An Explanatory Model of Nurse Practitioner Job Satisfaction
Pamela Wllkle Koelbel MSN, MPH, RN, FNP Medical-Surgical Educator, Maw Black Memorial Hospital, Spartanburg, South Carolina.
Sara G. Fuller
PhD, RN, CPNP Associate Professor, Department of Nursing Systems, University of South Carolina, Columbia.
Terry R. Mlsener
PhD, RN, FNP Professor, Chairperson, Department of Nursing Systems, College of Nursing, University of South Carolina, Columbia.
Job satisfaction influences employee retention, worker productivity, and performance quality. To retain qualified nurse practitioners (NPs), health administrators must identify sources of job satisfaction and dissatisfaction. Herzberg’s dual-factor theory of job satisfaction addresses extrinsic and intrinsic work-related factors. Expansion of the model to include global job satisfaction and individual differences provided a broad framework for the assessment of nurse.practitioner job satisfaction. The expanded model was used to analyze the job satisfaction of’l32 NPs registered with the South Carolina State Board of Nursing in 1988 (final response rate‘= 90%). Participants completed the Index of Job Satisfaction (IJS), the Minnesota Satisfaction Questionnaire-Short Form (MSQ-SF), and the Personal and Work Background Questionnaire (PWBQ). Although the NPs were moderately satisfied with their overall jobs, extrinsic factors were found to be major sources of dissatisfaction. The optimal combination of variables predicted by regression analysis to influence global job satisfaction were age, number of children, urban locations, achievement, company policies and practices, creativity, independence, and compensation. Implications for health administrators to improve the work environments of NPs are discussed.
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of dissatisfaction, but rather an interaction of the satisfiers and dissatisfiers with the satisfiers being dominant. Conversely, if the dissatisfiers outweigh the satisfiers, general dissatisfaction is present. Herzberg postulated that intrinsic factors or satisfiers arise from the performance of the job itself. He identified achievement, recognition, work itself, responsibility, advancement, and potential for growth as being satisfiers. Of these, responsibility, advancement, and a sense of performing interesting and important work (work itself) are the most influential. The satisfiers were termed “motivators” because they are necessary for enhancing job performance (Herzberg, 1966). The extrinsic factors or dissatisfiers emerge from surroundings in the work environment. Working conditions, interpersonal relations, salary, status, security, policies and administration, and supervision are dissatisfiers. The two most important dissatisfiers are the following: (a) company policies and administration which foster inefficiency or unfair treatment within an organization and (b) supervisors who lack competence in carrying out the mission as indicated by inability to delegate responsibility and motivate MODEL OF NP JOB SATISFACTION others (House & Wigdor, 1967). The dissatisfiers were Herzberg’s dual-factor theory of job satisfaction and labeled “hygienes” or “maintenance” factors because motivation (Herzberg et al., 1959) provides the basis they serve only as preventors of job dissatisfaction for the model of NP job satisfaction. Although (Herzberg, 1966). Herzberg’s dual-factor theory can be compared to frequently applied to nursing, Herzberg based his Maslow’s need hierarchy (Hodgetts & Cascio, 1983).The original theory on a study of 200 accountants and motivation-hygiene theory condenses the five level engineers. Herzberg’stheory focuses on the intrinsic and need hierarchy of Maslow into two independenr extrinsic factors contributing to job satisfaction but does categories of needs: animal needs (hygienes) and human not address individual differences or a global assessment needs (motivators). The animal needs at the lower end of job satisfaction. T h e present model expands of the scale may heighten dissatisfaction and do not Herzberg’s dual-factor theory of job satisfaction by produce satisfaction. The hygiene factors fulfill the including the concept of individual differences and an animal need to avoid discomfort whereas the motivator overall assessment of job satisfaction. Figure 1 displays factors gratify the human need to grow psychologically the conceptual model of job satisfaction for this study towards self-actualization (Cronin-Stubbs, 1977). Only by illustrating the interrelationships among these major if the animal needs are met, can attainment of the human concepts. or higher level needs promote satisfaction. Therefore, Herzberg and his associates concluded that job not only must administrators manipulate hygienic satisfaction and job dissatisfaction represent two factors to prevent dissatisfaction, but they also must separate continua (Herzberg et al., 1959).Intrinsic work stimulate the motivator forces to facilitate a greater sense factors, known as the satisfiers, form the satisfactionof job satisfaction (Herzberg, 1966). no satisfaction continuum. Factors extrinsic to work, A shortcoming of Herzberg’sdual-factor theory is the known as the dissatisfiers,comprise the dissatisfactionomission of focus on individual differences and overall no dissatisfaction continuum. T h e two continua job satisfaction (House & Wigdor, 1967). This omission support the possibility that individuals may be content o f the theory to NPs. Focusing limits the application with some job aspects but not others, i.e., satisfied and only on Herzberg’s intrinsic and extrinsic factors does dissatisfied (Lambert, Wertheimer, & Johnson, 1980). not account sufficiently for the satisfaction and A high level of satisfaction is not merely the absence dissatisfaction of NPs. As reflected in Figure 1, individual differences and global satisfaction also Address correspondence to Pamela Koelbel, RN, MSN, MPH, contribute to the explanation of job satisfaction of NPs. Education Department, Mary Black Hospital, P.O. Box 3217, Individual differences are important because they Spartanburg, SC 29304.
Maintenance of job satisfaction among N P presents ~ an important challenge for health care administrators and NPs. Stresses created by the economic and competitive climate of primary health care in the late 1980s and 1990s may lead to job dissatisfaction among NPs. Dissatisfied NPs are likely to leave the profession (Hayden, Davies, 8c Clore, 1982; Roos, 1979; Sultz, Zielezny, Gentry, & Kinyon, 1978)or perform their jobs less proficiently (Consolvo, 1979; Koerner, 1981; Weisman & Nathanson, 1985).A thorough understanding of the sources of job satisfaction and dissatisfaction can assist NPs and health care administrators to structure the work environments of NPs in a positive manner (Holton, 1978). Herzberg’s dual-factor theory of job satisfaction (Herzberg, Mausner, & Synderman, 1959) is a useful model for explaining the sources of job satisfaction and job dissatisfaction. The findings of a study on job satisfaction of 132 NPs in South Carolina (Koelbel, 1988) support the applicability of Herzberg’s dual-factor theory to NPs.
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influence whether or not a given factor will be a source of satisfaction or dissatisfaction, based on personal qualifications and past experiences of the individual (Smith & Kendall, 1963). Individuals use their own frames of reference to evaluate the characteristics of their jobs. Therefore, personal and work background factors, such as age (Anderson & Haag, 1963), gender ( H u h & Smith, 1964), educational level, tenure (Slavitt, Stamps, Piedmont, & Haase, 1979), work experience (Weisman, Alexander, & Chase, 1980), and hierarchical position (Munson & Heda, 1974) influence job satisfaction. Smith and Kendall (1963) emphasized the need for considering an overall measure of job satisfaction, i.e., global satisfaction of the worker, because workers may dislike certain features of their jobs, yet still feel content with their jobs overall. Conversely, workers may be unhappy with their jobs as a whole despite its many positive attributes (House & Wigdor, 1967). Research studies attempting to predict long-term behaviors, such as job termination, frequently assess global job satisfaction. The measurement of global job satisfaction provides information about the individual's general adaptation level rather than specific likes and dislikes (Lichtenstein, 1981). Within the context of global job satisfaction, satisfied workers are not disappointed that they took their jobs. They find their jobs more enjoyable and interesting than available alternatives and do not feel they must force themselves to go to work (Brayfield & Rothe, 1951). APPLICATION OF THE MODEL TO NPs
Using the model depicted in Figure 1, this study addressed the following research questions: 1. What are the global, general, intrinsic, and extrinsic levels of job satisfaction of NPs? 2. T o what extent are the intrinsic factors sources of job satisfaction and the extrinsic factors sources of job dissatisfaction for NPs? 3. T o what extent do personal, work background, intrinsic, and extrinsic factors correlate with the job satisfaction of NPs? 4. What are the most important personal, work background, intrinsic, and extrinsic factors in the determination of NPs' job satisfaction? METHODOLOGY To assess the interaction of the three components of the conceptual model (Figure l), all NPs in the state of South Carolina were surveyed with the IJS (Brayfield & Rothe, 1951), MSQ-SF (Weiss, Dawis, Lofquist, & England, 1967),and PWBQ (Koelbel, 1988).The survey
VOLUME 3, NUMBER 1 , JANUARY-MARCH, 1991
'I'
/p\ SATISFACTION
-Hotivators)
-achievement -recognition -work itself -responsibility -advancement -potential for growth
-age -gender -education -race -tenure -employment status -work experience -community s i z e -specialty area
-working conditions -interpersonal relations -salary .security -status -supervision -policies and administration
FIGURE 1. Conceptual model of job satisfaction using Herzberg's dual-factor theory, global measurement, and individual differences.
determined the direction and magnitude of the relationships among Herzberg's intrinsic and extrinsic factors, selected personal and work background factors, and global job satisfaction. INSTRUMENTS An lndex of Job Satisfaction. Brayfield and Rothe's (1951) 18-item IJS assessed the respondents' overall level of job satisfaction. The IJS has a high index of reliability (odd-evenproduct moment reliability coefficient = 0.77; Spearman-Brown reliability coefficient = 0.87; Brayfield & Rothe, 1951; Miller, 1970) and has been widely used in research studies as a unitary or global measure of job satisfaction (Evans, 1969; Hale, 1986; Miller, 1970; Wanous & Lawler, 1972). Analyses using an external criterion yielded estimates of validity significant at the .01 level. Furthermore, a comparison of the IJS and Hoppock's Scale yielded a product-moment correlation of 0.92 (Brayfield & Rothe, 1951; Miller, 1970).
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The Minnesota Satisfaction Questionnaire. The second questionnaire, the 20-item MSQ-SF constructed by Weiss et al. (1967),measures the degree of satisfaction of respondents with the extrinsic and intrinsic aspects of their jobs. The MSQ-SF is consistent with Herzberg’s Motivation-Hygiene theory (Buros, 1972) and has been shown to be reliable (Hoyt reliability coefficients range from 0.77 to 0.92 for all three scales)and valid (construct validity ranged from 0.03 to 0.12; Weiss et al., 1967). Personal and Work Background Questionnaire. The third questionnaire was the 22-item PWBQ (Koelbel, 1988).The PWBQ was devised specifically for this study to collect personal and work background information on each of the participants. The content of this questionnaire was adapted from the works of Redfern (1981) and Sultz et al. (1978) on the job satisfaction of nurses and NPs respectively. The development of the PWBQ was consistent with guidelines for mailed questionnaires (Dillman, 1978). POPULATION AND SAMPLE The target population consisted of all NPs and nurse midwives in South Carolina who met the following criteria: (a) registration with the South Carolina State Board of Nursing, (b) active employment for at least six months, and (c) current practice in South Carolina. Because of existing role similarities and allowing for comparison of the study’s findings with those of national surveys, the study included nurse midwives as potential respondents along with the NPs. The final population consisted of 128 NPs and 35 nurse midwives, collectively referred to as NPs in the rest of the study (N = 163). Ninety percent (n = 146)of the potential participants responded. Of these, 14 surveys were not usable. Eleven people did not meet the eligibility criteria: 7 were not currently working as NPs; 1 had less than six months of employment; and 3 were no longer practicing in South Carolina. An additional 3 respondents returned blank questionnaires. Therefore, the final sample consisted of 132 subjects yielding a usable response rate of 81%. The subjects represented a heterogeneous group of NPs in terms of personal and work background factors. The majority of the NPs were white (91.7%), female (98.5%),and ranged in age from 26 to 63 years (Mean (M) = 42; Standard Deviation (SD) = 8.4). Two thirds of the subjects were married and 42% had either one or two children. Three fourths of the survey participants were prepared in certificate NP programs although a large proportion (53.8%)had earned a baccalaureate or master’s degree in nursing. The most frequently reported specialty areas (44%) were family practice, pediatrics, obstetrics/gynecolog, and midwifery. Little employ-
20
ment time was spent in administrative functions. Nurse midwives (100%)were certified more frequently than NPs (67%). The survey participants were experienced NPs; two thirds of the subjects had 6-15 years of work experience (M = 8.9 years; SD = 4.9) and worked both part- (29.8%) and full-time (70.2%). Seventy-six percent worked in urban areas and 24% in rural areas. The majority reported incomes of 25,000 to 29,000 dollars. Hourly wages ranged from 8.71 to $26.22/hour (M = $13.95; SD = $3.29). Health departments comprised one third of the practice settings; private offices, 14.5%; and ambulatory health centers/clinics, 10.7%.More than half the respondents estimated that over 70%of the patients in their practice settings had low incomes. PROCEDURES A questionnaire packet including the survey instruments, a cover letter explaining the confidential survey, and a self-addressed post-paid return envelope was mailed to each NP. T h e return of a completed questionnaire indicated the subject’s consent to participate. At four and nine weeks, follow-up postcards were sent to nonrespondents encouraging their participation. At 11 weeks, data collection ceased. Two incentives were used to encourage a high response rate. In return for each completed questionnaire packet, the researcher offered to donate $1 to ii professional nursing organization of the respondent’s choice. In the sample, 131 respondents indicated an organization for the donation. Furthermore, an offer was made to send a copy of the study’s findings to respondents who so requested. One third of the respondents requested a copy of the findings. RESULTS The research questions were analyzed using descriptive and inferential statistics with the level of significance set at 0.05. Nominal variables were transformed into dummy variables for inclusion in the regression and correlation analyses. The results of the correlation and regression analyses are presented in depth (Tables 1-3). The analysis of the four job satisfaction categories (global, general, extrinsic, and intrinsic) and factor analysis are summarized (see Koelbel et al, in press, for the in-depth analysis). ScaIe R eiiabiiities of the Instruments. Although the survey instruments had been extensively used in other research studies, this was the first application to NPs. Therefore, the reliability of the instruments in this sample was calculated. The alpha coefficient for the IJS was 0.8893. This value exceeded the reliability coefficients (0.77 and 0.87) reported by Brayfield and Rothe (1951). The coefficient alpha for the MSQ-SF
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was 0.9020, which is similar to those (0.87 to 0.92) presented by Weiss et al. (1967).The two MSQ subscales, intrinsic (0.86) and extrinsic (0.83) satisfaction scales, also were reliable. Global Job Satisfaction. A combination of individual items from the IJS measured global job satisfaction. Using Brayfield and Rothe’s (1951) classification, the NPs indicated moderate satisfaction with their jobs; approximately 90%scored in the upper half of the global satisfaction scale. General Job Satisfaction. The sum of the 8 extrinsic and 12 intrinsic items of the MSQ-SF measured general job satisfaction. Using the categories of Weiss et al. (1967), the majority of NPs reported a moderate level of general job satisfaction; approximately 60% scored in the middle range of the general satisfaction scale. Intrinsic and Extrinsic Factors. Consistent with the predictions of Herzberg’s dual-factor theory, intrinsic factors (arising from performance of a job) were sources of job satisfaction and extrinsic factors (arising from the work environment) were sources of job dissatisfaction. NPs derived the most satisfaction from aspects intrinsic to work itself. Based on the responses to the MSQ-SF (Weiss et al., 1967), the most satisfying job factors were social service (M = 4.42), variety (M = 4.23), moral values (M = 4.20), security (M = 4.18), and ability utilization (M = 4.13). Security was the only satisfier considered to be an extrinsic factor by Herzberg. On the other hand, the NPs attributed their dissatisfaction to the contextual aspects of their jobs. They were dissatisfied with their compensation (M = 2.88), advancement (M = 2.99), company policies and practices (M = 3.13), recognition (M = 3.39), and supervision-human relations (M = 3.40). The largest proportion (48.5%)of NPs were dissatisfied with their compensation. Except €or recognition and advancement, these factors are congruent with Herzberg’s hygienes. The distribution of the overall intrinsic and extrinsic satisfaction scores indicated high intrinsic satisfaction for 66% of the NPs and low extrinsic satisfaction for 35%. A confirmatory principal components factor analysis with varimax rotation was performed on the MSQ-SF to check the validity of the dual-factor theory in the current sample. Using the criteria of only including factors with eigenvalues greater than one and factors on which at least three items loaded at the 0.4 level, two factors emerged. These factors were Internal Job Qualities and Clinical Environment and Reward System, both of which were equitable with the factors posited by Herzberg. Seven of the 12 motivators included in the study (moral values, ability utilization, responsibility, achievement, creativity, social service, and variety) loaded on factor 1, Internal Job Qualities. In
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addition to the seven motivators, one hygiene (social status) also loaded on factor 1. On the other hand, six of the eight hygienes (company policies and practices, working conditions, coworkers, compensation, supervision-human relation, and supervision-technical) and two motivators (recognition and advancement) loaded on factor 2, Clinical Environment and Reward System. Personal and Work Background Factors. The statistically significant Pearson product-moment correlation coefficients among four job satisfaction categories and selected personal and work background factors are presented in Table 1. Variables not found to be significant include gender, marital status, type of NP program, nursing preparation, specialty, population of county of residence, tenure, hierarchy position, gross income, rural, traveling distance to work, satisfaction with state nurse practice act, and satisfaction with physician acceptance. Both having children and private practice correlated strongly with all four outcome measures. NPs with more children or in private practice settings or both tended to score higher on all four job satisfaction scales. National certification correlated positively with both global job satisfaction and intrinsic job satisfaction. The Pearson correlation coefficient between national certification and global job satisfaction was 0.22 ( p = 0.01 ). National certification and intrinsic job satisfaction had a Pearson Y of 0.18 ( p = 0.037). These correlation coefficients suggest that certified NPs had a higher level of global and intrinsic job satisfaction than those not certified. Statistically significant positive correlations were also found between hourly wage and global job satisfaction ( r = 0.19; p = 0.03) and between urban practice settings and global job satisfaction (Y = 0.22; p = 0.01). NPs with higher hourly wages or that work in urban practice settings or both tended to be more satisfied overall with their jobs. A statistically significant negative correlation was found between percentage of low-income patients served and extrinsic job satisfaction (r = -0.26; p = 0.0029). This finding suggests that NPs serving a smaller percentage of low-income patients had more extrinsic job satisfaction than those serving a larger percentage of low-income patients. Interestingly, satisfaction with perceived patient acceptance correlated positively with intrinsic satisfaction ( r = 0.17; p = 0.049). This correlation describes a relationship where NPs with perceived high levels of patient acceptance had a greater amount of intrinsic job satisfaction than those with perceived low levels of patient acceptance. Almost one third of the study subjects felt either dissatisfied or very dissatisfied with physician acceptance. However, most
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TABLE 1. STATISTICALLY SIGNIFICANT PEARSON PRODUCT-MOMENT CORRELATION COEFFICIENTS AMONG FOUR JOB SATISFACTION CATEGORIES AND SELECTED PERSONAL AND WORK BACKGROUND FACTORS Global Satisfaction (IJS)
Factors Personal Age Nonwhite Children Certification Work Background Work experience Employment status Hourly wage Private practice Urban Percent of low income patients Satisfaction with patient acceptance Global satisfaction
General Satisfaction (MSQ)
Intrinsic Satisfaction
Extrinsic Satisfaction
0.115 0.073 0.312"' 0.220"
0.078 -0.1 19 0.283" 0.1 53
0.061 -0.1 16 0.286"' 0.1 82*
0.080 -0.090 0.205' 0.069
0.110 -0.072 0.1 90' 0.241 *** 0.21 9"' -0.1 61 0.139 -
0.044 -0.1 16 0.155 0.289"' 0.124 -0.1 64 0.155 0.718"'
0.063 -0.1 20 0.160 0.176* 0.097 -0.009 0.171' 0.620"'
0.024 -0.1 00 0.1 03 0.31 3"' 0.105 -0.263" 0.071 0.634"'
' p value < 0.05. **p value < 0.01. "'p value < 0.001
participants (95%)were either satisfied or very satisfied with the amount of patient acceptance. Although not part of the original research questions, the data were analyzed to determine if there were
TABLE 2. PEARSON PRODUCT-MOMENTCORRELATIONS BETWEEN GLOBAL JOB SATISFACTION AND INTRINSIC AND EXTRINSIC FACTORS
Factor Activity Independence Variety Social status Supervision-human relations Supervision-technical Moral values Security Social service Authority Ability utilization Company policies and practices Compensation Advancement Responsibility Creativity Working conditions Co-workers Recognition Achievement All MSQ items
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Global Sat isfaction UJS)
Significance
0.324 0.120 0.430 0.443 0.439 0.495 0.294 0.215 0.387 0.279 0.418 0.552 0.445 0.538 0.542 0.421 0.510 0.441 0.361 0.608 0.718
0.0001 0.1717 0.0001 0.0001 0.0001 0.0001 0.0006 0.0132 0.0001 0.0012 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001
significant differences between the NPs and nurse midwives. In comparison to the NPs, nurse midwives felt significantly less accepted by patients (t = -2.23; p = 0.037) and by physicians ( t = -4.51; p= 0.0001). However, there was no statistical difference between the job satisfaction levels of nurse midwives and nurse practitioners. The Pearson product-moment correlation between global job satisfaction and the 20 intrinsic and extrinsic factors are presented in Table 2. Statistically significant positive correlations were found between 19 of the MSQ items and global job satisfaction. T h e Pearson correlation between independence and global job satisfaction was 0.12 ( p = 0.17). This finding suggests that there was little relationship between independence and global job satisfaction for this group of nurse practitioners. The two major outcome measures of job satisfaction were highly correlated. Global job satisfaction correlated significantly to general job satisfaction with an I of 0.72 (@ = 0.0001). The correlations between global job satisfaction and intrinsic job satisfaction and between global job satisfaction and extrinsic job satisfaction also were strongly positive (Table 1). Regression Model for Global Job Satisfaction. After examining variables at the univariate level, stepwise multiple regression was used to determine which model best fit the data. Eight independent variables significantly ( p < .05) predicted global job satisfaction (Table 3). Achievement accounted for the greatest variance (35%) and entered the model first. The
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
TABLE 3. COEFFICIENTS OBTAINED FROM REGRESSION OF GLOBAL JOB SATISFACTION OF PERSONAL, WORK BACKGROUND, INTRINSIC, AND EXTRINSIC FACTORS Variable (Step Entered) Achievement Company policies & practices Creativity Children Age Urban setting Independence Compensation
B
SE
F
P
2.60 2.46 2.51 2.13 0.1 7 2.55 -1.64 1.06
0.69 0.62 0.66 0.59 0.07 1.11 0.72 0.51
14.02 15.81 14.23 12.97 5.88 5.28 5.15 4.29
0.0003 0.0001 0.0003 0.0005 0.0168 0.0233 0.0251 0.0404
6 = Unstandardized regression coefficient. SE = Standard error. F = F statistic. P = Level of significance.
other variables in order of entry into the regression were company policies and practices (14%), creativity (3%), age (3%), children (2%), urban setting (2%), and independence and compensation (3%). The total eight variable model accounted for approximately 62%of the variance in global job satisfaction (model R2 0.618; p = 0.0001).
DISCUSSION AND IMPLICATIONS FOR NP PRACTICE The survey results have important implications for health administrators and NPs. NPs indicated satisfaction with the content of their jobs and dissatisfaction with their work environments. Three aspects of the work environment were particularly dissatisfying: lack of adequate compensation, the implementation of organizational policies, and capabilities of supervisors. In addition, NPs were dissatisfied with their opportunities for advancement and recognition. By structuring the work environment to enhance the extrinsic factors, health administrators could prevent potential job dissatisfaction. Specifically, health administrators can clarify the roles of NPs to the administrative staff and implement a clinical ladder for advancement and recognition. Compensation can be enhanced by innovative benefit programs, third-party reimbursement, and NP consultation fees. In addition to structuring the work environment, health administrators can capitalize on intrinsic factors known to satisfy NPs. T o prevent job dissatisfaction, health administrators can facilitate the motivation of NPs by providing adequate opportunities for professional growth. Because social service is a strong motivator for NPs, positions should include a variety of clinical practice opportunities. Autonomy in identifying clinical projects of personal interest and
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managing a defined group of patients should be encouraged. Developing strategies such as these to promote achievement, autonomy, recognition, responsibility, challenge, and enjoyment in the work itself may assist in increasing intrinsic job satisfaction. The importance of personal/work background factors in relationship to NP job satisfaction also emerges as a finding with implications for health administrators. Health administrators should be aware of possible approaches to increase job satisfaction based on these personal/work background factors. One approach that a health administrators might take to foster job satisfaction is to encourage NPs to obtain national certification by (a) providing certification reimbursement, (b) promoting time-off for preparation for the certification exams, and (c) offering higher wages upon certification. A second approach is to provide incentives to retain NPs with youngchildren. Some of these incentives could include adjusting employee vacations to coincide with school vacations, providing (or supplementing the cost of) child care, and offering adequate health insurance with dependent coverage and flexible work schedules. For NPs in health departments providing care primarily to low-income families, health administrators should consolidate health services so that continuity of care is maintained. With less fragmentation of services, NPs could develop more satisfying nursepatient relationships. Professional isolation may be a source of job dissatisfaction for nurse practitioners in rural areas. Long drives, lack of interpersonal relationship with other nurse practitioners, and limited opportunities for professional development may often be experienced by rural nurse practitioners. Health administrators could reduce such sources of job dissatisfaction by facilitating communication with other nurse practitioners (e.g. computer networking, regional NP meetings, and peer
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review), using flexible scheduling, offering mileage reimbursement and journal subscriptions, and planning educational workshops. Not only might these approaches lead to higher job satisfaction levels, they might also lead to less absenteeism, increased retention, improved patient access, enhanced quality of care, and cost savings.
3. Conduct interviews, instead of mailed surveys, to qualitatively evaluate the meaning of the satisfiers and dissatisfiers to NPs. 4. Consider experimental testing of the effects of certain management strategies on the job satisfaction of NPs.
RECOMMENDATIONS
SUMMARY
The following are recommendations for further research: 1. Replicate this study using the census populations of NPs practicing in other states to compare with the degree of job satisfaction of NPs in South Carolina. Such investigations would increase the knowledge of the influence of various state economic environments, reimbursement, and prescription policies on the job satisfaction of NPs. 2. Examine the relationship between the quality and cost effectiveness of NP care and job satisfaction.
The expanded model of Herzberg’s dual-factor theory provides a useful framework for examining the job satisfaction of NPs. When applied to the survey results of NPs in South Carolina, the model explained the job satisfaction and dissatisfaction of the respondents. Herzberg’sbasic theory was upheld in this sample except for recognition, advancement, and security. The inclusion of the concepts, global job satisfaction and individual differences, strengthened Herzberg’s dualfactor theory by providing greater insight into NP job satisfaction.
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Carolina, Columbia. Koelbel, P. W., Fulter, S. G., & Misener, T. R. (in press). Job satisfaction of nurse practitioners: An analysis using Herzberg’s theory. Koerner, B: L. (1981). Selected correlates of job performance of community health nurses. Nursing Research, 30, 43-48. Lambert, R. L., Wertheimer, A. I., &Johnson, C. A. (1980). Herzberg’s theory of hygienes and motivators. American Pharmacy, 20(2). 43-44. Lichtenstein, R. L. (1981). Physician job satisfaction and retention in prison health programs. Unpublished doctoral dissertation, University of Michigan, Ann Arbor. Miller, D. C. (1970). Handbook of research design and social measurement (2nd ed.). New York: David Mckay. Munson, F. C., & Heda, S. S. (1974). An instrument for measuring nursing satisfaction. Nursing Research, 23, 159-1 66. Redfern, S. J. (1981). Hospital sisters: Their job attitudes and occupational stability. London: Whitefriars Press. Roos, P. D. (1979). Nurse practitioner employment, unemployment, reemployment. Nursing Research, 28, 348-353. Slavitt, D., Stamps, P., Piedmont, E., & Haase, A. M. (1979). Measuring nurses’ job satisfaction. Hospital and Health Services Administration, 24(3), 62-76. Smith, P. C., & Kendall, L. M. (1963). Cornell studies of job satisfaction. Unpublished manuscript, Cornell University, Ithaca, NY. Sultz, H. A,, Zielezny, M., Gentry, J. M., & Kinyon, L. (1978). Longitudinal study of nurse practitioners: Phase /I. (DHEW Publication No. 7892). Washington, DC: US. Government Printing Office. Wanous, J. P., & Lawler, E. E. (1972). Measurement and meaning of job satisfaction. Journal of Applied Psychology, 56, 95-1 05. Weisman, C. S., Alexander, C. S., & Chase, G. A. (1980). Job satisfaction among hospital nurses: A longitudinal study. Health Service!; Research, 15,341-364. Weisman, C. S., & Nathanson. C. A. (1985). Professional satisfaction and client outcomes. Medical Care, 23, 1179-1 192. Weiss, D. J., Dawis, R. V., Lofquist, L. H., & England, G . W. (1967). Manual for the Minnesota Satisfaction questionnaire. Minneapolis: University of Minnesota, Industrial Relations Center, Work Adjustment Project.
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
Pamela Wllkle Koelbel MSN, MPH, RN, FNP Medical-Surgical Educator, Maw Black Memorial Hospital, Spartanburg, South Carolina.
Sara G. Fuller
PhD, RN, CPNP Associate Professor, Department of Nursing Systems, University of South Carolina, Columbia.
Terry R. Mlsener
PhD, RN, FNP Professor, Chairperson, Department of Nursing Systems, College of Nursing, University of South Carolina, Columbia.
Job satisfaction influences employee retention, worker productivity, and performance quality. To retain qualified nurse practitioners (NPs), health administrators must identify sources of job satisfaction and dissatisfaction. Herzberg’s dual-factor theory of job satisfaction addresses extrinsic and intrinsic work-related factors. Expansion of the model to include global job satisfaction and individual differences provided a broad framework for the assessment of nurse.practitioner job satisfaction. The expanded model was used to analyze the job satisfaction of’l32 NPs registered with the South Carolina State Board of Nursing in 1988 (final response rate‘= 90%). Participants completed the Index of Job Satisfaction (IJS), the Minnesota Satisfaction Questionnaire-Short Form (MSQ-SF), and the Personal and Work Background Questionnaire (PWBQ). Although the NPs were moderately satisfied with their overall jobs, extrinsic factors were found to be major sources of dissatisfaction. The optimal combination of variables predicted by regression analysis to influence global job satisfaction were age, number of children, urban locations, achievement, company policies and practices, creativity, independence, and compensation. Implications for health administrators to improve the work environments of NPs are discussed.
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of dissatisfaction, but rather an interaction of the satisfiers and dissatisfiers with the satisfiers being dominant. Conversely, if the dissatisfiers outweigh the satisfiers, general dissatisfaction is present. Herzberg postulated that intrinsic factors or satisfiers arise from the performance of the job itself. He identified achievement, recognition, work itself, responsibility, advancement, and potential for growth as being satisfiers. Of these, responsibility, advancement, and a sense of performing interesting and important work (work itself) are the most influential. The satisfiers were termed “motivators” because they are necessary for enhancing job performance (Herzberg, 1966). The extrinsic factors or dissatisfiers emerge from surroundings in the work environment. Working conditions, interpersonal relations, salary, status, security, policies and administration, and supervision are dissatisfiers. The two most important dissatisfiers are the following: (a) company policies and administration which foster inefficiency or unfair treatment within an organization and (b) supervisors who lack competence in carrying out the mission as indicated by inability to delegate responsibility and motivate MODEL OF NP JOB SATISFACTION others (House & Wigdor, 1967). The dissatisfiers were Herzberg’s dual-factor theory of job satisfaction and labeled “hygienes” or “maintenance” factors because motivation (Herzberg et al., 1959) provides the basis they serve only as preventors of job dissatisfaction for the model of NP job satisfaction. Although (Herzberg, 1966). Herzberg’s dual-factor theory can be compared to frequently applied to nursing, Herzberg based his Maslow’s need hierarchy (Hodgetts & Cascio, 1983).The original theory on a study of 200 accountants and motivation-hygiene theory condenses the five level engineers. Herzberg’stheory focuses on the intrinsic and need hierarchy of Maslow into two independenr extrinsic factors contributing to job satisfaction but does categories of needs: animal needs (hygienes) and human not address individual differences or a global assessment needs (motivators). The animal needs at the lower end of job satisfaction. T h e present model expands of the scale may heighten dissatisfaction and do not Herzberg’s dual-factor theory of job satisfaction by produce satisfaction. The hygiene factors fulfill the including the concept of individual differences and an animal need to avoid discomfort whereas the motivator overall assessment of job satisfaction. Figure 1 displays factors gratify the human need to grow psychologically the conceptual model of job satisfaction for this study towards self-actualization (Cronin-Stubbs, 1977). Only by illustrating the interrelationships among these major if the animal needs are met, can attainment of the human concepts. or higher level needs promote satisfaction. Therefore, Herzberg and his associates concluded that job not only must administrators manipulate hygienic satisfaction and job dissatisfaction represent two factors to prevent dissatisfaction, but they also must separate continua (Herzberg et al., 1959).Intrinsic work stimulate the motivator forces to facilitate a greater sense factors, known as the satisfiers, form the satisfactionof job satisfaction (Herzberg, 1966). no satisfaction continuum. Factors extrinsic to work, A shortcoming of Herzberg’sdual-factor theory is the known as the dissatisfiers,comprise the dissatisfactionomission of focus on individual differences and overall no dissatisfaction continuum. T h e two continua job satisfaction (House & Wigdor, 1967). This omission support the possibility that individuals may be content o f the theory to NPs. Focusing limits the application with some job aspects but not others, i.e., satisfied and only on Herzberg’s intrinsic and extrinsic factors does dissatisfied (Lambert, Wertheimer, & Johnson, 1980). not account sufficiently for the satisfaction and A high level of satisfaction is not merely the absence dissatisfaction of NPs. As reflected in Figure 1, individual differences and global satisfaction also Address correspondence to Pamela Koelbel, RN, MSN, MPH, contribute to the explanation of job satisfaction of NPs. Education Department, Mary Black Hospital, P.O. Box 3217, Individual differences are important because they Spartanburg, SC 29304.
Maintenance of job satisfaction among N P presents ~ an important challenge for health care administrators and NPs. Stresses created by the economic and competitive climate of primary health care in the late 1980s and 1990s may lead to job dissatisfaction among NPs. Dissatisfied NPs are likely to leave the profession (Hayden, Davies, 8c Clore, 1982; Roos, 1979; Sultz, Zielezny, Gentry, & Kinyon, 1978)or perform their jobs less proficiently (Consolvo, 1979; Koerner, 1981; Weisman & Nathanson, 1985).A thorough understanding of the sources of job satisfaction and dissatisfaction can assist NPs and health care administrators to structure the work environments of NPs in a positive manner (Holton, 1978). Herzberg’s dual-factor theory of job satisfaction (Herzberg, Mausner, & Synderman, 1959) is a useful model for explaining the sources of job satisfaction and job dissatisfaction. The findings of a study on job satisfaction of 132 NPs in South Carolina (Koelbel, 1988) support the applicability of Herzberg’s dual-factor theory to NPs.
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influence whether or not a given factor will be a source of satisfaction or dissatisfaction, based on personal qualifications and past experiences of the individual (Smith & Kendall, 1963). Individuals use their own frames of reference to evaluate the characteristics of their jobs. Therefore, personal and work background factors, such as age (Anderson & Haag, 1963), gender ( H u h & Smith, 1964), educational level, tenure (Slavitt, Stamps, Piedmont, & Haase, 1979), work experience (Weisman, Alexander, & Chase, 1980), and hierarchical position (Munson & Heda, 1974) influence job satisfaction. Smith and Kendall (1963) emphasized the need for considering an overall measure of job satisfaction, i.e., global satisfaction of the worker, because workers may dislike certain features of their jobs, yet still feel content with their jobs overall. Conversely, workers may be unhappy with their jobs as a whole despite its many positive attributes (House & Wigdor, 1967). Research studies attempting to predict long-term behaviors, such as job termination, frequently assess global job satisfaction. The measurement of global job satisfaction provides information about the individual's general adaptation level rather than specific likes and dislikes (Lichtenstein, 1981). Within the context of global job satisfaction, satisfied workers are not disappointed that they took their jobs. They find their jobs more enjoyable and interesting than available alternatives and do not feel they must force themselves to go to work (Brayfield & Rothe, 1951). APPLICATION OF THE MODEL TO NPs
Using the model depicted in Figure 1, this study addressed the following research questions: 1. What are the global, general, intrinsic, and extrinsic levels of job satisfaction of NPs? 2. T o what extent are the intrinsic factors sources of job satisfaction and the extrinsic factors sources of job dissatisfaction for NPs? 3. T o what extent do personal, work background, intrinsic, and extrinsic factors correlate with the job satisfaction of NPs? 4. What are the most important personal, work background, intrinsic, and extrinsic factors in the determination of NPs' job satisfaction? METHODOLOGY To assess the interaction of the three components of the conceptual model (Figure l), all NPs in the state of South Carolina were surveyed with the IJS (Brayfield & Rothe, 1951), MSQ-SF (Weiss, Dawis, Lofquist, & England, 1967),and PWBQ (Koelbel, 1988).The survey
VOLUME 3, NUMBER 1 , JANUARY-MARCH, 1991
'I'
/p\ SATISFACTION
-Hotivators)
-achievement -recognition -work itself -responsibility -advancement -potential for growth
-age -gender -education -race -tenure -employment status -work experience -community s i z e -specialty area
-working conditions -interpersonal relations -salary .security -status -supervision -policies and administration
FIGURE 1. Conceptual model of job satisfaction using Herzberg's dual-factor theory, global measurement, and individual differences.
determined the direction and magnitude of the relationships among Herzberg's intrinsic and extrinsic factors, selected personal and work background factors, and global job satisfaction. INSTRUMENTS An lndex of Job Satisfaction. Brayfield and Rothe's (1951) 18-item IJS assessed the respondents' overall level of job satisfaction. The IJS has a high index of reliability (odd-evenproduct moment reliability coefficient = 0.77; Spearman-Brown reliability coefficient = 0.87; Brayfield & Rothe, 1951; Miller, 1970) and has been widely used in research studies as a unitary or global measure of job satisfaction (Evans, 1969; Hale, 1986; Miller, 1970; Wanous & Lawler, 1972). Analyses using an external criterion yielded estimates of validity significant at the .01 level. Furthermore, a comparison of the IJS and Hoppock's Scale yielded a product-moment correlation of 0.92 (Brayfield & Rothe, 1951; Miller, 1970).
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The Minnesota Satisfaction Questionnaire. The second questionnaire, the 20-item MSQ-SF constructed by Weiss et al. (1967),measures the degree of satisfaction of respondents with the extrinsic and intrinsic aspects of their jobs. The MSQ-SF is consistent with Herzberg’s Motivation-Hygiene theory (Buros, 1972) and has been shown to be reliable (Hoyt reliability coefficients range from 0.77 to 0.92 for all three scales)and valid (construct validity ranged from 0.03 to 0.12; Weiss et al., 1967). Personal and Work Background Questionnaire. The third questionnaire was the 22-item PWBQ (Koelbel, 1988).The PWBQ was devised specifically for this study to collect personal and work background information on each of the participants. The content of this questionnaire was adapted from the works of Redfern (1981) and Sultz et al. (1978) on the job satisfaction of nurses and NPs respectively. The development of the PWBQ was consistent with guidelines for mailed questionnaires (Dillman, 1978). POPULATION AND SAMPLE The target population consisted of all NPs and nurse midwives in South Carolina who met the following criteria: (a) registration with the South Carolina State Board of Nursing, (b) active employment for at least six months, and (c) current practice in South Carolina. Because of existing role similarities and allowing for comparison of the study’s findings with those of national surveys, the study included nurse midwives as potential respondents along with the NPs. The final population consisted of 128 NPs and 35 nurse midwives, collectively referred to as NPs in the rest of the study (N = 163). Ninety percent (n = 146)of the potential participants responded. Of these, 14 surveys were not usable. Eleven people did not meet the eligibility criteria: 7 were not currently working as NPs; 1 had less than six months of employment; and 3 were no longer practicing in South Carolina. An additional 3 respondents returned blank questionnaires. Therefore, the final sample consisted of 132 subjects yielding a usable response rate of 81%. The subjects represented a heterogeneous group of NPs in terms of personal and work background factors. The majority of the NPs were white (91.7%), female (98.5%),and ranged in age from 26 to 63 years (Mean (M) = 42; Standard Deviation (SD) = 8.4). Two thirds of the subjects were married and 42% had either one or two children. Three fourths of the survey participants were prepared in certificate NP programs although a large proportion (53.8%)had earned a baccalaureate or master’s degree in nursing. The most frequently reported specialty areas (44%) were family practice, pediatrics, obstetrics/gynecolog, and midwifery. Little employ-
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ment time was spent in administrative functions. Nurse midwives (100%)were certified more frequently than NPs (67%). The survey participants were experienced NPs; two thirds of the subjects had 6-15 years of work experience (M = 8.9 years; SD = 4.9) and worked both part- (29.8%) and full-time (70.2%). Seventy-six percent worked in urban areas and 24% in rural areas. The majority reported incomes of 25,000 to 29,000 dollars. Hourly wages ranged from 8.71 to $26.22/hour (M = $13.95; SD = $3.29). Health departments comprised one third of the practice settings; private offices, 14.5%; and ambulatory health centers/clinics, 10.7%.More than half the respondents estimated that over 70%of the patients in their practice settings had low incomes. PROCEDURES A questionnaire packet including the survey instruments, a cover letter explaining the confidential survey, and a self-addressed post-paid return envelope was mailed to each NP. T h e return of a completed questionnaire indicated the subject’s consent to participate. At four and nine weeks, follow-up postcards were sent to nonrespondents encouraging their participation. At 11 weeks, data collection ceased. Two incentives were used to encourage a high response rate. In return for each completed questionnaire packet, the researcher offered to donate $1 to ii professional nursing organization of the respondent’s choice. In the sample, 131 respondents indicated an organization for the donation. Furthermore, an offer was made to send a copy of the study’s findings to respondents who so requested. One third of the respondents requested a copy of the findings. RESULTS The research questions were analyzed using descriptive and inferential statistics with the level of significance set at 0.05. Nominal variables were transformed into dummy variables for inclusion in the regression and correlation analyses. The results of the correlation and regression analyses are presented in depth (Tables 1-3). The analysis of the four job satisfaction categories (global, general, extrinsic, and intrinsic) and factor analysis are summarized (see Koelbel et al, in press, for the in-depth analysis). ScaIe R eiiabiiities of the Instruments. Although the survey instruments had been extensively used in other research studies, this was the first application to NPs. Therefore, the reliability of the instruments in this sample was calculated. The alpha coefficient for the IJS was 0.8893. This value exceeded the reliability coefficients (0.77 and 0.87) reported by Brayfield and Rothe (1951). The coefficient alpha for the MSQ-SF
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
was 0.9020, which is similar to those (0.87 to 0.92) presented by Weiss et al. (1967).The two MSQ subscales, intrinsic (0.86) and extrinsic (0.83) satisfaction scales, also were reliable. Global Job Satisfaction. A combination of individual items from the IJS measured global job satisfaction. Using Brayfield and Rothe’s (1951) classification, the NPs indicated moderate satisfaction with their jobs; approximately 90%scored in the upper half of the global satisfaction scale. General Job Satisfaction. The sum of the 8 extrinsic and 12 intrinsic items of the MSQ-SF measured general job satisfaction. Using the categories of Weiss et al. (1967), the majority of NPs reported a moderate level of general job satisfaction; approximately 60% scored in the middle range of the general satisfaction scale. Intrinsic and Extrinsic Factors. Consistent with the predictions of Herzberg’s dual-factor theory, intrinsic factors (arising from performance of a job) were sources of job satisfaction and extrinsic factors (arising from the work environment) were sources of job dissatisfaction. NPs derived the most satisfaction from aspects intrinsic to work itself. Based on the responses to the MSQ-SF (Weiss et al., 1967), the most satisfying job factors were social service (M = 4.42), variety (M = 4.23), moral values (M = 4.20), security (M = 4.18), and ability utilization (M = 4.13). Security was the only satisfier considered to be an extrinsic factor by Herzberg. On the other hand, the NPs attributed their dissatisfaction to the contextual aspects of their jobs. They were dissatisfied with their compensation (M = 2.88), advancement (M = 2.99), company policies and practices (M = 3.13), recognition (M = 3.39), and supervision-human relations (M = 3.40). The largest proportion (48.5%)of NPs were dissatisfied with their compensation. Except €or recognition and advancement, these factors are congruent with Herzberg’s hygienes. The distribution of the overall intrinsic and extrinsic satisfaction scores indicated high intrinsic satisfaction for 66% of the NPs and low extrinsic satisfaction for 35%. A confirmatory principal components factor analysis with varimax rotation was performed on the MSQ-SF to check the validity of the dual-factor theory in the current sample. Using the criteria of only including factors with eigenvalues greater than one and factors on which at least three items loaded at the 0.4 level, two factors emerged. These factors were Internal Job Qualities and Clinical Environment and Reward System, both of which were equitable with the factors posited by Herzberg. Seven of the 12 motivators included in the study (moral values, ability utilization, responsibility, achievement, creativity, social service, and variety) loaded on factor 1, Internal Job Qualities. In
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addition to the seven motivators, one hygiene (social status) also loaded on factor 1. On the other hand, six of the eight hygienes (company policies and practices, working conditions, coworkers, compensation, supervision-human relation, and supervision-technical) and two motivators (recognition and advancement) loaded on factor 2, Clinical Environment and Reward System. Personal and Work Background Factors. The statistically significant Pearson product-moment correlation coefficients among four job satisfaction categories and selected personal and work background factors are presented in Table 1. Variables not found to be significant include gender, marital status, type of NP program, nursing preparation, specialty, population of county of residence, tenure, hierarchy position, gross income, rural, traveling distance to work, satisfaction with state nurse practice act, and satisfaction with physician acceptance. Both having children and private practice correlated strongly with all four outcome measures. NPs with more children or in private practice settings or both tended to score higher on all four job satisfaction scales. National certification correlated positively with both global job satisfaction and intrinsic job satisfaction. The Pearson correlation coefficient between national certification and global job satisfaction was 0.22 ( p = 0.01 ). National certification and intrinsic job satisfaction had a Pearson Y of 0.18 ( p = 0.037). These correlation coefficients suggest that certified NPs had a higher level of global and intrinsic job satisfaction than those not certified. Statistically significant positive correlations were also found between hourly wage and global job satisfaction ( r = 0.19; p = 0.03) and between urban practice settings and global job satisfaction (Y = 0.22; p = 0.01). NPs with higher hourly wages or that work in urban practice settings or both tended to be more satisfied overall with their jobs. A statistically significant negative correlation was found between percentage of low-income patients served and extrinsic job satisfaction (r = -0.26; p = 0.0029). This finding suggests that NPs serving a smaller percentage of low-income patients had more extrinsic job satisfaction than those serving a larger percentage of low-income patients. Interestingly, satisfaction with perceived patient acceptance correlated positively with intrinsic satisfaction ( r = 0.17; p = 0.049). This correlation describes a relationship where NPs with perceived high levels of patient acceptance had a greater amount of intrinsic job satisfaction than those with perceived low levels of patient acceptance. Almost one third of the study subjects felt either dissatisfied or very dissatisfied with physician acceptance. However, most
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TABLE 1. STATISTICALLY SIGNIFICANT PEARSON PRODUCT-MOMENT CORRELATION COEFFICIENTS AMONG FOUR JOB SATISFACTION CATEGORIES AND SELECTED PERSONAL AND WORK BACKGROUND FACTORS Global Satisfaction (IJS)
Factors Personal Age Nonwhite Children Certification Work Background Work experience Employment status Hourly wage Private practice Urban Percent of low income patients Satisfaction with patient acceptance Global satisfaction
General Satisfaction (MSQ)
Intrinsic Satisfaction
Extrinsic Satisfaction
0.115 0.073 0.312"' 0.220"
0.078 -0.1 19 0.283" 0.1 53
0.061 -0.1 16 0.286"' 0.1 82*
0.080 -0.090 0.205' 0.069
0.110 -0.072 0.1 90' 0.241 *** 0.21 9"' -0.1 61 0.139 -
0.044 -0.1 16 0.155 0.289"' 0.124 -0.1 64 0.155 0.718"'
0.063 -0.1 20 0.160 0.176* 0.097 -0.009 0.171' 0.620"'
0.024 -0.1 00 0.1 03 0.31 3"' 0.105 -0.263" 0.071 0.634"'
' p value < 0.05. **p value < 0.01. "'p value < 0.001
participants (95%)were either satisfied or very satisfied with the amount of patient acceptance. Although not part of the original research questions, the data were analyzed to determine if there were
TABLE 2. PEARSON PRODUCT-MOMENTCORRELATIONS BETWEEN GLOBAL JOB SATISFACTION AND INTRINSIC AND EXTRINSIC FACTORS
Factor Activity Independence Variety Social status Supervision-human relations Supervision-technical Moral values Security Social service Authority Ability utilization Company policies and practices Compensation Advancement Responsibility Creativity Working conditions Co-workers Recognition Achievement All MSQ items
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Global Sat isfaction UJS)
Significance
0.324 0.120 0.430 0.443 0.439 0.495 0.294 0.215 0.387 0.279 0.418 0.552 0.445 0.538 0.542 0.421 0.510 0.441 0.361 0.608 0.718
0.0001 0.1717 0.0001 0.0001 0.0001 0.0001 0.0006 0.0132 0.0001 0.0012 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001
significant differences between the NPs and nurse midwives. In comparison to the NPs, nurse midwives felt significantly less accepted by patients (t = -2.23; p = 0.037) and by physicians ( t = -4.51; p= 0.0001). However, there was no statistical difference between the job satisfaction levels of nurse midwives and nurse practitioners. The Pearson product-moment correlation between global job satisfaction and the 20 intrinsic and extrinsic factors are presented in Table 2. Statistically significant positive correlations were found between 19 of the MSQ items and global job satisfaction. T h e Pearson correlation between independence and global job satisfaction was 0.12 ( p = 0.17). This finding suggests that there was little relationship between independence and global job satisfaction for this group of nurse practitioners. The two major outcome measures of job satisfaction were highly correlated. Global job satisfaction correlated significantly to general job satisfaction with an I of 0.72 (@ = 0.0001). The correlations between global job satisfaction and intrinsic job satisfaction and between global job satisfaction and extrinsic job satisfaction also were strongly positive (Table 1). Regression Model for Global Job Satisfaction. After examining variables at the univariate level, stepwise multiple regression was used to determine which model best fit the data. Eight independent variables significantly ( p < .05) predicted global job satisfaction (Table 3). Achievement accounted for the greatest variance (35%) and entered the model first. The
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
TABLE 3. COEFFICIENTS OBTAINED FROM REGRESSION OF GLOBAL JOB SATISFACTION OF PERSONAL, WORK BACKGROUND, INTRINSIC, AND EXTRINSIC FACTORS Variable (Step Entered) Achievement Company policies & practices Creativity Children Age Urban setting Independence Compensation
B
SE
F
P
2.60 2.46 2.51 2.13 0.1 7 2.55 -1.64 1.06
0.69 0.62 0.66 0.59 0.07 1.11 0.72 0.51
14.02 15.81 14.23 12.97 5.88 5.28 5.15 4.29
0.0003 0.0001 0.0003 0.0005 0.0168 0.0233 0.0251 0.0404
6 = Unstandardized regression coefficient. SE = Standard error. F = F statistic. P = Level of significance.
other variables in order of entry into the regression were company policies and practices (14%), creativity (3%), age (3%), children (2%), urban setting (2%), and independence and compensation (3%). The total eight variable model accounted for approximately 62%of the variance in global job satisfaction (model R2 0.618; p = 0.0001).
DISCUSSION AND IMPLICATIONS FOR NP PRACTICE The survey results have important implications for health administrators and NPs. NPs indicated satisfaction with the content of their jobs and dissatisfaction with their work environments. Three aspects of the work environment were particularly dissatisfying: lack of adequate compensation, the implementation of organizational policies, and capabilities of supervisors. In addition, NPs were dissatisfied with their opportunities for advancement and recognition. By structuring the work environment to enhance the extrinsic factors, health administrators could prevent potential job dissatisfaction. Specifically, health administrators can clarify the roles of NPs to the administrative staff and implement a clinical ladder for advancement and recognition. Compensation can be enhanced by innovative benefit programs, third-party reimbursement, and NP consultation fees. In addition to structuring the work environment, health administrators can capitalize on intrinsic factors known to satisfy NPs. T o prevent job dissatisfaction, health administrators can facilitate the motivation of NPs by providing adequate opportunities for professional growth. Because social service is a strong motivator for NPs, positions should include a variety of clinical practice opportunities. Autonomy in identifying clinical projects of personal interest and
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managing a defined group of patients should be encouraged. Developing strategies such as these to promote achievement, autonomy, recognition, responsibility, challenge, and enjoyment in the work itself may assist in increasing intrinsic job satisfaction. The importance of personal/work background factors in relationship to NP job satisfaction also emerges as a finding with implications for health administrators. Health administrators should be aware of possible approaches to increase job satisfaction based on these personal/work background factors. One approach that a health administrators might take to foster job satisfaction is to encourage NPs to obtain national certification by (a) providing certification reimbursement, (b) promoting time-off for preparation for the certification exams, and (c) offering higher wages upon certification. A second approach is to provide incentives to retain NPs with youngchildren. Some of these incentives could include adjusting employee vacations to coincide with school vacations, providing (or supplementing the cost of) child care, and offering adequate health insurance with dependent coverage and flexible work schedules. For NPs in health departments providing care primarily to low-income families, health administrators should consolidate health services so that continuity of care is maintained. With less fragmentation of services, NPs could develop more satisfying nursepatient relationships. Professional isolation may be a source of job dissatisfaction for nurse practitioners in rural areas. Long drives, lack of interpersonal relationship with other nurse practitioners, and limited opportunities for professional development may often be experienced by rural nurse practitioners. Health administrators could reduce such sources of job dissatisfaction by facilitating communication with other nurse practitioners (e.g. computer networking, regional NP meetings, and peer
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review), using flexible scheduling, offering mileage reimbursement and journal subscriptions, and planning educational workshops. Not only might these approaches lead to higher job satisfaction levels, they might also lead to less absenteeism, increased retention, improved patient access, enhanced quality of care, and cost savings.
3. Conduct interviews, instead of mailed surveys, to qualitatively evaluate the meaning of the satisfiers and dissatisfiers to NPs. 4. Consider experimental testing of the effects of certain management strategies on the job satisfaction of NPs.
RECOMMENDATIONS
SUMMARY
The following are recommendations for further research: 1. Replicate this study using the census populations of NPs practicing in other states to compare with the degree of job satisfaction of NPs in South Carolina. Such investigations would increase the knowledge of the influence of various state economic environments, reimbursement, and prescription policies on the job satisfaction of NPs. 2. Examine the relationship between the quality and cost effectiveness of NP care and job satisfaction.
The expanded model of Herzberg’s dual-factor theory provides a useful framework for examining the job satisfaction of NPs. When applied to the survey results of NPs in South Carolina, the model explained the job satisfaction and dissatisfaction of the respondents. Herzberg’sbasic theory was upheld in this sample except for recognition, advancement, and security. The inclusion of the concepts, global job satisfaction and individual differences, strengthened Herzberg’s dualfactor theory by providing greater insight into NP job satisfaction.
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