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International Journal of Nursing Studies 42 (2005) 211227 www.elsevier.com/locate/ijnurstu

Job satisfaction among nurses: a literature review

Hong Lu, Alison E. While, K. Louise Barriball
Florence Nightingale School of Nursing and Midwifery, Kings College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, England, UK Received 13 May 2004; received in revised form 15 August 2004; accepted 7 September 2004

Abstract The current nursing shortage and high turnover is of great concern in many countries because of its impact upon the efciency and effectiveness of any health-care delivery system. Recruitment and retention of nurses are persistent problems associated with job satisfaction. This paper analyses the growing literature relating to job satisfaction among nurses and concludes that more research is required to understand the relative importance of the many identied factors to job satisfaction. It is argued that the absence of a robust causal model incorporating organizational, professional and personal variables is undermining the development of interventions to improve nurse retention. r 2004 Elsevier Ltd. All rights reserved.
Keywords: Job satisfaction; Nurse shortage; Nurse retention; Nurse turnover; Intention to quit

1. Introduction The widespread nursing shortage and nurses high turnover has become a global issue (Kingma, 2001) which is of increasing importance to both the developed and developing countries (Cavanagh, 1990; Blegen, 1993; Hancock, 1998; Lee, 1998; Aiken et al., 2001; Fang, 2001; Lu et al., 2002). In light of this, concern about recruitment and retention of nursing staff is increasing in a number of countries (Lundh, 1999). While numerous factors have been linked to nurses turnover, job satisfaction is the most frequently cited (Cavanagh and Cofn, 1992; Blegen, 1993; Irvine and Evans, 1995), and therefore merits attention. This review examines the extensive empirical literature regarding nurses job satisfaction and its associated factors.

2. The denition of job satisfaction Job satisfaction is a topic of wide interest to both people who work in organizations and people who study them. It is a most frequently studied variable in organizational behaviour research, and also a central variable in both research and theory of organizational phenomena ranging from job design to supervision (Spector, 1997). The traditional model of job satisfaction focuses on all the feelings that an individual has about his/her job. However, what makes a job satisfying or dissatisfying does not depend only on the nature of the job, but also on the expectations that individuals have of what their job should provide. The work of Maslow (1954) is seminal and suggested that human needs form a ve-level hierarchy ranging from physiological needs, safety, belongingness and love, esteem to self-actualization. Based on Maslows theory, job satisfaction has been approached by some researchers from the perspective of need fulllment (Kuhlen, 1963; Worf, 1970; Conrad et al., 1985).

Corresponding author.

E-mail address: hong.lu@kcl.ac.uk (H. Lu).

0020-7489/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2004.09.003

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However, this approach has become less popular with increasing emphasis on cognitive processes rather than on underlying needs so that the attitudinal perspective has become predominant in the study of job satisfaction (Spector, 1997). In contrast to the traditional view, Herzberg and Mausner (1959) formulated the two-factor theory of job satisfaction and postulated that satisfaction and dissatisfaction were two separate, and sometimes even unrelated phenomena. Intrinsic factors which they named motivators (i.e. factors intrinsic to the nature and experience of doing work) were found to be job satisers and included: achievement, recognition, work itself and responsibility. Extrinsic factors which they named hygiene factors were found to be job dissatisers and included: company policy, administration, supervision, salary, interpersonal relations and working conditions. Herzberg and Mausners Motivation-Hygiene theory has dominated the study of the nature of job satisfaction, and formed a basis for the development of job satisfaction assessment (Table 1). Thus job satisfaction is the affective orientation that an employee has towards his or her work (Price, 2001). It can be considered as a global feeling about the job or as a related constellation of attitudes about various aspects or facets of the job. The global approach is used when the overall attitude is of interest while the facet approach is used to explore which parts of the job produce satisfaction or dissatisfaction. Based on the review of the most popular job satisfaction instruments, Spector (1997) summarized the following facets of job satisfaction: appreciation, communication, co-workers, fringe benets, job conditions, nature of the work itself, the nature of the organization itself, an organizations policies and procedures, pay, personal growth, promoTable 1 Denition of job satisfaction Denition The individual matching of personal needs to the perceived potential of the occupation for satisfying those needs (Kuhlen, 1963) Need fulllment, that is, whether or not the job met the employees physical and psychological needs for the things within the work situation (Worf, 1970) A match between what individuals perceive they need and what rewards they perceive they receive from their jobs (Conrad et al., 1985) A function of satisfaction with the various elements of the job (Herzberg and Mausner, 1959) All the feelings that an individual has about his job (Gruneberg, 1976) The affective orientation that an employee has towards his or her work (Price, 2001)

tion opportunities, recognition, security and supervision.

3. Identication of the literature The literature relating to job satisfaction and nurses was identied through electronic databases. The electronic databases used to obtain the relevant literature were: CINAHL (19822004), Medline (19662004), PsycINFO (19742004) and British Nursing Index (19852004). Some databases in Chinese such as China Medical Academic Conference (19852004) and China Academic Journal (19852004) were also used. To maximize the amount of relevant literature, key phrases and similar phrases were utilized in the subject search in combination with nurses following guidelines for searching OVID interface. This identied 1189 published research papers from all the databases searched. The abstracts or full texts of the papers were reviewed prior to their inclusion in the literature review. One thousand and eighty-eight papers were deemed not relevant and 47 papers were of poor quality (research method including data analysis unclear). Additionally, the reference lists of the selected papers were examined to identify earlier seminal sources.

4. Sources of nurses job satisfaction Given that job satisfaction has been found to be related to performance within the work setting (Landeweerd and Boumans, 1988), it is not surprising that the concept of job satisfaction has attracted much attention. Researchers have attempted to identify the

Related theory Maslows human needs theory (Maslow, 1954)

Herzberg and Mausners motivation-hygiene theory (Herzberg and Mausner, 1959) Focus on cognitive process (Spector, 1997)

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various components of job satisfaction, measure the relative importance of each component of job satisfaction and examine what effect these components have on workers productivity (Burnard et al., 1999). A range of ndings derived from quantitative studies as well as qualitative studies has been reported in the literature on sources of job satisfaction among nurses. Aiken et al. (2001) found job dissatisfaction among nurses was highest in the United States (41%) followed by Scotland (38%), England (36%), Canada (33%) and Germany (17%). One third of nurses in England and Scotland and more than one fth in the United States planned on leaving their job within 12 months of data collection. More striking, however, was that 2754% of nurses under 30 years of age planned on leaving within 12 months of data collection in all countries. Regarding the work climate, only about one third of nurses in Canada and Scotland felt that they participated in developing their own work schedules in comparison with more than half in the other three countries. When compared with other countries, the nurses in Germany (61%) reported that they were more satised with the opportunities for advancement while the nurses in the United States (57%) and Canada (69%) felt more satised with their salaries. Similarly, Adamson et al. (1995) found that British nurses perceived themselves to be more dissatised than Australian nurses (po0:001). The British nurses perceived their professional status to be lower (po0:01), their relationship with hospital administrators to be poorer (po0:01), and their working conditions to be less adequate than Australian nurses (po0:01). They also reported more conict between the idealized perspective of work gained during training and actual work practice (po0:01), and were less satised with their professional organization (po0:01). The British nurses were also more concerned about the lack of communication between nurses and doctors (po0:01) and reported being less respected by other allied health professionals, hospital administrators and doctors (po0:01). However, there was no overall signicant difference between the Australian and British nurses regarding perceived level of autonomy of the medical profession (p40:01). Different measurements regarding nurses job satisfaction show various sources of satisfaction. The ndings derived from different studies using the same scales are more valuable in providing comparative information, particularly some cross-culture data. For example, the Adams et al.s (1995) Ward Organizational Features Scales were used in a set of studies to collect information from nurses about their perceptions of the various aspects of ward life and the impact which they had on care organization (Tovey and Adams, 1999; Adams and Bond, 2000). The tool comprised six sets of measures comprising 14 sub-scales rated on a 4-point Likert scale (1=strong disagree/very bad/very difcult,

4=strongly agree/very good inuence/very easy): physical environment of the ward, professional nursing practice, professional working relationships, ward leadership, nurses inuence and job satisfaction. The testretest reliabilities of the scales were good with a correlation coefcient of 0.7 or above (Adams et al., 1995). Utilizing this questionnaire, Tovey and Adams (1999) found that key sources of nurses dissatisfaction included working relationships, particularly those with management, lack of staff, professional concerns about poor standards of care and external work pressure. Adams and Bond (2000) found that most nurses positively rated aspects of ward services, facilities and layout (mean43, respectively). The highest correlations were found between job satisfaction and cohesion of the ward nursing team (r 0:51; po0:001), staff organization (r 0:46; po0:001), the level of professional practice achieved within the ward (r 0:46; po0:001) and collaboration with medical staff (r 0:41; po0:001). Furthermore, the most important contributors to nurses job satisfaction were the degree of cohesion existing among ward nurses (R2 0:26), the degree of collaboration with medical staff (R2 0:20) and perception of staff organization (R2 0:20). Nolan et al.s (1995) Job Satisfaction Questionnaire was also utilized in a series of studies in the different countries to assess nurses job satisfaction and morale (Nolan et al., 1995, 1998; Lundh, 1999). It comprises 16 items addressing aspects of the work environment, perceptions of change in the last 12 months and overall satisfaction and morale. Responses are rated on a 5point Likert scale (strongly agree/increased a lot to strongly disagree/ decreased a lot). Nolan et al. (1995) found that level of job satisfaction had remained stable and two factors were dominant in nurses understanding of satisfaction and morale, namely: the perceived ability to deliver good patient care and good collegiate relationships with co-workers. Together, these accounted for more than 50% of all the additional positive comments received. Nolan et al. (1998) further found that the vast majority of respondents (85%) considered that their work was interesting, and this was one of the most signicant factors inuencing job satisfaction. Regarding job satisfaction and morale, 35% of respondents considered that their job satisfaction had decreased in the last year and 69% felt that overall morale had fallen. Similarly, Lundhs (1999) study showed that over 90% of respondents saw their work as interesting and most respondents also thought that they received respect from their superiors (68%). Conversely, however, 55% of respondents reported that leadership within the organization was not seen to be particularly democratic with limited opportunities to inuence the decisions of managers. In addition, nearly three quarters of

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respondents reported that their levels of stress had increased over the last 12 months, while important aspects of their job satisfaction, such as satisfaction with pay and satisfaction with overall working conditions had fallen. In addition to providing a general outline of reported job satisfaction, Price (2002) explored key areas of job satisfaction using the Mueller and McCloskeys (1990a, b) Satisfaction Scale. It is a 5-point Likert scale (5=very satised, 1=very dissatised) comprising 31 items on eight dimensions: extrinsic rewards, scheduling, balance of family and work, co-workers, interaction opportunities, professional opportunities, praise and recognition, control and responsibility. The global scales correlation coefcient was reported as 0.89 and the validity ranged from 0.53 to 0.75, with the scale correlating positively with several established satisfaction scales. The results demonstrated that over half of the respondents (58%) were generally satised with their job. They identied that highest satisfaction was related to co-workers and extrinsic rewards (mean=3.8 and 3.5, respectively) and that most dissatisfaction was with the amount of control and responsibility they had and with professional opportunities (mean=2.7 and 2.6, respectively). The individual items on this scale with which nurses were most satised were identied as annual leave, nursing peers and hours worked (79%, 78% and
Table 2 Sources of nurses job satisfaction Sources of job satisfaction Working conditions Interaction Relationships with patients Relationships with co-workers Relationships with managers Work itself Workload; scheduling; challenging work; routinization; task requirements (abilities, skills etc) Remuneration (pay, salary) Self-growth and promotion Professional training; opportunities of advancement; job promotion; personal achievement Praise and recognition Control and responsibility Autonomy; decision-making Job security Leadership styles and organizational policies

76% of respondents scored 4 or 5, respectively), and for dissatisfaction compensation for working weekends and control over work conditions and childcare facilities (55%, 55% and 46% of respondents scored 1 or 2, respectively). Using the same scale, Wang (2002) found that Chinese nurses were more dissatised than satised (mean=2.51) and were mostly dissatised with pay (mean=1.85) and job promotion (mean=1.97). From another point of view, Lees (1998) crosssectional survey examined the level of job satisfaction regarding six job components (autonomy, professional status, pay, interaction, task requirements and organizational policies) using the Index of Work Satisfaction (Stamps and Piedmonte, 1986). The rst part addresses the relative importance of each of the six job components, using 15 sets of paired comparison statements. The second part is a 44-item Likert scale that requires subjects to respond to one of seven choices from strongly disagree to strongly agree to measure current levels of satisfaction regarding each of the six components. The results showed that nurses were dissatised more than satised (mean=3.46) and reported most satisfaction with professional status (mean=4.17) and most dissatisfaction with task requirements (mean=2.81). The level of need for autonomy was below the mid-score of the sub-scale with no signicant relationship (r 0:11; p40:1) between their satisfaction

Key empirical sources Adamson et al. (1995), Nolan et al. (1995), Tovey and Adams (1999), Adams and Bond (2000), Tzeng (2002a, b) Adamson et al. (1995), Nolan et al. (1995), Lee (1998), Tovey and Adams (1999), Adams and Bond (2000), Aiken et al. (2001), Price (2002), Tzeng (2002a, b), Wang (2002) Nolan et al. (1995, 1998), Lee (1998), Lundh, (1999), Tovey and Adams (1999), Adams and Bond (2000), Price (2002), Tzeng (2002a, b), Wang (2002) Adamson et al. (1995), Nolan et al. (1995), Lee (1998), Aiken et al. (2001), Price (2002), Tzeng (2002a, b), Wang (2002) Nolan et al. (1995), Lee (1998), Aiken et al. (2001), Price (2002), Tzeng (2002a, b), Wang (2002) Nolan et al. (1995), Lundh (1999), Aiken et al. (2001), Price (2002), Wang (2002) Nolan et al. (1995, 1998), Lee (1998), Price (2002), Wang (2002) Nolan et al. (1995, 1998) Lee (1998), Tzeng (2002a, b)

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with job autonomy and their individual need for autonomy. Tzeng (2002a, b) has also noted that expectation and reality may be a source of nurses dissatisfaction. The Nurses Job Satisfaction and the Perceived Importance Questionnaire was specially designed for the study and included 92 items, comprising of 8 job satisfaction scales and 8 importance indicators (indirect working environment, direct working environment, salary and promotion, self-growth, challenging work, interaction with patients, leadership style and working atmosphere). Responses were given on a 5-point Likert scale ranging from 1 (least satised) to 5 (most satised) for job satisfaction items and from 1 (least important) to 5 (most important) for importance items. Pearson correlation analyses revealed that, except for the scale of indirect working environment, all the scales were statistically and signicantly correlated to their corresponding scales (pp0:05). The nurse sample identied factors such as indirect working environment (a hospitals policies, benets, leisure activities, housing, parking, and vacation policy), salary and promotion as very important but strongly dissatisfying (Table 2). In conclusion, job satisfaction of nurses is an important concept as levels of job satisfaction may impact upon the global nursing workforce. Although the reported studies differed regarding levels of job satisfaction among nurses, the literature reveals that the sources of job satisfaction are relatively similar, e.g., physical working conditions, relationships with fellow workers and managers, pay, promotion, job security, responsibility, the recognition from managers and hours of work. Furthermore, it seems that nurses who had received tertiary education felt less satised with their jobs than those who had not received tertiary education (Table 3).

5. Effects of job satisfaction of nurses on absenteeism, burnout, turnover and intention to quit Absenteeism is an important problem for health-care providers because it is costly and related to preventable job stress (Matrunola, 1996). The impact of job satisfaction upon nursing absenteeism, burnout and nurses intention to quit and turnover has been explored in a number of research studies, however, the ndings are equivocal. Sius (2002) study of nurses in Hong Kong found that involvement (the degree of commitment displayed towards employees by the organization) (b 0:42; po0:05), job satisfaction (b 0:21; po0:05), psychological distress (b 0:20; po0:01) and age (b 0:20; po0:01) were signicant predictors of absenteeism for sample 1; and organization (the interaction between the worker and the organization) (b 0:70; po0:01),

involvement (b 0:51; po0:05) and occupational type (b 0:33; po0:001) were signicant predictors of absenteeism for sample 2. The inconsistent ndings may be explained by the relatively small sample sizes, the unmatched gender ratios, the unmatched occupational type, the relatively low response rate in sample 2 (57%) and the use of self-report sickness-absence. Such inconclusive results suggest that further research in this area should be replicated among other Chinese nurses. Conversely, Matrunolas (1996) found study of English nurses that there was no relationship between job satisfaction and absenteeism. In the light of the small sample size, the generalization of the ndings needs to be treated with caution. Lee et al.s (2003) South Korean study showed that the most frequently mentioned reasons for nurses intending to leave their jobs were work overload, rotating shifts and conict in interpersonal relationships. A total of 24%, 15% and 35% of variance regarding depersionalization, emotional exhaustion and personal accomplishment, respectively, was explained by the individual characteristics, job stress and personal resources. It was particularly noteworthy that nurses who experienced higher job stress showed lower cognitive empathy and empowerment, and worked on night shifts at tertiary hospitals were more likely to experience burnout. Regarding the effect of job satisfaction on nurse turnover, there are some similar ndings in the different studies. Cavanagh (1990) found that US public hospital nurse turnover could be predicted using kinship responsibility, promotion, salary and instrumental communication (R2 0:37; po0:05). Cavanagh and Cofn (1992) further found job satisfaction and participation at work to be important variables in the turnover process. There were four variables signicantly related to intent to stay (po0:05): job satisfaction (r 0:338), kinship responsibilities (r 0:123), pay (r 0:086) and opportunity (r 0:072). However, these ndings do not conclusively support the Price and Muellers (1981) model of nursing turnover. Gauci Borda and Norman (1997a) found a signicant positive relationship between job satisfaction and intent to stay (rs 0:48; po0:005) and negative relationships between job satisfaction and frequency of 1 day absence and short-term absence (lasting 3 days or less) (rs 0:14; po0:05; respectively) among Maltese nurses. Yin and Yangs (2002) meta-analysis also found that the strongest individual and organizational factors related to nurse turnover were job satisfaction (rxy 0:23; po0:05), autonomy (rxy 0:23; po0:05), advancement opportunity (rxy 0:22; po0:05), job stress (rxy 0:21; po0:05), pay (rxy 0:20; po0:05), group cohesion (rxy 0:19; po0:05), marital status (rxy 0:14; po0:05) and

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Table 3 Summary of included studies regarding sources of nurses job satisfaction Code study Adams and Bond (2000) Location England Sample and response rate 834 nurses of clinical grade C and above; a response rate of 57% Instruments Adams et als (1995) ward organizational features scales Specially designed scales: Nurses dissatisfaction scale Medical autonomy scale Medical authority scale Key ndings The most important contributors to nurses job satisfaction were the degree of cohesion (R2=0.20) and perception of staff organization (R2=0.20) Comments

H. Lu et al. / International Journal of Nursing Studies 42 (2005) 211227

Adamson et al. (1995)

Australia, England

133 Australian nurses (83% response rate) and 108 British nurses (78% response rate)

British nurses were more dissatised than Australian nurses (po0.001)

Medical dominance is a barrier to both Australian and British nurses workplace satisfaction

The British nurses perceived their professional status to be lower, their relationship with hospital administrators to be poorer and their working conditions to be less adequate than Australian nurses. Job dissatisfaction among nurses was highest in US The core problems in nurses work design and workforce management hold much in common

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Aiken et al. (2001)

US, Canada, England, Scotland, Germany

43,329 nurses working in adult acute hospital; a response rate of 4253%

Nurses working perceptions questionnaire (specially designed) Maslach and Jacksons (1986) burnout inventory Stamps and Piedmontes (1986) index of work satisfaction Edwards (1959) personal preference schedule (EPPS) Nolan et al.s (1995) job satisfaction questionnaire

The nurses in Germany were more satised with the opportunities for advancement while the nurses in the US and Canada (69%) felt more satised with their salaries Nurses more dissatised than satised

Lee (1998)

Hong Kong

190 nurses; response rates of 4583%

No signicant relationship between satisfaction with job autonomy and individual need for autonomy Nurses levels of stress had increased Satisfaction with pay and overall working conditions had fallen

Lundh (1999)

Sweden

439 nurses, 83 laboratory technologists, 31 midwives and 72 managers; an overall response rate of 59%

Nolan et al. (1995)

Wales

676 nurses, midwives and health visitors; a response rate of 41%

Nolan et al.s (1995) Job satisfaction questionnaire Nolan et al.s (1995) job satisfaction questionnaire Mueller and McCloskeys (1990a, b) satisfaction scale

Job satisfaction had remained stable Falling condence in the future of the NHS About 35% of respondents considered that their job satisfaction had decreased in the last year and 69% felt that overall morale had fallen H. Lu et al. / International Journal of Nursing Studies 42 (2005) 211227 Over half of the respondents (58%) were generally satised with their job Highest satisfaction was related to co-workers and extrinsic rewards and most dissatisfaction was with the amount of control and responsibility they had and with professional opportunities Key sources of dissatisfaction: working relationships, lack of staff, professional concerns about poor standards of care and external work pressure Indirect working environment, salary and promotion were very important but strongly dissatisfying Caution is needed in generalizing the results due to the sample bias with only one grade of nurses working in acute wards represented

Nolan et al. (1998)

Shefeld

518 nurses; a response rate of 35%

Price (2002)

England

141 E-grade nurses in a large teaching hospital; a response rate of 82%

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Tovey and Adams (1999)

England

265 nurses

Adams et al.s (1995) ward organizational features scales Tzengs (2002b) nurses job satisfaction and the perceived important questionnaire Mueller and McCloskeys (1990a, b) satisfaction scale

Tzeng (2002b)

Taiwan

786 nurses; a response rate of 76%

Wang (2002)

Mainland China

191 nurses; a response rate of 100%

Nurses were more dissatised than satised and mostly dissatised with pay and job promotion

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Table 4 Summary of included studies regarding effects of nurses job satisfaction Code study Cavanagh (1990) Location US Sample and response rate 232 hospital nurses; an overall response rate of 38.5% Instruments Price and Muellers (1981) turnover scale Price and Muellers (1981) turnover scale Key ndings The combination of the variables accounted for 36.8% (po0.05) of the explained variance in turnover rate Factors related to intention to stay: job satisfaction, kinship responsibilities, pay and opportunity Job satisfaction was a key determinant in the turnover process A signicant positive relationship between job satisfaction and intention to stay (r 0:48; po0:005) and negative relationships between job satisfaction and frequency of 1 day/short-term absence (r 0:14; po0:05; respectively) The Price and Muellers (1981) model of nursing turnover was not conclusively support Comments

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Cavanagh and Cofn (1992)

US

221 nurses; a response rate of 80.5% in a public hospital and 19.5% in a private hospital

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Gauci Borda and Norman (1997a)

Malta

171 nurses; a response rate of 67%

Lyons (1971) global satisfaction scale Mueller and McCloskeys (1990a, b) satisfaction scale Redferns (1981) propensity to leave index Maslach and Jacksons (1981) burnout inventory Mehrabians (1994) emotional empathy scale Barrett-Lennards (1978) empathy scale, etc. Specially designed scales: professional commitment scale

The model of absence and turnover (Gauci Borda and Norman, 1997b) was not totally supported

Lee et al. (2003)

South Korea

178 nurses; a response rate of 81%

A total of 24%, 15% and 35% of variance in depersionalization, emotional exhaustion and personal accomplishment, respectively, were explained by the predictor variables

Lu et al. (2002)

Taiwan

21,971 nurses; a response rate of 86.2%

Job satisfaction was positively correlated with professional commitment and negatively correlatively correlated with intention to leave the organization and profession

Further research needs to explore the effect of organizational commitment regarding any interrelationships

Job satisfaction scale

About 38.4% of nurses had the intention to leave the organization and 30.4% intending to leave the profession because of lack of job satisfaction

Intention to quit scale Matrunola (1996) England 34 nurses working within an elderly care unit; a response rate of 68% Matrunolas (1996) job satisfaction questionnaire Maslach and Jacksons (1981) burnout inventory Beck et al.s (1974) hopelessness scale Siu and Coopers (1998) psychological distress scale There was no signicant relationship between job satisfaction and absenteeism Due to the small sample size, generalization of these ndings needs to be treated with caution

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Siu (2002)

Hong Kong

144 nurses (sample 1) and 114 (sample 2); response rates of 100% and 57%, respectively 648 nurses; a response rate of 82%

Job satisfaction was a signicant predictor of absenteeism in sample 1; while no similar result was found in sample 2 General job satisfaction was signicant predictor of nurses intention to quit

Further research in this area should be replicated among other Chinese nurses

Tzeng (2002a)

Taiwan

Wu et al. (2000)

Mainland China

382 nurses; a response rate of 92.5%

Job stress scale (specially designed)

There was a positive and signicant relationship between job stress and intention to quit (r 0:46; po0:05) The strongest factors related to nurse turnover were job satisfaction, autonomy, opportunities for promotion, job stress, pay group cohesion, marital status and educational level

Further research is needed to conrm the ndings It suggests to group studies using the same measures for satisfaction and the related variables

Yin and Yang (2002)

Taiwan (metaanalysis)

129 studies relating to nursing turnover from 19781998

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educational level (rxy 0:09; po0:05). Similarly, Wu et al. (2000) reported a positive and signicant relationship between job stress and intention to quit among Mainland Chinese nurses (r 0:46; po0:05). Using the multiple regression, Tzeng (2002a) reported that institution (privately owned local hospital), age of the youngest child, level of education (e.g., diploma and associate degree), salary and promotion, general job satisfaction and general job happiness were signicant predictors of Taiwanese nurses intention to quit (the Nagelkerke Pseudo R2 0:410). The inuence of job satisfaction on intention to leave the nursing profession was examined in Lu et al.s (2002) study of Taiwanese nurses. Its ndings indicated that job satisfaction was positively correlated with professional commitment (r 0:386; po0:01) and negatively correlated with intention to leave the organization and profession (r 0:480; r 0:370; respectively, po0:01). In the discriminant analysis, 38.4% of the nurses could be classied as having the intention to leave the organization and 30.4% as intending to leave the profession because of lack of job satisfaction. In summary, most published research from various countries indicates that job satisfaction is a signicant predictor of nursing absenteeism, burnout, turnover and intention to quit; however, there have been some inconsistent ndings (Table 4).

6. Related factors to job satisfaction of nurses Job satisfaction is a complex phenomenon, as evidenced by the many related factors identied in the studies already discussed. The identication of these factors and exploration of their effects on job satisfaction has the potential to rene the theoretical models of nurses job satisfaction and aid the development of management interventions (Blegen, 1993). Blegens (1993) meta-analysis found that job satisfaction was most strongly associated with stress (r 0:61) and organizational commitment (r 0:53). Seven variables had correlations between 0.20 and 0.50: communication with supervisor, autonomy, recognition, routinization, communication with peers, fairness and locus of control; and four variables had very weak correlations: age (r 0:13), years of experience (r 0:09), education (r 0:07) and professionalism (r 0:06). A causal model of job satisfaction has been tested in Chu et al.s (2003) study of Taiwanese nurses and Seo et al.s (2004) study of South Korean nurses, respectively. In this model 11 independent variables included: job involvement, positive affectivity, negative affectivity, autonomy, distributive justice, procedural justice, job stress (role ambiguity, role conict, workload and resource inadequacy), pay, promotional chances, routinization and social support. Chu et al. (2003) found

that, with the exception of pay (p40:05), all of the independent variables were signicantly related to job satisfaction (po0:05). Seven of the exogenous variables were the major determinants of job satisfaction according to Pearsons correlation coefcients: positive affectivity (r 0:452), routinization (r 0:441), resource inadequacy (r 0:341), negative affectivity (r 0:333), role ambiguity (r 0:327), supervisor support (r 0:325) and co-worker support (r 0:309). The regression results indicated that six of the exogenous variables hypothesized to impact upon job satisfaction were signicant: routinization (b 0:286; po0:001), positive affectivity (b 0:266; po0:001), involvement (b 0:147; po0:01), negative affectivity (b 0:118; po0:05), co-worker support (b 0:118; po0:05) and role ambiguity (b 0:018; po0:05). The exogenous variables in this model explained 45% of the association of variance in job satisfaction. Seo et al. (2004) also found a reasonable t between the causal model and the data (CFI=0.904, IFI=0.907). When considering all of the independent variables (Model 1), seven variables had statistically signicant net effects on job satisfaction (po0:05): positive affectivity, supervisory support, pay, routinization, negative affectivity, workload and job opportunity (b 0:286; b 0:11; b 0:095; b 0:250; b 0:213; b 0:211; b 0:105; respectively). Model 1 explained about 53% of the variance in satisfaction, but when the psychological variables (positive and negative affectivity) were not included (Model 2), job opportunity was no longer signicant (p40:05). Pay and supervisor support positively impacted upon job satisfaction (b 0:185; b 0:164; respectively) while routinization and workload negatively impacted upon it (b 0:347; b 0:24; respectively). Model 2 explained 40% of the variance in satisfaction. Interestingly, Packard and Motowidlo (1987) found that stress and job satisfaction in the US were not directly related and that stress, primarily acting through depression, was associated with lower levels of job performance. Job satisfaction correlated with depression (r 0:55; po0:01), hostility (r 0:41; po0:01), subjective stress (r 0:27; po0:01), frequency of stressful events (r 0:22; po0:01), intensity of stressful events (r 0:18; po0:05) and anxiety (r 0:16; po0:05). However, multiple regression analysis showed depression had a strong effect on job satisfaction (b 0:53; po0:01) and hostility (b 0:23; po0:01) and fear of negative evaluation (b 0:20; po0:01) had weaker direct effects, but others showed no signicant impacts upon job satisfaction (p40:05). Organizational commitment refers to identication with and loyalty to the organization and its goals (Blau and Boal, 1987) which Mowday et al. (1979) dened as the relative strength of an individuals identication with and involvement in a particular organization. In

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H. Lu et al. / International Journal of Nursing Studies 42 (2005) 211227 221

particular, commitment is characterized by three factors: a strong belief in and an acceptance of the organizations goals and values; a willingness to exert considerable effort on behalf of the organization; and a strong desire to maintain membership in the organization. It has been found that organizational commitment is positively related to job satisfaction of hospital nurses (Blegen, 1993; Al-Aameri, 2000). Knoop (1995) found that organizational commitment was related to overall job satisfaction (r 0:64; po0:001), satisfaction with work (r 0:58; po0:001), promotion opportunity (r 0:55; po0:001), supervision (r 0:54; po0:001), co-workers (r 0:30; po0:001) and pay (r 0:22; po0:01) among Canadian nurses. Furthermore, the regression analysis revealed that organizational commitment explained 41% of the variance in job satisfaction. Professional commitment is a persons involvement, pledge, promise or resolution towards his/her profession (Fang, 2001). It has an incremental effect on a professionals intention to leave the organization (Blau and Lunz, 1998). Therefore, enhancing professional commitment in nursing has the potential to produce benets for both the individual and their organization (Cohen, 1998; Cohen, 1999). Furthermore, professional commitment is positively related to the job satisfaction of nurses (Lu et al., 2000; Jones, 2000). For example, Fangs (2001) study of Singaporean nurses demonstrated that job satisfaction was signicantly and positively related to organizational commitment (r 0:571; po0:01), professional commitment (r 0:347; po0:01) and supervisor satisfaction (r 0:155; po0:05) and negatively related to job stress (r 0:545; po0:01), turnover cognition (r 0:415;

po0:01) and intention to quit (r 0:283; po0:01). About 41% of the variance in turnover cognition was explained by the mentioned antecedents; however, the contributions of job stress, organizational commitment and professional commitment to job satisfaction were not identied. In addition, the nurses roles within their work situations and its effect on job satisfaction are also of primary concern with role conict and ambiguity being the main sources of job stress (Hingley and Cooper, 1986). Role conict is dened in terms of the dimensions of congruency-incongruency or compatibility-incompatibility in the requirements of the role, where congruency of compatibility is judged relative to a set of standards or conditions which impinge upon role performance. Role ambiguity is the predictability of the outcome or responses to ones behaviour and the existence or clarity of behavioural requirements, often in terms of inputs from the environment, which would serve to guide behaviour and provide knowledge that the behaviour is appropriate (Rizzo et al., 1970). Role conict and ambiguity are signicantly related to job stress, organizational commitment, job satisfaction and intentions to leave the nursing profession (Rosse and Rosse, 1981). Dailey (1990) found that tension discharge rate, role ambiguity and role conict were signicant predictors of experienced stress symptoms (b 0:24; 0.15, 0.08, respectively) among US nurses. Together, the three produced an overall multiple R2 value of 0.47 (po0:001). On the other hand, the most signicant predictor of intention to quit was experienced jobinduced stress symptoms (b 0:36), followed by tension discharge rate (b 0:22). Role ambiguity (b 0:13) and

Table 5 Related factors to job satisfaction of nurses Related factors Substantial to very strong relationship with job satisfaction (correlation coefcient40.5) Job stress; organizational commitment; depression; cohesion of the ward nursing team Moderate to substantial relationship with job satisfaction (correlation coefcient 0.20.5) Affectivity; role ambiguity; professional commitment; routinization; supervisor/co-worker support; collaboration with medical staff; job performance; job involvement; hostility staff organization; autonomy; recognition; fairness; locus of control; communication with supervisor/peers Slight relationship with job satisfaction (correlation coefciento0.2) Role conict; job involvement; age; year of experience; educational level; professionalism; anxiety; supervisor satisfaction Key empirical sources Packard and Motowidlo (1987), Blegen (1993), Knoop (1995), Adams and Bond (2000), Fang (2001)

Packard and Motowidlo (1987), Blegen (1993), Knoop (1995), Adams and Bond (2000), Fang (2001), Chu et al. (2003)

Packard and Motowidlo (1987), Blegen (1993), Fang (2001), Lu et al. (2002), Chu et al. (2003)

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222 H. Lu et al. / International Journal of Nursing Studies 42 (2005) 211227 Table 6 Predictors of job satisfaction among nurses Predictors Depression Organizational commitment Cohesion existing among ward nurses; collaboration of medical staff; perceptions of professional practice; team building skills of the ward managers Organizational commitment; job stress; supervisor satisfaction Psychological distress; occupational type (psychiatric/general); the physical conditions in the work area Routinization; affectivity; job involvement; co-worker support; educational level Key empirical sources Packard and Motowidlo (1987) Knoop (1995) Adams and Bond (2000)

Fang (2001) Siu (2002) Chu et al. (2003)

role conict (b 0:04) were also signicant predictors of intention to quit. The regression model explained 75% of the variance in intention to quit (po0:001). However, Mitchells (1994) US study found that there was not a signicant linear association between a nurses job satisfaction and the correlation between work role values and actual work roles (p40:05). This may be attributed to several factors. Firstly, the mean correlation (r 0:58) between work roles and work role values was weak and non-signicant (p40:05) and secondly, the scores of job satisfaction did not have a normal distribution, with 54% of respondents having a high level of satisfaction. Furthermore, the roles as used in the questionnaire for this study were not tested for validity and reliability. Therefore, further explanation of the relationship between personal work role values and actual work roles is needed in relation to nurses expressed job satisfaction (Tables 5 and 6). In summary, much research has revealed that job satisfaction of hospital nurses is closely related to job stress, role conict and ambiguity, organizational commitment and professional commitment (Table 7).

7. Conclusion Most member states of the WHO have reported nurse resource difculties (Kingma, 2001). Developed countries are faced with the double challenge of having an ageing nurse workforce and increasing demand for nursing care from an ageing population (Buchan, 2001). International migration of nurses has increased as nurses pursue opportunities for improved pay and opportunities in the wake of global liberalization of trade spurred on by developed countries increasing their international recruitment to meet their health-care workforce needs and in so doing creating a skills drain in many developing countries (Kingma, 2001). This increased mobility of the nursing workforce means that

factors which contribute to nurses turnover merit attention. Job satisfaction among nurses has been identied as a key factor in nurses turnover with the empirical literature suggesting that it is related to a number of organizational, professional and personal variables. While the literature indicates common issues across the world, it is possible that different issues have greater signicance in different countries due to the social context of the different labour markets. Further, the literature suggests that nurses are experiencing increasing levels of work-related stress over time and increased levels of work-related stress are associated with lower levels of satisfaction with reward packages and working conditions. Current workforce shortages are likely to place greater demands upon nurses which might be expected to increase their work-related stress and may reduce the quality of workplace relationships which has emerged as an important source of job satisfaction and contributes to organizational commitment. The lower levels of job satisfaction among nurses with tertiary education are noteworthy as such nurses probably represent the most well-educated element of the nursing workforce and the future leadership of the profession. Also noteworthy is the lower job satisfaction of those who had unfullled expectations regarding nursing work which suggests that some nurses retain an idealized view of nursing despite most initial nurse education including extended periods of clinical practice to prevent reality shock on entry into the workforce. The current worldwide shortage of nurses highlights the importance of understanding the impact and interrelationships of the identied variables if healthcare organizations are to implement interventions to improve the retention of their nursing workforce. Although several models of job satisfaction have been postulated, these models require further testing especially regarding the relative contribution of different factors. The literature suggests that the current models

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H. Lu et al. / International Journal of Nursing Studies 42 (2005) 211227 Table 7 Summary of included studies regarding related factors to job satisfaction of nurses Code study Location Sample and response rate 48 quantitative studies Instruments Key ndings Comments 223

Blegen (1993) (Metaanalysis)

Job satisfaction was most strongly associated with stress (r 0:61) and organizational commitment (r 0:53) The items from Price and Mueller (1986b), Watson et al. (1987), Cyphert (1990); Kim et al. (1996) and Price (2001) Six variables had signicant Impact of work unit on job satisfaction should be impact job satisfaction: considered routinization, positive affectivity, involvement, negative affectivity, coworker support and role ambiguity, which explained 45% of the variance in satisfaction

Chu et al. (2003)

Taiwan

308 nurses; a response rate of 75%

Dailey (1990)

US

116 nurses; a response rate of 38.7%

Rose et al.s (1978) Tension The regression model Discharge Rate Scale explained 75% of the Rizzo et al.s (1970) Role variance in intention to quit Conict and Ambiguity Scale Symptoms of Stress Index Mowday et al.s (1979) Organizational Commitment Scale Fangs (2001) Professional Commitment Scale Fangs (2001) Nursing Turnover Scale Mowday et al.s (1979) organizational Commitment Questionnaire Kanungos (1982) Graphic Job Involvement Iris and Barretts (1972) Job Satisfaction Scale, etc. Weiss et al.s (1967) Minnesota Satisfaction Questionnaire Benners (1984) Work Role Scale Price and Muellers (1981) Job Satisfaction Scale Others from Motowidlo et al. (1986) Job satisfaction was signicantly and positively related to organizational commitment, professional commitment and negatively related to job stress Organizational commitment was related to overall job satisfaction (r 0:64; po0:001) and explained 41% of the variance in job satisfaction The contributions of job stress, organizational commitment and professional commitment to satisfaction were not identied The impact of professional commitment upon job satisfaction should be taken into account

Fang (2001)

Singapore

180 nurses; a response rate of 90%

Knoop (1995) Canada

171 nurse educators and nurses; a response rate of 70%

Mitchell (1994)

US

201 nurses; a response rate of 33%

Further explanation of the There was not signicant linear association between a non-relationship is needed nurses job satisfaction and the correlation between work role values and actual work roles (p40:05) Job satisfaction correlated The model of job with depression, hostility, satisfaction was reasonable subjective stress, frequency but incomplete of stressful events, intensity of stressful events and anxiety There was a reasonable t between the causal model and the data All of the variables explained 53% of the variance in satisfaction The model could be used in Korean work organizations

Packard and Motowidlo (1987)

US

206 nurses; a response rate of 56%

Seo et al. (2004)

South Korea

353 nurses; a response rate of 65.4%

The items from Kahn et al. (1964), Rizzo et al. (1970), House (1981), Breaugh (1985), Watson and Tellegen (1985), etc.

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224 H. Lu et al. / International Journal of Nursing Studies 42 (2005) 211227 Australian and New Zealand Journal of Mental Health Nursing 8, 918. Cavanagh, S., 1990. Predictors of nursing staff turnover. Journal of Advanced Nursing 15, 373380. Cavanagh, S., Cofn, D., 1992. Staff turnover among hospital nurses. Journal of Advanced Nursing 17, 13691376. Chu, C.I., Hsu, H.M., Price, J.L., Lee, J.Y., 2003. Job satisfaction of hospital nurses: an empirical test of a causal model in Taiwan. International Nursing Review 50, 176182. Cohen, A., 1998. An examination of the relationship between work commitment and work outcomes among hospital nurses. Scandinavia Journal of Management 14, 117. Cohen, A., 1999. Relationships among ve forms commitment: an empirical assessment. Journal of Organizational Behaviour 20, 285308. Conrad, K.M., Conrad, K.J., Parker, J.E., 1985. Job satisfaction among occupational health nurses. Journal of Community Health Nursing 2, 161173. Cyphert, S.T., 1990. Employee absenteeism: an empirical test of the brook model. Ph.D Thesis, The University of Iowa, Iowa. (Cited in Chu, C.I., Hsu, H.M., Price, J.L., Lee, J.Y., 2003. Job satisfaction of hospital nurses: an empirical test of a causal model in Taiwan. International Nursing Review 50, 176182). Dailey, R.C., 1990. Role perceptions and job tension as predictors of nursing turnover. Nursing Connections 3 (2), 3342. Edwards, A.L., 1959. Edwards Personal Preference Schedule. Psychological Corporation, New York (Cited in Lee, F.-K., 1998. Job satisfaction and autonomy of Hong Kong registered nurses. Journal of Advanced Nursing 27, 355363). Fang, Y., 2001. Turnover propensity and its causes among Singapore nurses: an empirical study. International Journal of Human Resource Management 12 (5), 859871. Gauci Borda, R., Norman, I.J., 1997a. Testing a model of absence and intent to stay in employment: a study of registered nurses in Malta. International Nursing Studies 34 (5), 375384. Gauci Borda, R., Norman, I.J., 1997b. Factors inuencing turnover and absence of nurses: a research review. International Journal of Nursing Studies 34 (6), 385394. Gruneberg, M.M. (Ed.), 1976, Job SatisfactionA Reader. Macmillan Press, London. Hancock, C., 1998. Keeping staff means demonstrating to nurses that they matter. Nursing Times Research 3 (3), 165166. Herzberg, F., Mausner, B., 1959. The Motivation to Work, second ed. Wiley, New York. Hingley, P., Cooper, C.L., 1986. Stress and the Nurse Manager. Wiley, Chichester. House, J.S., 1981. Work Stress and Social Support. Addison Wesley Publishing Company, MA (Cited in Seo, Y., Ko, J., Price, J.L., 2004. The determinants of job satisfaction among hospital nurses: a model estimation in Korea. International Journal of Nursing Studies 41, 437446). Iris, B., Barrett, G., 1972. Some relations between job satisfaction and job performance. Journal of Applied Psychology 56, 301304.

of job satisfaction need to be modied as they omit some important predictors of job satisfaction such as role perception. The lack of a comprehensive model of job satisfaction in nursing is a major shortcoming and without which effective management interventions cannot be developed or tested.

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Further Reading
Beehr, T.A., Walsh, J.T., Taber, T.D., 1976. Relationship of stress to individually and organizationally valued states: higher order needs as a moderator. Journal of Applied Psychology 61, 4147 (Cited in Lee, H., Song, R., Cho, Y.S., Lee, G.Z., Daly, B., 2003. A comprehensive model for predicting burnout in Korean nurses. Journal of Advanced Nursing 44(5), 534545). Bluedorn, A.C., 1976. A causal model of turnover in organization. Unpublished Ph.D. Dissertation, University of Iowa. (Cited in Dailey, R.C., 1990. Role perceptions and job tension as predictors of nursing turnover. Nursing Connections 3(2), 3342). Fang, Y., Baba, V.V., 1993. Stress and turnover: a comparative study among nurses. International Journal of Comparative Sociology 34, 2438 (Cited in Fang, Y.Q., 2001. Turnover propensity and its causes among Singapore nurses: an empirical study. International Journal of Human Resource Management 12(5), 859871). Hatcher, S., Laschinger, H.K.S., 1996. Staff nurses; perceptions of job empowerment and level of burnout: a test of Kanters theoty of structural power in organizations. Canadian Journal of Nursing Administration 9, 7494 (Cited in Lee, H., Song, R., Cho, Y.S., Lee, G.Z., Daly, B., 2003. A comprehensive model for predicting burnout in Korean nurses. Journal of Advanced Nursing 44(5), 534545). McNeese-Smith, D., 1995. Job satisfaction, productivity, and organizational commitment: the result of leadership. Journal of Nursing Administration 25 (9), 1726. McNeese-Smith, D., 1999. A content analysis of staff nurse descriptions of job satisfaction and dissatisfaction. Journal of advanced Nursing 29 (6), 13321341. Morrow, P.C., Wirth, R.E., 1989. Work commitment among salaried professionals. Journal of Occupational Behavior 34, 5768. Oldham, G.L., Stepina, L.P., Ambrose, M.L., 1986. Relations between situational factors and the comparative referents

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H. Lu et al. / International Journal of Nursing Studies 42 (2005) 211227 used by employees. Academy of Management Journal 29, 599608 (Cited in Seo, Y., Ko, J., Price, J.L., 2004. The determinants of job satisfaction among hospital nurses: a model estimation in Korea. International Journal of Nursing Studies 41, 437446). Parker, D.F., Decotiis, T.A., 1983. Organizational determinants of job stress. Organizational Behavior and Human Performance 32, 160177 (Cited in Fang, Y.Q., 2001. Turnover propensity and its causes among Singapore nurses: an empirical study. International Journal of Human Resource Management 12 (5), 859871). Price, J.L., Mueller, C.W., 1986. Handbook of Organizational measurement. Harper Collins, Scranton (Cited in Seo, Y., Ko, J., Price, J.L., 2004. The determinants of job satisfac227 tion among hospital nurses: a model estimation in Korea. International Journal of Nursing Studies 41, 437446). Price, J.L., Mueller, C.W., 1990. Wilford Hall Medical Center Retention Survey, Lackland Air Force base, TX (Cited in Seo, Y., Ko, J., Price, J.L., 2004. The determinants of job satisfaction among hospital nurses: a model estimation in Korea. International Journal of Nursing Studies 41, 437446). Siu, O.L., 1999. Organizational climate, occupational stress, and employee health in Hong Kong and China. Ph.D. Thesis, The University of Liverpool, UK (Cited in Siu, O.L., 2002. Predictors of job satisfaction and absenteeism in two samples of Hong Kong nurses. Journal of Advanced Nursing 40(2), 218229).