IN THE MARCH ISSUE of Nursing2007, we invited nurses from Nursing2007's readership-and beyond-to answer 45 questions about their experiences on the job and what was important to them in their work. Ultimately, 1,783 nurses responded: 1,441 who participated on the Internet and 342 who responded by mail or fax. The typical respondent was a hospital-based RN with more than 15 years' experience working as a staff or charge nurse. (See Respondent snapshot for more details on survey respondents.)
Although answers provided by this group of volunteers can't provide us with a scientifically valid picture of any group of nurses other than themselves, the results line up pretty well with formal research surveys of nurses selected at random from larger populations. (See About this survey.)*
Here's an overview of the nurses responding to this survey.
* Sex: 93% were women.
* Experience in nursing: 56% reported more than 15 years' experience.
* Licensure: 84% were RNs.
* Salary: 77% reported earning between $40,000 and $80,000 annually.
* Clinical setting: 69% worked in hospitals.
* Job title: 56% were staff nurses.
* Specialty certification: 37% reported being certified in a clinical specialty.
* Nationality: 96% were from the United States; the rest were roughly divided between Canada and other countries.
Looking at the big picture
Let's examine what survey respondents had to say, starting with the "big picture" question: Overall, how do you rate your job satisfaction in your present position? Using a 1-to-5 scale, here's how they responded:
* very satisfied, 13%
* somewhat satisfied, 23%
* neither satisfied nor dissatisfied, 32%
* somewhat dissatisfied, 23%
* very dissatisfied, 9%.
Job satisfaction is a good top-line indicator of how people feel about their jobs and is one of many variables that predict how someone performs at work or whether she's likely to voluntarily leave her position. In our survey, responses to this question were pretty evenly distributed. When we allowed nurses to "sit on the fence" by choosing the neutral 3 on the 5-point scale, that's what the largest group (32%) did. But a similar proportion (36%) reported being either very satisfied or somewhat satisfied with their jobs.
The level of satisfaction reported here is higher than that found in surveys of Pennsylvania hospital nurses in 1999. During that particularly difficult time in the health care industry, 41% reported being somewhat or very dissatisfied with their jobs.1 There are some indications that things may have become better since salaries, job security, and attention to working conditions have all improved over the course of the current shortage.
However, other recent surveys have found considerably higher satisfaction than these results would suggest. For example, in the 2004 National Sample Survey of Registered Nurses, a major study conducted every 4 years by the federal government, 78% of respondents reported being extremely or somewhat satisfied. Only 8% "sat on the fence." This is considered one of the broadest, most representative surveys of nurses.2 Only 12% of nurses in a national sample of Canadian nurses in 2005 reported being dissatisfied.3
We can probably assume that, on average, our respondents were somewhat less happy with their jobs than nurses in other samples; they may have even chosen to participate in the survey on that basis.
Professional practice environment: Do you get the respect you deserve?
Nursing is knowledge work carried out by educated professionals who want freedom to exercise their good judgment on the job. They want their leaders and representatives to have a voice in the operations of their facilities, and they want respect.
When we queried nurses on this aspect of their jobs, the responses weren't particularly favorable, as shown in Figure 1.
|Figure 1: Control over practice|
Most nurses felt they could practice autonomously, and nearly half felt that nurse-leaders controlled issues related to nursing practice. But lower proportions of respondents reported staff nurse involvement on committees or said that their facility's culture supports the profession.
Only 28% reported that nurse job satisfaction was being measured and addressed in their facilities. This is somewhat surprising, given the deepening nursing shortage.
Does management have your back?
Frontline nurse-managers have an enormous impact on quality of work life by shaping the environment in which nurses provide care. Although almost half of the nurses reported that their leaders were visible and accessible, only 35% felt that their managers supported staff nurse decisions in the face of conflict outside nursing.
As far as our survey respondents were concerned, front-line leadership could stand some improvement too. Visibility of nurses at the executive level was very strong: 67% said a nurse-executive participates in decision making with other chief officers of the facility. This item got one of the highest positive responses on the entire questionnaire, which may indicate that our respondents see strong nurse leadership at the top levels but don't see enough impact "in the trenches."
Staffing levels: A key controversy
Nurses and health care leaders don't question whether staffing is important, but they do have strong opinions about what constitutes a reasonable patient load and about how staffing should be managed and possibly regulated. To see what our survey respondents had to say about staffing in their facilities, see Figure 2.
|Figure 2: Staffing levels|
The low agreement with these statements suggests that staffing is an ongoing problem for nurses in many settings. But keep in mind that in a convenience survey, respondents who take the time to fill out and return the survey may be more negative than their colleagues at large.
The nurses' perceptions here were similar to or more negative than responses to earlier surveys. Only 34% of hospital nurses in Pennsylvania surveyed in 1999 felt enough nurses were available to provide high-quality patient care. In 2005, 48% of nurses in a national Canadian sample agreed that nurse staffing was adequate for high quality patient care.1,3
Breaks and overtime
Relatively small but still sizable proportions of nurses (13% and 24%) report they never take meal or rest breaks during their shifts. And it's clear that nurses skip meals and breaks on a fairly regular basis. Comparatively few nurses were aware of facility policies that limit work hours or mandatory overtime (Figure 3).
|Figure 3: Breaks and overtime|
Growing evidence from health care and other fields links long work hours, particularly past 12 hours, with errors on the job and health problems.4,5 More states are passing or considering legislation barring mandatory overtime.
Working with physicians
We were disappointed to see that relatively few nurses answering the questionnaire indicated that relations between nurses and physicians were on the right track in their facilities, as shown in Figure 4.
|Figure 4: Nurse/physician relationships|
The survey of Pennsylvania nurses from 1999 found that 80% or more of hospital nurses reported positive relationships with physicians.1 However, various researchers have continued to report that negative nurse/physician interactions are an ongoing problem.6 In cases where the problem is especially severe, it can cause turnover and lead to safety problems.
How good is staff education?
Do you feel your facility provides nurses with adequate education and training? See how our survey respondents viewed the issue in Figure 5.
|Figure 5: Staff education|
Although most nurses agreed that formal programs for continuing education were in place in their facilities, only a minority agreed that clinically oriented education directly connected to their jobs was adequate.
Can you get the information you need?
Interestingly, despite ongoing discussions of the importance of integrating best practices based on evidence, a minority of respondents reported that their facilities readily change policies and procedures in response to external authoritative data (Figure 6). Only half of the nurses believed that patient-information systems and access to clinical references were strong in their jobs. These figures should improve as electronic health records are incorporated into more practice settings in the coming years.
|Figure 6: Availability of reliable information|
Mixed messages about benefits
Relatively few nurses reported being actively dissatisfied with their medical and dental plans and retirement benefit packages, but not many indicated they were actually satisfied (Figure 7). As the U.S. nurse workforce ages, many nurses are working longer at older ages than ever before-a big reason the nursing shortage isn't even worse than it is. Interestingly, when we analyzed these responses, we found that nurses earlier in their careers were no more likely to be satisfied with their benefit packages than more senior nurses. Many commentators have observed that the caliber of benefit packages for all nurses needs to be bolstered to improve retention.
|Figure 7: Medical and benefits plans|
Which of all of these factors counted most?
Every one of the factors we've discussed so far was correlated with nurses' overall job satisfaction when we conducted statistical analyses; that is, if a nurse agreed that any of the positive factors was present in her current position, she was more likely to be satisfied with her job.
Out of all of these questions, which one was the most strongly associated with overall job satisfaction? Here's the winner: "The culture in my facility supports the nursing profession." In Figure 8 below, note how strongly a positive response to this question correlates with job satisfaction.
|Figure 8: Facility culture|
This finding isn't surprising. At their core, nurses want to serve their patients and know that the facilities where they work respect their contributions.
Your perspective depends on your role[horizontal ellipsis]
Survey after survey of nurses has found that staff nurses tend to be somewhat less positive about their work environments than managers and administrators. Figure 9 shows a sampling of items in our questionnaire comparing perceptions of hospital staff nurses and respondents who hold management positions.
|Figure 9: Staff nurse vs. management perspectives|
At times, nurses and their managers are seeing the world through different eyes and, perhaps, with different biases. These findings suggest that we should keep these differences in mind when reviewing any survey results for any purpose.
[horizontal ellipsis] as well as where you work
Figure 10 highlights the items with the biggest differences across settings, along with overall job satisfaction. Although the National Sample Survey shows a decline from 1984 to 2004 in the proportion of nurses working in hospitals (from 68% to 56%), hospitals still employ the most RNs in the country. The 2004 National Sample Survey found satisfaction lowest among nursing-home RNs and highest in outpatient settings, which is similar to what we found in this survey.2
|Figure 10: Where you work matters|
What are nurses looking for when they seek new jobs?
Figure 11 shows what matters most to our survey respondents. Money may not be everything, but nurses acknowledge that salary is a major factor they consider when considering a new position, followed closely by staffing and benefits.
|Figure 11: What job-seekers look for|
Nurses in national surveys from 2002, 2004, and 2006 indicate that improvements in many of these features, including their work environments, are ones they believe would greatly help to resolve nurse shortages.7 Features such as tuition benefits, sign-on bonuses, and child care appear to enter into decisions for few nurses, perhaps because they're not offered, they aren't relevant, or they don't appeal to most nurses responding to this survey.
Clearly, years of nursing experience also affects what nurses value. Figure 12 suggests that what nurses value in a new nursing position will change as they gain experience.
|Figure 12: How experience affects values|
Predictably, nurses aren't necessarily interested in the same things as their careers and lives move forward. Early in their careers, nurses seem to care more about adequate staffing levels, flexible scheduling, and tuition reimbursement, which isn't surprising given that they're still learning their jobs and care about career mobility. More seasoned nurses focus on health care benefits, work located close to home, and opportunities to practice independently. Nurses later in their careers and lives seem to be more concerned about quality of life issues, such as the impact of commuting, access to health care, and an opportunity to apply the clinical knowledge they've gained in their careers.
How Magnet hospitals stack up
Sixteen percent of all respondents and 19% of hospital-based respondents reported working in a Magnet hospital. Currently the Magnet Recognition Program of the American Nurses Credentialing Center primarily involves hospitals.8 We examined responses from all nurses working in hospitals to compare the experiences of those working in Magnet and non-Magnet hospitals. For a summary of our findings, see Figure 13.
|Figure 13: Magnet vs. non-Magnet status|
Nearly all the job elements were superior in Magnet hospitals; all statistically significant differences we found favored Magnet nurses. These findings are consistent with the findings of recently published research that shows consistently higher scores on many questions and tools for Magnet hospitals or hospitals in the process of applying for Magnet status, but some of these differences are small.9,10
The items listed in Figure 13 are the ones that showed the biggest differences in our survey. Not surprisingly, these are key elements of the Magnet program itself.
On the whole, nurses working in Magnet hospitals were more likely to be satisfied with their jobs, but the difference was relatively small. Even Magnet hospitals may have more work to do, particularly in addressing the concerns of nurses who feel disenfranchised.
It's notable that the one item in this survey that was most closely associated with overall job satisfaction-support of nursing by the facility culture-has been a key Magnet characteristic since the beginning of the concept. This factor rated considerably higher among Magnet nurses.
As the best-known and best-researched package of principles for designing optimal work environments for nursing practice, the Magnet program clearly deserves continued study and development.
Here's the bottom line
So what did this convenience sample of Nursing2007 readers tell us about their job satisfaction in this survey? Although the patterns of answers to some questions suggest that those who answered may have had stronger negative feelings about some aspects of their jobs than nurses in general, nearly all the responses were in line with those of other studies that used different, more representative sampling strategies. There was indeed a range of opinions and experiences in these data.
On the whole, many of you indicated that your facilities still have some work to do to improve working environments and conditions. Meeting this major challenge will be critical to managing serious shortages of nurses in decades to come. Honest discussion of what's working well and what needs improvement can provide an important starting point for this work. Here's hoping that the responses you provided to this survey stimulate more discussion and progress.