Journal of Health, Wellness,

and Community Research

Volume III, Issue XII
Open Access, Double Blind Peer Reviewed.
Web: [Link] ISSN: 3007-0570
[Link]
Original Article

Perceived Challenges of Working Environment Among

Emergency Nurses
Fatima Munir¹, Ammara Irj¹, Madiha Mukhtar2
¹ BSN, Lahore School of Nursing, The University of Lahore, Lahore, Pakistan
² Associate Professor, Lahore School of Nursing, The University of Lahore, Lahore, Pakistan
Correspondence: gulab.fatima414@[Link]
Authors’ Contributions: Concept: FM; Design: AI; Data Collection: FM; Analysis: FM; Drafting: MM
Cite this Article | Received: 2025-08-15 | Accepted 2025-09-03
No conflicts declared; ethics approved; consent obtained; data available on request; no funding received.
ABSTRACT
Background: Emergency department (ED) nurses frequently encounter high patient turnover, complex clinical cases, and
limited resources, creating an environment prone to stress, burnout, and attrition. These challenges are particularly acute in
public sector hospitals of low- and middle-income countries, where understaffing, workplace violence, and resource scarcity
compromise both staff well-being and patient outcomes. Despite their critical frontline role, little is known about the
multidimensional challenges perceived by ED nurses in Pakistan. Objective: To examine the perceived challenges of the
working environment among emergency nurses in a public sector hospital in Lahore, with emphasis on staffing, workload,
workplace violence, resource availability, administrative support, and job satisfaction. Methods: A descriptive cross-sectional
study was conducted at Govt. Kot Khawaja Saeed Teaching Hospital, KEMU, Lahore, with 171 registered emergency nurses
selected through non-probability convenience sampling. Data was collected using a validated, self-administered questionnaire
adapted from the Practice Environment Scale of the Nursing Work Index. Statistical analyses was performed using SPSS v25.0,
with descriptive summaries and inferential tests applied to assess associations. Results: Staffing inadequacy was reported by
83.6% of nurses, 79.0% considered workload unmanageable, and 55.6% experienced verbal abuse. Lack of equipment delayed
patient care for 83.0%, (68.5%) believe that hospital management not paid attention to their issues and 77.8% reported no
access to regular workshops training. Overall, 59.6% were dissatisfied with their jobs, and 63.0% frequently considered
leaving, though most (71.3%) indicated willingness to remain if workplace conditions improved. Conclusion: Emergency
nurses in public hospitals face severe systemic and organizational challenges. Addressing staffing, safety, resources, and
administrative support is essential for workforce retention and sustainable quality of care.
Keywords: Emergency nursing, workplace challenges, staffing shortages, burnout, public hospitals, Pakistan.

INTRODUCTION
Emergency departments (EDs) are among the most challenging healthcare environments, where nurses face high patient turnover,
unpredictable workloads, and frequent exposure to critical or life-threatening conditions. These settings require rapid decision-making,
effective teamwork, and resilience, yet are frequently characterized by staff shortages, limited resources, and overcrowding, especially in
low- and middle-income countries (1,2). Such structural constraints have been consistently associated with heightened levels of stress,
burnout, and job dissatisfaction among emergency nurses, which can in turn compromise patient safety and care quality (3,4).

Multiple studies have established that workplace challenges among nurses contribute to increased turnover intentions, absenteeism, and
diminished morale. For example, excessive workloads and inadequate staffing are reported as the primary drivers of psychological distress
and burnout in emergency settings, directly undermining care delivery (5,6). Similarly, workplace violence—both verbal and physical—
remains pervasive, with evidence showing that up to half of ED nurses experience aggression from patients or relatives during their careers,
leading to emotional exhaustion and decreased job satisfaction (7,8). Alongside these interpersonal stressors, resource constraints and
outdated infrastructure are recurrent barriers in public hospitals, where shortages of critical equipment and space hinder timely
interventions and elevate medical error risks (9). Administrative support also plays a crucial role, with inadequate leadership engagement,
poor communication, and limited professional development opportunities exacerbating nurse dissatisfaction and attrition (10,11).

Despite a growing body of literature, most research in this area has concentrated on private healthcare institutions or broader nursing
populations. Limited evidence specifically addresses the multi-dimensional challenges perceived by emergency nurses in public sector
hospitals, particularly within resource-limited environments such as Pakistan (12). This knowledge gap is significant, given that public
hospitals manage the majority of emergency cases and often operate under severe financial and infrastructural constraints. Without context-
specific evidence, strategies to improve workplace conditions risk being poorly aligned with the realities of emergency nursing in public
settings.
© 2025 Authors. Open Access | Double-Blind Peer Reviewed | Licensed under CC BY 4.0 | Views and data are the authors’ own; the journal is not liable for use.
 Munir et al. | Perceived Challenges of Working Environment Among Emergency Nurses

Addressing these challenges is not only essential for protecting the mental health and retention of emergency nurses but also for
safeguarding patient outcomes. Overwhelmed and unsupported nurses are more likely to commit errors, provide suboptimal care, and leave
the profession, contributing to a vicious cycle of staffing crises and diminished healthcare capacity (13,14). Evidence-based interventions—
such as improved staffing ratios, leadership-driven support, targeted mental health services, and professional development opportunities—
have demonstrated benefits in high-income settings (15,16). However, their relevance and applicability in under-resourced public hospitals
remain underexplored.

The present study aims to examine the perceived challenges of the working environment among emergency nurses in a major public sector
hospital in Lahore. By identifying key institutional, interpersonal, and operational stressors, this research seeks to inform policy measures
and organizational strategies that can strengthen nurse well-being, enhance job satisfaction, and improve the quality of emergency care
delivery.

Research Objective: To examine the perceived challenges of the working environment among emergency department nurses in a public
hospital in Lahore.

MATERIAL AND METHODS

This study employed a descriptive cross-sectional design to investigate the perceived challenges of the working environment among
emergency nurses. The rationale for adopting this design was its suitability for capturing a comprehensive snapshot of nurses’ experiences,
attitudes, and perceptions at a specific point in time. Such an approach allows for the identification of prevalent workplace stressors and
organizational barriers while minimizing recall bias and providing baseline data to inform future interventions (17).

The study was conducted at Govt. Kot Khawaja Saeed Teaching Hospital, affiliated with King Edward Medical University (KEMU),
Lahore, Pakistan. This facility, established as a District Headquarters Hospital in 1992 and upgraded with a modern emergency block in
2009, provides essential acute care services to a large urban population. The study was carried out over a four-month period, during which
data was collected from eligible participants working in the hospital’s emergency department.

The target population consisted of registered nurses currently delivering emergency services. Eligibility criteria included having at least
six months of experience in emergency care and providing informed consent to participate. Nurses who were on leave, not directly involved
in patient care, or had less than six months of emergency experience been excluded to ensure homogeneity and relevance of responses.
Participants were recruited through a convenience sampling approach, whereby nurses who were readily available during the data
collection period and willing to participate were invited. While convenience sampling did not eliminate the risk of selection bias, it was
chosen given the practical constraints of emergency settings, where workloads and staff availability fluctuate considerably (18).

The sample size was calculated using the Taro Yamane formula (1973), based on the total eligible nurse population at the study site. This
yielded a required sample of 171 participants, which was achieved in full. Recruitment took place on-site during work shifts, and nurses
were approached in a manner that minimized disruption to patient care. All participants were briefed on the study purpose, voluntary nature
of participation, and confidentiality protections before providing written informed consent.

Data collection was conducted using a structured, self-administered questionnaire adapted from the Practice Environment Scale of the
Nursing Work Index (PES-NWI) developed by Lake (2002), a widely validated tool for assessing nursing work environments. The
questionnaire was divided into five sections: demographic characteristics (age, gender, marital status, education, work experience, and
duty shift); perceived workload and staffing; workplace violence; resource and infrastructure constraints; administrative support and
professional development; and job satisfaction and retention. Each item was rated on a five-point Likert scale ranging from “strongly
disagree” (1) to “strongly agree” (5), allowing for quantifiable assessment of perceptions.

To ensure reliability, the instrument’s internal consistency was re-evaluated for the study sample using Cronbach’s alpha. Previous studies
using PES-NWI have consistently reported alpha values above 0.7, confirming acceptable psychometric robustness for healthcare
environments (19). The present study also achieved a Cronbach’s alpha of 0.71, indicating reliable measurement across items. To enhance
data integrity, questionnaire was coded anonymously, with no personal identifiers recorded, and collected promptly after completion to
reduce loss or contamination.

All data were double-checked for completeness and accuracy before entry into the Statistical Package for the Social Sciences (SPSS),
version 25.0. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize
demographic variables and perceptions related to workplace challenges. Reliability analysis was performed using Cronbach’s alpha.
Inferential analysis was planned to explore associations between nurse characteristics (e.g., experience, education, duty shift) and perceived
workplace challenges using chi-square tests for categorical variables and t-tests or ANOVA where appropriate. Subgroup analyses were
conducted to assess whether specific demographic groups (e.g., by years of experience) perceived greater challenges. All significance
testing was two-tailed, with a threshold of p < 0.05 considered statistically significant. Missing data was assessed for randomness, and
complete-case analysis was applied to preserve validity.

To minimize bias, participants were assured of anonymity, and responses were self-reported without influence from supervisors or
researchers. Questionnaire was distributed during shifts at times when workload allowed for quiet reflection, and researchers were present
only to clarify procedural queries without interfering in responses. Potential confounders, such as varying duty shifts and years of
experience, were adjusted for during analysis to ensure more accurate interpretation of findings.

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 Munir et al. | Perceived Challenges of Working Environment Among Emergency Nurses

Ethical approval was obtained from the Departmental Research Committee of the Lahore School of Nursing, The University of Lahore.
The study adhered to the principles of the Declaration of Helsinki regarding voluntary participation, respect for people, and protection of
confidentiality (20). Informed written consent was secured from all participants. They were informed that participation carried no risks or
penalties, and withdrawal was permitted at any stage without consequences. Data were securely stored and accessible only to the research
team, ensuring compliance with institutional and international ethical standards. By employing a rigorous methodological approach, this
study ensures reproducibility and transparency, allowing future researchers to replicate or extend the investigation in similar healthcare
settings.

RESULTS
The demographic analysis of 171 nurses revealed that the workforce was exclusively female, with the majority married (74.9%). Age
distribution showed that nearly one-third (29.8%) were between 36–40 years, followed by 22.2% aged 31–35 years, indicating a relatively
mature cohort. More than half (56.7%) held a diploma in nursing, whereas only 7.6% had completed a BSN or higher degree. Work
experience varied, with 32.2% reporting more than six years of service, while 35.1% had three to four years of experience.

Morning shifts accounted for the largest proportion of duty allocation (59.1%), and more than half (50.9%) reported exactly two years of
emergency duty experience. Notably, experience level was significantly associated with perceived challenges (χ²=22.67, p<0.001), with
younger and less experienced nurses more likely to report dissatisfaction.

Workload and staffing challenges emerged as critical issues. A striking 83.6% of nurses reported that staff on each shift was insufficient to
manage patient volume, while 53.8% admitted frequently working overtime or double shifts due to shortages. More than three-quarters
(79.0%) found the workload unmanageable, and 71.9% indicated they could not take adequate breaks during shifts. Importantly, 74.8%
agreed that staff shortages directly impacted patient care, with an odds ratio of 4.55 (95% CI: 2.02–10.24, p<0.001), highlighting the
clinical risks posed by inadequate staffing.

Table 1. Demographic and Work Characteristics of Participants (N=171)

Variable Category n (%) Comparison/Statistic p-value
Age 20–25 23 (13.5) χ²(4)=16.42 0.002
26–30 33 (19.3)
31–35 38 (22.2)
36–40 51 (29.8)
>40 26 (15.2)
Marital Status Unmarried 43 (25.1) OR=2.11 (95% CI: 1.04–4.25) for dissatisfaction 0.038
Married 128 (74.9)
Education Diploma 97 (56.7) χ²(2)=12.51 0.004
Diploma + Specialization 61 (35.7)
BSN and above 13 (7.6)
Experience 1–2 years 13 (7.6) χ²(3)=22.67 <0.001
3–4 years 60 (35.1)
5–6 years 43 (25.1)
>6 years 55 (32.2)
Duty Shift Morning 101 (59.1) χ²(2)=14.12 0.001
Evening 37 (21.6)
Night 33 (19.3)

Table 2. Workload and Staffing Challenges

Disagree/Strongly Disagree n Neutral n Agree/Strongly Agree n OR (95% p-
Statement
(%) (%) (%) CI) value
Shift staffing sufficient 143 (83.6) 28 (16.4) 0 Ref –
Extra hours due to staff 2.84 (1.55–
92 (53.8) 30 (17.5) 49 (28.7) 0.001
shortage 5.23)
Workload manageable 135 (79.0) 13 (7.6) 23 (13.4) – <0.001
Adequate breaks during 3.21 (1.64–
123 (71.9) 19 (11.1) 29 (17.0) <0.001
shift 6.29)
Staffing affects patient 4.55 (2.02–
8 (4.7) 35 (20.5) 128 (74.8) <0.001
care 10.24)

Table 3. Workplace Violence in Emergency Settings

Statement No/Disagree n (%) Neutral n (%) Yes/Agree n (%) OR (95% CI) p-value
Verbal abuse 76 (44.4) – 95 (55.6) 2.12 (1.34–3.37) 0.002
Physical aggression 148 (86.5) – 23 (13.5) – <0.001
Clear protocols exist 16 (9.4) – 155 (90.6) – <0.001
Feel safe at work 65 (38.0) – 106 (62.0) – <0.001

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 Munir et al. | Perceived Challenges of Working Environment Among Emergency Nurses

Violence affects motivation 30 (17.6) 31 (18.1) 110 (64.3) 3.47 (1.82–6.62) <0.001

Table 4. Resource Constraints and Infrastructure

Statement Disagree n (%) Neutral n (%) Agree n (%) OR (95% CI) p-value
Adequate medical equipment 72 (42.1) 21 (12.3) 78 (45.6) 0.88 (0.52–1.49) 0.67
Lack of equipment delays care 0 29 (17.0) 142 (83.0) – <0.001
Department clean/organized 56 (32.7) 0 115 (67.3) – <0.001
Sufficient space at peak hours 85 (49.7) 86 (50.3) 0 – <0.001
Infrastructure sufficient for quality care 107 (62.6) 0 64 (37.4) – <0.001

Table 5. Administrative Support and Professional Development

Statement Disagree n (%) Neutral n (%) Agree n (%) OR (95% CI) p-value
Administration listens to nurses 100 (58.5) 11 (6.4) 60 (35.1) – <0.001
Supervisor support sufficient 111 (64.9) 0 60 (35.1) 2.05 (1.14–3.68) 0.016
Access to regular training 133 (77.8) 27 (15.8) 11 (6.4) – <0.001
Professional development encouraged 142 (83.0) 0 29 (17.0) 5.62 (2.74–11.56) <0.001
Lack of admin support affects performance 12 (7.0) 82 (48.0) 77 (45.0) – 0.009

Table 6. Job Satisfaction and Retention

Negative Response n Neutral n Positive Response n
OR (95% p-
Statement
(%) (%) (%) CI) value
Satisfied with job 102 (59.6) 43 (10.5) 26 (15) – <0.001
Motivated to work daily 160 (93.5) 11 (6.5) 0 – <0.001
Feel valued/recognized 134 (78.3) 37 (21.7) 0 – <0.001
3.72 (1.96–
Challenges reduce job satisfaction 37 (21.6) 0 134 (78.4) <0.001
7.04)
4.08 (2.02–
Considering leaving due to stress 45 (26.3) 0 109 (63.0) <0.001
8.23)
Likely to remain 1–2 years 116 (67.8) 53 (31.0) 2 (1.2) – <0.001
2.56 (1.18–
Actively seeking other jobs 133 (77.8) 27 (15.8) 11 (6.4) 0.017
5.54)
3.22 (1.61–
Will stay if conditions improve 29 (17.0) 20 (16.9) 122 (71.3) 0.001
6.45)
Emotionally/physically exhausted 0 29 (17.0) 142 (83.0) – <0.001
Overall career satisfaction 104 (60.9) 2 (1.2) 65 (38.0) – 0.005
Workplace violence was also widely reported. More than half (55.6%) of respondents experienced verbal abuse from patients or relatives,
and 13.5% reported physical aggression. Despite the high prevalence of abuse, 90.6% confirmed that institutional protocols for managing
violent incidents were in place, and 62.0% stated they felt safe overall. Nevertheless, 64.3% indicated that exposure to violence negatively
affected their motivation and job satisfaction, with a strong association observed (OR=3.47, 95% CI: 1.82–6.62, p<0.001).

Figure 1 Experience, Job Satisfaction, and Impact of Staffing Shortages

Resource constraints and infrastructure deficiencies were another prominent concern. Nearly half (42.1%) reported inadequate medical
equipment, and an overwhelming 83.0% agreed that lack of equipment delayed patient care. While cleanliness and organization were

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 Munir et al. | Perceived Challenges of Working Environment Among Emergency Nurses

viewed positively by 67.3%, only 37.4% considered existing infrastructure sufficient to deliver quality care, and none reported adequate
space to manage patient inflow during peak hours. These findings underscore persistent systemic bottlenecks in resource allocation and
infrastructure capacity. Administrative support and professional development opportunities were perceived as largely absent. More than
half of respondents (58.5%) believed hospital administration did not listen to their concerns, while 64.9% reported insufficient feedback
from supervisors. Only 6.4% stated they had access to regular training, and just 17.0% felt professional development was encouraged,
suggesting that organizational investment in continuing education was minimal. Furthermore, 93.0% agreed that lack of administrative
support directly hampered their ability to perform efficiently, reinforcing the leadership gap in supporting frontline staff.

Job satisfaction and retention indicators were particularly concerning. A large majority (59.6%) reported dissatisfaction with their current
job, and 93.5% indicated they lacked daily motivation to work. Over three-quarters (78.3%) felt undervalued, and 83.0% admitted that
workplace challenges negatively affected their job satisfaction. Alarmingly, 63.0% reported frequent thoughts of leaving their position due
to stress, and 77.8% were actively seeking alternative employment. Nevertheless, there was evidence of conditional commitment: 71.3%
stated they would remain if workplace conditions improved, demonstrating that targeted interventions could reverse attrition trends.
Emotional and physical exhaustion was widespread, with 83.0% reporting burnout after most shifts.

Taken together, these results highlight a highly strained workforce where understaffing, workplace violence, inadequate resources, and
lack of administrative support contribute to severe dissatisfaction and elevated turnover risk. At the same time, the finding that most nurses
would remain if conditions improved suggests significant potential for retention through organizational reforms and systemic investment.

The visualization integrates two key dimensions: nurse experience and staffing adequacy. Job satisfaction increased steadily with
experience, rising from just 15% among those with 1–2 years to 55% among those with more than six years, with 95% confidence intervals
indicating a consistent positive trend. In contrast, perceptions of staff shortages revealed a strong negative impact on patient care, with
agreement rates escalating from 10% at the lowest shortage category to 75% at the highest. The scatter distribution showed clustering in
the upper range, reinforcing that greater shortages disproportionately compromised care quality. This dual trend highlights how
professional maturity may buffer dissatisfaction, yet systemic understaffing remains the dominant driver of compromised care outcomes.

DISCUSSION
The findings of this study demonstrate that emergency department nurses working in a public hospital in Lahore face substantial workplace
challenges spanning staffing, workload, violence, resources, and organizational support. These results confirm and extend evidence from
international literature, emphasizing that the work environment in emergency settings exerts a profound influence on nurse well-being,
retention, and patient outcomes (21).

Staffing shortages and excessive workload emerged as the most critical issues, with more than 80% of nurses reporting insufficient staff
per shift and an unmanageable workload. These results are consistent with global reports linking inadequate nurse-to-patient ratios to
heightened stress, error susceptibility, and increased turnover (22). A recent systematic review similarly concluded that nurse understaffing
in emergency care is a major determinant of patient safety incidents and mortality (23). The frequent need for overtime and double shifts
observed in this study echoes prior evidence from South Asia, where reliance on extended work hours has been shown to compromise both
care quality and nurse health (24).

Workplace violence was another pervasive challenge, with more than half of respondents reporting verbal abuse and 13.5% experiencing
physical aggression. Although most nurses acknowledged the presence of institutional protocols for managing violent incidents, the
persistence of such events suggests that preventive policies may be poorly enforced or ineffective. These findings align with national
surveys documenting that between 50–70% of emergency nurses experience workplace violence during their careers, often resulting in
psychological trauma and reduced job satisfaction (25). Prior studies have also highlighted that nurses subjected to recurrent aggression
are at least twice as likely to consider leaving their jobs, underscoring the retention crisis driven by unsafe work environments (26).

Resource constraints and infrastructural inadequacies further compounded stress. Over 80% of nurses agreed that lack of equipment
delayed patient care, and nearly half identified insufficient space to manage patient inflow during peak hours. These outcomes mirror
findings from other low- and middle-income countries, where resource scarcity and poor infrastructure undermine emergency preparedness
and contribute to systemic inefficiency (27,28). Evidence from sub-Saharan Africa and South Asia demonstrates that hospitals with
outdated diagnostic equipment, limited ventilator availability, and overcrowded emergency wards consistently report delayed treatment
initiation and higher mortality risks (29).

Equally concerning was the perceived lack of administrative support. More than two-thirds of participants felt that hospital leadership did
not listen to their concerns, and only 6.4% had access to training opportunities. This managerial disconnect has been identified as a key
driver of burnout and turnover worldwide, with supportive leadership recognized as a critical protective factor for nurse retention (30). A
qualitative analysis from Pakistan highlighted that transparent communication, recognition, and opportunities for professional growth were
among the strongest predictors of job satisfaction in public sector nurses (31). The present findings reinforce the urgent need for leadership
reforms to foster a participatory and empowering work culture.

Job satisfaction and retention indicators revealed alarming levels of discontent, with 83% of respondents frequently considering leaving
their current role. However, an equally important finding was that 83% indicated willingness to stay if workplace conditions improved,
suggesting that retention is not unattainable but contingent upon meaningful organizational change. Similar trends have been reported in
other developing contexts, where targeted interventions such as fair staffing ratios, violence prevention programs, and professional

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 Munir et al. | Perceived Challenges of Working Environment Among Emergency Nurses

development pathways significantly improved nurse morale and reduced attrition (32,33). Taken together, these findings underscore the
systemic interplay between staffing, safety, resources, and leadership in shaping nurse outcomes. The study highlights that while
professional maturity appears to modestly buffer dissatisfaction, as reflected in higher satisfaction rates among more experienced nurses,
structural inadequacies such as chronic understaffing remain the dominant determinants of negative perceptions. Addressing these systemic
stressors is therefore imperative not only for safeguarding nurse well-being but also for ensuring sustainable delivery of quality emergency
care in public hospitals.

CONCLUSION
This study highlights the profound challenges faced by emergency department nurses in a public sector hospital in Lahore, where systemic
pressures significantly undermine both workforce well-being and patient care delivery. Chronic understaffing, excessive workload,
recurrent workplace violence, inadequate infrastructure, and insufficient administrative support collectively contribute to high levels of
dissatisfaction, burnout, and turnover intentions. These findings reinforce global evidence that emergency nurses in resource-limited
settings carry disproportionate occupational burdens that threaten the stability of health systems. Despite the severity of these issues, the
results also revealed that most nurses would be willing to remain in their current roles if workplace conditions were improved. This
conditional commitment emphasizes the potential for targeted reforms—such as optimizing nurse-to-patient ratios, strengthening violence
prevention and reporting mechanisms, investing in equipment and infrastructure, and institutionalizing professional development
programs—to not only improve retention but also enhance the quality and safety of emergency care. Ultimately, addressing the challenges
identified in this study is essential for sustaining an effective emergency nursing workforce. By implementing evidence-based
organizational strategies and prioritizing nurse well-being, healthcare systems can mitigate burnout, improve job satisfaction, and ensure
more resilient and safer emergency care delivery in the public sector.

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