Registered Nurses Job Satisfaction in Navy Hospitals

MILITARY MEDICINE, 174, 1:76, 2009 Registered Nurses Job Satisfaction in Navy Hospitals LCDR George A. Zangaro, USN NC (Ret.) ; Meg Johantgen, PhD RN ABSTRACT Because of the increasing use of civilian registered nurses to supplement the nursing staff at U.S. Navy hospitals, it is imperative to understand the factors that influence satisfaction in both Navy and civilian nurses in military hospitals. This study sought to expand knowledge of satisfaction in hospital-based active duty Navy registered nurses and federal civilian nurses. Respondents completed a survey with a response rate of 42% ( N = 496). The survey was designed using well-known satisfaction models and included measures of work attitudes, work setting, and demographic characteristics. Linear regression models explained 51% of the variance in job satisfaction for Navy nurses and 55% for civilian nurses. Routinization had the strongest significant negative association with job satisfaction for Navy and civilian nurses. Supervisor support was significantly associated with satisfaction for Navy nurses although coworker support was a significant factor for civilians. These findings have implications for nurse administrators and health care executives who desire to retain nurse employees. ASSOCIATION OF MILITARY SURGEONS OF THE U.S.The United States continues to grapple with a critical shortage of registered nurses. Because hospitals employ large numbers of registered nurses they face the challenge of recruiting and retaining competent nurse employees. Nursing administrators, and hospital leaders, will be better positioned to retain registered nurses by better understanding the factors that influence recruitment and retention.1 U.S. military hospitals are particularly vulnerable to the nursing shortage because of the increased demand for acute care services for service members who sustained injuries in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Job satisfaction has been studied previously, but this is the first examination of a population of nurses composed of both active duty Navy nurses and civilian nurses. BACKGROUND Nurses are the largest single group of health care workers in U.S. military hospitals and are providing significant amounts of care for casualities of the conflicts in Iraq and Afghanistan. In this challenging environment, military health care leaders are confronted with how to recruit and retain registered nurses. Degradation of military or civilian nursing staff has the potential to seriously compromise the Navy s peacetime and operational mission. One approach to handle the increased demand for care has been to increase the use of civilian nurses in military hospitals, yet no studies have examined how these two groups differ or the factors that influence their job satisfaction in Navy hospitals. Having an understanding of nurses perceptions of their workplace appears to enhance job satisfaction, University of Maryland Baltimore School of Nursing, 655 W. Lombard St., 4th floor, Baltimore, MD 21201. The information, content, and conclusions do not necessarily represent the official position or policy of the TriService Nursing Research Program, Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. government, and no official endorsement should be inferred. This manuscript was received for review in November 2007. The revised manuscript was accepted for publication in September 2008. Reprint & Copyright by Association of Military Surgeons of U.S., 2009. reduce job stress, and improve retention efforts. 2,3 Kovner and colleagues reported that supervisor support, job stress, promotional opportunity, and routinization are all significant predictors of job satisfaction. 2 Creating a work environment that encourages participative management, constant communication with staff, and visibility of the nurse manger in the clinical setting are some factors that have been associated with satisfaction and can be influenced by administrators. Although some personnel issues are common to all hospitals (e.g., salary, promotional opportunities, job stress, and job satisfaction), the Navy has unique issues that affect nurse recruitment and retention. A Navy nurse is required to sign a contract for a fixed number of years and will likely be asked to move their residence and work site every 3 or 4 years. These can be considered to be not attractive to some nurses. The Navy must also be concerned with the broader issues that affect the civilian nursing workforce since civilian nurses supplement military nurses in many military hospitals. Civilian nurses are becoming more difficult to recruit and retain in the military sector as opportunities increase in the civilian sector. A strategy used to address recruitment and retention has been to identify and address factors influencing job satisfaction. Several studies of military nurses job satisfaction have been conducted, but few have been published and the studies may not reflect the more recent shortages and wartime operational needs. 4 6 None of the previous studies have compared satisfaction of military and civilian nurses in Navy hospitals. Economists, psychologists, and sociologists have all contributed to the development of the models of employee satisfaction, commitment, and turnover. Price and Mueller s theory acknowledged that employees enter the workplace with certain expectations and values. 7 If these expectations and values are found in the workplace, the employee will be more satisfied, committed to the organization, and less likely to leave. These factors are most practically assessed in a survey instrument that is administered to employees. The concepts measured include autonomy, promotional opportunity, role ambiguity, routinization, coworker support, and several others. Price and 76 MILITARY MEDICINE, Vol. 174, January 2009

Mueller s instrument is supported with empirical evidence from several different samples including nurses in hospitals, 8,9 nurses holding doctoral degrees, 10 hospital-based military health care personnel, 11 military physicians, 12 dental hygienists, 13 and all employees in a U.S. Veterans Administration Medical Center. 14 Most recently Kovner and colleagues used the Price and Mueller conceptual model to guide their study of recent nursing graduates. 8,15 The nursing literature is replete with studies linking employee factors and work-related factors with job satisfaction. 2,8,16 20 In studies conducted at military and civilian facilities job satisfaction has been positively related to autonomy, coworker and supervisor support, resource adequacy, professional growth, promotional opportunity, and distributive justice. 2,4 6,10,17,20 22 Routinization and role ambiguity have been negatively related to nurse job satisfaction. 2,10,11 Military nurses and civilian nurses working for the U.S. government represent a relatively unexamined population. Moreover, there are distinct differences between military nurses and civilians employed in military facilities. For example, civilian nurses are often older, more experienced, and work part time. Military nurses have a larger proportion of males and higher education levels since a bachelor s degree is required for entry to each of the military nurse corps. Investigating differences in these two groups was expected to uncover new information about job satisfaction that would begin to fill gaps in current knowledge. METHODS Sample Using a cross-sectional design, a paper survey was administered anonymously to nurses working at three Navy hospitals on the East Coast. Sample size was based on Tabachnick and Fidell s recommendation that 10 respondents per variable are needed for adequate power in linear regression. 23 Assuming that 10 12 predictors would be used in the model, the sample size was more than adequate (military = 283 and civilian = 213). Data were collected, after Institutional Review Board approval at the three organizations. It was estimated that ~1,173 nurses meet the inclusion criteria. The return of the questionnaire was considered implied consent. The eligible nurses included Navy staff registered nurses with the rank of Ensign (0-1) through Lieutenant Commander (0-4) and civilian registered nurses employed in the Federal General Schedule (GS) system in grades GS-9 through GS-12. These employment levels were selected because they include most of the nurses who provide clinical care for inpatients. In the military, nurses in the ranks of 01 to 04 have the highest attrition rates. This is a critical group of nurses that are highly desired to be retained because of their clinical competence. Procedures Questionnaires were distributed using a modified Dillman approach.24 An e-mail was sent to all eligible nurses inviting them to participate in the upcoming survey. Two weeks later, the questionnaires were placed in each nurse s unit mail box. Two options were offered for returning the completed questionnaire. After placing the questionnaire in an envelope, the questionnaire could be placed into a designated box on the nursing unit or it could be sent via the hospital s internal mail system to the principal investigator (PI) at the hospital s research office. A reminder e-mail was sent to all nurses 3 weeks after the initial contact and a reminder postcard was placed in their mailboxes. Finally, an e-mail reminder was sent to all potential respondents 7 days before the data collection period was to end. Measures A modification of Price and Mueller s model of turnover guided the concepts examined in this study (see Figure 1). 7 The survey was adjusted to account for military concepts by modifying items to address specific military issues. The mapping of items to the concepts of the Price and Mueller model were maintained. Table I presents the constructs measured in the study, a conceptual definition of each, the number of items used to measure each concept, and mean and standard deviation for each scale used in the analysis. All items were measured on a 5-point Likert scale with anchors of 1 = strongly disagree and 5 = strongly agree. These items have been found to be reliable and valid in previous research. 2,7,12 For example, the three items used to assess routinization were related to variety in the job, having the opportunity to do different things on the job, and repetitiveness of the job (see Price and Mueller 7 for a summary of each concept and the items used to measure each concept). In the current sample, the average α coefficient was 0.74 for all items in the model. The survey also included open-ended questions where nurses could add comments. Analysis Data were analyzed using SPSS version 15.0. Descriptive statistics were compared to characterize the demographics characteristics of the military and civilian sample of nurses. Linear regression analysis was used to determine significant predictors of job satisfaction. Statistical assumptions of linearity and normality were tested and all assumptions were met. Multicollinearity was assessed using the tolerance test and variance inflation factor. 23 Since age and rank were highly correlated with both tenure and experience, only tenure and experience were included in the models as control variables. As the focus of the study was on isolating the factors that influence satisfaction, the analysis was conducted in two steps. In step one the demographic variables were entered, followed by the Price and Mueller concepts. RESULTS A total of 496 usable questionnaires were returned for a response rate of 42%. Military nurses had a response rate of MILITARY MEDICINE, Vol. 174, January 2009 77

FIGURE 1. Modified Conceptual Model. 35% (283/806) as compared to a 58% (213/367) response rate for civilian nurses. Table II depicts the demographic characteristics for the sample. More than half of the respondents were military nurses (57%). The distinct differences in Navy and civilian nurses are evident. There was a difference in age with 84% of the military nurses being between 21 and 40 as compared to only 19% of the civilian nurses. The majority of the nurses who completed the questionnaire were female in both groups although the military sample was one-third male (33%) as compared to only 7% of civilians. The military nurses represented the range of ranks whereas nearly twothirds of the civilian nurses were in GS-12 pay grade. All military nurses had a bachelor s degree or higher whereas 70% of the civilian sample had a bachelor s degree. Half of the civilian nurses had been working at the present organization for over 7 years as compared to the military nurses who had only 5% working in the organization for more than 7 years. This difference in tenure is expected because military nurses are changing duty stations every 2 to 4 years. The civilian nurses were also more experienced as reflected in the fact that 61% report being a registered nurse for 4 or more years whereas only 8% of the military nurses had that much experience. The military nurses were registered nurses for 6.33 years and the civilian nurses were registered nurses for 22.44 years. Since the purpose of the study was to compare the relative influence of factors influencing satisfaction of military and civilian nurses two demographic characteristics tenure and years of nursing experience were entered into the model as control variables. Regression models were fitted separately 78 MILITARY MEDICINE, Vol. 174, January 2009

TABLE I. Conceptual Definitions of Concepts with Number of Items, and Mean and Standard Deviation for Each Cohort Construct Number of Items Conceptual Definition Military Nurses Mean (SD) Civilian Nurses Mean (SD) Job satisfaction 4 Extent to which employees like 3.59 (0.96) 3.71 (0.98) their jobs Autonomy 4 Degree to which an employee exercises 3.26 (0.98) 3.38 (1.1) power relative to his/her job Distributive justice 6 Extent to which rewards and punishments 3.14 (1.1) 2.82 (1.2) are related to job performance Professional growth 4 Chances provided by the employer 3.43 (1.0) 3.00 (1.1) to increase job-related knowledge and skills Promotional opportunity 4 Degree of potential vertical occupational 3.80 (0.94) 2.66 (1.1) mobility within an organization Supervisor support 3 Assistance with job-related problems 3.61 (1.0) 3.43 (1.1) provided by immediate supervisor Coworker support 3 Assistance with job-related problems 3.85 (0.73) 3.73 (0.86) provided by coworkers Resource adequacy 4 Extent of insufficient resources to perform 3.40 (0.96) 3.23 (1.1) daily job Role ambiguity 3 Unclear job obligations 4.01 (0.71) 4.25 (0.73) Routinization 3 Extent to which jobs are repetitive 2.58 (0.95) 2.60 (1.0) TABLE II. Demographic Characteristics for Study Participants TABLE III. Linear Regression on Job Satisfaction Military N = 283 (57.1%) Civilian N = 213 (42.9%) Years of experience as 6.33 (5.80) 22.44 (10.06) a registered nurse a Age in years a 32.7 (6.88) 47.8 (7.60) Total N = 496 Ageb 21 40 237 (84) 40 (19) 277 41 60 44 (16) 159 (77) 203 >60 0 (0.0) 7 (4) 7 Gender b Male 92 (33) 15 (7) 107 Female 191 (67) 197 (93) 388 Military Rank b Ensign 71 (26) Lieutenant Junior 88 (32) Grade Lieutenant 70 (25) Lieutenant 46 (17) Commander Civilian Pay Grade b GS-9 14 (7) GS-10 0 (0) GS-11 122 (60) GS-12 66 (33) Educationb Associate s 0 (0) 55 (28) 55 Diploma 0 (0) 5 (2) 5 Bachelor s 226 (80) 111 (56) 337 Master s 56 (20) 28 (14) 84 Doctorate 1 (<1) 1 (<1) 2 Tenure b <1 year 89 (31) 24 (11) 113 1 4 years 172 (61) 59 (28) 231 4 7 years 9 (3) 23 (11) 32 7 years 13 (5) 104 (50) 117 a Values shown as mean (standard deviation). b Values shown as n (%). Items may not sum to total because of missing data. Standardized Coefficient ( β ) Construct Military Civilian Autonomy 0.037 0.051 Distributive justice 0.052 0.028 Professional growth 0.042 0.034 Promotional opportunity 0.254*** 0.152* Supervisor support 0.134* 0.087 Coworker support 0.089 0.213*** Resource adequacy 0.128** 0.087 Role ambiguity 0.060 0.124* Routinization 0.360*** 0.441*** N 262 160 F 28.53*** 16.70*** R 2 0.51 0.55 * p 0.05, **p 0.01, ***p 0.001. Tenure and years of experience were control variables in the models. for both military and civilian nurse subgroups. As shown in Table III, the models were significant and explain a substantial portion of variance in job satisfaction for both military (51%) and civil service nurses (55%). The standardized negative coefficients indicate that routinization has the strongest negative association with job satisfaction for both military and civil service nurses. Higher levels of routinization predicted lower levels of job satisfaction, even controlling for tenure in the organization and years of experience. Promotional opportunity was a significant predictor of job satisfaction for both military and civilian nurses, although the influence was stronger for the military nurses. For military nurses, resource adequacy and supervisor support were also significant predictors of job satisfaction, although coworker support and role ambiguity were significant for civilian nurses. Increasing amounts of role ambiguity were associated with lower levels of satisfaction. MILITARY MEDICINE, Vol. 174, January 2009 79

DISCUSSION This study has added additional information to the knowledge concerning job satisfaction in nurses by investigating two distinct nurse populations who work in the U.S. military health sector. Moreover, the survey items were derived from a comprehensive retention model and composite scores were created on the basis of the model. The strongest predictor of satisfaction for both groups was routinization and it was negatively associated with job satisfaction. This indicates that the more routinization employees experience on the job the less satisfied they are. Interestingly, the mean score for the routinization items in both groups was very similar (2.58 for military nurses and 2.60 for civilian nurses) and this represents a fairly low score compared to the other concepts in the model. The significant positive relationship between promotional opportunity and job satisfaction for both cohorts was also not unexpected. Nurses who perceive opportunities for promotion are more likely to be satisfied. This relationship is consistent with the Magnet hospital force standard of professional development ( http://www.nurse credentialing.org/model/index.htm ).25 On the basis of these findings, hospital and nursing administrators should consider that order and discipline are good, but more promotional opportunities are needed to ensure nurse satisfaction. For Navy nurses promotion offers instant benefits including public recognition (i.e., through uniform insignia), increased positional authority (i.e., through achieving a higher military rank), and increased pay. These characteristics promote higher self-worth, thus leading to increased job satisfaction. In contrast, the potential for promotion of the civilian nurses is quite limited in many Navy hospitals. On the basis of the narrative comments from civilian nurses, many did not feel they have an opportunity for promotion. Civilians expressed a strong sentiment that there is no clear career path available to them as there is for the military personnel. These findings may be particularly relevant to nursing administration in military hospitals because civilian nurses are playing a critical role on the military health care team. In addition to the loss of military nurses because of deployments to the combat theaters, there has been a move over the past decade to decrease the number of active duty nurses serving in the U.S. Department of Defense (and to replace them with civilian contract nurses). The findings also demonstrate that having adequate resources to do their job contributes to job satisfaction in Navy nurses. This finding is not surprising because to provide quality care to patients, supplies and support services must be available to the staff. This relationship is also consistent with the Magnet hospital force standard of consultation and resources ( http://www.nursecredentialing.org/model/ index.htm ) 25 The Navy nurses affirmed previous findings that supervisor support was a significant contributor to job satisfaction. This finding was supported by narrative comments related to concerns about leadership deficits in their supervisors. Military nurses in the early stages of their careers are likely to recognize the benefit of having more senior mentors who can guide their career. In a study of U.S. Army nurses serving in the Reserve component, nurses with less military seniority who had a mentor reported higher levels of job satisfaction and career commitment. 26 Prevosto noted that mentored relationships help the novice nurse become acclimated into the military culture. For civil service nurses, coworker support was the second strongest predictor of satisfaction. This may be the result of civilian nurses coming into military settings, where they are not part of the military hierarchy and must rely on coworkers to clarify their role and navigate the organization. Likewise, higher role ambiguity was associated with lower satisfaction, suggesting that civilian nurses roles are not clear. This finding is consistent with the narrative comments where both Navy and civilian nurses reported that they experienced a sense of teamwork and support from their peers. Coworker support has been identified as a crucial component in establishing a positive work environment. 27 One of the most important implications of the findings concerns civilian nurse retention in the military health sector. The current nursing shortage makes it difficult for the military to recruit and retain civilian nurses. The findings from this study have shown that there are different motivating and satisfying factors for military and civilian nurses. It would be desirable to tailor retention strategies differently for military and civilian nurses in military hospitals to enhance retention. At the organizational level, there may be value in integrating civilian nurses into the management structure. This might involve increased leadership opportunities and participation in governance and committee work. Civilian nurses, with their extensive years of experience are a valuable resource but based on narrative comments may be underutilized. Future research is needed to examine and test models that integrate more civilian nurses into the leadership team within the organization. At the hospital unit level, inclusion of more civilian nurses in management positions may add stability to operations. The findings from the study suggest a lack of coworker support and role ambiguity were related to dissatisfaction in civilian nurses. Strategies that increase teamwork and clarify civilian nursing roles may enhance satisfaction and should be examined. Finally, future research should examine the effect mentors have on both military and civilian nurses job satisfaction. Several limitations of the study must be acknowledged. The satisfaction data were obtained from a convenience sample of nurses, not a random sample. Although the response rate was better than in similar nurse survey studies, there may be response bias. Data were collected at three large acute care Navy hospitals and the findings cannot be generalized to all military hospitals. As with any survey approach to data collection there is the potential for bias in self-report measures. The study used a well-established model and instrument to assess a large sample of Navy and civilian nurses who work side by side. The lack of significant influences of autonomy, distributive justice, and professional growth might be considered a good result since these issues have been identified as 80 MILITARY MEDICINE, Vol. 174, January 2009

dissatisfiers by nurses in other studies. Yet, the importance of promotional opportunities, resource adequacy, and supervisor and coworker support are affirmed. Although some of the comments reported by nurses were critical in nature, the respondents also reported a strong sense of patriotism and were committed to caring for this patient population. Further investigation into factors affecting military nurses job satisfaction and civilian nurses job satisfaction must be explored, particularly as military operations continue overseas. ACKNOWLEDGMENTS This project was supported by TriService Nursing Research Program (Grant N02-031), Uniformed Services University of the Health Sciences. REFERENCES 1. Buerhaus PI, Donelan K, Ulrich BT, Noman L, Dittus R : Is the shortage of hospital registered nurses getting better or worse? Findings from two recent national surveys of RNs. Nurs Econ 2005 ; 23 : 61 71, 96. 2. Kovner C, Brewer C, Wu Y, Cheng Y, Suzuki M : Factors associated with work satisfaction of registered nurses. J Nurs Scholarsh 2006 ; 38 : 71 9. 3. Laschinger HK, Almost J, Tuer-Hodes D : Workplace empowerment and magnet hospital characteristics. J Nurs Adm 2003 ; 33 : 410 22. 4. Allgood C, O Rourke K, VanDerslice J, Hardy MA : Job satisfaction among nursing staff in a military health care facility. Milit Med 2000 ; 165 : 757 61. 5. Chung-Park MS : Perception of the nurse practitioner s role and job satisfaction in the United States Navy. Milit Med 1998 ; 163 : 26 32. 6. Yoder LH : Staff nurses career development relationships and self reports of professionalism, job satisfaction, and intent to stay. Nurs Res 1995 ; 44 : 290 7. 7. Price JL, Mueller CW : Absenteeism and Turnover of Hospital Employees. Greenwich, JAI Press, 1986. 8. Mueller CW, Price JL : Economic, psychological and sociological determinants of voluntary turnover. J Behav Econ 1990 ; 19 : 321 35. 9. Price JL, Mueller CW : A causal model of turnover for nurses. Acad Manage J 1981 ; 24 : 543 65. 10. Gurney CA, Mueller CW, Price JL : Job satisfaction and organizational attachment of nurses holding doctoral degrees. Nurs Res 1997 ; 46 : 163 71. 11. Price JL, Kim SW : The relationship between demographic variables and intent to stay in the military: medical personnel in a US Air Force hospital. Armed Forces Soc 1993 ; 20 : 125 44. 12. Kim SW, Price JL, Mueller CW, Watson TW : The determinants of career intent among physicians at a US Air Force hospital. Hum Relat 1996 ; 49 : 947 76. 13. Mueller CW, Boyer EM, Price JL, Iverson RD : Employee attachment and noncoercive conditions at work: the case of dental hygienists. Work Occup 1994 ; 20 : 179 212. 14. Agho AO, Mueller CW, Price JL : Determinants of employee job satisfaction: an empirical test of a causal model. Hum Relat 1993 ; 46 : 1007 27. 15. Kovner CT, Brewer CS, Fairchild S, Poornima S, Kim H, Djukic M : Newly licensed RNs: characteristics, work attitudes, and intentions at work. Am J Nurs 2007 ; 107 : 58 70. 16. Blegen MA : Nurses job satisfaction: a meta-analysis of related variables. Nurs Res 1993 ; 42 : 36 41. 17. Larrabee JH, Janney MA, Ostrow CL, Withrow ML, Hobbs GR, Burant C : Predicting registered nurse job satisfaction and intent to leave. J Nurs Adm 2003 ; 33 : 271 83. 18. Ma CC, Samuels ME, Alexander JW : Factors that influence nurses job satisfaction. J Nurs Adm 2003 ; 33 : 293 9. 19. Ruggiero JS : Health, work variables, and job satisfaction among nurses. J Nurs Adm 2005 ; 35 : 254 63. 20. Zangaro GA, Soeken KL : A meta-analysis of studies of nurses job satisfaction. Res Nurs Health 2007 ; 30 : 445 58. 21. McNeese-Smith DK, Crook M : Nursing values and a changing nurse workforce: values, age, and job stages. J Nurs Adm 2003 ; 33 : 260 70. 22. vanwijk C : Factors influencing burnout and job stress among military nurses. Milit Med 1997 ; 162 : 707 10. 23. Tabachnick BG, Fidell LS : Using Multivariate Statistics, Ed 4. New York, Harper Collins College Publishers, 2001. 24. Dillman DA : Mail and Internet Surveys: The Tailored Design Method. Hoboken, NJ, John Wiley, 2000. 25. American Nurses Credentialing Center: 2004 : Available at http://www. nursecredentialing.org/model/index.htm ; accessed June 3, 2008. 26. Prevosto P : The effect of mentored relationships on satisfaction and intent to stay of company-grade US Army Reserve nurses. Milit Med 2001 ; 166: 21 6. 27. Lacey SR, Cox KS, Lorfing KC, Teasley SL, Carroll CA, Sexton K : Nursing support, workload, and intent to stay in Magnet, Magnetaspiring, and non-magnet hospitals. J Nurs Adm 2007 ; 37 : 199 205. MILITARY MEDICINE, Vol. 174, January 2009 81