https://doi.org/10.1017/S1047951123000306 Published online by Cambridge University Press

 2516 J. E. Stark et al.

to develop ways to support nurses in the paediatric cardiac ICU Supplementary material. To view supplementary material for this article,
who are early in their careers. This area is ripe for further research please visit https://doi.org/10.1017/S1047951123000306
and implementation of educational curricula. New teaching
Acknowledgements. The authors would like to express deep gratitude to the
modalities and just-in-time teaching must be employed to engage
nurses who participated in this study. Our appreciation for their candor and
a new generation of learners.31 At minimum, we must never shame
thoughtful insight cannot be overstated.
or embarrass nurses for asking questions. At best, we can actively
cultivate a supportive teaching environment. In this and other Financial support. This research received no specific grant from any funding
studies, practice environment has been found to play a pivotal role agency, commercial, or not-for-profit sectors.
in critical care nurse job satisfaction.32
As new generations of nurses enter the field, the old model of Conflicts of interest. None.
bedside nursing for an entire career is increasingly rare. During
this study, multiple nurses volunteered that they were asked as References
early as nursing school what they were going to do after the bed-
side, such as advanced nursing degrees or administrative roles. 1. World Health Organization. A Global Survery Monitoring Progress in
Thus, the new paradigm must shift towards bringing nurses up Nursing and Midwifery. World Health Organization, 2010. https://apps.
who.int/iris/handle/10665/70371
to full capacity as quickly as possible. Continuing to develop
2. Tume LN, Menzies JC, Ray S, Scholefield BR, Group UKPICSS. Research
and hone new creative educational initiatives for nurses, which priorities for U.K. pediatric critical care in 2019: healthcare professionals’
are supported by both the nursing and medical team is impera- and parents’ perspectives. Pediatr Crit Care Med 2021; 22 (5): e294–e301.
tive. These range from just-in-time teaching that supports the 3. Dilig-Ruiz A, MacDonald I, Demery Varin M, Vandyk A, Graham ID,
nurse in their current patient assignment to unit-wide huddles Squires JE. Job satisfaction among critical care nurses: a systematic review.
which enhance overall unit awareness. The opportunities are Int J Nurs Stud 2018; 88: 123–134.
broad but should focus on meeting the needs of this generation 4. Sawatzky JA, Enns CL, Legare C. Identifying the key predictors for reten-
of learners. tion in critical care nurses. J Adv Nurs 2015; 71 (10): 2315–2325.
There were limitations to this study. Participation was self- 5. Mahon PR. A critical ethnographic look at paediatric intensive care nurses
selected, which can lead to selection bias if particularly passion- and the determinants of nurses’ job satisfaction. Intens Crit Care Nurs
2014; 30 (1): 45–53.
ate nurses volunteer to participate. A small number of inter-
6. Duffield CM, Roche MA, Homer C, Buchan J, Dimitrelis S. A comparative
views had an overtly negative or positive tone, but most review of nurse turnover rates and costs across countries. J Adv Nurs 2014;
interviews had the neutral tone of nurses who wanted to share 70 (12): 2703–2712.
their experiences. Another limitation to this study was the 7. Ritter D. The relationship between healthy work environments and reten-
impact of the interviewer on the information that was shared. tion of nurses in a hospital setting. J Nurs Manag 2011; 19 (1): 27–32.
In qualitative research, the relationship between the investiga- 8. Hickey PA, Gauvreau K, Tong E, Schiffer NP, Connor JA. Pediatric cardio-
tors and research participants must be defined. The primary vascular critical care in the United States: nursing and organizational char-
investigator and interviewer was a fellow physician in the paedi- acteristics. Am J Crit Care 2012; 21 (4): 242–250.
atric cardiac ICU. This could be considered a power differential, 9. Hickey PA, Gauvreau K, Curley MA, Connor JA. The effect of critical care
which might have skewed the nurse responses. During her time nursing and organizational characteristics on pediatric cardiac surgery
mortality in the United States. J Nurs Adm 2013; 43 (12): 637–644.
as a fellow, the primary investigator often stated that nurses
10. Hickey PA, Pasquali SK, Gaynor JW, et al. Critical care nursing’s impact on
were some of her greatest teachers. She developed close bonds pediatric patient outcomes. Ann Thorac Surg 2016; 102 (4): 1375–1380.
with many nurses, which facilitated open communication. 11. Li A, Early SF, Mahrer NE, Klaristenfeld JL, Gold JI. Group cohesion and
She encouraged interviewees to be candid, even if she was a sat- organizational commitment: protective factors for nurse residents’ job sat-
isfier or dissatisfier. All qualitative research is interpreted isfaction, compassion fatigue, compassion satisfaction, and burnout. J Prof
through the biases of the investigators. The weight placed on Nurs 2014; 30 (1): 89–99.
each finding in this study was impacted by the fact that a physi- 12. Blake N, Leach LS, Robbins W, Pike N, Needleman J. Healthy work envi-
cian was the primary investigator. Every effort was made to be ronments and staff nurse retention: the relationship between communica-
objective, however, including assessment of internal validity by tion, collaboration, and leadership in the pediatric intensive care unit. Nurs
nurses and triangulation of interview results. Of final note, this Adm Q 2013; 37 (4): 356–370.
13. Connor JA, Ziniel SI, Porter C, et al. Interprofessional use and validation of
research was conducted at the beginning of the SARS-CoV-2
the AACN healthy work environment assessment tool. Am J Crit Care
pandemic, which may also have influenced the interviewee per-
2018; 27 (5): 363–371.
ceptions of satisfiers and dissatisfiers. 14. Curry LA, Nembhard IM, Bradley EH. Qualitative and mixed methods pro-
In summary, this study applied qualitative assessment using the vide unique contributions to outcomes research. Circulation 2009; 119 (10):
constant comparative method to develop grounded theory and a 1442–1452.
rich foundation for further research and education in the paediat- 15. Merriam SB, Tisdell EJ. Qualitative Research: a Guide to Design and
ric cardiac ICU. While satisfiers like the paediatric cardiac ICU Implementation, 4th edn. Jossey-Bass, San Francisco, CA, 2016.
patient population and the paediatric cardiac ICU care team are 16. Corbin J. Strauss A: Basics of Qualitative Research: Techniques and
innate to the paediatric cardiac ICU, satisfiers like personal accom- Procedures for Developing Grounded Theory, 4th edn. Sage, Thousand
plishment and respect can be developed and enhanced. Similarly, Oaks, CA, 2015.
17. Glaser BG, Strauss A. The Discovery of Grounded Theory: Strategies for
dissatisfiers can be mitigated via initiatives like increased nursing
Qualitative Research. Aldine, Chicago, IL, 1967.
involvement in patient plans and educational curriculums for jun-
18. Bruce CR, Miller SM, Zimmerman JL. A qualitative study exploring moral
ior nurses. Tactics outlined here should be used to support reten- distress in the ICU team: the importance of unit functionality and intrateam
tion in the unique environment of the paediatric cardiac ICU. dynamics. Crit Care Med 2015; 43 (4): 823–831.
Retention of qualified nurses in the paediatric cardiac ICU is every- 19. Burke D, Flanagan J, Ditomassi M, Hickey PA. Characteristics of nurse
one’s responsibility, and it is paramount in providing high-quality directors that contribute to registered nurse satisfaction. J Nurs Adm
patient care. 2017; 47 (4): 219–225.

https://doi.org/10.1017/S1047951123000306 Published online by Cambridge University Press

 Cardiology in the Young 2517

20. American Association of Critical-Care N. AACN standards for establishing 27. Rushton CH, Batcheller J, Schroeder K, Donohue P. Burnout and resilience
and sustaining healthy work environments: a journey to excellence. Am J among nurses practicing in high-intensity settings. Am J Crit Care 2015;
Crit Care 2005; 14 (3): 187–197. 24 (5): 412–420.
21. Ulrich BT, Lavandero R, Woods D, Early S. Critical care nurse work envi- 28. Dodek PM, Wong H, Norena M, et al. Moral distress in intensive care unit
ronments 2013: a status report. Crit Care Nurse 2014; 34 (4): 64–79. professionals is associated with profession, age, and years of experience. J
22. Tao H, Ellenbecker CH, Wang YF, Li Y. Examining perception of job sat- Crit Care 2016; 31 (1): 178–182.
isfaction and intention to leave among ICU nurses in China. Int J Nurs Sci 29. Meyer RM, Li A, Klaristenfeld J, Gold JI. Pediatric novice nurses:
2015; 2 (2): 140–148. examining compassion fatigue as a mediator between stress exposure
23. Wahlin I, Ek AC, Idvall E. Staff empowerment in intensive care: nurses’ and compassion satisfaction, burnout, and job satisfaction. J Pediatr
and physicians’ lived experiences. Intensive Crit Care Nurs 2010; 26 (5): Nurs 2015; 30 (1): 174–183.
262–269. 30. van Dam K, Meewis M, van der Heijden BI. Securing intensive care:
24. De Almeida Vicente A, Shadvar S, Lepage S, Rennick JE. Experienced pedi- towards a better understanding of intensive care nurses’ perceived work
atric nurses’ perceptions of work-related stressors on general medical and pressure and turnover intention. J Adv Nurs 2013; 69 (1): 31–40.
surgical units: a qualitative study. Int J Nurs Stud 2016; 60: 216–224. 31. Mousazadeh S, Yektatalab S, Momennasab M, Parvizy S. Job satisfaction
25. Khan N, Jackson D, Stayt L, Walthall H. Factors influencing nurses’ inten- challenges of nurses in the intensive care unit: a qualitative study. Risk
tions to leave adult critical care settings. Nurs Crit Care 2019; 24 (1): 24–32. Manag Healthc Policy 2019; 12: 233–242.
26. Ko HK, Chin CC, Hsu MT. Moral distress model reconstructed using 32. Liu YE, While A, Li SJ, Ye WQ. Job satisfaction and work related variables
grounded theory. J Nurs Res 2018; 26 (1): 18–26. in Chinese cardiac critical care nurses. J Nurs Manag 2015; 23 (4): 487–497.

https://doi.org/10.1017/S1047951123000306 Published online by Cambridge University Press