Since January 2020 Elsevier has created a COVID-19 resource centre with

free information in English and Mandarin on the novel coronavirus COVID-

19. The COVID-19 resource centre is hosted on Elsevier Connect, the
company's public news and information website.

Elsevier hereby grants permission to make all its COVID-19-related

research that is available on the COVID-19 resource centre - including this
research content - immediately available in PubMed Central and other
publicly funded repositories, such as the WHO COVID database with rights
for unrestricted research re-use and analyses in any form or by any means
with acknowledgement of the original source. These permissions are
granted for free by Elsevier for as long as the COVID-19 resource centre
remains active.
 Asian Nursing Research 14 (2020) 178e187

Contents lists available at ScienceDirect

Asian Nursing Research

journal homepage: [Link]

Research Article

Developing Strategy: A Guide For Nurse Managers to Manage Nursing

Staff's Work-related Problems
Amal Refaat Gab Allah, Hayam Ahmed Elshrief, Marwa Hassan Ageiz*
Nursing Administration Department, Faculty of Nursing, Menoufia University, Menoufia Governorate, Egypt

a r t i c l e i n f o s u m m a r y

Article history: Purpose: The purpose of this study was to assess nursing staff's work-related problems as perceived by
Received 20 November 2019 their managers and thereafter develop strategies that would serve as a guide for nurse managers to
Received in revised form manage these problems.
25 June 2020
Methods: A descriptive research design was used. The participants included in the study consisted of the
Accepted 14 July 2020
following two groups: Group 1da convenience sample of 150 first-line managers working at three
different hospitals; and Group 2da panel of experts for the Delphi technique, selected using the
Keywords:
Snowball sampling technique. Tools for data collection included the following: Tool 1dquestionnaire
nursing staff
occupational stress
about nursing staff's problems; Tool 2dDelphi technique to develop strategies for managing nursing
personnel turnover staff's problems; and Tool 3dopinionnaire format.
workplace Results: The recruited first nurse managers were of the opinion that job stress, work overload, conflict,
workplace violence, poor performance, staff turnover, demotivation, lack of empowerment, and staff
absenteeism were among the common problems faced by staff nurses at work.
Conclusion: From the expert panelists’ perspectives, the newly developed strategy in this study was
considered valid; the researchers recommend the strategy developed in this study to be universalized in
different health care settings and used as a guide for nurse managers.
© 2020 Korean Society of Nursing Science. Published by Elsevier BV. This is an open access article under
the CC BY-NC-ND license ([Link]

Introduction Workplace-related problems are common nationally and inter-

nationally. Among the most frustrating personnel problems is that
Nursing is a high-pressure job. Contrary to popular belief, of absenteeismdthe rate at which an individual misses work on an
nurses’ duties consist of more than just checking vital signs and unexpected basis. In the health care industry, this results in the
administering medication. They have many responsibilities to impediment of the provision of health care to patients, specifically
attend: helping patients, assisting in procedures, documenting the health care institutions that are associated with a shortage of
care, as well as filling leadership roles at hospitals, health systems, available staff [2]. Work stress, particularly in the nursing profes-
and other organizations. However, issues at the organizational, sion, has become a major problem that nurses face; excessive
state, and national levels have brought about considerable chal- pressure, a heavy workload, job insecurity, low levels of job satis-
lenges, making it difficult for nurses to do their job effectively. It is faction, internal conflicts, and lack of autonomy contribute to that
essential to first recognize and understand every possible chal- stress [3].
lenges faced by nurses to deal with them efficiently and find the In addition, interpersonal conflict is another area of frustration
best possible solutions to mitigate them [1]. in the nursing profession. It is often considered a negative term
because individual interests are perceived to be in conflict or
negatively affected. Furthermore, workplace conflict is always
associated with lower-quality patient care, higher rates of adverse
effects, a higher level of staff burnout, and greater direct and in-
Amal Refaat Gab Allah: [Link] Hayam Ahmed
direct costs of care [4].
Elshrief: [Link] Marwa Hassan Ageiz: https://
[Link]/0000-0002-2921-880X Lack of empowerment is a significant work-related problem that
* Correspondence to: Marwa H. Ageiz, PhD, Faculty of Nursing, Menoufia Uni- nurses may be exposed to. Powerless nurses make for unproduc-
versity, Menoufia 32511, Egypt. tive, discontent nurses, who are more vulnerable to burnout and
E-mail address: marwa2006_said2008@[Link]

[Link]
p1976-1317 e2093-7482/© 2020 Korean Society of Nursing Science. Published by Elsevier BV. This is an open access article under the CC BY-NC-ND license (http://
[Link]/licenses/by-nc-nd/4.0/).
 A.R. Gab Allah et al. / Asian Nursing Research 14 (2020) 178e187 179

depersonalization. Empowerment for nurses consists of three thereafter develop strategies that would serve as a guide for nurse
components: a workplace that has the necessary structures to managers to manage these problems.
support empowerment, a psychological belief in one's ability to be
empowered, and acknowledgment that there is power in the re- Research questions
lationships and care that nurses afford. To help nurses become Q1. What are the common work-related problems of the nursing
empowered and use their power for better patient care, a more staff?
comprehensive understanding of these three components is Q2. What are the strategies that can be used by nurse managers
required [5]. to manage nursing staff work-related problems?
The nursing shortage is one of the many issues that needs Q3. What are the panel of experts' opinions regarding the newly
attention and necessitates involvement of all health care parties. developed strategy?
Nurses always work in a high-risk environment; they are prone to
numerous occupational health hazards that have harmful effects
Conceptual framework
both on their mental and on their physical health, as well as on
their productivity and efficacy at work [6]. Workplace violence is an
The American Association of Critical-Care Nurses developed a
incident of hostility that may be physical, sexual, verbal, emotional,
model for a healthy work environment (HWE), consisting of six
or psychological and it takes place when nurses are abused,
standards, which are used by researchers as a conceptual frame-
threatened, or assaulted in situations related to their work. Such
work for the present study. Strategies for solving work-related
violence upsets the organization in different ways, for example, the
problems were derived as criteria through which the six
loss of competent and trained nurses, a decrease in nursing pro-
evidence-based essential standards could help to create work and
ductivity, and a bad reputation of the organization in society and
patient care environments that are respectful, safe, and humane to
legal issues related to the safety of employees [7].
staff and all. These standards include the following: Skilled com-
In Egypt, nursing as a profession is affected by numerous factors
municationdnurses must be proficient in communication skills
that are considered dilemmas for working as a nurse. These factors
(written, verbal, and nonverbal communication) as they are in
included media, public image, social prestige, lack of role models,
practical skills. Ineffective professional relationships lead to
physicianenurse interaction, ineffective learning environment, risk
mistrust, disrespect, stress, and dissatisfaction. True collabo-
for violence, exposure to health hazards, conflict, stress, and
rationdthis is the process that is based on mutual respect for
exposure to infection [8]. Challenging workplace conditions that
knowledge and abilities of other professionals who are involved in
nurses face in Egypt include little institutional recognition or sup-
patients’ care. Nurses must be relentless in pursuing and fostering
port, shortage of nurses, insufficient funds, and high turnover of
true collaboration. Effective decision makingdnurses must be
ministers and decision makers at the Ministry of Health and Pop-
valued and committed partners in formulating policy, directing and
ulation (MOHP) , which in turn hinders the setting of rules to
evaluating clinical care, and leading organizational processes.
support nursing reforms, maldistribution of nurses in different
Staffing optimizationdstaffing process must ensure the effective
health services, poor image and poor public perception of nursing,
match between patient needs and nurse competencies. Meaningful
insufficient salaries, and risks during night shifts [9].
recognitiondnurses must be recognized and must recognize
Nurse managers are tasked with the near-impossible to ensure
others for the value each brings to the work of the organization.
the care provided in the unit is of high quality, keep patients and
Authentic leadershipdnurse leaders must fully embrace the
families satisfied with the care, as well as achieve productivity
imperative of an HWE, authentically live it, and engage others in its
goals, all while addressing the needs of the staff. [10]. The complex
cultivation. Nurse leaders must be positioned to influence decisions
work environment necessitates that nurse managers remain up to
that affect nursing practice and the work environment. [12].
date with the latest scientific developments in their field. They
The relationship between the study's conceptual framework,
must also be able to analyze problems effectively and consequently
the developed strategies, and staff nurses' workplace-related
determine the right course of action for each situation to achieve
problems was represented as follows: the six HWE standards
the most favorable outcome. Thus, nurses working in managerial
provided the evidence-based mechanisms for guiding actions and
positions must develop their problem-solving skills. Current liter-
behaviors of nurse managers with their subordinates and consid-
ature recommends that nurse manager candidates should receive
ered the origin on which the current developed strategies was
additional training in several areas including problem-solving
based. Therefore, the developed strategies will be the methodo-
skills. This training should be an essential part of orientation pro-
logical framework to manage different arising work-related prob-
grams designed before promotion to managerial positions [11].
lems, including decreasing stress and workload, eliminating sick
leave and absenteeism, optimizing staff in the unit, promoting
nurses' satisfaction and retention, improving nurses' motivation
Significance of the study
and empowerment, reinforcing team spirit and moral, and reducing
interpersonal conflict and workplace violence.
Tailoring strategies to solve nurses' work-related problems re-
quires a rich understanding of the most common problems that
nurses face during their work by their nurse managers who are Methods
expected to handle all problems that evolve in their areas of work.
Moreover, in Egypt, many nurse managers in different clinical Study design
settings are promoted to managerial positions based on their years
of experience regardless of their educational or managerial quali- The study adopted a descriptive research design.
fications, thus remain unfamiliar with and untrained in problem
solving skills as a paramount managerial requirement. Conse- Setting and samples
quently, effective strategies must be put in place to inform them
about ideal processes for managing their staff work-related prob- The study was conducted at three different hospitals in Egypt,
lems. Thus, the purpose of this study was to assess nursing staffs' two in the Delta Region and one in Cairo, all which provide sec-
work-related problems as perceived by their managers and ondary health care services.
180 A.R. Gab Allah et al. / Asian Nursing Research 14 (2020) 178e187

Hospital (1): it is affiliated to the Ministry of Higher Education. It Measurements/instruments

consists of four buildings: the main building, the specialty hospital
building, the emergency building, and the oncology institution. Its 1dQuestionnaire about nursing staffs' problems.
bed capacity stands at 1200 beds. This was a self-administered questionnaire designed by the re-
Hospital (2): It is affiliated to the higher authority of educational searchers after reviewing the relevant literature. This questionnaire
hospitals and institutions. It consists of four buildings: the main was used for conducting a preliminary study about the common
building, the economy building, the outpatient clinics, and the nursing staffs' work-related problems as perceived by first-line
hemodialysis building. Its bed capacity is 863 beds. nurse managers, and the proposed strategies for managing these
Hospital (3): It is affiliated to the Ministry of Health. It includes problems. It included two open-ended questions, namely:
the health services sector in addition to a research center. Its bed
capacity is 945 beds. 1. What are the common problems faced by nursing staff?
2. From your point of view, what are the strategies you can use to
manage these problems?
The participants included in the study were composed of two groups
The face and content validity of this questionnaire was tested by
Group 1: first-line nurse managers: nonprobability convenience a panel of five experts in nursing management.
sampling technique was used to select 150 first-line nurse man- Scoring of questionnaire:
agers working at hospital (1) (n ¼ 50), hospital (2) (n ¼ 50), and The nurse managers’ responses regarding work-related prob-
hospital (3) (n ¼ 50). lems were rated on three-point Likert scale as follows:
Inclusion criteria: the study included first-line managers of
different ages, different educational qualifications in nursing  Uncommon problems <40%
(including a bachelor and technical degree in nursing), both gender,  Average common 40e<60%
different marital status, working at different units and departments  Common problems 60%
at the respective hospitals, and who have six or more months of
experience at their current position. 2dDelphi technique to develop the strategies for managing
nursing staff problems.
Methods of recruiting nurse managers The Delphi technique is a widely used and accepted method for
arriving at a consensus of opinion concerning real-world knowl-
To recruit nurse managers as study participants, the researchers edge solicited from experts within certain topic areas [13]. A
revised the employees' database within each hospital to specify the questionnaire that included strategies for managing nursing staffs’
nurse managers who met the inclusion criteria. A sampling frame was problems was distributed for each Delphi round.
established for all nurse managers meeting the criteria. The re- Scoring of questionnaire:
searchers contacted them personally to explain the aims of the study Expert panelists rated each item within strategy on three-point
in addition to procure their acceptance to participate in the study. Likert scale from as follows: agree, need of modifications, and disagree.
Group 2: experts of nursing management: the snowball sam- The responses with highest score was considered as follows:
pling technique was used to select the panel experts for the Delphi
technique that was used for the development of the strategy.  Agree, which requires to be fixed in the following rounds.
Inclusion criteria: the snowball sampling technique was useful in  Need modification, which requires restatement in the following
this research to achieve the inclusion criteria that are listed below: rounds.
 Disagree, which requires to be excluded in the following rounds.
1. The expert must be either a professor of nursing management at
a faculty of nursing in Egypt or have a nursing director position 3dOpinionnaire format.
within Egyptian hospital, with at least 1-year experience in the This tool was designed by the researchers to validate the new
current position. strategy format. It contained items that examined the clarification
2. The expert must have a specific interest in the research topic, of the strategy purpose, its comprehensiveness, clarity, and
either through previous research work or practical experience at simplicity, along with how comprehendible, applicable, and
hospitals. feasible it was.

This technique resulted in a panel of seven professors of nursing Data collection/procedures

management from different nursing faculties across Egypt and
eight nursing directors from different hospitals in Egypt. They were o The preliminary study was conducted from September 15, 2018,
then contacted personally to be recruited for the study. till November 17, 2018.
o The questionnaire concerning the nursing staffs’ problems was
distributed to first-line nurse managers to determine the com-
Ethical consideration mon nursing staffs’ work-related problems. These responses
were then analyzed to prioritize and rank the nursing staffs’
To conduct the study, this study was approved by the institu- problems. Problems that scored 60% were considered common
tional review board of the Menoufia University (Approval no. 86). problems. The implementation of this scoring method lowered a
Written approval was obtained from the medical and nursing au- total of 13 reported problems to nine, which were later included
thority at the aforementioned study setting following an explana- in the developed strategies. In addition, the proposed strategies
tion of the purpose and procedures of the study. The respondents' by first-line managers were used by the researchers as a guide
rights were protected by ensuring voluntary participation, and for developing the strategy format.
informed consent was obtained after explaining the purpose, study o The Delphi technique was used to develop the strategies for
procedures, and potential benefits of the study. The respondents managing the nursing staffs’ problems. The Delphi process
were assured that the data would be treated as strictly confidential. lasted 3 months, starting from December 1 till the end of
 A.R. Gab Allah et al. / Asian Nursing Research 14 (2020) 178e187 181

Table 1 Distribution of Sociodemographic Characteristics of Studied Nurse Managers to review the items summarized by the researchers. Accord-
(N ¼ 150). ingly, Delphi panelists were required to rate or “rank-order”
Sociodemographic characteristics N %
items to establish preliminary priorities among items. Each
item within strategy was rated on three-point Likert scale
Age (yrs)
from as follows: agree, need of modifications, and disagree.
 20 to younger than 30 36 24.0
 30 to younger than 40 65 43.3 The highest score throughout the three scale was considered.
 40 or older 49 32.7 In the third round, each Delphi panelist received a question-
Gender naire that included the items summarized by the researchers
 Men 0 0
in the previous round and was asked to revise their
 Women 150 100
Years of experience
judgments.
 1e<5 49 32.6 o The newly designed strategies were validated by an opinionn-
 5e<10 56 37.4 aire format distributed to the panel of experts after the third
 10 or more 45 30.0 round of the Delphi technique.
Marital status
 Married 83 55.4
 Single 7 4.6
 Widow 44 29.3
 Divorced 16 10.7 Data analysis
Educational level
 Technical institute 13 8.6 Results were collected, tabulated, and statistically analyzed by
 Bachelor degree 137 91.4
an IBM personal computer and statistical package SPSS 22.0 (IBM
 Others - -
Department of work Corp., Armonk, NY, USA). Descriptive statistics such as numbers and
 Critical and emergency care units 77 51.3 percentages were used to determine common nursing staff prob-
 Inpatient departments 43 28.7 lems, analyze Delphi rounds and the expert panelists’ opinions
 Outpatient clinics 30 20.0 regarding the face and content validity of the developed strategies.
Attending workshops regarding human resource management
 Yes 85 56.6
 No 65 43.4
Results
Note. yrs ¼years.

The distribution of sociodemographic characteristics of the

studied nurse managers is displayed in Table 1. As shown in the
February 2019, until consensus regarding the strategies was table, the highest percentage of studied first-line managers were
achieved. The Delphi process consisted of three rounds: the between the age of 30e40 years (43.3%). All of them were women
first round traditionally begins with an open-ended ques- (100%) because the male gender only recently joined the faculty of
tionnaire, which is used to elicit the experts' opinions nursing. Regarding years of experience, most of them had 5e10
regarding the strategies that can be used by managers to years of experience (37.4%). More than half of the studied first-line
manage nursing staffs’ problems. Nine of 13 problems were managers were married (55.4%). In addition, most of them had a
included as the strategies' dimensions, each of the dimensions bachelor degree in nursing (91.4%). More than half of them were
included had its own explanatory note and a blank area for working in critical and emergency care units (51.3%). Lastly, most of
experts to write proposed solutions for managing each prob- them had attended workshops on human resource management
lem. After receiving the participants' responses (from experts (56.6%).
and first-line managers), researchers organized, refined, and As is evident from Table 2, the most common staff nurses’ work-
added other strategies derived from previous literature on related problems as perceived by nurse managers were job stress,
nursing problems (including published research findings and work overload, staff absenteeism, demotivation, lack of empower-
recommendations and textbooks), and then converted the ment, staff turnover, workplace violence, staff conflict, and poor
collected information into a well-structured questionnaire. staffs’ performance (60%). On the other hand, lack of organiza-
This questionnaire was used as the survey instrument for the tional justice, limited resources, nursing shortage, and unclear job
second round. In the second round, each Delphi participant description were average common staff nurses’ work-related
received a questionnaire comprising 79 items and was asked problems (40e<60%).

Table 2 Staff Nurses' Work-related Problems as Perceived by Nurse Managers at the Study Setting (N ¼ 150).

Staff nurses' work-related Hospital 1 (n ¼ 50) Hospital 2 (n ¼ 50) Hospital 3 (n ¼ 50) Total (n ¼ 150)
problems
N % N % N % N %

Job stress 50 100 50 100 50 100 150 100

Work overload 50 100 47 94.0 50 100 147 98.0
Staff absenteeism 48 96.0 44 88.0 47 94.0 139 92.6
Nursing shortage 25 50.0 25 50.0 19 38.0 69 46.0
Demotivation 50 100 39 78.0 21 42.0 110 73.3
Lack of empowerment 45 90.0 38 76.0 30 60.0 113 75.3
Staff turnover 50 100 20 40.0 22 44.0 92 61.3
Workplace violence 41 82.0 38 76.0 30 60.0 109 72.6
Staff conflict 46 92.0 43 86.0 39 78.0 128 85.3
Staff poor performance 33 66.0 39 78.0 23 46.0 95 63.3
Lack of organizational justice 25 50.0 22 44.0 19 38.0 66 44.0
Unclear job description 21 42.0 27 54.0 15 30.0 63 42.0
Limited resources 26 52.0 20 40.0 15 30.0 61 40.6
182 A.R. Gab Allah et al. / Asian Nursing Research 14 (2020) 178e187

Table 3 Number and Percentage Distribution of Experts Opinions Regarding Items of the Strategy to Solve Nursing Staff's Work-related Problems (Second Round; N ¼ 15).

Item Agree Need modification Not agree

3 2 1

N % N % N %

I. Managing stress
a Develop a supportive climate by promoting openness and trust through discussing problem areas with them. 15 100 - - - -
b Try to identify the source of the stress and decide how she or he can reduce or eliminate these sources. 14 93.3 1 6.7 - -
c Reducing job stress (e.g., by providing more time and more concrete information, adequate staff). 11 73 4 27.0 - -
d Clarify expectations and explain in detail how they may be expected to be evaluated. 15 100 - - - -
e Went on break and carryout exercises. 15 100 - - - -
f Improving coworker relations (by considering coworker compatibility when scheduled work and/or creating a work 14 93.3 1 6.7 - -
team.
g Recognize effective performance because failure to reward desirable behavior causes stress. 14 93.3 1 6.7 - -
II. Managing workload
a Support the concept of “self-scheduling as a strategy to the growing nursing shortage”. 15 100 - - - -
b Consider permanent shift assignments according to personal needs. 14 93.3 1 6.7 - -
c Personnel work schedules made in consideration of the effect of workload, and work hours. 15 100 - - - -
d Provide a sufficient number of off-duty hours to allow an uninterrupted sleep cycle of at least 8 h. 15 100 - - - -
e Ensure the unit has enough staff to handle the workload. 15 100 - - - -
f Negotiate with upper management that the unit needs extra staff for patient care. 14 93.3 1 6.7 - -
g Orient new hiring staff about on-call strategy. 15 100 - - - -
h Work is assigned fairly and equitably. 14 93.3 1 6.7 - -
III. Managing absenteeism
a Try to solve transportation problems. 15 100 - - - -
b Enriching the staff nurse's job by increasing its responsibility, variety, or challenge. 15 100 - - - -
cConsidering enough number of staff nurses per shift and overtime. 15 100 - - - -
d There is flexibility to take permission during shift. 14 93.3 1 6.7 - -
e Being a good role model by rarely taking sick days and attending late. 15 100 - - - -
f Try to solve social problems that contribute to increased absenteeism. 14 93.3 1 6.7 - -
g Enforcing absenteeism control policies (e.g., carrying through on employee discipline when there is an attendance 15 100 - - - -
problem).
h Creating a norm of excellent attendance (e.g., by emphasizing the negative impact of a nurse not coming to work). 15 100 - - - -
i Rewarding good attendance with providing bonus. 15 100 - - - -
j Implement sick leave policy that is strictly understood. 15 100 - - - -
k Consider employee's attendance during the performance appraisal. 15 100 - - - -
IV. Managing conflict among subordinates
a Protect each party's self-respect. 15 100 - - - -
b Deal with a conflict of issues not a personality. 15 100 - - - -
c Do not put blame or responsibility for the problem on the participants. 14 93.3 1 6.7 - -
d Allow open and complete discussion of the problem from each participant. 14 93.3 1 6.7 - -
e Maintain equity in the frequency and duration of each party presentation. 15 100 - - - -
f Encourage full expression of positive and negative feelings in an accepted atmosphere. 15 100 - - - -
g Make sure both parties listen actively to each other's words. 15 100 - - - -
h Encourage parties to provide frequent feedback to each other's comments. 15 100 - - - -
i Give positive feedback to participants regarding their cooperation in solving the conflict. 15 100 - - - –
j Follow-up on the progress of the plan to solve conflict. 15 100 - - - –
k Help the conflict parties develop alternative solutions, select a mutually agreeable one, and develop a plan to carry it 14 93.3 1 6.7 - -
out.
V. Managing not empowered staff
a Giving staff authority, tools, and information they needed to do their jobs. 12 80 3 20.0 - -
b Delegate assignments to provide learning opportunities and allow employees to share in the satisfaction derived from 15 100 - - - –
achievement.
c Delegate power and share information. 14 93.3 1 6.7 - -
d Managers must convey appropriate attitudes and develop the right interpersonal skills. 14 93.3 1 6.7 - -
e Present the powerful picture to others. 14 93.3 1 6.7 - -
f Maintaining democracy environment. 15 100 - - - –
g Maintain personal energy. 14 93.3 1 6.7 - -
h Enhance open communication. 15 100 - - - –
i Maintain a sense of humor. 15 100 - - - –
VI. Managing demotivated staff
a Integrate the staff's needs and wants with the organization's interests and purpose. 15 100 - - - –
b Remove traditional blocks between the employee and the work to be performed. 15 100 - - - –
c Have clear expectations for workers, and communicate these expectations effectively. 15 100 - - - –
d Develop group goals and projects that will build a team spirit. 5 34.0 10 66.0 - -
e Know the uniqueness of each employee. Let each know that you understand his/her uniqueness. 15 100 - - - –
f Be certain that employees understand the reason behind decisions and actions (e.g., reward and punishment). 15 100 - - - –
g Be consistent in handling undesirable behavior. 15 100 - - - –
h Be fair and consistent when dealing with all employees. 15 100 - - - –
i Provide learning opportunities that promote employees’ growth. 15 100 - - - –
j Provide opportunity for participation and input from all subordinates in decision making. 15 100 - - - –
k Whenever possible, give subordinates recognition and credit. 15 100 - - - –
VII. Managing workplace violence
a Establish and maintain a violence prevention program as part of their facility's safety policy. 15 100 - - - –
b Establishes a plan for maintaining security in the workplace. 15 100 - - - –
c Ensure that nurses receive specific training concerning the content of violence prevention programs and its 15 100 - - - –
implementation.
d Decrease the threat to worker safety. 3 26.6 - - 12 73.4
 A.R. Gab Allah et al. / Asian Nursing Research 14 (2020) 178e187 183

Table 3 (continued )

Item Agree Need modification Not agree

3 2 1

N % N % N %

e Creates and disseminates a clear policy that violence, verbal and nonverbal threats, and related actions, will not be 7 46.0 8 54.0 - -
tolerated.
f Track their progress in reducing work-related assaults. 15 100 - - - –
g Ensures that no reprisals are taken against employees who report or experience workplace violence. 15 100 - - - –
h Encourages prompt reporting of all violent incidents and recordkeeping of incidents to assess risk and to measure 14 93.3 1 6.7 - -
progress.
VIII. Managing poor performance
a Determine obstacles that interfere with good performance. 15 100 - - - –
b Confront nurses who have poor performance privately. 15 100 - - - –
c Counsel the employee privately, verbally and in writing, as well as concerning professional and nonprofessional 15 100 - - - –
behavior.
dUse objective and subjective methods for capturing data about staff’s performance. 15 100 - - - –
e Whenever possible engage underperformed nurses in educational seminars, workshops, or clinical educational 15 100 - - - –
program.
f Provide the employee with time to complete a self-evaluation during work. 15 100 - - - –
g Follow-up progress of staff performance. 15 100 - - - –
h Evaluate staffs’ performance based on specific standards. 15 100 - - - –
IX. Managing turnover
a Maintain a safe and healthy work environment that makes the nurses feel good about being there. 14 93.3 1 6.7 - -
b Place nurses in the ideal roles for their talents and interests, for greater job satisfaction and be less likely to burn out or 15 100 - - - -
quit.
c Being open about everything related to the unit and hospital to develop enthusiasm. 15 100 - - - -
d Make the work environment more enjoyable for nurses. 14 93.3 1 6.7 - -
e Advocate for nurses if decisions at the executive level might impact their jobs, duties, or earnings. 14 93.3 1 6.7 - -
f Provide constructive performance feedback not only from the direct boss but also from several quarters. 14 93.3 1 6.7 - -
Total 95.2% 3.9% 0.9%

The experts’ opinions regarding items to be included in the management, and staff. Staff nurses have a paramount role in
strategy to solve nursing staffs’ work-related problems are illus- keeping a supportive work environment, but nurse managers can
trated in Table 3, which displays the second Delphi round with a certainly have a significant impact [12]. Thus, the aim of this study
response rate of 100%. Most experts (95.2%) agreed on most of the was to assess nursing staff’s work-related problems as perceived by
proposed items to manage staff problems after they had been their managers and thereafter develop strategies that would serve
summarized by the researchers following the first round. The total as a guide for nurse managers to manage these problems.
percentage for modified items was 3.9%, whereas the total per- With regards to the first study question, the common staff
centage for disagreed on items was 1.9%. One item of the proposed nurses' work-related problems as perceived by nurse managers
strategy (decrease the threat to worker safety) with percentage were job stress, work overload, staff absenteeism, demotivation,
73.4% was disagreed on by the panel of experts, thus it was excluded lack of empowerment, staff turnover, workplace violence, staff
from the strategy in the third round. The number of modified items conflict, and staff poor performance. Although lack or organiza-
came in at two as follows, representing 66.0% and 54.0%, receptively: tional justice, limited resources, nursing shortage, and unclear job
(1) develop group goals and projects that will build a team spirit and description were average common problems. From the re-
(2) creates and disseminates a clear policy that violence, verbal and searchers’ point of view, the selected study hospitals were large
nonverbal threats, and related actions, will not be tolerated. public hospitals with high patient flow, thus these problems were
Final experts’ opinions regarding items to be included in the common.
strategy to solve nursing staff’s work-related problems are shown The current findings was in agreement with the study con-
in Table 4, that represents the round three with a response rate of ducted by Mahran et al [9], who reported that the most common
100%. This represents the final draft of the strategy to manage challenges and crisis facing critical care nurses were large number
nursing staff’s work-related problems developed by the re- of patients in intensive care units, work overload, working atmo-
searchers. The total percentage of panel of experts' agreement sphere filled with tension and stress, fear of the possibility of
regarding the developed strategy was 98.9%, whereas modified infection from patients, increased working hours and long shift,
items stood at 1.1%. and have conflict between nurses and doctors.
The panel of experts' opinions regarding face and content val- The study carried out by Rani and Thyagarajan [14] was in line
idity of the developed strategy are presented in Table 5. According with present study findings, which reported that most nurses
to this table, the developed strategy was valid from the panel of complained of a heavy workload, which is considered the primary
experts' perspectives as all of them [100%] agreed that the strategy contributing factor for work-related stress. Similarly, results from
is comprehensive, clear, simple, understandable, applicable, and the study performed by Godwin et al [15] reinforced the proposi-
feasible. tion that nurses experienced an above-average level of work-
related stress. Accordingly, the study by Vernekar and Shah [16]
Discussion concluded that 98.4% (from a total of 253 nurses) experienced
moderate to very severe stress. In addition, increased nursing
Workforce issues and challenges at the workplace are significant workload is one of the main challenges of national and interna-
because they have an important impact on nurses’ ability to deliver tional nursing. The study conducted by Madadzadeh et al [17]
safe, effective, and high-quality care. Maintaining a conducive work concluded that 83.3% of a total of 80 respondent nurses reported a
environment is the shared responsibility of employers, high workload.
184 A.R. Gab Allah et al. / Asian Nursing Research 14 (2020) 178e187

Table 4 Number and Percentage Distribution of Experts’ Opinions Regarding Items of the Strategy to Solve Nursing Staff's Work-related Problems (Third Round; N ¼ 15).

Item Agree Need modification Not agree

3 2 1

N % N % N %

I. Managing stress
a Develop a supportive climate by promoting openness and trust through discussing problem areas with them. 15 100 - - - -
b Try to identify the source of the stress and decide how she or he can reduce or eliminate these sources. 15 100 - - - -
c Reducing job stress (e.g., by providing more time and more concrete information, adequate staff). 15 100 - - - -
d Clarify expectations and explain in detail how they may be expected to be evaluated. 15 100 - - - -
e Went on break and carryout exercises. 15 100 - - - -
f Improving coworker relations (by considering coworker compatibility when scheduled work and/or creating a work 15 100 - - - -
team).
g Recognize effective performance because failure to reward desirable behavior causes stress. 14 93.3 1 6.7 - -
II. Managing workload
a Support the concept of “self-scheduling as a strategy to the growing nursing shortage”. 15 100 - - - -
b Consider permanent shift assignments according to personal needs. 15 100 - - - -
c Personnel work schedules made in consideration of the effect of workload, and work hours. 15 100 - - - -
d Provide a sufficient number of off-duty hours to allow an uninterrupted sleep cycle of at least 8 h. 15 100 - - - -
e Ensure the unit has enough staff to handle the workload. 14 93.3 1 6.7 - -
f Negotiate with upper management that the unit needs extra staff for patient care. 15 100 - - - -
g Orient new hiring staff about on-call strategy. 14 93.3 1 6.7 - -
h Work is assigned fairly and equitably. 15 100 - - - -
III. Managing absenteeism
a Try to solve transportation problems. 15 100 - - - -
b Enriching the staff nurse's job by increasing its responsibility, variety, or challenge. 15 100 - - - -
c Considering enough number of staff nurses per shift and overtime. 15 100 - - - -
d There is flexibility to take permission during shift. 14 93.3 1 6.7 - -
e Being a good role model by rarely taking sick days and attending late. 15 100 - - - -
f Try to solve social problems that contribute to increased absenteeism. 14 93.3 1 6.7 - -
g Enforcing absenteeism control policies (e.g., carrying through on employee discipline when there is an attendance 15 100 - - - -
problem).
h Creating a norm of excellent attendance (e.g., by emphasizing the negative impact of a nurse not coming to work). 15 100 - - - -
i Rewarding good attendance with providing bonus. 15 100 - - - -
j Implement sick leave policy that is strictly understood. 15 100 - - - -
k Consider employee's attendance during the performance appraisal. 15 100 - - - -
IV. Managing conflict among subordinates
a Protect each party's self-respect. 15 100 - - - -
b Deal with a conflict of issues not a personality. 15 100 - - - -
c Do not put blame or responsibility for the problem on the participants. 14 93.3 1 6.7 - -
d Allow open and complete discussion of the problem from each participant. 14 93.3 1 6.7 - -
e Maintain equity in the frequency and duration of each party presentation. 15 100 - - - -
f Encourage full expression of positive and negative feelings in an accepted atmosphere. 15 100 - - - -
g Make sure both parties listen actively to each other's words. 15 100 - - - -
h Encourage parties to provide frequent feedback to each other's comments. 15 100 - - - -
i Give positive feedback to participants regarding their cooperation in solving the conflict. 15 100 - - - –
j Follow-up on the progress of the plan to solve conflict. 15 100 - - - –
k Help the conflict parties develop alternative solutions, select a mutually agreeable one, and develop a plan to carry it 15 100 - - - -
out.
V. Managing not empowered staff
a Giving staff authority, tools, and information they needed to do their jobs. 15 100 - - - -
b Delegate assignments to provide learning opportunities and allow employees to share in the satisfaction derived from 15 100 - - - –
achievement.
c Delegate power and share information. 14 93.3 1 6.7 - -
d Managers must convey appropriate attitudes and develop the right interpersonal skills. 15 100 - - - -
e Present the powerful picture to others. 15 100 - - - -
f Maintaining democracy environment. 15 100 - - - –
g Maintain personal energy. 14 93.3 1 6.7 - -
h Enhance open communication. 15 100 - - - –
i Maintain a sense of humor. 15 100 - - - –
VI. Managing demotivated staff
a Integrate the staff's needs and wants with the organization's interests and purpose. 15 100 - - - –
b Remove traditional blocks between the employee and the work to be performed. 15 100 - - - –
c Have clear expectations for workers, and communicate these expectations effectively. 15 100 - - - –
d Develop group goals and projects that will build a team spirit. 15 100 - - - -
e Know the uniqueness of each employee. Let each know that you understand his/her uniqueness. 15 100 - - - –
f Be certain that employees understand the reason behind decisions and actions (e.g., reward and punishment). 15 100 - - - –
g Be fair and consistent when dealing with all employees. 15 100 - - - –
h Provide learning opportunities that promote employee growth. 15 100 - - - –
i Provide opportunity for participation and input from all subordinates in decision making. 15 100 - - - –
j Whenever possible, give subordinates recognition and credit. 15 100 - - - –
k Be consistent in handling undesirable behavior. 15 100 - - - –
VII. Managing workplace violence
a Establish and maintain a violence prevention program as part of their facility's safety policy. 15 100 - - - –
b Establishes a plan for maintaining security in the workplace. 15 100 - - - –
 A.R. Gab Allah et al. / Asian Nursing Research 14 (2020) 178e187 185

Table 4 (continued )

Item Agree Need modification Not agree

3 2 1

N % N % N %

c Ensure that nurses receive specific training concerning the content of violence prevention programs and its 15 100 - - - –
implementation.
d Creates and disseminates a clear policy of verbal and nonverbal threats and related actions will not be tolerated. 15 100 - - - -
e Track their progress in reducing work-related assaults. 15 100 - - - –
f Ensures that no reprisals are taken against employees who report or experience workplace violence. 15 100 - - - –
g Encourages prompt reporting of all violent incidents and record keeping of incidents to assess risk and to measure 14 93.3 1 6.7 - -
progress.
VIII. Managing poor performance
a Determine obstacles that interfere with good performance. 15 100 - - - –
15 100 - - - -
b Confront nurses who have poor performance privately. 15 100 - - - –
c Counsel the employee privately, verbally and in writing, concerning professional and nonprofessional behavior. 15 100 - - - –
d Whenever possible engage underperformed nurses in educational seminars, workshops or clinical educational 15 100 - - - –
programs.
e Provide the employee with time to complete a self-evaluation during work. 15 100 - - - –
f Follow-up progress of staff performance. 15 100 - - - –
g Evaluate staff performance based on specific standards. 15 100 - - - –
h Use objective and subjective methods for capturing data about staff performance. 15 100 - - - –
IX. Managing turnover
a Maintain a safe and healthy work environment that makes the nurses feel good about being there. 14 93.3 1 6.7 - -
b Place nurses in the ideal roles for their talents and interests, for greater job satisfaction and be less likely to burn out or 15 100 - - - -
quit.
c Being open about everything related to the unit and hospital to develop enthusiasm.
d Make the work environment more enjoyable for nurses. 15 100 - - - -
e Advocate for nurses if decisions at the executive level might impact their jobs, duties, or earnings. 14 93.3 1 6.7 - -
f Provide constructive performance feedback not only from the direct boss, but also from several quarters. 14 93.3 1 6.7 - -
Total 98.9% 1.1% 0%

The present study found absenteeism as the third highest work- Violence was reported as a common problem within the study's
related problem. Accordingly, Kurcgant et al [18] revealed that settings. This problem was also evident in the study conducted by
absenteeism is a world-wide problem increasing at an alarming Fute et al [22], who reported that, a significant proportion of nurses
rate, which could result in the hindrance of delivery of health care faced violence while providing care at public health facilities. In
to patients, particularly in health care organizations associated addition, this exposure to violence perpetrated by their patients or
with shortage of number of available health staff. Furthermore, relatives was 86.0% alone and 80.0% among physician's violence in
ineffective routine, work pressure, inability to manage the working different health care settings in Beni Suef Governorate, Egypt [23].
tasks, as well as an uncomfortable environment have a major in- Health care workers usually work in an unsafe environment
fluence on the rates of absence. because of a lack of security guards in some departments or inef-
The present study findings showed staff conflict as a work- fective security staff, as security is unarmed and patients are usu-
related problem. In accordance, nurses in the study conducted by ally accompanied by several relatives. With a lack of awareness in
Jerng et al [19] reported that the conflicts they experienced were Egypt concerning the nature of the health care service and its
mainly with other health care professionals, with a majority more complications, there is an increased risk of misunderstanding and
specifically reporting intragroup conflicts with physicians. In light misconception of rules and regulations that govern health care
of this, our study results may be interpreted as follows: in hospitals, facilities, which can lead to certain types of violence [24].
individual professionals have different goals, expectations, values, This study used the Delphi technique, which can usefully in-
and beliefs making conflict unavoidable when working as a team. fluence many areas for managing clinical activity and solving
This study shows that lack of empowerment was a common operational problems by identifying and obtaining agreement on
work-related problem among nurses as reported by first-line the underlying factors and strategies of resolutions. In the same
managers. Fittingly, Al-Dweik et al [20] concluded that lack of way, Sim et al [25] used the Delphi technique in their study to
nurses’ empowerment is a significant problem and many nurses do conclude that consensus was achieved between nurses on the most
not feel empowered and feel that organizational support is lacking. important concepts, which can provide the basis for measuring the
Moreover, when nurses are not properly empowered, many nega- quality and safety of nursing practice in a comprehensive way. The
tive consequences will ensue, such as feelings of lack of control and Delphi technique was also used to reach the findings of Bjorkman
having little influence on outcomes, which in turn leads to frus- et al [26], which presented a consensus view of tele-nurses’ expe-
tration at work, decreased job satisfaction, and increased risks of riences of important obstacles and prerequisites in their work
burnout. environment.
Regarding the problem of nurses' demotivation, it represented a With reference to the second study question, nurse managers
common work-related problem according to first-line managers' from different study settings suggested certain strategies for
opinion, which contradicted the findings of Weldegebriel et al [21] managing nursing staff's work-related problems, which were later
about nurses’ work motivation. The latter study revealed that most organized by the researchers and validated by expert panelists. In
nurses were intrinsically motivated, and about half of the re- addition, reviewing related literature by the researchers helped in
spondents also reported external work motivation. The contrasting formulating the current strategies in light of the present study
study findings can be attributed to differences in working condi- conceptual framework (The American Association of Critical-Care
tions, policies, and regulations that govern nursing jobs. Nurses' 6 HWE standards). The developed strategies were in
186 A.R. Gab Allah et al. / Asian Nursing Research 14 (2020) 178e187

Table 5 Panel of Experts' Opinion Regarding Face and Content Validity of the Developed
The developed strategies for boosting nurses’ empowerment in
Strategy (N ¼ 15). the present study stemmed from the standards of skilled commu-
nication, meaningful recognition, and authentic leadership, which
Items Yes To some extent No was in agreement with those of Al-Dweik et al [20], who showed
N % N % N % that nursing leaders play a significant role in creating a positive
Does the designed strategy clarify its 15 100 - - - - work environment by emphasizing self-related performance and
designed purpose? authentic leadership to enable nurses to perceive more access to
Is it comprehensive? 15 100 - - - - workplace empowerment structures.
The linguistic style used in the strategy is: By reference to current strategies for managing demotivated
- Clear 15 100 - - - -
staff, they were originated from various standards within the HWE
- Simple 15 100 - - - -
- Understandable 15 100 - - - - conceptual framework. The study by Drake [29] coincided with
- Applicable 15 100 - - - - current strategies, which reported that managers should have clear
Is it feasible? 15 100 - - - - expectations for workers and communicate these expectations
Do you recommend it to be applied as a 15 100 - - - -
effectively, be fair and consistent when dealing with all employees,
guide for nurse managers?
Total 15 100 - - - - provide opportunity for participation and input from all sub-
ordinates in decision making whenever possible, give subordinates
recognition and credit, and develop the concept of teamwork and
accordance with the assumption by Munro and Hope [27], who group goals.
proposed that developing an HWE in which the nursing staff feels In the same context regarding the previous strategies, the study
supported physically and emotionally; where one feels safe, conducted by Adjei et al [30] recommended that hospital man-
respected, and empowered is a crucial role of nurse managers who agement should continue to praise and recognize the nurses indi-
are always looking for effective strategies and solutions for advo- vidually or as a team for their achievement and contribution
cating their staff nurses. In addition, nurse managers should uphold toward the organization. In addition, career development, job
the responsibility to strive for a positive work environment for their enrichment, and providing greater autonomy would also enhance
subordinates. nurses' performance level in their jobs. It is suggested that imple-
The current developed strategies for managing work-related menting interventions in terms of training, guidance, and coun-
stress and workload incorporated certain criteria that reinforce seling would be able to produce motivated and high-performing
the standards of skilled communication, true collaboration, nurses in the hospitals.
meaningful recognition, staff optimization, and authentic leader- Regarding the topic of violence management, the strategy at
ship, which agreed with the findings of Vernekar and Shah [16], hand focused primarily on being proactive in dealing with violence
who found that most nurses adopt the following stress manage- events and reinforcing protection and safety measures for the staff,
ment strategies: identify the source of stress and avoid unnecessary which was in correspondence with the study by Boafo and Hancock
stress, manage time better, adjust standards and attitudes, and [31], which recommended various strategies for managing violence
express feelings instead of bottling them up. In the same line, as follows: ensuring a safe and respectful workplace environment,
Madadzadeh et al [17] concluded that a deep and comprehensive as well as integrating comprehensive prevention programs,
imbalance between resources and tasks and expectations has been reporting mechanisms, and disciplinary policies, policymakers and
perceived by the participants to be the main source of work over- other stakeholders should establish health and safety programs for
load and further recommended that paying more attention to the prevention and management of workplace violence. Finally,
resource allocation, education of the quality workforce, and according to the present study, it is important that security is
commitment with job description by managers is of paramount boosted at various governmental hospitals, especially the regional
importance. ones. It is also advisable to give precedence to women and young
The present study developed various strategies for managing nurses.
the problem of absenteeism that derived from the standards of Lastly, on managing turnover as a work-related problem in the
authentic leadership, meaningful recognition, and staff optimiza- study settings, the current measures focused on maintaining
tion within the study conceptual framework, which was corrobo- workplace environment with necessary elements that can keep
rated by Kurcgant et al [18], who further recommended the nurses from leaving their job, which mainly based on all the stan-
introduction of policies that would address absenteeism in the dards of HWE. In agreement, Bogonko and Kathure [32] recom-
workplace and assist and recognize nurses who handled the mended to improve salaries and allowances (terms of service)
workload of colleagues who are continuously absent. In addition, proportional with qualifications and experience, review and
ward managers are required to use nursing staff abilities and build improve scheme of service for nurses for clear career advancement,
trusting relationships with them so that nurses feel they can rely on support and recognize nurses, create more training opportunities
and confide in them. Other strategies for mitigating absenteeism in such as seminars/updates and workshops, and award recognition to
the present study were formulated as solutions for overcoming the those who develop their skills.
common causes of this problem, as reported by Kanwal et al [2] in
their study. Study implications
Referring to the current strategies for managing conflict, they
were based on the HWE standards of skilled communication, true The developed strategy is recommended to be adopted for
collaboration, and effective decision making. The study by Shah newly appointed first-line nurse managers during their transition
[28] suggested different strategies than the current one for dealing from practicing nursing' roles to managerial roles, as well as for
with staff conflict, including the application of formal reporting different nurses in managerial positions as an evidence-based tool
systems such as incident reporting systems to improve interper- to deal with existing workplace-related problems. Health care
sonal conflicts based on the proposition that management of the organizational policies need to be refined to be more flexible in
reported events are mainly task-oriented, helped to weaken the adopting different strategies. The spread of COVID-19 has put new
tension between the workers, and focus more on the goal of the pressures on already strained health systems across the world. So
task and the expected level of provided care. far, hospitals are facing severe crises trying to deliver necessary
 A.R. Gab Allah et al. / Asian Nursing Research 14 (2020) 178e187 187

care, whereas managers are making heart-breaking decisions on 8. Shukri R, Bakkar S, El-Damen MA, Ahmed SM. Attitudes of students at Sultan
Qaboos University towards the nursing profession. Sultan Qaboos Univ Med J.
how to allocate scarce resources. It would be helpful to replicate
2013;13(4):539e44.
this study at different hospitals with larger sample size to assess the 9. Mahran GS, Taher AA, Saleh NM. Challenges and work crisis facing critical care
emerging nursing staff’s problems in times of crises and refining nurses. Egypt Nurs J. 2017;14:235e41. [Link]
current strategies to be suitable to deal with emerging problems 10. Schmalenberg C, Kramer M. Nurse manager support: how do staff nurses
define it? Crit Care Nurse. 2009;29(4):61e9.
during times of adversity. [Link]
11. Marquis B, Huston C. Leadership roles and management functions in nursing:
Study limitations theory and application. 9th ed. Philadelphia: Lippincott Williams&Wilkins;
2017. p. 39e82.
12. American Association of Critical-Care Nurses. AACN standards for establishing
The use of nonprobability convenience sampling and small and sustaining healthy work environments: a journey to excellence. 2nd ed.
study sample size may limit the generalization of the study find- CA: AACN; 2019.
13. Hsu CC, Sandford BA. The Delphi technique: making sense of consensus.
ings. In addition, different policies in health care settings from Practical Assess, Rese Evaluation J. 2017;12(10):1e8.
which nurse managers were recruited limited the possibility of [Link]
reaching the most effective strategies as they listed only the stra- 14. Rani D, Thyagarajan V. Influence of workplace stress on well-being of nursing
staff. IJASRD. 2017;4(7):50e8.
tegies that were available to them. [Link]
15. Godwin A, Suuk LA, Selorm FH. Occupational stress and its management among
Conclusion nurses at St. Dominic Hospital, Akwatia, Ghana. Health Sci J. 2017;10(6):467.
[Link]
16. Vernekar Sh, Shah H. A study of work-related stress among nurses in a tertiary
In the light of the present study, it can be concluded that the care hospital in Goa. Int J Community Med Pub Health. 2018;5(2):657e61.
nurse managers who participated in this study perceived job stress, [Link]
work overload, conflict, workplace violence, poor performance, 17. Madadzadeh M, Barati H, Asour AA. The association between workload and job
stress among nurses in Vasei hospital, Sabzevar city, Iran, in 2016. JOHE.
staff turnover, demotivation, lack of empowerment, and staff 2018;7(2):83e9. [Link]
absenteeism as common problems faced by staff nurses at work. On 18. Kurcgant P, Passos AR, Oliveira JM, Pereira IM, Costa TF. Absenteeism of nursing
the other hand, other problems such as lack of organizational jus- staff: decisions and actions of nurse managers. J Sch Nurs. 2015;49.
19. Jerng JS, Huang SF, Liang HW, Chen LC, Lin CK, Huang HF, et al. Workplace
tice, unclear job description, the nursing shortage, and limited re- interpersonal conflicts among the health care workers: retrospective explo-
sources were less common. The developed strategy to manage staff ration from the institutional incident reporting system of a university-affiliated
nurses' work-related problems was valid and in line with the panel medical center. Plus One. 2017;12(2):e0171696.
[Link]
of experts' opinions and perspectives; all of the experts agreed that 20. Al-Dweik G, Al-Daken LI, Abu-Snieneh H, Ahmad MM. Work-related empow-
the strategy was comprehensive, clear, simple, understandable, erment among nurses: literature review. Int J Product Quality Manag.
applicable, and feasible. 2016;19(2):168. [Link]
21. Weldegebriel Z, Ejigu Y, Weldegebreal F, Woldie M. Motivation of health
workers and associated factors in public hospitals of West Amhara, Northwest
Conflict of interest Ethiopia. Dovepress. 2016;10:159e69. [Link]
22. Fute M, Mengesha ZB, Wakgari N, Tessema GA. High prevalence of workplace
violence among nurses working at public health facilities in Southern Ethiopia.
The researchers declared no conflict of interest.
BMC Nurs. 2015;14:9. [Link]
23. Abdellah RF, Salama KM. Prevalence and risk factors of workplace violence
Acknowledgments against health care workers in the emergency department in Ismailia,
Egypt. Pan Afr Med J. 2017;26:21.
[Link]
Our great thanks are submitted to ALLAH who provided us with 24. Sulaiman, E. Tarek, M. “Doctors” are calling on Parliament for a deterrent law to
the ability to complete this work. We would like to offer special stop attacks on its members in hospitals[internet]. Egypt: El-watan News;
thanks to nurse managers and the panel of experts for their [cited 2018 May 21]. Available from: [Link]
details/3378691?t=push. Egyptian.
participation and cooperation to complete this study. 25. Sim J, Crookes P, Walsh K, Halcomb E. Measuring the outcomes of nursing
practice: a Delphi study. J Clin Nurs. 2018;27(1-2):e368e78.
References [Link]
26. Bjorkman A, Engstrom M, Olsson A, Wahlberg A. Identified obstacles and
prerequisites in tele nurses' work environmentea modified Delphi study. BMC
1. Gormley DK. Are we on the same page? staff nurse and manager perceptions of
Health Serv Res. 2017;17:357. [Link]
work environment, quality of care and anticipated nurse turnover. J Nurs
27. Munro CL, Hope AA. Healthy work environment: resolutions for 2020. Am J
Manag. 2011;19(1):33e40. [Link]
Crit. 2020;29(1):4e6. [Link]
2. Kanwal N, Riaz G, Riaz MS, Safdar S. Identify the causes of absenteeism in
28. Shah M. Impact of interpersonal conflict in health care setting on patient care;
nurses mayo hospital Lahore Pakistan. Int J Soc Sci Manag. 2017;4(2):110e14.
the role of nursing leadership style on resolving the conflict. NCOAJ. 2017;2(2):
[Link]
44e6. [Link]
3. Olayinka AO, Osamudiamen OS, Ojoadeleke A. Occupational stress manage-
29. Drake K. The motivation to stay motivated. Nurs Manag. 2017;48(12):56.
ment among nurses in selected hospital in Benin city, Edo state, Nigeria. Eur J
[Link]
Exp Biol. 2013;3:473e81.
30. Adjei K, Emmanuel O, Forster OM. The impact of motivation on the work
4. Fassier T, Azoulay E. Conflicts and communication gaps in the intensive care
performance of health workers [Korle Bu Teaching Hospital]: evidence from
unit. Curr Opin Crit Care. 2010;16(6):654e65.
Ghana. Hosp Pract Res. 2016;1(2):47e52. [Link]
[Link]
31. Boafo IM, Hancock P. Workplace violence against nurses: a cross-sectional
5. Smith NJ. Nursing and change: is it time to revisit empowerment? Int J Nurs Sci.
descriptive study of Ghanaian nurses. SAGE Open. 2017:1e9.
2014;1(2):134e36. [Link]
[Link]
6. Tan CC. Occupational health problems among nurses. Scand J Work Environ
32. Monanyi NB, Kaimenyi CK. An investigation into factors causing high nurse
Health. 1991;17(4):221e30.
turnover in Mission Hospitals in Kenya: a Case for Pcea Chogoria Hospital.
7. Roche M, Diers D, Duffield C, Paul C. Violence towards nurses, the work envi-
IJARBSS. 2015;5(3):55e86. [Link]
ronment, and patient outcomes. J Nurs Scholarsh. 2010;42(1):13e22.
[Link]