Marquee Universiy e-publicaions@marquee College of Nursing Faculy Research and Publicaions Nursing, College of 9-1-2000 Influence of Sress and Nursing Leadership on Job Saisfacion of Pediaric Inensive Care Uni Nurses Marilyn Meyer Bra Marquee Universiy, marilyn.bra@marquee.edu Marion Broome Universiy of Alabama, Birmingham Sheryl Talco Kelber Universiy of Wisconsin - Milwaukee Lynne Losocco Naional Associaion of Children's Hospials and Relaed Insiuions Published version. American Journal of Criical Care, Vol. 9, No. 5 (Sepember 2000): 307-317. Permalink. 2000 American Associaion of Criical-Care Nurses. Used wih permission.
INFLUENCE OF STRESS AND NURSING LEADERSHIP ON JOB SATISFACTION OF PEDIATRIC INTENSIVE CARE UNIT NURSES Marilyn Meyer Bra, RN, MS. Marion Broome, RN, PhD. Sheryl Kelber, MS, and L.vnne Losocco, RV, i'.is/.,'. From Marquee Universiy, Milwaukee, Wis (M,HB), Universiy of Alabama a Birmingham (MB). Universiy ~{Wisconsin-Milwaukee (SK). and he Naional Associaion u.f Children:~ Hospials and Relaed Insiuions, Alexandria, Va (LL)_ BACKGROUND High levels of.<ore.'i.'i and he challenges of meeing he complex needs of criically ill children and heir families can hreaen job.'iiai.\facion and cause urnover in nurses. OBJECTIVE To explore he influences of nurses' aribues, uni characerisics, and elemens of he work environmen on he job saisfacion of nurses in pediaric criical care unis and o deermine sresson; ha are unique o nurses working in pediaric criical care. METHOD A cross-secional survey design was used. The sample con.\ ised of 1973 saff nurse.'\ in pediaric criical care unis in 65 insiuions in he Unied Sae.'\ and Canada. The following variables were measured: nurses' percepions of group cohesion, job sress, nurse-physician collaboraion, nursing leadership, professional job saisfacion, and organizaional work saisfacion. R:SVLTS Significan associaions (r = -0.37 o r = -0.56) were found beween job sress and group cohesion, professional job saisfacion, nurse-physician collaboraion, nursing leadership behaviors, and organizaional work saisfacion. Organizaional work saisfacion was posiively correlaed (r = 0.35 o r = 0.56) wih group L'ohe.'lion, professional job saisfacion, nurse-physician collaboraion, and nursing leader.'lhip behaviors..job sress, group cohesion, job saisfacion, nurse-physician collaboraion, and nursing leadership behaviors explained 51% of he variance in organizaional work sai.'ljo.dion. Dealing wih paiens' familie:<o was he mm; frequenly cied job sressor. CONCLVSJOI..,'S Job sress and nursing leadership are he mos influenial mriable~; in he explanaion of job saisfacion. Reenion effors argeed oward managemen sraegies ha empower saff o provide qualiy care along wih focal inervenion~ relaed o he diminishmen of sre~ ~ caused by nurse-family ineracions are warraned. (American Journal of Criical Care. 1000;9:307-317) Nurses working in pediaric inensive care unis (PICUs) are specialiss wihin a specialy. These nurses are faced wih complex challenges of no only meeing he needs of sick children bu also supporing he needs of he children's families. In addiion, issues relaed o caring for children Reprn requ.~.~: unovision Commum'calloll.l,!0! Columbia, Aliso Viejo. 01 92656. Phone, (BOO) 899-1712 or (949) 362 2()50 (ex 515):/ax, (949; 362 2049: e mjif. ivclleprin@aolcom. who are in pain, suffering, or dying can be exremely sressful. Conribuing o he sress ha PTCU nurses perceive are curren rends in hcalhcarc of cos conainmen, uni downsizing, increased acuiy of paiens, echnological advances, and diminishing resources. All hese facors can influence nurses' saisfacion wih heir jobs. Leaving he job (urnover) is more likely among nurses who experience sress and lack of saisfacion
in heir jobs han among nurses who do no experience hese condiions. Oehler and Davidson' repored ha job sress is he sronges predicor of burnou in pediaric nurses. Pediaric nursing aracs a unique group of nurses who are commied o he care of sick children. Because of he self-selecion o his specialy, mainaining job saisfacion and reenion of hese nurses is criical. Many of he facors ha affec nurses' job saisfacion have been linked o elemens in he pracice environmen. Previous research focused on he relaionship beween nurses' job saisfacion and job sress, ' 5 managemen syle of he nursing leadership, 4 >S empowermen, 9 10 group cohesion,w nurse-physician collaboraion,' 2 1. 1 and qualiy of care. 2 The relaionship beween nurses' job saisfacion and reenion, inen o say, or urnover has also been invesigaed. u 9 Sudie s ).l ~ 2 1 have also explored he influence of individual characerisics of nurses, such as age, experience, and anicipaed urnover. Characerisics of nurses' work seing, paricularly ype of shife and shif Iengh,u 2 have also been examined in relaionship o job saisfacion and levels of job sress. Mea-analyses 2 w of job saisfacion and exising sudies consisenly emphasize he imporan relaionship beween nurses' job saisfacion and he nurses' percepions of a posiive work environmen, cohesive and collaboraive saff relaions, and supporive managemen. These sudies also illusrae he adverse influence ha sress has on nurses' saisfacion and he qualiy of paiens' care. Previous sudies examined facors influencing nurses' saisfacion across a variey of acue care inpaien unis bu largely negleced nurses who work in PICUs. Because of he lack of previous research relaed o job saisfacion and pediaric nurses, i is unknown wheher exising models of job saisfacion are relevan o his specialy. The purpose of his sudy was o explore facors ha influence nurses' job saisfacion, including nurses' aribues, characerisics of he PICU, and nurses' percepions of he work environmen across a muliinsiuional populaion of PICU nurses. The specific research quesions were as follows: I. Wha is he relaionship beween percepions of he work environmen and job saisfacion? 2. Wha is he relaionship beween nurses' aribues, percepions of facors in he work environmen, and job saisfacion? 3. Wha facors bes predic nurses' saisfacion wih heir jobs? 4. Wha is he relaionship beween uni characerisics, percepions of facors in he work environmen, and job saisfacion? 5. Wha are he unique sressors for nurses working in a PICU? Concepual Model The model for his sudy (see Figure) is based on research,u 11 13 ' " 25 job saisfacion, and urnover. Variables included in he model are hose ha were significan in sudies of nurses from oher specialies. On he basis of more recen informaion, 1 6 ' 0 16 he variable of nursing leadership was added because of is influenial role in nurses' job saisfacion. Likewise, researchers are beginning o explore he relaionship beween nurse-physician collaboraion I Nurses' aribues Age Experience Educaion Shif ype Shif lengh Uni characerisics Lengh of say Number of beds Venilaor days/year Regisered nurse full-ime equivalens Acuiy Reenion raes I 1 l I Work environmen Group cohesion Job sress Nurse-physician collaboraion Nursing leadership Job saisfacion Professional job saisfacion Organizaional work saisfacion l Theoreical model of he relaionship among he sudy variables. ------------------------------------~ 308,1iffE'RIC:4N,/O!RNA/, OF CRITICAL CARE. Sepmd~er 2000. l'olumf' 9..Vo. 5
and job saisfacion."-" Because of he collegialiy ha nurses and physicians share in he PICU and he need for collaboraion, he effec of his variable on job saisfacion was of ineres. Las, because pedianc criical care is a disinc subspecialy, he unique influences of individual nurses' aribues, he characerisics of he PI CU. such as he size of he uni and he acuiy of he paiens, and he role of sress needed o be explored. Mehods A cross-secional descripive sudy was used. Paricipans The sample consised of 1973 regisered nurses. The sample was drawn from 65 pediaric acue care insiuions ha were members of he Naional Associaion of Children's Hospials and Relaed Insiuions, an associaion of pediaric faciliies in he Unied Saes and Canada. Procedure The Naional Associaion of Children's Hospials and Relaed Insiuions coordinaed he sudy across he paricipaing msiuions and provided adminisraive suppor. The principal invesigaor (MB) held a join appommcn wih a major universiy and one of he associaion member hospials. The projec coordinaor (LL), employed by he naional associaion, managed he sudy and mainained commumcaion across insiuions. Each paricipaing insiuion had a designaed sie coordinaor who was responsible for obaming approval from he appropriae insiuional review board and for implemening he sudy a ha sie. A docoral suden (MMB) and a universiy cener for nursing research provided research assisance, daa managemen, and saisical analysis (SK). Sudy msrumens were compiled in a packe of eleformaed quesionnaires and were disribued o each insiuion. The sie coordinaors, a regularly scheduled nursmg sao' meeings, recruied parici~ pans. Daa were colleced once a each sie during a 3-monh period. Measuremens The following predicor variables were measured by using self-repor quesionnaires: job sress, nursing leadcrsh1p, group cohesion, and nurse-physician (PJCU aending physician) collaboraion. The oucome variable job saisfacion was considered a mulidimensional consruc made up of elemens essenial o enjoymen and fulfillmen in a person's job. Two measures of saisfacion were used: a measure relaed o professional JOb saisfacion and a measure relaed o organizaional work saisfacion." ProfCssional job saisfacion is a more global measure, whereas organizaional work saisfacion is a muld"acorial measure composed of elemens relaed o he performance of he job and he larger orgamzaion. Table I is a summary of he variable definiions. measures, and psychomeric properlies_ All measures had adequae reliabiliy and validiy.''-'-''-"'-"'-'' In addiion, demographic informa1on was colleced on characerisics of each PICU and on Individual nurses' aribues_ Las, in order o deermine he naure of sressors ha PJCU nurses experience, an open-ended quesion asking nurses o sae wha hey hough was "uniquely sressful abou working m a pediaric inensive care uni" was included. Daa Analysis The daa were analyzed by usmg SPSS 10.0 for Windows (SPSS Inc. Chicago, HI, 1998). Descripive saisics were used o describe he sudy sample. Zero-order correlaion analysis was used o examine he relaionship beween he sudy variables. Analysis of variance was used o deermine differences in work environmen variables and job saisfacion according o nurses' demograph1c characensics (age groups, amoun of JCU experience, educaion, ype and lengh of shif worked)_ Regression analysis was used o deennine he predicive abiliy of he work environmen variables on job saisfacion. In order o maximize he sample size wih each variable measured, all useable daa were analyzed. However. no every paricipan provided useable daa on each quesionnaire; herefore variable sample sizes are noed for he saisical analyses. The larges dis+ crepancy for he differences in sample sizes is for he variable nurse+physici<m collaboraion_ Nurses were asked o complee 2 collaboraion insrumens: an insrumen abou collaboraion wih PICU aending physicians and an msrumen abou collaboraion wih nonaending physicians. Respondens perceived he 2 insrumens as duplicaive, and some nurses did no complee boh insrumens. Because of he large amoun of missing daa on he collaboraion beween nurses and nonaending physicians, his variable was deleed from furher analyses. In order o deennine he relaionship be\veen uni characerisics and he "-'Ork environmen variables, daa were aggregaed o he uni level. In order o jusify he aggregaion of individual daa o he uni level, crieria developed by Vcrran e ap.' \-Vere applied pos hoc. The firs crierion, conen validiy. was assessed by evaluaing each insrumen o deermine if he
Table 1 Variables and measures Variable and definiion Insrumens and subscales No. of iems Cronbach a Group cohesion General sense of individuals waning o say in a paricular group Group Judgmen Scale" 6 (7-poin Liker).85 Job saisfacion Mulidimensional consruc made up of elemens essenial o he enjoymen or liking of a person's job Work Saisfacion Scale" (Organizaional work saisfacion) Adminisraion Ineracion Pay Professional saus Task requiremens Nursing Job Saisfacion Scale" (Professional job saisfacion) Enjoymen Qualiy of care Time o do he job 32 (5-poin Liker) 23 (5-poin Liker).83 Subscales,.60-.84.86 Subscales,.62-.78 Job sress The amoun of sress nurses perceive in relaionship o heir jobs and work environmen Job Sress Scale" Compeence Physical work environmen Saffing Team respec 22 (4-poin Liker).85 Subscales,.65-.82 Nurse-physician collaboraion Sharing by nurses and physicians of responsibiliy for problem solving and decision making relaed o paiens' caren Collaboraion and Saisfacion Abou Care Decision 2 8 (7-poin Liker).96 Nursing leadership behaviors Managemen behaviors ha enable saff o accomplish heir work in meaningful ways Leader Empowering Behaviors",. Enhancing meaningfulness of work Fosering paricipaion in decision making Faciliaing goal achievemen Expressing confidence in high performance Providing auonomy from bureaucraic consrains 27 (7-poin Liker).96 Subscales,.67-.95 Nurse aribues Demographic characerisics of he nursing saff (age, experience, educaion, shif lengh and ype) Demographic Quesionnaire 15 NA Uni characerisics Demographic characerisics (number of beds, lengh of say, venilaor days per year, regisered nurse full-ime equivalens, acuiy, reenion rae, number of inensiviss} Nurse Manager Uni Demographic Quesionnaire 24 NA NA indicaes no applicable. iems refleced percepions of he work group or he uni raher han he percepions of individual nurses. Verran e ap 2 sugges ha 90% of he iems should reflec he collecive referen group. According o an analysis, 3 of he insrumens me his crierion: hose on nursing leadership behaviors, collaboraion, and group cohesion. However, 3 oher insrumens did no mee his crierion. Approximaely 45% of he iems on he job sress insrumen and 72% of he iems on he organizaional work saisfacion scale referred o he group or he uni, and I 00% of he iems on he nursing job saisfacion scale referred o he individual nurse. Because of he influenial naure of he work group or he uni on nurses' percepions of sress and 310 AMERICAN JOVRNAL OF CRITICAL CARE. 81'pPmber :2000. Polumr 9. No.5
job saisfacion, i was concluded ha aggregaion of individual responses refleced he collecive uni's impressions, hereby allowing analysis a he uni level. 2 Represenaiveness, he second crierion, is deermined by ensuring ha he majoriy of he members of he group respond. In his sudy, he response rae was 70%, a percenage ha exceeds he recommendaion by Verran e al ha a leas a 50% response rae is accepable for group represenaion. The las crieria for aggregaion o he uni level are reliabiliy and validiy. Reliabiliy was assessed by calculaing he Cronbach a for he iem means of he aggregaed daa. The Cronbach a for each insrumen was accepable, ranging from.83 o.96 (Table 1). Comparison of variabiliy wihin he group wih variabiliy across he group o assess inraclass correlaion was no performed o deermine validiy. Major hemes of qualiaive daa on sressors in he PICU were deermined by using conen analysis. Daa were hen clusered ino he hemaic caegories ha emerged. In some insances, specific quoes ha illusraed a paricular heme were included in he resuls. Resuls The reurn rae on he quesionnaires was 70%. Characerisics of be Sample A he ime of he sudy, all he subjecs bad been employed in pediaric criical care for a minimum of 3 monhs and worked a leas 20 hours per week (0.5 full-ime equivalens [FTEs ]). The majoriy of he sample were saff nurses (86%) wih baccalaureae or higher degrees in nursing (61%). More han half(58%) of he respondens were less han 36 years old; 90% were less han 46 years old. The larges par of he sample had 6 o 10 years of experience in inensive care (28%) and 6 o 10 years of enure a he curren insiuion (27.7%). New graduaes accouned for only 3.6% of he sample, and more han a quarer (27%) of he respondens had been in heir curren posiion less han 2 years. Nurses were almos evenly divided beween he ype of shif worked, wih 34.7% working days, 31.3% working nighs, and 31.2% working roaing shifs. The mean number of hours worked per week was 36 (SD = 9.18); 72.4% of he sample worked 12- hour shifs, and 12.1% worked 8-hour shifs. Characerisics of he Unis Sampled A oal of 70 unis voluneered o paricipae in he sudy. These unis were locaed primarily in academicbased insiuions (46%) and/or freesanding children's hospials (47%). The unis had a mean of 17.81 beds (SD = 7.03, range = 6-38), a mean lengh of say of 4.19 days (SD = 1.35, range= 2.1-8.6), and a mean daily census of 12.19 paiens (SD = 5.85, range = 2.4-30). The mean number of venilaor days per year was 2142, and he mean number of paien days per year was 4243. The mean number of regisered nurse FTEs per uni was 41.29 (SD = 23.31, range = 4.0-95.3). Each uni's nurse reenion rae was deermined by calculaing he percenage of individual nurses who were reained during he 12 monhs preceding daa collecion. According o his calculaion, he mean reenion rae was 80.46% (SD = 14.71%, range = 57%-100%). Nurses' Job Saisfacion and Percepions of he Work Environmen PICU nurses fel posiive abou he cohesiveness of heir peer group on he uni, were moderaely saisfied wih heir jobs, generally fel empowered by nursing managemen, and fel saisfied wih he degree of collaboraion ha ook place wih heir physicians. However, nurses repored being sressed in heir jobs. The means, SDs, and ranges for he sudy variables are summarized in Table 2. Resuls of he zero-order correlaions revealed ha he 2 measures of saisfacion, organizaional work saisfacion and professional job saisfacion, were posiively correlaed wih each oher (r = 0.46) Table 2 Work environmen variables: means, SDs, and ranges Variable Mea n Range so Poenial Acual Group cohesion (n = 1963) 5.18 Job sress (n = 1953) 2.05 Nurse-physician collaboraion (n = 1728) 4.34 Nursing leadership behaviors (n = 1960) 4.04 Organizaional work saisfacion (n = 1973) 3.03 Professional job saisfacion (n = 1970) 3.35 0.91 1.00-7.00 1.17-7.00 0.39 1.00-4.00 1.09-3.33 1.38 1.00-7.00 1.00-7.00 1.08 1.00-7.00 1.00-7.00 0.40 1.00-5.00 1.68-4.45 0.44 1.00-5.00 1.73-4.74 ;UIERI(.'AN JOURNAL OF CRITIC'AL ('ARE, S'epember 2()()(), Jlol~me 9, No. 5 311
I Table 3 Correlaion marix for sudy variables Variable 2 3 4 5 6 1. Group '"ohesion 2. Job sress -().43 3. Nurse-physician 0.29 collaboraion 0.37 4. Nursing 0.40 leadership 0.47 0.34 behaviors 5. Organizaional 0.52 work saisfacion -0.56 0.35 0.56 6. Professional job 0.29-0.52 0.20 0.28 0.46 saisfacion *P <.001 wi h a ll correlaions. and had significan posiive correlaions wih nursing leadership behaviors, group cohesion, and nursephysician collaboraion. On he oher hand, job sress had significan negaive correlaions wih all he oher variables. Job sress was negaively correlaed wih organizaional work saisfacion (r = -0.56), professional job saisfacion (r = -0.52), nursing leadership behaviors (r = - 0.47), group cohesion (r = - 0.43), and nurse-physician collaboraion (r = -0.37). Table 3 is a summary of he resuls. All repored correlaions were significan ap <.001. Predicors of J ob Saisfacion Wih he individual nurse as he level of analysis, sepwise muliple regression was used o deermine he conribuion of he sudy variables o organizaional work saisfacion. The enire model explained 52% of he variance in organizaional work saisfacion. Job sress alone explained 32% of he variance; nursing leadership, an addiional I J %; group cohesion, 6%; professional job saisfacion, 3%; and nurse-physician collaboraion, 0.5%. Anoher sepwise muliple regression was done wih professional job saisfacion as he dependen variable. The enire model explained 31% of he variance in professional job saisfacion. Job sress explained 27% of he variance; organizaional work saisfacion, 3%; and nursing leadership, 1%. Nu.rses' Aribues, Percepions of he Work Environmen, and Job Saisfacion In order o ascerain heir influence on percepions of facors in he work environmen, nurses' characerisics were examined. A!-way analysis of variance was used o deermine differences in he sudy variables according o ype of shif worked, number of hours in he shif worked (shif lengh), age caegories, educaion, and amoun oficu experience. Shif Type. Four ypes of shifs were compared: days, nighs, evenings, and roaing. Differences beween shif ypes were significan for professional job saisfacion, job sress, nursing leadership behaviors, and nurse-physician collaboraion. Pos hoc comparisons revealed ha nurses who worked day shifs perceived significanly higher levels of collaboraion wih physicians han did nurses who worked evening and nigh shifs. Nurses who worked roaing shifs perceived significanly more collaboraion han did nurses who worked nigh shifs. Nurses who worked day shifs perceived significanly higher levels of leadership behaviors han did nurses who worked nigh shifs. Nurses who worked roaing shifs perceived higher levels of sress han did nurses who worked eiher day or nigh shifs. Las, nurses who worked nigh shifs perceived significanly higher levels of professional job saisfacion han did nurses who worked all oher shifs. The resuls are summarized in Table 4. Shif Lengh. Four differen shif lenghs, 8 hours, 10 hours, 12 hours, and roaing (mixure of 8, 10, and/or 12 hours), were analyzed o deermine differences across he sudy variables. Differences were significan for nurses' percepions of job sress and professional job saisfacion. Pos hoc analysis revealed ha nurses who worked mixed shifs had higher levels of perceived job sress (mean = 2.19, Table 4 Analysis of variance summary able: variable means across ype of shif worked Variable Days Evenings Nighs Roaing df F p Group cohesion 5.22 5.21 5.22 5.08 3, 1638 2.46.06 Job sress 2.01 2.14 2.03 2.13 3, 1632 9.42.001 Nurse-physician collaboraion 4.52 3.95 4.08 4.31 3, 1631 10.12 <.001 Nursing leadership behaviors 4.14 3.88 3.93 4.05 3, 1633 3.78.01 Organizajonal work saisfacion 3.03 2.99 3.00 3.03 3, 1645.63.60 Professional job sa isfacion 3.34 3.22 3.41 3.33 3, 1643 5.15.002 Mean 312 iu IERICAN JOVRN,1L OF CRITICAL CA RE, Sepember 2000. folum(' 9, Xo..'i
Table 5 Comparisons of variable means beween nurses wih various lenghs of experience in an inensive care uni Mean lengh of experience, years Variable <2 Group cohesion 5.29 Job sress 2.1 7 Nurse-physician collaboraion 4.46 Nursing leadership behaviors 4.19 Organizaional work saisfacion 3.11 Professional job sa isfacion 3.32 2-5 >5 df F p 5.22 5.14 2, 1915 3.20.02 2.10 1.99 2, 1918 31.42 <.001 4.20 4.37 2, 1924 4.16.02 3.97 4.03 2, 1923 4.44.01 2.99 3.03 2, 1917 9.8 <.001 3.36 3.36 2, 1918.88.42 range = 1-4) han did nurses who worked 1 0-hour (mean= l.99) and 12-hour shifs (mean= 2.04) (F 3 1607 = 6.69, P <.00 1). Nurses who worked a mixun! of shif lenghs also had lower levels of professional job saisfacion (mean = 3.24, range = l-5) han did nurses who worked 12-hour shifs (mean = 3.38) (F 3, 1601 = 5.32, P =.001). Level of Educaion. In order o examine differences in ype of educaion, nurses w ih associae degrees were grouped wih diploma nurses and compared wih nurses wih baccalaureae and higher degrees. No significan differences were found across any of he sudy variables according o ype of educaional background. Age. Nurses were grouped ino 3 age caegories, 20 o 30 years (n = 623), 31 o 40 years (n = 855), and 41 years and older (n = 453). Differences beween he caegories were significan only for he amoun of perceived job sress. Younger nurses (20-30 years old) experienced significanly more job sress han did he 2 oher age groups (F 2 1928 = 13.72, P <.001). JCU Experience: Experience in an ICU was divided ino 3 caegories: less han 2 years, 2 o 5 years, and more han 5 years. Pos hoc comparisons revealed ha for all he sudy variables excep professional job saisfacion, differences beween nurses wih less han 2 years of ICU experience and all oher groups of nurses were significan (Table 5). Furhermore, nurses wih less han 2 years of experience had he highes means for all he sudy variables excep professional job saisfacion, in which all group means were no significanly differen. Uni Characerisics, Percepions of he Work Environmen, and Job Saisfacion In order o deermine he relaionship beween uni characerisics and percepions of he work environmen, daa were aggregaed o he uru level. No significan relaionships were found beween any of he sudy variables. However, i was hypohesized ha differences migh exis beween unis according o he acuiy level of paiens on he unis. An "acuiy variable" was consruced ha was based on a raio of he number of venilaor days per uni in he preceding year and he number of regisered nurse FTEs for ha uni. Fify-wo unis provided daa on boh variables. The raios for he sample were ranked across 4 quariles. Unis in he upper quarile were caegorized as high acuiy (n = 12); hose in he lowes quarile, as low acuiy (n = 13); and hose in he 2 middle quariles, as moderae acuiy (n = 27). A 1-way analysis of variance was used o compare differences across he 3 groups (Table 6). Significan differences were found across he 3 groups for all he variables excep professional job saisfacion. Nurses on unis wih low acuiy had significanly higher means on percepions of group cohesion, collaboraion wih physicians, nursing leadership behaviors, and organizaional work saisfacion han did nurses on unis wih moderae or high acuiy. On hese same unis, nurses also perceived significanly lower levels of job sress. Sressors in he PICU A oal of 1241 nurses provided qualiaive responses o he open-ended quesion abou unique sressors in he PICU. Conen analysis of he responses revealed 3 major hemes: issues concerning families, saffing, and deah and dying. Family issues and dynamics were he mos frequenly cied sressors, repored by more han half of he respondens. Respondens acknowledged ha i was sressful dealing wih parens who were srained, difficul, or demanding. Dealing wih "parens who are always on he edge," dealing wih families in crisis, answering quesions, and being held o a higher level of accounabiliy ("having responsibiliy for someone's child is he greaes sress of all") were sressors repored. Nurses saed ha hey had "2 paiens, he child and he family" and ha boh required nursing care. Having parens and family members a he bedside 24 JUIERICAN JOURN1iL OF CRI11CMJ C:4RE. Sepember :.!000. J i,/~m! 9. No. J 313
Table 6 Comparison of variables across level of uni acuiy Variable low (n= 13) Mean level of acuiy Moderae (n = 17) High (n = 12) p Significan differences Lowvs Low vs Moderae moderae high vs high Group cohesion Job sress Nurse-physician collaboraion Leadership behaviors Organizaional work saisfacion Professional job saisfacion 5.52 1.91 4.78 4.43 3.16 3.42 5.17 2.04 4.37 4.09 3.06 3.37 5.08 2.05 3.92 3.86 2.96 3.34 <.001 <.001 <.001 <.001 <.001.08 "Daa available from 52 unis was aggregaed o uni level.!significan differences exis beween groups. hours per day was anoher source of difficuly because of he consan inensiy of conac and an inabiliy for nurses o ge heir work done. Saffing concerns were he nex mos commonly saed sressor, repored by 27% of he respondens. Undersaffing, high acuiy, and unsafe assignmens were ofen cied. Respondens saed ha inadequae saffing coupled wih high acuiy compromised heir abiliy o provide qualiy care. Heavy workload assignmens, failure o ake breaks or ge meals, inabiliy o aend educaional opporuniies, inexperienced saff, mandaory overime, and rapid urnover of paiens also conribued o nurses' level of sress. Children and families who are experiencing dying and deah were also prevalen sressors, cied by 22% of he nurses. Respondens described difficulies winessing a child's deah, experiencing he loss of a child ha hey have become aached o, and dealing wih grieving families. Nurses also repored sress relaed o he socieal norm ha children should no suffer and die and o he ehical issues of prolonging a child's life when he oucome is hopeless. Oher sressors repored included he uni environmen and working relaionships. Difficulies wih inerpersonal relaionships beween nurses, shifs, managemen, and physicians were also described. Oher concerns focused on he physical environmen, paricularly problems of noise, lack of space, and lack of available equipmen. Las, nurses described difficulies in dealing wih cases of child abuse and he occurrence of prevenable injuries such as hose experienced by unresrained children in moor vehicle crashes. Discussion This sudy was designed o examine facors ha influence job saisfacion of nurses who work in PJCUs. In general, he respondens scored higher in group cohesion, professional job saisfacion, and organizaional work saisfacion and lower in perceived job sress han did nurses in oher seings. u Job Saisfacion Several of he variables explained a significan amoun of variance in boh professional job saisfacion and organizaional work saisfacion. Job sress was he mos imporan predicor of boh professional job saisfacion and organizaional work saisfacion. Professional job saisfacion refleced how nurses generally fel abou heir work, whereas organizaional work saisfacion refleced heir saisfacion wih various facors in boh he immediae work environmen and he larger organizaion. The relaionship beween job saisfacion and sress as a major predicor is no surprising because of he small bu srong uni culure ha is ofen found in PICUs. High acuiy levels, shor saffing, and inerpersonal relaionships are all sressors cied by criical care nurses.s.ju Nursing Leadership The finding ha leadership was a srong predicor of work saisfacion corroborae he resuls of previous research in he area. Leveck and Jones 2 and Nakaa and Saylor' also found ha managemen syle was associaed wih job saisfacion for nurses. Nurses who perceived heir managers as having a paricipaive syle had higher job saisfacion han did nurses who had a differen percepion. Similarly, Morrison e al 10 and Laschinger 9 found a srong relaionship beween nurses' job saisfacion and a nursing managemen syle ha was perceived as one ha empowered saff o perform heir jobs effecively. Las, Boyle e af" also repored a relaionship beween job saisfacion and managers' characerisics, paricularly managers' conrol over he work environmen. 314 AMERJC,LV JOVHNAI~ OF CRITICAL C.RE. S~pnnb~r 2000, l'olum.e 9,.Vu.,:;
The resuls of he sudy repored here highligh he imporance of he nurse-manager relaionship and effecive leadership as componens of job saisfacion for pediaric criical care nurses. The daa underscore he noion ha nursing leadership ha is perceived as supporive, and as providing a cohesive work environmen in which nurses can collaborae effecively wih oher healh professionals, has a posiive influence on job saisfacion. Nurses wan o feel ha hey arc valued members of a eam and ha heir conribuion does make a difference, especially in he lives of criically ill children. In oday's fas-paced healhcare seings and he sressful PJCU environmen, nurses find i crucial o have leaders who remove he barriers and secure for he nurses he resources needed for he provision of qualiy care. Job Sress Sress levels were highes among new and inexperienced nurses, a finding consisen wih he resuls of oher sudies.' This finding is no surprising, because new graduaes end o be he leas experienced members of he PICU saff, are leas comforable wih collaboraion, and are sill rying o find heir "place" on he uni. The findings of his sudy did no suppor hose of Gowell and Boverie: who found ha sress levels were highes for nurses who worked 10-hour shifs. In he sudy repored here, i was no he lengh of he shif bu raher he roaion of shifs ha influenced job sress. Job sress was highes for nurses who roaed be\vecn ypes of shifs (days, evening, nighs) and differen lenghs of shifs (8, 10, and 12 hours). The analysis of he qualiaive daa on sressors indicaes ha families and heir consan presence arc influenial facors in nurses' percepions of he work environmen. PICU nurses can feel overwhelmed rying o deal simulaneously wih he muliple needs of an acuely ill child and he needs of he child's parens. Family-cenered care is a core value in mos children's hospials," ye implemenaion of his philosophy can place a significan burden on any nurse who is rying o deliver care o a criically ill child while also caring for he child's anxious family members. Unis ha allow unlimied family visiaion and embrace he family care philosophy should be cognizan of he sress ha his pracice places on saff personnel. Nurses on hese unis need o have resources in place o help hem deal wih complex family siuaions. Addiionally, he ime and energy needed o suppor paiens' families should be recognized and facored ino saff nurses' workload. The emoional impac of caring for dying children is also a concern. In order o deal wih his sressor, suppor sysems should be available o help nurses cope wih issues of deah and dymg. "' Group Cohesion Group cohesion IS mos srongly linked o percepions of he work environmen and was a significan predicor of orgamzaional work saisfacion in oher sudies.'' In his sudy, nurses' percepions of cohesiveness wihin he work group did no vary significanly across shif ype or shif lengh. However, percepions of group cohesion were lowes among nurses who roaed beween day, evening, and nigh shirs. Apparenly. cohesiveness, which is a relaionship-based variable, is easier o achieve when a person works wih he same people on a consisen basis. Percepions of cohesiveness were also inversely relaed o level of experience. As nurses gained experience, heir sense of cohesiveness declined. On he basis of his finding, reenion effors for more experienced saff should focus on eam building and on mainaining a sense of connecedness wih he peer work group. Nurse-Physician Collaboraion The resuls provided only modes suppor for he inclusion of nurse-physician collaboraion as a significan variable. Consisen wih he findings of Baggs e a\" and Sichler," nurses percepions of collaboraion wih physicians, alhough imporan, were no srong predicors of job saisfacion. However, Sichler, using an insrumen ha measured inerpersonal aspecs of collaboraion, found ha nursephysician collaboraion was a slighly sronger predicor of organizaional job saisfacion. Similar o Sichler's findings, he resuls of he sudy repored here indicaed ha nurses who worked evenings and nighs had significanly IO\'.'Cr percepions of collaboraion han did nurses who worked days. This finding is consisen wih he decreased frequency of nursephysician ineracion ha akes place during he evening and nigh hours. Inexperienced nurses also perceived higher levels of collaboraion han did nurses wih more experience. This finding mos likely is relaed o a greaer need o collaborae as he nurses learn and gain experise in heir new posiion. Nurses' Aribues The resuls of his sudy did no suppor hose of oher sudies' 3 _., ha found an inverse relaionship beween level of educaion and job saisfacion. In his sudy, none ofhc sudy variables differed according o level of educaion. Furhermore, his sudy did
no suppor findings ;-_, ha percepions of joh saisfacion were greaer among older nur~es han among younger nurses In hs sudy. differences m hoh organwlional work saisfacion and professional JOb saisfacion across age groups were no s1gnifican. In a compan~on beween he vanablcs and amoun of PICU cxpcncncc. nurses wh lcs~ han 2 years of expcncncc had he highc~ mean~ for all he sudy variables. On he bass of ins findmg, effors should be made o main am hese posiive percepwns of he \Vork environmen as nurses gain enure on a uni 1-lowewr, his group of nurses also had he highes levels of job sress. Assising new saff members in a successful ransiion mo heir criical care nurs ing role s essenial o mainaining posi1vc percepions of he work env1ronmcn. V ni Characerisics In an efor o capure some mdicaor of uni acuiy, number of venilaor days and number of regisered nurse FTb were combined. Analysis based on he creaion of his variable revealed a rdamnship bel\.vcen acuiy and mos of he ~udy vanabk~. L""nis wih he lowes acuiy had he lowes means for job sress and he highes means for group cohc~ion, nur:'.e-phy~ician collaboraion, nursmg leadership behaviors, and organizcjjonal work saisfacion. As acuiy inneased. he means for JOb saisfacion and he work environmen variables dccre:.~scd and job src~s incrca!.ed. Ineresingly, professional JOb saisfacion d1d no vary significanly beween unis v. ih di!tcrcn levels of acuiy. This finding presens a difficul challenge for unis wih a sicker, more complex populaion of paiens. Lnis wih large numbers of saff aking care of more acuely ill paiens can hreaen nurses' sai~facion. Reenion effors m hese unis ~hould I(Jcu.~ on helping nurses deal wih he sressor~ and workload is,ues associaed wil1 caring for he more acuely ill populaion. b ni Reenion Raes In his sudy. he uni reenion raes were ongjnally o he con~idercd as an oucome variable as n oher sud1es.' '' '''However. he resuls did no mdicae significan relaionships bcmcen any of he vanablcs and uni reenion raes. The usc of reenion raes requlred aggregaion of daa o he uni level, a sep ha yielded nons1gnifican resuls for any of he sudy variables as a predicor of reenion. The ab~cnce of significan pred1cors for reenion may be due o he lack of variabiliy in reenion r<jcs acrnss unis raher han o a lack of a relaionship beween facors. In order o md1rccly assess he influence of he vanablcs on urnover. a more pracical alernaive would be o examine nurse urnover as measured by he inen of leaving. or anicip<jcd urnover, which IS a person's percepion of he possibiliy of leanng an orgamzaion. In oher ~udjes,:' '' 1 'anic1paed urnover, wh1ch 1~ a behavioral inenion. was correlaed wih acual uni urnover raes. Limiaions and Fuure llirecions "l he cross-~ccional design of he sudy limis he gcnera!zab!liy of he findings A cross-secional dcs1gn. wih a smgle penod of daa collecion, provides only a view or par1upans response:. a ha ime. Wheher he responses reflec percepions over a longer period is unknown. Demographic mfonnaion abou sex was no colleced. Poss1bly. male and female nurses would hav~ differen percepions. Because of he pivoal role or sress in job saisfacion, re~earch effm1s should focus on esmg inervenions argeed o areas of mos concern o PICU nurses, namely family concerns and care of dying children, and o larger organi/.aional issues relaed o ~aitmg and \\orkload. l\"ursing managemen remains a key variable in he job saisfacion of PICU nurses. Research effors should coninue o explore managemen mervcn1ons ha empower saff and creae a posiive work chmac. Fuure shdy of he prcdicjve abi!jy of sudy vanabies ha uses heoreical and saisical modehng echniques ls warraned. Th1s sudy provides imporan baseline daa for fuure research focused on reenion sraeg1cs and mc<sures o 1mprovc job saisfacion. AC"KNOWLEil;l\ff.l\ IS The 199~ \alio11~l ~';onallrm of Ch ldn 11'> Ho.'lmal< and 1\ela d ln,li<lion< l'.ha\n(; ln\"n">e Can l m locu<group cnn;is!ed of!he followmg in;ll!lllinn<. llahle< and Children's floopilal. \('\\York. ~Y: C S.\loll Cluldn n' Ho;pial-Lniwr"y of \l chi~an Halh ~,,em Ann Arbor..\l rh. Ch ldren's I[("Jli~!l Me<.hC'al C m r of Akron.,\kron, Oluo, The Children's I!O<J"WI. M<~lical l~lll'er";- of Snllh C~rolina, Charle;on. SC: ChifdrPn\ llo>plal ol.\lahama. Birmin~lwm. Ala: ChiJ,lr n'; Hn;pial ol \olldngo.n /Jwml, M ch; Childrm'< llo>pial l nivcf'll) Healh ~\\rrn' nf f.a\ie'rn.\orh Carolina, Grecnvil \C. Clnldren" Ho<1nal of ViL,lOTISLil. \lilwaukce. 1 ld1: Cook Childrfn\ Mrd al Cenrcr. J orr 'l>orrh. ']",.,. Alfn d I dupo!ll H'"l"wl lor Cluldrcu. \liilhilllglon. lld. Huf:l""' SpaulJmg Ch lrlml'> llo;plla.\lama. CJ. l.dlonheur Childr n' \ledlcal Cener, \lcmph', Tenn. l11ma LLTH.Li llrhh"f\il C:hddren\ l!os)llal. Loma Unda. CJ.lif. Mar, land, ll%pial for Cluldm1 Balnmore..\1d. Sollfl}. Chil<!ren'l Hnllh C1 nr< of ~orhern,\lhera Edmomon..\lherla. '1< \a\ Clnldrn' llo\pllal, IIOL!<on, J'ex. \ niver~i) uf Ch~rago Chll!rcn's llo;pi:li. Chic~go lli: \ nm r>i\ of \i'\consm Chldren'> Hoopial. \ladisnn, \lis: \andrrhil Children, Hospial. \a,hille. Tenn. Th" Mud~"'"-' fund d h< h ~Jllonal "-"oci~ion of (hildn n, H"'l"all and Relaed Tns11uwn<. Rf.H"l{E[',("f:S I O~!lkr JM. ll:"'d"'" M(, Joh >c" :md buromji ll: ''""'"and nonacuw rcdjonc nuroc' imj C!'ll Cme 1'!'!2 ' H:.'J() C l.c ed.\jl, J~ne' ("fl 1 h: n JT>Jng rrae11c~ ~"''"l>:r:wn ;vlil n cr"''m ::116..IIEH/l A.\./Of :u.\",ij. OF ('H/T/C-11. (~1RF. S'"f'lnulwr :H!OO. """"'"' ').. \,..>
a~d ~u.!hly of care R~-' Vun J/calrh I ~90. I~, 3! I 14 \ Lucas MD. /\v,ooo JR. l!agamon R Replicaion and >aihialldn of amicipa cd um over mn<ld <n LIT~m n:gi<e.-.;d nurses. \ un Res ]Q93,42 2~-35 ~- Gm ell YM. Ho, en~ Pf' Src,\ "nd '"'"fa~l<m "',, re<ul of sh1fi and number of hours "or ked Sur.\ Admm Q Sumn.e 1"').:'.1 0: 14-i<l_ '5_ ~awarky JV Sn <> m cnucal care aelual and pcrcel\ccl. lh orj Lrmg 19%:2~ 4M- 1l_l_ ~ Moss R, Ro,.ks CJ. Sall' nurse JOb sam'anwn and managemen syle,\'ur<.\lalla);<'- January I ~97:2kl2-.i4. '>:akaa JA. Sa} lor C Managemen <lyle.!ml 'aft nu"c,a"facinn m a changmg en"'ronmcn.\'ur>.-ldmm Q. Spring 1994:18.51-57 Volk MC l_u,as ll-11l. Rda1onsh1p of managemen syle and anllcipaed urnu cr. lj"'''"''" Or1 Core Nws 1'!9UO 35 40_ 9 I aoch1nger JKS lmp,,o nl-lcadcr<hrp bdwvrm> n~ Slafr nur<c work crnj""'crrncnl Paper presened al Mcchng nf rhc MidiH>l NuroiTrg Research Sociey,.\1arch 30 I ~n. Columbus. Oh1o. 10 MmT«mr RS. lone' L.l-ulkr H l'hc r~la!hm,hjp h<:'>ccn lcadcf'hrp 'yle a11d ernp~"c rnrcn nn rob,al,f.lcilon of nuo>es_ J Nr<r.> Admin_.\lay 19~7.27 2'-34 I I Hm,ha" /1~. /l,.nnd.ir 4n11Crpar. d urnol'<'r Amon~.Vur<mg Si.:Jfj Swdr. { mal 1/<'P""- lk!hnd~. Md )',aronal ln,!j!u!c\ of Healh, NaH>n~l C.'Onel for ~urs1ng Research. 1985_ Publicaion ROIKL00908_ I' llagg' JG. Schmn MI-l Colbborannn beween nur<c' ;md phy>iclan< /mag<' 1.-\ur~ >ch 19S~;:2l 145-4~i3_ Baggs JG. Schmi.\1!(, Mushlm AL Lldredge DIL Oake< D. Huson AD_ "'ursc-phym~<m colabora1<>n ;md "''"'f"olon w1lh ho decnon m'lkjn!~ pm.;c" LTl llr~e Lnical c.lre WlllS_ Am J Ceil C""'- 1997:~ 393"399 I~ Agho AO. The moderajng effecs of disposihonal affccjvy on rrlahonshps bcne<n JOb charm crrsrcs and """'' job "''"f"cum /-/,,, Vur, llealh 1~93.16451-458 l'i Blcgm M,.\, lioodc l'j, Johm<>ll \1..\loa, 'I-lL, ~1L(I~>kcy JC Moorhe.ld SA_ Rc-cognLing san nme JOb performance and achic,cmcnls lie.< \'ur< l/ealh 1'192_15 57-66_ 16 Bnrd.1 RU. Nonnan ij 1-acnrl inauencrro!' urrm cr.lnd ab>c!l<-c of nu> "'-" rc>carch re""" lm J 1\iur- sr,.j I ~97:34:385-W4. 17. Ko,mo;kl KA. Cakrn IIJ_ Cn~eal care nur>.cs' 1nlcnl o _,ay m hcjt pos.- 1\0n,_ R < Suer 1/eallh 1986:~ 3.1 0_ 18 Parasumman S )\'ursmg nunover an inegmcd modc l 1/n.Vur<!fm/h 1~8~_[2 ][,7-).77 19 l'ncc II.. Mudkr ('W Pm/e«wnul l'11rno>cr!he ('a.<e oj;;'~<rsn_ J.ln.OI~.J. NY Specrum Pubhcawm 19~ I Zl Al~~andcr Jll. l..chensc!n R, Oh J!J Ullm<>n E _.\causal model oholunury urno-er among nursmg personnel m long-cnn psych1anc <cm~,, 1/e, Sur< Ji<:alh l'l'ls.21 41~ 427_ "I DJVIdWn )_ FolcarcllL Pll. Cr.Jv.limi ~- llhpral U. Clrllnrd JC The cftcu' of healh care rd'onnc- on 10b >al>facjon and >OlUilldy um~\ cr amoug hmpiwi-ha<~d nllrlc' Med Can' 1~97_35-634-645 C2 Bemreue _I. f. ~ulli'an \_ :.un-cy and cniql!c (lhhdies rclarxl o sluf le<gh >an<~j<m m nur>mg!rom I 970--1 'N3 bu J.\w' Sr11d. 'l~\32: 1 S8-- I ~7 23 l:llegcn \./1_ "'ur>c> J"b <1Lll\lacwn a mcj analy;js of relaed vall~hb.v~>s R~s 19'13:4/. 30-40 24_ ]" me lj.\1. J vam \1(; J<1h _,arsl, clon and urnover among nurse,_ incgramg research findngs a~rus< sudleo.\'ucs R< s 1995;44.246-/53 25 Hm.<haw 1\S. -\!wood JR. 1\ursing <ali urrw\cr. Sire", and "''"facum model,_ mea'""" and managemen A>mu Rn Yun ll s 1983:1 IJ3.153_ 26 Boyle DK, Bon MJ.!!amen HL. W(><>d,; CQ. aunon RL Manager>' lcada,hp a"'l uilcal ca c "'"-'"'' '"'"'" ~ >L~v 4m J Crr CMe lg99_8 361-371_ 27 llu1 C f_'[/e, J,\ of L ad~1 f)iij>o"'''',nl< Reil"'wr,, ""d!-'oil ower,-/'~'-'"""/ Conlrol. l'uu~. and Self.effic an on In-Roil and Exrm-Role l'er/ocmance ;In f:xlo<<roii und 1-:mr"'"a/ Tnl uj Conga and A'anUIIf:O,!:mpm<erm< nl 1 r<k<'\' Mmld ]dolior l ""'erraron]. Rloomrngon,!nd!ndana Umver.iy, I'N4_ "~ Con.,cr JA, Kanungo RN Traming charisma!lc leader;hr a '"ky and crical a.-k_ ln Cmf:er.1-\. Kanungo R"-1, cd>. Chammauc L~ader>hip Th Elr<Si<~ { uuor in Orgumzillwnul Lfl( rm,ne." ~"n ~wnc!<cn. Cll'..lo,;cy Hass. 1988:30~-32] :'~ (iond I R, Ncl"'" ll \ Ffkc" o' p.;rson-group and mragroup aiude similariy on pe-ccl\ed group arad>cnc\' and cohc"vcnc"- Pswhol R~p 1471.<1-.151 >60 30 Elaggs JG, Ryan SA Phclp' (!:. Rich~'"" Jf Johnson J[_ l'hc """"'""'" bcv:ecn imordiscphnary Ccllabora!O\\ and pa<ien uucumcs Ln med.cal rncn;i;cc""'- HPIM lr<ng l~n.? 18-24. _II Hagg' JG. lk,dopmcn nf an m>nmcnl In me"'un collobonuron and S.!ILS!OcoH abou cac deci>i~n> J Ad> Nur_, 19'14.20 176-182. 1? Vemn JA, Gerber RM. \1 1on DA Daa aggrcgjon crie"a for psychorncrrc ~'"lua1<m. 1/o.\',r.l fl, a/ih ~~~-~;ls 77-811 _13_ Ro,enl>al SL. Schlllid KD. Black ~1.\1_ Sc,; and copmg m a >,'(('(J_ /In.\'un 1/~.:Jilh 1~8~;12::)57-21>\. _14_ ropf M l'er,onahy hadmc;s_ oc.:upamnal 're». "nd burn<1ul m cmical <'Or'niir<c,_J/,,_,,\'w<J/,,a/h I~H~.12 179-lgh l~- -\]unarm L. Fanlil; ccncred caic. In llroome.\ie, Rnlhn' JA, cd> CTJrc Cumn lum o - h, \',o "nl.' Care<~/ C/11/dr< n "nj Th.-rr f'amdre, Pman..._J: J;<nnCIU l'ubli.::"""'" Inc 1'-l'l~ _;7_1._19! 16 _1.\ile-; M. Demi A Guil< in berea"'d parens In: Rand<> T cd_ Pmenlal I"" n/ '' Ch1/d CJ-.ampa1gn. Ill: R<>, an h Pres-', (gs6 97- I IS 37 S"<hlcr JF The F!fecs of Cal/~hNMIOir U gammrronal Clmi.:lle. and.lah Sm <s ~".loh.\aj,/i.cjon and Anu:1pa1< d TumaH r in \'1ming [docoal disscra1ion] San D ego. Calif: Ln" ersiy of San D cgo: 19~0.-Uif.'HJ(' AA JOl-'R:V:II, 01-" ('llj11l:-l, (JIRE,.'i, pnnber 2000. J (,f,nu '1. -'" :; :117