Review article

Debra C. Hairr Helen Salisbury

Mark Johannsson Nancy Redfern-Vance

Nurse Staffing and the Relationship to Job Satisfaction

And Retention Executive Summary

p The purpose of this quantita­ tive, correlational research study was to examine the rela­ tionships between nurse staffing, job satisfaction, and nurse retention in an acute care hospital environment.

p Results indicated a moderately strong, inverse relationship between job satisfaction and nurse retention.

P - A weak positive relationship between job satisfaction and nurse staffing was identified.

p Nurses reported experiencing job dissatisfaction in the past 6 months specifically related to the number of patients assigned.

p Analysis suggested nurses are staying with their current employer because of the cur­ rent economic environment.

P Improving nurse staffing will be necessary when the economy improves to prevent the depar­ ture of discontented nurses from acute care facilities.

I n 2004, the Institute of Medicine released a report, Keeping Patients Safe: Trans­ forming the Nursing Work

Environment. This report recog­ nized appropriate nurse staffing levels are essential for patient safety. Nurse-patient ratios are a starting point in the discussion of appropriate levels of nurse staf­ fing. Researchers agree patient acuity and skill mix must also be taken into consideration when addressing nurse staffing issues (Tevington, 2011). There is a pau­ city of research that addresses pa­ tient acuity, skill mix, and nurse- patient ratios.

The American Nurses Creden- tialing Center (ANCC) Magnet® hospitals are widely recognized for promoting safe and appropri­ ate nurse staffing and generally

have good patient outcomes (Trinkoff et al., 2010). According to Needleman and colleagues (2011), Magnet hospitals also have lower patient morbidity and mor­ tality rates than non-Magnet hos­ pitals. A 3-year study conducted in a Magnet hospital analyzed over three million patient records. Researchers examined the effect of inadequate nurse staffing on mor­ tality. There was a 6% risk of death for patients when a shift with a nurse staffing shortage of just 8 hours occurred. The litera­ ture suggests nurse-patient ratios of 4:1 or less provide the most optimal outcomes for patients (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Aiken et al., 2010; Needleman et al., 2011; Rosenberg, 2011).

DEBRA C. HAIRR, DHSc, MSN, RNC-OB, is Contributing Faculty, College of Health Sciences, School of Nursing, Walden University, Minneapolis, MN.

HELEN SALISBURY, PhD, is Assistant Professor, Arizona School of Health Sciences at A. T. Still University, Mesa, AZ.

MARK JOHANNSSON, DHSc, MPH, is Adjunct Professor, Arizona School of Health Sciences at A. T. Still University, Mesa, AZ.

NANCY REDFERN-VANCE, PhD, RN, CNM, is Associate Professor, College of Nursing, Valdosta State University, Valdosta, GA.

142 NURSING ECONOMIC$/May-June 2014/Vol. 32/No. 3

Health care in the United States is a commodity, and nurses are an expensive budgetary con­ sideration. Health care facilities have the potential to achieve large financial savings by reducing the number of nurses. Despite the evi­ dence, many institutions are un­ willing or unable to provide nurse staffing that is supported by the growing body of research (Duffin, 2012; Garretson, 2004). Imple­ menting this one evidence-based practice could have a positive impact on patient outcomes, ulti­ mately decreasing patient morbid­ ity and mortality (Aiken et al., 2002; Aiken et ah, 2008; Aiken et al., 2010; Needleman et al., 2011; Shamliyan, Kane, Mueller, Duval, & Wilt, 2009).

Positive patient outcomes are not the only benefit from improv­ ed nurse staffing. Aiken and asso­ ciates (2002) examined nurse sat­ isfaction and retention issues. The authors noted that when nurses are exposed to inadequate staffing levels, they leave their positions. Retaining as many nurses in their roles as possible makes fiscal sense for any organization. Costs to an organization to retrain a spe­ cialty nurse have been estimated as being as high as $80,000 (Burr, Stichler, & Poeitler, 2011; Tellez, 2012). Not only will patient care and outcomes improve with addi­ tional nurses, but also cost savings may result. Aiken and co-authors (2010) suggested a ratio of four patients to one nurse will save each health care organization $60,000 a year. Retaining just one nurse and utilizing the recom­ mended nurse-patient ratios may result in savings of around $140,000 every year. That is just for one nurse retained in his or her position, taking care of four pa­ tients on a medical-surgical floor. Extrapolating that number to every medical-surgical floor, in every hospital across the United States, would result in the realiza­ tion of enormous savings to health care. In the current economy, administrators would not be fis­

cally responsible if they did not examine every avenue that could save lives, improve nursing job satisfaction, retain nurses at the bedside, and save health care dol­ lars.

Methods Study participants. This quan­

titative, correlational research study was developed to examine the relationships between nurse staffing, job satisfaction, and nurse retention in an acute care hospital environment.

Survey participants were prac­ ticing licensed registered nurses with at least 6 months of acute care nursing experience. A con­ secutive sample was recruited on nursing listserv’s, Facebook, My- Space, and Allaboutnurses.com. Consecutive sampling is a “form of non-probability sampling where survey participants are recruited as they become available” (Portney & Watkins, 2009, p. 865).

Inclusion criteria for partici­ pating in the survey included (a) licensed as a registered nurse, (b) a minimum of 6 months direct pa­ tient care nursing experience, and (c) employed in an acute care hos­ pital. Additional demographic data were collected and included (a) gender, (b) age, (c) academic pre­ paration for initial licensure, (d) highest level of education attain­ ed, (e) nursing specialty, (f) if em­ ployed in a Magnet hospital, and (g) number of years nursing expe­ rience. The research protocol for this study was approved by the A. T. Still University Institutional Review Board.

Survey tool. The survey tool is a revision of one of the most wide­ ly used tools to assess the clinical nursing environment, the Nursing Work Index (NWI) (Kramer & Hafner, 1989). The NWI consists of 65 items on a 4-point Likert- type scale ranging from 1 (strongly agree) to 4 (strongly disagree). The NWI scale was revised by Aiken and Patrician (2000). The authors used 57 of the original 65 NWI items for the Nursing Work Index-

Revised (NWI-R). The NWI-R cap­ tures organizational attributes that characterize professional nursing practice environments including job satisfaction (Aiken & Patrician, 2000). The NWI-R has four sub­ scales. The subscale that can be attributed to job satisfaction is the Control Over Practice (COP) sub­ scale. The reliability of the NWI-R survey tool has been previously demonstrated with Cronbach’s alpha of 0.96 for the entire NWI-R, and the subscale COP alpha noted at 0.91 (Aiken & Patrician, 2000).

Additional survey questions addressed the survey participants’ current experiences with nurse- patient ratios and job dissatisfac­ tion. The participants were asked the following additional ques­ tions: How many patients were assigned to you at the beginning of your last shift? Has the number of patients you have been assigned resulted in job dissatisfaction? Have you thought about leaving your current nursing position in the last 6 months due to job dissat­ isfaction? If this question was answered in the affirmative, an additional question was asked; Has the current economic down­ turn influenced your decision to stay in your current position? These additional questions were an attempt to gauge the effect that the economy may have on a nurse’s reluctance to change jobs in spite of job dissatisfaction.

Data collection. Data were col­ lected via an electronic survey. An explanatory invitation was posted online with inclusion criteria and the link to SurveyMonkey. The link was available for 30 days.

Statistical Analysis Data were analyzed using the

IBM Statistical Package for Social Sciences (SPSS), version 20. Des­ criptive statistics were obtained for demographic and NWI-R COP subscale variables. The NWI-R COP data were tested for normali­ ty. Percentages and frequencies were also obtained.

NURSING ECONOMIC$/May-June 2014/Vol. 32/No. 3 143

Correlational analyses for each research question were per­ formed. As ordinal scales were used in this study, and data were not normally distributed, non- parametric statistical analysis was appropriate. Spearman’s Rank Correlation Coefficient Analysis was used to determine whether the predictive variables of job sat­ isfaction and nurse staffing were related to the criterion variables of nurse retention and job satisfac­ tion, respectively. The NWI-R COP was used to measure job sat­ isfaction.

An additional retention vari­ able was analyzed. The question was asked if the current economic downturn had affected a decision to stay in a current position. Fre­ quencies and percentages were analyzed. Statistical significance [p) level of the analysis was set at a = 0.05, two-tailed.

Results Participant characteristics. Of

70 respondents, the majority were female (n=59; 84.3%). The median age of respondents was 36-45 years (n=15; 21.4%). As Table 1 indicates, registered nurse educa­ tion data revealed that most of the respondents (n=38; 58.3%) had earned an associate’s degree in nursing. Participants holding a master’s degree in nursing were 15.7% (n=ll), while those with a non-nursing master’s degree were noted at 5.7% (n=4). No survey respondents reported holding a doctor of musing practice or doc­ tor in nursing; two respondents (2.9%) reported doctoral degrees in non-nursing disciplines.

Nursing experience ranged from 6 months to greater than 16 years. Most of the nurses reported having 2 to 5 years of experience (n=19; 27.1%), or greater than 16 years of experience (n=25; 35.7%) (see Table 1). Nurses working in a hospital with Magnet designation were 25.7% (n=18). Four respon­ dents reported they did not know if their facility held the Magnet designation (5.7%).

Table 1. Sample Demographics

Characteristics Specific Attribute Study Sample

N (%)

Gender Female 59 (84.3)

Male 9 (12.9)

Prefer not to answer 2 (2.9)

Age 19-25 6 (8.6)

26-30 12 (17.1)

31-35 10 (14.3)

36-40 7 (10.0)

41-45 8 (11.4)

46-50 9 (12.9)

51-55 9 (12.9)

56-59 6 (8.6)

60 and older 3 (4.3)

Basic RN education

Diploma 5 (7.1)

Associate’s degree 38 (54.3)

Bachelor’s degree 23 (32.9)

Master’s degree 4 (5.7)

Highest level of formal education

Associate’s degree (AD) 22 (31.4)

Bachelor’s degree in nursing (BSN) 23 (32.9)

Other bachelor’s degree (non-nursing) 8 (11.4)

Master’s degree in nursing (MSN, MN) 11 (15.7)

Other master’s degree (non-nursing) 4 (5.7)

Doctor of nursing practice (DNP) 0 (0.0)

PhD (nursing) 0 (0.0)

Other doctoral degree 2 (2.9)

Nursing specialty3

Medical/Surgical 28 (40.6)

Intensive care 11 (15.9)

Emergency department 9 (13)

Pediatrics 1 (1.4)

Surgical services 1 (1.4)

Mental health 2 (2.9)

Women’s health 7 (10.1)

Outpatient services 10 (14.5)

Years of nursing experience

6 months -1 year 11 (15.7)

2 - 5 years 19 (27.1)

6 - 1 0 years 8 (11.4)

11-15 years 7 (10.0)

16 years and greater 25 (35.7)

ANCCb Magnet status

Yes 18 (25.7)

No 48 (68.6)

Don’t know 4 (5.7)

aOne participant did not define nursing specialty. b American Nurses Credentialing Center

144 NURSING ECONOMIC$/May-June 2014/Vol. 32/No. 3

Table 2. Additional Survey Questions

Question Specific Attribute Study Sample

N (%)

Has the number of patients assigned resulted in job satisfaction?

Yes/Sometimes 61 (75.4)

Has the current economic downturn influenced your decision to stay in your current position?

Yes 61 (63.9)

The first research question ex­ plored whether there was a rela­ tionship between nurse staffing (nurse-patient ratios) and job satis­ faction. Survey participants were asked to quantify the number of patients they had been assigned during the last shift they had worked. The data were not nor­ mally distributed. Overall, the reported mean patient assignment for each nurse for his or her last worked shift was 5.6. The range for all respondents was 1:1 to 1:10 or greater (n=63). In Magnet insti­ tutions, the mean nurse-patient ratio was 1:5.3 (n=17). Job satisfac­ tion was determined using the COP subscale, which is derived from the NWI-R survey tool (Aiken & Patrician, 2000). Nine participant responses were remov­ ed from the COP analysis as there was either no response to all of the subscale questions (n=5) or there was a limited response (n=4). Two additional respondents answered all but one question in the sub­ scale. Data substitution was implemented for these two sub­ jects. The mean of all answered subscale responses was substitut­ ed for the missing value. The data for the COP are a sum of all ques­ tion responses in the subscale, which were normally distributed. Correlation coefficients between nurse-patient ratios and the NWI- R COP subscale were examined using Spearman’s rho. A weak positive relationship between COP and nurse staffing was identi­ fied, (59) = 0.33, p = 0.01, two- tailed. This weak relationship implies there is a relationship between workload and job satis­ faction.

The second research question explored whether there was a rela­ tionship between job satisfaction and nurse retention. Spearman’s rho was used to test the correla­ tion between job satisfaction, using the NWI-R COP subscale, and whether nurses had thought about leaving their position in the past 6 months. The data for this variable were not normally dis­

tributed. A moderately strong neg­ ative correlation was demonstrat­ ed, p(59) = -0.43, p = 0.01, two- tailed. The null hypothesis was rejected as there was a demon­ strated inverse relationship bet­ ween job satisfaction and nurse retention which indicates as job dissatisfaction increases, the more likely a nurse will think about leaving his or her nursing posi­ tion.

Responses from the additional survey questions are shown in Table 2. The additional questions addressed whether nurses felt job dissatisfaction, which can be attributed to nurse-patient ratios, and was the economy a factor in remaining in their current nursing position.

Discussion The COP subscale of the NWI-

R measures six aspects of profes­ sional nurses’ control over their nursing practice. This study sug­ gests there is a problem in the pro­ fessional nurses’ work environ­ ment, which has created job dissatisfaction for many nurses participating in this research. Identifying the issues that create dissatisfaction at work is impor­ tant. Job satisfaction is the fore­ most indicator of the likelihood an individual will remain in a posi­ tion, and is a significant factor in nurse turnover (Brewer, Kovner, Greene, Tukov-Shuser, & Djukic, 2012; Hill, 2011; Larrabee et al., 2003; O’Brien-Pallas, Murphy, Shamian, Li, & Hayes, 2010; Tellez, 2012; Wang, Tao, Ellenbecker & Liu, 2012).

Nurse turnover is a costly pro­ position with estimates from $42, 000 for a medical-surgical nurse to $80,000 to hire and orientate a specialty nurse (Burr et al., 2011; Tellez, 2012). Some researchers argue that improving nurse-pa­ tient ratios will not result in any cost savings for an organization but will in fact increase health care costs (Buerhaus, 2010; Reiter, Harless, Pink, & Mark, 2012; Tevington, 2011). Salary expenses will increase immediately when an organization adds nursing staff to meet staffing recommendations (Reiter et al., 2012; Welton, 2007). However, a growing body of re­ search suggests long-term savings will be indirect and will occur as nurse retention and patient out­ comes improve (Burr et ah, 2011; Cho, Ketefian, Barkauskas, & Smith, 2003; Shamliyan et ah, 2009).

During the recent period of economic upheaval, which began in late 2007, the shortage of nurs­ es has significantly lessened (Staiger, Auerbach, & Buerhaus, 2012). Buerhaus, Auerbach, and Staiger (2009) stated that between 2006 and 2008, there was an increase of 250,000 nursing full­ time equivalents, marking an un­ precedented period of growth. This growth was attributed to the recession and the need for nurses to return to the workforce as confi­ dence in job stability waned and the potential for a nurse’s spouse losing his or her job became a real­ ity (Buerhaus & Auerbach, 2011). Nurses are remaining in their positions, older nurses are not retiring, and new graduate nurses

NURSING ECONOMIC$/May-June 2014/Vol. 32/No. 3 145

are having difficulty finding their first staff nurse position (Tellez, 2012). This study confirms that many nurses are not leaving their current positions because of the uncertain economy, despite de­ clining job satisfaction. This find­ ing is supported by Buerhaus and Auerbach (2011).

Limitations and recommenda­ tions for future research. The pri­ mary limitation for this study was sample size. With over three mil­ lion nurses practicing in the United States, it is difficult to determine the generalizability of this research to the larger popula­ tion.

The COP subscale is widely recognized as a valid survey tool to measure job satisfaction in a nurse’s professional work environ­ ment. The COP is a broad indica­ tor of job satisfaction, and meas­ ures many aspects of the work environment that impact a nurse’s job satisfaction. Future research may benefit from the use of a spe­ cific tool that addresses nurse staffing issues that are specifically related to nursing job satisfaction.

In addition, data collection was a convenience sample collect­ ed over 30 days. Further research with a larger sample is indicated to explore the relationship bet­ ween nurse staffing and job dissat­ isfaction in the current economic environment. Magnet hospitals have the reputation for providing an improved nursing work envi­ ronment, which includes decreas­ ed patient assignments for nurses. Exploring a comparison between Magnet and non-Magnet facilities may well demonstrate the value the Magnet designation has for a hospital in terms of nurse satisfac­ tion and subsequent retention of professional nurses.

Implications for practice. Im­ proving nurse staffing will be nec­ essary when the economy im­ proves to prevent an exodus of discontented nurses. Improving nurse staffing can be a feasible solution for patients, health care facilities, and nurses. Evidence

has shown patient outcomes will improve, which will indirectly decrease costs associated with longer lengths of stay, costs associ­ ated with hospital-acquired condi­ tions, and medical errors.

The mandatory nurse-patient ratio law enacted in California in 2004 has been associated with improved nurse satisfaction (Spetz, 2008; Spetz & Herrera, 2010; Tellez, 2012). Buffington, Zwink, Fink, DeVine, & Sanders (2012) des­ cribed themes identified by regis­ tered nurses for reasons they leave a bedside nursing position. One such theme was workload and staffing. Those same nurses were also asked to identify strategies that would retain them in their bedside nursing role. A key strate­ gy for retaining bedside nurses was identified as improving nurse-patient ratios. Improving nurse staffing will likely improve nurses’ job satisfaction and in doing so will help in keeping needed nurses at the bedside and decrease the likelihood of a new nursing shortage.

Conclusion Preventing nurse turnover

will decrease the high cost of employing and training new nurs­ ing staff. Improving job satisfac­ tion among nurses will be a key factor in retaining experienced nurses at the bedside. The present study has suggested a relationship between job satisfaction and an appropriate patient assignment. Reducing the number of patients a nurse is responsible for during a work shift will improve job satis­ faction, improve patient out­ comes, and save health care dol­ lars. $

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Multiple Patient Safety Problems Are Uncommon But Resource Intensive It is uncommon for a patient to experience multiple patient safety prob­

lems during one single hospitalization, according to a recent study. A team of RAND Corporation researchers found that multiple patient safety events (MPSEs) occurred in approximately 1 in every 1,000 hospitalizations and affected more than 30,000 patients in 2004.

The vast majority of hospital admissions involved no MPSEs; about 2% involved one safety event, and 0.1% met the criteria for an MPSE. Among MPSE admissions, the most common type of adverse event was failure to res­ cue (from complications of hospital care), occurring in about half of all such cases.

The study concluded that, despite their low prevalence, MPSEs have dis­ tinct characteristics and are far more resource-intensive than hospital admis­ sions generally.

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