Journal of Nursing Management, 2015, 23, 1076–1085
Relationship between job satisfaction, professional identity and intention to leave the profession among nurses in Turkey SELMA SABANCIOGULLARI
PhD, RN
1
and SELMA DOGAN
PhD, RN
2
1
Assistant Professor, Department of Psychiatric Nursing, Cumhuriyet University, Health High School of Susehri, Sivas, and 2Professor, Uskudar University, Faculty of Health Sciences, Istanbul, Turkey
Correspondence Selma Sabanciogullari Department of Psychiatric Nursing Health High School of Susehri Cumhuriyet University 58140 Sivas Turkey E-mail: [email protected]
SABANCIOGULLARI S, DOGAN S.
(2015) Journal of Nursing Management 23, 1076– 1085. Relationship between job satisfaction, professional identity and intention to leave the profession among nurses in Turkey Aims The purpose of this study is to investigate the relationship between job satisfaction, professional identity and intention to leave the profession among nurses in Turkey. Background Although there are many studies on job satisfaction among nurses in Turkey, there is a gap in the literature in relation to professional identity, particularly for intentions to leave the profession. Method This cross-sectional, descriptive and correlational study was conducted with 2122 nurses from Turkey. Results A positive and significant correlation was determined between the nurses’ job satisfaction and professional identities. It was found that 15.5% of the nurses intended to leave their profession. Intention to leave the profession was greater among the nurses with inadequate professional identity development and low job satisfaction. Conclusion Professional identity is a factor affecting job satisfaction. Both professional identity and job satisfaction are important factors affecting nurses’ intention leaving the profession. Implications for nursing management Given that professional identity and job satisfaction affect intention to leave the profession and professional identity affects job satisfaction, nurse managers who are mainly responsible for the quality of nursing care should develop strategies that support nurses’ professional identity and increase their job satisfaction if they are to prevent nurses from leaving the profession.
Keywords: intention to leave the profession, job satisfaction, professional identity, registered nurse Accepted for publication: 26 June 2014
Introduction Nursing shortages and nurse turnover have become an issue of international importance (Hyrkas & Morton 2013). The European Commission has estimated that there will be a shortage of 590 000 nurses by the year 2020 (Flinkman et al. 2013). In addition, most of the member countries of the Organisation for Economic Co-operation and Development (OECD) have 1076
reported concerns regarding nurse shortages (Flinkman et al. 2010). Whereas the number of the nurses per 1000 persons is 8.4 in OECD countries, 10.8 in the USA and 9.7 in the UK, it is only 1.56 in Turkey (OECD 2011). Nursing shortages in the health sector threaten the quality and safety of the patient care services. Several studies have reported that higher nurse staffing levels are associated with better quality and safety of care for patients (Needleman et al. 2011, DOI: 10.1111/jonm.12256 ª 2014 John Wiley & Sons Ltd
Job satisfaction, professional identity in nurses
Aiken et al. 2012, Zhu et al. 2012). Tervo-Heikkinen et al. (2008) found that if the nursing staff took care of more than eight patients, satisfaction with the care received dropped. Many health-service providers are being monitored for quality, therefore, managers must control and supervise issues of quality, and this includes provision of the workforce that matches the patients’ needs for care. Nurse turnover is described as a withdrawal process in which nurses first leave the unit, then the hospital and finally the profession (Cortese 2012, Flinkman et al. 2013). While much of the research has focused on nurses’ intentions to or considerations about leaving their job or organisation, fewer studies have been conducted on intentions to leave the profession (Flinkman et al. 2010). Therefore, in this study, nurses’ intention to leave was considered as the intention to leave the profession. Several international studies have determined that from 9% to 26% of the nurses express intentions to leave the profession (Flinkman et al. 2008, De Milt et al. 2011, Cortese 2012, Heinen et al. 2013). It is thus of critical importance for nursing managers to understand and act on factors that may influence nurses’ decision to leave their occupation. Several previous studies have indicated that job satisfaction, burnout, professional identity and the characteristics of the work environment are factors affecting nurses’ intention to leave the profession (Cowin et al. 2008, Sharbaugh 2009, Heinen et al. 2013). Although Turkey is a country experiencing an intense shortage of nurses, there are no studies on the causes, or of the incidence of nurses the profession. Therefore, this study aimed at investigating the relationship between nurses’ job satisfaction, professional identity and intention to leave the profession in Turkey. The findings of this study are important because illumination of the relationship between job satisfaction, professional identity and intention to leave the profession will contribute to the establishment of new strategies to retain nurses in the profession and the workforce.
Overview of the literature Job satisfaction has been identified as a strong factor associated with nurses’ intention to leave the profession (Cowin et al. 2008, Deppoliti 2008, Sharbaugh 2009). Research has shown that nurses with high job satisfaction do not leave the profession (Cowin et al. 2008, Flinkman et al. 2008, Sharbaugh 2009). Job satisfaction is an emotional response and behavioural expression, and is established by an individual’s assessment of his/ her job, working environment and working life (Saygılı & Celik 2011, Yılmazel 2013). Job satisfaction is ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1076–1085
defined from two perspectives: intrinsic and extrinsic satisfaction. While intrinsic job satisfaction refers to people’s own feelings about the nature of the job tasks, extrinsic job satisfaction refers to feelings about aspects of the work situation that are external to the job tasks or work itself (Kumar et al. 2013). Therefore, job satisfaction has to do with an individual’s perceptions and evaluation of his/her job, and this perception is influenced by person-specific circumstances such as needs, values and expectations. Previous studies (Saygılı & Celik 2011, Yılmazel 2013, Asegid et al. 2014) have shown that nurses’ job satisfaction is generally low or moderate. Factors leading to nurses’ job dissatisfaction have been well described in the literature (El-Jardali et al. 2009, Aiken et al. 2013). These factors are stated as inadequate involvement in decision-making processes, poor relationship with the management, low wages and inadequate social opportunities, lack of job security, poor public recognition for nursing/poor image of nursing and inflexible working hours (El-Jardali et al. 2009). Job satisfaction is important both for nurses and for the quality of the service they provide. Nurses who are satisfied with their job work actively, establish professional goals and improve the quality of care and patient satisfaction (Zarea et al. 2009). Nurses who are not satisfied with their job display behaviours such as complaining about profession and they are not engaged in their work (e.g. come to work late, working speed is slow and resigning) (Deppoliti 2008). Nurses who are satisfied with their job (De Milt et al. 2011) and profession (Duffield et al. 2009) are less likely to leave nursing. Therefore, enhancing nurses’ job satisfaction is an important strategy to retain nurses in the profession. Professional identity has been reported as a strong factor associated with nurses’ job satisfaction and intention to leave the profession (Cowin et al. 2008, Sharbaugh 2009). A sense of role-fulfilment and a match between self-concept and professional identity are important aspects of staff retention (Cowin et al. 2008, Deppoliti 2008, Sharbaugh 2009). In a study by Cowin et al. (2008), self-concept, which represents nurses’ professional identity was determined to have a stronger relationship with retention plans (b = 0.45) compared with job satisfaction (b = 0.28). In the same study, a strong relationship was found between nurses’ retention plans and of self-concept (r = 0.57). Professional identity, which has a core meaning of ‘occupational integration’ is the person’s perception of himself/herself as the member of the profession (Deppoliti 2008). Cowin et al. (2008) defined professional identity as the professional self-perception or self-concept of the nurse regarding their nursing abili1077
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would be useful in dissuading nurses from leaving in the future.
Source of funding The authors did not receive any funding for this paper.
Ethical approval Ethical approval was obtained from the Gaziosmanpasa University Ethics Committee (Decision no. 83116987-049).
References Aiken L.H., Sermeus W., Van Den Heede K. et al. (2012) Patient safety, satisfaction and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ 344, e1717. Aiken L.H., Sloane D.M., Bruyneel L., Van Den Heede K. & Sermeus W. (2013) Nurses’ reports of working conditions and hospital quality of care in 12 countries in Europe. International Journal of Nursing Studies 50, 143–153. American Association of Colleges of Nursing (AACN). (2014) Nursing Shortage Fact Sheet. Available at: https://www. aacn.nche.edu/media-relations/NrsgShortageFS.pdf, accessed 20 December 2013. Asegid A., Belachew T. & Yimam E. (2014) Factors influencing job satisfaction and anticipated turnover among nurses in sidama zone public health facilities, south Ethiopia. Nursing Research and Practice 1–26. Article ID 909768 Baycan A.F. (1985) Analysis of Several Affects of Job Satisfaction Between Different Occupational Groups. Master’s dissertation, Bogazici University, Institute of Health Science. C ß elik S. & Hisar F. (2012) The influence of the professionalism behavior of nurses working in health institutions on job satisfaction. International Journal of Nursing Practice 18 (2), 180–187. Cortese C.G. (2012) Predictors of critical care nurses’ intention to leave the unit, the hospital, and the nursing profession. Open Journal of Nursing 2, 311–326. Cowin L.S., Maree J., Rhonda G.C. & Herbert W.M. (2008) Causal modeling of self-concept, job satisfaction, and retention of nurses. International Journal of Nursing Studies 45 (10), 14–49. Cowin L.S., Johnson M., Wilson I. & Borgese K. (2013) The psychometric properties of five Professional Identity measures in a sample of nursing students. Nurse Education Today 33, 608–613. De Milt D.G., Fitzpatrick J.J. & McNulty S.R. (2011) Nurse practitioners’ job satisfaction and intent to leave current positions, the nursing profession, and the nurse practitioner role as a direct care provider. Journal of the American Academy of Nurse Practitioners 23 (1), 42–50. Deppoliti D. (2008) Exploration how new registered nurses construct professional identity in hospital settings. Journal of Continuing Education in Nursing 39 (6), 255–262.
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Duffield C., Roche M., O’Brien-Pallas L., Catling-Paull C. & King M. (2009) Staff satisfaction and retention and the role of the nursing unit manage. Collegian 16, 11–17. El-Jardali F., Dimassi H., Dumit N., Jamal D. & Mouro G. (2009) A national cross-sectional study on nurses’ intent to leave and job satisfaction in Lebanon: implications for policy and practice. BMC Nursing 8 (3), 1–13. Flinkman M., Laine M., Leino-Kilpi H., Hasselhorn H.M. & Salantera S. (2008) Explaining young registered Finnish nurses intention to leave the profession: a questionnaire survey. International Journal of Nursing Studies 45 (5), 727–739. Flinkman M., Leino-Kilpi H. & Salanter€ a S. (2010) Nurses’ intention to leave the profession: integrative review. Journal of Advanced Nursing 66, 1422–1434. Flinkman M., Isopahkala-Bouret U. & Salantera S. (2013) Young Registered Nurses’ Intention to Leave the Profession and Professional Turnover in Early Career: A Qualitative Case Study. Hindawi Publishing Corporation, ISRN Nursing Article ID 916061. Available at: http://dx.doi.org/10.1155/ 2013/916061, accessed 5 January 2014. Hayes B., Bonner A. & Pryor J. (2010) Factors contributing to nurse job satisfaction in the acute hospital setting: a review of recent literature. Journal of Nursing Management 18 (7), 804–814. Heinen M.M., Van Achterberg T., Schwendimann R. et al. (2013) Nurses’ intention to leave their profession: a cross sectional observational study in 10 European countries. International Journal of Nursing Studies 50 (2), 174–184. Hwang I.J., Lou S.S., Han F., Cao W., Kim O. & Li P. (2009) Professionalism: the major factor influencing job satisfaction among Korean and Chinese nurses. International Nursing Review 56, 313–318. Hyrkas K. & Morton J.L. (2013) International perspectives on retention, stress and burnout. Journal of Nursing Management 21, 603–604. Jourdain G. & Chenevert D. (2010) Job demands – resources, burnout and intention to leave the nursing profession: a questionnaire survey. International Journal of Nursing Studies 47 (6), 709–722. Kelly S. & Courts N. (2007) The professional self-concept of new graduate nurses. Nurse Education in Practice 7, 332– 337. Kumar P., Khan A.M., Inder D. & Sharma N. (2013) Job satisfaction of primary health-care providers (public sector) in urban setting. Journal of Family Medicine and Primary Care 2, 227–233. Lorber M. & Savic B.S. (2012) Job satisfaction of nurses and identifying factors of job satisfaction in Slovenian Hospitals. Croatian Medical Journal 53 (3), 263–270. Martins H. & Proencßa T. (2012) Minnesota Satisfaction Questionnaire – Psychometric Properties and Validation in a Population of Portuguese Hospital Workers. FEP Economics and Management. JEL–Code: J28. Available at: http://wps.fep. up.pt/wps/wp471.pdf, accessed 25 December 2013. Ministry of Health of Turkey (2011) Health Statistics Yearbook. Available at: http://sbu.saglik.gov.tr/Ekutuphane/kitaplar/siy_ 2011.pdf, accessed 1 December 2011. Needleman J., Buerhaus P., Pankratz V.S., Leibson C.L., Stevens S.R. & Harris M. (2011) Nurse staffing and inpatient hospital mortality. New England Journal of Medicine 364 (11), 1037– 1045. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1076–1085
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Table 1 Individual and working characteristics of nurses (n = 2122) Variables Age (years) 18–30 31–40 41 or more Gender Female Male Marital status Married Single Divorced Educational level Health occupation college Associate degree Graduate (Baccalaureate) Master’s degree Duration of work (years) 1–5 6–10 11 or more Position at work Clinical nurse Chief nurse Work type Shift Daytime
n
%
1069 893 160
50.4 42.1 7.5
2041 81
96.2 3.8
1432 633 57
67.5 29.8 2.7
433 902 738 49
20.4 42.5 34.8 2.3
717 516 889
33.8 24.3 41.9
1766 356
83.2 16.8
1556 566
73.3 26.7
Data collection tools Data were collected using paper-and-pencil surveys. A demographic form and two instruments were administered: Professional Self-Concept Inventory (PSCI) and Minnesota Satisfaction Questionnaire (MSQ). Intention to leave the profession was determined with a question included in the sociodemographic questionnaire. Nurses were asked to answer the question ‘Are you currently considering leaving the profession?’ by choosing one of the three options, ‘yes’, ‘no’ or ‘undecided’. A similar question, has been used in previous studies (De Milt et al. 2011, Cortese 2012) conducted on intention to leave the nursing profession. The questionnaire also included questions about the nurses’ background, such as age, marital status, educational status, and working conditions, such as the employer, length of employment and occupation. The PSCI was developed by Sabanciogullari et al. (2011) within the sample of hospital nurses. The inventory is a four-point Likert type assessment inventory (1 = ’I totally disagree’ and 4 = ’I totally agree’) consisting of 36 items with three subscales: ‘professional satisfaction’, ‘professional competence’ and ‘professional attitude and skill’. Professional satisfaction (five items) refers to nurses’ professional satisfaction and is the person’s perception of themselves as ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1076–1085
the member of the profession. Professional competence (seven items) includes questions of oneself in terms of professional qualifications, such as problemsolving skills, decision-making, professional knowledge and skills, and professional competency required to perform the nursing profession. Professional attitude and skill (24 items) includes questions regarding feelings, thoughts and beliefs related to the fulfilment and the qualifications of the profession. The scores obtained for each item are summed to determine the total score. The higher the score, the better and the more advanced the professional self-concept is. Sabanciogullari et al. (2011) have reported the total Cronbach’s alpha coefficient of the inventory as 0.87. In the present study, the total Cronbach’s alpha coefficient of the inventory was 0.80. The MSQ was developed by Weiss et al. (1967) and the reliability and validity of the Turkish version of the scale was established by Baycan (1985). The MSQ has been widely used for the measurement of intrinsic, extrinsic and overall job satisfaction. The individuals are asked to rate their satisfaction with each of 20 work-related needs on a five-point scale ranging from ‘not satisfied’ (1) to ‘extremely satisfied’ (5). The scores for the responses are summed to produce a general satisfaction score. Intrinsic job satisfaction (11 items) is related to recognition, responsibility, achievement and progress of the psychological needs of the people. Extrinsic job satisfaction (nine items) is related to the work environment, compensation, supervision, promotion, working conditions and operating policies. The scores obtained for each item are summed to determine the total score. The higher the score the higher the job satisfaction. Martins and Proencßa (2012) have reported total Cronbach’s alpha coefficient of the inventory of 0.91. In the present study, the total Cronbach’s alpha coefficient of the inventory was 0.90.
Data analysis Data were analysed using the Statistical Package for Social Sciences for Windows (SPSS 16.0; SPSS, Chicago, IL, USA). In order to determine the nurses’ professional identity and job satisfaction, the means and standard deviations were calculated. To determine their intention to leave the profession, percentage distributions were used. The relationship between the nurses’ professional identity and job satisfaction were analysed using Pearson’s correlation and stepwise multiple regression. The relationship between the intention to leave the profession, the professional identity 1079
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and job satisfaction were assessed with the one-way ANOVA and logistical regression analysis. The level of significance for all the analyses was set at P < 0.05.
Results Respondents’ professional identity, job satisfaction and intention to leave the nursing profession The distribution of nurses’ mean overall and subscale scores for the Job Satisfaction Scale, the PSCI and of their intent to leave the profession are shown in Table 2. While 15.5% (n = 328) of the nurses considered leaving the profession, 64.7% (n = 1373) of them did not and 19.8% (n = 412) of them were undecided (Table 1). The nurses’ mean score for the MSQ was 3.18 (SD = 0.64), which is an indication of a moderate job satisfaction. Nurses received the highest score from the intrinsic job satisfaction subscale (mean = 3.37, SD = 0.65) and the lowest from the extrinsic job satisfaction subscale (mean = 2.90, SD = 0.78). The nurses’ mean overall score for the PSCI (mean = 109.18, SD = 12.35) was above average and was considered as a positive indication of strong professional identity.
Scales MSQ Overall job satisfaction Internal job satisfaction External job satisfaction PSCI, general Intention to leave the profession Yes No Undecided
Mean SD
3.18 3.37 2.90 109.18
0.64 0.65 0.78 12.35
Relationships between nurses’ professional identity and job satisfaction The correlation between the nurses’ the PSCI and Job Satisfaction Scale are shown in Table 3. A moderate but statistically significant and positive relationship was determined between the overall and intrinsic and extrinsic satisfaction subscales (r = 0.25–0.43) and their overall and professional satisfaction (r = 0.41– 0.49) and professional attitudes and skills (r = 0.19– 0.36) for the PSCI (P < 0.01). While there was a weak positive correlation between the professional competence for the PSCI and overall (r = 0.14) and intrinsic satisfaction (r = 0.20), there was no relationship between their professional competence for the PSCI and extrinsic satisfaction (r = 0.04) for job satisfaction (P > 0.05). The results of stepwise multiple linear regression analysis of job satisfaction and professional self-concept are shown in Table 4. Analysis of the t-test for significance of regression indicated that professional self-concept predicted job satisfaction (R = 0.52, R2 = 0.27, F = 256.100, P = 0.000). Professional selfconcept variables accounted for approximately 27% of the total variance of job satisfaction. The variables that affected job satisfaction most were professional
Minimum
Maximum
1 1 1 36
5 5 5 144
n (%)
Table 2 Mean scores of nurses in Minnesota Satisfaction Questionnaire (MSQ) and Professional Self-Concept Inventory (PSCI), and distribution of intention to leave the profession (n = 2122)
328 (15.5) 1373 (64.7) 421 (19.8)
Table 3 Correlation between Minnesota Satisfaction Questionnaire (MSQ) and Professional Self-Concept Inventory (PSCI) (n = 2122) Inventory PSCI General Professional satisfaction Professional competence Professional attitude and skill MSQ General Internal satisfaction External satisfaction
1
2
3
4
5
6
7
– 0.56** 0.78** 0.96**
– 0.15** 0.36**
– 0.72**
–
0.38** 0.43** 0.25**
0.49** 0.49** 0.41**
0.14** 0.20* 0.04
0.31** 0.36** 0.19**
– 0.93** 0.89**
– 0.67**
–
Key: 1, PSCI general; 2, professional satisfaction; 3, professional competence; 4, professional attitude and skill; 5, MSQ general; 6, internal satisfaction; 7, external satisfaction. *P < 0.05; **P < 0.01.
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Table 4 Stepwise multiple regression analysis of predictors of job satisfaction (n = 2122) Variables
B
PSCI General Professional satisfaction Professional attitude and skill
0.01 0.09 0.03
SE
ß
0.00 0.00 0.00
0.27 0.50 0.39
T
P-value
2.48 15.22 4.00
0.013 0.000 0.001
PSCI, Professional Self-Concept Inventory. R = 0.52, R2 = 0.27, F = 256.100, P = 0.000.
satisfaction (b = 0.50), professional attitude and skills (b = 0.39) and overall professional self-concept (b = 0.27). The variable excluded with stepwise multiple linear regression analysis was professional competence, which was in line with the correlation analysis.
The relationships between nurses’ professional identity, job satisfaction and intention to leave the nursing profession The comparison between nurses’ intention to leave the profession and the overall Job Satisfaction and PSCI is shown in Table 5. A significant relationship was determined between the intention to leave the profession and the Job Satisfaction Scale and the PSCI (P = 0.000). Nurses with low job satisfaction and low professional self-concept considered leaving the profession more than did the other nurses. In addition, according to the logistic regression analysis, job satisfaction (b = 0.646, SE = 0.081, Wald = 63.947, df = 1, P = 0.000) and professional identity (b = 0.026, SE = 0.004, Wald = 36.074, df = 1, P = 0.000) significantly affected the nurses’ intention to leave the profession.
Discussion With the increase in the number of nurses leaving the profession, nurse shortages are deepening (American Association of Colleges of Nursing (AACN) 2014). In the present study, 15.5% of the nurses in Turkey stated that they had an intention to leave the profession. Similar results have been reported in the international literature (De Milt et al. 2011, Cortese 2012, Heinen et al. 2013). In addition, if the nurses who stated that they were undecided about leaving the profession were included in the results of the present study, it is possible to argue that more than one-third of the Turkish nursing workforce (35.3%) considers leaving the profession. The need for health services in our society is increasing and nurses are essential resource. Retention of nurses in the profession is important for the provision of safe and high-quality patient care (Aiken et al. 2012) and for the nursing profession (Hwang et al. 2009). Nurse managers are in a key role supporting their staff in job satisfaction, professional self-concept and ultimately intention to stay in the profession. According Cortese (2012), intention to leave the profession starts as a withdrawal process, in which nurses may first leave their unit, then the organisation and finally the profession. By knowing the predictors and that the first steps of this process are important, if human resource departments and nurse managers can identify, intervene and stop this process early, more nurses may be retained in the profession. Job satisfaction plays an important role in retaining nurses in the profession and motivates nurses to provide quality care (Deppoliti 2008, Duffield et al. 2009, Sharbaugh 2009). Identifying the factors that contribute to job satisfaction will make it possible to implement effective plans to retain the nursing workforce. According to the findings of this study, nurses’
Table 5 Comparison of nurses’ intention to leave the profession and their mean overall and subscale scores for the Minnesota Satisfaction Questionnaire (MSQ) and Professional Self-Concept Inventory (PSCI) (n = 2122) Intention to leave the profession Yes (n = 328, % 15.5) Inventories MSQ General Internal satisfaction External satisfaction PSCI General Professional satisfaction Professional competence Professional attitude and skill
Mean
SD
No (n = 1373,% 64.7) Mean
SD
Undecided (n = 421, % 19.8) Mean
SD
Test (F/P)
2.88 3.05 2.61
0.71 0.73 0.84
3.29 3.48 3.01
0.61 0.61 0.77
3.04 3.24 2.75
0.55 0.57 0.70
71.753/0.000 73.311/0.000 44.699/0.000
105.24 10.49 22.34 72.39
12.74 3.08 3.49 9.07
111.09 14.21 22.52 74.34
12.27 3.23 3.02 8.33
106.02 12.01 21.78 72.22
10.89 2.69 2.96 7.63
48.920/0.000 227.085/0.000 9.374/0.000 14.671/0.000
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job satisfaction in Turkey is moderate, which is consistent with the findings of several other previous studies (Lorber & Savic 2012, Yılmazel 2013, Asegid et al. 2014). This study revealed that nurses with low job satisfaction had a greater intention to leave the profession. These results are consistent with Flinkman et al.’s (2013) and Cortese’s (2012) findings. In addition, in the present study, the logistic regression analysis results showed that job satisfaction was affecting nurses’ intention to leave the profession. It is critical that nurse managers in Turkey start developing strategies that are targeted at increasing nurses’ job satisfaction so that they can retain a qualified workforce and maximise the quality, safety and continuity of care. The most striking finding of the present study was that professional identity significantly affected both job satisfaction and nurses’ intention to leave the profession. The literature has drawn attention to professional identity and has emphasised its importance for nursing (Cowin et al. 2008, Sharbaugh 2009). There are discussions, for example, about the positive effects of professional identity on individuals, including positive self-image, professional satisfaction, sense of belonging and recognition of professional competence (Sharbaugh 2009, Jourdain & Chenevert 2010, Vliegher et al. 2011). This study showed that nurses had a strong sense of professional identity. This finding is consistent with the results of Sharbaugh (2009), Kelly and Courts (2007) and Park et al. (2007). In the present study, a positive and moderately significant relationship was determined between the nurses’ professional identities and job satisfaction. In Hwang et al.’s (2009) study, professionalism, which also involves professional identity, was identified as an important factor affecting job satisfaction. There is a stronger relationship between professional identity and extrinsic job satisfaction than between professional identity and intrinsic job satisfaction. Intrinsic job satisfaction is related to recognition, responsibility, achievement, autonomy and progress of the psychological needs of the people. These features can thus be advanced with the development of professional identity. It may be argued that the growth of professional identity will also increase nurses’ intrinsic job satisfaction. According to the results of the regression analysis, professional identity accounted for 27% of the total variance of job satisfaction. Given that many factors influence nurses’ job satisfaction, this result is very important. Regression analysis also revealed that the variable which job satisfaction affected most was professional satisfaction. This refers to a person’s perception of themselves as a member of the profession. 1082
Advancement of professional identity may increase job satisfaction by bringing out a sense of belonging to the profession. Based on these results, it may be claimed that professional identity is an important factor for nurses to have satisfaction in their work. Moreover, this finding is very important because it suggests that job dissatisfaction, which is one of the major causes of their intention to leave the profession, can be reduced by means of advancing nurses’ professional identity. Furthermore, the result underscores the importance of an organisation and its supportive programmes targeted at enhancing professional identity by increasing job satisfaction initiated by nurse managers. In the present study, intention to leave the profession was lower among the nurses with a high professional identity. This finding is consistent with the results of the studies of Jourdain and Chenevert (2010), Cowin et al. (2008) and Sharbaugh (2009). Nurses’ commitment to the profession (Sharbaugh 2009) and intention to stay in the profession (Jourdain & Chenevert 2010) increases as they develop strong feelings of being a nurse. In Sharbaugh’s (2009) and Vliegher et al.’s (2011) studies, professional identity was identified as the best predictor of the intention to stay in the profession. In line with these findings, it can be argued that development of professional identity is necessary if nurses are to be retained in the profession. Strategies aimed at supporting the growth of increasing professional identity emphasise, for example reliance on oneself and one’s own skills when learning and using nursing knowledge and these may be useful skills to stress, starting in nursing education, to retain nurses in the profession. Cowin et al. (2008) determined that self-concept plays a more effective role in increasing nurses’ willingness to stay in the profession than did job satisfaction. Given that professional identity can affect both job satisfaction and intention to leave the profession, it is critical that nurse managers focus on the advancement of nurses’ professional identity. What is important is how to develop professional identity. In her study Sabanciogullari (2010) prepared a professional identity development programme for nurses based on Strasen’s (1992) model and investigated its effects on professional self-concept, job satisfaction and burnout levels. The programme significantly improved nurses’ professional self-concept and considerably reduced their burnout but did not increase their job satisfaction. The programme reduced the burnout caused by job dissatisfaction and, therefore, it can be argued that reduction in burnout increases job satisfaction in the ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1076–1085
Job satisfaction, professional identity in nurses
long term. In the literature, there is, however, a gap in knowledge about how to grow nurses’ professional identity and job satisfaction. More empirical studies should be conducted and the effectiveness of different strategies should be explored and tested.
Limitations of the study A major limitation of this study was the sample and how it represented nurse population in Turkey. It is not possible to generalise the results because the study included only nurses working in hospitals. These nurses represented only 2.8% of the entire population. In addition, nurses’ intention to leave the profession was assessed by asking a question directly related to the topic. This question has not been tested for its psychometric sensitivity. Qualitative methods might have been more advantageous to study opinions about the profession and working conditions in detail. Therefore, it is recommended that qualitative methods be implemented in further studies on this subject. The present study is the first to investigate the relationship between job satisfaction, perception of professional identity and intention to leave the profession in Turkey. It is recommended that future studies with larger sample sizes should be performed on this subject in Turkey.
Conclusion The results of this study revealed that nurses that had moderate levels of job satisfaction, displayed positive professional identity and that there was a significant relationship between their professional identity and job satisfaction. More than one-third of the nurses either had intentions to leave the profession or were undecided about it. Nurses with low professional identity and low job satisfaction considered leaving the profession more often than the other nurses. Professional identity and job satisfaction are therefore important factors affecting intention to leave the profession.
Implications for nursing management Providing opportunities for nurses to participate in professional activities could be a first step for nurse managers to start new strategies that contribute to their staff’s sense of being part of other nurses and of the profession (Jourdain & Chenevert 2010, Aiken et al. 2013). Participation in decision making in nursing practices and co-management models would also ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1076–1085
increase nurses’ sense of belonging in the organisation (Flinkman et al. 2010, Jourdain & Chenevert 2010, Aiken et al. 2013). In addition, support for staff education (i.e. education inside and outside of the organisation) contributes to professional identity and practice, both of which increase job satisfaction (Hwang et al. 2009, Sabanciogullari 2010). Therefore, it is important that nursing educators and managers encourage and allocate resources that enable nurses to access and participate in educational programmes and conferences (Cortese 2012, Aiken et al. 2013, Asegid et al. 2014). In addition, it is important for hospital administrators and employers to make use of the staff education that is available inside an organisation; it is much more cost-effective to invite a guest speaker to a hospital than to send a handful of staff to an educational event. In addition, rearrangement of work shift patterns for internal education that promotes the professional development of nurses is a cost-effective approach (Flinkman et al. 2010, Jourdain & Chenevert 2010). These efforts will foster professionalism and thereby enhance job satisfaction and retention of nurses in practice. Nursing managers can determine the effects of these strategies by measuring staff satisfaction regularly and monitoring retention in collaboration with the human resources department. To retain qualified staff, it is important for nurse managers to recognise and review the factors contributing to job satisfaction of nurses working in hospitals. Nursing managers can greatly increase nurse job satisfaction by ensuring opportunities, such as working with competent peers, promoting collaborative nurse–physician relationships, enhancing clinical autonomy, providing continuously support to staff, advocating and promoting control over nursing practice, securing adequate staffing, and supporting staff education (Hayes et al. 2010). Nurse managers should regularly monitor for signs of dissatisfaction, for example as a part of annual development discussions and by conducting job satisfaction surveys. Staff’s intention to apply positions on other units or hospitals may be the first symptoms of leaving the workforce and the profession. The literature shows (Flinkman et al. 2010, Cortese 2012) that it may take nurses up to 3 years before they make the final decision to leave and thus nurse managers have time and the opportunity to change the trajectory of this process. Nurse managers and/or the human resource department need to have interviews (so called ‘exit interview’) with nurses who have decided to leave the nursing profession to find out why they have made the final decision to leave: such information 1083
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would be useful in dissuading nurses from leaving in the future.
Source of funding The authors did not receive any funding for this paper.
Ethical approval Ethical approval was obtained from the Gaziosmanpasa University Ethics Committee (Decision no. 83116987-049).
References Aiken L.H., Sermeus W., Van Den Heede K. et al. (2012) Patient safety, satisfaction and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ 344, e1717. Aiken L.H., Sloane D.M., Bruyneel L., Van Den Heede K. & Sermeus W. (2013) Nurses’ reports of working conditions and hospital quality of care in 12 countries in Europe. International Journal of Nursing Studies 50, 143–153. American Association of Colleges of Nursing (AACN). (2014) Nursing Shortage Fact Sheet. Available at: https://www. aacn.nche.edu/media-relations/NrsgShortageFS.pdf, accessed 20 December 2013. Asegid A., Belachew T. & Yimam E. (2014) Factors influencing job satisfaction and anticipated turnover among nurses in sidama zone public health facilities, south Ethiopia. Nursing Research and Practice 1–26. Article ID 909768 Baycan A.F. (1985) Analysis of Several Affects of Job Satisfaction Between Different Occupational Groups. Master’s dissertation, Bogazici University, Institute of Health Science. C ß elik S. & Hisar F. (2012) The influence of the professionalism behavior of nurses working in health institutions on job satisfaction. International Journal of Nursing Practice 18 (2), 180–187. Cortese C.G. (2012) Predictors of critical care nurses’ intention to leave the unit, the hospital, and the nursing profession. Open Journal of Nursing 2, 311–326. Cowin L.S., Maree J., Rhonda G.C. & Herbert W.M. (2008) Causal modeling of self-concept, job satisfaction, and retention of nurses. International Journal of Nursing Studies 45 (10), 14–49. Cowin L.S., Johnson M., Wilson I. & Borgese K. (2013) The psychometric properties of five Professional Identity measures in a sample of nursing students. Nurse Education Today 33, 608–613. De Milt D.G., Fitzpatrick J.J. & McNulty S.R. (2011) Nurse practitioners’ job satisfaction and intent to leave current positions, the nursing profession, and the nurse practitioner role as a direct care provider. Journal of the American Academy of Nurse Practitioners 23 (1), 42–50. Deppoliti D. (2008) Exploration how new registered nurses construct professional identity in hospital settings. Journal of Continuing Education in Nursing 39 (6), 255–262.
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Duffield C., Roche M., O’Brien-Pallas L., Catling-Paull C. & King M. (2009) Staff satisfaction and retention and the role of the nursing unit manage. Collegian 16, 11–17. El-Jardali F., Dimassi H., Dumit N., Jamal D. & Mouro G. (2009) A national cross-sectional study on nurses’ intent to leave and job satisfaction in Lebanon: implications for policy and practice. BMC Nursing 8 (3), 1–13. Flinkman M., Laine M., Leino-Kilpi H., Hasselhorn H.M. & Salantera S. (2008) Explaining young registered Finnish nurses intention to leave the profession: a questionnaire survey. International Journal of Nursing Studies 45 (5), 727–739. Flinkman M., Leino-Kilpi H. & Salanter€ a S. (2010) Nurses’ intention to leave the profession: integrative review. Journal of Advanced Nursing 66, 1422–1434. Flinkman M., Isopahkala-Bouret U. & Salantera S. (2013) Young Registered Nurses’ Intention to Leave the Profession and Professional Turnover in Early Career: A Qualitative Case Study. Hindawi Publishing Corporation, ISRN Nursing Article ID 916061. Available at: http://dx.doi.org/10.1155/ 2013/916061, accessed 5 January 2014. Hayes B., Bonner A. & Pryor J. (2010) Factors contributing to nurse job satisfaction in the acute hospital setting: a review of recent literature. Journal of Nursing Management 18 (7), 804–814. Heinen M.M., Van Achterberg T., Schwendimann R. et al. (2013) Nurses’ intention to leave their profession: a cross sectional observational study in 10 European countries. International Journal of Nursing Studies 50 (2), 174–184. Hwang I.J., Lou S.S., Han F., Cao W., Kim O. & Li P. (2009) Professionalism: the major factor influencing job satisfaction among Korean and Chinese nurses. International Nursing Review 56, 313–318. Hyrkas K. & Morton J.L. (2013) International perspectives on retention, stress and burnout. Journal of Nursing Management 21, 603–604. Jourdain G. & Chenevert D. (2010) Job demands – resources, burnout and intention to leave the nursing profession: a questionnaire survey. International Journal of Nursing Studies 47 (6), 709–722. Kelly S. & Courts N. (2007) The professional self-concept of new graduate nurses. Nurse Education in Practice 7, 332– 337. Kumar P., Khan A.M., Inder D. & Sharma N. (2013) Job satisfaction of primary health-care providers (public sector) in urban setting. Journal of Family Medicine and Primary Care 2, 227–233. Lorber M. & Savic B.S. (2012) Job satisfaction of nurses and identifying factors of job satisfaction in Slovenian Hospitals. Croatian Medical Journal 53 (3), 263–270. Martins H. & Proencßa T. (2012) Minnesota Satisfaction Questionnaire – Psychometric Properties and Validation in a Population of Portuguese Hospital Workers. FEP Economics and Management. JEL–Code: J28. Available at: http://wps.fep. up.pt/wps/wp471.pdf, accessed 25 December 2013. Ministry of Health of Turkey (2011) Health Statistics Yearbook. Available at: http://sbu.saglik.gov.tr/Ekutuphane/kitaplar/siy_ 2011.pdf, accessed 1 December 2011. Needleman J., Buerhaus P., Pankratz V.S., Leibson C.L., Stevens S.R. & Harris M. (2011) Nurse staffing and inpatient hospital mortality. New England Journal of Medicine 364 (11), 1037– 1045. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1076–1085
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OECD (2011) Health at a Glance, OECD Indicators 2011. Available from at: http://www.oecd.org/els/health-systems/ 49105858.pdf, accessed 20 December 2013. Park J.R., Chapple M., Wharrad H. & Bradley S. (2007) Early nursing career experience for 1994–2000 graduates from the University of Nottingham. Journal of Nursing Management 15 (4), 414–423. Sabanciogullari S. (2010) The Effect of Professional Identity Development Programme on Professional Self Concept, Job Satisfaction and Burnout Levels of the Nurses. Doctoral dissertation, Cumhuriyet University, Institute of Health Science. Sabanciogullari S., Dogan S. & Bircan H. (2011) Professional selfconcept scale in clinician nurses; development, reliability, validity. Turkiye Clinics Journal of Nursing Science 3 (1), 16–28. Saygılı M. & Celik Y. (2011) Evaluate the relationship between job satisfaction with perceptions related to hospital employees’ work environment. Hacettepe Journal of Health Administration 14 (1), 40–70. Sharbaugh S.M. (2009) Relationships Among Nurses’ Professional Identity, Career Satisfaction, Occupational Commitment, and Intent to Stay. Doctoral dissertation, Faculty of the School of Nursing Widener University, UMI 3407361. ProQuest LLC. Strasen L. (1992) The Images of Professional Nursing: Strategies for Action, J.B Lippincott, Philadelphia, PA.
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Tervo-Heikkinen T., Kvist T., Partanen P., Vehvilainen-Julkunen K. & Aalto P. (2008) Patient satisfaction as a positive nursing outcome. Journal of Nursing Care Quality 23 (1), 58–65. Vliegher K., Milisen K., Wouters R. et al. (2011) The professional self-image of registered home nurses in Flanders (Belgium): a cross sectional questionnaire survey. Applied Nursing Research 24 (1), 29–36. Weiss D.J., Dawis R.V., England G.W. & Lofquist L.H. (1967) Manual for the Minnesota Satisfaction Questionnaire. Minnesota Studies in Vocational Rehabilitation, Vol. 22. University of Minnesota, Industrial Relations Center, Minneapolis. Yılmazel G. (2013) Mobbing, job satisfaction and affecting factors in the nurse. Turkiye Clinics Journal of Nursing Science 5 (2), 55–63. Zarea K., Negarandeh R., Dehghan-Nayeri N. & Rezaei-Adaryani M. (2009) Nursing staff shortages and job satisfaction in Iran: issues and challenges. Nursing and Health Sciences 11, 326–331. Zhu X., You L., Zheng J., Liu K., Fang J. & Hou S. (2012) Nurse staffing levels make a difference on patient outcomes: a multisite study in Chinese hospitals. Journal of Nursing Scholarship 44 (3), 266–273.
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Relationship between job satisfaction, professional identity and intention to leave the profession among nurses in Turkey SELMA SABANCIOGULLARI
PhD, RN
1
and SELMA DOGAN
PhD, RN
2
1
Assistant Professor, Department of Psychiatric Nursing, Cumhuriyet University, Health High School of Susehri, Sivas, and 2Professor, Uskudar University, Faculty of Health Sciences, Istanbul, Turkey
Correspondence Selma Sabanciogullari Department of Psychiatric Nursing Health High School of Susehri Cumhuriyet University 58140 Sivas Turkey E-mail: [email protected]
SABANCIOGULLARI S, DOGAN S.
(2015) Journal of Nursing Management 23, 1076– 1085. Relationship between job satisfaction, professional identity and intention to leave the profession among nurses in Turkey Aims The purpose of this study is to investigate the relationship between job satisfaction, professional identity and intention to leave the profession among nurses in Turkey. Background Although there are many studies on job satisfaction among nurses in Turkey, there is a gap in the literature in relation to professional identity, particularly for intentions to leave the profession. Method This cross-sectional, descriptive and correlational study was conducted with 2122 nurses from Turkey. Results A positive and significant correlation was determined between the nurses’ job satisfaction and professional identities. It was found that 15.5% of the nurses intended to leave their profession. Intention to leave the profession was greater among the nurses with inadequate professional identity development and low job satisfaction. Conclusion Professional identity is a factor affecting job satisfaction. Both professional identity and job satisfaction are important factors affecting nurses’ intention leaving the profession. Implications for nursing management Given that professional identity and job satisfaction affect intention to leave the profession and professional identity affects job satisfaction, nurse managers who are mainly responsible for the quality of nursing care should develop strategies that support nurses’ professional identity and increase their job satisfaction if they are to prevent nurses from leaving the profession.
Keywords: intention to leave the profession, job satisfaction, professional identity, registered nurse Accepted for publication: 26 June 2014
Introduction Nursing shortages and nurse turnover have become an issue of international importance (Hyrkas & Morton 2013). The European Commission has estimated that there will be a shortage of 590 000 nurses by the year 2020 (Flinkman et al. 2013). In addition, most of the member countries of the Organisation for Economic Co-operation and Development (OECD) have 1076
reported concerns regarding nurse shortages (Flinkman et al. 2010). Whereas the number of the nurses per 1000 persons is 8.4 in OECD countries, 10.8 in the USA and 9.7 in the UK, it is only 1.56 in Turkey (OECD 2011). Nursing shortages in the health sector threaten the quality and safety of the patient care services. Several studies have reported that higher nurse staffing levels are associated with better quality and safety of care for patients (Needleman et al. 2011, DOI: 10.1111/jonm.12256 ª 2014 John Wiley & Sons Ltd
Job satisfaction, professional identity in nurses
Aiken et al. 2012, Zhu et al. 2012). Tervo-Heikkinen et al. (2008) found that if the nursing staff took care of more than eight patients, satisfaction with the care received dropped. Many health-service providers are being monitored for quality, therefore, managers must control and supervise issues of quality, and this includes provision of the workforce that matches the patients’ needs for care. Nurse turnover is described as a withdrawal process in which nurses first leave the unit, then the hospital and finally the profession (Cortese 2012, Flinkman et al. 2013). While much of the research has focused on nurses’ intentions to or considerations about leaving their job or organisation, fewer studies have been conducted on intentions to leave the profession (Flinkman et al. 2010). Therefore, in this study, nurses’ intention to leave was considered as the intention to leave the profession. Several international studies have determined that from 9% to 26% of the nurses express intentions to leave the profession (Flinkman et al. 2008, De Milt et al. 2011, Cortese 2012, Heinen et al. 2013). It is thus of critical importance for nursing managers to understand and act on factors that may influence nurses’ decision to leave their occupation. Several previous studies have indicated that job satisfaction, burnout, professional identity and the characteristics of the work environment are factors affecting nurses’ intention to leave the profession (Cowin et al. 2008, Sharbaugh 2009, Heinen et al. 2013). Although Turkey is a country experiencing an intense shortage of nurses, there are no studies on the causes, or of the incidence of nurses the profession. Therefore, this study aimed at investigating the relationship between nurses’ job satisfaction, professional identity and intention to leave the profession in Turkey. The findings of this study are important because illumination of the relationship between job satisfaction, professional identity and intention to leave the profession will contribute to the establishment of new strategies to retain nurses in the profession and the workforce.
Overview of the literature Job satisfaction has been identified as a strong factor associated with nurses’ intention to leave the profession (Cowin et al. 2008, Deppoliti 2008, Sharbaugh 2009). Research has shown that nurses with high job satisfaction do not leave the profession (Cowin et al. 2008, Flinkman et al. 2008, Sharbaugh 2009). Job satisfaction is an emotional response and behavioural expression, and is established by an individual’s assessment of his/ her job, working environment and working life (Saygılı & Celik 2011, Yılmazel 2013). Job satisfaction is ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1076–1085
defined from two perspectives: intrinsic and extrinsic satisfaction. While intrinsic job satisfaction refers to people’s own feelings about the nature of the job tasks, extrinsic job satisfaction refers to feelings about aspects of the work situation that are external to the job tasks or work itself (Kumar et al. 2013). Therefore, job satisfaction has to do with an individual’s perceptions and evaluation of his/her job, and this perception is influenced by person-specific circumstances such as needs, values and expectations. Previous studies (Saygılı & Celik 2011, Yılmazel 2013, Asegid et al. 2014) have shown that nurses’ job satisfaction is generally low or moderate. Factors leading to nurses’ job dissatisfaction have been well described in the literature (El-Jardali et al. 2009, Aiken et al. 2013). These factors are stated as inadequate involvement in decision-making processes, poor relationship with the management, low wages and inadequate social opportunities, lack of job security, poor public recognition for nursing/poor image of nursing and inflexible working hours (El-Jardali et al. 2009). Job satisfaction is important both for nurses and for the quality of the service they provide. Nurses who are satisfied with their job work actively, establish professional goals and improve the quality of care and patient satisfaction (Zarea et al. 2009). Nurses who are not satisfied with their job display behaviours such as complaining about profession and they are not engaged in their work (e.g. come to work late, working speed is slow and resigning) (Deppoliti 2008). Nurses who are satisfied with their job (De Milt et al. 2011) and profession (Duffield et al. 2009) are less likely to leave nursing. Therefore, enhancing nurses’ job satisfaction is an important strategy to retain nurses in the profession. Professional identity has been reported as a strong factor associated with nurses’ job satisfaction and intention to leave the profession (Cowin et al. 2008, Sharbaugh 2009). A sense of role-fulfilment and a match between self-concept and professional identity are important aspects of staff retention (Cowin et al. 2008, Deppoliti 2008, Sharbaugh 2009). In a study by Cowin et al. (2008), self-concept, which represents nurses’ professional identity was determined to have a stronger relationship with retention plans (b = 0.45) compared with job satisfaction (b = 0.28). In the same study, a strong relationship was found between nurses’ retention plans and of self-concept (r = 0.57). Professional identity, which has a core meaning of ‘occupational integration’ is the person’s perception of himself/herself as the member of the profession (Deppoliti 2008). Cowin et al. (2008) defined professional identity as the professional self-perception or self-concept of the nurse regarding their nursing abili1077
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would be useful in dissuading nurses from leaving in the future.
Source of funding The authors did not receive any funding for this paper.
Ethical approval Ethical approval was obtained from the Gaziosmanpasa University Ethics Committee (Decision no. 83116987-049).
References Aiken L.H., Sermeus W., Van Den Heede K. et al. (2012) Patient safety, satisfaction and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ 344, e1717. Aiken L.H., Sloane D.M., Bruyneel L., Van Den Heede K. & Sermeus W. (2013) Nurses’ reports of working conditions and hospital quality of care in 12 countries in Europe. International Journal of Nursing Studies 50, 143–153. American Association of Colleges of Nursing (AACN). (2014) Nursing Shortage Fact Sheet. Available at: https://www. aacn.nche.edu/media-relations/NrsgShortageFS.pdf, accessed 20 December 2013. Asegid A., Belachew T. & Yimam E. (2014) Factors influencing job satisfaction and anticipated turnover among nurses in sidama zone public health facilities, south Ethiopia. Nursing Research and Practice 1–26. Article ID 909768 Baycan A.F. (1985) Analysis of Several Affects of Job Satisfaction Between Different Occupational Groups. Master’s dissertation, Bogazici University, Institute of Health Science. C ß elik S. & Hisar F. (2012) The influence of the professionalism behavior of nurses working in health institutions on job satisfaction. International Journal of Nursing Practice 18 (2), 180–187. Cortese C.G. (2012) Predictors of critical care nurses’ intention to leave the unit, the hospital, and the nursing profession. Open Journal of Nursing 2, 311–326. Cowin L.S., Maree J., Rhonda G.C. & Herbert W.M. (2008) Causal modeling of self-concept, job satisfaction, and retention of nurses. International Journal of Nursing Studies 45 (10), 14–49. Cowin L.S., Johnson M., Wilson I. & Borgese K. (2013) The psychometric properties of five Professional Identity measures in a sample of nursing students. Nurse Education Today 33, 608–613. De Milt D.G., Fitzpatrick J.J. & McNulty S.R. (2011) Nurse practitioners’ job satisfaction and intent to leave current positions, the nursing profession, and the nurse practitioner role as a direct care provider. Journal of the American Academy of Nurse Practitioners 23 (1), 42–50. Deppoliti D. (2008) Exploration how new registered nurses construct professional identity in hospital settings. Journal of Continuing Education in Nursing 39 (6), 255–262.
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Duffield C., Roche M., O’Brien-Pallas L., Catling-Paull C. & King M. (2009) Staff satisfaction and retention and the role of the nursing unit manage. Collegian 16, 11–17. El-Jardali F., Dimassi H., Dumit N., Jamal D. & Mouro G. (2009) A national cross-sectional study on nurses’ intent to leave and job satisfaction in Lebanon: implications for policy and practice. BMC Nursing 8 (3), 1–13. Flinkman M., Laine M., Leino-Kilpi H., Hasselhorn H.M. & Salantera S. (2008) Explaining young registered Finnish nurses intention to leave the profession: a questionnaire survey. International Journal of Nursing Studies 45 (5), 727–739. Flinkman M., Leino-Kilpi H. & Salanter€ a S. (2010) Nurses’ intention to leave the profession: integrative review. Journal of Advanced Nursing 66, 1422–1434. Flinkman M., Isopahkala-Bouret U. & Salantera S. (2013) Young Registered Nurses’ Intention to Leave the Profession and Professional Turnover in Early Career: A Qualitative Case Study. Hindawi Publishing Corporation, ISRN Nursing Article ID 916061. Available at: http://dx.doi.org/10.1155/ 2013/916061, accessed 5 January 2014. Hayes B., Bonner A. & Pryor J. (2010) Factors contributing to nurse job satisfaction in the acute hospital setting: a review of recent literature. Journal of Nursing Management 18 (7), 804–814. Heinen M.M., Van Achterberg T., Schwendimann R. et al. (2013) Nurses’ intention to leave their profession: a cross sectional observational study in 10 European countries. International Journal of Nursing Studies 50 (2), 174–184. Hwang I.J., Lou S.S., Han F., Cao W., Kim O. & Li P. (2009) Professionalism: the major factor influencing job satisfaction among Korean and Chinese nurses. International Nursing Review 56, 313–318. Hyrkas K. & Morton J.L. (2013) International perspectives on retention, stress and burnout. Journal of Nursing Management 21, 603–604. Jourdain G. & Chenevert D. (2010) Job demands – resources, burnout and intention to leave the nursing profession: a questionnaire survey. International Journal of Nursing Studies 47 (6), 709–722. Kelly S. & Courts N. (2007) The professional self-concept of new graduate nurses. Nurse Education in Practice 7, 332– 337. Kumar P., Khan A.M., Inder D. & Sharma N. (2013) Job satisfaction of primary health-care providers (public sector) in urban setting. Journal of Family Medicine and Primary Care 2, 227–233. Lorber M. & Savic B.S. (2012) Job satisfaction of nurses and identifying factors of job satisfaction in Slovenian Hospitals. Croatian Medical Journal 53 (3), 263–270. Martins H. & Proencßa T. (2012) Minnesota Satisfaction Questionnaire – Psychometric Properties and Validation in a Population of Portuguese Hospital Workers. FEP Economics and Management. JEL–Code: J28. Available at: http://wps.fep. up.pt/wps/wp471.pdf, accessed 25 December 2013. Ministry of Health of Turkey (2011) Health Statistics Yearbook. Available at: http://sbu.saglik.gov.tr/Ekutuphane/kitaplar/siy_ 2011.pdf, accessed 1 December 2011. Needleman J., Buerhaus P., Pankratz V.S., Leibson C.L., Stevens S.R. & Harris M. (2011) Nurse staffing and inpatient hospital mortality. New England Journal of Medicine 364 (11), 1037– 1045. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1076–1085
Job satisfaction, professional identity in nurses
Table 1 Individual and working characteristics of nurses (n = 2122) Variables Age (years) 18–30 31–40 41 or more Gender Female Male Marital status Married Single Divorced Educational level Health occupation college Associate degree Graduate (Baccalaureate) Master’s degree Duration of work (years) 1–5 6–10 11 or more Position at work Clinical nurse Chief nurse Work type Shift Daytime
n
%
1069 893 160
50.4 42.1 7.5
2041 81
96.2 3.8
1432 633 57
67.5 29.8 2.7
433 902 738 49
20.4 42.5 34.8 2.3
717 516 889
33.8 24.3 41.9
1766 356
83.2 16.8
1556 566
73.3 26.7
Data collection tools Data were collected using paper-and-pencil surveys. A demographic form and two instruments were administered: Professional Self-Concept Inventory (PSCI) and Minnesota Satisfaction Questionnaire (MSQ). Intention to leave the profession was determined with a question included in the sociodemographic questionnaire. Nurses were asked to answer the question ‘Are you currently considering leaving the profession?’ by choosing one of the three options, ‘yes’, ‘no’ or ‘undecided’. A similar question, has been used in previous studies (De Milt et al. 2011, Cortese 2012) conducted on intention to leave the nursing profession. The questionnaire also included questions about the nurses’ background, such as age, marital status, educational status, and working conditions, such as the employer, length of employment and occupation. The PSCI was developed by Sabanciogullari et al. (2011) within the sample of hospital nurses. The inventory is a four-point Likert type assessment inventory (1 = ’I totally disagree’ and 4 = ’I totally agree’) consisting of 36 items with three subscales: ‘professional satisfaction’, ‘professional competence’ and ‘professional attitude and skill’. Professional satisfaction (five items) refers to nurses’ professional satisfaction and is the person’s perception of themselves as ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1076–1085
the member of the profession. Professional competence (seven items) includes questions of oneself in terms of professional qualifications, such as problemsolving skills, decision-making, professional knowledge and skills, and professional competency required to perform the nursing profession. Professional attitude and skill (24 items) includes questions regarding feelings, thoughts and beliefs related to the fulfilment and the qualifications of the profession. The scores obtained for each item are summed to determine the total score. The higher the score, the better and the more advanced the professional self-concept is. Sabanciogullari et al. (2011) have reported the total Cronbach’s alpha coefficient of the inventory as 0.87. In the present study, the total Cronbach’s alpha coefficient of the inventory was 0.80. The MSQ was developed by Weiss et al. (1967) and the reliability and validity of the Turkish version of the scale was established by Baycan (1985). The MSQ has been widely used for the measurement of intrinsic, extrinsic and overall job satisfaction. The individuals are asked to rate their satisfaction with each of 20 work-related needs on a five-point scale ranging from ‘not satisfied’ (1) to ‘extremely satisfied’ (5). The scores for the responses are summed to produce a general satisfaction score. Intrinsic job satisfaction (11 items) is related to recognition, responsibility, achievement and progress of the psychological needs of the people. Extrinsic job satisfaction (nine items) is related to the work environment, compensation, supervision, promotion, working conditions and operating policies. The scores obtained for each item are summed to determine the total score. The higher the score the higher the job satisfaction. Martins and Proencßa (2012) have reported total Cronbach’s alpha coefficient of the inventory of 0.91. In the present study, the total Cronbach’s alpha coefficient of the inventory was 0.90.
Data analysis Data were analysed using the Statistical Package for Social Sciences for Windows (SPSS 16.0; SPSS, Chicago, IL, USA). In order to determine the nurses’ professional identity and job satisfaction, the means and standard deviations were calculated. To determine their intention to leave the profession, percentage distributions were used. The relationship between the nurses’ professional identity and job satisfaction were analysed using Pearson’s correlation and stepwise multiple regression. The relationship between the intention to leave the profession, the professional identity 1079
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and job satisfaction were assessed with the one-way ANOVA and logistical regression analysis. The level of significance for all the analyses was set at P < 0.05.
Results Respondents’ professional identity, job satisfaction and intention to leave the nursing profession The distribution of nurses’ mean overall and subscale scores for the Job Satisfaction Scale, the PSCI and of their intent to leave the profession are shown in Table 2. While 15.5% (n = 328) of the nurses considered leaving the profession, 64.7% (n = 1373) of them did not and 19.8% (n = 412) of them were undecided (Table 1). The nurses’ mean score for the MSQ was 3.18 (SD = 0.64), which is an indication of a moderate job satisfaction. Nurses received the highest score from the intrinsic job satisfaction subscale (mean = 3.37, SD = 0.65) and the lowest from the extrinsic job satisfaction subscale (mean = 2.90, SD = 0.78). The nurses’ mean overall score for the PSCI (mean = 109.18, SD = 12.35) was above average and was considered as a positive indication of strong professional identity.
Scales MSQ Overall job satisfaction Internal job satisfaction External job satisfaction PSCI, general Intention to leave the profession Yes No Undecided
Mean SD
3.18 3.37 2.90 109.18
0.64 0.65 0.78 12.35
Relationships between nurses’ professional identity and job satisfaction The correlation between the nurses’ the PSCI and Job Satisfaction Scale are shown in Table 3. A moderate but statistically significant and positive relationship was determined between the overall and intrinsic and extrinsic satisfaction subscales (r = 0.25–0.43) and their overall and professional satisfaction (r = 0.41– 0.49) and professional attitudes and skills (r = 0.19– 0.36) for the PSCI (P < 0.01). While there was a weak positive correlation between the professional competence for the PSCI and overall (r = 0.14) and intrinsic satisfaction (r = 0.20), there was no relationship between their professional competence for the PSCI and extrinsic satisfaction (r = 0.04) for job satisfaction (P > 0.05). The results of stepwise multiple linear regression analysis of job satisfaction and professional self-concept are shown in Table 4. Analysis of the t-test for significance of regression indicated that professional self-concept predicted job satisfaction (R = 0.52, R2 = 0.27, F = 256.100, P = 0.000). Professional selfconcept variables accounted for approximately 27% of the total variance of job satisfaction. The variables that affected job satisfaction most were professional
Minimum
Maximum
1 1 1 36
5 5 5 144
n (%)
Table 2 Mean scores of nurses in Minnesota Satisfaction Questionnaire (MSQ) and Professional Self-Concept Inventory (PSCI), and distribution of intention to leave the profession (n = 2122)
328 (15.5) 1373 (64.7) 421 (19.8)
Table 3 Correlation between Minnesota Satisfaction Questionnaire (MSQ) and Professional Self-Concept Inventory (PSCI) (n = 2122) Inventory PSCI General Professional satisfaction Professional competence Professional attitude and skill MSQ General Internal satisfaction External satisfaction
1
2
3
4
5
6
7
– 0.56** 0.78** 0.96**
– 0.15** 0.36**
– 0.72**
–
0.38** 0.43** 0.25**
0.49** 0.49** 0.41**
0.14** 0.20* 0.04
0.31** 0.36** 0.19**
– 0.93** 0.89**
– 0.67**
–
Key: 1, PSCI general; 2, professional satisfaction; 3, professional competence; 4, professional attitude and skill; 5, MSQ general; 6, internal satisfaction; 7, external satisfaction. *P < 0.05; **P < 0.01.
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Table 4 Stepwise multiple regression analysis of predictors of job satisfaction (n = 2122) Variables
B
PSCI General Professional satisfaction Professional attitude and skill
0.01 0.09 0.03
SE
ß
0.00 0.00 0.00
0.27 0.50 0.39
T
P-value
2.48 15.22 4.00
0.013 0.000 0.001
PSCI, Professional Self-Concept Inventory. R = 0.52, R2 = 0.27, F = 256.100, P = 0.000.
satisfaction (b = 0.50), professional attitude and skills (b = 0.39) and overall professional self-concept (b = 0.27). The variable excluded with stepwise multiple linear regression analysis was professional competence, which was in line with the correlation analysis.
The relationships between nurses’ professional identity, job satisfaction and intention to leave the nursing profession The comparison between nurses’ intention to leave the profession and the overall Job Satisfaction and PSCI is shown in Table 5. A significant relationship was determined between the intention to leave the profession and the Job Satisfaction Scale and the PSCI (P = 0.000). Nurses with low job satisfaction and low professional self-concept considered leaving the profession more than did the other nurses. In addition, according to the logistic regression analysis, job satisfaction (b = 0.646, SE = 0.081, Wald = 63.947, df = 1, P = 0.000) and professional identity (b = 0.026, SE = 0.004, Wald = 36.074, df = 1, P = 0.000) significantly affected the nurses’ intention to leave the profession.
Discussion With the increase in the number of nurses leaving the profession, nurse shortages are deepening (American Association of Colleges of Nursing (AACN) 2014). In the present study, 15.5% of the nurses in Turkey stated that they had an intention to leave the profession. Similar results have been reported in the international literature (De Milt et al. 2011, Cortese 2012, Heinen et al. 2013). In addition, if the nurses who stated that they were undecided about leaving the profession were included in the results of the present study, it is possible to argue that more than one-third of the Turkish nursing workforce (35.3%) considers leaving the profession. The need for health services in our society is increasing and nurses are essential resource. Retention of nurses in the profession is important for the provision of safe and high-quality patient care (Aiken et al. 2012) and for the nursing profession (Hwang et al. 2009). Nurse managers are in a key role supporting their staff in job satisfaction, professional self-concept and ultimately intention to stay in the profession. According Cortese (2012), intention to leave the profession starts as a withdrawal process, in which nurses may first leave their unit, then the organisation and finally the profession. By knowing the predictors and that the first steps of this process are important, if human resource departments and nurse managers can identify, intervene and stop this process early, more nurses may be retained in the profession. Job satisfaction plays an important role in retaining nurses in the profession and motivates nurses to provide quality care (Deppoliti 2008, Duffield et al. 2009, Sharbaugh 2009). Identifying the factors that contribute to job satisfaction will make it possible to implement effective plans to retain the nursing workforce. According to the findings of this study, nurses’
Table 5 Comparison of nurses’ intention to leave the profession and their mean overall and subscale scores for the Minnesota Satisfaction Questionnaire (MSQ) and Professional Self-Concept Inventory (PSCI) (n = 2122) Intention to leave the profession Yes (n = 328, % 15.5) Inventories MSQ General Internal satisfaction External satisfaction PSCI General Professional satisfaction Professional competence Professional attitude and skill
Mean
SD
No (n = 1373,% 64.7) Mean
SD
Undecided (n = 421, % 19.8) Mean
SD
Test (F/P)
2.88 3.05 2.61
0.71 0.73 0.84
3.29 3.48 3.01
0.61 0.61 0.77
3.04 3.24 2.75
0.55 0.57 0.70
71.753/0.000 73.311/0.000 44.699/0.000
105.24 10.49 22.34 72.39
12.74 3.08 3.49 9.07
111.09 14.21 22.52 74.34
12.27 3.23 3.02 8.33
106.02 12.01 21.78 72.22
10.89 2.69 2.96 7.63
48.920/0.000 227.085/0.000 9.374/0.000 14.671/0.000
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job satisfaction in Turkey is moderate, which is consistent with the findings of several other previous studies (Lorber & Savic 2012, Yılmazel 2013, Asegid et al. 2014). This study revealed that nurses with low job satisfaction had a greater intention to leave the profession. These results are consistent with Flinkman et al.’s (2013) and Cortese’s (2012) findings. In addition, in the present study, the logistic regression analysis results showed that job satisfaction was affecting nurses’ intention to leave the profession. It is critical that nurse managers in Turkey start developing strategies that are targeted at increasing nurses’ job satisfaction so that they can retain a qualified workforce and maximise the quality, safety and continuity of care. The most striking finding of the present study was that professional identity significantly affected both job satisfaction and nurses’ intention to leave the profession. The literature has drawn attention to professional identity and has emphasised its importance for nursing (Cowin et al. 2008, Sharbaugh 2009). There are discussions, for example, about the positive effects of professional identity on individuals, including positive self-image, professional satisfaction, sense of belonging and recognition of professional competence (Sharbaugh 2009, Jourdain & Chenevert 2010, Vliegher et al. 2011). This study showed that nurses had a strong sense of professional identity. This finding is consistent with the results of Sharbaugh (2009), Kelly and Courts (2007) and Park et al. (2007). In the present study, a positive and moderately significant relationship was determined between the nurses’ professional identities and job satisfaction. In Hwang et al.’s (2009) study, professionalism, which also involves professional identity, was identified as an important factor affecting job satisfaction. There is a stronger relationship between professional identity and extrinsic job satisfaction than between professional identity and intrinsic job satisfaction. Intrinsic job satisfaction is related to recognition, responsibility, achievement, autonomy and progress of the psychological needs of the people. These features can thus be advanced with the development of professional identity. It may be argued that the growth of professional identity will also increase nurses’ intrinsic job satisfaction. According to the results of the regression analysis, professional identity accounted for 27% of the total variance of job satisfaction. Given that many factors influence nurses’ job satisfaction, this result is very important. Regression analysis also revealed that the variable which job satisfaction affected most was professional satisfaction. This refers to a person’s perception of themselves as a member of the profession. 1082
Advancement of professional identity may increase job satisfaction by bringing out a sense of belonging to the profession. Based on these results, it may be claimed that professional identity is an important factor for nurses to have satisfaction in their work. Moreover, this finding is very important because it suggests that job dissatisfaction, which is one of the major causes of their intention to leave the profession, can be reduced by means of advancing nurses’ professional identity. Furthermore, the result underscores the importance of an organisation and its supportive programmes targeted at enhancing professional identity by increasing job satisfaction initiated by nurse managers. In the present study, intention to leave the profession was lower among the nurses with a high professional identity. This finding is consistent with the results of the studies of Jourdain and Chenevert (2010), Cowin et al. (2008) and Sharbaugh (2009). Nurses’ commitment to the profession (Sharbaugh 2009) and intention to stay in the profession (Jourdain & Chenevert 2010) increases as they develop strong feelings of being a nurse. In Sharbaugh’s (2009) and Vliegher et al.’s (2011) studies, professional identity was identified as the best predictor of the intention to stay in the profession. In line with these findings, it can be argued that development of professional identity is necessary if nurses are to be retained in the profession. Strategies aimed at supporting the growth of increasing professional identity emphasise, for example reliance on oneself and one’s own skills when learning and using nursing knowledge and these may be useful skills to stress, starting in nursing education, to retain nurses in the profession. Cowin et al. (2008) determined that self-concept plays a more effective role in increasing nurses’ willingness to stay in the profession than did job satisfaction. Given that professional identity can affect both job satisfaction and intention to leave the profession, it is critical that nurse managers focus on the advancement of nurses’ professional identity. What is important is how to develop professional identity. In her study Sabanciogullari (2010) prepared a professional identity development programme for nurses based on Strasen’s (1992) model and investigated its effects on professional self-concept, job satisfaction and burnout levels. The programme significantly improved nurses’ professional self-concept and considerably reduced their burnout but did not increase their job satisfaction. The programme reduced the burnout caused by job dissatisfaction and, therefore, it can be argued that reduction in burnout increases job satisfaction in the ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1076–1085
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long term. In the literature, there is, however, a gap in knowledge about how to grow nurses’ professional identity and job satisfaction. More empirical studies should be conducted and the effectiveness of different strategies should be explored and tested.
Limitations of the study A major limitation of this study was the sample and how it represented nurse population in Turkey. It is not possible to generalise the results because the study included only nurses working in hospitals. These nurses represented only 2.8% of the entire population. In addition, nurses’ intention to leave the profession was assessed by asking a question directly related to the topic. This question has not been tested for its psychometric sensitivity. Qualitative methods might have been more advantageous to study opinions about the profession and working conditions in detail. Therefore, it is recommended that qualitative methods be implemented in further studies on this subject. The present study is the first to investigate the relationship between job satisfaction, perception of professional identity and intention to leave the profession in Turkey. It is recommended that future studies with larger sample sizes should be performed on this subject in Turkey.
Conclusion The results of this study revealed that nurses that had moderate levels of job satisfaction, displayed positive professional identity and that there was a significant relationship between their professional identity and job satisfaction. More than one-third of the nurses either had intentions to leave the profession or were undecided about it. Nurses with low professional identity and low job satisfaction considered leaving the profession more often than the other nurses. Professional identity and job satisfaction are therefore important factors affecting intention to leave the profession.
Implications for nursing management Providing opportunities for nurses to participate in professional activities could be a first step for nurse managers to start new strategies that contribute to their staff’s sense of being part of other nurses and of the profession (Jourdain & Chenevert 2010, Aiken et al. 2013). Participation in decision making in nursing practices and co-management models would also ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1076–1085
increase nurses’ sense of belonging in the organisation (Flinkman et al. 2010, Jourdain & Chenevert 2010, Aiken et al. 2013). In addition, support for staff education (i.e. education inside and outside of the organisation) contributes to professional identity and practice, both of which increase job satisfaction (Hwang et al. 2009, Sabanciogullari 2010). Therefore, it is important that nursing educators and managers encourage and allocate resources that enable nurses to access and participate in educational programmes and conferences (Cortese 2012, Aiken et al. 2013, Asegid et al. 2014). In addition, it is important for hospital administrators and employers to make use of the staff education that is available inside an organisation; it is much more cost-effective to invite a guest speaker to a hospital than to send a handful of staff to an educational event. In addition, rearrangement of work shift patterns for internal education that promotes the professional development of nurses is a cost-effective approach (Flinkman et al. 2010, Jourdain & Chenevert 2010). These efforts will foster professionalism and thereby enhance job satisfaction and retention of nurses in practice. Nursing managers can determine the effects of these strategies by measuring staff satisfaction regularly and monitoring retention in collaboration with the human resources department. To retain qualified staff, it is important for nurse managers to recognise and review the factors contributing to job satisfaction of nurses working in hospitals. Nursing managers can greatly increase nurse job satisfaction by ensuring opportunities, such as working with competent peers, promoting collaborative nurse–physician relationships, enhancing clinical autonomy, providing continuously support to staff, advocating and promoting control over nursing practice, securing adequate staffing, and supporting staff education (Hayes et al. 2010). Nurse managers should regularly monitor for signs of dissatisfaction, for example as a part of annual development discussions and by conducting job satisfaction surveys. Staff’s intention to apply positions on other units or hospitals may be the first symptoms of leaving the workforce and the profession. The literature shows (Flinkman et al. 2010, Cortese 2012) that it may take nurses up to 3 years before they make the final decision to leave and thus nurse managers have time and the opportunity to change the trajectory of this process. Nurse managers and/or the human resource department need to have interviews (so called ‘exit interview’) with nurses who have decided to leave the nursing profession to find out why they have made the final decision to leave: such information 1083
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would be useful in dissuading nurses from leaving in the future.
Source of funding The authors did not receive any funding for this paper.
Ethical approval Ethical approval was obtained from the Gaziosmanpasa University Ethics Committee (Decision no. 83116987-049).
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