Job satisfaction trends during nurses' early career
Trevor Murrells*, Sarah Robinson and Peter Griffiths
Address: National Nursing Research Unit, King's College London, Florence Nightingale School of Nursing and Midwifery, 57 Waterloo Road,
London SE1 8WA, UK
Email: Trevor Murrells* - trevor.murrells@kcl.ac.uk; Sarah Robinson - sarah.robinson@kcl.ac.uk; Peter Griffiths - peter.griffiths@kcl.ac.uk
* Corresponding author
Abstract
Background:
patient safety, productivity and performance, quality of care, retention and turnover, commitment
to the organisation and the profession. Little is known about job satisfaction in early career and
how it varies for different groups of nurses. This paper investigates how the components of job
satisfaction vary during early career in newly qualified UK nurses.Job satisfaction is an important component of nurses' lives that can impact on
Methods:
Data were collected by questionnaire at 6 months, 18 months and 3 years after qualification
between 1998 and 2001. Scores were calculated for seven job satisfaction components and a single
item that measured satisfaction with pay. Scores were compared longitudinally and between
nursing speciality (general, children's, mental health) using a mixed model approach.Nurses were sampled using a combined census and multi-stage approach (n = 3962).
Results:
component. Rank order of job satisfaction components, from high to low scores, was very similar
for adult and child branch nurses and different for mental health. Nurses were least satisfied with
pay and most satisfied with relationships at 6 and 18 months and with resources (adult and child)
and relationships (mental health) at 3 years. Trends were typically upwards for adult branch nurses,
varied for children's nurses and downwards for mental health nurses.No single pattern across time emerged. Trends varied by branch and job satisfaction
Conclusion:
specialism. Different contexts, settings and organisational settings lead to varying experiences.
Future research should focus on understanding the relationships between job characteristics and
the components of job satisfaction rather than job satisfaction as a unitary construct. Research that
further investigates the benefits of a formal one year preceptorship or probationary period is
needed.The impact of time on job satisfaction in early career is highly dependent on
Background
Job satisfaction is an important component of nurses'
lives that can impact on patient safety, staff morale, productivity
and performance, quality of care, retention and
turnover, commitment to the organisation and the profession
with additional replacement costs (e.g. agency staff)
and further attempts to hire and orientate new staff [1].
Turnover rates of 35% to 55% in first year of employment
have been reported in the US [2]. In the UK nursing
employment fell to 82% 3 years after qualification in a
longitudinal study of early career nurses [3]. The cost of a
US graduate nurse who leave nursing within 1 year of
Published: 5 June 2008
BMC Nursing
Received: 24 September 2007
Accepted: 5 June 2008
This article is available from: http://www.biomedcentral.com/1472-6955/7/7
© 2008 Murells et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.2008, 7:7 doi:10.1186/1472-6955-7-7
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qualification has been estimated at $40 K [4]. It has been
shown that when job satisfaction increases turnover
decreases (e.g. [5]). Job satisfaction is dynamic and can
vary according to individual characteristics, expectations,
style of management, changes to policy and individual
lifestyle choices [6-8]. Ensuring that needs of nurses are
met is particularly important during early career since
what is laid down here could impact dramatically on
nurses' contribution in the longer-term.
This paper reports on research that investigated how the
components of job satisfaction vary during early career in
newly qualified UK nurses using an instrument recently
developed for nurses in early career that was valid and reliable
across specialty and time.
Interpretation of findings draws on previous research to
explain why particular trends may have emerged. This
research provided a longitudinal perspective to the understanding
of nurses' job satisfaction. Past research has often
been cross-sectional, focusing on all types of nurses at all
career stages rather than on nurses specifically in early
career across different specialties. The few studies on early
career have all have focused on the first year or eighteen
months [2,4,9]. This study therefore makes a distinctive
contribution to the study of nurses' job satisfaction over a
longer period of time than previously studied.
Theories of job satisfaction
Understanding what motivates workers and how this
impacts on performance has always interested organisations
and managers and different theories have sought to
answer this question. Fung-Kam [10] identified four general
theories: need/value fulfilment theory; person-environment
(P-E) fit theory, the theory of career and the
theory of work adjustment. Similarly Adams and Bond
[11] classified job satisfaction theories into three groups:
discrepancy theories, which examine the extent to which
employees needs are satisfied in the work place; equity
theories, which highlight social comparisons in the evaluation
of job rewards; and expectancy theories which focus
on employee motivations. The theory of need/value fulfilment
proposes that the discrepancy between individual
needs and the extent to which the job meets these needs is
negatively related to job satisfaction and expectation gaps
[12] have been linked to the violation of the psychological
contract between employer and employee [13]. Theory of
P-E fit suggests there are person characteristics that suit
working environments better than others and working
environment characteristics that suit certain individuals
better. Drawing on both theories failure to meet expectation
has been shown to be related to lower work commitment
of graduates and the extent they 'fitted' in was a
central motivation to remain with an employer [14]. Connected
to P-E fit is the theory of work adjustment. This
theory is concerned with the degree of correspondence
between individuals and their work environments. Hackman
and Lawler [15] believed that the employees' perception
of their job rather than the jobs objective
characteristics was a more important determinant of job
satisfaction. Holland's theory of career [16,17] suggests
that personality and type of work are congruent so similar
types of individuals converge on the same occupations.
The two theories that have been important in the development
of an understanding of job satisfaction in nursing
are Maslow's human needs theory [18] and Herzberg and
Mausner's motivation-hygiene theory [19]. Maslow identified
two types of needs; deficiency needs (physical,
safety and belonging) and growth needs (self-actualization
and self esteem) [20]. Herzberg and Mausners' theory
consists of intrinsic factors or 'motivators' that promote
job satisfaction and extrinsic factors or 'hygiene factors'
that cause dissatisfaction [8]. Kramer's reality shock theory
[21] is based on the reaction new nurses feel once they
enter a work situation that they are unprepared for and
has also been used to understand job satisfaction in
nurses in early career.
Determinants of satisfaction
Blegen [6] synthesised findings from 48 studies and identified
thirteen variables that were most strongly associated
with job satisfaction. These included stress, commitment,
communication (with supervisor and peers), autonomy
(and locus of control), recognition, routinization, and
fairness. A secondary analysis of data [22] from the 1977
Quality of Employment Survey [23] found that task variety,
relations with co-workers, financial rewards and age
were all positively associated with job satisfaction. Conversely
role conflict and tenure had negative effects
although the latter finding was not consistent with other
literature [22]. Work attitudes (supervisor support, workgroup
cohesion, variety of work, autonomy, organizational
constraint, promotional opportunities, work and
family conflict, and distributive justice) were also important
in explaining the job satisfaction of registered nurses
in the United States [24].
Different managerial styles and practices at the organisational
unit level (e.g. ward) can have a direct bearing on
nurse satisfaction. The work of Adams and Bond [11]
highlighted the importance of interpersonal relationships
with nurses and other medical staff, workload and ward
cohesiveness. A number of studies [25-28] have shown a
positive association between autonomy and levels of job
satisfaction and which has been confirmed amongst
nurses [6,10,29-31].
The effect of educational level on job satisfaction has been
conflicting. Some studies have found a positive associa
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tion with job satisfaction [32,33] and others a negative
association [3,6,34]. Lower level qualifications impacted
positively on job satisfaction based on findings from a
survey of NHS nurses [35]. The same study found training
had a positive impact on job satisfaction but diminished
with the number of training spells. The inverse relationship
supports the argument that education raises expectations
that subsequently are not met [14] whereas a
positive correlation suggests that the greater extrinsic
rewards that come with education raises satisfaction. Blegen
[6] found that job satisfaction correlated less strongly
with age or years of experience, while Shields and Ward
[35] found that increasing age, marriage, and children
impacted positively on nurses' satisfaction.
In a study of nurses working in the NHS [35], individuals
who stressed non-pecuniary reasons (e.g. flexibility of
hours, helping others) had significantly higher job satisfaction
than those who did not (e.g. attracted by job security,
promotion prospects, pay). Not being graded fairly
was the largest negative determinant of overall job satisfaction
and not having the hours to suit an individual's
preference had a negative impact. Absolute and relative
levels of pay (compared with other occupational groups)
are also important [36].
Job satisfaction in early career
There have been a number of US studies recently which
have researched job experience and satisfaction during the
early years after qualification [1,2,4,5,9]. These have covered
the period up to 18 months after qualification and
some are longitudinal [2,4,9]. Graduate nurses were
found to lack confidence in skill performance and had
concerns with peer and preceptor relationships, dependence
(on others) and becoming an independent practitioner,
the work environment, organizational and priority
setting and communications with physicians [9]. Lowpoints
in satisfaction and confidence between 6 and 12
months have been reported in the US [9]. Graduates participating
in residency programs were particularly vulnerable
between entry and 6 months [2]. Dissatisfaction with
patient care, scheduling (work-life balance) and pay may
precipitate job exit [4]. Low pay satisfaction has been
reported in the US [9].
Before a nurse can practice in the UK they must hold a
bachelors degree or diploma in nursing. These educational
programmes consist of theory and practice (in community
and hospital settings) in roughly equal
proportions beginning with a common foundation programme
(CFP) lasting 12 months followed by about two
years in one of the four branches of nursing: adult(general),
mental health, learning disabilities or children's
nursing. Either qualification allows a nurse to register
with the Nursing and Midwifery Council (formally the
United Kingdom Central Council (UKCC)). The diploma
qualification is similar in educational level to a US associate
degree but training extends over three years and there
is a single level of professional registration (equivalent to
a US Registered Nurse) irrespective of the training programme.
Adult nurses work with adults of all ages and
children's nurses with newborns to adolescent (0–16
years). Both provide care to patients with chronic and
acute health conditions. Learning disability nurses help,
care and develop the skills of people with disabilities in
family, community and residential settings, and adult and
young peoples' education. Mental health nurses provide
care for mentally ill people and their families primarily in
the community and less often in a hospital setting. Nurses
can specialise further after gaining experience in more
general settings post-registration. At the time of the study
the pre-registration degree and diploma were the only
points of entry. The majority (over 80%) of individuals
opted for the diploma programme.
Newly qualified nurses in the UK typically used to start as
D Grade nurses and after a minimum of 6 months postregistration
experience could become E grade nurses.
Nurses at this grade were often encouraged to gain valuable
management experience and/or receive further training
in a specialty (e.g. accident and emergency). F grade
nurses had more of a managerial role and were sometimes
left in charge of a ward or other setting. In December 2004
these grades were superseded in the UK by Agenda for
Change pay bands [37].
Our research examines how job satisfaction varies
amongst newly qualified nurses in the England over time
in early career (6 months, 18 months, 3 years) and to what
degree trends in factors arising from a factor analysis of a
multi-item job satisfaction question [38] vary between
specialisms.
Methods
Design
The design was longitudinal and correlational with data
collected at four time-points (qualification, 6 months, 18
months, 3 years). The 6 month time-point was selected to
reflect early experiences, 18 months to reflect established
early experiences and first promotion, and three years to
reflect consolidation. More frequent follow-up was considered
but deemed undesirable due to the potential burden
this would place on respondents who were asked to
complete large questionnaires at each survey sweep.
Sample
The study population was formed from all nurses qualifying
in 1997/98 from the diploma programme in England.
A mixed approach to sampling was undertaken determined
by the population size of each branch. Initial esti
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mates of the children's and learning disability branch
nurse populations were small (574 and 246 respectively).
Estimates of the adult and mental health branches were
much larger (4850 and 1142 respectively). A decision was
taken therefore to sample all children's and learning disability
nurses qualifying in England. The larger adult and
mental health branch nurse populations were sampled
using a multistage approach based on the eight regional
health authorities (that existed at the time), colleges and
intakes. Between three and eight college of nursing
(depending on branch) were located in each region.
Approximately a half and two-thirds of colleges were sampled
from each region for the adult and mental health
branches respectively. These sampling fractions were
based on information previously collected from the English
National Board and our own enquiries to Colleges of
Nursing. There was further sub-sampling at the college
level of the adult branch when intakes were large. The
number of college intakes(classes) for the adult, children's
nurses, mental health and learning disability branches
was 46, 49, 56 and 34, the total number eligible to be
recruited was 2109, 758, 293 and 802 respectively (total
3962) and recruitment rates were 87%, 93%, 90% and
85% respectively (88% overall). A comprehensive report
of the sampling strategy is found in Marsland and Murrells
[39].
The number and percentage responding at each sweep was
as follows: qualification (3009, 80%), 6 months (2524,
64%), 18 months (2118, 53%), three years (1785, 45%).
Non-response is common to most longitudinal postal surveys
particularly when the point of contact is home
address. We asked nurses to inform us of address changes.
Questionnaires were always sent to last known address
and if no response to second address (typically parents)
and finally to the UKCC registered address (written on the
envelope at the UKCC premises). Higher non-response
rates were noted in parts of the country where nurses were
likely to change address more often (e.g. London) and
therefore contact was more easily lost. Region of workplace
was therefore included in the statistical model to
compensate for regional heterogeneity.
Job satisfaction measure
We wanted to measure job satisfaction specifically for
nurses in early career. Existing nursing scales suffer from a
number of limitations. Some have not been adequately
tested for reliability and validity, they are often very long
or very short, not contemporary, developed from theory
without contextual representation and developed on
nurses from different healthcare systems [40]. For this reason
we chose to develop a new instrument [40] using the
five-step method recommended by Spector [41]. Following
in-depth interviews of 30 diploma-qualified nurses a
pool of items was generated and the number of interviewees
who regarded each item as important was noted. A
total of 34 items were identified. A small number of items
were added as the study progressed to reflect aspects pertinent
to career after qualification. Each item was measured
on a five point scale from
dissatisfied
response option. The set of items available for psychometric
analysis was reduced because either the item did not
apply (e.g. many respondents did not have a family or
partner) or the item did not apply across all time points
(e.g. content of appraisals). Further analysis was confined
to the twenty items applicable to over 90% of respondents.
Psychometric analysis was initially confined to the
adult branch and included tests of temporal stability
across time. Further validation across specialties and over
time has now taken place [38]. Factor analysis (not
reported here) of twenty selected items that were asked at
all three time-points and were applicable to at least 90%
of respondents identified two potential seven factor measurement
models (Client Care, Staffing, Development,
Relationships, Education, Work-Life Interface, Resources)
for nurses' job satisfaction in early career that differed on
the loading of one item,
line-managervery satisfied to very. Some items had a 'not applicable' or similaremotional support from immediateeither on the Relationship(Model I) or the
Development
in the fit of the two models. Model I was a better fit for the
adult branch and model II for the child and mental health
branches. The difference in overall fit however was small
(Root Mean Square Error Approximation 0.021 and 0.022
respectively). We did not want to further burden respondents
who were asked to complete a large questionnaire
(sometimes running to over 60 questions) on four occasions
over a three year period) with an additional questionnaire
to test inter-rater reliability however internal
consistency was good with Cronbach's alphas all above
0.7 except for
factor scores recorded at 6 and 18 months ranged from
0.27 to 0.42. The instrument did not provide a good fit for
the learning disability nurses and for this reason we have
excluded this branch from the data analysis. Findings
were similar for both models and for this reason (and for
brevity) we report on the second measurement model
(Table 1) which had a better fit for two of the three
remaining branches.
Pay which was represented by a single question item was
included as a notional eighth factor. The job satisfaction
question included two items on pay and grade which were(Model II) factor. There was little differenceWork-Life Interface and correlations between
Pay in relation to responsibility
to level of responsibility
months onwards and was therefore excluded from the
psychometric analysis on the grounds that it had not been
asked across all three time-points.and Grade/position in relation. The second item was asked from 18
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Access, participation and data collection
All participants gave informed consent. An initial request
to access students was made by letter to the 'head' of each
college [42]. The letter described the project and asked if
research team members could meet with students and
invite them to participate. The letter emphasised that participation
was voluntary. The recruitment meeting consisted
of a short presentation of 10 minutes followed by a
discussion of up to 30 minutes. During the meeting forms
were circulated and completed by those willing to participate.
Information requested included current address, a
second, more permanent, address (e.g. parents). The form
was accompanied by an information sheet. Various strategies
were used to recruit non-attendees such as asking
group members and course leaders to pass on recruitment
packs, writing to non-attendees via the course leader and
repeating the visit when there were a large number of nonattendees.
Agreement to participate was high for those who attended
these meetings (over 80%) but on the few occasions when
face-to-face recruitment was not possible this fell to below
50%. Participants were supplied with change of address
slips (and freepost envelopes) so if they moved we were
kept informed. Change of address slips were also supplied
with each survey questionnaire. Between 18 months and
3 years after qualification lost participants were traced via
the UKCC.
Job satisfaction information was collected as part of a
much larger postal questionnaire sent at 6 months, 18
months and 3 years after qualification. Baseline demographics
and other profile information were collected at
qualification. A question was designed specifically to collect
career history information and some of this information
(e.g. number of previous nursing posts) was used in
the modelling.
Ethical Considerations
Although the longitudinal study of nurses qualifying from
the pre-registration diploma course predated the requirement
of Multi-Centre Research Ethics Committee
approval, guidance was followed from staff of the university
from which students were recruited as to the internal
procedures required for ethical approval.
Data Analysis
Factor scores for each nurse were produced by taking the
mean of all the non-missing item scores. We applied the
more stringent condition that at least half of each factor's
items had to be answered otherwise the factor score was
set to missing. There is not set guideline on this. Bryman
and Cramer [43] used 50% or more as their exclusion criteria
in the example they presented. We could have considered
multiple imputation [44] but the success of this
method depends very much on the correction specification
of the non-response model and so this option was
Table 1: Measurement Model
Factor Item
Client Care
Opportunities to provide good quality care
Proportion of time I spend/spent on paperworkProportion of time I spend/spent providing direct client care ('hands on' care)
Staffing
Number of staff usually on daysRatio of qualified to unqualified staff on days
Development
Opportunity to reflect on practice with a group of colleagues
Opportunity to reflect on my own practice on my own while at work
Frequency of discussions about developing my career
Constructive feedback on my work from staff of a higher grade/position
Emotional support from my immediate line managerOpportunity to reflect on my practice with someone of a higher grade/position
Relationships
Emotional support from nurses of the same grade/positionQuality of working relationships with colleagues
Education
Opportunity to go on study days/workshopsOpportunitiy to go on courses other than study days/workshops
Work-Life Interface
Combining work hours with social life
Frequency with which I leave work on timeNotice of off duty
Resources
Adult and Child
Availability of supplies (e.g. dressings)Availability of equipment(e.g. hoists)
Mental Health
Availability of facilities (e.g. day room, quiet room, interview room)Availability of equipment (e.g. audiovisual, art materials, books)
PayPay in relation to level of responsibility
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not pursued. The average percentage of respondents
answering all items of a factor was 94% therefore any
resulting biases should be small.
A comparison of previous satisfaction levels of responders
and those who did not respond at subsequent time points
was conducted in order to determine if non-response was
itself related to satisfaction. Response group means were
compared statistically using ANOVA. This analysis did not
reveal any major differences in job satisfaction scores
between response groups nor did an analysis confined to
those nurses with complete data across all three timepoints
differ from nurses who provided data at one or
more time-points. On the few occasions where differences
did emerge these have been identified in the tables showing
factor means.
Summary statistics (means, standard errors) were produced,
by branch, across the three time-points. A strategy
for fitting repeated measures models, similar to the one
proposed by Wolfinger and Chang [45] was followed.
Three possible covariance structures (compound symmetry,
Huynh-Feldt and unstructured) were tested statistically
and the best fitting covariance structure was selected.
Differences between branches at each time-point were
tested statistically using ANOVA. The F-test for the time
effect within branch was obtained from a mixed model
incorporating the selected covariance structure. In the
tables showing factor means we test the equality of branch
means at each time-point and show the result in the far
right hand column. At the foot of each factor sub-column
we test the equality of means across the three time-points
within branch. At the end of the same row is a test of
equality of means across branch and time as indicated by
the four degrees of freedom in the numerator of the F-test.
All these tests were computed using SAS Version 8.
The analysis across time within branch was then repeated
having accounted for variation, attributable to ten moderating
variables. Some were time varying (children, spouse
or partner, job grade, region, age, number of previous
nursing posts, time in current job) whilst others did not
change across time (sex, ethnicity, highest education qualification)
(Table 2). All these variables were entered into
the model along with a factor representing the three timepoints.
Results
Sample Profile
The sample profile is shown in Table 2.
Mental health nurses were older at qualification than
adult branch nurses by about two and a half years who
were themselves older than child branch nurses also by
two and a half years. Over 90% of adult and child
branches were female compared with about 70% of mental
health nurses. Mental health nurses were more likely to
belong to an ethnic minority than the other two branches
and already have a degree level qualification. Grade progression
occurred more rapidly for mental health nurses
whereas progression was slowest for adult branch nurses.
By 3 years most nurses were onto their second or third
post. Nurses tended to stay in post for similar amounts of
time and by three years had been in their current post for
almost a year.
Job satisfaction trends, six months to three years postqualification
For
nurses and lowest for mental health nurses. Scores
changed little across time in both cases. The time profile
was different for the adult branch with a similar score to
the mental health branch (3.18 vs. 3.13) at 6 months rising
to 3.44 at 3 years. Children's nurses were on the whole
happier with
branches. Satisfaction with
for children's nurses and mental health nurses whereas a
linear upward trend was observed for adult branch nurses.
For these nurses a low score (3.12) was obtained at 6
months and by 3 years adult branch nurses were more satisfied
withClient Care (Table 3), scores were highest for the children'sStaffing (Table 3) than the other twoStaffing dipped at 18 monthsStaffing than mental health nurses.
Development
across time for all branches. The adult branch had a significantly
lower score at 6 months but had caught up children's
nurses by 18 months.
The only factor to produce scores in excess of 4 across all
branches and time-points was
Trends were stable across time and were significantly
higher for children's nurses than the other two branches
although in real terms the differences were small.
A common profile for
for all branches starting off low at 6 months followed by
a sharp increase at 18 months where it remained, apart
from a small increase, for children's and mental health
nurses whereas the score continued on an upward trajectory
for the adult branch. By 3 years the adult branch
nurses had almost caught up the mental health nurses.
Satisfaction with
positively, although at different rates across all branches.
Mental health nurses had established higher levels early
on. Greatest progress was observed for the adult branch
nurses who started from a significantly lower base at 6
months and had overtaken children's nurses by 3 years.
Satisfaction with
throughout for mental health nurses whereas satisfactionscores (Table 3) remained reasonably stableRelationships (Table 3).Education scores (Table 4) emergedWork-Life Interface (Table 4) progressedResources (Table 4) remained low
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Table 2: Sample profile
Adult Child Mental Health
Profile variable 6 months
Mean Mean Mean Mean Mean Mean Mean Mean Mean(1338) 18 months (1117) 3 years (901) 6 months (558) 18 months (477) 3 years (373) 6 months (442) 18 months (365) 3 years (300)
Age
% % % % % % % % %† 27.4 28.5 29.8 24.8 25.8 27.3 30.1 31.1 32.8
Female93.4 94.1 94.4 95.2 85.2 94.9 70.0 72.7 75.0
Ethnic Group
White British 87.1 88.8 90.0 91.6 93.1 92.8 80.6 83.4 86.4
White Irish 5.4 4.2 3.3 2.3 1.7 1.6 5.7 4.8 3.7
Other White 2.9 2.9 2.2 2.5 2.3 2.4 3.7 3.9 3.4
Asian, Black, Chinese 4.1 3.4 3.6 2.9 2.1 2.1 9.6 7.4 6.2
Highest Educational Qualification
Degree 4.5 4.6 4.8 3.1 2.5 2.1 15.9 14.9 16.0
Sufficient for degree entry 24.9 26.1 27.4 32.6 32.1 34.9 22.8 23.3 23.3
Not sufficient for degree entry 41.3 41.6 42.8 44.3 44.4 41.6 34.4 37.0 37.0
Access course/DC test 18.6 17.5 15.6 8.2 8.6 9.9 18.7 18.3 17.4
Other 10.7 10.2 9.5 11.8 12.4 11.5 8.3 6.6 6.3
Children living with respondent† 22.4 28.0 33.2 10.6 13.6 18.5 28.5 32.7 37.5
Spouse or Partner† 68.7 72.8 77.6 59.8 68.1 71.1 65.6 74.0 76.1
Region†
London 12.1 9.5 8.8 26.0 25.0 24.9 15.3 14.5 12.1
South East 18.4 17.5 14.7 17.1 14.3 12.6 21.0 18.6 18.5
South West 9.5 9.1 9.8 5.7 6.5 7.2 9.0 10.4 9.6
West Midlands 8.8 8.8 8.3 12.2 12.2 12.1 8.4 10.3 10.2
Eastern 10.2 10.6 10.4 5.3 6.5 7.5 9.8 9.1 10.6
Trent 9.5 9.4 9.5 6.3 7.6 8.0 8.8 8.0 7.3
North West 14.9 13.3 13.8 15.5 13.4 11.5 10.3 9.5 9.1
Northern & Yorkshire 15.4 14.7 13.6 10.9 10.5 8.9 15.7 15.9 15.0
Other/Not Nursing 1.3 7.3 11.2 1.1 4.2 7.2 1.7 3.8 7.6
Nursing grade†
D or Lower 99.6 73.2 38.0 99.5 59.5 20.4 93.7 23.8 8.6
E 0.1 11.0 40.0 0.2 31.9 57.4 3.7 63.5 50.0
F or higher 0.0 0.7 3.3 0.0 0.4 5.1 0.0 3.6 24.5
Other/Not Nursing 0.3 15.2 18.6 0.4 8.2 17.2 2.6 9.0 16.9
Mean Mean Mean Mean Mean Mean Mean Mean Mean
Number of nursing posts† n/a 1.6 2.4 n/a 1.6 2.4 n/a 2.1 2.9
Time in current nursing job† 5.5 10.2 11.2 5.6 10.3 10.3 5.3 8.7 12.2
† time varying variable
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improved over time for both adult branch and children's
nurses although there was a slight dip at 18 months for
children's nurses. The scores for the mental health nurses
were comparable to that obtained on
would not be unreasonable to assume that there was connection
between the two.
The lowest scoring factor of all was
improved over time for the adult branch and
after starting off low (2.44) had almost caught up mental
health nurses (2.63 vs. 2.65) by 3 years whereas it fell for
children's nurses although this was neither statistically
significant nor substantial in real terms.
In summary the strongest trends emerged for the adult
branch with increasing job satisfaction from six months
onwards for
Interface
significant increases between six and eighteen months forClient Care and itPay (Table 4). Pay satisfactionClient Care, Staffing, Education, Work-Lifeand Resources (Tables 3 and 4). There were also
Development
for the child and mental health branches. Mean profiles
over time were found to vary significantly between
branches on theand Pay. Fewer significant trends were apparentCare, Staffing, Development, Work-Life
Table 3: Factor means for Client Care, Staffing, Development and Relationships by branch and time
Adult Child Mental Health
Factor Time-point No. Mean SE No. Mean SE No. Mean SEBranch comparison (F [dfn, dfd] p)
Client Care
18 months 942 3.37 0.03 446 3.51 0.04 336 3.14 0.05 (16.27 [2,2325] < .001)
3 years 755 3.44 0.04 326 3.53 0.05 255 3.03 0.06 (24.34 [2,2325] < .001)
(F [df6 months 1255 3.18 0.03 533 3.54 0.04 427 3.13 0.05 (31.75 [2,2325] < .001)n, dfd] p) (23.26 [2,1322] < .001) (0.33 [2,558] .72) (1.75 [2,568] .17)1 (8.55 [4,2325] < .001)
Staffing
18 months 909 3.27 0.04 435 3.39 0.05 305 3.24 0.06 (2.60 [2,2301] .075)
3 years 711 3.41 0.04 307 3.51 0.05 213 3.32 0.07 (2.26 [2,2301] .10)
(F [df6 months 1241 3.12 0.03 529 3.55 0.04 414 3.41 0.05 (32.17 [2,2301] < .001)n, dfd] p) (17.28 [2,1312] < .001) (3.92 [2,715] .020)2 (2.67 [2,491] .070)1 (8.15 [4,2301] < .001)
Development
18 months 942 3.18 0.03 446 3.18 0.04 336 3.34 0.05 (4.48 [2,2327] .011)
3 years 755 3.16 0.03 326 3.20 0.05 255 3.32 0.06 (2.51 [2,2327] .081)
(F [df6 months 1257 3.05 0.03 534 3.23 0.04 427 3.30 0.04 (16.14 [2,2327] < .001)n, dfd] p) (9.45 [2,1323] < .001) (0.53 [2,559] .59) (0.26 [2,568] .77)1 (2.87 [4,2327] .022)
Relationships
18 months 938 4.19 0.03 446 4.32 0.03 335 4.14 0.04 (7.07 [2,2326] < .001)
3 years 753 4.16 0.03 324 4.25 0.04 254 4.08 0.05 (3.71 [2,2326] .025)
(F [df
Unstructured covariance unless indicated by superscript6 months 1257 4.19 0.02 535 4.32 0.03 425 4.17 0.04 (6.19 [2,2326] .002)n, dfd] p) (0.45 [2, 1323] .64) (1.44 [2,559] .24) (1.20 [2,565] .30)1 (0.28 [4,2326] .89)1 Compound symmetry; 2Huynh-Feldt
Table 4: Factor means for Education, Work-life interface, Resources and Pay by branch and time
Adult Child Mental health
Factor Time-point No. Mean SE No. Mean SE No. Mean SE (F [dfBranch comparisonn, dfd] p)
Education
18 months 940 3.40 0.04 445 3.66 0.05 334 3.61 0.06 (9.90 [2,2323] < .001)
3 years 754 3.59 0.04 326 3.70 0.06 255 3.63 0.07 (1.16 [2,2323] .31)
(F [df6 months 1248 3.06 0.04 531 3.36 0.05 425 3.18 0.06 (10.76 [2,2323] < .001)n, dfd] p) (56.22 [2,1321] < .001) (16.57 [2,558] < .001) (19.27 [2,444] < .001) (1.77 [4,2323] .13)
Work-Life Interface
18 months 939 3.46 0.03 446 3.49 0.04 336 3.63 0.05 (4.88 [2,2325] .008)
3 years 755 3.63 0.03 326 3.59 0.05 256 3.78 0.05 (4.13 [2,2325] .016)
(F [df6 months 1257 3.37 0.03 533 3.49 0.04 427 3.69 0.04 (18.82 [2,2325] < .001)n, dfd] p) (21.06 [2,1322] < .001) (1.80 [2,558] .17) (2.97 [2,569] .052)1 (2.47 [4,2325] .043)
Resources
18 months 938 3.69 0.03 445 3.69 0.04 333 3.09 0.06 (48.24 [2,2324] < .001)
3 years 740 3.78 0.03 320 3.80 0.05 254 3.08 0.07 (60.41 [2,2324] < .001)
(F [df6 months 1253 3.52 0.03 532 3.73 0.04 427 3.15 0.05 (36.74 [2,2324] < .001)n, dfd] p) (24.13 [2,1321] < .001) (2.16 [2,558] .12) (0.61 [2,565] .54)1 (6.46 [4,2324] < .001)
Pay
18 months 933 2.67 0.04 444 2.81 0.06 330 2.66 0.07 (2.29 [2,2321] .10)
3 years 751 2.63 0.04 326 2.78 0.07 255 2.65 0.07 (2.13 [2,2321] .12)
(F [df
Unstructured covariance unless indicated by superscript
Results biased by non-response (attrition): Adult, resources; Mental Health, pay6 months 1254 2.41 0.04 530 2.88 0.05 427 2.55 0.06 (26.06 [2,2321] < .001)n, dfd] p) (20.74 [2,1318] < .001) (1.02 [2,739] .36)1 (1.48 [2,563] .23)1 (5.56 [4,2321] < .001)1 Compound symmetry
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Interface
significantly between branches at six months. Six
differed significantly at eighteen months and four at threeyears.
The rank order of job satisfaction components was
very similar for adult and child branch nurses (Figure 1).
Means were then adjusted to account for variation attributable
to the ten moderating variables. These variables
accounted for a small proportion of the variability and
findings remained largely unchanged although there was
some change in statistical significance (Adult,, Resources and Pay factors. All eight factors differedDevelopment
andResources no longer significant; Mental health,
Resources
for Children's nurses,
but the direction of trend changed (6 months: 3.51,
18 months: 3.57, 3 years 3.22)significant downward trend) and more substantivelyEducation remained significant
Discussion
The confusing picture about the impact of time on satisfaction
in the literature is confirmed here. There is no single
pattern and the different experiences of the three
specialities studied seem to lead to different patterns. Further,
the effect of time varies across dimensions of satisfaction.
Many of the trends are of little practical significance
and some of the differences between branches are small.
What does emerge strongly is that recently qualified
nurses are not satisfied with their pay (in relation to level
of responsibility) which has been reported frequently
elsewhere for nurses generally [32,35,36,46-49] while
they are highly satisfied with the quality of working relationships
and emotional support that they receive from
colleagues. This confirms previous research that nurses are
satisfied with aspects of support received in their immediate
work area but often less satisfied with higher level
management and development opportunities [1].
First impressions are positive for the adult branch, where
the trends were mostly upwards, mixed for the child
branch and a tendency towards the negative for the mental
health branch. It would appear that newly qualified
adult branch nurses have been able to make the adjustment
to work more effectively than the other two
branches although their satisfaction levels early on are
lower than the other two branches. The decline in satisfaction
for mental health nurses suggests that these nurses
have perhaps faced the bigger challenge. Satisfaction with
client care and resources both start at a low level and
remain stubbornly low and it would not be unreasonable
to propose that there was casual relationship between the
two.
The V-shaped trend reported by William's and colleagues
[2] amongst postbaccalaureate nurses undergoing a residency
program was found to be consistent with Kramer's
theory [21] and a decline in job satisfaction measured
SFaigtiusfraect i1on trends
Satisfaction trends.
Adult (General)
6 months 18 months 3 years
Satisfaction
2.2
2.4
2.6
2.8
3.0
3.2
3.4
3.6
3.8
4.0
4.2
4.4
Resources
Relationships
W-L Interface
Education
Development
Pay
Care
Staffing
Children's Nurses
6 months 18 months 3 years
Satisfaction
2.2
2.4
2.6
2.8
3.0
3.2
3.4
3.6
3.8
4.0
4.2
4.4
Resources
Relationships
W-L Interface
Staffing
Education
Care
Development
Pay
Mental Health Nurses
6 months 18 months 3 years
Satisfaction
2.2
2.4
2.6
2.8
3.0
3.2
3.4
3.6
3.8
4.0
4.2
4.4
Care
Staffing
Development
Relationships
Education
W-L Interface
Resources
Pay
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using the McCloskey-Mueller Satisfaction Scale was
observed between entry and 6 months. Casey and colleagues
[9] have suggested that new nurses take at least 12
months to feel comfortable and confident. In this study
mean scores were lower at 6 months than either of the two
later time-points on all job satisfaction components
except
nurses had a greater number of lowest scores at 18 months
(Relationships for adult branch nurses. Children'sClient Care, Staffing, Development, Work-Life Interface,
Resources
and 3 years (
had three lowest scores at 6 months () than at 6 months (Education, Work-Life Interface)Relationships, Pay). Mental health nursesDevelopment, Education,
Pay
(
suggesting that if reality shock is operating its effects happen
at different times and probably in different ways
depending on the specialism. The adult branch nurses
would appear to provide the best fit to the theory. The theory
states that satisfaction drops as formal orientation
ends and working independently begins [4]. The findings
for children's nurses and mental nurses suggest that reality
shock may extend beyond the period specified by Kramer
[21] and confirmed by Williams [2], or be replaced by
another phase which is less about shock and more about
realism and coping with additional responsibilities. By 3
years 63% of children's nurses and 75% of mental health
nurses were employed as staff or senior nurses and almost
25% of mental health nurses were in senior staff nurse
posts. The rapid ascendancy of mental health nurses could
be one reason for their lack of upward job satisfaction
trends.
The exposure of student nurses today to the nursing environment
is different from the past when UK training was
hospital based and students were employees of the organisation.
Nurses then were perhaps in a better position to
adapt, often working in the organisation where they
trained and therefore were less likely to suffer from the
type of reality shock that newly qualified nurses' encounter
today. They may have been better able come to terms
with any discrepancies between their own needs and that
of the job and organisation prior to qualification allowing
for a smoother transition.
There may be a desire for nurses to compare themselves
against other graduates and professions. Pay has become
a major issue above that of autonomy, flexibility and a
supportive organization particularly when there are shortages
of nurses, rising levels of acuity and increasing workloads
[49]. Satisfaction with
factor to produce scores consistently below 3. There was
some improvement over time for the adult and mental
health branch nurses however there was a small non-significant
decrease in
Nurses feel poorly paid compared with other public sector
workers [50] but paradoxically the estimated impact of
increased wages on nurse retention is potentially small
[51]. Children's nurses, because of their young age, may
be more prone than older nurses to making comparisons
with their peers who on graduating are moving into better
paid jobs. The larger the differential between the NHS
wage and the outside wage the more likely nurses are to
leave [51]. Around 25% of children's nurses work in the
London region where higher non-nursing salaried jobs are
found. There are constant reminders of city bonuses in the
press and media, housing costs are high and it is very difficult
for nurses, along with other key workers, to get on
the housing ladder. Reasons for poor retention in London
include large numbers of young mobile workers, lack of
access to affordable child care, high cost of living and
heavy workloads [52,53]. Therefore financial considerations
will be central to nurses thinking. It has been suggested
that more research is required on the effect of new
nurses personal and financial stressors [9]. The effect of
peer comparison may lessen as the UK higher education
sector moves towards even higher levels of participation,
more graduates are saddled with debts and there are not
the jobs to match the degree qualifications. Grow your
own approaches have been suggested as one way of retaining
nurses and reflecting the diversity of local populations
[53].
In this study pay was measured by only one item. We
advise that the excluded item
level of responsibility
of time in work. Other items could be added or alternatively
a generic instrument measuring satisfaction with
rewards could be used.
Previous research on registered general nurses found that
younger nurses were less satisfied with their overall jobs
than older nurses [35]. Children's nurses had higher
scores on six of the factors suggesting that this specialism
may have a counterbalancing effect on age.
The loss of the academic schedule requires a period of
adjustment and has described as something akin to a
"grieving process" [4]. Satisfaction with), one at 18 months (Staffing) and four at 3 yearsClient Care, Relationships, Work-Life Interface, Resources)Pay was low and was the onlyPay satisfaction for children's nurses.Grade/position in relation tobe included after a reasonable periodWork-life Interface
is comparatively high for the child and mental health
nurses. For adult branch nurses
gradual improvement over time from a lower base level.
Becoming accustomed to regular shift work and juggling
the tensions between work and personal life may have
taken longer for these nurses. The management of shifts
and schedules during orientation [4] so as not to disaffect
newly qualified staff is important. TheWork-Life Interface showsWork-Life Interface
factor in this study was limited. It was not possible to
include items for combining work hours with life with
spouse/partner and responsibilities for children since they
did not apply to a sufficient number of nurses. The transi
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tional nature of work and life satisfaction probably
requires a more dynamic tool for its measurement than
the one used here that goes beyond leaving work on time,
notice of duty and social life.
The whole issue of resources, and that includes staffing,
will have a direct impact on patient care. It is worth noting
for adult branch nurses in this study that when satisfaction
with
with
18 months for children's nurses however this did not
impact on satisfaction with
health nurses satisfaction with resources remained consistently
low as did satisfaction with
reflects the longstanding perception that mental health
services are under resourced in comparison with other
services [54,55]. Satisfaction with
with
has shown that better staffing (e.g. patient-to-nurse ratios)
is linked to improved patient outcomes [56,57]. It is well
established that high nurse turnover can impact considerably
on the well-being of nurses who remain and patient
outcomes [7,35].
A consistent picture emerged with respect to satisfaction
with
days/workshops). There was a sharp increase in satisfaction
between 6 and 18 months across all branches. The
biggest increase was for mental health nurses. Between 6
and 18 months the proportion of mental health nurses in
staff nurse (E grade) positions increased from 4% to 64%
compared with 0% to 11% and 0% to 32% for adult and
children's nurses. There is an expectation that once someone
becomes a staff nurse they should start attending
post-registration courses and the fact that more mental
health nurses were promoted correlates with this finding.
Adjustment for moderating variables reversed the trend in
satisfaction with
there was now a very small increase between 6 and 18
months and a sharp fall between 18 months and 3 years
(the proportion of children's nurses in staff nurse positions
increased from 32% to 57%) suggesting that opportunities
to attend courses had become more difficult as
other responsibilities took hold and that expectations
were no longer being met.
The
three year period although a small increase was observed
between 6 and 18 months for adult branch nurses.
Adjusted figures indicated a steady, but non-significant,
downward trend across all three branches. Job satisfaction
scores for
for adult and child branch nurses. Nurses are therefore
lacking opportunities to reflect on practice and are not
receiving sufficient feedback and guidance on career
development. Not having support and guidance has been
identified as a reason for graduates leaving their first nursing
post [1]. Higher acuity levels and inadequate nurse-topatient
ratios maybe contributing to low development
scores by cutting down the time nurses have to reflect on
practice and receive support.
Overall, the two branches that had the most similar findings
were the adult and child branches. This perhaps was
not unexpected because they have more in common with
each other than they do with mental health.
The mix of censuses and samples had implications for
sampling error. A census with complete information on
all sampling units (nurses) will have no sampling error.
Other sampling approaches may reduce sampling error by
design (e.g. stratification) or increase sampling error (e.g.
cluster sampling). The sampling fractions for both adult
and mental branch nurses are 50% or higher and this
more than compensated for any loss of precision induced
by the multistage design. However we wanted to generalise
findings beyond the year of survey [58] to the future
and adopted a more conservative approach to sampling
error by treating each population sample as a simple random
sample. Additional non-sampling error may also
result from non-response. This was addressed by comparing
job satisfaction scores across response groups and by
including variables known to predict non-response (e.g.
age, gender and ethnicity) in the analysis.
Interpretation of these finding should be considered in
the context of the time period in which the data were collected
(1997/8 – 2000/1). Many of these findings may be
as relevant as they were seven years ago although under
the current climate in the NHS some of the more positive
aspects that have emerged from these data may have lessened.
We end by providing some suggestions on how nurses can
be supported in early career that may help improve their
job satisfaction. US Research has identified a number of
useful avenues that could be pursued which include providing
one-year support programmes, forming new nurse
support groups that meet regularly and beyond the first
year and encouraging more experienced nurses to become
mentors [1,9]. In the UK preceptorship is not mandatory
however a formal one year preceptorship or probationary
year should be considered best practice [59].
Generally supporting nurses during the transition from
student to nurse will reap longer terms benefits of reduced
turnover, better patient care and reduction in costs which
in the UK can run as high as £10 K and result in lost productivity
[53,60].Resources and Staffing increased so did satisfactionClient Care. Satisfaction with Staffing dipped atClient Care whilst for mentalClient Care andStaffing tracks satisfactionClient Care and supports previous research thatEducation (opportunities to go on courses an studyEducation for children's nurses so thatDevelopment profiles remained flat throughout theDevelopment were the second lowest (above Pay)
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Conclusion
We conclude that the impact of time on job satisfaction in
early career is highly dependent upon specific jobs, even
within the same profession. Adult, children's and mental
health nurses work in different contexts and settings,
often with very different organisational cultures and all of
this may lead to a very different experience. Of course
individuals choosing these career paths may also differ in
terms of characteristics and aspirations and this also may
influence the development of satisfaction. There is no single,
simple answer to the trend in job satisfaction over
time. Future research should focus upon understanding
whether particular job characteristics could explain these
findings and should not simply explore satisfaction as a
unitary construct when looking at variation over time
since contradictory findings emerge from different aspects
of satisfaction. Further research that investigates the benefits
of a formal one year preceptorship or probationary
period would also come in very useful.
Competing interests
This work was undertaken by the National Nursing
Research Unit, which receives funding from the Department
of Health (DH). The views expressed in this publication
are those of the authors and not necessarily those of
the DH.
Authors' contributions
TM participated in study design, was involved in data
processing, carried out the analysis, drafted the manuscript
and the interpreted the findings. SR made a major
contribution to the conception of the study, the design,
data collection and interpretation. PG provided intellectual
and theoretical input for the paper and interpretation
of the findings. All authors were involved in revising the
manuscript and have read and approved the final version.
Acknowledgements
We are grateful to: members of the diplomate pilot cohort for their help in
developing the questionnaires; members of the main cohort for carefully
completing them, and previous team members who worked on the project:
Susanne Cox, Rachel Hardyman, Gary Hickey, Louise Marsland and Alison
Tingle.
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