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International Journal of Mental Health Nursing (2014) 23, 460–467
doi: 10.1111/inm.12070
Feature Article
Job satisfaction and turnover intention among Jordanian nurses in psychiatric units Faris Alsaraireh,1 Mary T. Quinn Griffin,2 Scott R. Ziehm3 and Joyce J. Fitzpatrick2 1
Department of Community and Psychiatric/Mental Health Nursing, Mutah University, Mutah, Jordan, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio and 3School of Nursing and Dental Hygiene, University of Hawai’i at Manoa, Honolulu, Hawai’i, USA 2
ABSTRACT: Psychiatric nursing has been identified as a stressful occupation, and this stress could affect individuals’ health, well-being, and job satisfaction. The stress of nurses might also affect the organization in terms of absenteeism and quality of care. The purpose of this study was to examine the relationship between job satisfaction and turnover intention among Jordanian nurses in the psychiatric units of the Jordanian National Mental Health Center. A descriptive, correlational, crosssectional design was used. Nurses were asked to complete a demographic data sheet and questionnaires regarding job satisfaction and turnover intention. Of the 179 questionnaires distributed, 154 were completed, with an 86% response rate. The results revealed a statistically-significant negative relationship between job satisfaction and turnover intention. The findings of the study are consistent with previous research regarding the negative relationship between job satisfaction and turnover intention. The findings provide new information about Jordanian nurses who work in government hospital psychiatric services. KEY WORDS: job satisfaction, Jordon, nursing, psychiatric nurse, turnover intention.
INTRODUCTION Nurses constitute the largest group of healthcare professionals in Jordan. In psychiatric units, nurses are responsible for providing a safe and appropriate environment and maintaining a therapeutic environment for psychiatric patients. Although the past decade witnessed significant landmarks in capacity building in nursing education and service, as well as in the improvement of nurses’ image and status, many issues remain for nurses in Jordan, especially those who work in government psychiatric hospitals.
Correspondence: Joyce J. Fitzpatrick, Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA. Email: [email protected] Faris Alsaraireh, DNP, PMHNP, RN. Mary T. Quinn Griffin, PhD, RN, FAAN. Scott R. Ziehm, DNP, RN. Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN. Accepted March 2014.
© 2014 Australian College of Mental Health Nurses Inc.
Psychiatric nursing has been identified as a stressful occupation, and this stress could affect individuals’ health, well-being, and job satisfaction. The stress of nurses might also affect their organizations in terms of absenteeism and turnover, which in turn affects the quality of patient care (Edward et al. 2000). Researchers have identified a variety of stressors in psychiatric nursing, including low salary, heavy workload, lack of positive feedback, lack of resources, and poor work environments (Paris & Hoge 2010). The stigma linked to this specialty, the challenging interactions with other mental health professionals, and demanding relationships with patients have also been identified as stressors (Paris & Hoge 2010). In psychiatric hospitals, work is difficult, and there is often burnout among staff (Happell et al. 2003) and high turnover (Sumner & Townsend-Rocchiccioli 2003). Aronson (2005) found that nurses who work in psychiatric hospitals had lower job satisfaction than other workers in the hospital. Ito et al. (2001) examined psychiatric nurses’ intention to leave their jobs, and found that 44.3% of
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psychiatric nurses in their sample intended to leave, and those who intended to leave were significantly younger than those who did not intend to leave.
Background The literature review included studies of nurses’ job satisfaction, intent to leave current position, and intent to leave the profession, which were retrieved from multiple sources from the period 2000 to 2013. The search terms included nurses, job satisfaction, intent to leave, mental health, and Jordan, in various combinations. Factors that might affect job satisfaction and turnover intention can be divided into personal characteristics (age, sex, marital status, and experience) and organizational factors. Age has been positively correlated with job satisfaction among nurses in Kuwaiti (Shah et al. 2004); the USA (Klaus et al. 2012), and Korea (Hwang et al. 2009). Sex has also been linked to job satisfaction, with men in nursing having lower job satisfaction (Torkelson & Seed 2011). In studies of Lebanese and Turkish nurses, individuals who were single had lower job satisfaction than those who were married (Cimete et al. 2003; Yaktin et al. 2003). In Saudi Arabia, researchers identified a positive relationship between years of experience, organizational commitment, and job satisfaction (Al-Ahmadi 2009). In a study of Chinese nurses, Wang et al. (2011) examined the relationship between job satisfaction, occupational commitment, and intent to stay. The findings revealed that job satisfaction and occupational commitment were positively correlated with intent to stay. Promotions and age also positively correlated with job satisfaction, occupational commitment, and intent to stay. The negative relationship between job satisfaction and turnover intention of nurses has been supported in previous research in Japan (Kudo et al. 2006), China (Cai & Zhou 2009; Liu et al. 2011), Lebanon (El-Jardali et al. 2009), Taiwan (Tsai & Wu 2010), Turkey (Gok 2011), and the USA (Applebaum et al. 2010). There are few studies among nurses working in psychiatric hospitals. In a study of European psychiatric nurses, Ward and Cowman (2007) found that job satisfaction was related to organizational factors, including work location and other organizational factors within the work environment. Aronson (2005) studied nurses working in private psychiatric hospitals in the USA and found that, compared to other mental health workers, registered nurses had lower job satisfaction. Ito et al. (2001) examined job satisfaction and intent to leave among psychiatric nurses in 27 hospitals in Japan, and found that 44% of nurses intended to leave their jobs, a result they linked to © 2014 Australian College of Mental Health Nurses Inc.
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job dissatisfaction; 37.7% were dissatisfied with their jobs (Ito et al. 2001). Aims: Although there is considerable research on nurses in a variety of settings, including studies of job satisfaction, personal and organizational variables, and job satisfaction and turnover intention, there is a paucity of research on psychiatric nurses. Further, there is no prior research on nurses in Jordan, and in particular, nurses working in psychiatric units. The present study was designed to fill a gap in the understanding of psychiatric nursing in Jordan and provide information for future human resource planning. The research question for the study was: What is the relationship between job satisfaction and turnover intention among Jordanian nurses working in psychiatric units?
RESEARCH METHODS Design and setting This study was quantitative, with a descriptive, crosssectional design. The setting was a governmental hospital for mental health in Jordan. The hospital has 250 beds, 200 nurses, and more than 30 outpatient clinics.
Sample The potential sample included nurses working in the main hospital of the National Mental Health Center (NMHC). Nurses working in the outpatient clinics and nurses with administrative responsibilities were excluded. Only nurses who had been working at the NMHC for at least 4 months were invited to participate. Of the 200 nurses employed in the setting, 179 met the inclusion criteria.
Procedure The study was approved by the hospital and the Jordanian Ministry of Health. Institutional Review Board approval was granted. The director of each psychiatric unit was informed of the purpose of the study before data collection commenced. The nurses were informed of the purpose and procedures of the study, and provisions to maintain confidentially. The participants were also assured that their non-participation or withdrawal from the study would not affect their current or future relationship with their employer. Although Arabic is the native language in Jordan, English is the official language for hospital documentation and for teaching in nursing schools. Therefore, English versions of the questionnaires were used. No identifiable information about the nurses was collected. Completed questionnaires were dropped into a locked box located on each unit.
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Instruments A background data sheet contained information to describe characteristics of the sample, including age, sex, marital status, shift worked, years of experience in nursing, level of education, type of units or wards, and salary. A question was added to evaluate factors related to workplace stress. Possible responses were: (i) insufficient time to do your job; (ii) lack of control over work; (iii) risk of violence and abuse from patients or service users; (iv) unclear job responsibilities; and (v) overcrowding or cramped work areas. The Minnesota Job Satisfaction Questionnaire (MSQ) – short form, developed by Weiss and colleagues, was used to measure nurses’ job satisfaction (Weiss et al. 1967). The MSQ is a self-report instrument, through which respondents indicate how satisfied they are with various aspects of their present job. The 20 questions are ranked on a fivepoint scale; scores range from 20 to 100, with higher scores indicating higher job satisfaction. The MSQ – short from has a Cronbach’s alpha of 0.91 (Ben-Bakr et al. 1994). The validity and reliability of the MSQ – short from has been well documented (Weiss et al. 1967). In the present study, Cronbach’s alpha was 0.91. To measure nurses’ turnover intention, the modified version of the Withdrawal Cognition Scale (WCS) (Takase et al. 2005), a five-item, self-report instrument, was used. The original scale was developed by Mowday et al. (1984) to measure the three factors of turnover (thinking of quitting, searching for new jobs, and intention to quit). Modifications made by Takase et al. (2005) included measuring two different occasions of nurses’ turnover intention: (i) leaving the organization and looking for a new nursing job; and (ii) leaving nursing as a profession. The scale is a six-point scale, with responses ranging from 1 to 6; the possible range of scores is 6–30, with higher scores indicating strong turnover intention. The WCS was found to have a reliability score of 0.79; construct validity was previously established (Takase et al. 2005). In the present study Cronbach’s alpha was 0.76. Job satisfaction was operationally defined as the total score on the MSQ – short from. Intent to leave current position was operationally defined by the total score on the WCS.
Data analysis The Statistical Package for the Social Sciences (version 17; SPSS, Chicago, IL, USA) was used. Frequency distributions were used to describe the percentage of nurses for each categorical demographic variable (sex, marital status, shift worked, level of education, type of units or wards), while means and standard deviations were used to
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describe continuous variables (age, experience in years, and satisfaction with salary). For the research question, Pearson correlation analysis was calculated. In addition, Pearson correlation analyses were used to test the relationship between the participants’ continuous demographic characteristics and the main study variables (job satisfaction and turnover intention). To test the relationship between the participants’ categorical demographic characteristics and the main study variables (job satisfaction and turnover intention), the independent-sample t-test were used. One-way ANOVA was used to test the relationship and the difference between the four participant work settings and the main study variables (job satisfaction and turnover intention).
RESULTS Sample characteristics A total of 154 nurses completed the questionnaires, indicated an 86% response rate. The majority of the participants were married women with an associate degree in nursing. The majority of the nurses worked day shift, and all of the four units were represented in the sample. Detailed sample characteristics are included in Table 1.
Relationship between job satisfaction and turnover intention among Jordanian nurses in psychiatric units The mean job satisfaction score was 60.13 (standard deviation (SD) = 10.81), with a range of 40–84. The mean turnover intention score was 10.87 (SD = 3.30), with a range of 6–18. The Pearson correlation between job TABLE 1:
Sample characteristics (n = 154)
Demographic characteristics Sex Male Female Marital status Single Married Level of education Associate degree Bachelor degree Work setting Acute male unit Long-term male unit Acute female unit Long-term female unit Shift worked Day Evening
Frequency
Percentage (%)
70 84
45.5 54.5
64 90
41.6 58.4
126 28
81.8 18.2
38 34 39 43
24.7 22.1 25.3 27.9
118 36
76.6 23.4
© 2014 Australian College of Mental Health Nurses Inc.
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satisfaction and turnover intention was r = −0.796 (P < 0.01). Job satisfaction was very strongly negatively correlated to turnover intention. Additional analyses were undertaken to determine relationships among demographic variables and the two main study variables: job satisfaction and turnover intention. Independent-sample t-tests were conducted to determine differences in job satisfaction and turnover intention based on sex. The results showed that female participants (mean = 64.07, SD = 8.88) scored significantly higher than their male participants ((mean = 55.40, SD = 11.08), t (152) = −5.39, P = 0.000) on job satisfaction. Male participants (mean = 12.11, SD = 3.31) scored significantly higher than the female participants ((mean = 9.83, SD = 2.92), t (152) = 4.54, P = 0.000) on turnover intention. Between-subjects independent-sample t-tests were conducted to determine differences in job satisfaction and turnover intention based on marital status. The results showed a significant difference in job satisfaction based on marital status; married participants (mean = 63.10, SD = 10.41) scored significantly higher than single participants ((mean = 55.95, SD = 10.03), t (152) = −4.263, P = 0.000). There was also a significant difference in turnover intention; single participants (mean = 11.81, SD = 3.23) scored significantly higher than married participants ((mean = 10.20, SD = 3.20), t (152) = 3.072, P = 0.003). Between-subjects independent-sample t-tests were conducted to determine the effect of participants’ levels of education on job satisfaction. The results showed that participants with an associate degree (mean = 61.45, SD = 10.60) scored significantly higher than participants with a bachelor degree ((mean = 54.18, SD = 9.85), t (152) = 3.324, P = 0.001). A betweensubjects independent-sample t-test was conducted to determine the effect of participants’ levels of education on turnover intention. The results showed that participants with a bachelor degree (mean = 13.25, SD = 3.19) scored significantly higher than participants with an associate degree ((mean = 10.34, SD = 3.09), t (152) = −4.477, P = 0.000). A between-subjects independent-sample t-test was conducted to determine the effect of shift on job satisfaction. The results showed that there was no statisticallysignificant difference between two conditions (day shift and evening shift, t (152) = 1.551, P = 0.123). A betweensubjects independent-sample t-test was conducted to determine the effect of shift on turnover intention. The results showed that there was no statistically-significant difference between two conditions (day shift and evening shift, t (152) = −1.963, P = 0.052). © 2014 Australian College of Mental Health Nurses Inc.
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One-way ANOVA was conducted to determine the difference between the respondents from different units regarding job satisfaction. Acute female units showed the highest score for job satisfaction (mean = 64.95, SD = 8.95), while acute male units showed the lowest score (mean = 55.18, SD = 10.61). Long-term female and male units were in the middle (mean = 63.51, SD = 8.85 and mean = 55.85, SD = 11.62, respectively). There was a significant difference in job satisfaction between acute male and female units (P = 0.001); acute female units showed higher job satisfaction. There was also a significant difference in job satisfaction between acute male and long-term female units, (P = 0.004); long-term female units showed higher job satisfaction. There was no significant difference in job satisfaction between acute male and long-term male units. A significant difference was found for job satisfaction between long-term male and acute female units (P = 0.002); acute female units showed higher job satisfaction. Also, there was a significant difference in job satisfaction between long-term male and female units (P = 0.013); long-term female units show higher job satisfaction. There was no significant difference in job satisfaction between acute female and longterm female units. One-way ANOVA was conducted to determine the difference between the respondents from different work units regarding turnover intention. Acute male units showed the highest score for turnover intention (mean = 12.16, SD = 3.42), while long-term female units showed the lowest score (mean = 9.77, SD = 2.65). There was a significant difference in turnover intention between acute male and female units (mean = 12.16, SD = 3.42 and mean = 9.85, SD = 3.16, respectively; P = 0.017); acute male units showed higher turnover intention. There was also a significant difference in turnover intention between acute male and long-term female units (mean = 12.16, SD = 3.42, and mean = 9.77, SD = 2.65, respectively; P = 0.010); acute male units showed higher turnover intention. There was no significant difference in turnover intention between acute male and long-term male units (mean = 12.16, SD = 3.42 and mean = 12.00, SD = 3.28, respectively). There was a significant difference in turnover intention between the long-term male and acute female units (mean = 12.00, SD = 3.28 and mean = 9.85, SD = 3.16, respectively; P = 0.038); longterm male units showed higher turnover intention. There was also a significant difference in turnover intention between the long-term male and female units (mean = 12.00, SD = 3.28 and mean = 9.77, SD = 2.65, respectively; P = 0.024); long-term male units showed higher turnover intention. There was no significant
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difference in turnover intention between acute female and long-term female units (mean = 9.85, SD = 3.16 and mean = 9.77, SD = 2.65), respectively.
Relationship between respondents’ continuous demographic characteristics and job satisfaction and turnover intention Pearson correlations were used to test relationships between respondents’ age, experience, satisfaction with salary, and job satisfaction, and also with these same variables and turnover intention. Job satisfaction was significantly and strongly positively correlated with age (r = 0.508, P = 0.01); job satisfaction was significantly and strongly positively correlated with experience (r = 0.566, P = 0.01) and very strongly positively correlated with satisfaction with salary (r = 0.780, P = 0.01). Turnover intention was significantly and negatively correlated with age (r = −0.467, P = 0.01); turnover intention was significantly and strongly negatively correlated with experience (r = −0.564, P = 0.01); and turnover intention was significantly and strongly negatively correlated with satisfaction with salary (r = −0.689, P = 0.01).
Factors related to workplace stress Overcrowding or cramped work areas represented the highest frequency (n = 75, 29.6%) among the responses, while unclear job responsibilities represented the lowest frequency (n = 26, 10.3%). These results are included in Table 2. For acute male units, overcrowding or cramped work areas represented the highest frequency (n = 19), while both risk of violence and abuse from patients or service users and unclear job responsibilities represented the
TABLE 2: Frequency of responses: Factors related to workplace stress Unit environmental factors
n
Percentage (%)
Insufficient time Lack of control Risk of violence Unclear job responsibility Overcrowding
69 53 30 26 75
27.3 20.9 11.9 10.3 29.6
n = 253 (participants could respond to one or more factors).
lowest frequency (n = 6) for both. For long-term male units, overcrowding or cramped work areas represented the highest frequency (n = 26), while risk of violence and abuse from patients or service represented the lowest frequency, with zero responses. For acute female units, lack of control over work represented the highest frequency (n = 24), while unclear job responsibilities represented the lowest frequency (n = 3). For long-term female units, overcrowding or cramped work areas represented the highest frequency (n = 20), while risk of violence and abuse from patients or service users represented the lowest frequency (n = 4). These results are included in Table 3. In summary, the results of this study revealed a statistically-significant relationship between job satisfaction and turnover intention. The relationship between the two main variables was found to be significant, with a very strong negative relationship. Age, nursing experience, and satisfaction with salary were found to have a significant positive relationship with job satisfaction, but they had a significant negative relationship with turnover intention. Female nurses, married nurses, nurses with an associate nursing degree showed higher job satisfaction than male nurses, single nurses, and nurses with a bachelor nursing degree. Male nurses, single nurses, and nurses with a bachelor nursing degree showed higher turnover intention than female nurses, married nurses, and nurses with an associate nursing degree. Nurses in acute female units showed the highest level of job satisfaction in comparison to other psychiatric units, with nurses in acute male unit showing the lowest. Nurses in acute male units showed the highest level of turnover intention, and nurses in longterm female units showed the lowest. Overcrowding or cramped work areas represented the greatest concern of the nurses on the acute male, longterm male, and long-term female units. Lack of control over their work represented the greatest concern of the nurses on the acute female unit.
DISCUSSION This is the first study that has examined job satisfaction and turnover intentions among Jordanian nurses in
TABLE 3: Factors related to workplace stress by type of unit on which nurses worked Work setting Acute male unit Long-term male unit Acute female unit Long-term female unit
Insufficient time
Lack of control
Risk of violence
Unclear responsibilities
Overcrowding
17 21 12 19
15 3 24 11
6
6 4 3 13
19 26 10 20
20 4
© 2014 Australian College of Mental Health Nurses Inc.
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psychiatric units. Consistent with the literature, job satisfaction was found to be negatively related to turnover intention. The findings are also consistent with those reported in other countries, including Lebanon (El-Jardali et al. 2009), the USA (Applebaum et al. 2010), China (Cai & Zhou 2009; Liu et al. 2011), Japan (Kudo et al. 2006), and Turkey (Gok 2011). Previous research has revealed that job satisfaction is consistently significantly and negatively related to intention to leave (Applebaum et al. 2010; Cai & Zhou 2009; El-Jardali et al. 2009; Gok 2011; Kudo et al. 2006; Liu et al. 2011; Tsai & Wu 2010). The findings of the present study suggest that personal characteristics have important influences on nurses’ job satisfaction and turnover intention. The positive relationship between age, nursing experience, and salary and job satisfaction found in this study is consistent with, and supported by, the literature. Increased job satisfaction with age could be attributed to the fact that the expectations and goals become more realistic as people mature. Individuals might view their work life differently in relation to other aspects of their personal and professional lives. Also, age and years of work experience are related variables, as younger nurses who have less work experience are more dissatisfied with their accomplishments, professional support, workload, the opportunity to continue their education, and their pay and prospects for promotion (Torkelson & Seed 2011). The findings of higher job satisfaction among female nurses and married nurses, and lower job satisfaction among male nurses and single nurses, are consistent with prior research (Cimete et al. 2003; Torkelson & Seed 2011; Yaktin et al. 2003). Regarding the relationship between participants’ age and turnover intention, the findings of this study are consistent with those reported in other studies; older nurses had lower turnover intention compared with their younger counterparts (Hayes et al. 2006; McNeese-Smith & Servellen 2000; Takase et al. 2009). The findings of the present study are consistent with the study of Maslach et al. (2001), who reported that male nurses have higher turnover intention than female nurses. In terms of marital status, the results of that study found that single nurses, especially men, are more exposed to burnout than married individuals, which is consistent with the literature (Maslach et al. 2001). Level of education is believed to impact turnover intention, in that more highly-educated individuals are more likely to quit, seeking career advancement or considering alternative employment opportunities, especially if there are limited opportunities in their current organization (Yin & Yang 2002). This is consistent with the © 2014 Australian College of Mental Health Nurses Inc.
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present study, which found that nurses with a bachelor degree in nursing had a higher level of turnover intention than nurses with an associate nursing degree. Concerning the relationship between participants’ experience and turnover intention, it has been shown that new graduate nurses have a higher turnover rate within the first year of practice (Halfer & Graf 2006). These findings are consistent with the findings of the present study, as participants’ experience was found to be negatively related to turnover intention. The relationship between working shift and turnover intention was in contrast to the results of Letvak and Buck (2008), who reported that higher job stress and turnover intention scores were associated with working the day shift, no significant relationship was found between working shift and turnover intention in the present study. The findings of the present study indicate that overcrowding or cramped work areas represent the greatest concern of the nurses on the acute male, long-term male, and long-term female units in this study. Much of the nurse turnover research explores how turnover behaviour is influenced by organizational characteristics associated with workload and work stress. Although continued recruitment of new nurses and improved compensation might help offset nurse shortages in the short term, researchers have suggested that administrative interventions to improve quality of work life are more effective long-term strategies to reduce turnover (Shields & Ward 2001). The findings of this study show that lack of control and risk of violence are concerns that nurses in different psychiatric units have, and represent the main issue and concern of nurses on the acute female unit. This result is consistent with that of Erdos and Hughes (2001), who found that staff members who spend the most time with psychiatric patients are at greatest risk of experiencing an assault, and those at most risk were mental health nursing staff. In another study of mental health staff, nurses and advanced practice nurses reported the highest prevalence of violence against them (Privitera et al. 2005).
Limitations The sample was limited to nurses employed in the government psychiatric hospital in Jordan, and thus the findings are relevant to this sample only. No conclusions can be made regarding nurses in Jordan who work in private psychiatric hospitals.
Implications This is the first study to address the relationship between job satisfaction and turnover intention among Jordanian
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nurses in psychiatric units. The study results should be of concern to nursing administrators and healthcare policy makers in Jordan. The findings of this study show that job satisfaction is related to all categories of nurse demographic characteristics. Thus, during planning and training, administrators should recognize that dissatisfaction is not a problem for only certain categories of nurses.
Recommendations One research recommendation is to compare job satisfaction and turnover intention among nurses from different Jordanian psychiatric hospitals from different healthcare sectors (e.g. public and private). Studies comparing job satisfaction and turnover intention from psychiatric nurses in different countries are also recommended. Violence and stress in the workplace is a pressing concern for nurses in all settings, and for psychiatric nurses in particular (Privitera et al. 2005). A better understanding of factors influencing nurses’ stress and job satisfaction in mental health nursing might allow identification of strategies to improve working conditions for these nurses, with resulting benefits for the quality of care provided. The findings from the present study show that lack of control and risk of violence are concerns of psychiatric nurses in Jordan, and represent the main issue and concern of nurses who work on the acute female unit. It is important for the Ministry of Health, in coordination with the administration board of the NMHC in Jordan, to establish and maintain safe work environments; education and training programmes about risk management and prevention; stricter laws and mandatory regulations enforcing safe work practices; and a comprehensive programme for the prevention, reporting, and management of all types of workplace violence.
Conclusion The findings of the present study mirror previous findings in the literature regarding the negative relationship between job satisfaction and turnover intention. The findings provide new information about Jordanian nurses who work in government hospital psychiatric services.
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International Journal of Mental Health Nursing (2014) 23, 460–467
doi: 10.1111/inm.12070
Feature Article
Job satisfaction and turnover intention among Jordanian nurses in psychiatric units Faris Alsaraireh,1 Mary T. Quinn Griffin,2 Scott R. Ziehm3 and Joyce J. Fitzpatrick2 1
Department of Community and Psychiatric/Mental Health Nursing, Mutah University, Mutah, Jordan, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio and 3School of Nursing and Dental Hygiene, University of Hawai’i at Manoa, Honolulu, Hawai’i, USA 2
ABSTRACT: Psychiatric nursing has been identified as a stressful occupation, and this stress could affect individuals’ health, well-being, and job satisfaction. The stress of nurses might also affect the organization in terms of absenteeism and quality of care. The purpose of this study was to examine the relationship between job satisfaction and turnover intention among Jordanian nurses in the psychiatric units of the Jordanian National Mental Health Center. A descriptive, correlational, crosssectional design was used. Nurses were asked to complete a demographic data sheet and questionnaires regarding job satisfaction and turnover intention. Of the 179 questionnaires distributed, 154 were completed, with an 86% response rate. The results revealed a statistically-significant negative relationship between job satisfaction and turnover intention. The findings of the study are consistent with previous research regarding the negative relationship between job satisfaction and turnover intention. The findings provide new information about Jordanian nurses who work in government hospital psychiatric services. KEY WORDS: job satisfaction, Jordon, nursing, psychiatric nurse, turnover intention.
INTRODUCTION Nurses constitute the largest group of healthcare professionals in Jordan. In psychiatric units, nurses are responsible for providing a safe and appropriate environment and maintaining a therapeutic environment for psychiatric patients. Although the past decade witnessed significant landmarks in capacity building in nursing education and service, as well as in the improvement of nurses’ image and status, many issues remain for nurses in Jordan, especially those who work in government psychiatric hospitals.
Correspondence: Joyce J. Fitzpatrick, Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA. Email: [email protected] Faris Alsaraireh, DNP, PMHNP, RN. Mary T. Quinn Griffin, PhD, RN, FAAN. Scott R. Ziehm, DNP, RN. Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN. Accepted March 2014.
© 2014 Australian College of Mental Health Nurses Inc.
Psychiatric nursing has been identified as a stressful occupation, and this stress could affect individuals’ health, well-being, and job satisfaction. The stress of nurses might also affect their organizations in terms of absenteeism and turnover, which in turn affects the quality of patient care (Edward et al. 2000). Researchers have identified a variety of stressors in psychiatric nursing, including low salary, heavy workload, lack of positive feedback, lack of resources, and poor work environments (Paris & Hoge 2010). The stigma linked to this specialty, the challenging interactions with other mental health professionals, and demanding relationships with patients have also been identified as stressors (Paris & Hoge 2010). In psychiatric hospitals, work is difficult, and there is often burnout among staff (Happell et al. 2003) and high turnover (Sumner & Townsend-Rocchiccioli 2003). Aronson (2005) found that nurses who work in psychiatric hospitals had lower job satisfaction than other workers in the hospital. Ito et al. (2001) examined psychiatric nurses’ intention to leave their jobs, and found that 44.3% of
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psychiatric nurses in their sample intended to leave, and those who intended to leave were significantly younger than those who did not intend to leave.
Background The literature review included studies of nurses’ job satisfaction, intent to leave current position, and intent to leave the profession, which were retrieved from multiple sources from the period 2000 to 2013. The search terms included nurses, job satisfaction, intent to leave, mental health, and Jordan, in various combinations. Factors that might affect job satisfaction and turnover intention can be divided into personal characteristics (age, sex, marital status, and experience) and organizational factors. Age has been positively correlated with job satisfaction among nurses in Kuwaiti (Shah et al. 2004); the USA (Klaus et al. 2012), and Korea (Hwang et al. 2009). Sex has also been linked to job satisfaction, with men in nursing having lower job satisfaction (Torkelson & Seed 2011). In studies of Lebanese and Turkish nurses, individuals who were single had lower job satisfaction than those who were married (Cimete et al. 2003; Yaktin et al. 2003). In Saudi Arabia, researchers identified a positive relationship between years of experience, organizational commitment, and job satisfaction (Al-Ahmadi 2009). In a study of Chinese nurses, Wang et al. (2011) examined the relationship between job satisfaction, occupational commitment, and intent to stay. The findings revealed that job satisfaction and occupational commitment were positively correlated with intent to stay. Promotions and age also positively correlated with job satisfaction, occupational commitment, and intent to stay. The negative relationship between job satisfaction and turnover intention of nurses has been supported in previous research in Japan (Kudo et al. 2006), China (Cai & Zhou 2009; Liu et al. 2011), Lebanon (El-Jardali et al. 2009), Taiwan (Tsai & Wu 2010), Turkey (Gok 2011), and the USA (Applebaum et al. 2010). There are few studies among nurses working in psychiatric hospitals. In a study of European psychiatric nurses, Ward and Cowman (2007) found that job satisfaction was related to organizational factors, including work location and other organizational factors within the work environment. Aronson (2005) studied nurses working in private psychiatric hospitals in the USA and found that, compared to other mental health workers, registered nurses had lower job satisfaction. Ito et al. (2001) examined job satisfaction and intent to leave among psychiatric nurses in 27 hospitals in Japan, and found that 44% of nurses intended to leave their jobs, a result they linked to © 2014 Australian College of Mental Health Nurses Inc.
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job dissatisfaction; 37.7% were dissatisfied with their jobs (Ito et al. 2001). Aims: Although there is considerable research on nurses in a variety of settings, including studies of job satisfaction, personal and organizational variables, and job satisfaction and turnover intention, there is a paucity of research on psychiatric nurses. Further, there is no prior research on nurses in Jordan, and in particular, nurses working in psychiatric units. The present study was designed to fill a gap in the understanding of psychiatric nursing in Jordan and provide information for future human resource planning. The research question for the study was: What is the relationship between job satisfaction and turnover intention among Jordanian nurses working in psychiatric units?
RESEARCH METHODS Design and setting This study was quantitative, with a descriptive, crosssectional design. The setting was a governmental hospital for mental health in Jordan. The hospital has 250 beds, 200 nurses, and more than 30 outpatient clinics.
Sample The potential sample included nurses working in the main hospital of the National Mental Health Center (NMHC). Nurses working in the outpatient clinics and nurses with administrative responsibilities were excluded. Only nurses who had been working at the NMHC for at least 4 months were invited to participate. Of the 200 nurses employed in the setting, 179 met the inclusion criteria.
Procedure The study was approved by the hospital and the Jordanian Ministry of Health. Institutional Review Board approval was granted. The director of each psychiatric unit was informed of the purpose of the study before data collection commenced. The nurses were informed of the purpose and procedures of the study, and provisions to maintain confidentially. The participants were also assured that their non-participation or withdrawal from the study would not affect their current or future relationship with their employer. Although Arabic is the native language in Jordan, English is the official language for hospital documentation and for teaching in nursing schools. Therefore, English versions of the questionnaires were used. No identifiable information about the nurses was collected. Completed questionnaires were dropped into a locked box located on each unit.
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Instruments A background data sheet contained information to describe characteristics of the sample, including age, sex, marital status, shift worked, years of experience in nursing, level of education, type of units or wards, and salary. A question was added to evaluate factors related to workplace stress. Possible responses were: (i) insufficient time to do your job; (ii) lack of control over work; (iii) risk of violence and abuse from patients or service users; (iv) unclear job responsibilities; and (v) overcrowding or cramped work areas. The Minnesota Job Satisfaction Questionnaire (MSQ) – short form, developed by Weiss and colleagues, was used to measure nurses’ job satisfaction (Weiss et al. 1967). The MSQ is a self-report instrument, through which respondents indicate how satisfied they are with various aspects of their present job. The 20 questions are ranked on a fivepoint scale; scores range from 20 to 100, with higher scores indicating higher job satisfaction. The MSQ – short from has a Cronbach’s alpha of 0.91 (Ben-Bakr et al. 1994). The validity and reliability of the MSQ – short from has been well documented (Weiss et al. 1967). In the present study, Cronbach’s alpha was 0.91. To measure nurses’ turnover intention, the modified version of the Withdrawal Cognition Scale (WCS) (Takase et al. 2005), a five-item, self-report instrument, was used. The original scale was developed by Mowday et al. (1984) to measure the three factors of turnover (thinking of quitting, searching for new jobs, and intention to quit). Modifications made by Takase et al. (2005) included measuring two different occasions of nurses’ turnover intention: (i) leaving the organization and looking for a new nursing job; and (ii) leaving nursing as a profession. The scale is a six-point scale, with responses ranging from 1 to 6; the possible range of scores is 6–30, with higher scores indicating strong turnover intention. The WCS was found to have a reliability score of 0.79; construct validity was previously established (Takase et al. 2005). In the present study Cronbach’s alpha was 0.76. Job satisfaction was operationally defined as the total score on the MSQ – short from. Intent to leave current position was operationally defined by the total score on the WCS.
Data analysis The Statistical Package for the Social Sciences (version 17; SPSS, Chicago, IL, USA) was used. Frequency distributions were used to describe the percentage of nurses for each categorical demographic variable (sex, marital status, shift worked, level of education, type of units or wards), while means and standard deviations were used to
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describe continuous variables (age, experience in years, and satisfaction with salary). For the research question, Pearson correlation analysis was calculated. In addition, Pearson correlation analyses were used to test the relationship between the participants’ continuous demographic characteristics and the main study variables (job satisfaction and turnover intention). To test the relationship between the participants’ categorical demographic characteristics and the main study variables (job satisfaction and turnover intention), the independent-sample t-test were used. One-way ANOVA was used to test the relationship and the difference between the four participant work settings and the main study variables (job satisfaction and turnover intention).
RESULTS Sample characteristics A total of 154 nurses completed the questionnaires, indicated an 86% response rate. The majority of the participants were married women with an associate degree in nursing. The majority of the nurses worked day shift, and all of the four units were represented in the sample. Detailed sample characteristics are included in Table 1.
Relationship between job satisfaction and turnover intention among Jordanian nurses in psychiatric units The mean job satisfaction score was 60.13 (standard deviation (SD) = 10.81), with a range of 40–84. The mean turnover intention score was 10.87 (SD = 3.30), with a range of 6–18. The Pearson correlation between job TABLE 1:
Sample characteristics (n = 154)
Demographic characteristics Sex Male Female Marital status Single Married Level of education Associate degree Bachelor degree Work setting Acute male unit Long-term male unit Acute female unit Long-term female unit Shift worked Day Evening
Frequency
Percentage (%)
70 84
45.5 54.5
64 90
41.6 58.4
126 28
81.8 18.2
38 34 39 43
24.7 22.1 25.3 27.9
118 36
76.6 23.4
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satisfaction and turnover intention was r = −0.796 (P < 0.01). Job satisfaction was very strongly negatively correlated to turnover intention. Additional analyses were undertaken to determine relationships among demographic variables and the two main study variables: job satisfaction and turnover intention. Independent-sample t-tests were conducted to determine differences in job satisfaction and turnover intention based on sex. The results showed that female participants (mean = 64.07, SD = 8.88) scored significantly higher than their male participants ((mean = 55.40, SD = 11.08), t (152) = −5.39, P = 0.000) on job satisfaction. Male participants (mean = 12.11, SD = 3.31) scored significantly higher than the female participants ((mean = 9.83, SD = 2.92), t (152) = 4.54, P = 0.000) on turnover intention. Between-subjects independent-sample t-tests were conducted to determine differences in job satisfaction and turnover intention based on marital status. The results showed a significant difference in job satisfaction based on marital status; married participants (mean = 63.10, SD = 10.41) scored significantly higher than single participants ((mean = 55.95, SD = 10.03), t (152) = −4.263, P = 0.000). There was also a significant difference in turnover intention; single participants (mean = 11.81, SD = 3.23) scored significantly higher than married participants ((mean = 10.20, SD = 3.20), t (152) = 3.072, P = 0.003). Between-subjects independent-sample t-tests were conducted to determine the effect of participants’ levels of education on job satisfaction. The results showed that participants with an associate degree (mean = 61.45, SD = 10.60) scored significantly higher than participants with a bachelor degree ((mean = 54.18, SD = 9.85), t (152) = 3.324, P = 0.001). A betweensubjects independent-sample t-test was conducted to determine the effect of participants’ levels of education on turnover intention. The results showed that participants with a bachelor degree (mean = 13.25, SD = 3.19) scored significantly higher than participants with an associate degree ((mean = 10.34, SD = 3.09), t (152) = −4.477, P = 0.000). A between-subjects independent-sample t-test was conducted to determine the effect of shift on job satisfaction. The results showed that there was no statisticallysignificant difference between two conditions (day shift and evening shift, t (152) = 1.551, P = 0.123). A betweensubjects independent-sample t-test was conducted to determine the effect of shift on turnover intention. The results showed that there was no statistically-significant difference between two conditions (day shift and evening shift, t (152) = −1.963, P = 0.052). © 2014 Australian College of Mental Health Nurses Inc.
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One-way ANOVA was conducted to determine the difference between the respondents from different units regarding job satisfaction. Acute female units showed the highest score for job satisfaction (mean = 64.95, SD = 8.95), while acute male units showed the lowest score (mean = 55.18, SD = 10.61). Long-term female and male units were in the middle (mean = 63.51, SD = 8.85 and mean = 55.85, SD = 11.62, respectively). There was a significant difference in job satisfaction between acute male and female units (P = 0.001); acute female units showed higher job satisfaction. There was also a significant difference in job satisfaction between acute male and long-term female units, (P = 0.004); long-term female units showed higher job satisfaction. There was no significant difference in job satisfaction between acute male and long-term male units. A significant difference was found for job satisfaction between long-term male and acute female units (P = 0.002); acute female units showed higher job satisfaction. Also, there was a significant difference in job satisfaction between long-term male and female units (P = 0.013); long-term female units show higher job satisfaction. There was no significant difference in job satisfaction between acute female and longterm female units. One-way ANOVA was conducted to determine the difference between the respondents from different work units regarding turnover intention. Acute male units showed the highest score for turnover intention (mean = 12.16, SD = 3.42), while long-term female units showed the lowest score (mean = 9.77, SD = 2.65). There was a significant difference in turnover intention between acute male and female units (mean = 12.16, SD = 3.42 and mean = 9.85, SD = 3.16, respectively; P = 0.017); acute male units showed higher turnover intention. There was also a significant difference in turnover intention between acute male and long-term female units (mean = 12.16, SD = 3.42, and mean = 9.77, SD = 2.65, respectively; P = 0.010); acute male units showed higher turnover intention. There was no significant difference in turnover intention between acute male and long-term male units (mean = 12.16, SD = 3.42 and mean = 12.00, SD = 3.28, respectively). There was a significant difference in turnover intention between the long-term male and acute female units (mean = 12.00, SD = 3.28 and mean = 9.85, SD = 3.16, respectively; P = 0.038); longterm male units showed higher turnover intention. There was also a significant difference in turnover intention between the long-term male and female units (mean = 12.00, SD = 3.28 and mean = 9.77, SD = 2.65, respectively; P = 0.024); long-term male units showed higher turnover intention. There was no significant
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difference in turnover intention between acute female and long-term female units (mean = 9.85, SD = 3.16 and mean = 9.77, SD = 2.65), respectively.
Relationship between respondents’ continuous demographic characteristics and job satisfaction and turnover intention Pearson correlations were used to test relationships between respondents’ age, experience, satisfaction with salary, and job satisfaction, and also with these same variables and turnover intention. Job satisfaction was significantly and strongly positively correlated with age (r = 0.508, P = 0.01); job satisfaction was significantly and strongly positively correlated with experience (r = 0.566, P = 0.01) and very strongly positively correlated with satisfaction with salary (r = 0.780, P = 0.01). Turnover intention was significantly and negatively correlated with age (r = −0.467, P = 0.01); turnover intention was significantly and strongly negatively correlated with experience (r = −0.564, P = 0.01); and turnover intention was significantly and strongly negatively correlated with satisfaction with salary (r = −0.689, P = 0.01).
Factors related to workplace stress Overcrowding or cramped work areas represented the highest frequency (n = 75, 29.6%) among the responses, while unclear job responsibilities represented the lowest frequency (n = 26, 10.3%). These results are included in Table 2. For acute male units, overcrowding or cramped work areas represented the highest frequency (n = 19), while both risk of violence and abuse from patients or service users and unclear job responsibilities represented the
TABLE 2: Frequency of responses: Factors related to workplace stress Unit environmental factors
n
Percentage (%)
Insufficient time Lack of control Risk of violence Unclear job responsibility Overcrowding
69 53 30 26 75
27.3 20.9 11.9 10.3 29.6
n = 253 (participants could respond to one or more factors).
lowest frequency (n = 6) for both. For long-term male units, overcrowding or cramped work areas represented the highest frequency (n = 26), while risk of violence and abuse from patients or service represented the lowest frequency, with zero responses. For acute female units, lack of control over work represented the highest frequency (n = 24), while unclear job responsibilities represented the lowest frequency (n = 3). For long-term female units, overcrowding or cramped work areas represented the highest frequency (n = 20), while risk of violence and abuse from patients or service users represented the lowest frequency (n = 4). These results are included in Table 3. In summary, the results of this study revealed a statistically-significant relationship between job satisfaction and turnover intention. The relationship between the two main variables was found to be significant, with a very strong negative relationship. Age, nursing experience, and satisfaction with salary were found to have a significant positive relationship with job satisfaction, but they had a significant negative relationship with turnover intention. Female nurses, married nurses, nurses with an associate nursing degree showed higher job satisfaction than male nurses, single nurses, and nurses with a bachelor nursing degree. Male nurses, single nurses, and nurses with a bachelor nursing degree showed higher turnover intention than female nurses, married nurses, and nurses with an associate nursing degree. Nurses in acute female units showed the highest level of job satisfaction in comparison to other psychiatric units, with nurses in acute male unit showing the lowest. Nurses in acute male units showed the highest level of turnover intention, and nurses in longterm female units showed the lowest. Overcrowding or cramped work areas represented the greatest concern of the nurses on the acute male, longterm male, and long-term female units. Lack of control over their work represented the greatest concern of the nurses on the acute female unit.
DISCUSSION This is the first study that has examined job satisfaction and turnover intentions among Jordanian nurses in
TABLE 3: Factors related to workplace stress by type of unit on which nurses worked Work setting Acute male unit Long-term male unit Acute female unit Long-term female unit
Insufficient time
Lack of control
Risk of violence
Unclear responsibilities
Overcrowding
17 21 12 19
15 3 24 11
6
6 4 3 13
19 26 10 20
20 4
© 2014 Australian College of Mental Health Nurses Inc.
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psychiatric units. Consistent with the literature, job satisfaction was found to be negatively related to turnover intention. The findings are also consistent with those reported in other countries, including Lebanon (El-Jardali et al. 2009), the USA (Applebaum et al. 2010), China (Cai & Zhou 2009; Liu et al. 2011), Japan (Kudo et al. 2006), and Turkey (Gok 2011). Previous research has revealed that job satisfaction is consistently significantly and negatively related to intention to leave (Applebaum et al. 2010; Cai & Zhou 2009; El-Jardali et al. 2009; Gok 2011; Kudo et al. 2006; Liu et al. 2011; Tsai & Wu 2010). The findings of the present study suggest that personal characteristics have important influences on nurses’ job satisfaction and turnover intention. The positive relationship between age, nursing experience, and salary and job satisfaction found in this study is consistent with, and supported by, the literature. Increased job satisfaction with age could be attributed to the fact that the expectations and goals become more realistic as people mature. Individuals might view their work life differently in relation to other aspects of their personal and professional lives. Also, age and years of work experience are related variables, as younger nurses who have less work experience are more dissatisfied with their accomplishments, professional support, workload, the opportunity to continue their education, and their pay and prospects for promotion (Torkelson & Seed 2011). The findings of higher job satisfaction among female nurses and married nurses, and lower job satisfaction among male nurses and single nurses, are consistent with prior research (Cimete et al. 2003; Torkelson & Seed 2011; Yaktin et al. 2003). Regarding the relationship between participants’ age and turnover intention, the findings of this study are consistent with those reported in other studies; older nurses had lower turnover intention compared with their younger counterparts (Hayes et al. 2006; McNeese-Smith & Servellen 2000; Takase et al. 2009). The findings of the present study are consistent with the study of Maslach et al. (2001), who reported that male nurses have higher turnover intention than female nurses. In terms of marital status, the results of that study found that single nurses, especially men, are more exposed to burnout than married individuals, which is consistent with the literature (Maslach et al. 2001). Level of education is believed to impact turnover intention, in that more highly-educated individuals are more likely to quit, seeking career advancement or considering alternative employment opportunities, especially if there are limited opportunities in their current organization (Yin & Yang 2002). This is consistent with the © 2014 Australian College of Mental Health Nurses Inc.
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present study, which found that nurses with a bachelor degree in nursing had a higher level of turnover intention than nurses with an associate nursing degree. Concerning the relationship between participants’ experience and turnover intention, it has been shown that new graduate nurses have a higher turnover rate within the first year of practice (Halfer & Graf 2006). These findings are consistent with the findings of the present study, as participants’ experience was found to be negatively related to turnover intention. The relationship between working shift and turnover intention was in contrast to the results of Letvak and Buck (2008), who reported that higher job stress and turnover intention scores were associated with working the day shift, no significant relationship was found between working shift and turnover intention in the present study. The findings of the present study indicate that overcrowding or cramped work areas represent the greatest concern of the nurses on the acute male, long-term male, and long-term female units in this study. Much of the nurse turnover research explores how turnover behaviour is influenced by organizational characteristics associated with workload and work stress. Although continued recruitment of new nurses and improved compensation might help offset nurse shortages in the short term, researchers have suggested that administrative interventions to improve quality of work life are more effective long-term strategies to reduce turnover (Shields & Ward 2001). The findings of this study show that lack of control and risk of violence are concerns that nurses in different psychiatric units have, and represent the main issue and concern of nurses on the acute female unit. This result is consistent with that of Erdos and Hughes (2001), who found that staff members who spend the most time with psychiatric patients are at greatest risk of experiencing an assault, and those at most risk were mental health nursing staff. In another study of mental health staff, nurses and advanced practice nurses reported the highest prevalence of violence against them (Privitera et al. 2005).
Limitations The sample was limited to nurses employed in the government psychiatric hospital in Jordan, and thus the findings are relevant to this sample only. No conclusions can be made regarding nurses in Jordan who work in private psychiatric hospitals.
Implications This is the first study to address the relationship between job satisfaction and turnover intention among Jordanian
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nurses in psychiatric units. The study results should be of concern to nursing administrators and healthcare policy makers in Jordan. The findings of this study show that job satisfaction is related to all categories of nurse demographic characteristics. Thus, during planning and training, administrators should recognize that dissatisfaction is not a problem for only certain categories of nurses.
Recommendations One research recommendation is to compare job satisfaction and turnover intention among nurses from different Jordanian psychiatric hospitals from different healthcare sectors (e.g. public and private). Studies comparing job satisfaction and turnover intention from psychiatric nurses in different countries are also recommended. Violence and stress in the workplace is a pressing concern for nurses in all settings, and for psychiatric nurses in particular (Privitera et al. 2005). A better understanding of factors influencing nurses’ stress and job satisfaction in mental health nursing might allow identification of strategies to improve working conditions for these nurses, with resulting benefits for the quality of care provided. The findings from the present study show that lack of control and risk of violence are concerns of psychiatric nurses in Jordan, and represent the main issue and concern of nurses who work on the acute female unit. It is important for the Ministry of Health, in coordination with the administration board of the NMHC in Jordan, to establish and maintain safe work environments; education and training programmes about risk management and prevention; stricter laws and mandatory regulations enforcing safe work practices; and a comprehensive programme for the prevention, reporting, and management of all types of workplace violence.
Conclusion The findings of the present study mirror previous findings in the literature regarding the negative relationship between job satisfaction and turnover intention. The findings provide new information about Jordanian nurses who work in government hospital psychiatric services.
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