JONA Volume 45, Number 5, pp 250-253 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
THE JOURNAL
OF N U R S I N G
ADMINISTRATION
A Comparison of Salary-Wage and Hourly-Wage Acute Care Nursing Units A Pitot Study
Rosa G. H ickey, MSN, RN, NEA-BC
P aula F. Coe, M SN, RN, NEA-BC
B arbara L. B u ch ko , DNP, RNC-M NN
A n n e B. W oods, PhD, M P H , RN
O BJECTIV E: This pilot study exam ined differences in R N perception of the professional practice environ ment and financial indicators between salary-wage and hourly-wage compensation models. B A C K G R O U N D : There is a dearth of current infor m ation regarding use of salary-wage models for com pensation for direct care nurses. M E T H O D S : A descriptive, com parative design was used to exam ine the Revised Professional Practice E nviro n m en t Scale (RPPE) and financial indicators o f nu rses in a n o n p ro fit h e a lth c a re system over a 6 -m o n th perio d . RESULTS: M ean scores on the RPPE w ere signifi cantly low er for hourly-w age R N s, and the hourlyw age m odel resulted in a 1.2% ad d itio n al cost for overtim e h o u rs co m p ared w ith the fixed cost of the salary-w age m odel. C O N C L U SIO N S: Nurses in an hourly-wage unit re ported a significantly low er perception of the clinical practice environm ent th a n did their peers in a salarywage unit, indicating th a t professional practice per ceptions in a salary-wage unit m ay provide a m ore
effective professional practice environm ent. Finan cial analysis resulted in a budget-neutral impact.
A uthor Affiliations: Chief N ursing Officer and D irector of Patient Care (Ms Hickey), WellSpan Surgery and Rehabilitation Hospital, York; Director of EBP and Nursing Research (Dr Buchko), WellSpan Health, York; Director of Nursing Excellence and Innova tion (Ms Coe), WellSpan Health/York Hospital, York; Professor and Chair of Department of Nursing (Dr Woods), Messiah College, Mechanicsburg, Pennsylvania. Funding was received from the South Central Organization of Nurse Leaders ($1,000). The authors declare no conflicts of interest. Correspondence: Dr Buchko, WellSpan Health, York Hospital, 1001 S George St, York, PA 17403 ([email protected]). DOI: 10.1097/N N A .0000000000000194
250
The theoretical underpinnings of the nursing p ro fessional practice environm ent (PPE) are rooted in the sociology of organizations, occupations, and w ork, w hich is a com plex construct to conceptualize and m easure.1 The PPE is defined as the organizational characteristics of a w ork setting that facilitate or con strain the professional practice of the registered nurse (RN).2 The practice environm ent for nursing profes sionals is among the most demanding of all work environ m ents. C om pounding this stress, recent healthcare reform legislation focuses on efficient and affordable healthcare, often resulting in restructuring healthcare system operations to obtain m axim um efficiencies, w hich directly im pact the w ork environm ent.3 N urse leaders are tasked w ith exploring various strategies to enhance the PPE for RNs in the context of provid ing a financially viable w ay to provide direct patient care. A salary-wage model may provide a solution. The purpose of this pilot study is to exam ine differences in R N perception of the PPE and financial indicators between salary-wage versus hourly-w age m odels of com pensation. Current inform ation regarding the use of a salarywage model for direct care nurse compensation is lack ing, with most studies more than 15 years old. However, the use of a salary-wage model has dem onstrated ben efits for both nurses and healthcare organizations. M ul tiple authors report im proved nurse satisfaction w ith the implementation of a salary-wage model A 8 A pretestposttest evaluation of a staff nurse salary program at 2 m etropolitan hospitals found a significant positive
JO N A • Vol. 45, N o. 5 • May 2015
change in staff nurses’ intrinsic, extrinsic, an d general sa tisfactio n (P < .05), w ith the salary-w age m odel as m easured by the M innesota Satisfaction Q uestionnaire.5 In th e q u a s i-e x p e rim e n ta l, m a tc h e d d esig n stu d y o f Z elau sk a s a n d H o w e s,8 a statistically significant in crease in job sa tisfactio n afte r im p lem e n ta tio n o f a salary -w age m odel w as fo u n d fo r th e Jo b D escription Index subscale regarding p ay (preim plem entation, 28; p o stim p le m en ta tio n , 4 0 .5 7 ; P - .01). T he rem ain in g studies th a t rep o rted im proved nurse satisfaction after im plem enting salary-w age co m pensation did n o t p ro vide adequate data or statistical analysis in their findings.4’6’7 D e G ro o t et a l9 did n o t find a significant increase in job satisfaction in a salaried differentiated pay stru c tu re m odel. T his study is strengthened by an a prio ri p o w er analysis for sam ple size, alth o u g h the study did n o t achieve an ad e q u ate sam ple, resulting in an in creased risk o f a type II error, w hich potentially explains the lack o f statistical significance.9 O rganizational benefits dem onstrated by the stud ies include a decrease in overtim e hours an d subsequent cost savings.5,6’8,10' 12 E valuation o f these financial o u t com es is lim ited because of the different m ethods used to analyze costs in the studies. D eG ro o t and colleagues9 fo u n d th a t th e salaried differen tiated p ay scale m odel resu lted in co st increases ran g in g fro m 3 .4 % to 12% co m p ared w ith the hourly-w age m odel. T h eir analysis is strengthened by the inclusion of paid hours for hours n o t w o rk e d enco m p assed in th e salary-w age m odel. D eG ro o t et al9 attrib u te this to variations in m anaging self-scheduling b etw een th e 2 study units. A d d itio n al benefits include im p ro v ed n u rse re te n tio n 5' 8’10 and d ec rease in sick tim e u se .5’8 In th e c u rre n t p ra c tic e an d p olitical en v iro n m en t, it is im p o rta n t to explore th e im plications o f a salary-w age m odel.
review bo ard . Institutional review b o ard ap proval w as a t th e system level co vering b o th o rg an izatio n s. T h e study setting included 2 acute care hospitals, 1 of w hich w as a Magneto-designated facility at the time of the study, in a single, nonprofit h ea lth c are system in the n o rth e a st United States. T he hourly-w age m odel w as the standard co m p en sa tio n fo r nu rses th ro u g h o u t th is h ea lth c are system . In 2 0 1 2 , th e h ea lth c are system o p en ed a su r gical an d reh a b ilita tio n h o sp ital using the salary-w age m odel. Both study sites w ere postsurgical units o f co m parable size an d p atien t acuity. To be included in the study, the employee m ust have been a licensed R N p ro viding direct patien t care on the designated study units. A convenience sam ple o f R N s from each u n it w as recruited via e-m ail sent fro m the research team w ith a link to an an o n y m o u s research survey. P articip atio n w as voluntary. T w enty-three R N s com prised the to tal sam ple, 12 from the hourly-w age u n it a n d 11 from the salary-w age unit. T his co n stitu ted a 5 2 .3 % response rate. P artic ip an ts ran g e d in age fro m 23 to 61 years (m ean [SD], 4 1 .4 [10.9] years) a n d w o rk e d as a n R N an average of 14.5 years (SD, 10.6; range, 2-40 years). Nurses on the salary-wage unit were significantly younger (34.5 vs 47.7 years; t = 3.6, df = 21, P = .002), have w orked few er to ta l years as an R N (9.6 vs 19.1 years; t = 2 .3 , df = 2 1; P = .03), an d have w o rk e d few er years o n th e ir c u rre n t u n it (1.3 vs 8 .4 years; t = 3 .4 , df = 11; P - .006) com pared w ith R N s on the hourlyw ag e u n it. M o st p a rtic ip a n ts w ere w o m en (9 5 .7 % ) an d 6 9 .5 % h a d a b ach elo r’s degree. T h ere w ere no statistically significant differences between R N s on the hourly-w age m odel unit and those on the salary-wage m odel unit in gender, entry-level professional education, highest level o f ed u cation, o r history o f w o rk in g in an hourly-w age m odel an d salary-w age m odel unit.
P u rp o s e o f th e S tu d y
In stru m e n ts
T h e p u rp o se o f this p ilo t study is to ex am in e the dif ferences b etw een a salary-w age m o d el an d an h ou rly w age m odel for R N satisfaction and financial indicators. T h e specific aim s are (1) to identify th e difference in n u rses’ p erc ep tio n o f th e PPE a n d (2) to identify th e difference in total cost and base cost of R N com pensation betw een nurses em ployed in a salary-w age m odel and those em ployed in an hourly-w age m odel. It w as hypo thesized that nurses’ perception of the PPE will be greater in the salary-wage m odel com pared w ith the hourly-wage m o d el an d th a t w age costs w ill be lo w er in th e salaryw age m odel c o m p a re d w ith the hourly -w ag e m odel. M e th o d s
D esign, S etting, a n d S am ple A descriptive, com parative design w as used. T his study w as deem ed exem pt by the organ izatio n ’s institutional
JONA • Vol. 45, No. 5 • May 2015
To ad d ress stu d y aim 1, th e n u rses’ p erc ep tio n o f th e PPE w as m easured w ith the Revised Professional Prac tice E n v iro n m en t Scale (RPPE), a p sy ch o m etrically so u n d , 39-item , self-adm inistered, 4 -p o in t L ikert scale in stru m e n t th a t ta k es a p p ro x im a te ly 10 m in u tes to com plete.13 T he RPPE measures 8 com ponents of p ro fessional clinical practice in acute care settings: (1) dis agreem ent an d conflict, (2) leadership an d autonom y, (3) internal w o rk m otivation, (4) co n tro l over practice, (5) te a m w o rk , (6) co m m u n ic atio n a b o u t p atien ts, (7) cultural sensitivity, and (8) staff relationships w ith phy sicians. H igh scores represent high levels of the co n stru ct. Seven item s req u ire reverse scoring to arriv e at th e subscale an d to ta l scores. T h e in stru m e n t has a p p lic atio n a t b o th in d iv id u al an d o rg a n iz a tio n a l level analysis. All 8 subscales have d o cu m en te d co n stru c t valid ity a n d high in te rn al reliability, w ith an overall C ro n b a c h ’s a o f .93 a n d subscale a values from .81
251
Table 1.
RPPE Scale Scores for Total Sample
Total RPPE score (39 items; potential range, 39-156) Subscale 1: Disagreement Sc Conflict (9 items; potential range, 9-36) Subscale 2: Leadership Sc Autonomy (5 items; potential range, 5-20) Subscale 3: Internal Work Motivation (8 items; potential range, 8-32) Subscale 4: Control Over Practice (5 items; potential range, 5-20) Subscale 5: Teamwork (4 items; potential range, 4-16) Subscale 6: Communication About Patients (3 items; potential range, 3-12) Subscale 7; Cultural Sensitivity (3 items; potential range, 3-12) Subscale 8; Staff Relationships With MD (2 items; potential range, 2-8)
to .88.lj In this study, the C ronbach’s a for the overall instrum ent was .97, and all subscales had C ronbach’s a values greater than .71. To address study aim 2, financial indicators were examined using unit budgets and aver age daily census (ADC) data. D ata Analysis D ata w ere analyzed w ith SPSS Statistics version 21.0 (Chicago, Illinois). M easures of central tendency were used to describe the study sample along with independentsample t tests and j 2 to identify difference in study groups. To identify the difference in nurses’ percep tion of the PPE between salary-wage and hourly-wage m odels (study aim 1), m easures of central tendency w ere used to describe overall nurse perceptions of the PPE. Skewness and kurtosis measures m et param eters for a norm al d istrib u tio n . T h erefore, independentsamples t tests were used to identify differences. Sig nificance level was set at .05. To identify differences between total and base cost between salary-wage and hourly-wage models (study aim 2), com parisons using frequency data were made over a 6-m onth period from O ctober 2013 to M arch 2014.
Results Table 1 provides descriptive data for the RPPE total and subscale scores. M ean scores w ere statistically
Table 2.
Range
Mean (SD)
83-148 17-30 9-20 22-32 6-20 7-16 4-12 5-12 4-8
118.3 24.8 15.6 26.6 14.6 11.7 9.2 9.3 6.4
(19.4) (3.7) (3.3) (2.9) (4.3) (2.6) (1.9) (2.1) (1.3)
Median 116 25 16 27 15 12 9 9 6
significantly low er for R N s on the hourly-w age unit com pared w ith RNs on the salary-wage unit for the total RPPE score and for all subscale scores (Table 2). Considering that the dependent variable is ordinal level, a reanalysis using the nonparam etric M ann-W hitney U test yielded identical results, w ith all findings statis tically significant at .016 to .000 levels, confirming the independent-sam ple f-test findings. Financial com parisons identified th at during the 6-month study period, the salary-wage unit, with fixed salary costs, exceeded the budgeted ADC by an average 3% above budget. O n the hourly-wage unit, the ADC was 2% below budget, on average. However, the hourlywage unit also experienced 1.2% in RN overtime, which resulted in a cost of $2,000 per month over the 6-month study period. W hen the ADC was at or below budget on the hourly-wage unit during the first 3 m onths of the study period, RNs were floated to other units. M ost of R N overtime occurred during the second 3 m onths, w hen the hourly-wage unit was at or above its bud geted ADC.
Discussion Nurses in an hourly-wage model unit have significantly lower perceptions of the clinical practice environm ent com pared with RNs in a salary-wage model unit, in d icatin g th a t the pro fessio n al p ractice m odel in a
Differences in RPPE Scores Mean (SD) Score Hourly
Total RPPE score Subscale 1; Disagreement & Conflict Subscale 2: Leadership & Autonomy Subscale 3: Internal Work Motivation Subscale 4; Control Over Practice Subscale 5: Teamwork Subscale 6; Communication About Patients Subscale 7; Cultural Sensitivity Subscale 8: Staff Relationship With MDs
252
103.5 22.3 13.3 25.3 11.2 9.9 8.0 8.0 5.5
(12.1) (3.1) (2.7) (2.4) (2.4) (1.8) (1.6) (1.7) (0.7)
Salary 134.4 27.6 18.1 28.1 18.4 13.6 10.5 10.7 7.5
(11) (1.9) (1.6) (2.9) (2) (1.7) (1.3) (1.3) (0.8)
t
P
-6 .4 -4 .8 -5 .0 -2 .6 -7 .8 -4 .9 -3 .9 -4 .2 -6 .3
.000 .000 .000 .018 .000 .000 .001 .000 .000
JONA • Vol. 45, No. 5 • May 2015
salary-wage model may be a more effective PPE. The characteristics of an organization’s PPE are correlated with nurse satisfaction.14 Our findings of higher nurse perceptions of the PPE support previous research dem onstrating improved nurses’ satisfaction with a salarywage model. These findings are also clinically impor tant as the tool is aligned with the model elements of Magnet recognition: transformational leadership; struc tural empowerment; exemplary professional practice; new knowledge, innovation, and improvement; and empirical outcomes.1’ These findings may be impacted by the significant demographic differences in age and years of practice between the 2 study groups. The small sample size impeded a linear regression analysis to control for this potential confounder. The hourly-wage model resulted in an additional cost of 1.2% for overtime hours compared with the fixed cost of the salary-wage model, which exceeded ADC by 3% . The comparison resulted in a budgetneutral impact. This is similar to the findings of DeGroot and colleagues9 that a salaried pay scale model resulted in increased cost compared with the hourly-wage model but with an overall budget-neutral impact.
Limitations Our study is strengthened by the use of a valid psy chometric instrument with documented internal con sistency for this study sample to measure the concept of nurses’ perception of the PPE. In addition, the sta tistically significant findings mitigate the risk of a type II error due to small sample size. However, there are several im portant limitations. The small sample size within 1 healthcare system in a single geographic area limits generalizability. The basic financial analysis does not include the myriad of other financial indicators such as hours worked, sick time, on-call time, or staff turnover.
Conclusions The findings from this small pilot study indicate that RNs’ perceptions of professional practice in a salarywage model may provide a more satisfying PPE. The salary-wage model is 1 strategy to enhance the PPE for RNs providing a financially viable way to provide direct patient care. Future research is needed with larger, more diverse samples in a variety of practice settings and more complex financial analysis to confirm the findings of this pilot study.
References 1. Lake E. Development of the Practice Environment Scale of the Nursing Work Index. Res Nurs Health. 2002;25(3):176-188. 2. Lake E. The nursing practice environment: measurement and evidence. Med Care Res Rev. 2007;64(104):1048-1228. 3. Hallmarks of the Professional Nursing Practice Environment. American Association of Colleges of Nurses Web site. http://www .aacn.nche.edu/publications/white-papers/hallmarks-practiceenvironment. Published January 2002. Accessed M ay 27,2014. 4. Avigne G, Guin P, Pittman L, Surdez M. Moving from an hourly pay model to a professional salary model. AORN J. 1998;68(3):400^I08. 5. Blouin AS. Exempt salary administration: redesigning staff nurse com pensation. / Nurs Adtn. 1992;22(6):24-28. 6. Borromeo AR, Windle PE, Eagen MK. The professional salary model: meeting the bottom lines. Nurs Econ. 1996;14(4):241-244. 7. Hill BM. The McAuley experience with changing compensation within the context of a professional nursing practice culture. Nurs Adm Q. 1989;14(l):78-82.
JO NA • Vol. 45, N o. 5
May 2015
8. Zelauskas B, Howes DG. The effects of implementing a pro fessional practice model. J Nurs Adm. 1992;22(7/8): 18-23. 9. DeGroot HA, Burke LJ, George VM. Implementing the dif ferentiated pay structure model: process and outcomes. J Nurs Adm. 1998;28(5):28-38. 10. Masaro T, Munroe D, Schisler L. A professional practice model: two key components. Nurs Manage. 1996;27(9):43-47. 11. Mushala ME, Henderson MA. A salaried compensation model for postanesthesia n urses./ Post Anesthesia Nurs. 1995;10(4): 208-210. 12. Sills LR. Implementation of a salaried compensation program for registered nurses. / Nurs Adm. 1993;23(l):55-59. 13. Erickson JI, Duffy ME, Ditomassi M , Jones D. Psychometric evaluation of the Revised Professional Practice Environment (RPPE) scale. / Nurs Adm. 2009;39(5):236-243. 14. Ditomasi M. A multi-instrument evaluation of the professional practice environm ent./ Nurs Adm. 2012;42(5):266-272.
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THE JOURNAL
OF N U R S I N G
ADMINISTRATION
A Comparison of Salary-Wage and Hourly-Wage Acute Care Nursing Units A Pitot Study
Rosa G. H ickey, MSN, RN, NEA-BC
P aula F. Coe, M SN, RN, NEA-BC
B arbara L. B u ch ko , DNP, RNC-M NN
A n n e B. W oods, PhD, M P H , RN
O BJECTIV E: This pilot study exam ined differences in R N perception of the professional practice environ ment and financial indicators between salary-wage and hourly-wage compensation models. B A C K G R O U N D : There is a dearth of current infor m ation regarding use of salary-wage models for com pensation for direct care nurses. M E T H O D S : A descriptive, com parative design was used to exam ine the Revised Professional Practice E nviro n m en t Scale (RPPE) and financial indicators o f nu rses in a n o n p ro fit h e a lth c a re system over a 6 -m o n th perio d . RESULTS: M ean scores on the RPPE w ere signifi cantly low er for hourly-w age R N s, and the hourlyw age m odel resulted in a 1.2% ad d itio n al cost for overtim e h o u rs co m p ared w ith the fixed cost of the salary-w age m odel. C O N C L U SIO N S: Nurses in an hourly-wage unit re ported a significantly low er perception of the clinical practice environm ent th a n did their peers in a salarywage unit, indicating th a t professional practice per ceptions in a salary-wage unit m ay provide a m ore
effective professional practice environm ent. Finan cial analysis resulted in a budget-neutral impact.
A uthor Affiliations: Chief N ursing Officer and D irector of Patient Care (Ms Hickey), WellSpan Surgery and Rehabilitation Hospital, York; Director of EBP and Nursing Research (Dr Buchko), WellSpan Health, York; Director of Nursing Excellence and Innova tion (Ms Coe), WellSpan Health/York Hospital, York; Professor and Chair of Department of Nursing (Dr Woods), Messiah College, Mechanicsburg, Pennsylvania. Funding was received from the South Central Organization of Nurse Leaders ($1,000). The authors declare no conflicts of interest. Correspondence: Dr Buchko, WellSpan Health, York Hospital, 1001 S George St, York, PA 17403 ([email protected]). DOI: 10.1097/N N A .0000000000000194
250
The theoretical underpinnings of the nursing p ro fessional practice environm ent (PPE) are rooted in the sociology of organizations, occupations, and w ork, w hich is a com plex construct to conceptualize and m easure.1 The PPE is defined as the organizational characteristics of a w ork setting that facilitate or con strain the professional practice of the registered nurse (RN).2 The practice environm ent for nursing profes sionals is among the most demanding of all work environ m ents. C om pounding this stress, recent healthcare reform legislation focuses on efficient and affordable healthcare, often resulting in restructuring healthcare system operations to obtain m axim um efficiencies, w hich directly im pact the w ork environm ent.3 N urse leaders are tasked w ith exploring various strategies to enhance the PPE for RNs in the context of provid ing a financially viable w ay to provide direct patient care. A salary-wage model may provide a solution. The purpose of this pilot study is to exam ine differences in R N perception of the PPE and financial indicators between salary-wage versus hourly-w age m odels of com pensation. Current inform ation regarding the use of a salarywage model for direct care nurse compensation is lack ing, with most studies more than 15 years old. However, the use of a salary-wage model has dem onstrated ben efits for both nurses and healthcare organizations. M ul tiple authors report im proved nurse satisfaction w ith the implementation of a salary-wage model A 8 A pretestposttest evaluation of a staff nurse salary program at 2 m etropolitan hospitals found a significant positive
JO N A • Vol. 45, N o. 5 • May 2015
change in staff nurses’ intrinsic, extrinsic, an d general sa tisfactio n (P < .05), w ith the salary-w age m odel as m easured by the M innesota Satisfaction Q uestionnaire.5 In th e q u a s i-e x p e rim e n ta l, m a tc h e d d esig n stu d y o f Z elau sk a s a n d H o w e s,8 a statistically significant in crease in job sa tisfactio n afte r im p lem e n ta tio n o f a salary -w age m odel w as fo u n d fo r th e Jo b D escription Index subscale regarding p ay (preim plem entation, 28; p o stim p le m en ta tio n , 4 0 .5 7 ; P - .01). T he rem ain in g studies th a t rep o rted im proved nurse satisfaction after im plem enting salary-w age co m pensation did n o t p ro vide adequate data or statistical analysis in their findings.4’6’7 D e G ro o t et a l9 did n o t find a significant increase in job satisfaction in a salaried differentiated pay stru c tu re m odel. T his study is strengthened by an a prio ri p o w er analysis for sam ple size, alth o u g h the study did n o t achieve an ad e q u ate sam ple, resulting in an in creased risk o f a type II error, w hich potentially explains the lack o f statistical significance.9 O rganizational benefits dem onstrated by the stud ies include a decrease in overtim e hours an d subsequent cost savings.5,6’8,10' 12 E valuation o f these financial o u t com es is lim ited because of the different m ethods used to analyze costs in the studies. D eG ro o t and colleagues9 fo u n d th a t th e salaried differen tiated p ay scale m odel resu lted in co st increases ran g in g fro m 3 .4 % to 12% co m p ared w ith the hourly-w age m odel. T h eir analysis is strengthened by the inclusion of paid hours for hours n o t w o rk e d enco m p assed in th e salary-w age m odel. D eG ro o t et al9 attrib u te this to variations in m anaging self-scheduling b etw een th e 2 study units. A d d itio n al benefits include im p ro v ed n u rse re te n tio n 5' 8’10 and d ec rease in sick tim e u se .5’8 In th e c u rre n t p ra c tic e an d p olitical en v iro n m en t, it is im p o rta n t to explore th e im plications o f a salary-w age m odel.
review bo ard . Institutional review b o ard ap proval w as a t th e system level co vering b o th o rg an izatio n s. T h e study setting included 2 acute care hospitals, 1 of w hich w as a Magneto-designated facility at the time of the study, in a single, nonprofit h ea lth c are system in the n o rth e a st United States. T he hourly-w age m odel w as the standard co m p en sa tio n fo r nu rses th ro u g h o u t th is h ea lth c are system . In 2 0 1 2 , th e h ea lth c are system o p en ed a su r gical an d reh a b ilita tio n h o sp ital using the salary-w age m odel. Both study sites w ere postsurgical units o f co m parable size an d p atien t acuity. To be included in the study, the employee m ust have been a licensed R N p ro viding direct patien t care on the designated study units. A convenience sam ple o f R N s from each u n it w as recruited via e-m ail sent fro m the research team w ith a link to an an o n y m o u s research survey. P articip atio n w as voluntary. T w enty-three R N s com prised the to tal sam ple, 12 from the hourly-w age u n it a n d 11 from the salary-w age unit. T his co n stitu ted a 5 2 .3 % response rate. P artic ip an ts ran g e d in age fro m 23 to 61 years (m ean [SD], 4 1 .4 [10.9] years) a n d w o rk e d as a n R N an average of 14.5 years (SD, 10.6; range, 2-40 years). Nurses on the salary-wage unit were significantly younger (34.5 vs 47.7 years; t = 3.6, df = 21, P = .002), have w orked few er to ta l years as an R N (9.6 vs 19.1 years; t = 2 .3 , df = 2 1; P = .03), an d have w o rk e d few er years o n th e ir c u rre n t u n it (1.3 vs 8 .4 years; t = 3 .4 , df = 11; P - .006) com pared w ith R N s on the hourlyw ag e u n it. M o st p a rtic ip a n ts w ere w o m en (9 5 .7 % ) an d 6 9 .5 % h a d a b ach elo r’s degree. T h ere w ere no statistically significant differences between R N s on the hourly-w age m odel unit and those on the salary-wage m odel unit in gender, entry-level professional education, highest level o f ed u cation, o r history o f w o rk in g in an hourly-w age m odel an d salary-w age m odel unit.
P u rp o s e o f th e S tu d y
In stru m e n ts
T h e p u rp o se o f this p ilo t study is to ex am in e the dif ferences b etw een a salary-w age m o d el an d an h ou rly w age m odel for R N satisfaction and financial indicators. T h e specific aim s are (1) to identify th e difference in n u rses’ p erc ep tio n o f th e PPE a n d (2) to identify th e difference in total cost and base cost of R N com pensation betw een nurses em ployed in a salary-w age m odel and those em ployed in an hourly-w age m odel. It w as hypo thesized that nurses’ perception of the PPE will be greater in the salary-wage m odel com pared w ith the hourly-wage m o d el an d th a t w age costs w ill be lo w er in th e salaryw age m odel c o m p a re d w ith the hourly -w ag e m odel. M e th o d s
D esign, S etting, a n d S am ple A descriptive, com parative design w as used. T his study w as deem ed exem pt by the organ izatio n ’s institutional
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To ad d ress stu d y aim 1, th e n u rses’ p erc ep tio n o f th e PPE w as m easured w ith the Revised Professional Prac tice E n v iro n m en t Scale (RPPE), a p sy ch o m etrically so u n d , 39-item , self-adm inistered, 4 -p o in t L ikert scale in stru m e n t th a t ta k es a p p ro x im a te ly 10 m in u tes to com plete.13 T he RPPE measures 8 com ponents of p ro fessional clinical practice in acute care settings: (1) dis agreem ent an d conflict, (2) leadership an d autonom y, (3) internal w o rk m otivation, (4) co n tro l over practice, (5) te a m w o rk , (6) co m m u n ic atio n a b o u t p atien ts, (7) cultural sensitivity, and (8) staff relationships w ith phy sicians. H igh scores represent high levels of the co n stru ct. Seven item s req u ire reverse scoring to arriv e at th e subscale an d to ta l scores. T h e in stru m e n t has a p p lic atio n a t b o th in d iv id u al an d o rg a n iz a tio n a l level analysis. All 8 subscales have d o cu m en te d co n stru c t valid ity a n d high in te rn al reliability, w ith an overall C ro n b a c h ’s a o f .93 a n d subscale a values from .81
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Table 1.
RPPE Scale Scores for Total Sample
Total RPPE score (39 items; potential range, 39-156) Subscale 1: Disagreement Sc Conflict (9 items; potential range, 9-36) Subscale 2: Leadership Sc Autonomy (5 items; potential range, 5-20) Subscale 3: Internal Work Motivation (8 items; potential range, 8-32) Subscale 4: Control Over Practice (5 items; potential range, 5-20) Subscale 5: Teamwork (4 items; potential range, 4-16) Subscale 6: Communication About Patients (3 items; potential range, 3-12) Subscale 7; Cultural Sensitivity (3 items; potential range, 3-12) Subscale 8; Staff Relationships With MD (2 items; potential range, 2-8)
to .88.lj In this study, the C ronbach’s a for the overall instrum ent was .97, and all subscales had C ronbach’s a values greater than .71. To address study aim 2, financial indicators were examined using unit budgets and aver age daily census (ADC) data. D ata Analysis D ata w ere analyzed w ith SPSS Statistics version 21.0 (Chicago, Illinois). M easures of central tendency were used to describe the study sample along with independentsample t tests and j 2 to identify difference in study groups. To identify the difference in nurses’ percep tion of the PPE between salary-wage and hourly-wage m odels (study aim 1), m easures of central tendency w ere used to describe overall nurse perceptions of the PPE. Skewness and kurtosis measures m et param eters for a norm al d istrib u tio n . T h erefore, independentsamples t tests were used to identify differences. Sig nificance level was set at .05. To identify differences between total and base cost between salary-wage and hourly-wage models (study aim 2), com parisons using frequency data were made over a 6-m onth period from O ctober 2013 to M arch 2014.
Results Table 1 provides descriptive data for the RPPE total and subscale scores. M ean scores w ere statistically
Table 2.
Range
Mean (SD)
83-148 17-30 9-20 22-32 6-20 7-16 4-12 5-12 4-8
118.3 24.8 15.6 26.6 14.6 11.7 9.2 9.3 6.4
(19.4) (3.7) (3.3) (2.9) (4.3) (2.6) (1.9) (2.1) (1.3)
Median 116 25 16 27 15 12 9 9 6
significantly low er for R N s on the hourly-w age unit com pared w ith RNs on the salary-wage unit for the total RPPE score and for all subscale scores (Table 2). Considering that the dependent variable is ordinal level, a reanalysis using the nonparam etric M ann-W hitney U test yielded identical results, w ith all findings statis tically significant at .016 to .000 levels, confirming the independent-sam ple f-test findings. Financial com parisons identified th at during the 6-month study period, the salary-wage unit, with fixed salary costs, exceeded the budgeted ADC by an average 3% above budget. O n the hourly-wage unit, the ADC was 2% below budget, on average. However, the hourlywage unit also experienced 1.2% in RN overtime, which resulted in a cost of $2,000 per month over the 6-month study period. W hen the ADC was at or below budget on the hourly-wage unit during the first 3 m onths of the study period, RNs were floated to other units. M ost of R N overtime occurred during the second 3 m onths, w hen the hourly-wage unit was at or above its bud geted ADC.
Discussion Nurses in an hourly-wage model unit have significantly lower perceptions of the clinical practice environm ent com pared with RNs in a salary-wage model unit, in d icatin g th a t the pro fessio n al p ractice m odel in a
Differences in RPPE Scores Mean (SD) Score Hourly
Total RPPE score Subscale 1; Disagreement & Conflict Subscale 2: Leadership & Autonomy Subscale 3: Internal Work Motivation Subscale 4; Control Over Practice Subscale 5: Teamwork Subscale 6; Communication About Patients Subscale 7; Cultural Sensitivity Subscale 8: Staff Relationship With MDs
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103.5 22.3 13.3 25.3 11.2 9.9 8.0 8.0 5.5
(12.1) (3.1) (2.7) (2.4) (2.4) (1.8) (1.6) (1.7) (0.7)
Salary 134.4 27.6 18.1 28.1 18.4 13.6 10.5 10.7 7.5
(11) (1.9) (1.6) (2.9) (2) (1.7) (1.3) (1.3) (0.8)
t
P
-6 .4 -4 .8 -5 .0 -2 .6 -7 .8 -4 .9 -3 .9 -4 .2 -6 .3
.000 .000 .000 .018 .000 .000 .001 .000 .000
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salary-wage model may be a more effective PPE. The characteristics of an organization’s PPE are correlated with nurse satisfaction.14 Our findings of higher nurse perceptions of the PPE support previous research dem onstrating improved nurses’ satisfaction with a salarywage model. These findings are also clinically impor tant as the tool is aligned with the model elements of Magnet recognition: transformational leadership; struc tural empowerment; exemplary professional practice; new knowledge, innovation, and improvement; and empirical outcomes.1’ These findings may be impacted by the significant demographic differences in age and years of practice between the 2 study groups. The small sample size impeded a linear regression analysis to control for this potential confounder. The hourly-wage model resulted in an additional cost of 1.2% for overtime hours compared with the fixed cost of the salary-wage model, which exceeded ADC by 3% . The comparison resulted in a budgetneutral impact. This is similar to the findings of DeGroot and colleagues9 that a salaried pay scale model resulted in increased cost compared with the hourly-wage model but with an overall budget-neutral impact.
Limitations Our study is strengthened by the use of a valid psy chometric instrument with documented internal con sistency for this study sample to measure the concept of nurses’ perception of the PPE. In addition, the sta tistically significant findings mitigate the risk of a type II error due to small sample size. However, there are several im portant limitations. The small sample size within 1 healthcare system in a single geographic area limits generalizability. The basic financial analysis does not include the myriad of other financial indicators such as hours worked, sick time, on-call time, or staff turnover.
Conclusions The findings from this small pilot study indicate that RNs’ perceptions of professional practice in a salarywage model may provide a more satisfying PPE. The salary-wage model is 1 strategy to enhance the PPE for RNs providing a financially viable way to provide direct patient care. Future research is needed with larger, more diverse samples in a variety of practice settings and more complex financial analysis to confirm the findings of this pilot study.
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