adams et al-2000-journal of advanced nursing
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Hospital nurses' job satisfaction, individualand organizational characteristics
Ann Adams PhD MSc BA Hons RGN
Research Fellow, European Institute of Health and Medical Sciences,
University of Surrey, Guildford
and Senga Bond PhD FRCN RGN
Professor of Nursing Research, Centre for Health Services Research,
The University, Newcastle upon Tyne, England
Accepted for publication 21 February 2000
ADAMSADAMS AA. && BONDBOND SS. (2000)(2000) Journal of Advanced Nursing 32(3), 536±543
Hospital nurses' job satisfaction, individual and organizational characteristics
Using the Ward Organizational Features Scales (WOFS), relationships between
aspects of the organization of acute hospital wards, nurses' personal charac-
teristics and nurses' job satisfaction are examined among a nationally repre-
sentative sample of 834 nurses in England. The analysis contributes to a
growing body of evidence demonstrating the importance of interpersonal
relationships to nurses' job satisfaction. In particular, the positive contribution
of the cohesiveness of ward nursing staff is highlighted, but the potential for
many current NHS staf®ng strategies and work environments to undermine the
development of cohesive working relationships is also noted. Other in¯uential
factors are nurses' relationships with medical staff, perceptions of their
workload and their evaluation of the appropriateness of the system of nursing
being practised. The importance of measuring nurses' subjective assessments of
their work environment is emphasized. A weak association was found between
grade and job satisfaction. Individual nurse characteristics were found not to be
associated with job satisfaction.
Keywords: job satisfaction, ward organization, working relationships, clinical
grade, nurse characteristics, work environment, British NHS, human resource
management, retention, commitment
INTRODUCTION
It has long been recognized in Britain that there is a
consistent relationship between aspects of the organiza-
tion and management of hospitals, staff responses to these
processes and clinical outcomes of care. The number of
quali®ed nurses available to provide care in the National
Health Service (NHS) is associated with the effectiveness
and ef®ciency of nursing services (Ministry of Health
1948), while Revans (1964) pointed to the association
between staff morale and length of patient stay. More
recently, other aspects of the organization of hospitals and
individual wards have been associated with the effective-
ness of hospital care as measured by patient outcomes.
These include the organization of nursing care and ways
in which hospital restructuring rede®nes the context for
provider±patient relations and clinical decision making
(Aiken et al. 1994, 1997). In a study of intensive care units
in the United States of America (USA), Knaus et al. (1986)
found that the pattern of communication between nurses
Correspondence: Ann Adams, European Institute of Health and Medical
Sciences, Edward Duke of Kent Building, University of Surrey, Guildford
GU2 5TE, England. E-mail: [email protected]
Journal of Advanced Nursing, 2000, 32(3), 536±543 Nursing and health care management issues
536 Ó 2000 Blackwell Science Ltd
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and physicians was the most important factor associated
with variation in mortality. This ®nding may be speci®c to
a culture where many physicians have patients in a single
ward and to a highly acute care setting where patients
require prompt treatment decisions. At a common-sense
level, however, where organizational environments facili-
tate good communication between staff, then patients are
likely to bene®t.
While, arguably, patient outcomes are the best measure
of the effectiveness of hospital care, also important are the
effects of hospitals on the staff they employ. Intractable
and negative staff outcomes associated with working in
hospitals are high levels of stress which undermine
performance and lead to high staff turnover (Packard &
Motowidlo 19871 , Cavanagh & Cof®n 1992, Wheeler &
Riding 1994, Janssen et al. 1999). Recent nurse recruit-
ment and retention problems in Britain have brought this
issue to the forefront of politicians' and health service
managers' minds (Buchan et al. 1998). The United
Kingdom (UK) government's White Paper Working
Together (Department of Health 1999a) is the ®rst national
policy document to lay down speci®c requirements for the
development of a range of human resource management
(HRM) policies within the NHS. This is to ensure that the
workforce is properly equipped to prosecute the govern-
ment's health improvement programme to meet national
targets (Deparment of Health 1998b), and to enhance
management and retention of the human resource. This
aim is also re¯ected in the government's Human Resource
Management Research Initiative (Department of Health
1998c) which seeks to develop an evidence base to
underpin effective staff deployment and management
within the NHS.
This paper focuses on nurses' job satisfaction, an import-
ant facet of HRM. It is treated here as an intervening variable
between ward organization on the one hand, and job
performance and staff turnover on the other, and attends
to some of the antecedents of nurses' job satisfaction.
The importance of ward level analysis
Acute sector organizations are amenable to analysis at
different levels. It is possible to characterize the larger unit
of the hospital as a distinct entity embracing categories
such as urban, rural or teaching/non-teaching and char-
acterized by variables such as size and range of clinical
services provided. However, hospitals can also be charac-
terized according to management arrangements such as
degree of centralization or devolution and these are
known to have an impact on nurses' work experiences.
Weissman et al. (19802 ) found that predictors of nurses' job
satisfaction differed between hospitals, and Tovey &
Adams (1999) found differences in staff morale associated
with variation in management styles and HRM practice.
Findings derived from the important series of studies of
Magnet hospitals in the USA also pointed to the import-
ance of hospital level differences. Those hospitals deemed
to have high quality nursing which both `magnetically'
attracted and retained staff, were characterized by a ¯at
organizational structure and having a nurse director with a
strong position in the management executive (McClure
et al. 1982).
While hospital level variables are in¯uential, the ward
as a physical and social organizational unit probably
remains the most signi®cant unit of analysis when exam-
ining determinants of nurses' feelings about their work
and patient outcomes. The smaller clinical units within
the Magnet hospitals had organizational attributes recog-
nized in other studies as being positively associated with
reduced mortality, namely: decentralized decision
making, standardization of nursing procedures, a high
ratio of quali®ed nurses and good relationships with
medical staff (Aiken et al. 1994).
The importance of the ward as an organizational unit
has also been demonstrated. Ward culture was found to
have a pervasive in¯uence over patterns of nurses' beha-
viour and their views of the work environment (Thomas
1992). These patterns are consistent between staff grades
within wards, and are related to the way in which patient
care is provided (Anderson & Choi 1980, Thomas 1992).
Moreover, wards within the same hospital have been
shown to vary on a number of organizational characteris-
tics (Adams et al. 1995). While there are occasions when it
is appropriate to consider the relationship between
hospital as the organizational unit and nurses' job satis-
faction, there is also compelling evidence that aggregating
wards to provide a hospital-level analysis masks impor-
tant between-ward variation.
Job satisfaction
As well as being associated with reduced mortality,
Magnet hospitals are acknowledged as good places for
nurses to work, as evidenced by low turnover rates.
Consistent features of USA Magnet hospitals associated
with job satisfaction were greater professional autonomy,
greater control over the practice environment and the use
of nursing systems that promote accountability and conti-
nuity of care. Conversely, in other settings, higher turn-
over rates and propensity to leave have been associated
with job dissatisfaction (Cavanagh 1990, Irvine & Evans
1995) and stress (Cavanagh & Cof®n 1992). There is a need
to understand more about the relationship between
nurses' job satisfaction and aspects of ward organization.
Different groups of job satisfaction theories can be
described as: (i) discrepancy theories, which examine
the extent to which employee needs or wants are satis®ed
within the workplace; (ii) equity theories, which highlight
social comparisons in the evaluation of job rewards; and
(iii) expectancy theories, which focus on employee moti-
Nursing and health care management issues Job satisfaction
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vation. Job satisfaction is also conceived as an overall
rating or as the sum of several discrete dimensions of job
characteristics (Stamps & Peidmont 1986, Mueller &
McCloskey 1990, Traynor & Wade 1993). Despite these
differences there is consensus that job satisfaction may be
de®ned as the degree of positive affect towards a job or its
components. This is determined by characteristics both of
the individual and of the job, and particularly how work is
organized within the corporate work environment.
Job satisfaction and ward organization
Associations have been found between a number of
organizational features and job satisfaction. Blegen's
(1993) meta-analysis of North American studies shows a
strong relationship between stress and job satisfaction.
The importance of stress in human service work is being
increasingly recognized (Williams et al. 1998). In this
context, the way in which nurses perceive work attributes,
or their evaluations of them, may be more important than
objective measures. In this regard the recent high and
increasing levels of reported stress and work intensi®ca-
tion among UK nurses (Harvey 1995, McNeese-Smith
1999) is likely to have a bearing on job satisfaction. Stress
is particularly associated with increasing workloads, but
also with methods of work organization which reduce
variability among patients' care needs within speci®c
settings, so that nurses caring for highly dependent
patients experience little respite in their pace of work.
Skill-mix strategies which transfer new clinical tasks and
areas of responsibility from other health care professionals
onto already busy nurses, while simultaneously replacing
professional nursing colleagues with larger numbers of
health care assistants, are also perceived to give rise to
increased stress and isolation (Adams et al. 1998).
Commitment to the organization, associated with staying,
has a strong relationship with job satisfaction (Blegen
1993). However, rather than being antecedent, commit-
ment is often placed causally after job satisfaction.
Job autonomy, cited as a cause of job satisfaction is
found to be moderately related across a number of
occupational groups, including nurses (Loher et al.
1985). So too is recognition for performance, while rout-
inization of work shows a moderate negative correlation
with job satisfaction. Interpersonal factors comprising
communication with supervisor and with peers are also
moderately correlated (Blegen 1993). Thus while having
autonomy in performing their work impacts on nurses' job
satisfaction, they also require the support of good inter-
personal relationships both with manager and colleagues.
Nurses do not work in isolation and, as well as relation-
ships with nursing peers, their relationships with medical
colleagues are important features of the work environ-
ment. The quality and quantity of interaction with
medical staff is particularly in¯uential in how nurses
regard their work (Mackay 1991, Shortell et al. 1994,
Walby et al. 1994). So too are changes to job boundaries
between nurses and doctors, with extensions to nurses'
work having the effect of increasing job satisfaction for
some, while reducing it for others (Adams et al. 1998),
particularly if such work is regarded as inappropriate (Last
et al. 1992), or occurring in the absence of professional
recognition and career development (Furlong & Glover
1998).
Individual nurse characteristics
Individual characteristics such as age, years of experience
and education are found to have lower order, but stable
correlations across studies. They have been shown to
contribute far less to the understanding of nurses' job
satisfaction than perceptions of the ward, quality of
working relationships and content and standards achieved
in work (Blegen 1993). The current study provides an
opportunity to re-examine the relative importance of
individual nurse characteristics and organizational
features Ð arguably individual perceptions of the organ-
ization and job are more potent than objective indicators
as predictors of job satisfaction. Consequently relation-
ships between nurses' perceptions of organizational and
structural aspects of the ward which they identi®ed as
important, nurses' personal characteristics and nurses' job
satisfaction are examined.
METHODS
The Ward Organizational Features Scales (WOFS) were
developed to enable comparisons of the views of nurses
working in acute hospitals of ward structure and organ-
ization, care processes and job satisfaction. WOFS include
six sets of measures comprising 14 sub-scales (Table 1)
presented as Likert-type four-point scales.
Full details of the samples, methods of scale develop-
ment and the statistical properties of scales are reported in
Adams et al. (1995). Brie¯y, data were collected by means
of a postal survey in 1994 using a self-completion ques-
tionnaire sent to a sample of 1499 day nurses of clinical
grade C and above, listed as permanently allocated to 119
acute adult wards randomly selected from 17 hospitals
strati®ed to include all English health regions. Excluded
were wards in maternity and psychiatric specialities as
well as those treating highly dependent patients such as
intensive and coronary care. With one reminder question-
naire, an overall response rate of 57% was obtained,
providing a ®nal sample of 834 nurses. The ®nal sample
was biased towards the south of England (54% vs. 46%),
with a higher response rate (66% vs. 47%). We have no
reason to believe that the high level of non-response
biased the sample in ways that in¯uenced the results
obtained.
A. Adams and S. Bond
538 Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 32(3), 536±543
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Data analysis occurred in three stages. The ®rst stage
explored relationships between individual nurse charac-
teristics, job satisfaction and other WOFS scores using
analysis of variance. The second stage examined relation-
ships between nurses' job satisfaction and their percep-
tions of other aspects of the ward organizational
environment by correlating scale scores using the Pearson
correlation coef®cient. Finally, in order to asses the
cumulative effects of ward organizational features on
nurses' job satisfaction, multiple regression analysis was
carried out using a stepwise procedure. Job satisfaction
was treated as the dependent variable, and sub-scales of
WOFS the independent variables.
FINDINGS
Job satisfaction and individual nursecharacteristics
Mean item scores according to clinical grade are shown in
Table 2. These demonstrate variations in how positively
nurses rated the different organizational features of their
ward. Most positively rated are aspects of ward services
which include facilities and layout, while the sample as a
whole perceived that they had little control over aspects of
ward management, including when events took place or
in¯uence over human resources.
Between grade comparisons, using analysis of variance,
show that there are no differences between grades in the
scales measuring perceptions of ward facilities, layout or
services, but differences are obtained on all of the other
sub-scales. Differences are in the direction of more posi-
tive views of ward organization and job satisfaction the
higher the grade. The trend to lower scores in the
hierarchical practice scale is because there is an inverse
relationship between scores on this scale and the level of
development of professional practice achieved within
wards.
With regard to job satisfaction, no differences were
found between scale scores according to nurses' age, level
of education or length of ward service, while there was a
signi®cant difference between nurses of different clinical
grades (P < 0á001). However, despite systematic grade
differences in score, these were not large, and little
variance is explained by clinical grade (r2� 0á03). On the
strength of this ®nding, data used in all subsequent
analyses relate only to nurses of grades C to F. Separate
analysis for ward managers is not presented because a full
set of data is not available, i.e. the team building skills of
ward leaders was not collected from this group. Individual
nurse characteristics were not included in any subsequent
analyses.
Job satisfaction and ward organizational features
Pearson correlation coef®cients of job satisfaction scores
and other WOFS scores are presented in Table 3. The
Table 1 Summary of scales
and their statistical
properties Name of scale
No. of
items
Cronbach's
alpha
Test-retest Pearson
correlation coef®cient
I. Physical environment of the ward
Ward facilities 5 0á79 0á80
Staff organization 5 0á80 0á71
Ward layout 6 0á81 0á75
Quality of ward services 4 0á68 0á71
II. Professional nursing practice
Professional practice 13 0á83 0á77
Hierarchical practice 6 0á66 0á74
III. Ward leadership
Team-building skills of ward leader 9 0á92 0á90
IV. Professional working relationships
Collaboration with medical staff 9 0á86 0á83
Collaboration with other health
care professionals 7 0á84 0á70
Cohesion amongst nurses 10 0á91 0á84
V. Nurses' in¯uence over:
Ward management 10 0á90 0á80
Timing of ward and patient events 9 0á85 0á71
Financial and human resources 5 0á81 0á78
VI. Job satisfaction
Job satisfaction 7 0á77 0á77
Nursing and health care management issues Job satisfaction
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highest correlations found are between job satisfaction
and cohesion of the ward nursing team (0á51), staff
organization (0á46) (which includes items about the rela-
tionship between staf®ng and workload), the level of
professional practice achieved within the ward (0á46) and
collaboration with medical staff (0á41).
Table 4 shows the results of including nurses' WOFS
scale scores in a multiple regression analysis using a
stepwise procedure incorporating elements of both
forwards and backwards selection of variables to identify
the most important predictors of job satisfaction.
This analysis (Table 4) shows a similar pattern in results
to those presented in Table 3, that the most important
Table 2 Mean scale item scores by clinical grade
Clinical grade
Name of scale
C
(n = 32)
D
(n = 313)
E
(n = 285)
F
(n = 91)
G and above
(n = 113)
ANOVAANOVA
P value
R2
value
Ward facilities 3á2 3á2 3á2 3á2 3á4 ± ±
Staff organization 2á6 2á6 2á8 2á8 3á2 <0á001 0á03
Ward layout 3á5 3á3 3á3 3á2 3á4 ± ±
Quality of ward services 3á5 3á8 3á8 3á8 3á8 ± ±
Professional practice 3á1 3á2 3á2 3á2 3á5 <0á001 0á05
Hierarchical practice 2á8 2á7 2á5 2á3 2á0 <0á001 0á11
Team-building skills of ward leader 2á9 2á9 2á93 3á3 ± <0á001 0á04
Collaboration with medical staff 2á4 2á7 2á6 2á6 2á8 <0á001 0á02
Collaboration with other health
care professionals
3á0 3á0 3á1 3á1 3á3 <0á001 0á02
Cohesion amongst nurses 2á7 2á7 2á9 3á0 3á3 <0á001 0á05
In¯uence over ward management 1á3 1á7 2á1 2á8 3á5 <0á001 0á58
In¯uence over the timing of ward
and patient events
1á7 1á9 2á1 2á2 2á6 <0á001 0á14
In¯uence over human and ®nancial resources 1á0 1á2 1á2 1á8 3á3 <0á001 0á62
Job satisfaction 2á9 2á9 3á0 3á0 3á3 <0á001 0á03
Name of scale
Correlation
coef®cient
Signi®cance
level
Ward facilities 0á31 P < 0á001
Staff organization 0á46 P < 0á001
Ward layout 0á28 P < 0á001
Quality of ward services 0á18 P < 0á001
Professional practice 0á46 P < 0á001
Hierarchical practice )0á35 P < 0á001
Team-building skills of ward leader 0á33 P < 0á001
Collaboration with medical staff 0á41 P < 0á001
Collaboration with other health care professionals 0á26 P < 0á001
Cohesion amongst nurses 0á51 P < 0á001
In¯uence over ward management 0á25 P < 0á001
In¯uence over the timing of ward and patient events 0á23 P < 0á001
In¯uence over human and ®nancial resources 0á20 P < 0á001
Table 3 Correlations
between job satisfaction and
scores for other WOFS scales
Table 4 Results of step-wise regression analysis
Name of scale
Standardized
regression coef®cient
Cohesion amongst nurses 0á26
Staff organization 0á20
Collaboration with medical staff 0á20
Hierarchical practice )0á11
Professional practice 0á11
Ward facilities 0á08
Team-building skills of ward leader 0á06
R2 = 0á42.
A. Adams and S. Bond
540 Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 32(3), 536±543
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contributors to nurses' job satisfaction are the degree of
cohesion existing among ward nurses, the degree of
collaboration with medical staff and perceptions of staff
organization, respectively, i.e. the system of nursing
organization used and the perceived appropriateness of
staf®ng levels to cope with the ward workload. Percep-
tions of professional practice and the perceived team
building skills of the ward manager remain important, but
have less bearing on job satisfaction.
DISCUSSION
This study has considered the effects of both nurses'
individual characteristics and their perceptions of organ-
izational aspects of the wards in which they work,
including perceptions of their practice and relationships
with nurses and other staff, and how these elements relate
to job satisfaction.
Most salient to nurses were their social and professional
relationships with nursing and other professional coll-
eagues. It is fashionable to talk about multidisciplinary
teamwork and the ward team while much of the literature
is anecdotal and exhortatory (Opie 1997). WOFS do not
assess the extent of team functioning. They address
nurses' views of their relationships with nursing, medical
and other professional colleagues. The scales measuring
nurses' views of cohesion with their ward nursing
colleagues and collaboration with medical staff were
found to be the best predictors of job satisfaction.
However, the scale measuring relationships with therapy
staff was not found to contribute to nurses' job satisfaction
Ð perhaps re¯ecting their lesser signi®cance to many
nurses' work in general wards.
Ward facilities, services provided by hospital depart-
ments which have a bearing on nurses' work and aspects
of the physical environment considered to in¯uence
patient care, are often omitted from studies of nurses'
job satisfaction. We included these and examined the
effects of nurses' views of staff, the appropriateness of
grade mix and rostering practice for providing patient
care. These elements of ward nursing practice were all
associated with nurses' job satisfaction in a positive
direction, i.e. where they considered suf®cient numbers
of skilled staff were rostered and organized appropriately,
nurses' satisfaction was greater.
The quality of the professional service nurses consider
they provide is also predictive of job satisfaction.
Certainly lack of pride in the quality of service and
perceived inability to provide a service at appropriate
standards are reported elsewhere as reasons for job
dissatisfaction, stress and leaving nursing (Mackay
1989). The professional practice scale included a number
of items related to nurses' own professional development
as well as to the involvement of patients and families in
care decisions. These ideas are regarded as `progressive' in
nursing literature and recent policy documents (Ersser &
Tutton 1991, NHS Executive 1996, Department of Health
1999a), and evidence of their importance to nurses was
found in views expressed in the qualitative phase of scale
development. The other side of the coin, as shown by its
negative correlation with job satisfaction, is hierarchical
practice. This scale re¯ects a staff that feels they and their
work are devalued by nursing superiors and medical staff.
The team building skills of the ward manager also contrib-
uted to staff nurses' job satisfaction, as reported in other
studies (McNeese-Smith 1993, Boumans & Landeweerd
19933 , Hart & Rotem 1995, Morrison et al. 1997). While this
variable is related to professional practice in how staff are
treated regarding professional development, it also
includes aspects of managing relationships and the atmo-
sphere that prevails in the wards.
Thus from the range of the ward features that nurses
identi®ed as being important to the provision of patient
care, the elements that predict their job satisfaction are the
quality of working relationships, having suf®cient staff
with the right mix of skills to cope with their workload,
and to a lesser extent, achieving professional standards of
practice and personal development. Absent from this list
are the extents to which nurses have control over a range
of features of the ward. However, participation in the
aspects of ward management included in the scale was
generally at a very low level among this staff nurse sample.
This points to the need to include items in scales that have
a high degree of salience for the staff grades concerned.
We found signi®cantly higher scores on this scale among
ward managers. While a correlation with job satisfaction
was found, control over ward events did not predict it.
Individual nurse characteristics, with the exception of
clinical grade, were not found to be associated with job
satisfaction. However, the explanatory relationship
between grade and job satisfaction was weak. These
®ndings are broadly in line with those of previous
research, where nurses' experience, tenure and position
in the hierarchy have been found to be signi®cantly
associated with job satisfaction (Hinshaw & Attwood
1984). However, recent qualitative work (Tovey & Adams
1999) highlighted the increasingly different work experi-
ences of ward managers (G grade) compared with nurses of
lower clinical grades, suggesting that grade differences
may become more marked in future. Ward managers are
frequently dissatis®ed because they feel under pressure to
take on additional work roles for themselves and their
staff, both managerial responsibilities and expanded clin-
ical roles, which causes them to experience role con¯ict.
On the other hand, managers derive greater satisfaction
from team working with other disciplines. Nurses of lower
clinical grades are dissatis®ed with low staf®ng and
perceived falling standards of care provision, as well as
with local Trust management practice and service-wide
changes in the NHS (Robinson et al. 1999).
Nursing and health care management issues Job satisfaction
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Our qualitative work that preceded scale construction
led to the conclusion that nurses are an increasingly
heterogeneous group with regard to job satisfaction and
given the increasing diversi®cation and extension of
nurses' work roles (Adams et al. 1998, Department of
Health 1999b), this trend looks set to continue. While the
®ndings presented in this paper demonstrate that clinical
grade explained little variance in nurses' experiences of
job satisfaction in the mid-1990s, it may be that data
collected at the present time would reveal a stronger
relationship between these two variables. The increasing
heterogeneity evident in nurses' work roles needs to be
re¯ected in future empirical work.
CONCLUSION
This paper has highlighted the importance of organiza-
tional features of acute hospital wards as predictors of
nurses' job satisfaction, over and above the importance
of individual nurse characteristics. It also points to the
importance of exploring subjective perceptions of ele-
ments of the physical work environment, work processes
and job design, rather than relying purely on objective
measures. By using scales grounded in nurses' views of
their work, they were able to alert us to the importance
of several new factors likely to impinge on providing
good quality patient care and which affect their job
satisfaction, and which seldom appear in traditional
studies or measures of their work experience. These
include the quality of ward facilities and of services
provided to the ward by other departments, which affect
nurses' ability to do their work. Most importantly,
nurses highlighted their perceptions of the appropriate-
ness of the balance between number of available staff,
skill mix, care organization and rostering practice and
the ward's workload as a major in¯uence on their job
satisfaction.
Overall, relatively high levels of job satisfaction were
found among staff, at a time of immense change in the
health care system in the UK. In particular, the study
reinforces the importance of the quality of nurses' working
relationships in enhancing job satisfaction. Even in times
of turbulence and objectively high workloads, similar
factors impact on job satisfaction. Our research demon-
strates that the cohesiveness of the ward nursing staff is
the most important working relationship for nurses, with
the most signi®cant impact on their job satisfaction. Yet its
development requires staff stability and a suf®cient core of
permanent staff. These conditions are threatened by
recruitment and retention dif®culties and reliance on
transient staff because of the HRM policies emphasizing
¯exibility. Recent proposals for continuing to expand
nurses' work roles to make better use of their knowledge
and skills (Department of Health 1999b) are likely to
exacerbate these conditions.
In order to break the negative cycle of job dissatisfaction
leading to reduced commitment and turnover, and to solve
recruitment and retention problems, our ®ndings suggest
that NHS managers need to focus attention on creating
conditions that facilitate intra-professional teamwork
amongst nurses and inter-professional teamwork with
medical colleagues. This requires long-term commitment
to resourcing, workforce planning and achieving strategic
aims such as those set out in Working Together (Depart-
ment of Health 1999a). Cohesive ward nursing teams
developed with the capacity to support each other while
coping with heavy workloads are needed to yield the
health improvements cherished by our political masters.
Acknowledgements
We would like to thank all the nurses and managers who so
generously gave their time to assisting us in this study, and
research staff at the Universities of Surrey and Newcastle
who assisted with data collection. The study was supported
by a grant from the Department of Health. The views
expressed are those of the authors and not the funding body.
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