Hospital Nurse Job Satisfaction and Retention
I. Overview on Nurses’ Job Satisfaction and Retendion
Job satisfaction and retention of nurses in the hospital’s working environment are desirable factors that can greatly affect the totality of health care delivery system. The component, productivity, comprises a diverse and multi-faceted criterion that pertains to a broader scope of performance outcome. However, job satisfaction and retention among nurses are now becoming controversial issues, especially inside the actual hospital facilities due to (1) increased demand of labor among nurses, (2) increasing patient-nurses ratio, (3) issues on job stress and burnouts, and (4) increased cases of problematic nurses’ relationship with higher hospital executives. With the increasing labor demand among nurses, job satisfaction and nursing retention are now being considered as essential considerations in hospital workforce planning and human resource management. In fact, according to Joint Commission Resources (2005), hospitals are now considering the importance of fostering retention better recruitment of new nurses, and establishment of better working conditions among nurses to maintain job satisfaction and high levels of professional morale (p.48).
In the following sections of the literary review, two main subjects shall be considered as the focal points of the discussion, particularly (1) to analyze the relationship between nurses’ retention and job satisfaction, and their employers and hospital executives, and (2) determine the relationship between retention and job satisfaction including the potential factors influencing the componential relationship.
II. Job Satisfaction among Hospital Nurses
Job satisfaction of these hospital nurses directly possesses significant relationship towards following attributes: (1) capacity of hospital executives and administration to properly organize the staffing structure of the nurse servicing staffs (e.g. patient-nurse ratio, working conditions of the nurses, etc), (2) appropriately legislate needed policies protecting the job description and specialization coverage of the nurses in a health nursing facility, and (3) provide appropriate monetary benefits proportionate to the working conditions, standards of services offered and the credential status of the hospital nurses (Turner and Hurley 2002 p.144). In the survey issued by the Advisory Board’s Nurse Executive Center (2004; cited in Contino, 2004), n=1,100 nurses have been evaluated through qualitative simple random sampling interview that aims to determined the respondents’ perceptions regarding the factors that affect job satisfaction of hospital nurses. In the findings, three components have been ranked as the main contributing factors of nurses’ working environment within their hospital, namely (1) collaborative role of nurses in health care and policy legislation, (2) relationship among executives and physicians, and (3) working conditions (e.g. concerns with staffing, patient-nurse ratio, etc). Based on the exhaustive quantitative results of the study, 84% (n=924 out of 1100 respondents) of the respondents have indicated the collaborative function of nurses with the hospital executive as the primary concern imposed to the higher leaders (e.g. medical director). Meanwhile, 43% (n=473 out of 1100 respondents) for relationship in the workforce environment, and 16% (n=116 out of 1100 respondents) for working conditions have considered these factors as the second and third concerns affecting their job satisfaction (Contino 2004).
Therefore, three primary factors affect the working conditions of nurses within the hospital, (1) leadership and management of the hospital executives, (2) relationship of nurses to other members of the health team, and (3) complexity of patient demands. According to Craven and Hirnle (2006), working conditions in the hospital have largely affected the job satisfaction and frequent turn over of nursing staffs. The difficulties of hospital working conditions have provided stressful conditions among these nurses posing significant threat to job satisfaction (p.119). Job stress and burnouts imposed by the working conditions in the hospital are the frequent complaints of nurses. In fact, according to the study of Larrabee, Janney and Osfow et al (2003), a sample of 90 registered staff nurses interviewed have considered job dissatisfaction and stressful working environment as the primary predictor of job resignation, while psychological empowerment is pointed as the major predictor of job satisfaction. Larrabee, Janney and Osfow et al have mentioned the effects of leadership style, nurse-physician collaboration and group cohesion as primary factors affecting job satisfaction levels.
a. Influence of Leadership and Management
In a cross-sectional survey study of Bratt, Broome and Kelber (2000), 1,973 staff nurses in pediatric critical care units in 65 hospital institutions in the United States and Canada have been interviewed regarding their perceptions of group cohesion, job stress, nurse-physician collaboration, nursing leadership, professional job satisfaction and organizational work satisfaction. According to the results of the study, there are significant associations of (r=0.37 to r=0.56) between job stress and group cohesion, professional job satisfaction, nurse-physician collaboration, nursing leadership behaviors, and organizational work satisfaction. Furthermore, organizational work satisfaction is positively correlated (r=0.35 to r=0.56 with 52% variation) with group cohesion, professional job satisfaction, nurse-physician collaboration, nursing leadership behaviors. However, despite of the perceptive surveys and studies from the two latter studies, cultural atmosphere and professional background of the institutions largely affect the perceptions of these sample respondents.
The influence of clinical leadership has been clearly demonstrated in practice patterns of various institutions, which establish normative conditions within the hospitals and eventually stereotypes pertaining to satisfaction levels of every member of the health care team. As supported by Resnick (2004), the perceptions of the hospital nurses in their job satisfaction are influenced by the policy legislation, staffing conditions, and monetary benefits obtained by these nurses in exchange to their specialized (p.87). However, these components influencing job satisfaction are largely dependent to the administrative and legislative bodies of every hospital institution. According to Lugon and Walker (2001), hospital executives, hospital policies and regulations, and organizational structures of the hospitals are the key influential figures that impose the profession culturalism and modify the working atmosphere of the nurses (p.135). In addition, the American College Health Association (ACHA) have stated that nursing staffs are oriented primarily by the policies (inclusive of health service limitations, specialty considerations and responsibilities) legislated by the hospital executives, primarily by the nursing director and the medical director. Hence, considering the work atmosphere modifications made by the administrative and executive departments of the every health care institutions, job satisfaction can be entirely related to the
b. Influence of working relationships
Another influential component of job satisfaction is the relational condition among every member of the health care team. According to Cho, Ketefian, and Barkauskas (2003) and Shortell and Kaluzny (2000), productivity, work satisfaction and professional morale of the hospital nursing staffs largely depend on the working environment, significantly on the interactive conditions between nurses and physicians, and team collaboration among health care team. Organizational commitment involves the overall satisfaction of the nurses in the hospital environment and working conditions.
In the study of Rosenstein (2002), the study has surveyed a total of n=1200 respondents, specifically nurses, physicians and hospital executives, aiming to obtain the prevailing perceptions on the influence of daily interactions between nurses and physicians to job satisfaction. The study further examines the effects of nurse-physician relationships, disruptive physician behavior, the institutional response to such behavior, and the effects of these behaviors in nurses’ job satisfaction. According to the results of the study, nurses are more concerned in their relationship with their collaborators and other members of the health care. Although, majority of respondents (n=1200; c1=1044 – 87%) saw a direct relationship between inappropriate physician behavior and nurse satisfaction as well as job retention, the three groups examined still possess variances in terms of their (1) beliefs about responsibility, (2) barriers to progress, and (3) potential solutions, which further diversified the findings of the study. The results and findings of the study suggest that the quality of nurse-physician relationships must be addressed as facilities seek to enhance job satisfaction, working atmosphere and professional relationship among members of the health care team.
c. Other Influences: Leadership Styles and Work Stresses
From the latter portions of the discussion, various forms of indirect and direct influences on job satisfaction have been examined, particularly (1) leadership and management of hospital executives, and (2) working relationships competencies towards College health nurse staffs’ work performances have been shown. In a survey study conducted by the Joint Commission Resources (JCR 2004), nurses’ perceptions towards the leadership capacity of their hospital executives have been assessed through descriptive random sampling study with 27 respondents (specifically, nursing heads of different departments) from four different hospital institutions in the United States. The top three perceived influences of medical directors to their nursing staffs are (1) the legislation of policies and structure of health care delivery (n=27; mean=3.60), (2) the boosting of nurses’ morale (n=27; mean=3.30), and (3) collaboration of nurse-physician work relationship in providing primary care modalities (n=27; mean=2.90).
Based from the results of the study, leadership qualities and styles of hospital employers or executives manifested through (1) policy legislations, (2) working relationships, and (3) collaborative health care delivery among members of the team, possess the potential of influencing the productivity and work performances of nursing staffs. According to Sharpe, Doran and Almost (2003), job satisfaction among nurses largely depends on components being manipulated by hospital executives and employers, as well as other members of the health team, specifically (1) monetary benefits (2) communication, (3) social integration, (4) justice in the working area, (5) promotion and opportunities to excel, (6) participation, (7) education and (8) routine (p.284).
Diversities and extensions of the roles and duties of the hospital executives have directly affected nursing work performances through the said channels. Meanwhile, the administration, policies and management strategies implemented by these executives and hospital legislators have in turn affected the (1) work load, (2) working atmosphere and (3) tasks and responsibilities of these nurses, which all correlate to the work complexities and stresses experienced by the nurses. According to Turner and Hurley (2002), the complexities of nursing tasks largely vary per institution, and most significantly being influenced the diverse leadership and management of higher positions present in the hospital (p.144).
Job stresses and actual working conditions of present in the environment greatly influence the levels of job satisfaction among nurses. According to Wood, Ross-Kerr and Brink (2006), the ability to provide high quality care often conflicts with the job stresses of diminished resources and increased responsibilities, which directly contribute to job satisfaction as well (p.491). In the study conducted by Kalliath and Morris (2002), a descriptively designed survey has been conducted among nurses working at Midwestern U.S general hospital, which aims to assess the impact of job satisfaction on burnout levels among nurses. Using the Maslach Burnout Inventory (MBI) as the tool in measuring emotional exhaustion, depersonalization and personal accomplishment, the results of the study have stated job satisfaction has a significant direct negative effect on emotional exhaustion, while burnout levels also provide direct positive effect on depersonalization. According to the study of Kalliath and Morris (2002), the path coefficient implies that job satisfaction has both direct and indirect effects on burnout; hence, can be subjected as a potential predictor of burnout.
III. Retention Among Nurses and its Contributing Factors
From the earlier sections, most studies (Wood, Ross-Kerr and Brink, 2006; JCR 2004; Rosenstein, 2002) have concluded significant place of job satisfaction in influencing the productivity and work performances of nursing staffs, which eventually harness and coordinate nurses’ intention of staying in the institution. Retention is directly influenced by the various factors, such as legislation of appropriate and needed policies, and performance of duties and roles according to the rightful job description (Lugon and Walker 2001). Various components influencing the current shortage and brain drain of nurses are already beyond the control of hospital leaders and nursing directors; however, there are still controllable factors related to the work environment that nurse leaders must address to enhance nursing retention.
Retention is another component in nursing management being influenced by the managerial and administrative role of hospital executives and legislative bodies through the channels of (1) policy legislations governing the standard protocols of the college health care hospital, (2) recruitment qualifications, and (3) quality assurance protocols being implemented in the health care setting. Due to the rising concerns of nurse shortage due to work environment-related concerns (e.g. staffing conditions, monetary concerns in other areas, etc.), most health institutions are confronted by issues decreased man power and declining health service provision. Various factors are considered to influence the nurses’ retention in most hospital institutions. Different studies (Rosenstein, 2002; Aiken, Clarke and Sloane et al. 2002; Gifford, Zammuto and Goodman 2002) have considered the effects of (1) relationship and communication, (2) staffing and role conditions, and (3) workforce policies and benefits in nurses’ retention.
According to Ribelin’s (2003), retention of nurse staffs largely depends on the working environment and relational conditions present in the hospital environment. Establishing a professional nursing environment is crucial to retaining nursing staff since the ideal professional practice presented within the workforce environment integrates beliefs, values, philosophy, and vision of the hospital, which eventually direct nursing staff in their practice and relationship in the field of nursing (JRC 2005 p.48). According to Shi (2006), retention of hospital nurses requires adequate monetary compensation and adequate staffing that coincides with the ideal patient-nurse ratio being imposed by the health institution (p.192). JCR (2007) adds that the effects of job satisfaction to nursing staffs’ performance vary according to the workplace setup and the cultural backgrounds of the institutional atmosphere, which eventually influence as nurses intent to stay in institution.
Recruitment and retention of nurses are persistent issues associated with job satisfaction. According to Shi (2006), there are eight components that further links job satisfaction and nurses retention, specifically (1) professional autonomy, (2) communication and interpersonal relationships, (3) administrative aspects such as the structure of the department or prevalent leadership style, (4) recognition on both internal and external employment site, (5) working conditions, (6) professional practice, (7) pay and benefits, and last, (8) staffing and scheduling issues (p.192). Retention is a significant issue of job satisfaction since increasing staff retention through enhancement of job satisfaction further saves hospital costs in terms of staff recruitment and replacement. Furthermore, according to Mullahy (), increased retention also supports the continuity of care for the hospital and managed care populations (p.52).
a. Factors Affecting Retention
According to the studies of Shi (2006), JCR (2007), In the study of Aiken, Clarke and Sloane (2002), Clarke and Sloane et al. (2002), and Gifford, Zammuto and Goodman (2002), retention is largely affected the primary factors: (1) staffing conditions of the hospital, and (3) working relationship with other members of the health care team.
In the study of Newman, Maylor and Chansarkar (2002), 136 nurses and midwives in four health care institutions in London Trust hospitals have been interviewed based on their perception of he nurse satisfaction, service quality and nurse retention chain. According to the exhaustive findings of the study, staffing conditions (n=87) have been considered as the primary contributing factor to the nurses’ intent of staying in an institution, while other identified components include (1) management (n=64) and (2) relationship and professional collaboration (n=58). In the essence, increasing patient-staff ratio from the ideal value of 1:1 as proposed by the American Nurses Association can compromise the health care delivery and focus of the nurses to their daily tasks (Aiken, Clarke and Sloane 2002).
In another study of Aiken, Clarke and Sloane (2002), there are 319 surgical and medical nursing participants from 303 different hospitals across the five jurisdictions (Pennsylvania, Ontario, British Columbia, England and Scotland) that have been assessed via a cross-sectional study on implications of staffing to health care delivery. The study aims to examine the effects of nurse staffing and organizational support on nurses’ dissatisfaction with their jobs associated to work burnout, job stresses, and nurse reports of quality of patient care in an international sample of hospitals. The study has conducted its multiple site cross-sectional survey measuring job dissatisfaction, burnout scale and nurse-rated quality of care via MSQ or Minnesota Satisfaction Questionnaire. According to the findings of the study, dissatisfaction, burnout, and job stresses have been found common to sample hospitals in all five sites. Organizational/managerial support for nursing had a pronounced effect on nurse dissatisfaction and burnout, and both organizational support for nursing and nurse staffing have been directly, and independently, related to nurse-assessed quality of care (Aiken, Clarke and Sloane 2002). Multivariate results state that nurse reports of low quality care are correlated with low staffing and support for nurses compared to those hospitals with high staffing and support. Therefore, staffing considerations provide chained effects between nurse retention and quality of health care delivery.
Meanwhile, another considerable component influencing retention is working relationship with other members of the health care team, especially among hospital executives. According to Gifford, Zammuto and Goodman (2002), the cultural setup and working conditions being experienced by the nurses greatly influence their workforce retention; hence, the findings of the study have considered various components that can affect nursing retention: (1) communication and interaction relationships between nurse-physician, (2) philosophy mandated by the organization, (3) adequate and appropriate collaboration among members of the health care team, and (5) legislation of policies that affect the standards of nursing care delivery. According to the findings in the study of Lok and Crawford (1999), organizational commitment and retention among nurses is largely dependent in two components: (1) nurses’ trust in the organization and the administration behind it, and (2) suitable and appropriate working conditions present in the health care institution.
b. Strategies in Retaining Nursing Staffs
Organizational commitment and retention of hospital nurses is an important consideration in the maintenance of a well-functioning health care delivery system (Aiken, Clarke and Sloane 2002; Gifford, Zammuto and Goodman 2002; Newman, Maylor and Chansarkar 2002). Due to the various concerns in the workforce environment of nurses stated in the latter sections of the discussion, health care system is threatened by the controversial issue of nursing shortage (Upenieks 2005). Significantly, there are essential needs (e.g policy legislation fostering nurse’s commitment, increasing monetary benefits, etc.) that should be considered when fostering and establishing organizational commitment and attitude inclined to institutional retention among nurses. Joint Commission Resources (2005) describes various strategies in order to retain quality nurses through the enhancement of the following fields (p.49):
1. Leadership and collaborative participation and contribution of nurses in activities of the institution,
2. Workplace empowerment through moral enhancements and career development activities,
3. Adequate and appropriate staffing and work scheduling,
4. Enhancement and incorporation of high-technological means of care,
5. Enhancement of professional working environment, and lastly,
6. Foster continuous education and updates on modern nursing care
Magnet organizations have been introduced in order to resolve the crisis on nursing workforce shortage. The so-called Magnet Hospital Prevention Model is inclined to the utilization of managerial and administrative strategies that should be able to foster retention among nurses (Upenieks 2005). According to JCR (2005) and Shi (2006), the current concerns of national health care institutions have now transferred their focus from recruitment to enhancement of retention among nurses since this form of manpower strategy further provide beneficial effects than recruitment, which is primarily the reduction of turnover costs.
c. Retention and Costs of Turnover
Job dissatisfaction is the major cause of nurse turnover, which can then exacerbate the controversy on nursing shortage. The cost of nurse turnover can cost twice as the actual standard salary of a nurse. According to McEwen and Wills (2006), the average salary of a medical surgical nurse in the United States is $45,832 annually as of 2005, while the cost of replacing one nurse is $92,442. Meanwhile, replacement costs for a nurse in a specialty area can exceed by $150,000 per nurse (p.470). According to Roussel, Swansburg and Swansburg (2006), the annual national turnover rate among hospital nurses is between 20% to 70% since turnover rates are being determined by unit and organizational structure (p.191).
Aiken, Clarke and Sloane (2002) have mentioned that the appropriate patient-nurse ratio can only exceed up to three patients per nurse. Exceeding to this ratio of 3:1 can further increase nurse burnout by 235 and job dissatisfaction rates to an approximate of 15%; hence, with such further increase in job dissatisfaction ratings, the chain effect can lead to reduction of nurse workforces. In such case, the possible implication is the further increase in nurse shortage and increased value of turnover costing.
In fact, according to Waldman, Frank and Sanjeev (2004), as of 2000, the turnover rate of nurses has already increased to 21.3% and expected to increase annually by an approximate of 2.33% due to the decreasing trends of nursing supply. According to the study of Aiken, Clarke and Sloane (2002), reducing the turnover rates of a 500-bed capacity hospital to at least 10 to 13 percent can actually save $800,000 annually. Due to this consideration, health care institutions have already considered the alternative of fostering retention than the usual turnover ratings.
IV. Synthesis and Conclusion of Literature Review
Job satisfaction and retention are both interlinked components influenced by diversified factors involving (1) hospital workings conditions, (2) prevailing leadership and management, (3) organization and policy structure, and (4) staffing conditions of every institution. Job satisfaction of nurses is influenced by the significant hospital executives and legislators through their administrative roles in structuring and organizing the systems of the institution (e.g. staffing structure, fostering of collaborating relationship, etc.). Meanwhile, retention has become a major concern of hospital institutions due to the increasing shortage of nurses primarily due to their job dissatisfaction. Such phenomenon has largely contributed to the increase of turnover costs amounting twice of the salary of a nurse. In addition, annual increase of turnover has already been considered due to the increasing job dissatisfaction, which also increases the rate of nursing shortage and turnover costs.
Aiken, L. H., Clarke, S. P., ; Sloane, D. M. (2002, August). Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. Journal of American Medical Association, 288, 987-1993.
Aiken, L. H., Clarke, S. P., ; Sloane, D. M. (2002, February). Hospital staffing, organization, and quality of care: cross-national findings. International Journal for Quality in Health Care, 14, 5-13.
Bratt, M. M., Broome, M., ; Kelber, S. (2003, May). Influence of stress and nursing leadership on job satisfaction of pediatric intensive care unit nurses. American Journal of Critical Care, 9, 307-317.
Contino, D. S. (2004, June). Leadership Competencies: Knowledge, Skills, and Aptitudes Nurses Need to Lead Organizations Effectively. Critical Care Nurse, 24, 52-64.
Craven, R. F., ; Hirnle, C. J. (2005). Fundamentals of Nursing: Human Health and Function. New York, U.S.A: Lippincott Williams ; Wilkins.
Gifford, B. D., Zammuto, R. F., ; Goodman, E. A. (2002, February). The relationship between hospital unit culture and nurses’ quality of work life. Journal of Health Care Management, 47, 13-25.
JCR (Joint Commission Resources). (2007). Assessing hospital staff competence. New York, U.S.A: JCR (Joint Commission Resources).
(Jcaho) Joint Commission Resources. (2005). Issues and Strategies for Nurse Leaders: Meeting Hospital Challenges Today. New York, U.S.A: Joint Commission Resources.
Kalliath, T., & Morris, M. (2002, December). Job Satisfaction Among Nurses: A Predictor of Burnout Levels. Journal of Nursing Administration, 32, 648-654.
Larrabee, J. H., Janney, M. A., & Osfrow et al., C. L. (2003, May). Predicting Registered Nurse Job Satisfaction and Intent to Leave. Journal of Nursing Administration, 33, 271-283.
Lugon, M., & Walker, J. (2001). Clinical Governance: Making It Happen. Tennesse, U.S.A: RSM Press.
McEwan, M., & Wills, E. M. (2006). Management and leadership for nurse administrators. New York, U.S.A: Lippincott Williams & Wilkins.
Mullahy, C. M. (1998). Essential Readings in Case Management. New York, U.S.A: Jones & Bartlett Publishing.
Newman, K., Maylor, U., & Bal, C. (2002, June). “The nurse satisfaction, service quality and nurse retention chain”: Implications for management of recruitment and retention. Journal of Management in Medicine, 16, 271 – 291.
Resnick, B. (2004). Restorative Care Nursing for Older Adults: A Guide for All Care Settings. London, U.K: Springer Publishing.
Ribelin, P. J. (2003, August). Retention reflects leadership style. Nursing Management, 34, 18-19.
Robinson, D., & Kettles, A. (2000). Forensic Nursing and Multidisciplinary Care of the Mentally Disordered Offender. Tennesse, U.S.A: Jessica Kingsley Publishers.
Rosenstein, A. H. (2002, June). Nurse-Physician Relationships: Impact on Nurse Satisfaction and Retention. American Journal of Nursing, 102, 26-34.
Roussel, L., Swansburg, R. C., & Swansburg, J. S. (2006). Management and leadership for nurse administrators. New York, U.S.A: Jones & Bartlett Publishing.
Sharpe, P. J., Doran, D., & Almost, J. (2003). Nursing Sensitive Outcomes: State of the Science. New York, U.S.A: Jones & Bartlett Publishing.
Shi, L. (2006). Managing Human Resources in Health Care Organizations. New York, U.S.A: Jones & Bartlett Publishing.
Turner, S. H., & Hurley, L. J. (2002). The History and Practice of College Health. Kentucky, U.S: University Press of Kentucky .
Upenieks, V. (2005, February). Recruitment and retention strategies: a Magnet hospital prevention model. Journal of Medical Surgical Nursing, 21, 21-27.
Waldman, D. J., Frank, A., & Sanjeev, S. (2004, February). The Shocking Cost of Turnover in Health Care. Health Care Management Review, 4, 2-7.
Wood, M. J., Ross-Kerr, J. C., & Brink, P. J. (2006). Basic Steps in Planning Nursing Research: From Question to Proposal. New York, U.S.A: Jones & Bartlett Publishing.