Evidence Digest

The Latest Evidence on Factors Impacting NurseRetention and Job Satisfaction

Bernadette Mazurek Melnyk, RN, PhD, CPNP/NPP, FAAN, FNAP

The purpose of Evidence Digest, a recurring columnin Worldviews, is to provide concise summaries of

well-designed and/or clinically important recent studiesalong with implications for practice, research, administra-tion, and/or health policy. Articles included in this columnmay include quantitative and qualitative studies, system-atic and integrative reviews, as well as consensus state-ments by expert panels. Along with relevant implications,the level of evidence generated by the studies or reportshighlighted in this column (see Figure 1) is included atthe end of each summary so that readers can integrate thestrength of evidence into their health care decisions.

• Level I: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs), or evidence-based clinical practice guidelines based on systematic reviews of RCTs

• Level II: Evidence obtained from at least one well-designed RCT • Level III: Evidence obtained from well-designed controlled trials without randomization • Level IV: Evidence from well-designed case-control and cohort studies • Level V: Evidence from systematic reviews of descriptive and qualitative

studies • Level VI: Evidence from a single descriptive or qualitative study • Level VII: Evidence from the opinion of authorities and/or reports of expert committees

Modified from Guyatt & Rennie, 2002; Harris et al., 2001

Figure 1. Rating System for the Hierarchy of Evidence (fromMelnyk & Fineout-Overholt, 2005).

Brown H., Zijlstra F. & Lyons, E. (2006). The psycho-logical effects of organizational restructuring on nurses.Journal of Advanced Nursing, 53(3), 244–357.

Purpose: The purpose of this study was to comparenurses affected by restructuring associated with health careorganization mergers (1998–2000) in the United Kingdomand those nurses who were not involved with the restruc-turing of their organizations.

Sample: The sample comprised 351 registered nursesfrom southern England. Participants either worked in anorganization that restructured its work environment dueto organizational mergers or one that did not experience

Copyright ©2006 Sigma Theta Tau International1545-102X1/06

restructuring. The ages of the nurses ranged from 22 to68 years; 94% were female.

Design: Descriptive causal-comparative.Measures: Dependent variables included information

and participation, coping action, and coping effectiveness.Methods/Procedure: A questionnaire developed for this

study that tapped restructuring initiatives (i.e., stressors)information and participation, coping action, and copingeffectiveness (i.e., outcomes) was disseminated to the par-ticipants. Eight National Health Service institutions agreedto give permission for their nurses (n = 204) to participateand the remainder of the nurses was recruited throughthe Royal College of Nursing, which is the UK’s largestprofessional organization for nurses. The questionnaire atTime 1 (1–6 months prior to the event) was completed by71 nurses. The Time 2 questionnaire (1–6 months after theevent) was completed by 188 nurses. Ninety-two nurseswho did not experience reorganization also completed thequestionnaire. The study was approved by the NationalHealth Services ethics committee process.

Findings: Nurses in the affected groups were found tohave been for more years in their grade, on ward, and inhospitals. They also were older and had less previous ex-perience with restructuring. Nurses affected by restructur-ing reported statistically higher restructuring initiatives be-fore and after the event than nonaffected nurses. Affectednurses reported lower information and participation, andlower coping effectiveness (i.e., higher job stress, insecu-rity, and pressure; lower job satisfaction, physical, psycho-logical, and environmental quality of life) than nonaffectednurses. No differences in coping action were found betweenaffected and nonaffected nurses.

Commentary with Implications for Clinical Practice andAdministration. Although the authors stated that thedesign of this study was quasi-experimental, it was adescriptive causal-comparative study because the in-dependent variable (i.e., restructuring) was not in-troduced by the investigators. Nurses in the affected

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institutions were compared to the nonaffected nurses onthe study’s outcomes. The fact that there were signifi-cant differences on some important demographic vari-ables between the affected and nonaffected nurses (e.g.,the affected nurses were older and had less experiencewith restructuring) could have confounded the study’sfindings.

Despite the limitations of this study, the findings haveimportant implications for administration and manage-ment in that nurses in the affected groups perceivedlow information and participation in decision makingas well as higher job stress and lower job satisfaction.When any organizational restructuring is undertaken, itis critical to create a common vision and encourage staffinvolvement/participation in some of the decision mak-ing. It also is important to recognize that there will betemporary reduction in productivity when change or re-structuring is introduced into an organization (Melnyk& Fineout-Overholt, 2005). Frequent, clear communi-cation about the changes is critical as is involving staffin developing solutions for challenges that may arise aspart of the process.

Level of Evidence: VI

Wagner, S.E. (2006). From “satisfied” to “engaged.”Nursing Management, 37(3), 24–29.

Purpose: To examine the level of nurse engagement in14 hospitals across New York state in the United States.According to the Quality Data Management, Inc.’s work-force engage system, the organization that conducted thisstudy, engagement encompasses seven core practices: (1)Establish an open learning environment, (2) Nourish teamsand networks, (3) Generate a sense of community, (4) Ar-range work to minimize stress and maximize balance, (5)Grow exceptional managers and supervisors, (6) Embracepersonal strengths, and (7) Develop pride and confidence(Wagner 2006).

Sample: The convenience sample comprised an unre-ported number of nurses from 14 hospitals across the stateof New York (2 hospitals from each of the 7 geographicregions). No demographic information about the samplewas provided.

Design: Descriptive survey.Measures: A survey, consisting of less than 60 questions

that included a few open-ended questions, was developed,which tapped nurse engagement. No information was pro-vided on the validity and reliability of the questionnaire.

Methods: Hospitals implemented a variety of strategiesto encourage nurses to participate in the survey, including

letters from the chief nursing officers and informationalmeetings.

Findings: An average of 54% of the participating hospi-tals’ nursing staff completed the web-based survey. Find-ings revealed three levels of engagement: (a) highly en-gaged (51% of the participating nurses); (b) moderatelyengaged (32% of the participating nurses); and (c) dis-engaged (17% of the participants). Although the category“moderately engaged” was used as a label for that group’scategory, the author reported that this group leaned moretoward being disengaged than highly engaged. Regardingleaving the organization in the next 12 months, 85% ofthe highly engaged nurses said that they would not leavethe organization in comparison to only 42% of the dis-engaged nurses. Ten items captured the highly engagedcategory, including: (1) This organization values me; (2)The organization practices what it preaches; (3) I wouldrecommend this organization to anyone; (4) Employeesare included within the organization’s decision making;(5) There are safe and effective ways to communicatea complaint; (6) Upper management is trustworthy; (7)Upper management listens to employee ideas and opin-ions; (8) Supervisors understand key issues in their de-partments; (9) The organization encourages and supportsinnovation; and (10) Overall, my supervisor is an effectiveleader.

Implications for Clinical Practice, Administration, andFuture Research. A major limitation of this report wasthe omission of important information describing thesample (e.g., age and education of the nurses, numberof years employed at their site). This type of informa-tion would have allowed additional research questionsto be answered (e.g., what was the level of educationin the highly engaged group in comparison to the othergroups). In addition, it would have been interesting todocument certain hospital and leadership variables (e.g.,style of management) that were related to level of en-gagement. Future studies should explore relationshipsbetween level of engagement and these types of vari-ables.

Despite these limitations, valuable information wasgathered from this survey that characterizes the ele-ments of engagement for nurses. Findings from thestudy also indicated that nurses who reported be-ing highly engaged had less intention of leaving theirjobs in the next 12 months. The construct of en-gagement may be a key factor in predicting intent toleave and turnover rates in nursing. Because specific

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items in the construct (i.e., engagement) were identified,nurse managers and hospital administrators can imple-ment strategies to enhance engagement, which may re-sult in less nurse turnover rates in an era of the most se-vere nursing shortage that the United States will face by2020.

Level of Evidence: VI

Altier M.E., & Kresek C. (2006). Effects of a 1-year res-idency program on job satisfaction and retention of newgraduate nurses. Journal for Nurses in Staff Development,22(2), 70–77.

Purpose: To determine the efficacy of a year-longpost-baccalaureate residency program on new graduatenurses.

Sample: The convenience sample began with 316nurses, but with attrition, the final sample consisted of111 participants with complete data (i.e., pre- and post-surveys). The overall sample of 316 nurses ranged from21 to 59 years; 89% were females. Most of the partici-pants were white (i.e., 79%). One hundred and seventeen(37%) received a GPA of 3.5 to 4.0 upon graduation and160 reported a GPA of 3.0 to 3.49 from their baccalaureateprogram. The participants were from six academic healthcenters.

Design: Pre-experimental (i.e., pre-test, post-test, one-group design).

Measures: The McCloskey–Mueller Satisfaction Surveywith its established construct validity and internal consis-tency reliability of .89 was used. This instrument has 31Likert-scale items and taps eight domains of job satisfac-tion (e.g., intrinsic rewards, balance, praise, professionalopportunities).

Methods/Procedure: Nurses completed a demographicsurvey of resident and organizational factors when ac-cepted into the program as well as the satisfaction survey.At 12 months after the commencement of the residencyprogram, they again completed the job satisfaction survey.Approval of the study by the institutional review board wasobtained.

The Residency Program: The residency program used astandardized curriculum that comprised a series of learningand work experiences focused on research-based practice,patient safety-minimizing risk, as well as communication,leadership, and professional development. The nurses hadpreceptor-guided clinical experiences, access to a residentfacilitator who mentored them in role development andspecific clinical course work related to the nurses’ practicesite and specialty area.

Findings: Six of the subscale scores on the satisfactionsurvey demonstrated minimal change from pre- to post-test

(i.e., satisfaction with intrinsic rewards, scheduling, bal-ance, coworkers, interaction opportunities, control, andresponsibility). Only two of the subscales (i.e., satisfac-tion with praise and satisfaction with professional oppor-tunities) demonstrated a statistically significant decreasein score.

Commentary with Implications for Clinical Practice, StaffEducation, and Future Research. The major limitation ofthis study was that the design used was a one-group pre-experiment, not a randomized controlled trial. There-fore, internal validity (i.e., being able to say that it wasthe residency program intervention that was responsi-ble for the outcomes) is weak. Another limitation of thestudy was that it used a satisfaction instrument that hadhigh test–retest reliability (i.e., .79). This is an importantissue in that the instrument might not have been sensi-tive enough to detect intervention effects over time. Inaddition, there was a high attrition rate in the study andit is not known whether nurses with higher or lowersatisfaction levels were the ones that dropped from thestudy. Although satisfaction levels of the nurses did notincrease over time, the authors argue that nurses did notdecline in their job satisfaction on the majority of jobsatisfaction subscales, unlike so many new nurses whobecome dissatisfied with their role in the first year oftheir jobs.

Before residency programs become standard practicein hospitals, future research needs to be conducted togather additional evidence to support the implementa-tion of residency programs in the form of randomizedcontrolled trials using a two-group design that includesa comparison program (e.g., enhancing physical assess-ment skills) to control for the time being spent withnurses in the residency program. Simply receiving extratime and attention in the context of the residency pro-gram could have resulted in the outcomes obtained overtime, along with the fact that test–retest reliability of thejob satisfaction instrument used is high. Future exper-imental studies should use an instrument that is moresensitive to change over time so that the intervention be-ing implemented has the potential ability to demonstrateits influence on the outcomes measured.

Level of Evidence: VI

Haut E.R., Sicoutris C., Meredith D., Sonnad S.S., ReillyP.M., Schwab W., Hanson W., & Gracias V.H. (2006). Im-proved nurse job satisfaction and job retention with thetransition from a “mandatory consultation” model to a“semiclosed” surgical intensive care unit: A 1-year prospec-tive evaluation. Critical Care Medicine, 34(2), 387–395.

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Purpose: The purpose of this study was to determine ifnursing job satisfaction, turnover rates, and hospital costsfor temporary agency nurses changed with greater involve-ment of a dedicated surgical critical care service (SCCS)

Sample: The convenience sample comprised surgicalintensive care unit (SICU) nurses in a 56-bed unit at amajor medical center in the northeast of the United States.Twenty-two percent of the 503 respondents over five timeperiods assessed were certified by the American Associationof Critical Care Nurses. The average time in their positionwas 4.2 years.

Design: Longitudinal prospective.Measures: A nurse job satisfaction survey was devel-

oped. The 10-item, 5-point Likert scale included items suchas “There is good communication between physicians andmy patients or family members in the ICU,” I am confidentin the clinical judgment of the physicians who round andmake the plan for my patients,” and “I am satisfied withthe physician intervention in response to an urgent patientcare issue.” No validity and reliability information was pro-vided for this scale. Monthly nursing staff turnover rateswere calculated as well as the costs incurred for agencynurses per month.

Methods/Procedure: The SICU nurses were surveyed fivetimes at 3-month intervals, including baseline and aftercompletion, during a year-long transition from a manda-tory consultation model to a semiclosed SICU (i.e., one inwhich the surgical critical care service (SCCS) wrote pa-tient orders instead of the primary surgical team). Criticalcare nurse practitioners dedicated to the SCCS also wereadded at the beginning of the transition. The anonymoussurveys were disseminated to all SICU nurses through theoffice of the medical directors and nurse managers of eachSICU section. The institution’s institutional review boardgranted an exemption from review of the study.

Findings: There was a 55% overall return rate of the sur-veys. Nurse job satisfaction scores significantly improvedover time for all 10 items on the job satisfaction survey.Hospital spending on agency nurses decreased significantlyand the yearly nurse job turnover rated dropped from 25%

to 16%. The scores for the year-end statements, “I am moresatisfied with my job now than 1 year ago” and “The SCCSmanagement of all orders has improved my job satisfac-tion” were significantly higher in sections of the SICU withgreater SCCS involvement.

Commentary with Implications for Clinical Practice, Ad-ministration and Future Research. Although this was nota randomized controlled trial with intervention and con-trol groups and there is the question about whether the10-item survey truly measured nurse satisfaction or be-liefs about the type of care being delivered in the SICU,the findings indicate that transition to a model where pa-tient management is conducted by the SCCS team maylead to lesser costs from hiring fewer agency nurses dueto lower numbers of sick days by the regular nursingstaff, and less nurse turnover rates. However, cautionmust be exercised in arriving at this definitive conclu-sion since internal validity of the research is weak dueto the study not being a randomized controlled trial.

Future research is needed to test this model in thecontext of a full-scale randomized controlled trial, sostronger conclusions about the validity of the findingscan be drawn. In addition, the use of an establishedvalid and reliable instrument to measure job satisfactionwould strengthen a future study.

Level of Evidence: VI.

ReferencesGuyatt G., & Rennie D. (2002). Users’ guides to the medical

literature. Washington, DC: American Medical Associa-tion Press.

Harris R.P., Hefland M., Woolf S.H., Lohr K.N., MulrowC.D., Teutsch S.M., et al. (2001). Current methods of theU.S. Preventive Services Task Force: A review of the pro-cess. American Journal of Preventive Medicine, 20(Suppl.3), 21–35.

Melnyk B.M., & Fineout-Overholt E. (2005). Evidence-based practice in nursing and healthcare. A guide to bestpractice. Philadelphia: Lippincott, Williams & Wilkins.

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