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International Journal of Nursing Studies 44 (2007) 297314

Literature review

Impact of job satisfaction components on intent to leave andturnover for hospital-based nurses: A review

of the research literature

Billie Coomber , K. Louise BarriballKings College London, London, UK

Received 12 October 2005; received in revised form 31 January 2006; accepted 10 February 2006

Abstract

Background: The United Kingdom (UK), alongside other industrialised countries, is experiencing a shortage of nursespartly due to low retention rates. Job satisfaction has been highlighted as a contributing factor to intent to leave andturnover, yet this is a complex area with many elements affecting its measurement.Aim: The aim of this paper is to explore the impact of job satisfaction components on intent to leave and turnover forhospital-based nurses in order to identify the most inuential factors.Methods: To achieve this, a systematic search of the literature was undertaken to identify relevant internationalresearch. Three databases (i.e. BNI, CINAHL and PsychInfo) were utilised, resulting in nine articles that met theinclusion criteria. Four recurrent themes were identied in the literature: leadership, educational attainment, pay and

stress.Findings: The key ndings suggest that stress and leadership issues continue to exert inuence on dissatisfaction andturnover for nurses. Level of education achieved and pay were found to be associated with job satisfaction, although theresults for these factors were not consistent.Conclusion: Investigating possible changes over time in sources of dissatisfaction revealed that factors related to thework environment rather than individual or demographic factors were still of most importance to nurses turnoverintentions. The differences found to occur across work settings necessitates analysis of job satisfaction at ward level,and the contribution of qualitative methods to develop more detailed insight is emphasised. The inconsistent ndingsover time associated with the effects of educational attainment and pay on intent to leave suggest that it is imperativethat sources of job satisfaction are reassessed in the light of ongoing changes.r 2006 Elsevier Ltd. All rights reserved.

Keywords: Job satisfaction; Nurse turnover; Intent to leave; Nurse retention; Nurse shortage; Attrition; Research review

What is already known ?

Recruitment and retention of nurses is a contemporaryissue of concern internationally as well as in Britain.

Job satisfaction is a concept closely linked to intent toleave and, hence, turnover within the nursing profession.A multitude of factors can exert an effect on the jobsatisfaction of nurses.

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www.elsevier.com/locate/ijnurstu

0020-7489/$- see front matter r 2006 Elsevier Ltd. All rights reserved.

doi: 10.1016/j.ijnurstu.2006.02.004

Corresponding author. Tel.: +4420 7274 0348.E-mail address: [email protected] (B. Coomber).
http://www.elsevier.com/locate/ijnurstuhttp://localhost/var/www/apps/conversion/tmp/scratch_6/dx.doi.org/10.1016/j.ijnurstu.2006.02.004mailto:[email protected]:[email protected]://localhost/var/www/apps/conversion/tmp/scratch_6/dx.doi.org/10.1016/j.ijnurstu.2006.02.004http://www.elsevier.com/locate/ijnurstu

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What this paper adds

Reviews international research on job satisfactionexposing the factors most inuential on turnover.Highlights the need to analyse job satisfaction atindividual ward level.Considers the contribution of qualitative researchmethods to develop insight.Reconrms organisational factors (particularly stressand leadership) as more inuential than individualfactors (or demographics) on job satisfaction andturnover intentions.

1. Introduction

For 2003, the Ofce of Manpower Economics (OME)

(2003) reported that the rate of nursing staff leaving theNational Health Service (NHS) in Britain was 9.4%.Given that nurses account for approximately 356,000members of staff in the NHS, the scope of this wastageamounts to approximately 33,500 nurses per annum.Nursing shortages have effects on many aspects of health care in Britain, not least constraining the effectivedelivery of services ( Department of Health (DH), 2001 ).The problems associated with the shortage of registerednurses are compounded by an increasing demand forhealth care due to advances in medical technology,longer life expectancy, and the subsequent number of people living with serious illness and chronic disease(Buchan and Seccombe, 2003 ). Furthermore, there areincreased demands for nurses as roles have widened toinclude those responsibilities formerly undertaken bymedical staff, which emphasises the negative impact anursing shortage may have on the quality of patient care(Aiken et al., 2002 ).

A fundamental policy shift has occurred in the BritishNHS with the introduction of modernisation plans andthe implementation of strategies for improving theworking lives of health care staff ( DH, 2000, 2001 ).The NHS Plan ( DH, 2000 ) acknowledges workforceplanning and effective approaches to recruitment,

retention and motivation of NHS nurses as key elementsto achieving a modernised health service. However, thehealth gain targets imposed by the NHS Planare dependent on increasing the numbers of nurses inthe NHS ( Buchan and Seccombe, 2003 ).

2. Background

2.1. Turnover

Turnover at an organisational level is seen to be a

major contributor to the shortage of nurses ( Gauci-

Borda and Norman, 1997 ). Additionally, the loss of performance and efciency on part of the leaver prior todeparture is a major consequence of turnover, and highabsence is seen as a critical problem in times of highturnover ( Cavanagh, 1989 ). This has the effect of increasing pressure on, and decreasing morale of theremaining staff, resulting in the possibility of furtherturnover ( Gauci-Borda and Norman, 1997 ). The im-plications of this vicious cycle serve to focus attentionon retention as a means to inhibit turnover and addressthe burden of shortages.

There are inconsistencies within the literature regard-ing turnover, which may be attributable to theuncertainty surrounding both denition and measure-ment ( Cavanagh, 1989 ). Turnover is generally viewed asthe movement of staff out of an organisation, yet thisconsistently presents problems within turnover researchfor two reasons. Firstly, the incongruent inclusion in

sample populations of staff who are retiring or aredismissed alongside those who voluntarily leave; andsecondly, distinction between intra- (i.e. movementbetween units within the same organisation) and extra-(i.e. movement across organisations) institutional turn-over is not made freely within the literature, which hasparticular resonance for the health service. Bluedorn(1978) viewed turnover as a two-dimensional concept,distinguishing between the act of leaving as voluntary orinvoluntary, and between the leaving and joining of anindividual to an organisation. This dened view is usefulto consider when attempting to distinguish the variablesthat may have a relationship with voluntary turnover.

To promote clarity, the theorists Fishbein and Ajzen(1975) sought to explain factors that predict actualturnover, summarising that behavioural intention is theprimary antecedent to actual behaviour. This infers thatthe cognitive process of turnover intention (intent toleave) is an important predictor of actual turnover, aconcept that has much empirical and theoretical supportwithin turnover research ( Mobley et al., 1978 ; Bluedorn,1982 ; Steele and Ovalle, 1984 ; Prestholdt et al., 1987 ).Therefore, turnover intention (or intent to leave/stay) isconsequently considered as an outcome of affectivevariables (such as job satisfaction) rather than actualturnover, which may be mediated by other variablessuch as age and tenure ( Hellman, 1997 ). Actual turnovercan thus be tested, but may not be subject to variablesthat are directly predictive.

2.2. Job satisfaction

As a shortage ensues and difculties in retention arehighlighted, it follows that the reasons nurses leave their jobs must be clearly identied if the issue is to besuccessfully addressed. Job satisfaction has been citedas a major contributory factor to intent to stay in

the international nursing literature ( Cavanagh, 1992 ;

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Gauci-Borda and Norman, 1997 ; Strachota et al., 2003 ),but job satisfaction is a complex phenomenon with manyaffecting components. Its status as an important predictorof intent to stay has the secondary effect of decreasingturnover, with many authors concluding that a decrease inturnover occurs when a workforce is satised ( Saleh et al.,1965; Blegen, 1993 ; Irvine and Evans, 1995 ; Hellman,1997).

Whilst substantial literature exists regarding jobsatisfaction among employees in general and withinnursing specically, there appears to be no agreedprecise denition ( Cavanagh, 1992 ). It has been de-scribed as an individual attitude to how well personalexpectations at work correspond to outcomes ( McKen-na, 2000 ). Therefore, an individuals appraisal of thedegree to which the job fulls ones own job values cancause a positive emotional state of satisfaction or acontrasting negative feeling of dissatisfaction.

Job satisfaction is considered within empirical studieseither as an overall (global) feeling about the job, or as arelated set of attitudes about various aspects of the job(facet approach) ( Spector, 1997 ). The global approach tomeasurement is used when the interest is in overall attitudeto the job. However, facet approaches can determine whichparticular aspects of the job are producing satisfaction ordissatisfaction for the individual and are, therefore,important in determining areas for improvement. Facetsof job satisfaction can involve any aspect of the job andthose frequently assessed include pay, co-workers, super-visors, organisational factors and work environment ( Smithet al., 1969 ; Stamps and Piedmonte, 1986 ).

2.3. Concept of job satisfaction

Whilst denitions can provide a broad understandingof what job satisfaction entails, it remains a complexconcept illustrated by the multiple variables that havebeen studied in relation to it. Different theories presentdiffering conceptualisations of job satisfaction thatcan be categorised as content or process theories(Campbell et al., 1970 ). Herzbergs (1966) Motivator Hygiene theory and Maslows (1970) Hierarchy of Needs exemplify content theories, and attempt toidentify needs or values to be realised in order for anindividual to be satised at work. For instance,Herzberg (1966) identied maintenance and motivatingfactors related to peoples attitudes to work: main-tenance or dissatisers such as pay and associatedbenets, organisational policies and working environ-ment; and motivating factors including recognition,achievement and self-satisfaction. Together with deni-tions, two main themes run through these theories: that job satisfaction has an affective component, i.e. a feelingof satisfaction, and a perceptual component which is anevaluation of whether ones job meets ones needs

(Tovey and Adams, 1999 ). This is particularly pertinent

when appraising the reasons why different studies utilisediffering measurement approaches, and provides ratio-nale for this occurrence.

2.4. The link between job satisfaction and turnover

According to Hellman (1997) , increasing dissatisfac-tion in employees results in a higher chance of considering other employment opportunities. In hismeta-analysis of US studies of non-nursing workers,the relationship between job satisfaction and intent toleave was found to be signicantly different from zeroand consistently negative. These ndings were reiteratedin nursing research with many authors concluding thatincreasing job satisfaction decreased rates of turnover(Saleh et al., 1965 ; Price and Mueller, 1981 ; Cavanaghand Cofn, 1992 ). Seccombe and Smith (1997) foundthat the factors given by nurses as reasons for leaving

were centred on issues known to affect job satisfactionsuch as ineffective supervisory relationships and pooropportunities for professional development, rather thanexternal labour market forces of which managers would justiably feel unable to control.

A summary of disciplinary perspectives contributingto the understanding of nurse turnover behaviourwas provided by Mueller and Price (1990) . Thisincluded: economic research with its emphasis onindividual choice and labour market variables; socio-logical research emphasising characteristics of the workenvironment and content; and psychological researchwhich emphasised individual variables and cognitiveprocesses. Irvine and Evans (1995) developed thisconcept into a model for their meta-analytical studyon job satisfaction and turnover, a summary of whichcan be seen in Fig. 1 .

3. Methods

3.1. Search strategy

The aim of this review was to explore the impact of job satisfaction components on intent to leave andturnover for hospital-based nurses. In order to extractrelevant research from the published literature toachieve this aim the electronic databases CumulativeIndex to Nursing and Allied Health Literature (CI-NAHL 19822004), Psychology Information (PsycIN-FO 20002004) and British Nursing Index (BNI19852004) were searched. Keywords were nurses,retention and job satisfaction with synonyms andphrases being used as appropriate (for example, the termretention was used and combined with attrition, intentto leave, intent to quit, propensity to leave, intent to stayand turnover). The years 19972004 were chosen as a

limit option in order to select only recent published work

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that may hold more relevance for the nursing professiontoday due to the rapidly changing nature of nursing overrecent years. Where possible, the search was globallylimited to research (e.g. within CINAHL) and manuallywhere electronic search limits were not possible. Speciccriteria for inclusion and exclusion ( Table 1 ) were alsoapplied to ensure fullment of the aim of this review andmanual scanning of abstracts was undertaken for thepurpose of checking article suitability. While it was notpossible to retrieve a small number of papers, theapplication of the inclusion/exclusion criteria resulted innine research articles being selected. These articles are

summarised in Table 2 .

3.2. Framework for analysis

With a plethora of themes found within the chosenliterature, a decision was made to systematically identifythe most frequently cited using an adaptation of thematic content analysis. This entailed scrutinisingeach paper, logging each theme contained within eachpaper and selecting those themes with the greatestcounts for analysis. The four themes with the highestfrequencies were: (1) leadership, (2) educational attain-ment, (3) stress and (4) pay. Whilst an alternativeapproach to inclusion could have been to choose the

most statistically signicant themes, this was not

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ECONOMIC FACTORS

PayJob marketTraining

JOBSATISFACTION

BEHAVIOURALINTENTIONS

STRUCTURAL FACTORSWork environmentWork context

TURNOVER

PSYCHOLOGICAL FACTORSIndividualDemographic

Fig. 1. Model of nurse turnover behaviour ( Irvine and Evans, 1995 ).

Table 1Showing criteria for inclusion and exclusion of articles

Inclusion Exclusion

Adult nurses Paediatric/mental health/learning difculties nursesHospital nursing Primary/community/correctional/public health/hospice/nursing

homes/NHS direct/militaryNurses in general medical and surgical units Solely specialist areas e.g. ICU, oncology, theatres, nurse

practitioners, management, nurse anaesthetistsBoth job satisfaction+intent to leave/turnover a key focus of the paper

Only job satisfaction covered

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possible due to the difculties in comparability of thedata and the variation in reports of each statistic.

4. Findings

4.1. Leadership

One of the problematic issues regarding leadership isthe lack of consensus regarding denition. Despite this,some recognition that it refers to either the direct superioror ward manager exists and that certain characteristicspertaining to leadership are particularly pertinent ininuencing intent to leave. Five of the nine papers usedscale measurement of leadership styles and characteristicsused in ward environments ( Fang, 2001 ; Fletcher, 2001 ;Tzeng, 2002 ; Yin and Yang, 2002 ; Larrabee et al., 2003 ).Whilst leadership was dened differently in each study,

similar results were obtained with one exception.Fang (2001) used a specically constructed super-

vision satisfaction scale consisting of ve items measur-ing competency, fairness, recognition, communicationand collaboration (strongly disagree 1, stronglyagree 5). Regression results indicated that supervisorsatisfaction was one of the most signicant predictors of turnover intention (coefcient standardised 0.168, po 0:05) but not turnover cognition ( 0.032). The studysurveyed 180 nurses in Singapore and obtained a 90%response rate strengthening the validity of the resultsalthough it was undertaken in a single hospital, thuslimiting generalisability.

Fletcher (2001) used a six-item scale of immediatesupervisor measuring perceived qualities such as supervisorreliability, competency and helpfulness (very true 1,not at all true 4), as well as the supervisory subscalefrom the Job Diagnostic Survey (JDS, Hackman andOldham, 1975 ) (extremely dissatised 1, extremelysatised 7). The denition given for immediate super-visor was generally the nurse manager, and the lowestratings attained were related to this subject. The lowestindividual item means for the subscale of JDS were forsupervisor support (mean 4.34) and quality of super-vision (mean 4.46). For the Immediate Supervisorscale the highest means (and therefore lowest ratings)were for supervisor helpfulness (2.81) and reliability(2.68). The low ratings were claried with writtencomments from participants that were categorised intofour general themes: quality of leadership, lack of physical presence, failure to address problems andstafng issues. Whilst the results pertaining to intent toleave indicated that the participants surveyed were likelyto remain in nursing, this was measured with a singlequestion scored on a 5-point Likert scale without furtherstatistical tests applied. Despite the large sample size(n 1780 for JDS, n 509 for qualitative component)

and the number of hospitals surveyed ( n

10), the

response rate for both components was low (34.5% and28.6%). Furthermore, no report or prole of non-respondents was provided, which may have affected therepresentativeness of this US sample.

Larrabee et al. (2003) also reported associationsbetween leadership and intent to leave, but acknowl-edged that this was an indirect link. Their US studycollected data ( n 90, RR 60%) via nine subscales of the Multifactor Leadership Scale ( Bass and Avolio,1995 ) with varying numbers of items in each subscale:transformational leadership (5), transactional leadership(3), non-transactional (1) and leadership outcomes (3).Intent to leave was measured using a single item(denitely will not leave 1, denitely will leave 5).The results of stepwise multiple regression suggestedthat leadership was not directly related to intent to leavebut indirectly related through various other predictors.Transformational leadership style was found to predict

psychological empowerment of nurses ( po 0:001) whichin turn predicted an increase in job satisfaction( po 0:001) which was then a major predictor of adecrease in intent to leave ( po 0:001). These ndingsillustrate the complexity involved in various perceptualand attitudinal factors contributing to an individualsintention to leave.

In contrast to the ndings of the studies presentedabove, the results of Tzengs (2002) work suggested thatleadership style exerted no inuence on job satisfactionand intent to leave ( n 648, RR 82%). The differentmethod of modelling utilised by Tzeng distinguishes thisstudy from the others and may account for the variancein ndings, although it is noteworthy that large p-values(model 2, p 0:10; model 3, p 0:35) were obtained forleadership style. This study was undertaken in Taiwanand whilst the potential for cultural inuences to explainthe differences is acknowledged, interestingly Yin andYang (2002) attained opposing results in their meta-analysis of 13 Taiwanese studies. In particular, consis-tently signicant results were reported for experiencedturnover and potential turnover due to supervisordissatisfaction (ranked 5/18 and 3/16, respectively, po 0:05). The specic areas of supervisor dissatisfaction,while measured, were not presented thus lowering theopportunity for direct application of ndings topractice.

4.2. Educational attainment

Conicting results were found for the effect of theindividual factor of educational attainment on jobsatisfaction and on intent to leave. Six studies usedself-reported demographic data to ascertain the educa-tional level of participants ( Fang, 2001 ; Lu et al., 2002 ;Tzeng, 2002 ; Yin and Yang, 2002 ; Larrabee et al., 2003 ;Rambur et al., 2003 ). Three studies found positive

correlations for educational level and job satisfaction. A

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U n s t a b l e s c h e d u l i n g .

T o p 1 0 r e a s o n s f o r p o t e n t i a l t u r o v e r :

S a l a r y a n d f r i n g e b e n e t s

P e e r g r o u p r e l a t i o n s h i p s

L e a d e r s h i p s t y l e o f d i r e c t s u p e r i o r s

L e v e l o f c h a l l e n g e

A d m i n i s t r a t i v e p o l i c i e s

P o o r p r o m o t i o n o p p o r t u n i t i e s

W o r k s t r e s s d u e t o h i g h w o r k l o a d

A c h i e v e m e n t

P r o f e s s i o n a l i s m

W o r k e n v i r o n m e n t .

M a r i t a l s t a t u s a n d e d u c a t i o n a l l e v e l

c o r r e l a t e d w i t h j o b s a t i s f a c t i o n .

E d u c a t i o n a l l e v e l c o r r e l a t e d w i t h

a u t o n o m y .

T

a b l e 2 ( c o n t i n u e d

)

T

i t l e a n d A u t h o r ( s )

R e s e a r c h q u e s t i o n

M e t h o d , s a m p l e & d a t a c o l l e c t i o n

D a t a a n a l y s i s

F i n d i n g s


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secondary analysis of US relicensure surveys by Ramburet al. (2003) (n 4418, RR 85%) reported that jobdissatisfaction decreased with higher educational level,and Yin and Yangs (2002) work in Taiwan conrmedthis nding, suggesting that nurses with lower educa-tional levels are less satised with their jobs ( po 0:05).This is reiterated by Tzeng (2002) , whose results for thenal ordinal regression indicated that holding a diploma(estimate 1.790, Wald w2 4:28, p 0:04), holdingan associate degree ( 1.639, Wald w2 4:00, p 0:05)and general job satisfaction ( 0.862, Wald w2 22:89, p 0:00) are signicant predictors of Taiwanese nursesintention to quit. Yins and Yangs (2002) meta-analysisof individual factors related to nurse turnover asserted asmall but stable relationship for educational attainment(rxy 0:09), with this relationship being one of thestrongest out of the individual factors that includedmarital status, years of tenure, age and position.

Interestingly, opposing results were obtained by Lu etal. (2002) who found a signicant association indicatingeducational level to be negatively correlated with jobsatisfaction (Spearmans correlation 0.101, po 0:01)and positively correlated with intent to leave theorganisation (.054, po 0:05) and the profession (0.058, po 0:01) for a Taiwanese sample ( n 2197,RR 86.2%). The studies by Fang (2001) and Larrabeeet al. (2003) both concluded that there were nosignicant relationships between any demographicfactors and turnover cognition or intention. Fang(2001) further reported that job satisfaction did notexhibit any signicant inuence on turnover in a sampleof Singaporean nurses (coefcients standardised forcognition 0.108; for intention 0.007). The small, non-random sample in Larrabee et al.s (2003) study couldindicate a reason for their opposing results, with largerstudies required to conrm these as valid ndings.Additionally, the purpose of their study did notspecically involve the investigation of demographicvariables on job satisfaction and intent to leave, soresults of statistical tests were not provided for educa-tional attainment, thus disallowing independent assess-ment of the effect.

Overall, there was no consensus regarding educationalattainment and its relationship with either job satisfac-tion or intent to leave. The inconsistent, yet sometimessignicant results allow for considerable confusion whenattempting to interpret the importance and implicationsof educational attainment for retention. Similarities indata collection methods and use of statistics acrossstudies further hinders the clarication of reasonsfor the differences in ndings. It could be assumed fromthese results that assessment of educational level isfraught with methodological challenges, or perhaps thesamples were very distinct. Certainly the ndings aremixed, and as such conclusions should be drawn with

caution.

4.3. Pay

Throughout the studies that measured the importanceof pay for nurses ( Fang, 2001 ; Fletcher, 2001 ; Cowin,2002 ; Rambur, 2003), denitions were implied as salaryor salary and fringe benets, which enhanced compar-ability of ndings. However, the impact of salary relatedto culture is difcult to determine without detailedknowledge of the wider social and economic climate inwhich it operates. In addition, several different ndingswere produced from differing methods of assessment.

Cowin (2002) measured satisfaction with pay over an8-month period among a sample of Australian graduatenurses ( n 506 at T1, n 110 at T2) and experiencednurses ( n 528 at T1, n 332 at T2) through acomponent of the Index of Work Satisfaction (IWS,Stamps and Piedmonte, 1986 ) at two points in time(T1 0 months, T2 8 months). The ndings indicated

that although the issue of pay was not ranked as themost important, it rated as the least satisfying forgraduates (T1 and T2) and second least satisfying forexperienced nurses (T2). Furthermore, the importanceof pay increased over time for both groups (from 3/6 to2/6). This could be attributable to other confoundingfactors occurring over the 8 months of the study but notmeasured, or may indicate a growing concern that hasthe potential to become a considerable source of importance. However, the specically constructed NurseRetention Index (NRI, 8-point forced choice Likert) wasadministered to the two groups at T2, and Cowin (2002)stated that the results of multiple regression analysissuggest that pay was not a statistically signicantindicator of intent to leave for either group (guresundisclosed). Despite this, the qualitative component of Cowins (2002) study, which consisted of writtencomments, indicated that dissonance between pay andlevel of responsibility may lead to retention issues. Amajor source of concern for graduates and experiencednurses was the perceived inequality of pay for high levelof responsibility. In particular, experienced nursescompared their workloads, level of knowledge andresponsibility to their perception of less qualiedprofessions, resulting in expressions of disappointmentwith career choice. Other comments suggested that paywas not a primary problem for retention when enjoy-ment of other aspects (undisclosed) of the work washigh.

Fang (2001) also found no statistically signicantinuence of pay on turnover cognition (coefcientstandardised 0.108) or turnover intention (0.007). Acomplete assessment of the importance of pay was,however, complicated by the loading of pay into thesame factor of job satisfaction. The overlap betweenthese two factors was found during factor analysis and itwas therefore found to possess a lack of empirical

distinctiveness. The question asked of the sample

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relating to pay also included the element of job security.It is possible that this multiple question could haveaffected the assessment of salary satisfaction if partici-pants were satised with the security of their positionand scored accordingly.

The inability to assess pay individually was alsoevident in Fletchers (2001) study. A job satisfactionsubscale of the JDS ( Hackman and Oldham, 1975 ) wasused to measure pay satisfaction of US nurses(n 1780, RR 34.5%) via two items (Spearman-Brown reliability for items on scale 0.86). The payitems were measured with a 7-point Likert scale(extremely dissatised 1, extremely satised 7) butthe only result presented was that of an overall score forthe subscale which consisted of 14 items. This assertedthat participants were slightly satised with their jobs(mean 5.04, SD 0.99), but rendered specic resultsfor the pay items inaccessible. Written comments from

participants provided some clarity, with an expression of similar feelings to those from Cowins Australian (2002)study. They indicated feelings of inadequate reward fortheir education, experience and expertise, and unfair-ness of pay compared with other professions. Fletcher(2001) argued that the sample was likely to remain innursing, although this conclusion was drawn on thebasis of a single question providing little insight into thefactors inuencing participants responses. Generalisa-bility is compromised due to the low response rate(34.5%), and a reported demographic of nurses beingrepresented by a bargaining unit (type of union thatnegotiates salary each year) which is unrepresentative of the nursing profession in other countries.

An interesting feature of the issue of pay and resultinginuence for intent to leave for nurses was reported inRambur et als (2003) large US study. A genderdifference affecting pay satisfaction was found duringsecondary analysis of self-reported data. Pay wascollapsed into the category of job dissatisfaction alongwith aspects such as short stafng and poor manage-ment. Of those intending to leave (males 23%,females 20%), 75% of male participants were intend-ing to leave for reasons of job dissatisfaction in contrastto 51% of female participants ( w2 10:31, po 0:01). Inaddition, male participants (53%) were more likely to beleaving due to dissatisfaction with salary than femaleparticipants (26%) ( w2 16:31, po 0:01). As no statis-tically signicant results for gender differences wereobtained for the majority of other categories inuencingintent to leave, gender expectations and socialisationmay play a particular role in pay.

4.4. Stress

Four studies specically investigated the effect of stress on intent to leave, with stress consistently being

cited as a major predictor of anticipated turnover. This

had particular international signicance with studiesconducted in the US ( Shader et al., 2001 ), Singapore(Fang, 2001 ), Australia ( Cowin, 2002 ) and Taiwan ( Yinand Yang, 2002 ) reporting similar results. Methods usedto measure stress were varied and included scales ( Fang,2001 ; Shader et al., 2001 ), written comments ( Fletcher,2001 ; Cowin, 2002 ) and meta-analysis ( Yin and Yang,2002).

Stress exerted the most substantial impact on turnovercognition (coefcent standardised 0.351, po 0:000)and turnover intention (coefcient standardised 0.29, po 0:001) of all variables measured in Fangs (2001)study. Whilst reporting that stress explained 8.5% froma total of 41% of the variance for turnover cognitionand 4.6% from a total of 32% for turnover, the speciccauses of stress remained undifferentiated. This detractsfrom the wider focus of the study, which was to identifythe most critical causes of the turnover problem in

Singapore with a view to mitigating the problem. Whilstan indication that stress is a major cause is helpful fordirecting future research, a scale identifying specicstressors would have been helpful in ascertaining areasrequiring improvement.

Shader et als (2001) US study partly identiedparticular stressors via the Job Stress Scale ( Hinshawand Atwood, 1985 ), a 22-item, 4-point Likert with foursubscales. The mean job stress score was 2.06(SD 0.39, range 14), demonstrating that nursesreported moderate levels of job stress ( n 151,RR 63%). The Anticipated Turnover Scale consistingof 12 items rated on a 5-point Likert measure (possibleresponses undisclosed) reected individual perceptionsabout the possibility of leaving their current positions(mean score of 3.45, SD 1.06, range 17), rating theirintention to leave as moderate. Pearsons correlationanalyses were performed on all major study variables.The main stressor was assessed to be lack of stability inthe work schedule (constantly changing rota), with themore stable the schedule, the less work-related stress(r 0:205, po 0:001) and lower anticipated turnover(r 0:29, po 0:001). Higher job stress was also foundto lower job satisfaction through the lowering of groupcohesion ( r 0:41, po 0:001) which then increasedanticipated turnover ( r 0:37, po 0:001). A stepwiseregression model including the variables of job satisfac-tion ( 0.35), weekend overtime (0.27), job stress (0.16)and group cohesion ( 0.13) explained 31% of thevariance in anticipated turnover. Shader et al. investi-gated turnover further by looking at different age groupsin relation to these factors. The ndings indicated thatlow job satisfaction and job stress were signicantpredictors of anticipated turnover for 2030-year-oldnurses ( R2 16, po 0:001), low job satisfaction was apredictor for 3140-year-old nurses ( R2 0:31, po 0:001) and low job satisfaction together with low

group cohesion for 4150-year-old nurses ( R2

0:28,

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environments are not generic makes achieving thiscomplicated. In view of this, interventions that seek tosupport the individual, such as stress-managementtraining, which enables individuals to utilise their mosteffective coping strategies, and increasing support fromcolleagues and senior staff have both been suggested asappropriate measures to counteract stress within thenursing profession ( McVicar, 2003 ).

The UK Government recognises the need to addresslow retention in health care, with initiatives designed toreverse the trend in turnover. Introduction of exibleworking practices are part of the Governments commit-ment to improving the worklife balance of staff ( DH,1999). This may be particularly relevant for retention of younger nurses who were found to perceive stress fromlack of control over work scheduling ( Shader et al.,2001 ). An increase in stafng levels via improvedretention is also a means to address the cited stressor

of workload (Yin and Yang, 2001). With an increase indemand for health care, the burden of high workloadcan only be ameloriated by increasing nurse numbers.The RCN (2002) maintains this point, and adds thatrecruitment efforts will produce little signicant im-provement in workload stress in the near future andshould perhaps be seen as a medium to long-termmeasure. Government initiatives designed to meet needsof the majority is a starting point, but in view of theindividual nature of stress may not provide the answerfor all nurses ( McVicar, 2003 ). In view of the fact thatorganisational change is a recognised source of stress(Kouzes and Posner, 2003 ) and that changes constantlyoccur in the health services in line with modernisationplans, this issue is unlikely to be solved imminentlywithin the British NHS.

5.4. Leadership

The variable of leadership, or supervisory relation-ship, has a consistent relationship with job satisfactionand intent to leave in both early and recent studies(Sorrentino, 1992 ; McNeese-Smith, 1995 ; Chiok FoongLoke, 2001 ; Fang, 2001 ; Fletcher, 2001 ; Yin and Yang,2002 ; Larrabee et al., 2003 ). Nursing leadership style, orsupervisory relationship, is a phenomenon of interna-tional relevance that is linked to the work environment.Fletchers (2001) study suggested that job dissatisfactionensues when nurse managers fail to give due recognitionand support, disregard stafng issues and neglect toaddress problems. Furthermore, Larrabee et al. (2003)asserted that the main effect on intent to leave was adecrease in job satisfaction through a lack of empower-ment perceived by nurses to be a result of leadershipstyle. This suggests that when stafng levels are reduced,as they are for todays profession, leadership thatencompasses an open, empowering approach to staff

may be able to buffer low retention. Transformational

leadership style engenders motivation of others topursue high standards, concentrates on creating opencommunication and a willingness to embrace change(Morrison et al., 1997 ; Upenieks, 2003 ). This wouldseem most desirable for a profession that experiencesmuch change and that has expressed concern aboutsupervisory relations to a point that it negatively affectsturnover and possibly quality of care ( McNeese-Smith,1993 ; Davidson et al., 1997 ; Needleman and Buerhaus,2003). Introduction of participative styles of manage-ment is central to the human resource proposals of the NHS Plan ( DH, 2000 ), but change in leadershipbehaviour may not be easily obtained if this is not placedhigh on the agenda for managers ( Finlayson et al.,2002 ).

5.5. Pay

Nurses pay has been measured as a component onmany scales, although early studies found it tocontribute little to job satisfaction ( Blegen and Mueller,1987 ; Blegen, 1993 ; Irvine and Evans, 1995 ). However,the issue of pay and its contribution to job satisfactionincreases in importance when nurses perceive discrepan-cies between their remuneration and that of otherprofessions ( Tovey and Adams, 1999 ). This wasreiterated in the written comments obtained in thestudies of Fletcher (2001) and Cowin (2002) . It has alsobeen suggested that perceived lack of reward contributesto role disengagement ( Demerouti et al., 2000 ) and,although pay was not found to exert an effect on intentto leave in these studies, such perceptions have thepotential to become inuential. Comments from theparticipants of Cowins (2002) study suggesting that paywas not an issue only when other factors were satisfyingreiterates this possibility. It is further supported by thedissatisfaction expressed by participants regarding thediscrepancy between the high responsibility of the joband perceived low pay. As roles for nurses expand,and their responsibility increases, the potential fordissatisfaction and intent to leave could be amplied inthe UK.

Addressing pay via the Agenda for Change ( DH,2003) programme, which aims to modernise the salarysystem of the British NHS by providing competency-based pay (a variant of performance-related pay), hasbeen suggested as a potential source of conict foremployees expectations, norms of fairness and practice(Grimshaw, 2000 ) although such a perspective has itsdetractors. In a case study undertaken as a precursor toAgenda for Change evaluation, Meerabeau et al.(2004)found that a competency-based pay system was valuedby staff who felt that it provided structured roledevelopment. This dissonance demands that closeattention be paid to evaluation of this system when it

is introduced nationally.

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5.6. Educational attainment

Inconsistencies were apparent in overall results for therelationship between levels of education and jobsatisfaction. However, some ndings contradicted theearlier research of Price and Mueller (1981) andCavanagh (1992) by suggesting that higher educationalattainment led to greater satisfaction at work andlowered intention to leave ( Tzeng, 2002 ; Yin and Yang,2002 ; Rambur et al., 2003 ). This contradiction may haveoccurred as a result of changes to nursing education thathave developed over recent years in the countries wherethese studies were located (i.e. Australia, Singapore,Taiwan, US), most notably the introduction andexpansion of degree-level qualications. For example,Rambur et als (2003) US study, elucidates thatbaccalaureate education emphasises a greater under-standing of the context of health care delivery allowing

for greater satisfaction. They suggest that it is thisenhanced understanding that empowers nurses toinuence the macro factors impacting on their workenvironment resulting in a reduction of dissatisfaction.If so, it could have relevance for the profession in theUK which, in an era of fast-paced change, may benetfrom further expansion of degree education. However,the inconsistent results in both early and recent studieswould suggest that educational attainment is a widelyvarying factor for which conclusions cannot yet bedrawn and as such warrants further investigation.

5.7. Reection on ndings and model of nurse turnoverbehaviour

The ndings of this review were found to reect themodel of nurse turnover proposed by Irvine and Evans(1995) . Although Irvine and Evans conducted theirmeta-analysis in a different employment climate to thatwhich currently exists, the major ndings of leadership/supervisory relationship and stress remain inextricablylinked to intent to leave. These factors comprise part of the work environment, which was found to have astronger relationship with job satisfaction and intent toleave in both their meta-analysis and the ndings of thispaper. Changes over time have occurred regarding theeffects on intent to leave for educational attainment andpay. This suggests that it is imperative that sources of satisfaction are reassessed in the light of changes overtime. The empirical evidence shows that stress and issuesconcerning leadership consistently exert both direct andindirect effects on job satisfaction and intent to leave.

Despite the improvement in techniques to analyseresults from nurses job satisfaction studies, the relianceon quantitative methods for data collection has over-shadowed qualitative investigations ( McNeese-Smith,1999). Nevertheless, some qualitative inquiry has been

used, often as a small component of a larger investiga-

tion. This is exemplied in Cowins (2002) and Fletchers(2001) studies where additional written comments servedto clarify issues raised in results from scale measure-ment. The information gained from qualitative inquirycould be utilised more widely to provide a relevant datasource to complement quantitative methods. Not onlywould this serve to enhance contemporary and specicknowledge of nurses job satisfaction, but would alsoassist in providing the nursing profession with amethodology evolved from, but independent of, non-nursing areas.

5.8. Contextual factors

Despite much research, denitive results of whichvariables are statistically and consistently related tonurses job satisfaction remain elusive ( Tovey andAdams, 1999 ). The demonstration of variation in the

factors inuencing job satisfaction in different levels of the profession (e.g. of ward managers and staff nurses)and in differing environments (e.g. hospitals, commu-nities, geographical regions) reects the difculties facedwhen searching for authoritative results. Furthermore,there are discrepancies regarding sampling that involvesmixing data from samples of nurses whose jobs havedistinctive features such as paediatric, intensive care ormental health, as well as the inclusion of health careassistants. This lack of distinctiveness serves to invali-date generalisability of results to ward-based medicaland surgical adult nurses. Similar problems exist withgeographical locations that may have differing labourmarkets and population densities that may affect theopportunities for alternative employment or workloadsrespectively.

Studies undertaken in differing types of hospitalsoffering different types of care (e.g. long-term or acute)may further produce results specic only to thatenvironment, and therefore limit the relevance for thewider profession. Additionally, the generalisability of research based on theories and frameworks developed inone culture or nation and then undertaken in dissimilarcountries has been questioned ( Rosenzweig, 1994 ).However, in response to this, some internationalresearch on job satisfaction now offers comparisonsacross nations, contributing to empirical generalisation(Fang and Baba, 1993 ). Furthermore, the extent towhich international recruitment has occurred overrecent years and the paucity of research relating toimmigrant nurses experiences of the British NHSnecessitates the use of international data on jobsatisfaction to illuminate the views of nursing staff.

5.9. Implications for research

Given the multitude of issues surrounding the study of

job satisfaction components and their effects on intent

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to leave, generalised conclusions should be drawn withcaution. The use of scales developed for use onoccupational groups other than nurses may no longerbe appropriate, as the changing nature and specicityof work areas demand measurement approaches to bemore exclusive. Research to identify particular stressorsand effective ways of detecting stress early may beuseful to address the impact that stress has on retention,and outcomes of the introduction of participativemanagement for leadership dissatisfaction should beassessed.

The literature selected for analysis contained no UKstudies. This was unexpected and may indicate adiscrepancy between the espoused importance of reten-tion issues and the UKs research priorities and assuch should be addressed and acted upon. Some workis, however, being undertaken such as the developmentof a tool for measuring job satisfaction in the

contemporary UK nursing profession ( Murrells et al.,2005 ), which will serve to accurately assess thisexigent issue.

6. Conclusion

This review set out to assess the components of jobsatisfaction most inuential on intent to leave for nursesworking with adults in ward environments. In additionto identifying these components, an exploration of howthe sources of job satisfaction may have changed overtime was undertaken. The results suggest that althoughmany of the same factors are being assessed withinscales, a more appropriate and relevant approach maybe to assess each environment individually. Scales,whilst useful tools for comparability, need to evolvewithin the nursing profession for maximum effective-ness. If to be used as a means for implementing policychange and improving the working lives of nurses, it isessential that scales generate specic and accurate data.When the aim is improvement of job satisfaction fornurses, the conclusions made from this study pointstrongly toward the need for analysis at ward level. Asdiffering results are found across work environments,more appropriate techniques such as qualitative inter-views or action research may be employed to gaindetailed insight into which components are of impor-tance to particular workforces. This could be under-taken ward-wide, for policy change at NHS Trust level,as a nation-wide policy may not be apt given thediscrepancies shown.

Although consistent results were not always found,the issues of leadership and stress were highlighted asexerting particular inuence on intent to leave. Theimplications of these issues remaining unresolved are

detrimental for practice and the health service.

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