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International Journal of Nursing Practice 2014; ••: ••–••

RESEARCH PAPER

Profiling nurses’ job satisfaction, acculturation, work environment, stress, cultural values and coping abilities: A cluster analysis Yong-Shian Goh RN RMN PhD Candidate, Senior Lecturer, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, Singapore

Alice Lee BSc (Hons) Nursing Student, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, Singapore

Sally Wai-Chi Chan RN PhD Head and Professor, School of Nursing & Midwifery, Faculty of Health and Medicine, University of Newcastle, New South Wales, Australia

Moon Fai Chan PhD CStat Associate Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, Singapore

Accepted for publication November 2013 Goh Y-S, Lee A, Chan SW, Chan MF. International Journal of Nursing Practice 2014; ••: ••–•• Profiling nurses’ job satisfaction, acculturation, work environment, stress, cultural values and coping abilities: A cluster analysis

This study aimed to determine whether definable profiles existed in a cohort of nursing staff with regard to demographic characteristics, job satisfaction, acculturation, work environment, stress, cultural values and coping abilities. A survey was conducted in one hospital in Singapore from June to July 2012, and 814 full-time staff nurses completed a self-report questionnaire (89% response rate). Demographic characteristics, job satisfaction, acculturation, work environment, perceived stress, cultural values, ways of coping and intention to leave current workplace were assessed as outcomes. The two-step cluster analysis revealed three clusters. Nurses in cluster 1 (n = 222) had lower acculturation scores than nurses in cluster 3. Cluster 2 (n = 362) was a group of younger nurses who reported higher intention to leave (22.4%), stress level and job dissatisfaction than the other two clusters. Nurses in cluster 3 (n = 230) were mostly Singaporean and reported the lowest intention to leave (13.0%). Resources should be allocated to specifically address the needs of younger

Correspondence: Moon Fai Chan, Alice Lee Centre for Nursing Studies, National University of Singapore, MD11, Level 2, 10 Medical Drive, Singapore 117597, Singapore. Email: [email protected] doi:10.1111/ijn.12318

© 2014 Wiley Publishing Asia Pty Ltd

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Y-S Goh et al.

nurses and hopefully retain them in the profession. Management should focus their retention strategies on junior nurses and provide a work environment that helps to strengthen their intention to remain in nursing by increasing their job satisfaction. Key words: acculturation, cluster analysis, job satisfaction, nurse, stress, work environment.

INTRODUCTION The global health-care system is experiencing significant changes, notably with regard to scarcity of resources and centralized control. Many countries are experiencing a shortage of nurses, together with increasing demands related to the needs of patients with acute and chronic illnesses. There is also a growing emphasis on costeffectiveness.1 These accelerating changes influence nurses’ job satisfaction.2,3 Dissatisfied nurses could be distracted from the needs of their patients and fail to provide quality care. Singapore is no exception to the increasing global shortage of nurses. The current projection is that there will be a shortage of 6400 nurses by the year 2020 and that the shortage will continue to escalate.4–6 As the nursing shortage remains critical, it is important to understand whether the nursing turnover rate is related to job satisfaction. One of the ways to increase the size of the nursing workforce is to retain those who already employed as nurses. Many studies have suggested that nurses’ intention to leave nursing is associated with job dissatisfaction.1,2,7 Job satisfaction is defined by two components: affective feelings of satisfaction and perceptual evaluation of the fulfilment of one’s needs.8 When personal job expectations do not correspond to actual circumstances, a negative psychological response is likely to result. Inconsistency with expectations exerts a mediating effect on job satisfaction and, ultimately, a direct effect on turnover intent. Various factors have been associated with the outcome of job satisfaction, but different investigators have found different degrees of impact for these factors. This paper reports the findings of a study on factors related to nurses’ job satisfaction, acculturation, work environment, stress, cultural values and coping abilities. The literature has suggested many factors as related to job satisfaction. Staff welfare, including pay, benefits and support facilities, has been found to be significantly associated with job satisfaction in many studies.8–13 Workplace environment, comprising interpersonal relationships and interactions, managerial and organizational culture and support services, professional opportunities and degree of © 2014 Wiley Publishing Asia Pty Ltd

autonomy, has also been found important in the evaluation of job satisfaction.7,10,11,14 On the other hand, professional stress and poor leadership quality have been highlighted as major sources of job dissatisfaction among nurses.8,14 Patrician and colleagues15 found that nurses working in a favourable working environment were three times more likely to remain in their current employment. With active global recruitment of nurses across national boundaries in an effort to manage nursing shortage, acculturation has been found to be a predictor of job satisfaction among migrant nurses.16 Migrant nurses have reported the experience of feeling lost and lonely when they left their home countries.17 Numerous cultural obstacles and challenges must be overcome to adapt to the host country. Language has often been reported as the most significant challenge for foreign-educated migrant nurses.16,18,19 Incongruence in sociocultural practice has been reported to affect acculturation.20–22 However, studies have found language competency to be linked to positive psychological outcome and effective in reducing acculturative stress.23,24 To help retain migrant nurses, employers must help them to develop culturally appropriate coping strategies. Other factors associated with job satisfaction include nurses’ demographic characteristics, such as age, work experience and educational attainment.3,10,25 For many years, an inverse relationship between age and turnover has been demonstrated. As a possible explanation of their greater tendency to stay on the job, McNeese-Smith and van Servellen26 suggested that mature nurses have greater productivity, job satisfaction and organizational commitment. Shader and colleagues27 reported that younger nurses were more likely to leave the workforce because they had experienced more stress and less job satisfaction. Chan et al.10 found that nurses who had worked for less than 5 years were 4.62 times more likely to leave than nurses with over 10 years of working experience. However, Chan and Morrison9 did not find age to be significant in determining nurses’ intent to leave. In summary, findings are inconclusive regarding the relationship among nurses’ job satisfaction, demographic

Cluster analysis of nursing staff

characteristics, working environment, stress, acculturation, cultural values and ways of coping. In Singapore, there are few studies on the relationships among these factors. In addition, there is also limited knowledge about whether definable profiles exist in a cohort of nursing staff with regard to these factors. The present quantitative study addresses this information gap for Singapore nurses. The aim of this study was to determine whether definable profiles exist in a cohort of nursing staff regarding factors associated with nurses’ demographic characteristics, job satisfaction, working environment, stress, acculturation, cultural values and ways of coping. If nursing staff have different profiles on these factors, then understanding each profile is important from a management point of view. Management could develop integrated approach for each profile group to promote staff communication and recognition of nurses’ contributions within the hospital. Two specific research objectives were formulated: 1. To identify the profiles of nursing staff based on seven variables: demographic characteristics, job satisfaction, working environment, stress, acculturation, cultural values and ways of coping. 2. To explore differences among nursing staff in terms of the seven variables.

METHODS Design, setting and sample A cross-sectional survey was conducted in an acute hospital in Singapore. Data were collected from June to July 2012. All full-time registered nurses (nurses registered with the Singapore Nursing Board) working at the study venue during the data collection period composed the target population. A power analysis assuming a 10% variation of interest, an 80% response rate, desired power of 80% and alpha of 5% indicated that the initial target recruitment should be around 800 participants.28,29 We expected a 10–15% non-response rate from the sample, so we needed to survey around 914 nurses from the target hospital. This sample size was reasonable because the target hospital had employed more than 1000 full-time registered nurses during the data collection period. A total of 868 participants returned the questionnaire. Returned questionnaires that were less than 90% completed were considered invalid. A total of 814 valid questionnaires were analysed for this report (response rate was 89%).

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Measures The instrument consisted of seven sections in English. Content validity was ascertained by a panel of three academic nurses and three clinical nurses. The content validity index (CVI) of the instruments was > 0.89, representing an acceptable value.30 The seven sections were the following; 1. Sociodemographic data. Gender, age, citizenship, religion, marital status, nursing qualification, nursing experience, nursing rank and living arrangements were included. In addition, the question ‘Do you have the intention to leave nursing in the coming year?’ was asked, with two response choices (‘yes’ and ‘no’). 2. Nurses’ Job Satisfaction Scale. This 37-item Likertscaled tool was used to examine nurses’ job satisfaction levels with regard to five components:10,31 (i) pay and benefits (10 items; α = 0.87); (ii) support (7 items; α = 0.87); (iii) autonomy and professional opportunities (10 items; α = 0.83); (iv) scheduling (6 items; α = 0.77); and (v) relationships and interaction (4 items; α = 0.67). Overall internal consistency was α = 0.82. Items were ranked on a five-point scale, from 5, ‘very satisfied’, to 1, ‘very dissatisfied’. The average total scores were used for comparison, with higher scores indicating positive job satisfaction levels. 3. A short acculturation scale. This self-administered 12-item questionnaire was used to measure three dimensions of acculturation: (i) language use and preference at work, at home and with friends (5 items; α = 0.78); (ii) language use and preference in media (TV and radio) programmes (3 items; α = 0.81); and (iii) preferred ethnicity for social relations (4 items; α = 0.71). Each item is scored from 1 to 5; the lowest possible score is 12, and the highest is 60. Lower scores indicate less acculturation, and higher scores indicate more acculturation.32 4. The Practice Environment Scale of the Nursing Work Index—Revised. This scale comprises 31 items.33 It was used to measure how the practice environment influences nurse and patient outcomes in five domains (Cronbach’s alpha for overall internal consistency: α = 0.96): (i) nurse participation in hospital affairs (9 items; α = 0.83); (ii) nursing foundations for quality of care (10 items; α = 0.80); (iii) nurse manager ability, leadership and support of nurses (5 items; α = 0.84); (iv) staffing and resource adequacy (4 items; α = 0.80); and (v) collegial nurse–physician relations (3 items; α = 0.71). Each item is scored © 2014 Wiley Publishing Asia Pty Ltd

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according to the value assigned to the response, from 1 to 4. The average total scores were used for comparison, with lower scores indicating stronger agreement that an organizational characteristic is present. 5. The Expanded Nursing Stress Scale. This 34-question scale was used to measure the frequency and major sources of stress experienced by nurses through three components (Cronbach’s alpha for overall internal consistency: α = 0.89): (i) the physical environment (workload; α = 0.86); (ii) the psychological environment (α = 0.81); and (iii) the social environment (α = 0.77). Scores are scaled from 1 to 4; possible scores range from 34 to 136, with higher scores indicating more frequent stress.34 6. Cultural Value Scale. This 26-item scale was used to assess cultural dimensions at the individual level based on five dimensions: (i) power distance (5 items; α = 0.63); (ii) uncertainty avoidance (5 items; α = 0.81); (iii) collectivism (6 items; α = 0.81); (iv) masculinity (4 items; α = 0.61); and (v) long-term orientation (6 items; α = 0.85). Each item was rated on a five-point scale from ‘strongly disagree’ or ‘not at all important’ (1) to ‘strongly agree’ or ‘very important’ (5). Possible scores range from 26 to 130, with higher scores indicating more frequent stress due to cultural issues.35,36 7. Ways of Coping Questionnaire. This 66-item instrument is used to analyse how people deal with internal and external demands of a specific stressful encounter through a range of thoughts and actions.37,38 Respondents were asked to answer the questionnaire with regard to a specific stressful situation experienced in the past week. Coping factors are categorized into eight domains: (i) confrontive coping (6 items; α = 0.70); (ii) distancing (7 items; α = 0.61); (iii) self-controlling (7 items; α = 0.76); (iv) seeking social support (6 items; α = 0.76); (v) accepting responsibility (4 items; α = 0.66); (vi) escape/avoidance (8 items; α = 0.76); (vii) planful problem solving (6 items; α = 0.68); and (viii) positive reappraisal (7 items; α = 0.79). Each item was rated from 0 to 3. Raw scores describe the coping effort for each of the coping methods, with higher raw score indicating a higher frequency of use of the behaviour when coping with a stressful event. Relative score is used to describe the proportion of effort represented for each coping method, expressed as a percentage. © 2014 Wiley Publishing Asia Pty Ltd

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Data collection and ethical issues Ethical approval was obtained from the institutional review board of the National University Health System (DSRB 2011/02051). A stratified random sample from each stratum (ward or centre) was selected using proportional sampling, based on strata sizes and the required study sample sizes. Using a computer program, the research team generated 914 unique random numbers from 0001 to 9999.39 Nursing staff whose working numbers’ last four digits matched the randomly generated numbers were selected to participate in this survey. A cover letter explaining the purpose of this research study was included in an envelope together with the participant information sheet, consent form and questionnaire. Approximately 40 min was required to complete the questionnaire. Participation in the survey was voluntary, and confidentiality was assured through maintenance of anonymity; no identification was needed upon return of the questionnaires. Participants were given a 2-week period to complete the questionnaire before the research team returned to the wards for collection.

Statistical analysis Cluster analysis is an approach allowing exploratory analysis of a sample when researchers suspect it is not homogeneous.28,40 In this study, a two-step technique was used to analyse both ordinal and categorical variables together in the same model. The analysis was performed with SPSS v. 1641 and includes seven main variables, as described in the Measures section. Cronbach’s alpha was used to examine the internal consistency of each tool used in the instrument. The choice of a similarity measure and determination of the number of clusters were based on the smallest change in Akaike information criterion (AIC) values.42 When clusters had been identified within the samples, group comparison was performed. Descriptive statistics were used to describe the data by clusters. For categorical and ordinal data, the χ2-test and ANOVA, respectively, were used to examine any significant differences between the clusters. The post hoc test (Bonferroni correction) was used for multiple-group comparisons, and all results were considered significant at P < 0.05.

RESULTS Cluster analysis The two-step cluster analysis split the study sample into three clusters based on AIC changes (change = −21.17)

Cluster analysis of nursing staff

(Table 1). Clusters 1, 2 and 3 contained 222 (27.3%), 362 (44.5%) and 230 (28.2%) registered nurses, respectively. The three clusters were formed based on similarity in their responses to the seven instruments measuring the variables of demographic characteristics, job satisfaction, working environment, stress, acculturation, culture and ways of coping. Subsequently, the three clusters were compared with regard to the seven variables. Cluster 1 was characterized by nurses who were experienced (55.8% having more than 9 years of experience) but junior in rank (76.6%). The majority were Filipino (93.1%) and living with friends (30.5%), and 16.2% of them reported intention to leave in the next year. Cluster 2 was mostly under 30 years of age (88.4%) and junior-level (83.1% were staff nurses); the majority were Chinese (65.2%), single (80.9%) and with less than 5 years of nursing experience (76.8%), and 22.4% of them had the intention to leave in the following year. In cluster 3, the majority of the nurses were senior-level (77.4% were senior staff nurses/managers) and middleaged (52.2% were more than 36 years old); most were Singaporean (61.3%) and had more than 9 years of nursing experience (86.5%). This group reported the lowest degree (13.0%) of intention to leave among the three clusters. Upon comparison, it was clear that there were significant differences in demographic factors among the three clusters.

Comparison of data by clusters Table 2 shows the Cronbach’s alpha values and scores obtained for the nurses for each instrument. For the job satisfaction instrument, nurses in cluster 2 (Mean = 3.29, SD = 0.44) were least satisfied when compared with nurses in clusters 1 (Mean = 3.46, SD = 0.42) and 3 (Mean = 3.55, SD = 0.41) with regard to the total score as well as all five subscales (P < 0.001). On the acculturation scale, nurses in cluster 1 reported the lowest acculturation score (Mean = 34.45, SD = 5.82) compared with cluster 2 (Mean = 36.38, SD = 8.94) and cluster 3 (Mean = 38.13, SD = 8.14) (P < 0.001). On the nursing stress scale, nurses in cluster 2 (physical: Mean = 14.21, SD = 2.89; psychological: Mean = 33.87, SD = 5.62; social: Mean = 18.52, SD = 3.69) reported a higher level of stress in comparison with those in cluster 1 (physical: Mean = 13.35, SD = 2.71; psychological: Mean = 31.23, SD = 6.27; social: Mean = 18.41, SD = 3.52) and cluster 3 (physical: Mean = 13.49, SD = 3.05; psy chological: Mean = 31.80, SD = 6.25; social:

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Mean = 17.62, SD = 3.55). Significance of differences was P = 0.001 for physical stress, P < 0.001 for psychological stress and P = 0.008 for social stress. On the cultural values scale, nurses in cluster 2 (Mean = 82.02, SD = 8.12) reported the lowest level of stress due to cultural issues as compared with cluster 1 (Mean = 84.85, SD = 7.49) and cluster 3 (Mean = 85.19, SD = 8.32) (P < 0.001). However, stress levels were higher with regard to uncertainty avoidance (Mean = 21.22, SD = 2.86) and long-term orientation (Mean = 24.05, SD = 3.01) among nurses in cluster 1 when compared with the other two clusters. With regard to ways of coping, nurses in cluster 1 (Mean = 111.95, SD = 25.77) indicated more frequent use of coping strategies than nurses in cluster 2 (Mean = 94.01, SD = 25.10) and cluster 3 (Mean = 93.49, SD = 26.90) (P < 0.001). Cluster 1 nurses scored lower on distancing (Mean = 11.07, SD = 2.87; P = 0.031) and self-controlling (Mean = 11.95, SD = 2.13; P = 0.001) and higher on escape/ avoidance (P < 0.001) and positive reappraisal (P < 0.001) when compared with those in the other clusters.

DISCUSSION The aim of this study was to determine whether definable profiles existed in a cohort of nursing staff with regard to nurses’ demographic characteristics, job satisfaction, working environment, stress, acculturation, cultural values and ways of coping. The findings indicate that the members of this sample are a heterogeneous group. There were also differences among the three clusters regarding nurses’ job satisfaction. Previous investigators have always concentrated on particular factors as determinants of job satisfaction,2,8,11 but contradictory results were found in this study. The increasing heterogeneity evident in nurses’ job satisfaction needs to be reflected in future empirical work. For example, it could be that personality of the worker could be more important than the nature of the work in explaining job satisfaction. People can become dissatisfied with their jobs if their higher-order needs, such as achievement, are not fulfilled. Accordingly, Knoop43 concluded that ‘work may merely lead to the satisfaction of lower-order needs like pay and security’. These reflections on aspects of job satisfaction were taken into account in Tourangeau and colleagues’ study of 78 Canadian nurses, where findings showed that hospital nurse intention to stay primarily depends on relationships with patients, co-workers and supervisors, conditions in the work environment, work rewards, © 2014 Wiley Publishing Asia Pty Ltd

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Table 1 Comparison of nurse characteristics by cluster (n = 814) Total

χ2

Cluster, n (%)

P-value

1 (n = 222) 2 (n = 362) 3 (n = 230) Gender Male 35 (4.3) 2 (0.9) Female 779 (95.7) 220 (99.1) Age (years) Below 30 412 (50.6) 68 (30.6) 31–35 163 (20.0) 62 (27.9) > 36 34 (29.4) 92 (41.5) Race Chinese 352 (43.2) 11 (5.0) Filipino 212 (26.0) 207 (93.1) Malay 94 (11.5) 0 (0.0) Indian 116 (14.3) 2 (0.9) 40 (4.9) 2 (1.0) Other† Nationality Singaporean 319 (39.2) 2 (0.9) Non-Singaporean 495 (60.8) 220 (99.1) Religion Freethinker 192 (23.6) 83 (37.4) Buddhist/Taoist 148 (18.2) 0 (0.0) Muslim 112 (13.8) 2 (0.9) Christian 304 (37.3) 137 (61.7) Hindu 58 (7.1) 0 (0.0) Marital status Single 419 (51.5) 94 (42.3) Married 374 (45.9) 120 (54.1) 21 (2.6) 8 (3.6) Other‡ Years of nursing experience ≤5 306 (37.6) 25 (11.3) 6–8 159 (19.5) 73 (32.9) ≥9 349 (42.9) 124 (55.8) Professional rank Staff nurse 523 (64.3) 170 (76.6) Senior staff nurse 235 (28.9) 51 (23.0) Manager 56 (6.8) 1 (0.4) Intention to leave in the coming year Yes 147 (18.1) 36 (16.2) No 667 (81.9) 186 (83.8) Living arrangements With family 496 (60.9) 62 (27.9) With friends 248 (30.5) 146 (65.8) Alone 70 (8.6) 14 (6.3)

Overall

1 vs. 2

12.59 < 0.001** < 0.001** 25 (6.9) 337 (93.1)

8 (3.5) 222 (96.5)

320 (88.4) 15 (4.1) 27 (7.5)

24 (10.4) 86 (37.4) 120 (52.2)

236 (65.2) 2 (0.6) 59 (16.3) 36 (9.9) 29 (8.0)

105 (45.7) 3 (1.3) 35 (15.2) 78 (33.9) 9 (3.9)

176 (48.6) 186 (51.4)

141 (61.3) 89 (38.7)

85 (23.5) 100 (27.7) 70 (19.3) 87 (24.0) 20 (5.5)

24 (10.5) 48 (20.8) 40 (17.4) 80 (34.8) 38 (16.5)

293 (80.9) 68 (18.8) 1 (0.3)

32 (13.9) 186 (80.9) 12 (5.2)

278 (76.8) 58 (16.0) 26 (7.2)

3 (1.3) 28 (12.2) 199 (86.5)

301 (83.1) 59 (16.3) 2 (0.6)

52 (22.6) 125 (54.3) 53 (23.1)

81 (22.4) 281 (77.6)

30 (13.0) 200 (87.0)

222 (61.3) 95 (26.3) 45 (12.4)

212 (92.1) 7 (3.1) 11 (4.8)

0.106

2 vs. 3 0.10

391.09 < 0.001** < 0.001** < 0.001** < 0.001**

790.27 < 0.001** < 0.001** < 0.001** < 0.001**

197.27 < 0.001** < 0.001** < 0.001** < 0.001**

229.39 < 0.001** < 0.001** < 0.001** < 0.001**

264.61 < 0.001** < 0.001** < 0.001** < 0.001**

516.91 < 0.001** < 0.001** < 0.001** < 0.001**

283.40 < 0.001**

8.98

0.011*

0.134

0.089

< 0.001** < 0.001**

0.411

0.004*

237.66 < 0.001** < 0.001** < 0.001** < 0.001** \

* P < 0.05; ** P < 0.01. † Including Eurasian, Burmese, etc. ‡ Divorced, separated, widowed, etc.

© 2014 Wiley Publishing Asia Pty Ltd

1 vs. 3

© 2014 Wiley Publishing Asia Pty Ltd

* P < 0.05; ** P < 0.01.

Nurses’ Job Satisfaction Scale Pay and benefits (10 items) Support (7 items) Autonomy and professional opportunities (10 items) Scheduling (6 items) Relationships and interaction (4 items) Acculturation scale Preference at work, home, friends (5 items) Preference in media (3 items) Preferred ethnicity for social relations (4 items) Practice Environment Scale of Nursing Work Indez—Revised Nurse participation in hospital affairs (9 items) Nursing foundations for quality of care (10 items) Nurse manager ability, leadership, support of nurses (5 items) Staffing and resource adequacy (4 items) Collegial nurse–physician relations (3 items) Expanded Nursing Stress Scale Physical environment Psychological environment Social environment Cultural Value Scale Power distance (5 items) Uncertainty avoidance (5 items) Collectivism (6 items) Masculinity (4 items) Long-term orientation (6 items) Ways of Coping Questionnaire Confrontive coping (6 items) Distancing (7 items) Self-controlling (7 items) Seeking social support (6 items) Accepting responsibility (4 items) Escape/avoidance (8 items) Planful problem solving (6 items) Positive reappraisal (7 items)

Outcome

0.70 0.61 0.76 0.76 0.66 0.76 0.68 0.79

0.63 0.81 0.81 0.61 0.85

0.86 0.81 0.77

0.83 0.80 0.84 0.80 0.71

0.78 0.81 0.71

0.87 0.87 0.83 0.77 0.67

Cronbach’s alpha

3.46 (0.42) 3.22 (0.52) 3.37 (0.50) 3.79 (0.46) 3.36 (0.67) 3.56 (0.51) 34.35 (5.82) 13.78 (3.26) 10.71 (2.28) 9.86 (1.96) 2.19 (0.30) 2.22 (0.35) 2.10 (0.27) 2.18 (0.49) 2.38 (0.47) 2.20 (0.41) 63.00 (10.36) 13.35 (2.71) 31.23 (6.27) 18.41 (3.52) 84.85 (7.49) 10.15 (3.54) 21.22 (2.86) 19.80 (3.76) 9.64 (2.86) 24.05 (3.01) 111.95 (25.77) 10.33 (2.75) 11.07 (2.87) 11.95 (2.13) 14.50 (2.54) 13.41 (2.34) 9.01 (2.71) 14.69 (2.56) 15.04 (2.21)

3.29 (0.44) 3.04 (0.54) 3.10 (0.55) 3.57 (0.51) 3.32 (0.64) 3.52 (0.52) 36.38 (8.94) 14.36 (4.47) 9.48 (3.08) 12.54 (3.41) 2.27 (0.33) 2.32 (0.40) 2.16 (0.31) 2.23 (0.48) 2.48 (0.48) 2.25 (0.60) 66.60 (10.24) 14.21 (2.89) 33.87 (5.62) 18.52 (3.69) 82.02 (8.12) 9.78 (2.99) 19.55 (3.31) 19.53 (3.46) 10.00 (3.04) 23.16 (3.09) 94.01 (25.10) 10.09 (3.24) 11.75 (3.54) 12.80 (2.82) 15.01 (3.67) 13.17 (3.04) 9.27 (3.40) 14.41 (3.23) 13.51 (3.24)

3.55 (0.41) 3.40 (0.56) 3.31 (0.59) 3.76 (0.40) 3.59 (0.52) 3.79 (0.45) 38.13 (8.14) 16.01 (4.09) 9.39 (3.28) 12.73 (3.01) 2.18 (0.31) 2.22 (0.39) 2.12 (0.29) 2.13 (0.37) 2.33 (0.45) 2.17 (0.49) 62.91 (10.69) 13.49 (3.05) 31.80 (6.25) 17.62 (3.55) 85.19 (8.32) 10.91 (3.47) 20.24 (2.74) 20.15 (3.22) 10.62 (3.01) 23.27 (2.84) 93.49 (26.90) 10.37 (3.39) 11.22 (3.25) 12.50 (2.91) 14.70 (3.51) 13.04 (3.35) 7.93 (3.22) 15.47 (3.24) 14.75 (3.70)

29.08 32.50 20.15 19.84 14.75 22.82 12.69 18.94 15.02 69.80 6.60 7.64 2.90 3.82 7.46 1.61 12.37 7.54 16.02 4.80 14.17 8.34 20.75 2.24 6.32 6.45 39.95 0.73 3.49 6.85 1.65 0.90 12.85 8.46 19.96

F-statistic

3 (n = 230)

1 (n = 222)

2 (n = 362)

ANOVA

Cluster, mean (SD)

Table 2 Comparison of nurses’ responses to survey instruments by cluster (n = 814)

1 vs. 2 < 0.001** < 0.001** < 0.001** < 0.001** 0.791 0.666 0.003** 0.200 < 0.001** < 0.001** 0.015* 0.003** 0.054 0.476 0.035* 0.570 < 0.001** 0.002** < 0.001** 0.997 < 0.001** 0.481 < 0.001** 0.769 0.457 0.002** < 0.001** 0.704 0.046* < 0.001** 0.147 0.648 0.690 0.880 < 0.001**

Overall < 0.001** < 0.001** < 0.001** < 0.001** < 0.001** < 0.001** < 0.001** < 0.001** < 0.001** < 0.001** 0.001** 0.001** 0.056 0.022* 0.001** 0.200 < 0.001** 0.001** < 0.001** 0.008** < 0.001** < 0.001** < 0.001** 0.108 0.002** 0.002** < 0.001** 0.485 0.031* 0.001** 0.194 0.407 < 0.001** < 0.001** < 0.001**

P-value

0.080* 0.001** 0.647 0.773 < 0.001** < 0.001** < 0.001** < 0.001** < 0.001** < 0.001** 0.998 0.998 0.853 0.520 0.953 0.885 0.995 0.999 0.704 0.057 0.993 0.064 0.001** 0.641 0.001** 0.019* < 0.001** 0.998 0.995 0.064 0.873 0.439 < 0.001** 0.021* 0.686

1 vs. 3

< 0.001** < 0.001** < 0.001** < 0.001** < 0.001** < 0.001** 0.043 < 0.001** 0.980 0.863 0.004** 0.004** 0.331 0.009** 0.001** 0.248 < 0.001** 0.010* < 0.001** 0.009** < 0.001** < 0.001** 0.018* 0.079 0.043* 0.995 0.993 0.665 0.177 0.537 0.669 0.948 < 0.001** < 0.001** < 0.001**

2 vs. 3

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organizational support and psychological responses to work.3 It is possible that the absence of satisfaction with these aspects results in lack of involvement among nurses.8,12 Involvement and commitment are necessary for nurses to stay in their jobs but might be experienced differently. Instead of identification or loyalty, as Chan et al.10 suggested, commitment could mean making a pledge to the nursing staff. Satisfaction with the work in particular, but also with supervision, was found to be related to commitment.9 The majority of the respondents in the study by Tourangeau and colleagues3 felt that their managers had direct influence on their work environment, process and reward; therefore, fair supervision is seen as a form of support for nurses in the ward. These findings seem reasonable because when staff enjoy their work, they will stay on with the organization.3 This implies that commitment can decrease if the job ceases to be challenging, either because its nature changes or because the staff get bored with it.8 Nursing staff might feel satisfaction from caring for patients and remain committed to the hospital, but the hospital at which they are employed might not mean as much as the profession itself. Results from our study showed that 18.1% of nurses had the intention to leave, and this was most evident among the nurses in cluster 2 (22%), who were younger in age. This result is similar to that of the study conducted by Shader and colleagues,27 who reported that younger nurses were more likely to leave the workforce than nurses in middle age because they experienced more stress and less job satisfaction. Nurses in cluster 3, with the majority being seniorlevel, middle-aged, Singaporean and with more than 9 years’ nursing experience, had the lowest intention to leave among the three groups. This result corresponds with those of the study conducted by Adams and Bond,44 where it was suggested that nurses’ job grade affects their perceived satisfaction level, with those in higher management reporting greater satisfaction. Similarly, Tsai and Wu45 found that nurses who were 31–40 years old reported greater job satisfaction than those below 30 years. These results might be due to nurses in their mid30s shifting to less physically demanding and non-acute work roles26 or to managerial positions, where they experience a higher level of satisfaction and better jobs compared with their younger counterparts.2 Nurses from cluster 2 were generally dissatisfied with their pay and benefits and staff scheduling, as well as relationships and interactions. This result is congruent © 2014 Wiley Publishing Asia Pty Ltd

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with the findings of Chan and Morrison,9 who found that nurses in their study reported similar dissatisfaction with pay and benefits. Likewise, Tzeng46 reported that support for autonomy, executives’ leadership styles and communication remained important factors influencing nurses’ reported job satisfaction.

Limitations This study used self-report questionnaires to collect data, which might have led to response bias.30 In future studies, a longitudinal design could be employed to examine potential changes in intent to leave or job satisfaction over time. Finally, greater use of qualitative methods could further enrich understanding of these phenomena.

Implications for nursing practice Hospital management should focus their retention strategies on junior nurses and provide a work environment that helps increase their job satisfaction. For nurses who are younger or come from overseas, attention should also be given to collaborative efforts to promote better communication between health-care workers and to establishment of programmes that promote recognition of nurses’ contribution to the hospital. However, such strategies might have a positive impact only on nurses whose profiles are similar to those of the nurses in clusters 1 and 2 in our study. For senior staff, small-group meetings that allow staff members to share reflections on their own work can be used to promote job satisfaction. Further, in promoting job satisfaction, it is crucial that the nurses work together with top management. Finally, the key findings from this study should be communicated to hospital administrators so that they can be utilized to improve job satisfaction and thus manage the turnover rate among nurses.

CONCLUSION The nursing shortage in Singapore affects the quality of care provided to health-care consumers in the hospitals. It is therefore important for health-care administrators to understand the determining factors that affect job satisfaction among nurses working in Singapore. The results of this study showed that 18.1% of participants had the intention to leave their organization within the next year. This intention was most evident among the nurses in cluster 2 (22%), who were younger in age. Resources should be allocated to specifically address the needs of young nurses and hopefully retain them in the profession.

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ACKNOWLEDGEMENTS The authors would like to thank the nursing director of the study venue and all the participants of the study. This study was supported by a Nursing Research Grant from the Ministry of Health, Singapore (R-545-000-041–290).

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