RESEARCH doi: 10.1111/nicc.12083
Nurses well-being in intensive care units: study of factors promoting team commitment Maura Galletta, Igor Portoghese, Rosa C Coppola, Gabriele Finco and Marcello Campagna ABSTRACT Background: Intensive care units (ICUs) are challenging work environments because of the critical condition of patients, and ICU nurses frequently lament low job satisfaction and high staff turnover. Nevertheless, organizational and work characteristics, and the quality of relationships with staff can help to maintain nurses’ enthusiasm and increase job satisfaction. Aim: The aim of this study was to analyse how nursing work environment factors affect identification and commitment among ICU nurses. Design: A cross-sectional study was carried out in 12 ICUs from four Italian urban hospitals. Method: A total of 222 nurses participated and completed a self-reported questionnaire. Results and conclusion: Results show that nursing work characteristics are directly related to team commitment, and that the nursing work characteristics and team commitment relationship was mediated by both perceived supervisor support and job satisfaction. Relevance to clinical practice: Our findings may concretely contribute to literature and offer additional suggestions to improve nurses’ work conditions and patient health in ICUs. Key words: Intensive care unit • Mediating role • Nurses • Nursing work characteristics • Team commitment
INTRODUCTION Intensive care units (ICUs) can have very difficult work environments due to the daily challenges care staff have to face with critically ill patients. These challenges, which can generate stress, include much responsibility, frequent change of patients, changes in technology, and continual exposure to pain, suffering and death (Hurst and Koplin-Baucum, 2005; Li and Lambert, 2008). In fact, compared with other hospital units, ICU nurses are exposed to low job satisfaction and consequently to high staff turnover (e.g. Braithwaite, 2008; Zhang Authors: M Galletta, PhD, MSc, Research fellow, Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Italy; I Portoghese, PhD, MSc, Research fellow, Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Italy; RC Coppola, MD, MSc, Full Professor, Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Italy; G Finco, MD, MSc, Full Professor, Anesthesia and Intensive Care Department, Pain Therapy Service, University of Cagliari, Italy; M Campagna, MD, MSc, Research fellow, Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Italy Address for correspondence: I Portoghese, Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, SS554 bivio per Sestu, Monserrato, Cagliari, Italy E-mail: [email protected]
146
et al., 2013). Nevertheless, a previous study has shown that nurses can thrive in ICUs and maintain enthusiasm for their work (Burgess et al., 2010). This might depend on both organizational and work characteristics, as well as on daily work relationships which can contribute to the quality of working life (QWL). In health care organizations, QWL factors (e.g. job autonomy, quality of interpersonal relationships, worker involvement and satisfaction, and belief in supervisor support) have been recognized as affecting staff performance (e.g. Pot and Koningsveld, 2009; Sheel et al., 2012). This paper aims to examine how some aspects of work environment affects experiences of identification and commitment among ICU staff nurses.
BACKGROUND Improving nursing QWL is crucial for the wellbeing and effectiveness of an organization. Poor QWL leads to high voluntary nursing turnover (Hayes et al., 2006). High staff turnover not only increases recruitment and training costs, but it can also be detrimental to the patient’s health, and compromise © 2014 British Association of Critical Care Nurses • Vol 21 No 3
Nurses well-being in ICUs
quality and continuity of care. Thus, good work environment conditions are important with regards to retention, productivity and adequacy of care. Several studies have demonstrated that among the factors affecting intention to leave, organizational commitment is a significant direct predictor (e.g. Wasti, 2003; Wagner, 2007; Liou and Cheng, 2010). Organizational commitment is defined as a force linking an individual to his/her organization (Allen and Meyer, 1990). According to Mowday et al. (1982), organizational commitment is the extent to which nurses identify with, and feel involved in their work units. Commitment is fundamental to develop a good individual-organization relationship. In fact, studies have shown that committed employees are more satisfied (Khowaja et al., 2005) and afford high value to their work. In particular, when the binding force is of the affective type, employees experience high identification and involvement with organizational goals, thus desire to remain part of the organization (Thompson and Prottas, 2005; Gaan, 2008). Furthermore, it has been shown that the more nurses felt affectively committed to their unit, the lower ICU’s standardized mortality ratios were (Reis et al., 1997; Le Blanc et al., 2010). Considering that the aim of this study was to analyse a specific work context in health care, such as an ICU, our primary focus was on team commitment, defined as the psychological attachment of staff towards their team or unit. Thus, the target of the attachment is the team rather than the larger organization. Literature concerning organizational commitment has profusely shown the important role of commitment in preventing intent to leave and in promoting positive behaviour (e.g. Liou and Cheng, 2010; Bakhshi et al., 2011). It has also shown which factors facilitate the development of affective commitment in a work environment. Specifically, some recent studies have reported both working and organizational factors, as well as the quality of work relationships, as being the principal factors that increase affective commitment, thus reducing turnover risk (e.g. Hayes et al., 2012; Galletta et al., 2013). Nevertheless, recent studies analysing the role of these factors in ICUs, which we believe play a pivotal role also in critical care environments, are non-existent.
between physicians and nurses is important to improve clinical outcome of patient care (Taylor, 1996; Baggs et al., 1999). Studies have shown that physicians often perceive themselves as the main decision-makers when it comes to the applicability or modification of treatment plans. Hence, physicians make decisions without nursing consultation, thus neglecting and often underestimating nurses’ competence (e.g. Coombs, 2003). In this sense, compared with physicians, ICUs nurses often perceive lower levels of collaboration and are less satisfied (e.g. Thomas et al., 2003; Hamric and Blackhall, 2007). High collaborative communication between physicians and nurses increases nurses’ job satisfaction and affective commitment (e.g. Zangaro and Soeken, 2007; Galletta et al., 2013). Job autonomy is one of the most important predictors of nurses’ job satisfaction and organizational commitment (Kramer and Schmalenberg, 2003; Upenieks, 2003; Humphrey et al., 2007; Camerino and Mansano Sarquis, 2010). Job autonomy means freedom and discretion in scheduling work, making decisions and choosing procedures to perform work activities (Morgeson and Humphrey, 2006). A highly autonomous job allows employees to perceive work outcomes as dependent on their efforts. It has been reported that ICUs require high autonomy (Boumans and Landeweerd, 1994) due to the critical health condition of patients which often requires immediate interventions. Therefore, job autonomy can activate a crucial psychological state promoting important work outcomes such as job satisfaction and affective commitment (e.g. Iliopoulou and While, 2010; Galletta et al., 2011). Quality of working practice is fundamental to retaining a qualified workforce (Li et al., 2007). Studies have shown a positive relationship between work environment characteristics and affective commitment (Vanaki and Vagharseyyedin, 2009). Thus, it is reasonable to think that when employees perceive that their team is able to offer effective care to patients, as well as promote both autonomy and control over the practice, and support good nurse-physician relationships, they feel more attached to their unit and will not leave it (Laschinger et al., 2003).
Nursing work characteristics
Mediating factors linking nursing work characteristics to team commitment
ICUs are contexts in which collaboration between physicians and nurses is fundamental to the effective functioning of these units. In fact, ICUs are characterized by the need for interdependent teamwork (Stein-Parbury and Liaschenko, 2007). Therefore, the quality of collaborative practice and communication
In their meta-analysis, Zangaro and Soeken (2007) reported that characteristics of nursing practice such as job autonomy and nurse-physician collaboration are variables commonly identified in nursing studies as directly linked with job satisfaction and employees’ general well-being (Hinshaw et al., 1987; Wells et al.,
© 2014 British Association of Critical Care Nurses
147
Nurses well-being in ICUs
2002; Best and Thurston, 2004). Locke (1976) defined job satisfaction as a ‘pleasurable or positive emotional state resulting from the appraisal of one’s job or job experiences’ (p. 1304). Utriainen and Kynga (2009) in their systematic review on nurse’s job satisfaction showed that interpersonal relationships, such as relationships with other nurses and collaboration with medical staff, patient care and autonomy are fundamental predictors of job satisfaction (McNeese-Smith, 1999; Adams and Bond, 2000; Manojlovich, 2005). In turn, Mowday et al. (1982) suggested that job satisfaction is an important antecedent for organizational commitment. A strong positive relationship between job satisfaction and organizational commitment has been widely confirmed in literature (Price and Mueller, 1981; Mathieu and Zajac, 1990; Lok and Crawford, 2001; McNeese-Smith, 2001). In this sense, it is reasonable to suppose that nurses satisfied with their jobs show high levels of loyalty towards their units. Organizational commitment includes the assumption that workers obtain support from organization (Brown, 1996). Specifically, within the social exchange perspective (Blau, 1964), perceived organizational support (POS) has been defined as employees’ ‘beliefs concerning the extent to which the organization values their contributions and cares about their well-being’ (Eisenberger et al., 1986, p. 501). The relationship between organizational commitment and POS emerges from the induced felt obligation to reciprocate in employees (Gouldner, 1960). Particularly, in literature POS has been found to be a socio-emotional resource leading workers to experience affective commitment towards the organization (Rhoades et al., 2001; Meyer et al., 2002; Panaccio and Vandenberghe, 2009). Thus, affective commitment is a response to positive work experiences perceived as being offered by the organization (Meyer et al., 1998). A supervisor – in this context, the supervisor is the ICU nurse coordinator – represents a personification of the organization, because he/she is a person who directly works with the staff, evaluates their contribution and manages the reward systems (Galletta et al., 2011). Thus, we considered perceived supervisor support (PSS), in this study, as a variable affecting team commitment (Figure 1).
148
affects experiences of identification and commitment among ICU staff. On the basis of this proposal, we postulated the following hypotheses: • Hypothesis 1: Job autonomy, physician-nurse collaboration and perceived quality of practice are positively related to team affective commitment. • Hypotheses 2: Job satisfaction and supervisor support mediate the relationship between nursing work characteristics and team affective commitment.
METHODS Study design A cross-sectional survey with a self-reported questionnaire was carried out in order to understand factors related to organizational well-being in ICU.
Participants and setting A total of 12 ICUs were involved from four Italian urban hospitals. The participating ICUs had different sizes (average number of nurses 20, range 13–39) and specialties, including cardiac, cardiothoracic and neonatal units. The study used a convenience sample consisting of ICU staff nurses working in the four hospitals. To participate in the study, nurses had to work in ICU for at least 6 months and complete their orientation/training period.
Ethical consideration Consent to conduct the study in each hospital was obtained from the appropriate ethics committees of the Italian public health system. Formal permission to access the ICUs was obtained from the Health Director of each unit. After this formal approval, nurses were contacted and recruited. To ensure ethical clarity, nurses were informed about the nature and purpose of the study. The recruitment process was conducted by the researchers during a series of meetings with nurses and managers of each unit in order to explain the research aim. Oral consent was obtained from nurses before data collection, and informed consent to participate was assumed on receipt of the completed questionnaires.
RESEARCH AIM AND HYPOTHESES
Data collection methods and tools
Despite a plethora of studies on retention and organizational identification factors, a study that analyzes all these factors together as a whole model is lacking in ICU literature. Nurses play a major role in the care offered in ICUs because they are usually in very close contact with patients. Thus, the aim of this study was to examine how nursing work environment
A self-reported paper questionnaire based on validated scales derived from psycho-social literature was used to collect data. The questionnaire included six variables related to working life areas described below. Also, unit tenure was included as control variables as previous studies showed that tenure is a potential predictor of organizational commitment (Gambino, 2010). © 2014 British Association of Critical Care Nurses
Nurses well-being in ICUs
Independent variables
Dependent variable
Mediators
NURSING WORK CHARACTERISTICS -Work aspects (job autonomy) -Human relationship aspects (nurse-physician collaboration)
+ Path α
-Individual aspects (job satisfaction) -Perceived organizational aspects (supervisor support)
+ Path β
Team commitment
-Perceived quality of nursing practice Figure 1 Hypothesized model.
Nurses-physicians collaboration: Three high-loading items (loadings from 0·64 to 0·68) adapted from the Nursing Work Index-Revised (Aiken and Patrician, 2000) were used. Job autonomy: Nine items from the Work Design Questionnaire (WDQ) (Morgeson and Humphrey, 2006) were employed. Perceived quality of nursing practice: Three highloading items (loadings from 0·63 to 0·78) adapted from Nursing Work Index-Revised (NWI-R) (Aiken and Patrician, 2000) were used. Perceived supervisor support: Four high-loading items (loadings from 0·62 to 0·82) from Survey of Perceived Organizational Support (SPOS) (Eisenberger et al., 1986) were adapted by changing the word ‘organization’ to ‘supervisor’. The supervisor was the ICU nurse coordinator. Job satisfaction: The Questionnaire of Organizational Satisfaction (QSO) (Cortese, 2001) was used to assess job satisfaction. Four high-loading items (loadings from 0·62 to 0·78) referring to satisfaction with job activities were used. Team affective commitment: Four high-loading items (loadings from 0·52 to 0·85) from the Organizational Commitment Questionnaire developed by Allen and Meyer (1990) were used. Sample items of the questionnaire are presented in Table 1. The translation-back-translation procedure (Brislin, 1980) was adopted because not all the measures used were validated in Italian. Two bilingual experts in nursing translated the questionnaire from English into Italian, then back-translated into English. The pilot of the questionnaire was conducted by involving 32 nurses in order to ensure further validity of the whole instrument. Minimal improvements were made to the wording for improving understandability of the instrument. © 2014 British Association of Critical Care Nurses
The questionnaires were administered to the nurses through the researchers during a presentation meeting. A written description attached to the questionnaire regarding the study procedure was provided in particular for nurses who could not attend the meeting (e.g. nurses who were off work due to illness or who had the night shift). Nurse supervisors of each ICU assured that completed questionnaires were put in locked boxes. Participation to the study was voluntary and participants completed the anonymous questionnaire during working hours. Nurses were given 3 weeks to complete and return the questionnaire. The time required to complete the questionnaire was about 15 min.
Data analysis Statistical analyses were carried out using PASW Statistics 18·0 and AMOS 16·0 (Chicago, IL, USA, Arbuckle, 2007). Both Exploratory and confirmatory factor analyses were carried out for the construct measurement, and reliability analysis of them was performed using Cronbach’s α measure (α). Correlation analysis between variables was performed by using Pearson coefficient (r). The relationships between variables were examined via hierarchical regression analyses. In order to support hypothesis 1, linear hierarchical regression analysis was performed by including organizational tenure in the first step as a control variable. In fact, tenure was found to be a strong predictor of organizational commitment (Cohen, 1993; English et al., 2010). In the second step, independent variables (job autonomy, nurse-physician collaboration and quality of practice) were introduced in the regression equation. To verify hypothesis 2, the hypothetical mediating variables (job satisfaction and PSS) were entered in the third step of the regression equation. 149
Nurses well-being in ICUs
Table 1 Description of the items used∗ Variable (scale)
N item
Sample item
Nurses-physicians collaboration
3
Physicians and nurses have good working relationships.
Job autonomy
9
The job allows me to plan how I do my work (work scheduling autonomy). The job provides me with significant autonomy in making decisions (decision-making autonomy). The job gives me considerable opportunity for independence and freedom in how I do the work (work methods autonomy).
Perceived quality of nursing practice
3
Perceived supervisor support
4
My supervisor really cares about my well-being.
Job satisfaction
4
I am satisfied with the professional growth resulting from my job
Team affective commitment
4
I feel part of my team/unit.
∗ All
In my unit, the care offered to patients is appropriate to their needs.
the items of the questionnaire were assessed on a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree).
In order to confirm the results for the mediation model and support hypothesis 2, mediation effects were examined using the joint significance test (JST) (MacKinnon et al., 2002). Three steps were performed. In the first step, path α (relationship between the independent variables and the mediators) was computed; in the second step, path β (relationship between the mediators and team commitment) was calculated by controlling the effects of independent variables; in the third step, the mediated effect, which is the product of paths α and β (αβ), was computed. Mediation is present when the αβ product is statistically significant (p < 0·05). Confidence intervals (95%) of mediation effects were calculated. Finally, a complete mediating model was tested by carrying out a structural equation model that considers all the relationship between variables in a whole model. The following fit indices were used to test the final complete structural model: incremental fit index (IFI), comparative fit index (CFI) and rootmean-square error of approximation (RMSEA). To indicate a good fit of the model, the IFI and CFI critical values should be ≥00·90, and RMSEA ≤ 0·08 (Kline, 2005).
RESULTS Descriptive characteristics For this study, a total of 323 questionnaires were provided and 222 were returned entirely completed, thus yielding a response rate of 68·1%.The majority of the nurses worked in general ICU (62%, n = 137, See Table 2). The sample mainly included women. Average age of the sample was about 36 years and average organizational tenure was 13·26 years (see Table 3). Table 4 shows mean, standard deviations, and correlations between variables analysed in this study. 150
Table 2 Intensive care units (ICUs) characteristics (N = 222) Hospital clinical ICU
n
Percentage
Cardiac ICU
56
25
Cardiothoracic ICU
44
20
General ICU
93
42
Neonatal ICU
29
13
Table 3 Participants’ demographics (N = 222) Gender
Percentage
n
Male Female
30·5 69·5
65 157
Age Organizational tenure
Mean (range)
Standard deviation
36·4 (21–56 years) 13·26 (1–38 years)
7·25 8·32
The direction and magnitude of the correlations are in line with predictions. The table also shows that ICU nurses have moderate-high levels of perceived quality of practice, job satisfaction and team commitment.
Factorial validity of the scales The exploratory factor analysis results revealed a six-factor structure explaining 58·2% of the variance of the indicators. Keiser-Meyer-Olkin (KMO) test of sampling adequacy was 0·846. The (KMO test) measure of 0·92, and Bartlett’s Test of sphericity, was significant (χ 2 = 2255·84, df = 210, p < 0·001). These results indicate adequate inter-correlation among the questionnaire items (Hair et al., 2006). Reliability analysis of measures showed good internal consistency © 2014 British Association of Critical Care Nurses
Nurses well-being in ICUs
Table 4 Means, standard deviation and Pearson correlations (r) between variables of the study† M
SD
1
2
3
4
5
6
Organizational tenure
13·26
8·32
—
Job autonomy
2·85
0·72
−0·25**
(0·92)
N-Ph collaboration
2·60
0·87
−03
0·35**
(0·70)
Quality of practice
3·50
0·72
−0·12
0·10
0·14*
(0·75)
Supervisor support
2·56
0·75
0·02
0·34**
0·47**
0·36**
(0·85)
0·61
−0·06
0·41**
0·37**
0·31**
0·49**
(0·78)
0·77
−0·08
0·33**
0·33**
0·27**
0·45**
0·49**
Job satisfaction Team commitment
3·35 3·29
7
(0·79)
M, mean; N-Ph, nurse-physician; SD, standard deviation. † Cronbach’s α is shown in the diagonal. * p < 0·05; ** p < 0·01.
(inter-correlation between items of the same scale, from 0·70 to 0·92). Confirmatory factor analysis was carried out by comparing the six-factor structure to a one-factor structure. All indicators of the six-factor structure loaded significantly on their corresponding constructs (p < 0·001) and the measurement model showed a good fit to the data, χ 2 (df = 174) = 301·2, IFI = 0·94, CFI = 0·94, RMSEA = 0·06. Yet, the one-factor model fitted the data poorly [χ 2 (df = 189) = 1211·2, IFI = 0·52, CFI = 0·52, RMSEA = 0·16]. Thus, the six-factor model was significantly supported [χ 2 (df = 15) = 910·0, p < 0·001].
Hierarchical regression analyses Consistent with hypotheses 1, the results showed that job autonomy, nurse-physician collaboration, and quality of practice were positively and directly related to team commitment (p < 0·01). These variables lost significance (p > 0·05) when the mediating variables in step 3 were included. Therefore, the positive relationship between job autonomy, nurse-physician collaboration, and quality of practice and team commitment was mediated by job satisfaction and supervisor support. The mediation coefficient resulted significant with a notable increment in explained variance (R2 = 12%, p < 0·001) (see Table 5 for results). Organizational tenure (control variable) was not a significant factor in this study, thus adding more support to the findings.
Mediation effects analysis The results showed that job satisfaction and supervisor support fully mediated the relationship between all of the three independent variables and team affective commitment, thus supporting hypothesis 2 (see Table 6 for results). Finally, all the hypothesized relationships © 2014 British Association of Critical Care Nurses
were examined in a whole model, which showed a good fit to the data: χ 2 (df = 177) = 338·7, IFI = 0·93, CFI = 0·92, RMSEA = 0·06.
DISCUSSION This study explored the way in which nursing work characteristics, perceived support and job satisfaction are related to each other and team commitment in ICUs. The results show that having good relationship with physicians, high autonomy and control to manage one’s own work, as well as high perceived quality of practice, affects identification with work group and with its objectives. The results of both structural model and mediation analyses show that job satisfaction and an individual’s perception to be supported by his/her supervisor mediate the relationship between nurses work characteristics and ICU nurses’ affective commitment. In other words, giving importance to individuals’ needs, as well as working in a safe and efficient team, affects satisfaction with job experience and perceived support, which in turn promote both affective team identification and quality of working relationships. The positive relationship of both perceived support and job satisfaction to commitment is consistent with the social exchange theory in employment relationships (Eisenberger et al., 1986; Rhoades and Eisenberger, 2002), and with the findings of previous studies in other contexts (Moser, 1997; Malik et al., 2010), respectively. Conditions of the critically ill patients and challenges nurses have to face daily are factors affecting job satisfaction and team identification (Hurst and Koplin-Baucum, 2005). Nevertheless, this study has shown that job characteristics, organizational and relationship factors play an important role for feelings of attachment. This is in line with previous studies conducted in other units (e.g. Galletta et al., 2011). 151
Nurses well-being in ICUs
Table 5 Results of hierarchical regression analysis for the relationship between the variables studied and team commitment† Step 1
Tenure (control variable) Job autonomy N-Ph collaboration Quality of practice Supervisor support Job satisfaction R2 Adjusted R2 df F R2 F
Step 2
Step 3
β
SE
β
SE
β
SE
−0·08 (−1·23)
0·01
0·00 (0·08) 0·23** (3·46) 0·22** (3·41) 0·21** (3·44)
0·01 0·07 0·06 0·07
−0·04 (−0·60) 0·09 (1·37) 0·08 (1·21) 0·07 (1·11) 0·22** (2·98) 30*** (4·27) 0·32 0·30 2215 17·01*** 0·12*** 18·27***
0·00 0·07 0·06 0·07 0·08 0·09
0·01 0·00 1220 1·51
0·21 0·19 3217 14·13*** 0·20*** 18·22***
df, degree of freedom; F, Fisher test value; F, Fisher value change; N-Ph, nurse-physician; SE, standard error; R2 , portion of variance explained; R2 , variance explained change; β, regression coefficient. † t (t-test value) statistics are presented in parentheses. ** p < 0·01; *** p < 0·001. Table 6 Indirect effects of autonomy, N-Ph collaboration and quality of practice on team commitment through job satisfaction and PSS: results for joint significance effect†
Mediator PSS Job satisfaction
Autonomy effect on mediator (α) 0·35***
(0·07) 0·35*** (0·05)
Mediator effect on team commitment (β) 0·27**
(0·07) 0·41*** (0·09)
95% CI Indirect effect (αβ) 0·09**
(0·03) 0·14*** (0·04)
Lower limit of mediated effect
Upper limit of mediated effect
0·03 0·08
0·17 0·23
F = 32·96; df = 3, 218; R2 adjusted = 0·30; p < 0·001
PSS Job satisfaction
95% CI
N-Ph collaboration effect on mediator (α)
Mediator effect on team commitment (β)
Indirect effect (αβ)
Lower limit of mediated effect
Upper limit of mediated effect
0·40*** (0·05) 0·26*** (0·04)
0·25*** (0·07) 0·43*** (0·08)
0·10** (0·03) 0·11*** (0·03)
0·03 0·06
0·18 0·19
F = 32·47; df = 3, 218; R2 adjusted = 0·30; p < 0·001
PSS Job satisfaction
95% CI
Quality of practice effect on mediator (α)
Mediator effect on team commitment (β)
Indirect effect (αβ)
Lower limit of mediated effect
Lower limit of mediated effect
0·38*** (0·06) 0·27*** (0·05)
0·27*** (0·07) 0·44*** (0·08)
0·10** (0·03) 0·12** (0·03)
0·05 0·06
0·18 0·18
F = 31·96; df = 3, 218; R2 adjusted = 0·30; p < 0·001 CI, confidence interval; N-Ph, nurse-physician, PSS, perceived supervisor support; Path (α) = relationship between the independent variables and the mediators; Path (β) = relationship between the mediators and team commitment; (αβ) = product of Paths α and β for mediating effect. † Coefficients in boldface denote mediation. Standard error in parentheses. *** p < 0·001, ** p < 0·01.
Limitations and future directions This study has some limitations. First, the survey was carried out during working hours. This could have altered the quality of participants’ responses, thus leading to interpretation bias. Furthermore, a 152
self-report was used to collect data. Thus, results may have been contaminated by common method bias (Podsakoff and Organ, 1986; Goffin and Gellatly, 2001). Nevertheless, self-report is a fast instrument to collect and analyse perception data. Moreover, © 2014 British Association of Critical Care Nurses
Nurses well-being in ICUs
the relationships model obtained in this study is in line with theoretical assumptions and with results of previous studies, thus offering an acceptable representation of the relationships between the variables studied. However, future research should integrate perceptual data with objective data such as job performance or actual turnover, which would concretely represent the extent to which an individual is identified with his/her organization. Second, we used a convenience sample and we were unable to study the whole nursing population. Only the entirely completed questionnaires were used to analyse data. Nevertheless, we obtained a response rate of 68%, which is an acceptable percentage. This allows us to generalize the results to the studied ICUs. Third, this research lacks a longitudinal-type study method. As this research was a cross-sectional investigation, we were unable to analyse causal influence and changes in the studied variables across time. Another limitation regards the impossibility to compare the ICUs studied with other wards in the same hospitals. This would have allowed us to test a control model in order to give more strength to the relationships between the studied variables, as well as more external validity of the research. Thus, future research should consider expanding the study by using other types of wards to generalize the results. These future developments would make a valuable addition to the study and to specific literature.
Implications for practice Despite the limitations, the results present some implications for practice in ICUs. On the basis of the findings, these units should activate managerial strategies in order to increase autonomy and the perception of a good quality of clinical practice, as well as the interpersonal relationships within the unit. The self-determination theory (Deci and Ryan, 1985; 2000) affirms that environments which care about employee’s well-being by satisfying their needs for autonomy, competence and relatedness, increase job control and mastery sense. Therefore, this is relevant as a strategy to improve both job satisfaction and retention by increasing nurses’ identification with the unit. Moreover, when teamwork is not experienced, nurses may feel overloaded and dissatisfied with both the staff and the level of care offered (Irvine and Evans, 1995; Darvas and Hawkins, 2002). This is especially important in ICUs as reduced effectiveness may translate into low quality of care. Hence, a sense of team collaboration should be fostered by nurse managers of the unit in order to promote job satisfaction among nurses and increase staff retention (Borda and © 2014 British Association of Critical Care Nurses
Norman, 1997; McNeese-Smith, 1997). For example, involving staff in the definition of goals, decision making, problem solution and meetings related to the organizational life, would increase time employees spend within their unit, as well as their opportunities to interact and coordinate with team members, thus increasing perceived support of nurses. According to the organizational support theory (Eisenberger et al., 1986), employees trade their working effort for valued benefits and to meet their socio-emotional needs. Being supported by the organization helps individuals to satisfy their need for approval, esteem, autonomy and affiliation. Such perceived support would increase workers obligation to help the organization achieve its objectives, their affective commitment and the expectation that their efforts will be rewarded. This results in positive behavioural outcomes including high job performance and low absenteeism. Thus, management styles that support autonomy, nursing practice and good interpersonal relationships might increase internalization of organizational values (Ryan, 1995; Greguras and Diefendorff, 2009; Galletta and Portoghese, 2012), thereby strengthening individualorganization relationship and fostering well-being among ICU nurses.
CONCLUSIONS This study has shown that team identification among ICU nurses is stimulated by a good climate for clinical practice and by a work environment which promotes support and employees’ job satisfaction. As a positive nurse work environment is a result of multiple organizational and structural factors (International Council of Nurses, 2006), these results may concretely contribute to literature and offer additional suggestions to improve nurses work conditions and patient health in ICUs. Therefore, it is important to emphasize that caring about well-being of health professionals improves their working life and, indirectly, the health of patients. When employees feel satisfied with their organizational climate, they will likely be more effective in their job, thus reducing the risk of errors and increasing general organizational efficacious (e.g. Goodman et al., 2011). However, to give more support to the study, it would be valuable to understand if the results can be generalized to other teams/units of the health care environment.
ACKNOWLEDGEMENT The authors would like to thank Mr Barry Mark Wheaton for his invaluable linguistic and editing assistance with this study.
153
Nurses well-being in ICUs
WHAT IS KNOWN ABOUT THIS TOPIC • ICUs are usually difficult work environments because of the daily challenges caring staff have to face with critically ill patients. These challenges include much responsibility, frequent change of patients, changes in technology, and continual exposure to pain, suffering and death. • Compared with other hospital units, ICU nurses are exposed to low job satisfaction and consequently high staff turnover. • Both work and organizational factors and the quality of work relationship are primary aspects to increase affective commitment towards the work unit. WHAT THIS PAPER ADDS • Organizational factors and the quality of work relationship are also important aspects to increase affective commitment in ICUs. • Nursing work characteristics (job autonomy, nurse-physician collaboration, perceived quality of nursing practice) are directly related to team affective commitment, and the nursing work characteristics and team commitment relationship is mediated by both perceived supervisor support and job satisfaction.
REFERENCES Adams A, Bond S. (2000). Hospital nurses’ job satisfaction, individual and organizational characteristics. Journal of Nursing Management; 32: 536–543. Aiken LH, Patrician P. (2000). Measuring organizational traits of hospitals: the Revised Nursing Work Index. Nursing Research; 49: 146–153. Allen NJ, Meyer JP. (1990). The measurement and antecedents of affective, continuance, and normative commitment to the organization. Journal of Occupational Psychology; 63: 1–18. Arbuckle JL. (2007). Amos™ 16 User’s Guide. Crawfordsville: Amos Development Corp. Baggs JG, Schmitt MH, Mushlin AI, Mitchell PH, Eldredge DH, Oakes D, Hutson AD. (1999). The association between nurse-physician collaboration and patient outcomes in three intensive care units. Critical Care Medicine; 27: 1991–1998. Bakhshi A, Sharma AD, Kumar K. (2011). Organizational commitment as predictor of organizational citizenship behavior. European Journal of Business and Management; 3: 78–86. Best ME, Thurston NE. (2004). Measuring nurse job satisfaction. Journal of Nursing Administration; 34: 283–290. Blau PM. (1964). Exchange and Power in Social Life. New York: Wiley. Borda RG, Norman IJ. (1997). Factors influencing turnover and absence of nurses: a research review. International Journal of Nursing Studies; 34: 385–394. Boumans NPG, Landeweerd JA. (1994). Working in an intensive or non-intensive unit: does it make a difference? Heart & Lung; 23: 71–79. Braithwaite M. (2008). Nurse burnout and stress in the NICU. Advances in Neonatal Care; 8: 343–347. Brislin RW. (1980). Translation and content analysis of oral and written materials. In: Triandis HC, Berry JW, (eds), Handbook of Cross-Cultural Psychology. Vol. 2. Boston: Allyn and Bacon. Brown RB. (1996). Organizational commitment: clarifying the concept and simplifying the existing construct typology. Journal of Vocational Behavior; 49: 230–251. Burgess L, Irvine F, Wallymahmed A. (2010). Personality, stress and coping in intensive care nurses: a descriptive exploratory study. Nursing in Critical Care; 15: 129–140. Camerino D, Mansano Sarquis LM. (2010). Nurses’ working conditions, health and well-being in Europe (Nurses’ Early Exit Study). Professioni Infermieristiche; 63: 53–61.
154
Cohen A. (1993). Organizational commitment and turnover: a meta-analysis. Academy of Management Journal; 36: 1140–1157. Coombs M. (2003). Power and conflict in intensive care clinical decision making. Intensive and Critical Care Nursing; 19: 125–135. Cortese CG. (2001). Prima standardizzazione del Questionario per la Soddisfazione per il lavoro (QSO). Risorsa Uomo; 8: 331–349. Darvas JA, Hawkins LG. (2002). What makes a good intensive care unit: a nursing perspective. Australian Critical Care; 15: 77–82. Deci EL, Ryan RM. (1985). Intrinsic Motivation and SelfDetermination in Human Behavior. New York: Plenum. Deci EL, Ryan RM. (2000). The ”what” and ”why” of goal pursuits: human needs and the self-determination of behavior. Psychological Inquiry; 11: 227–268. Eisenberger R, Huntington R, Hutchison S, Sowa D. (1986). Perceived organizational support. Journal of Applied Psychology; 71: 500–507. English B, Morrison D, Chalon C. (2010). Moderator effects of organizational tenure on the relationship between psychological climate and affective commitment. Journal of Management Development; 29: 394–408. Gaan N. (2008). Stress, social support, job attitudes and job outcome across gender. Journal of Organizational Behavior; 52: 34–44. Galletta M, Portoghese I. (2012). Organizational citizenship behavior in healthcare: the roles of autonomous motivation, affective commitment and learning orientation. Revue Internationale de Psychologie Sociale; 25: 121–145. Galletta M, Portoghese I, Penna MP, Battistelli A, Saiani L. (2011). Turnover intention among Italian nurses: the moderating roles of supervisor support and organizational support. Nursing & Health Sciences; 13: 184–191. Galletta M, Portoghese I, Battistelli A, Leiter MP. (2013). The roles of unit leadership and nurse–physician collaboration on nursing turnover intention. Journal of Advanced Nursing; 69: 1771–1784. Gambino KM. (2010). Motivation for entry, occupational commitment and intent to remain: a survey regarding Registered Nurse retention. Journal of Advanced Nursing; 66: 2532–2541. Goffin RD, Gellatly IR. (2001). A multi-rater assessment of organizational commitment: are self-report measures biased? Journal of Organizational Behavior; 22: 437–451.
© 2014 British Association of Critical Care Nurses
Nurses well-being in ICUs
Goodman PS, Ramanujam R, Carroll JS, Edmondson AC, Hofmann DA, Sutcliffe KM. (2011). Organizational errors: directions for future research. Research in Organizational Behavior; 31: 151–176. Gouldner AW. (1960). The norm of reciprocity: a preliminary statement. American Sociological Review; 25: 161–178. Greguras GJ, Diefendorff JM. (2009). Different fits satisfy different needs: linking person-environment fit to employee commitment and performance using self-determination theory. Journal of Applied Psychology; 94: 465–477. Hair JJF, Black WC, Babin BJ, Anderson RE, Tatham RL. (2006). Multivariate Data Analysis. Upper Saddle River: PearsonPrentice Hall. Hamric A, Blackhall L. (2007). Nurse-physician perspectives on the care of dying patients in Intensive care units: collaboration, moral distress, and ethical climate. Critical Care Medicine; 35: 422–429. Hayes LJ, O’Brien-Pallas L, Duffield C, Shamian J, Buchan J, Hughes F, Spence HK, North N, Stone PW. (2006). Nurse turnover: a literature review. International Journal of Nursing Studies; 43: 237–263. Hayes LJ, O’Brien-Pallas L, Duffield C, Shamian J, Buchan J, Hughes F, Laschinger HK, North N. (2012). Nurse turnover: a literature review–an update. International Journal of Nursing Studies; 49: 887–905. Hinshaw AS, Smeltzer CH, Atwood JR. (1987). Innovative retention strategies for nursing staff. Journal of Nursing Administration; 1: 8–16. Humphrey SE, Nahrgang JD, Morgeson FP. (2007). Integrating motivational, social, and contextual work design features: a meta-analytic summary and theoretical extension of the work design literature. Journal of Applied Psychology; 92: 1332–1356. Hurst S, Koplin-Baucum S. (2005). A pilot qualitative study relating to hardiness in ICU nurses: hardiness in ICU nurses. Dimensions of Critical Care Nursing; 24: 97–100. Iliopoulou KK, While AE. (2010). Professional autonomy and job satisfaction: survey of critical care nurses in mainland Greece. Journal of Advanced Nursing; 66: 2520–2531. International Council of Nurses and the Florence Nightingale International Foundation. (2006). The Global Nursing Shortage: Priority Areas for Intervention. Geneva: The Global Nursing Review Initiative. Irvine DM, Evans MG. (1995). Job satisfaction and turnover among nurses: integrating research findings across studies. Nursing Research; 44: 246–253. Khowaja K, Merchand RJ, Hirani D. (2005). Registered nurses perception of work satisfaction at a Tertiary Care University Hospital. Journal of Nursing Management; 13: 32–39. Kline RB. (2005). Principles and Practice of Structural Equation Modelling. 2nd edn. New York: The Guilford Press. Kramer M, Schmalenberg C. (2003). Magnet hospital nurses describe control over practice. Western Journal of Nursing Research; 25: 434–452. Laschinger HKS, Almusi J, Tuer-Hodes D. (2003). Workplace empowerment and Magnet hospital characteristics: making the link. Journal of Nursing Administration; 33: 4l0–4l422. Le Blanc PM, Schaufeli WB, Salanova M, Llorens S, Nap RE. (2010). Efficacy beliefs predict collaborative practice among intensive care unit nurses. Journal of Advanced Nursing; 66: 583–594. Li J, Lambert VA. (2008). Workplace stressors, coping, demographics and job satisfaction in Chinese intensive care nurses. Nursing in Critical Care; 13: 12–24. Li Y, Dick AW, Glance LG, Cai X, Mukamel DB. (2007). Misspecification issues in risk adjustment and construction of
© 2014 British Association of Critical Care Nurses
outcome-based quality indicators. Health Services and Outcomes Research Methodology; 7: 39–56. Liou SR, Cheng CY. (2010). Organisational climate, organisational commitment and intention to leave amongst hospital nurses in Taiwan. Journal of Clinical Nursing; 19: 1635–1644. Locke EA. (1976). Nature and causes of job satisfaction. In: Dunnette MD, (ed), Handbook of Industrial and Organizational Psychology. Chicago: Rand McNally. Lok P, Crawford J. (2001). Antecedents of organizational commitment and the mediating role of job satisfaction. Journal of Managerial Psychology; 16: 594–613. MacKinnon D, Lockwood C, Hoffman J, West S, Sheets V. (2002). A comparison of methods to test mediation and other intervening variable effects. Psychological Methods; 7: 83–104. Malik OF, Waheed A, Malik KUR. (2010). The mediating effects of job satisfaction on role stressors and affective commitment. International Journal of Business and Management; 5: 223–235. Manojlovich M. (2005). Linking the practice environment to nurses’ job satisfaction through nurse/physician communication. The Journal of Nursing Scholarship; 37: 367–373. Mathieu JE, Zajac DM. (1990). A review and meta-analysis of the antecedents, correlates and consequences of organizational commitment. Psychological Bulletin; 108: 171–194. McNeese-Smith DK. (1997). The influence of manager behavior on nurses’ job satisfaction, productivity and commitment. Journal of Nursing Administration; 27: 47–55. McNeese-Smith DK. (1999). A content analysis of staff nurse descriptions of job satisfaction and dissatisfaction. Journal of Advanced Nursing; 29: 1332–1341. McNeese-Smith DK. (2001). Staff nurse views of their productivity and nonproductivity. Health Care Management Review; 26: 7–19. Meyer JP, Irving PG, Allen NJ. (1998). Examination of the combined effects of work values and early work experiences on organizational commitment. Journal of Organizational Behavior; 19: 29–52. Meyer JP, Stanley DJ, Herscovitch L, Topolnytsky L. (2002). Affective, continuance and normative commitment to the organization: a meta-analysis of antecedents, correlates and consequences. Journal of Vocational Behavior; 61: 20–52. Morgeson FP, Humphrey SE. (2006). The work design questionnaire (WDQ): developing and validating a comprehensive measure for assessing job design and the nature of work. Journal of Applied Psychology; 91: 1321–1339. Moser K. (1997). Commitment in organizations. Psychologies; 41: 160–170. Mowday RT, Porter LW, Steers RM. (1982). Employee Organizational Linkages. New York: Academy Press. Panaccio AJ, Vandenberghe C. (2009). Perceived organizational support, organizational commitment and psychological wellbeing: alongitudinal study. Journal of Vocational Behavior; 75: 224–236. Podsakoff PM, Organ DW. (1986). Self-reports in organizational research: problems and prospects. Journal of Management; 12: 531–544. Pot FD, Koningsveld EAP. (2009). Quality of working life and organizational performance: two sides of the same coin? Scandinavian Journal of Work, Environment & Health; 35: 421–428. Price JL, Mueller CW. (1981). A casual model of turnover for nurses. Academy of Management Journal; 24: 543–565. Reis MD, Ryan DW, Schaufeli WB, Fidler V. (1997). Organisation and Management of Intensive Care: A Prospective Study of 12 European Countries. Berlin: Springer Verlag.
155
Nurses well-being in ICUs
Rhoades L, Eisenberger R. (2002). Perceived organizational support: a review of the literature. Journal of Applied Psychology; 87: 698–714. Rhoades L, Eisenberger R, Armeli S. (2001). Affective commitment to the organization: the contribution of perceived organizational support. Journal of Applied Psychology; 86: 825–836. Ryan RM. (1995). Psychological needs and the facilitation of integrative processes. Journal of Personality; 63: 397–427. Sheel S, Sindhwani BK, Goel S, Pathak S. (2012). Quality of work life, employee performance and career growth opportunities: a literature review. International Journal of Multidisciplinary Research; 2: 291–300. Stein-Parbury J, Liaschenko J. (2007). Understanding collaboration between nurses and physicians as knowledge at work. American Journal of Critical Care; 16: 470–478. Taylor JS. (1996). Collaborative practice within the intensive care unit: a deconstruction. Intensive and Critical Care Nursing; 12: 64–70. Thomas E, Sexton J, Helmreich R. (2003). Discrepant attitudes about teamwork among critical care nurses and physicians. Critical Care Medicine; 31: 956–959. Thompson CA, Prottas DJ. (2005). Relationships among organizational family support, job autonomy, perceived control, and employee well-being. Journal of Occupational Health Psychology; 11: 100–118.
156
Upenieks VV. (2003). The interrelationship of organizational characteristics of magnet hospitals, nursing leadership, and nursing job satisfaction. Health Care Manager; 22: 83–98. Utriainen K, Kynga H. (2009). Hospital nurses’ job satisfaction: a literature review. Journal of Nursing Management; 7: 1002–1010. Vanaki Z, Vagharseyyedin SA. (2009). Organizational commitment, work environment conditions, and life satisfaction among Iranian nurses. Nursing & Health Sciences; 11: 404–409. Wagner CM. (2007). Organizational commitment as a predictor variable in nursing turnover research: literature review. Journal of Advanced Nursing; 60: 235–247. Wasti SA. (2003). Organizational commitment, turnover intentions and the influence of cultural values. Journal of Occupational and Organizational Psychology; 76: 303–321. Wells N, Roberts L, Medlin LC. (2002). Issues related to staff retention and turnover. Seminars for Nurse Managers; 10: 171–179. Zangaro GA, Soeken KL. (2007). A meta-analysis of studies of nurses’ job satisfaction. Research in Nursing & Health; 30: 445–458. Zhang A, Tao H, Ellenbecker CH, Liu X. (2013). Job satisfaction in mainland China: comparing critical care nurses and general ward nurses. Journal of Advanced Nursing; 69: 1725–1736.
© 2014 British Association of Critical Care Nurses
Nurses well-being in intensive care units: study of factors promoting team commitment Maura Galletta, Igor Portoghese, Rosa C Coppola, Gabriele Finco and Marcello Campagna ABSTRACT Background: Intensive care units (ICUs) are challenging work environments because of the critical condition of patients, and ICU nurses frequently lament low job satisfaction and high staff turnover. Nevertheless, organizational and work characteristics, and the quality of relationships with staff can help to maintain nurses’ enthusiasm and increase job satisfaction. Aim: The aim of this study was to analyse how nursing work environment factors affect identification and commitment among ICU nurses. Design: A cross-sectional study was carried out in 12 ICUs from four Italian urban hospitals. Method: A total of 222 nurses participated and completed a self-reported questionnaire. Results and conclusion: Results show that nursing work characteristics are directly related to team commitment, and that the nursing work characteristics and team commitment relationship was mediated by both perceived supervisor support and job satisfaction. Relevance to clinical practice: Our findings may concretely contribute to literature and offer additional suggestions to improve nurses’ work conditions and patient health in ICUs. Key words: Intensive care unit • Mediating role • Nurses • Nursing work characteristics • Team commitment
INTRODUCTION Intensive care units (ICUs) can have very difficult work environments due to the daily challenges care staff have to face with critically ill patients. These challenges, which can generate stress, include much responsibility, frequent change of patients, changes in technology, and continual exposure to pain, suffering and death (Hurst and Koplin-Baucum, 2005; Li and Lambert, 2008). In fact, compared with other hospital units, ICU nurses are exposed to low job satisfaction and consequently to high staff turnover (e.g. Braithwaite, 2008; Zhang Authors: M Galletta, PhD, MSc, Research fellow, Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Italy; I Portoghese, PhD, MSc, Research fellow, Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Italy; RC Coppola, MD, MSc, Full Professor, Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Italy; G Finco, MD, MSc, Full Professor, Anesthesia and Intensive Care Department, Pain Therapy Service, University of Cagliari, Italy; M Campagna, MD, MSc, Research fellow, Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Italy Address for correspondence: I Portoghese, Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, SS554 bivio per Sestu, Monserrato, Cagliari, Italy E-mail: [email protected]
146
et al., 2013). Nevertheless, a previous study has shown that nurses can thrive in ICUs and maintain enthusiasm for their work (Burgess et al., 2010). This might depend on both organizational and work characteristics, as well as on daily work relationships which can contribute to the quality of working life (QWL). In health care organizations, QWL factors (e.g. job autonomy, quality of interpersonal relationships, worker involvement and satisfaction, and belief in supervisor support) have been recognized as affecting staff performance (e.g. Pot and Koningsveld, 2009; Sheel et al., 2012). This paper aims to examine how some aspects of work environment affects experiences of identification and commitment among ICU staff nurses.
BACKGROUND Improving nursing QWL is crucial for the wellbeing and effectiveness of an organization. Poor QWL leads to high voluntary nursing turnover (Hayes et al., 2006). High staff turnover not only increases recruitment and training costs, but it can also be detrimental to the patient’s health, and compromise © 2014 British Association of Critical Care Nurses • Vol 21 No 3
Nurses well-being in ICUs
quality and continuity of care. Thus, good work environment conditions are important with regards to retention, productivity and adequacy of care. Several studies have demonstrated that among the factors affecting intention to leave, organizational commitment is a significant direct predictor (e.g. Wasti, 2003; Wagner, 2007; Liou and Cheng, 2010). Organizational commitment is defined as a force linking an individual to his/her organization (Allen and Meyer, 1990). According to Mowday et al. (1982), organizational commitment is the extent to which nurses identify with, and feel involved in their work units. Commitment is fundamental to develop a good individual-organization relationship. In fact, studies have shown that committed employees are more satisfied (Khowaja et al., 2005) and afford high value to their work. In particular, when the binding force is of the affective type, employees experience high identification and involvement with organizational goals, thus desire to remain part of the organization (Thompson and Prottas, 2005; Gaan, 2008). Furthermore, it has been shown that the more nurses felt affectively committed to their unit, the lower ICU’s standardized mortality ratios were (Reis et al., 1997; Le Blanc et al., 2010). Considering that the aim of this study was to analyse a specific work context in health care, such as an ICU, our primary focus was on team commitment, defined as the psychological attachment of staff towards their team or unit. Thus, the target of the attachment is the team rather than the larger organization. Literature concerning organizational commitment has profusely shown the important role of commitment in preventing intent to leave and in promoting positive behaviour (e.g. Liou and Cheng, 2010; Bakhshi et al., 2011). It has also shown which factors facilitate the development of affective commitment in a work environment. Specifically, some recent studies have reported both working and organizational factors, as well as the quality of work relationships, as being the principal factors that increase affective commitment, thus reducing turnover risk (e.g. Hayes et al., 2012; Galletta et al., 2013). Nevertheless, recent studies analysing the role of these factors in ICUs, which we believe play a pivotal role also in critical care environments, are non-existent.
between physicians and nurses is important to improve clinical outcome of patient care (Taylor, 1996; Baggs et al., 1999). Studies have shown that physicians often perceive themselves as the main decision-makers when it comes to the applicability or modification of treatment plans. Hence, physicians make decisions without nursing consultation, thus neglecting and often underestimating nurses’ competence (e.g. Coombs, 2003). In this sense, compared with physicians, ICUs nurses often perceive lower levels of collaboration and are less satisfied (e.g. Thomas et al., 2003; Hamric and Blackhall, 2007). High collaborative communication between physicians and nurses increases nurses’ job satisfaction and affective commitment (e.g. Zangaro and Soeken, 2007; Galletta et al., 2013). Job autonomy is one of the most important predictors of nurses’ job satisfaction and organizational commitment (Kramer and Schmalenberg, 2003; Upenieks, 2003; Humphrey et al., 2007; Camerino and Mansano Sarquis, 2010). Job autonomy means freedom and discretion in scheduling work, making decisions and choosing procedures to perform work activities (Morgeson and Humphrey, 2006). A highly autonomous job allows employees to perceive work outcomes as dependent on their efforts. It has been reported that ICUs require high autonomy (Boumans and Landeweerd, 1994) due to the critical health condition of patients which often requires immediate interventions. Therefore, job autonomy can activate a crucial psychological state promoting important work outcomes such as job satisfaction and affective commitment (e.g. Iliopoulou and While, 2010; Galletta et al., 2011). Quality of working practice is fundamental to retaining a qualified workforce (Li et al., 2007). Studies have shown a positive relationship between work environment characteristics and affective commitment (Vanaki and Vagharseyyedin, 2009). Thus, it is reasonable to think that when employees perceive that their team is able to offer effective care to patients, as well as promote both autonomy and control over the practice, and support good nurse-physician relationships, they feel more attached to their unit and will not leave it (Laschinger et al., 2003).
Nursing work characteristics
Mediating factors linking nursing work characteristics to team commitment
ICUs are contexts in which collaboration between physicians and nurses is fundamental to the effective functioning of these units. In fact, ICUs are characterized by the need for interdependent teamwork (Stein-Parbury and Liaschenko, 2007). Therefore, the quality of collaborative practice and communication
In their meta-analysis, Zangaro and Soeken (2007) reported that characteristics of nursing practice such as job autonomy and nurse-physician collaboration are variables commonly identified in nursing studies as directly linked with job satisfaction and employees’ general well-being (Hinshaw et al., 1987; Wells et al.,
© 2014 British Association of Critical Care Nurses
147
Nurses well-being in ICUs
2002; Best and Thurston, 2004). Locke (1976) defined job satisfaction as a ‘pleasurable or positive emotional state resulting from the appraisal of one’s job or job experiences’ (p. 1304). Utriainen and Kynga (2009) in their systematic review on nurse’s job satisfaction showed that interpersonal relationships, such as relationships with other nurses and collaboration with medical staff, patient care and autonomy are fundamental predictors of job satisfaction (McNeese-Smith, 1999; Adams and Bond, 2000; Manojlovich, 2005). In turn, Mowday et al. (1982) suggested that job satisfaction is an important antecedent for organizational commitment. A strong positive relationship between job satisfaction and organizational commitment has been widely confirmed in literature (Price and Mueller, 1981; Mathieu and Zajac, 1990; Lok and Crawford, 2001; McNeese-Smith, 2001). In this sense, it is reasonable to suppose that nurses satisfied with their jobs show high levels of loyalty towards their units. Organizational commitment includes the assumption that workers obtain support from organization (Brown, 1996). Specifically, within the social exchange perspective (Blau, 1964), perceived organizational support (POS) has been defined as employees’ ‘beliefs concerning the extent to which the organization values their contributions and cares about their well-being’ (Eisenberger et al., 1986, p. 501). The relationship between organizational commitment and POS emerges from the induced felt obligation to reciprocate in employees (Gouldner, 1960). Particularly, in literature POS has been found to be a socio-emotional resource leading workers to experience affective commitment towards the organization (Rhoades et al., 2001; Meyer et al., 2002; Panaccio and Vandenberghe, 2009). Thus, affective commitment is a response to positive work experiences perceived as being offered by the organization (Meyer et al., 1998). A supervisor – in this context, the supervisor is the ICU nurse coordinator – represents a personification of the organization, because he/she is a person who directly works with the staff, evaluates their contribution and manages the reward systems (Galletta et al., 2011). Thus, we considered perceived supervisor support (PSS), in this study, as a variable affecting team commitment (Figure 1).
148
affects experiences of identification and commitment among ICU staff. On the basis of this proposal, we postulated the following hypotheses: • Hypothesis 1: Job autonomy, physician-nurse collaboration and perceived quality of practice are positively related to team affective commitment. • Hypotheses 2: Job satisfaction and supervisor support mediate the relationship between nursing work characteristics and team affective commitment.
METHODS Study design A cross-sectional survey with a self-reported questionnaire was carried out in order to understand factors related to organizational well-being in ICU.
Participants and setting A total of 12 ICUs were involved from four Italian urban hospitals. The participating ICUs had different sizes (average number of nurses 20, range 13–39) and specialties, including cardiac, cardiothoracic and neonatal units. The study used a convenience sample consisting of ICU staff nurses working in the four hospitals. To participate in the study, nurses had to work in ICU for at least 6 months and complete their orientation/training period.
Ethical consideration Consent to conduct the study in each hospital was obtained from the appropriate ethics committees of the Italian public health system. Formal permission to access the ICUs was obtained from the Health Director of each unit. After this formal approval, nurses were contacted and recruited. To ensure ethical clarity, nurses were informed about the nature and purpose of the study. The recruitment process was conducted by the researchers during a series of meetings with nurses and managers of each unit in order to explain the research aim. Oral consent was obtained from nurses before data collection, and informed consent to participate was assumed on receipt of the completed questionnaires.
RESEARCH AIM AND HYPOTHESES
Data collection methods and tools
Despite a plethora of studies on retention and organizational identification factors, a study that analyzes all these factors together as a whole model is lacking in ICU literature. Nurses play a major role in the care offered in ICUs because they are usually in very close contact with patients. Thus, the aim of this study was to examine how nursing work environment
A self-reported paper questionnaire based on validated scales derived from psycho-social literature was used to collect data. The questionnaire included six variables related to working life areas described below. Also, unit tenure was included as control variables as previous studies showed that tenure is a potential predictor of organizational commitment (Gambino, 2010). © 2014 British Association of Critical Care Nurses
Nurses well-being in ICUs
Independent variables
Dependent variable
Mediators
NURSING WORK CHARACTERISTICS -Work aspects (job autonomy) -Human relationship aspects (nurse-physician collaboration)
+ Path α
-Individual aspects (job satisfaction) -Perceived organizational aspects (supervisor support)
+ Path β
Team commitment
-Perceived quality of nursing practice Figure 1 Hypothesized model.
Nurses-physicians collaboration: Three high-loading items (loadings from 0·64 to 0·68) adapted from the Nursing Work Index-Revised (Aiken and Patrician, 2000) were used. Job autonomy: Nine items from the Work Design Questionnaire (WDQ) (Morgeson and Humphrey, 2006) were employed. Perceived quality of nursing practice: Three highloading items (loadings from 0·63 to 0·78) adapted from Nursing Work Index-Revised (NWI-R) (Aiken and Patrician, 2000) were used. Perceived supervisor support: Four high-loading items (loadings from 0·62 to 0·82) from Survey of Perceived Organizational Support (SPOS) (Eisenberger et al., 1986) were adapted by changing the word ‘organization’ to ‘supervisor’. The supervisor was the ICU nurse coordinator. Job satisfaction: The Questionnaire of Organizational Satisfaction (QSO) (Cortese, 2001) was used to assess job satisfaction. Four high-loading items (loadings from 0·62 to 0·78) referring to satisfaction with job activities were used. Team affective commitment: Four high-loading items (loadings from 0·52 to 0·85) from the Organizational Commitment Questionnaire developed by Allen and Meyer (1990) were used. Sample items of the questionnaire are presented in Table 1. The translation-back-translation procedure (Brislin, 1980) was adopted because not all the measures used were validated in Italian. Two bilingual experts in nursing translated the questionnaire from English into Italian, then back-translated into English. The pilot of the questionnaire was conducted by involving 32 nurses in order to ensure further validity of the whole instrument. Minimal improvements were made to the wording for improving understandability of the instrument. © 2014 British Association of Critical Care Nurses
The questionnaires were administered to the nurses through the researchers during a presentation meeting. A written description attached to the questionnaire regarding the study procedure was provided in particular for nurses who could not attend the meeting (e.g. nurses who were off work due to illness or who had the night shift). Nurse supervisors of each ICU assured that completed questionnaires were put in locked boxes. Participation to the study was voluntary and participants completed the anonymous questionnaire during working hours. Nurses were given 3 weeks to complete and return the questionnaire. The time required to complete the questionnaire was about 15 min.
Data analysis Statistical analyses were carried out using PASW Statistics 18·0 and AMOS 16·0 (Chicago, IL, USA, Arbuckle, 2007). Both Exploratory and confirmatory factor analyses were carried out for the construct measurement, and reliability analysis of them was performed using Cronbach’s α measure (α). Correlation analysis between variables was performed by using Pearson coefficient (r). The relationships between variables were examined via hierarchical regression analyses. In order to support hypothesis 1, linear hierarchical regression analysis was performed by including organizational tenure in the first step as a control variable. In fact, tenure was found to be a strong predictor of organizational commitment (Cohen, 1993; English et al., 2010). In the second step, independent variables (job autonomy, nurse-physician collaboration and quality of practice) were introduced in the regression equation. To verify hypothesis 2, the hypothetical mediating variables (job satisfaction and PSS) were entered in the third step of the regression equation. 149
Nurses well-being in ICUs
Table 1 Description of the items used∗ Variable (scale)
N item
Sample item
Nurses-physicians collaboration
3
Physicians and nurses have good working relationships.
Job autonomy
9
The job allows me to plan how I do my work (work scheduling autonomy). The job provides me with significant autonomy in making decisions (decision-making autonomy). The job gives me considerable opportunity for independence and freedom in how I do the work (work methods autonomy).
Perceived quality of nursing practice
3
Perceived supervisor support
4
My supervisor really cares about my well-being.
Job satisfaction
4
I am satisfied with the professional growth resulting from my job
Team affective commitment
4
I feel part of my team/unit.
∗ All
In my unit, the care offered to patients is appropriate to their needs.
the items of the questionnaire were assessed on a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree).
In order to confirm the results for the mediation model and support hypothesis 2, mediation effects were examined using the joint significance test (JST) (MacKinnon et al., 2002). Three steps were performed. In the first step, path α (relationship between the independent variables and the mediators) was computed; in the second step, path β (relationship between the mediators and team commitment) was calculated by controlling the effects of independent variables; in the third step, the mediated effect, which is the product of paths α and β (αβ), was computed. Mediation is present when the αβ product is statistically significant (p < 0·05). Confidence intervals (95%) of mediation effects were calculated. Finally, a complete mediating model was tested by carrying out a structural equation model that considers all the relationship between variables in a whole model. The following fit indices were used to test the final complete structural model: incremental fit index (IFI), comparative fit index (CFI) and rootmean-square error of approximation (RMSEA). To indicate a good fit of the model, the IFI and CFI critical values should be ≥00·90, and RMSEA ≤ 0·08 (Kline, 2005).
RESULTS Descriptive characteristics For this study, a total of 323 questionnaires were provided and 222 were returned entirely completed, thus yielding a response rate of 68·1%.The majority of the nurses worked in general ICU (62%, n = 137, See Table 2). The sample mainly included women. Average age of the sample was about 36 years and average organizational tenure was 13·26 years (see Table 3). Table 4 shows mean, standard deviations, and correlations between variables analysed in this study. 150
Table 2 Intensive care units (ICUs) characteristics (N = 222) Hospital clinical ICU
n
Percentage
Cardiac ICU
56
25
Cardiothoracic ICU
44
20
General ICU
93
42
Neonatal ICU
29
13
Table 3 Participants’ demographics (N = 222) Gender
Percentage
n
Male Female
30·5 69·5
65 157
Age Organizational tenure
Mean (range)
Standard deviation
36·4 (21–56 years) 13·26 (1–38 years)
7·25 8·32
The direction and magnitude of the correlations are in line with predictions. The table also shows that ICU nurses have moderate-high levels of perceived quality of practice, job satisfaction and team commitment.
Factorial validity of the scales The exploratory factor analysis results revealed a six-factor structure explaining 58·2% of the variance of the indicators. Keiser-Meyer-Olkin (KMO) test of sampling adequacy was 0·846. The (KMO test) measure of 0·92, and Bartlett’s Test of sphericity, was significant (χ 2 = 2255·84, df = 210, p < 0·001). These results indicate adequate inter-correlation among the questionnaire items (Hair et al., 2006). Reliability analysis of measures showed good internal consistency © 2014 British Association of Critical Care Nurses
Nurses well-being in ICUs
Table 4 Means, standard deviation and Pearson correlations (r) between variables of the study† M
SD
1
2
3
4
5
6
Organizational tenure
13·26
8·32
—
Job autonomy
2·85
0·72
−0·25**
(0·92)
N-Ph collaboration
2·60
0·87
−03
0·35**
(0·70)
Quality of practice
3·50
0·72
−0·12
0·10
0·14*
(0·75)
Supervisor support
2·56
0·75
0·02
0·34**
0·47**
0·36**
(0·85)
0·61
−0·06
0·41**
0·37**
0·31**
0·49**
(0·78)
0·77
−0·08
0·33**
0·33**
0·27**
0·45**
0·49**
Job satisfaction Team commitment
3·35 3·29
7
(0·79)
M, mean; N-Ph, nurse-physician; SD, standard deviation. † Cronbach’s α is shown in the diagonal. * p < 0·05; ** p < 0·01.
(inter-correlation between items of the same scale, from 0·70 to 0·92). Confirmatory factor analysis was carried out by comparing the six-factor structure to a one-factor structure. All indicators of the six-factor structure loaded significantly on their corresponding constructs (p < 0·001) and the measurement model showed a good fit to the data, χ 2 (df = 174) = 301·2, IFI = 0·94, CFI = 0·94, RMSEA = 0·06. Yet, the one-factor model fitted the data poorly [χ 2 (df = 189) = 1211·2, IFI = 0·52, CFI = 0·52, RMSEA = 0·16]. Thus, the six-factor model was significantly supported [χ 2 (df = 15) = 910·0, p < 0·001].
Hierarchical regression analyses Consistent with hypotheses 1, the results showed that job autonomy, nurse-physician collaboration, and quality of practice were positively and directly related to team commitment (p < 0·01). These variables lost significance (p > 0·05) when the mediating variables in step 3 were included. Therefore, the positive relationship between job autonomy, nurse-physician collaboration, and quality of practice and team commitment was mediated by job satisfaction and supervisor support. The mediation coefficient resulted significant with a notable increment in explained variance (R2 = 12%, p < 0·001) (see Table 5 for results). Organizational tenure (control variable) was not a significant factor in this study, thus adding more support to the findings.
Mediation effects analysis The results showed that job satisfaction and supervisor support fully mediated the relationship between all of the three independent variables and team affective commitment, thus supporting hypothesis 2 (see Table 6 for results). Finally, all the hypothesized relationships © 2014 British Association of Critical Care Nurses
were examined in a whole model, which showed a good fit to the data: χ 2 (df = 177) = 338·7, IFI = 0·93, CFI = 0·92, RMSEA = 0·06.
DISCUSSION This study explored the way in which nursing work characteristics, perceived support and job satisfaction are related to each other and team commitment in ICUs. The results show that having good relationship with physicians, high autonomy and control to manage one’s own work, as well as high perceived quality of practice, affects identification with work group and with its objectives. The results of both structural model and mediation analyses show that job satisfaction and an individual’s perception to be supported by his/her supervisor mediate the relationship between nurses work characteristics and ICU nurses’ affective commitment. In other words, giving importance to individuals’ needs, as well as working in a safe and efficient team, affects satisfaction with job experience and perceived support, which in turn promote both affective team identification and quality of working relationships. The positive relationship of both perceived support and job satisfaction to commitment is consistent with the social exchange theory in employment relationships (Eisenberger et al., 1986; Rhoades and Eisenberger, 2002), and with the findings of previous studies in other contexts (Moser, 1997; Malik et al., 2010), respectively. Conditions of the critically ill patients and challenges nurses have to face daily are factors affecting job satisfaction and team identification (Hurst and Koplin-Baucum, 2005). Nevertheless, this study has shown that job characteristics, organizational and relationship factors play an important role for feelings of attachment. This is in line with previous studies conducted in other units (e.g. Galletta et al., 2011). 151
Nurses well-being in ICUs
Table 5 Results of hierarchical regression analysis for the relationship between the variables studied and team commitment† Step 1
Tenure (control variable) Job autonomy N-Ph collaboration Quality of practice Supervisor support Job satisfaction R2 Adjusted R2 df F R2 F
Step 2
Step 3
β
SE
β
SE
β
SE
−0·08 (−1·23)
0·01
0·00 (0·08) 0·23** (3·46) 0·22** (3·41) 0·21** (3·44)
0·01 0·07 0·06 0·07
−0·04 (−0·60) 0·09 (1·37) 0·08 (1·21) 0·07 (1·11) 0·22** (2·98) 30*** (4·27) 0·32 0·30 2215 17·01*** 0·12*** 18·27***
0·00 0·07 0·06 0·07 0·08 0·09
0·01 0·00 1220 1·51
0·21 0·19 3217 14·13*** 0·20*** 18·22***
df, degree of freedom; F, Fisher test value; F, Fisher value change; N-Ph, nurse-physician; SE, standard error; R2 , portion of variance explained; R2 , variance explained change; β, regression coefficient. † t (t-test value) statistics are presented in parentheses. ** p < 0·01; *** p < 0·001. Table 6 Indirect effects of autonomy, N-Ph collaboration and quality of practice on team commitment through job satisfaction and PSS: results for joint significance effect†
Mediator PSS Job satisfaction
Autonomy effect on mediator (α) 0·35***
(0·07) 0·35*** (0·05)
Mediator effect on team commitment (β) 0·27**
(0·07) 0·41*** (0·09)
95% CI Indirect effect (αβ) 0·09**
(0·03) 0·14*** (0·04)
Lower limit of mediated effect
Upper limit of mediated effect
0·03 0·08
0·17 0·23
F = 32·96; df = 3, 218; R2 adjusted = 0·30; p < 0·001
PSS Job satisfaction
95% CI
N-Ph collaboration effect on mediator (α)
Mediator effect on team commitment (β)
Indirect effect (αβ)
Lower limit of mediated effect
Upper limit of mediated effect
0·40*** (0·05) 0·26*** (0·04)
0·25*** (0·07) 0·43*** (0·08)
0·10** (0·03) 0·11*** (0·03)
0·03 0·06
0·18 0·19
F = 32·47; df = 3, 218; R2 adjusted = 0·30; p < 0·001
PSS Job satisfaction
95% CI
Quality of practice effect on mediator (α)
Mediator effect on team commitment (β)
Indirect effect (αβ)
Lower limit of mediated effect
Lower limit of mediated effect
0·38*** (0·06) 0·27*** (0·05)
0·27*** (0·07) 0·44*** (0·08)
0·10** (0·03) 0·12** (0·03)
0·05 0·06
0·18 0·18
F = 31·96; df = 3, 218; R2 adjusted = 0·30; p < 0·001 CI, confidence interval; N-Ph, nurse-physician, PSS, perceived supervisor support; Path (α) = relationship between the independent variables and the mediators; Path (β) = relationship between the mediators and team commitment; (αβ) = product of Paths α and β for mediating effect. † Coefficients in boldface denote mediation. Standard error in parentheses. *** p < 0·001, ** p < 0·01.
Limitations and future directions This study has some limitations. First, the survey was carried out during working hours. This could have altered the quality of participants’ responses, thus leading to interpretation bias. Furthermore, a 152
self-report was used to collect data. Thus, results may have been contaminated by common method bias (Podsakoff and Organ, 1986; Goffin and Gellatly, 2001). Nevertheless, self-report is a fast instrument to collect and analyse perception data. Moreover, © 2014 British Association of Critical Care Nurses
Nurses well-being in ICUs
the relationships model obtained in this study is in line with theoretical assumptions and with results of previous studies, thus offering an acceptable representation of the relationships between the variables studied. However, future research should integrate perceptual data with objective data such as job performance or actual turnover, which would concretely represent the extent to which an individual is identified with his/her organization. Second, we used a convenience sample and we were unable to study the whole nursing population. Only the entirely completed questionnaires were used to analyse data. Nevertheless, we obtained a response rate of 68%, which is an acceptable percentage. This allows us to generalize the results to the studied ICUs. Third, this research lacks a longitudinal-type study method. As this research was a cross-sectional investigation, we were unable to analyse causal influence and changes in the studied variables across time. Another limitation regards the impossibility to compare the ICUs studied with other wards in the same hospitals. This would have allowed us to test a control model in order to give more strength to the relationships between the studied variables, as well as more external validity of the research. Thus, future research should consider expanding the study by using other types of wards to generalize the results. These future developments would make a valuable addition to the study and to specific literature.
Implications for practice Despite the limitations, the results present some implications for practice in ICUs. On the basis of the findings, these units should activate managerial strategies in order to increase autonomy and the perception of a good quality of clinical practice, as well as the interpersonal relationships within the unit. The self-determination theory (Deci and Ryan, 1985; 2000) affirms that environments which care about employee’s well-being by satisfying their needs for autonomy, competence and relatedness, increase job control and mastery sense. Therefore, this is relevant as a strategy to improve both job satisfaction and retention by increasing nurses’ identification with the unit. Moreover, when teamwork is not experienced, nurses may feel overloaded and dissatisfied with both the staff and the level of care offered (Irvine and Evans, 1995; Darvas and Hawkins, 2002). This is especially important in ICUs as reduced effectiveness may translate into low quality of care. Hence, a sense of team collaboration should be fostered by nurse managers of the unit in order to promote job satisfaction among nurses and increase staff retention (Borda and © 2014 British Association of Critical Care Nurses
Norman, 1997; McNeese-Smith, 1997). For example, involving staff in the definition of goals, decision making, problem solution and meetings related to the organizational life, would increase time employees spend within their unit, as well as their opportunities to interact and coordinate with team members, thus increasing perceived support of nurses. According to the organizational support theory (Eisenberger et al., 1986), employees trade their working effort for valued benefits and to meet their socio-emotional needs. Being supported by the organization helps individuals to satisfy their need for approval, esteem, autonomy and affiliation. Such perceived support would increase workers obligation to help the organization achieve its objectives, their affective commitment and the expectation that their efforts will be rewarded. This results in positive behavioural outcomes including high job performance and low absenteeism. Thus, management styles that support autonomy, nursing practice and good interpersonal relationships might increase internalization of organizational values (Ryan, 1995; Greguras and Diefendorff, 2009; Galletta and Portoghese, 2012), thereby strengthening individualorganization relationship and fostering well-being among ICU nurses.
CONCLUSIONS This study has shown that team identification among ICU nurses is stimulated by a good climate for clinical practice and by a work environment which promotes support and employees’ job satisfaction. As a positive nurse work environment is a result of multiple organizational and structural factors (International Council of Nurses, 2006), these results may concretely contribute to literature and offer additional suggestions to improve nurses work conditions and patient health in ICUs. Therefore, it is important to emphasize that caring about well-being of health professionals improves their working life and, indirectly, the health of patients. When employees feel satisfied with their organizational climate, they will likely be more effective in their job, thus reducing the risk of errors and increasing general organizational efficacious (e.g. Goodman et al., 2011). However, to give more support to the study, it would be valuable to understand if the results can be generalized to other teams/units of the health care environment.
ACKNOWLEDGEMENT The authors would like to thank Mr Barry Mark Wheaton for his invaluable linguistic and editing assistance with this study.
153
Nurses well-being in ICUs
WHAT IS KNOWN ABOUT THIS TOPIC • ICUs are usually difficult work environments because of the daily challenges caring staff have to face with critically ill patients. These challenges include much responsibility, frequent change of patients, changes in technology, and continual exposure to pain, suffering and death. • Compared with other hospital units, ICU nurses are exposed to low job satisfaction and consequently high staff turnover. • Both work and organizational factors and the quality of work relationship are primary aspects to increase affective commitment towards the work unit. WHAT THIS PAPER ADDS • Organizational factors and the quality of work relationship are also important aspects to increase affective commitment in ICUs. • Nursing work characteristics (job autonomy, nurse-physician collaboration, perceived quality of nursing practice) are directly related to team affective commitment, and the nursing work characteristics and team commitment relationship is mediated by both perceived supervisor support and job satisfaction.
REFERENCES Adams A, Bond S. (2000). Hospital nurses’ job satisfaction, individual and organizational characteristics. Journal of Nursing Management; 32: 536–543. Aiken LH, Patrician P. (2000). Measuring organizational traits of hospitals: the Revised Nursing Work Index. Nursing Research; 49: 146–153. Allen NJ, Meyer JP. (1990). The measurement and antecedents of affective, continuance, and normative commitment to the organization. Journal of Occupational Psychology; 63: 1–18. Arbuckle JL. (2007). Amos™ 16 User’s Guide. Crawfordsville: Amos Development Corp. Baggs JG, Schmitt MH, Mushlin AI, Mitchell PH, Eldredge DH, Oakes D, Hutson AD. (1999). The association between nurse-physician collaboration and patient outcomes in three intensive care units. Critical Care Medicine; 27: 1991–1998. Bakhshi A, Sharma AD, Kumar K. (2011). Organizational commitment as predictor of organizational citizenship behavior. European Journal of Business and Management; 3: 78–86. Best ME, Thurston NE. (2004). Measuring nurse job satisfaction. Journal of Nursing Administration; 34: 283–290. Blau PM. (1964). Exchange and Power in Social Life. New York: Wiley. Borda RG, Norman IJ. (1997). Factors influencing turnover and absence of nurses: a research review. International Journal of Nursing Studies; 34: 385–394. Boumans NPG, Landeweerd JA. (1994). Working in an intensive or non-intensive unit: does it make a difference? Heart & Lung; 23: 71–79. Braithwaite M. (2008). Nurse burnout and stress in the NICU. Advances in Neonatal Care; 8: 343–347. Brislin RW. (1980). Translation and content analysis of oral and written materials. In: Triandis HC, Berry JW, (eds), Handbook of Cross-Cultural Psychology. Vol. 2. Boston: Allyn and Bacon. Brown RB. (1996). Organizational commitment: clarifying the concept and simplifying the existing construct typology. Journal of Vocational Behavior; 49: 230–251. Burgess L, Irvine F, Wallymahmed A. (2010). Personality, stress and coping in intensive care nurses: a descriptive exploratory study. Nursing in Critical Care; 15: 129–140. Camerino D, Mansano Sarquis LM. (2010). Nurses’ working conditions, health and well-being in Europe (Nurses’ Early Exit Study). Professioni Infermieristiche; 63: 53–61.
154
Cohen A. (1993). Organizational commitment and turnover: a meta-analysis. Academy of Management Journal; 36: 1140–1157. Coombs M. (2003). Power and conflict in intensive care clinical decision making. Intensive and Critical Care Nursing; 19: 125–135. Cortese CG. (2001). Prima standardizzazione del Questionario per la Soddisfazione per il lavoro (QSO). Risorsa Uomo; 8: 331–349. Darvas JA, Hawkins LG. (2002). What makes a good intensive care unit: a nursing perspective. Australian Critical Care; 15: 77–82. Deci EL, Ryan RM. (1985). Intrinsic Motivation and SelfDetermination in Human Behavior. New York: Plenum. Deci EL, Ryan RM. (2000). The ”what” and ”why” of goal pursuits: human needs and the self-determination of behavior. Psychological Inquiry; 11: 227–268. Eisenberger R, Huntington R, Hutchison S, Sowa D. (1986). Perceived organizational support. Journal of Applied Psychology; 71: 500–507. English B, Morrison D, Chalon C. (2010). Moderator effects of organizational tenure on the relationship between psychological climate and affective commitment. Journal of Management Development; 29: 394–408. Gaan N. (2008). Stress, social support, job attitudes and job outcome across gender. Journal of Organizational Behavior; 52: 34–44. Galletta M, Portoghese I. (2012). Organizational citizenship behavior in healthcare: the roles of autonomous motivation, affective commitment and learning orientation. Revue Internationale de Psychologie Sociale; 25: 121–145. Galletta M, Portoghese I, Penna MP, Battistelli A, Saiani L. (2011). Turnover intention among Italian nurses: the moderating roles of supervisor support and organizational support. Nursing & Health Sciences; 13: 184–191. Galletta M, Portoghese I, Battistelli A, Leiter MP. (2013). The roles of unit leadership and nurse–physician collaboration on nursing turnover intention. Journal of Advanced Nursing; 69: 1771–1784. Gambino KM. (2010). Motivation for entry, occupational commitment and intent to remain: a survey regarding Registered Nurse retention. Journal of Advanced Nursing; 66: 2532–2541. Goffin RD, Gellatly IR. (2001). A multi-rater assessment of organizational commitment: are self-report measures biased? Journal of Organizational Behavior; 22: 437–451.
© 2014 British Association of Critical Care Nurses
Nurses well-being in ICUs
Goodman PS, Ramanujam R, Carroll JS, Edmondson AC, Hofmann DA, Sutcliffe KM. (2011). Organizational errors: directions for future research. Research in Organizational Behavior; 31: 151–176. Gouldner AW. (1960). The norm of reciprocity: a preliminary statement. American Sociological Review; 25: 161–178. Greguras GJ, Diefendorff JM. (2009). Different fits satisfy different needs: linking person-environment fit to employee commitment and performance using self-determination theory. Journal of Applied Psychology; 94: 465–477. Hair JJF, Black WC, Babin BJ, Anderson RE, Tatham RL. (2006). Multivariate Data Analysis. Upper Saddle River: PearsonPrentice Hall. Hamric A, Blackhall L. (2007). Nurse-physician perspectives on the care of dying patients in Intensive care units: collaboration, moral distress, and ethical climate. Critical Care Medicine; 35: 422–429. Hayes LJ, O’Brien-Pallas L, Duffield C, Shamian J, Buchan J, Hughes F, Spence HK, North N, Stone PW. (2006). Nurse turnover: a literature review. International Journal of Nursing Studies; 43: 237–263. Hayes LJ, O’Brien-Pallas L, Duffield C, Shamian J, Buchan J, Hughes F, Laschinger HK, North N. (2012). Nurse turnover: a literature review–an update. International Journal of Nursing Studies; 49: 887–905. Hinshaw AS, Smeltzer CH, Atwood JR. (1987). Innovative retention strategies for nursing staff. Journal of Nursing Administration; 1: 8–16. Humphrey SE, Nahrgang JD, Morgeson FP. (2007). Integrating motivational, social, and contextual work design features: a meta-analytic summary and theoretical extension of the work design literature. Journal of Applied Psychology; 92: 1332–1356. Hurst S, Koplin-Baucum S. (2005). A pilot qualitative study relating to hardiness in ICU nurses: hardiness in ICU nurses. Dimensions of Critical Care Nursing; 24: 97–100. Iliopoulou KK, While AE. (2010). Professional autonomy and job satisfaction: survey of critical care nurses in mainland Greece. Journal of Advanced Nursing; 66: 2520–2531. International Council of Nurses and the Florence Nightingale International Foundation. (2006). The Global Nursing Shortage: Priority Areas for Intervention. Geneva: The Global Nursing Review Initiative. Irvine DM, Evans MG. (1995). Job satisfaction and turnover among nurses: integrating research findings across studies. Nursing Research; 44: 246–253. Khowaja K, Merchand RJ, Hirani D. (2005). Registered nurses perception of work satisfaction at a Tertiary Care University Hospital. Journal of Nursing Management; 13: 32–39. Kline RB. (2005). Principles and Practice of Structural Equation Modelling. 2nd edn. New York: The Guilford Press. Kramer M, Schmalenberg C. (2003). Magnet hospital nurses describe control over practice. Western Journal of Nursing Research; 25: 434–452. Laschinger HKS, Almusi J, Tuer-Hodes D. (2003). Workplace empowerment and Magnet hospital characteristics: making the link. Journal of Nursing Administration; 33: 4l0–4l422. Le Blanc PM, Schaufeli WB, Salanova M, Llorens S, Nap RE. (2010). Efficacy beliefs predict collaborative practice among intensive care unit nurses. Journal of Advanced Nursing; 66: 583–594. Li J, Lambert VA. (2008). Workplace stressors, coping, demographics and job satisfaction in Chinese intensive care nurses. Nursing in Critical Care; 13: 12–24. Li Y, Dick AW, Glance LG, Cai X, Mukamel DB. (2007). Misspecification issues in risk adjustment and construction of
© 2014 British Association of Critical Care Nurses
outcome-based quality indicators. Health Services and Outcomes Research Methodology; 7: 39–56. Liou SR, Cheng CY. (2010). Organisational climate, organisational commitment and intention to leave amongst hospital nurses in Taiwan. Journal of Clinical Nursing; 19: 1635–1644. Locke EA. (1976). Nature and causes of job satisfaction. In: Dunnette MD, (ed), Handbook of Industrial and Organizational Psychology. Chicago: Rand McNally. Lok P, Crawford J. (2001). Antecedents of organizational commitment and the mediating role of job satisfaction. Journal of Managerial Psychology; 16: 594–613. MacKinnon D, Lockwood C, Hoffman J, West S, Sheets V. (2002). A comparison of methods to test mediation and other intervening variable effects. Psychological Methods; 7: 83–104. Malik OF, Waheed A, Malik KUR. (2010). The mediating effects of job satisfaction on role stressors and affective commitment. International Journal of Business and Management; 5: 223–235. Manojlovich M. (2005). Linking the practice environment to nurses’ job satisfaction through nurse/physician communication. The Journal of Nursing Scholarship; 37: 367–373. Mathieu JE, Zajac DM. (1990). A review and meta-analysis of the antecedents, correlates and consequences of organizational commitment. Psychological Bulletin; 108: 171–194. McNeese-Smith DK. (1997). The influence of manager behavior on nurses’ job satisfaction, productivity and commitment. Journal of Nursing Administration; 27: 47–55. McNeese-Smith DK. (1999). A content analysis of staff nurse descriptions of job satisfaction and dissatisfaction. Journal of Advanced Nursing; 29: 1332–1341. McNeese-Smith DK. (2001). Staff nurse views of their productivity and nonproductivity. Health Care Management Review; 26: 7–19. Meyer JP, Irving PG, Allen NJ. (1998). Examination of the combined effects of work values and early work experiences on organizational commitment. Journal of Organizational Behavior; 19: 29–52. Meyer JP, Stanley DJ, Herscovitch L, Topolnytsky L. (2002). Affective, continuance and normative commitment to the organization: a meta-analysis of antecedents, correlates and consequences. Journal of Vocational Behavior; 61: 20–52. Morgeson FP, Humphrey SE. (2006). The work design questionnaire (WDQ): developing and validating a comprehensive measure for assessing job design and the nature of work. Journal of Applied Psychology; 91: 1321–1339. Moser K. (1997). Commitment in organizations. Psychologies; 41: 160–170. Mowday RT, Porter LW, Steers RM. (1982). Employee Organizational Linkages. New York: Academy Press. Panaccio AJ, Vandenberghe C. (2009). Perceived organizational support, organizational commitment and psychological wellbeing: alongitudinal study. Journal of Vocational Behavior; 75: 224–236. Podsakoff PM, Organ DW. (1986). Self-reports in organizational research: problems and prospects. Journal of Management; 12: 531–544. Pot FD, Koningsveld EAP. (2009). Quality of working life and organizational performance: two sides of the same coin? Scandinavian Journal of Work, Environment & Health; 35: 421–428. Price JL, Mueller CW. (1981). A casual model of turnover for nurses. Academy of Management Journal; 24: 543–565. Reis MD, Ryan DW, Schaufeli WB, Fidler V. (1997). Organisation and Management of Intensive Care: A Prospective Study of 12 European Countries. Berlin: Springer Verlag.
155
Nurses well-being in ICUs
Rhoades L, Eisenberger R. (2002). Perceived organizational support: a review of the literature. Journal of Applied Psychology; 87: 698–714. Rhoades L, Eisenberger R, Armeli S. (2001). Affective commitment to the organization: the contribution of perceived organizational support. Journal of Applied Psychology; 86: 825–836. Ryan RM. (1995). Psychological needs and the facilitation of integrative processes. Journal of Personality; 63: 397–427. Sheel S, Sindhwani BK, Goel S, Pathak S. (2012). Quality of work life, employee performance and career growth opportunities: a literature review. International Journal of Multidisciplinary Research; 2: 291–300. Stein-Parbury J, Liaschenko J. (2007). Understanding collaboration between nurses and physicians as knowledge at work. American Journal of Critical Care; 16: 470–478. Taylor JS. (1996). Collaborative practice within the intensive care unit: a deconstruction. Intensive and Critical Care Nursing; 12: 64–70. Thomas E, Sexton J, Helmreich R. (2003). Discrepant attitudes about teamwork among critical care nurses and physicians. Critical Care Medicine; 31: 956–959. Thompson CA, Prottas DJ. (2005). Relationships among organizational family support, job autonomy, perceived control, and employee well-being. Journal of Occupational Health Psychology; 11: 100–118.
156
Upenieks VV. (2003). The interrelationship of organizational characteristics of magnet hospitals, nursing leadership, and nursing job satisfaction. Health Care Manager; 22: 83–98. Utriainen K, Kynga H. (2009). Hospital nurses’ job satisfaction: a literature review. Journal of Nursing Management; 7: 1002–1010. Vanaki Z, Vagharseyyedin SA. (2009). Organizational commitment, work environment conditions, and life satisfaction among Iranian nurses. Nursing & Health Sciences; 11: 404–409. Wagner CM. (2007). Organizational commitment as a predictor variable in nursing turnover research: literature review. Journal of Advanced Nursing; 60: 235–247. Wasti SA. (2003). Organizational commitment, turnover intentions and the influence of cultural values. Journal of Occupational and Organizational Psychology; 76: 303–321. Wells N, Roberts L, Medlin LC. (2002). Issues related to staff retention and turnover. Seminars for Nurse Managers; 10: 171–179. Zangaro GA, Soeken KL. (2007). A meta-analysis of studies of nurses’ job satisfaction. Research in Nursing & Health; 30: 445–458. Zhang A, Tao H, Ellenbecker CH, Liu X. (2013). Job satisfaction in mainland China: comparing critical care nurses and general ward nurses. Journal of Advanced Nursing; 69: 1725–1736.
© 2014 British Association of Critical Care Nurses
