The role of work environment in keeping newly licensed RNs in nursing: A questionnaire survey

International Journal of Nursing Studies 50 (2013) 1678–1688

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The role of work environment in keeping newly licensed RNs in nursing: A questionnaire survey Lynn Unruh a,*, Ning Jackie Zhang b,1 a

Department of Health Management & Informatics, College of Health and Public Affairs, HPA-2, Rm 210-L, University of Central Florida, Orlando, FL 32816-2200, United States b College of Health and Public Affairs, HPA-1, Rm 217, University of Central Florida, Orlando, FL 32816-2200, United States

A R T I C L E I N F O

A B S T R A C T

Article history: Received 9 October 2012 Received in revised form 2 April 2013 Accepted 3 April 2013

Background: In prior studies, newly licensed registered nurses (RNs) describe their job as being stressful. Little is known about how their perceptions of the hospital work environment affect their commitment to nursing. Objectives: To assess the influence of hospital work environment on newly licensed RN’s commitment to nursing and intent to leave nursing. Design: Correlational survey. Settings: Newly licensed RNs working in hospitals in Florida, United States. Participants: 40% random sample of all RNs newly licensed in 2006. Methods: The survey was mailed out in 2008. Dependent variables were indicators of professional commitment and intent to leave nursing. Independent variables were individual, organizational, and work environment characteristics and perceptions (job difficulty, job demands and job control). Statistical analysis used ordinary least squares regressions. Level of significance was set at p < 0.05. Results: Job difficulty and job demand were significantly related to a lower commitment to nursing and a greater intent to leave nursing, and vice versa for job control. The strongest ranked of the job difficulties items were: incorrect instructions, organizational rules, lack of supervisor support, and inadequate help from others. Workload and other items were significant, but ranked lower. The strongest ranked of the job pressure items were: ‘‘having no time to get things done’’ and ‘‘having to do more than can be done well.’’ The strongest ranked of job control items were ‘‘ability to act independent of others.’’ Nurses with positive orientation experiences and those working the day shift and more hours were less likely to intend to leave nursing and more likely to be committed to nursing. Significant demographic characteristics related to professional commitment were race and health. Conclusions: Negative perceptions of the work environment were strong predictors of intent to leave nursing and a lower commitment to nursing among newly licensed RNs. These results indicate that retention of newly licensed RNs in nursing can be improved through changes in the work environment that remove obstacles to care-giving, increase resources and autonomy, and reduce workload and other job pressure factors. ß 2013 Elsevier Ltd. All rights reserved.

Keywords: Job demands Job difficulties Job control Job satisfaction Newly licensed RNs Nursing work environment

What is already known about the topic? * Corresponding author. Tel.: +1 407 823 4237. E-mail addresses: [email protected], [email protected] (L. Unruh), [email protected] (N.J. Zhang). 1 Tel.: +1 407 823 3344. 0020-7489/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2013.04.002

 Negative work experiences of some newly licensed registered nurses (RNs) have been linked to lower job commitment and greater job quitting,

L. Unruh, N.J. Zhang / International Journal of Nursing Studies 50 (2013) 1678–1688

 Other than one article that links newly licensed RN job satisfaction to professional satisfaction and retention, it is not known whether work experiences affect newly licensed RNs’ commitment to or intent to leave nursing.  Among the RN population in general, work environment issues such as patient load, difficulties with different aspects of work, stress, and lack of autonomy contribute to lower professional commitment and intent to leave nursing.  It is important to understand the factors that affect newly licensed RN professional commitment and intent to leave nursing in order to keep them in nursing. What this paper adds  Most respondents had positive attitudes about nursing and did not intend to leave nursing. They experienced a fair amount of job difficulties, and a significant amount of job demands, but they also had the ability to act independently on the job.  Most individual characteristics of respondents were not related to professional commitment or intent to leave nursing.  Negative perceptions of the work environment, such as high job demands and job pressures and low job control, were strong predictors of intent to leave nursing and a lower commitment to nursing among newly licensed RNs. Job difficulty contributed to a significant proportion of the variance in professional commitment and intent to leave.  In contrast, perceptions of having a positive orientation, day shift opportunities, supportive organizations and colleagues, supportive supervisors, adequate help, and autonomy contributed to professional commitment and intent to stay in nursing. 1. Introduction A number of newly licensed registered nurses (RNs) find that their initial years are difficult (Bowles and Candela, 2005; Pellico et al., 2009; Yeh and Yu, 2009). Many feel unprepared for the high work demands in hospitals (Bowles and Candela, 2005; Duchscher, 2001). Some report that they struggle with work that does not match their ideals of nursing (Duchscher, 2001; Pellico et al., 2009). Some become disillusioned or dissatisfied with their jobs (Anderson et al., 2009; Cowin and HengstbergerSims, 2006; Giallonardo et al., 2010; Halfer and Graf, 2006), and a number intend to leave or do leave their first job within one year (Bowles and Candela, 2005; Kovner et al., 2007; Yeh and Yu, 2009). Although the negative work experiences of some newly licensed RNs have been linked to lower job commitment and greater job quitting (Bowles and Candela, 2005), it is not known how these experiences affect their commitment to or intent to stay in nursing. It is possible that negative work experiences of newly licensed RNs contribute to lowered commitment to nursing and thoughts of leaving nursing. It is therefore important to explore the impact of newly licensed RNs’ perceptions of their work environment on their professional commitment, and to

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identify work environment issues that contribute to thoughts of leaving the profession. This study describes survey results of newly licensed RNs’ professional commitment and intent to leave nursing, and the individual, organizational, and work environment factors that were related to those professional attitudes. 2. Background In 2006, a review of the international literature on attrition from nursing school and the graduate nursing workforce found no studies on factors involved in the retention of graduate nurses in the profession (Gaynor et al., 2006). Our independent (unpublished) review of the literature corroborated that up to 2006 there were no studies of predictors of newly licensed RN professional commitment, intent to stay or leave nursing, or actual attrition from nursing. Although we found no literature on the topic prior to 2006, we found one 2008 study addressing this issue. Scott et al. (2008) found that Associate Degree newly licensed RNs were 3 times more likely to be satisfied with nursing as a career compared to those with Bachelor’s Degrees. Those who were more satisfied with their job were also more likely to be satisfied with nursing as a career. Intent to leave nursing was predicted by lower career satisfaction. One other paper was published on a related group of RNs – ‘‘young’’ nurses under the age of 30 years (Flinkman et al., 2008). Although this cohort of nurses does not capture all newly licensed RNs, some of whom are over 30 years of age, and conversely includes RNs who have practiced for a number of years (up to around 10), the results may be instructive regarding newly licensed RNs. This 2008 survey of young Finnish nurses found that 26% often thought about leaving nursing (Flinkman et al., 2008). These feelings were related to burnout, poor opportunities for development, work–family conflicts, high work demands, and low job satisfaction and professional commitment. Since there is little empirical information about what influences newly licensed RN commitment to nursing versus leaving nursing, in what follows we review studies of professional commitment, attrition from nursing, and intent to stay in or leave nursing among the general population of RNs. These studies may suggest factors that should be explored in the current study as contributors to newly licensed RN professional commitment or intent to leave nursing. 2.1. Predictors of RN professional commitment Professional (or career) commitment is reflected in nurses’ attitudes toward the profession, such as the degree to which they desire to invest in the profession and perform well (Gould and Fontena, 2006). Those who have high levels of professional commitment take pride in their profession, are satisfied with the nature and value of their work, engage in ongoing learning, and tend to perform well (Gould and Fontena, 2006). Professional commitment has been measured through a set of questions regarding the desire to work in the given field and continue a career in that field (Blau, 1985).

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Little research has been conducted on predictors of RN commitment to nursing. A small number of studies find that a higher level of professional commitment is found in nurses who have been in nursing longer, are not married, have career aspirations, have a well-defined role in the organization, have supervisors with clear direction and structure, and who identify with their jobs and organizations (Blau, 1985; Hodges et al., 2010). Pay, autonomy, and professional status are also ranked as important to career satisfaction (Hoffman and Scott, 2003). Supportive organizations and colleagues, and a belief in the value of nursing are factors contributing to staying in nursing (Gould and Fontena, 2006). In a qualitative study, authors found that RN ‘‘career persistence’’ is built through a interplay between personal needs and principles and the external environment (Hodges et al., 2010). Expertise in how to optimize the environment builds over time, so nurses with more professional tenure have prior experience that helps them make decisions and gives them greater expertise in negotiating the system and obtaining needed resources for themselves, coworkers, patients, and families. 2.2. Predictors of RN professional attrition Professional attrition is the actual leaving of individuals from their profession (Blau, 2007). The decision to leave one’s profession is a much more difficult choice than the decision to leave an organization (Blau et al., 2003; Cheung, 2004). The difficulty appears to be due to the loss of the investment in education, the effect of leaving the profession on one’s self and family, and the efforts needed to find a new career (Blau, 2007). Little is known about professional attrition among RNs due to the difficulty of following RNs over time and collecting information from RNs that have left the nursing workforce. A few European studies that followed RNs over time, including after they left the workforce, found that predictors of early separation from nursing were male gender, younger age, family responsibilities (except young children), less tenure in the profession, the presence of musculoskeletal problems, and poor work environment (ergonomic issues, lack of autonomy, and high patient load (Barron and West, 2005; Holmas, 2002; Fochsen et al., 2006). In surveys of former or inactive nurses in Europe, New Zealand, and the U.S., workplace reasons for leaving nursing were high workload or understaffing, the physical nature of the work, shift work, lack of autonomy, wage compression, lack of opportunities for advancement, and stress/burnout (Cheung, 2004; Duffield et al., 2004; Jamieson and Taua, 2009). Personal reasons were higher educational level, family responsibilities, and trouble balancing work life with family responsibilities. In one study, White nurses were more likely to leave nursing than African American nurses (Smith et al., 2007). Using data from the United States (U.S.) national RN Sample Survey, an analysis of nurses who left active nursing found that the probability of leaving nursing was higher if the RN was male, married, providing care to dependents in the home (such as young children or elderly

parents), higher educated (except having an advanced practice credential, which reduced the probability of leaving nursing), or currently enrolled in a non-nursing degree program (Nooney et al., 2010). 2.3. Predictors of RN intent to leave the profession While actual attrition from the profession is hard to capture, due to the difficulty in contacting those who have dropped out of the nursing workforce, a nurse’s intent to leave the profession is more readily available since he or she is still in the workforce, and it is a fairly good predictor of actually leaving the profession (Lane et al., 1988). Intent to leave the profession has been measured by thoughts about leaving the profession or intentions to look for a new profession, versus intentions to stay in the profession (Blau, 2007). Depending upon the country, between 10 and 46 percent of RNs report an intention to leave (ITL) nursing (Borowski et al., 2007; Estryn-Behar et al., 2007). Contributors appear to be both demographic characteristics and work environment issues. Demographic characteristics related to intent to leave nursing include male gender, younger age and less experience (Borowski et al., 2007; Estryn-Behar et al., 2007; Nogueras, 2006). A nurse’s educational level has been linked to higher probabilities of career change, as discussed earlier, but inexplicably, to lower ITL (Nogueras, 2006; Borowski et al., 2007). ITL is also higher when the nurse’s salary is a small part of the total family income (Lynn and Redman, 2005). Work environment issues in intent to leave nursing include conflict between the responsibilities of family and work, lack of career progression, lack of autonomy or decisionmaking, stress, burnout, physical strain, low salary, high patient loads, shift work, paperwork, scheduling, long hours, and low levels of job satisfaction (Estryn-Behar et al., 2007; Flinkman et al., 2008; Gould and Fontena, 2006; McIntosh et al., 2006; Stone et al., 2006). Respondents in a 2005 study, who indicated that they intended to leave the profession, said that greater respect from frontline management and administration would cause them to reconsider leaving (Ulrich et al., 2005). The nurses considered ‘‘respect’’ to be: their involvement in decision making; administration placing a high value on nursing, including benefits and pay; manager’s attention to their concerns; administrative intervention when it is perceived that nurses are being treated unfairly; adequate staffing levels; quality nursing care as a priority; and recognition of nurses as a part of the patient care team. In a 2005 Finnish study, early retirement thoughts were related to high job demands and low job control (Elovainio et al., 2005). Job demand was measured by how much time pressures and deadlines worried or stressed the participants. Job control was measured by extent to which employees felt free to decide three factors in their own work process (variability, procedures, amount of work). Intent to leave nursing has been found to be related to commitment to nursing. One study found that the higher the nurse’s commitment to nursing the less likely it was that the nurse intended to leave the profession (Nogueras, 2006).

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This relationship suggests that professional commitment is a negative indicator of intent to leave nursing and vice versa. 3. Conceptual framework Based on the prior literature, several individual and work environment factors appear to contribute to professional commitment and, conversely, intent to leave nursing among RNs in general. Individual characteristics include age, gender, marital status, family responsibilities, educational level, and professional tenure. Work environment characteristics include shift work, scheduling, shift length, supervisory issues, role clarity, degree of respect from management, the level of organizational and collegial support, opportunities for advancement, degree of autonomy, staffing and workload, physical demands of the work, and salary. Several of the work environment factors that were related to RN professional commitment, attrition, or intent to leave nursing in prior studies can be characterized by three constructs: job difficulties, job demands, and job control. Job difficulties are working conditions that impede good performance (Gurney et al., 1997). These can be inadequate resources, role conflict, supervisory issues, lack of collegial support, and high workload, among others (Kovner et al., 2007; Gurney et al., 1997). Job demand is a perception of time pressure and heavy workload (Karasek, 1979). It is a feeling of not having enough time to get things done, or of having to work too fast or too hard (Karasek, 1979.) Perceived workload is a factor in both job difficulty and job demand (Gurney et al., 1997). Heavy workload impedes a nurse’s ability to get work done, which makes it an aspect of job difficulty (Gurney et al., 1997). Heavy workload also contributes to feelings of having to work too hard or of not having enough time to complete tasks, which makes it an aspect of job demands. Job control is the ability of a worker to make decisions for his/her own activities (Karasek, 1979; Elovainio et al., 2005). It has been operationalized in the literature as the ability to act independently of others, including one’s supervisor, and to make decisions independently and carry them out (Karasek, 1979). Work empowerment is a similar construct except that it includes a psychological component whereas job control does not (Li et al., 2008). Work empowerment has not been studied in relationship to professional commitment or intent to leave nursing. In this study we use the narrower concept of job control since the prior literature indicates a relationship between job control measures and professional commitment or intent to leave nursing among RNs in general, whereas the literature on work empowerment does not. We hypothesize that these individual and work environment characteristics that are related to professional commitment and intent to leave nursing among RNs in general are also ones that affect a newly licensed RN’s professional commitment and intent to leave nursing. We also hypothesize that two hospital organizational characteristics affect newly licensed RNs’ professional commitment and intent to leave nursing. Whether the hospital has magnet status may influence their professional commitment or intent to leave nursing due to the

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reportedly good work environments in these hospitals (Aiken et al., 2008). Type of hospital may also influence work environment, and therefore their professional commitment or intent to leave nursing. Type of hospital is defined by the mission and services offered. Academic medical centers, often large teaching hospitals located in urban areas, may provide the most professional opportunities for newly licensed RNs, followed by community teaching and community non-teaching hospitals. The hypothesized relationships between individual, organizational and work environment factors and newly licensed RN professional commitment or intent to leave nursing are summarized in the following functional equation: Newly licensed RN professional commitment or intent to leave nursing = f (individual, organizational, work environment characteristics) Where professional commitment and intent to leave nursing are constructs analyzed separately; f = ‘‘function of’’; individual characteristics = age, gender, marital status, children in the home, health, nursing education, prior work experience and professional tenure; organizational characteristics = magnet status and type of hospital; work environment characteristics = shift length and time, number of hours worked, number of shifts worked outside the usual unit; patient load, wages, and perceptions of orientation preparation, job difficulties, job demands, and job control. 4. Methods 4.1. Sample and survey administration Between August 1 and October 31, 2008 we conducted a survey of RNs who were newly licensed in the state of Florida in the United States. Institutional Review Board approval was obtained from authors’ university. Names and contact information for the RNs were obtained from the Florida Board of Nursing (FBON) list of RNs who received their first RN license between January 1 and December 31 2006. We sent surveys to a random selection of 40 percent (3027) from this population. The surveys contained a cover letter informing potential participants of the benefits and risks of completing the survey and that by taking the survey they indicated their informed consent. The survey was distributed via U.S. mail. Using Dillman (2000) Tailored Design Method, we assigned each survey a tracking number, and sent postcard reminders to nonrespondents after three weeks and a second survey to the remaining non-respondents. Thirty-two surveys were returned due to incorrect or changed address. 533 surveys were completed and returned, for a response rate of 18%. This study used a subsample of 414 surveys (n = 414) from respondents who were working in hospitals. Due to concerns regarding a response rate of 18 percent, we conducted a bias analysis, comparing the demographic and geographical information of our respondents with that of the 2006 population of all newly licensed RNs in Florida, using the demographic and geographic information maintained for each nurse as part of Florida’s licensure database. Table 1 shows that the sample of this study is

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fairly representative of the entire newly licensed RN population in Florida along several demographics. Our sample had slightly more females, individuals identifying themselves as White, and individuals with Associate Degrees. Mean age was the same and the number of hours worked was similar. A county-level comparison (not presented in the table) showed that the number of responses per county were generally proportionally similar to the population of newly licensed RNs in that county. 4.2. Survey instrument The survey was composed of questions regarding demographic characteristics of the nurses, organizational and work environment characteristics of their workplaces (e.g. orientation, shifts, hours of work, overtime, workload, perceptions of job difficulty, demand and control), and nurses’ professional commitment and intent to leave nursing. The main part of the survey was obtained from Kovner et al. (2007) with their permission. These authors obtained the survey items and scales from a number of sources, including Gurney et al. (1997), Frone et al. (1997), and Spector and Jex (1998). In addition to the items used by the Kovner team, we added questions regarding commitment to nursing (professional commitment) and intent to leave nursing. We obtained these from surveys developed by Blau and colleagues (Blau, 1985; Blau et al., 2003). All items and scales in the survey have been used in a number of studies for a number of years, and the validity and reliability of scales were tested in these earlier studies (Blau, 1985; Blau et al., 2003; Gurney et al., 1997; Frone et al., 1997; Unruh and Nooney, 2011; Spector and Jex, 1998). Kovner et al. (2007) also assessed Cronbach’s alpha for the job difficulty, demand and control scales, and reported values of 0.8 or greater. We further tested the validity of all the scales. Our tests and results are discussed in the subsection on data analyses. 4.3. Measures The questions in the survey measured professional commitment, intent to leave nursing, and personal, organizational and work environment characteristics and perceptions that could affect that commitment and intent. Professional commitment and intent to leave nursing were measured through seven and four items respectively, all listed in Table 2. Responses for each item were on a 5-point Likert scale, ranging from ‘‘strongly disagree’’ to ‘‘strongly agree.’’ Composite scales were created for each construct, composed of the summed values of the individual items divided by the number of items. These two scales were the two separate dependent variables used in the analyses. Personal (individual) characteristics in the analysis were: age (in years), gender, Hispanic ethnicity, race (White, African-American, other), self-perceived health, level of basic nursing education (associate degree, diploma, bachelor’s degree), whether there were children in the home, whether the respondent was married or not, prior work experience in healthcare (yes or no), and professional

Table 1 Individual, organizational, and work environment characteristics of NLRN respondents (N = 414). Frequency sample

Gender 35 Male Female 364 Ethnic identity Hispanic/Latino 49 Not Hispanic/Latino 344 Racial identity Black/African American 36 White 315 Other 63 Marital status Married 253 Not married 161 Children in home No children in home 220 Children in home 194 Health Poor 1 Fair 17 Good 107 Very good 179 Excellent 109 Nursing education Diploma 20 Associate 266 Bachelors 119 Masters 1 Doctorate 3 Prior work experience in health care Yes 221 No 193 Hospital is magnet Yes 106 No 308 Type of hospital Academic medical center 63 Community teaching 167 Community non-teaching 247 Perception of adequacy of orientation Extremely well 133 Fairly well 128 Adequately 101 Inadequately 37 Extremely inadequately 13 Shift length Twelve hour 392 Other 22 Shift time Day 257 Other 157 Mandatory overtime policy Yes 35 No 379

Age (years) Professional tenure (months) No. of shifts floated previous month No. of hours actually worked No. of patients in recent shift Hourly wages

Percent sample

Percent all NLRNs in Florida in 2006

8.77 91.23

14.87 85.13

12.47 87.53

15.81 84.19

8.70 76.09 15.21

15.32 55.27 29.41

61.11 38.89 53.14 46.86 0.24 4.12 25.91 43.34 26.39 4.89 65.04 29.10 0.24 0.73

10.84 49.17 36.88 2.62 0.46

53.38 46.62 25.60 74.40 15.22 40.34 44.44 32.28 31.07 24.51 8.98 3.16 94.69 5.31 62.08 37.92 8.45 91.55 Mean

SD

Mean

35.63 27.6 1.01 38.35 4.91 24.03

14.88 5.6 1.82 9.60 2.15 4.45

35.63

39.3

Note: This table was originally published in a paper by Unruh and Nooney (2011). It is reprinted here with permission from the prior publisher.

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Table 2 Respondents’ professional commitment, intent to leave nursing, and perceptions regarding job difficulties, demands, and control (N = 414). Percentage of respondents who: Professional commitment items would take a non-nursing job if it paid the samea definitely want a career in nursing would not work in nursing if could choose career againa would stay in nursing even if income was enough to not work like nursing too much to give it up believe that nursing is the ideal vocation are disappointed that they ever entered nursinga Professional commitment composite: mean 3.64, SD = 0.87 Intent to leave nursing are thinking about leaving the nursing profession intend to look for a new profession intend to stay in nursing for a long timea plan to have a job that requires an RN license next yeara Intent to leave nursing composite: mean 1.9, SD = 0.76 Percentage of respondents who experienced: Job difficulty items: Difficulty with org. rules and procedures Difficulty with supervisor Lack of equipment Interruptions Lack of information Conflicting job demands Inadequate help Incorrect instructions Too high workload Job difficulty composite: mean 2.90, SD = 0.89 Job demand items: Job requires working very fast Job requires working very hard Job leaves little time to get things done Job requires doing more than can be done well Job demand composite: mean = 4.17, SD = 1.04

Strongly disagree

Disagree

Neither agree or disagree

Agree

Strongly agree

18.6 1.5 31.0 12.4 5.0 4.0 38.5

35.5 2.5 37.7 17.8 16.7 11.9 40.8

18.8 23.7 14.7 16.1 25.5 26.6 14.0

17.8 41.4 11.0 41.9 37.9 41.6 4.8

9.2 30.8 5.5 11.7 14.9 15.8 1.9

41.6 40.8 2.5 3.7

37.2 36.7 2.9 1.4

12.6 16.0 11.9 9.8

5.9 4.6 54.7 42.1

2.7 1.9 28.0 42.9

Never

<1/month

1–3 days/month

1–2 day/week

3–4 days/week

5 or >days/week

16.8 38.3 13.2 8.1 14.6 18.4 17.3 23.8 9.0

27.3 33.7 22.4 16.7 36.8 20.8 26.0 46.5 19.5

27.9 15.7 27.5 22.3 27.3 27.7 27.2 20.2 26.5

16.0 5.8 21.4 25.0 14.1 17.6 18.9 7.2 20.8

8.1 4.8 10.8 17.9 5.7 10.2 6.8 1.8 15.4

3.8 1.8 4.7 9.9 1.4 5.2 3.8 0.4 8.8

2.7 2.8 4.1 9.3

5.3 4.2 11.7 17.6

10.8 9.7 21.6 24.0

28.8 28.1 27.9 23.2

32.1 35.0 23.6 18.6

20.1 20.2 11.1 7.3

Job control items:

None at all

Only a little

A moderate amount

Quite a bit

A great deal

Ability to act independently of supervisor Ability to make decisions and carry them out Ability to act independently of others Job control composite: mean = 4.00, SD = 0.77

0.2 0.7 1.0

5.1 4.9 4.6

16.3 20.7 21.5

43.2 45.3 43.0

35.1 28.5 29.8

Note: This table was originally published in a paper by Unruh and Nooney (2011). It is reprinted here with permission from the prior publisher. a Reverse coded for composite scale and regression analyses.

tenure (months of employment since graduation). Organizational variables were: the respondent’s hospital magnet status, and the type of hospital (i.e. academic medical center, community teaching, community non-teaching). Work environment characteristics in the analysis were: whether the respondent’s work shift was 8-h or 12-h; whether the shift was day (12 or 8 h) or other (evening, 8-h night, or 12 h night); the number of shifts worked on a unit different than the usual unit (‘‘floating’’) in the previous month; the number of actual hours worked in the past week; whether the hospital has mandatory overtime; perception of the adequacy of orientation preparation (5point Likert, from ‘‘extremely poorly’’ to ‘‘extremely well’’); the length of the orientation; the number of patients the respondent had in the most recent shift; the respondent’s hourly wages, and perceptions of job difficulties, demands and control. Perceptions of job difficulties, demands and control were measured through three constructs composed of

nine, four and three items respectively. Perceptions of job difficulties and demands were measured using six-point Likert scales that indicated the frequency at which the job was perceived as difficult or demanding, ranging from ‘‘never’’ to ‘‘five or more times a week.’’ Perceptions of job control were measured using five-point Likert scales that indicated the level of job control from ‘‘none at all,’’ to ‘‘a great deal.’’ All items are listed in Table 2. Composite scales were created for each construct by summing the values of the individual items and dividing by the number of items. We used both individual items and composite scales in the analyses (in separate regressions). 4.4. Data analyses Our data analyses included testing the validity of the scales used in the study, performing descriptive and correlational statistics (regression analyses), and ranking the standardized beta values from the regressions of

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individual items in the job difficulty, demand and control constructs. First, we tested all the scales used in the analyses even though validities of the scales had been tested in prior studies. Principal components analysis (PCA), with an oblique (promax) rotation, was performed on the items in the two dependent variables (professional commitment and intent to leave nursing). The rotated PCA retained two factors with eigenvalues above 1, explaining 68 percent of the total variance. Items for each construct loaded strongly (>0.71) on the corresponding factor. PCA with a promax (oblique) rotation was also performed for the items in the three independent variables (job difficulty, job demand, job control). The PCA retained three factors with eigenvalues above 1, explaining 65 percent of the total variance. Items for each construct loaded strongly (>0.50) on a single factor, but the ‘‘too high workload’’ item in the job difficulty scale also loaded strongly on the job demand scale (as expected). Standardized Cronbach’s Alpha values for the scales were as follows: professional commitment = 0.91; intent to leave scale = 0.84; for job difficulty = 0.90; job demand = 0.88; and for job control = 0.86. These results indicated high internal consistency of all the scales and allowed us to proceed with the rest of the statistical analyses with confidence regarding the validity of the scaled variables. Next, descriptive analyses were performed on all variables. Following that, regression analyses were performed using ordinary least squares. Each composite dependent variable (professional commitment, intent to leave nursing,) was regressed on the three composite perceptions of work environment variables (job difficulty, job demand, job control) and each of their items (9, 4 and 3, respectively) in separate regressions (total of 2  19 = 38 regressions). The job difficulty, demand and control composites and items were placed in regressions separately because of their large number (19) and their correlation within, and to some degree between, constructs (as detailed above). Individual, organizational and other work environment variables were included in each regression. Analyses were performed using Statistical Analysis Software (SAS) version 9.3.1. Statistical significance was set at an alpha level of 0.05. The final step in the analyses was to explore the strength of influence of each of the job difficulty, demand and control items on professional commitment and intent to leave nursing. This was done by ranking the standardized beta values that were obtained for these items. Partial R-squares for each beta were also reported. 5. Results Table 1 presents descriptive information about the respondents’ background, the organizational characteristics of the hospitals where they worked, and characteristics of their work environments at the time of the survey. Respondents’ were 35 years old on the average, 91 percent were female, 76 percent were white, 12.5 percent were Hispanic, 61 percent were married, and nearly half had children in the home. Nearly all reported that their health was good to excellent. Over half had an Associate

Degree and worked in healthcare prior to graduating. They had been employed an average of 27.6 months since taking their first job. One-quarter worked in Magnet hospitals and almost half worked in community nonteaching hospitals. All but 12 percent of respondents felt that their orientation was adequate to extremely adequate. The vast majority of respondents worked twelvehour shifts, and over half worked day shifts. They floated to another unit an average of one shift in the previous month and had an average of five patients on their most recent shift. The average wage of respondents was $24 per hour. Table 2 presents respondents’ professional commitment and intent to leave nursing, and their perceptions of job difficulties, demands and control at their workplaces. Most respondents had positive attitudes about nursing. For example, 72 percent wanted a career in nursing, and 53 percent liked nursing too much to give it up and would stay in nursing even if they had enough income to not have to work. Only 6.7 percent were disappointed that they went into nursing. However, 27 percent would take a nonnursing job if it paid the same, 8.6 percent were thinking about leaving nursing and 6.5 intended to look for a new profession. Most respondents experienced job difficulties only 1–3 days or less each month. However, they experienced job demands 1–2 days or more each week. Most felt that they had ‘‘quite a bit’’ or ‘‘a great deal’’ of job control. Thus, the nurses in this sample experienced a fair amount of job difficulties, and a significant amount of job demands, but they also had the ability to act independently on the job. The results of six of our regressions are presented in Table 3. Three regressions are shown for the scaled composite dependent variable ‘‘professional commitment,’’ and three for the scaled composite dependent variable ‘‘intent to leave nursing.’’ Each of the three regressions used one of the composite job difficulty, job demands, or job control scales, and all of the demographic, organizational and other work environment characteristics. A number of demographic, organizational and work environment variables were not significantly related to professional commitment or intent to leave nursing. These were: age, gender, ethnicity, health, education, presence of children at home, marital status, having worked in healthcare prior to becoming RN, professional tenure, hospital magnet status, type of hospital (AMC, community teaching, community non-teaching), orientation length, twelve hour shifts, floating, mandatory OT, number of patients in recent shift, and wages. Among the significant predictors of professional commitment and intent to leave nursing, we find the following: newly licensed RNs who were White and in better health had a greater commitment to nursing and less intent to leave nursing. Those who perceived their orientation to be good, who worked day shift, and who worked more hours had greater professional commitment and less intent to leave. Finally, those who perceived less job difficulties and demands and more job control had greater professional commitment and less intent to leave nursing.

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Table 3 Predictors of newly licensed RNs’ professional commitment and intent to leave to nursinga. Professional commitment

Intent to leave nursing

Job difficulty regression

Job demands regression

Job control regression

Job difficulty regression

Job demands regression

Job control regression

Standardized b

Standardized b

Standardized b

Standardized b

Standardized

Standardized b

b Racial identity: white Health Orientation preparation Day shift Hours worked Job difficulty composite Job demand composite Job control composite

0.155 NS 0.163 0.132 0.112 0.344 – –

*

NS ** ** * ****

– –

*

0.144 0.130 0.227 0.137 0.115 – 0.230 –

* **** ** *

– ****

–

NS 0.113 0.227 NS NS – – 0.159

NS * ****

NS NS – – **

0.166 NS NS 0.129 0.191 0.359 – –

*

NS NS * *** ****

– –

0.133 0.119 0.115 0.116 0.189 – 0.195 –

* * ** * ***

– ***

–

NS NS NS NS 0.157 – – 0.136

NS NS NS NS **

– – *

a

The following were not significantly related to intent to leave nursing: age, gender, ethnicity, health, education, presence of children at home, marital status, having worked in healthcare prior to becoming RN, professional tenure, hospital magnet status, type of hospital (AMC, community teaching, community non-teaching), orientation length, twelve hour shifts, floating, mandatory OT, number of patients in recent shift, and wages. NS = not significant – = not applicable. * p < = 0.05. ** p < = 0.01. *** p < = 0.001. **** p < = 0.0001.

Coefficients of determination (R-squares or R2s) are not reported in Table 3. Total R2s for the six regressions ranged from 0.1627 to 0.2679, indicating that the proportion of variance explained by the models was from 16.27% to 26.79%. The partial R2s for the independent relationships between job difficulty on the one hand, and professional commitment and intent to leave nursing on the other were 0.097 and 0.114 respectively. This indicates that job difficulty alone explained 9.7% of the variance in professional commitment and 11.4% of the variance in intent to leave. Likewise, partial R2s for job demand were 0.045 and 0.034, indicating that job demand explained 4.5% and 3.4% of the variance in professional commitment and intent to leave. Partial R2s for job control were 0.021 and 0.016, indicating that job control explained 2.1% and 1.6% of the variance in professional commitment and intent to leave. We also ran regressions using the individual job difficulty, demand and control items. Although all demographic, organizational and work environment characteristics were included in each regression, we report and rank only the standardized beta values and partial R2s for the job difficulty, demand or control items (beta values for the

other variables were not significantly different than those presented in Table 3). Tables 4–7 present the ranking of job difficulty, job demand and job control items according to their strength of independent correlation with professional commitment and intent to leave nursing. The ranking for job difficulty items did not line up the same for both professional commitment and intent to leave nursing, so results were presented in two different tables (Tables 4 and 5). Otherwise, rankings for job demand and job control lined up the same for the two dependent variables, so these were reported together in Tables 6 and 7. The ranking of betas and partial R2s also did not always line up the same, so we initially ranked the items according to their beta values. Ranking according to standardized beta values indicate that the job difficulty items that contribute the most to lower professional commitment and greater intent to leave nursing are problems with organizational rules and procedures, interruptions, incorrect instructions, inadequate help from others, and lack of supervisor support. According to partial R2s, lack of supervisor support should rank third in contribution to lower professional

Table 4 Rank of impact of job difficulty factors on the professional commitment of newly licensed RNsa. Difficult to do job d/t: Organizational rules and procedures Interruptions Incorrect instructions Inadequate help from others Lack of supervisor support Too high workload Lack of sufficient equipment Conflicting job demands Lack of information a

Rank 1 2 3 4 5 6 7 8 9

Partial R2

Standardized b 0.266 0.260 0.236 0.230 0.228 0.215 0.210 0.198 0.176

****

0.063 0.060 0.042 0.042 0.050 0.034 0.039 0.031 0.023

**** **** **** **** *** *** *** ***

The ranking goes from the factor having the strongest to least effect based on standardized beta values and partial R2s. *p < = 0.05; *** p < = 0.001. **** p < = 0.0001.

**

p < = 0.01.

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Table 5 Rank of impact of job difficulty factors on newly licensed RNs’ intent to leave nursinga. Difficult to do job d/t: Lack of supervisor support Incorrect instructions Organizational rules and procedures Interruptions Inadequate help from others Conflicting job demands Lack of sufficient equipment Too high workload Lack of information

Partial R2

Standardized b

Rank 1 2 3 4 5 6 7 8 9

****

0.294 0.291 0.280 0.244 0.238 0.197 0.187 0.178 0.160

0.081 0.069 0.071 0.053 0.046 0.036 0.031 0.022 0.019

**** **** **** **** *** *** ** **

a

The ranking goes from the factor having the strongest to least effect based on standardized beta values and partial R2s. *p < = 0.05. ** p < = 0.01. *** p < = 0.001. **** p < = 0.0001.

Table 6 Rank of impact of job demand factors on newly licensed RNs’ professional commitment and intent to leave nursinga. Job requires:

Rank

Professional commitment

Having to do more than can be done well Having no time to get things done Working very fast Working very hard

1 2 3 4

0.281 0.228 0.130 0.118

Intent to leave nursing Partial R2

Standardized b **** **** * *

0.061 0.043 0.015 0.014

Standardized b 0.227 0.212 0.115 0.094

**** *** *

NS

Partial R2 0.040 0.039 0.013 0.009

a

The ranking goes from the factor having the strongest to least effect based on standardized beta values and partial R2s. NS = not significant. **p < = 0.01. * p < = 0.05. *** p < = 0.001. **** p < = 0.0001.

commitment, instead of 6th, as indicated by the standardized beta. Lack of information, lack of sufficient equipment, and workload contributed the least to problems with professional commitment. According to partial R2s, lack of sufficient equipment should have ranked slightly higher. Using the standardized betas, the same job difficulty items were in the top five and lower four ranks for intent to leave nursing. However, the order of their ranking in these categories was different. Partial R2s indicated the same ranking, with the exception of organizational rules and procedures, which ranked second instead of third. By both standardized betas and partial R2s the job demand items that were most strongly related to professional commitment and intent to leave nursing were ‘‘having to do more than can be done well,’’ and ‘‘having no time to get things done.’’ Job demand issues that were less strongly related were ‘‘working very fast’’ and ‘‘working very hard.’’ By both standardized betas and partial R2s the job control ranking that was most strongly

related to professional commitment and intent to leave nursing was the ‘‘ability to act independently of others,’’ followed by ‘‘ability to act independently of supervisor’’ and ‘‘ability to make decisions and carry them out.’’ 6. Discussion Although most of the newly licensed RNs in this study had a high level of professional commitment, over a quarter of them said that they would take a non-nursing job if it paid the same, and a small number were thinking about leaving nursing and intended to look for non-nursing jobs. Few demographic characteristics of the newly licensed RNs predicted these attitudes: race and health were the only ones. Neither organizational characteristic in our study (type of hospital, magnet status) was a predictor. Similarly, the only objective work environment characteristic that contributed to the results were working the day shift, perceptions of orientation preparation, and number

Table 7 Rank of impact of job control factors on newly licensed RNs’ professional commitment and intent to leave nursinga. Respondent has the:

Rank

Professional commitment Standardized b

Ability to act independently of others Ability to act independently of supervisor Ability to make decisions and carry them out a

1 2 3

0.151 0.147 0.135

** * *

Partial R2 0.019 0.016 0.016

Intent to leave nursing Partial R2

Standardized b 0.155 0.112 0.082

** *

NS

0.020 0.011 0.006

The ranking goes from the factor having the strongest to least effect based on standardized beta values and partial R2s. NS = not significant. * p < = 0.05. ** p < = 0.01. *** p < = 0.001. **** p < = 0.0001.

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of hours. However, perceptions of job difficulties, demand and control were significant predictors of professional commitment and intent to leave. Job difficulty in particular contributed to a significant proportion of the variance in professional commitment and intent to leave. Our results regarding predictors of professional commitment and intent to leave nursing differed slightly from studies of the general RN population, as reviewed in the background section. In these studies, individual predictors of greater professional commitment and staying in nursing included being single, young, and more highly educated. These were not significant predictors in our study. In some studies RNs who were male or who had family responsibilities were more likely to be committed to nursing or to stay, or intend to stay, in nursing, but in others they were less likely, while in our study this was not a predictor either way. In one study, White nurses were more likely to leave nursing than African Americans (Smith et al., 2007), but in our study White newly licensed RNs had greater professional commitment and less intent to leave nursing. Regarding the work environment, our study differed from those of the general RN population that found that patient load and pay were important to career satisfaction or staying in nursing. Our results were similar to studies of the general population of RNs in finding that professional tenure and shift work were significantly related to professional commitment or intent to leave nursing. As in our study, a prior study found that high job demand and low job control (composite measures) were related to early retirement thoughts in the general RN population (Elovainio et al., 2005). Prior studies also had similar results for several of our individual job difficulty, demand and control items: supportive organizations and colleagues, supportive supervisors, and autonomy contributed to staying in nursing. The significant predictors of professional commitment and intent to leave nursing in this study indicate that certain improvements in the work environment could help keep newly licensed RNs in nursing. These improvements would be to strengthen newly licensed RN orientation, provide day shift opportunities, encourage full time work, and reduce factors that lead to perceptions of job difficulty, demands and lack of control. The ranking of job difficulty items indicate that priorities should be placed on improving supervisor support, ensuring adequate help from others, and reducing difficulties with organizational rules and procedures, interruptions, and incorrect instructions. The ranking of job demands shows that changes need to be made to the work environment to reduce perceptions of work pressures (‘‘having to do more than can be done well,’’ and ‘‘having no time to get things done’’). These could include changes to unit structure and procedures, better staffing, and less paperwork. To improve perceptions of control on the job, newly licensed RNs need to be given the ability to work independently of others.

respondents with the most negative (or most positive) perceptions did not complete and return the survey. We feel more confident about results after running the bias analysis which showed no significant demographic differences between our sample and the newly licensed RN population in Florida in that year. The generalizability of our results may be diminished due to the fact that the sample was from one state in the U.S. This is problematic not only from a national but also international standpoint. Our results may not apply to the U.S., let alone the rest of the world. However, as far as the U.S. goes, the RN population in Florida is demographically representative of the RN population in the entire U.S. (Florida Center for Nursing, 2010) so we feel confident that results can be extrapolated to the U.S. population as a whole. Also, since newly licensed RNs in other countries face similar work environment challenges they may have similar perceptions and responses, so results may be generalizable at an international level. However, more research should be done internationally to ascertain whether and to what degree this is the case.

6.1. Limitations of the study

References

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7. Conclusion The findings of this study indicate that several work environment factors strongly predict newly licensed RN professional commitment and intent to stay in nursing. Hospitals need to strengthen newly licensed RN orientation and provide day shift opportunities for them. Impediments to getting work done and time pressures need to be reduced. In particular, hospitals should provide strong supervisor support and clear instructions, cultivate a culture of assisting others with work, reduce paperwork and interruptions, and improve staffing. Increasing newly licensed RNs’ ability to make decisions and act independently will also improve their commitment to and staying in the profession. Acknowledgements This study was supported in part by the Florida Center for Nursing and the Blue Cross and Blue Shield Foundation of Florida. Conflict of interest: There are no conflicts of interest. Funding: Florida Center for Nursing funded a portion of the study. Their contribution was obtained from a grant from the Blue Cross and Blue Shield Foundation. Ethical approval: IRB approval was obtained from the University. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/ j.ijnurstu.2013.04.002.

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