Angelite Nurses

from Military Medicine .. 

By Zangaro, George A USN NC Johantgen, Meg PhD RN 

ASSOCIATION OF MILITARY SURGEONS OF THE U.S.The United States continues to grapple with a critical shortage of registered nurses. Because hospitals employ large numbers of registered nurses they face the challenge of recruiting and retaining competent nurse employees. Nursing administrators, and hospital leaders, will be better positioned to retain registered nurses by better understanding the factors that influence recruitment and retention.1 U.S. military hospitals are particularly vulnerable to the nursing shortage because of the increased demand for acute care services for service members who sustained injuries in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Job satisfaction has been studied previously, but this is the first examination of a population of nurses composed of both active duty Navy nurses and civilian nurses. BACKGROUND 

Nurses are the largest single group of health care workers in U.S. military hospitals and are providing significant amounts of care for casualities of the conflicts in Iraq and Afghanistan. In this challenging environment, military health care leaders are confronted with how to recruit and retain registered nurses. Degradation of military or civilian nursing staff has the potential to seriously compromise the Navy's peacetime and operational mission. One approach to handle the increased demand for care has been to increase the use of civilian nurses in military hospitals, yet no studies have examined how these two groups differ or the factors that influence their job satisfaction in Navy hospitals. Having an understanding of nurses' perceptions of their workplace appears to enhance job satisfaction, reduce job stress, and improve retention efforts.2- 3 Kovner and colleagues reported that supervisor support, job stress, promotional opportunity, and routinization are all significant predictors of job satisfaction.2 Creating a work environment that encourages participative management, constant communication with staff, and visibility of the nurse manger in the clinical setting are some factors that have been associated with satisfaction and can be influenced by administrators. 

Although some personnel issues are common to all hospitals (e.g., salary, promotional opportunities, job stress, and job satisfaction), the Navy has unique issues that affect nurse recruitment and retention. A Navy nurse is required to sign a contract for a fixed number of years and will likely be asked to move their residence and work site every 3 or 4 years. These can be considered to be not attractive to some nurses. The Navy must also be concerned with the broader issues that affect the civilian nursing workforce since civilian nurses supplement military nurses in many military hospitals. Civilian nurses are becoming more difficult to recruit and retain in the military sector as opportunities increase in the civilian sector. 

A strategy used to address recruitment and retention has been to identify and address factors influencing job satisfaction. Several studies of military nurses' job satisfaction have been conducted, but few have been published and the studies may not reflect the more recent shortages and wartime operational needs.4-* None of the previous studies have compared satisfaction of military and civilian nurses in Navy hospitals. Economists, psychologists, and sociologists have all contributed to the development of the models of employee satisfaction, commitment, and turnover. Price and Mueller's theory acknowledged that employees enter the workplace with certain expectations and values.7 If these expectations and values are found in the workplace, the employee will be more satisfied, committed to the organization, and less likely to leave. These factors are most practically assessed in a survey instrument that is administered to employees. The concepts measured include autonomy, promotional opportunity, role ambiguity, routinization, coworker support, and several others. Price and Mueller's instrument is supported with empirical evidence from several different samples including nurses in hospitals,8,9 nurses holding doctoral degrees,10 hospital-based military health care personnel," military physicians,12 dental hygieniste,13 and all employees in a U.S. Veterans Administration Medical Center.14 Most recently Kovner and colleagues used the Price and Mueller conceptual model to guide their study of recent nursing graduates.8,15 

The nursing literature is replete with studies linking employee factors and work-related factors with job satisfaction.2,8,16-20 In studies conducted at military and civilian facilities job satisfaction has been positively related to autonomy, coworker and supervisor support, resource adequacy, professional growth, promotional opportunity, and distributive justice.2,4-6,10,11,20-22 Routinization and role ambiguity have been negatively related to nurse job satisfaction.2,10,11 

Military nurses and civilian nurses working for the U.S. government represent a relatively unexamined population. Moreover, there are distinct differences between military nurses and civilians employed in military facilities. For example, civilian nurses are often older, more experienced, and work part time. Military nurses have a larger proportion of males and higher education levels since a bachelor's degree is required for entry to each of the military nurse corps. Investigating differences in these two groups was expected to uncover new information about job satisfaction that would begin to fill gaps in current knowledge. 

METHODS 

Sample 

Using a cross-sectional design, a paper survey was administered anonymously to nurses working at three Navy hospitals on the East Coast. Sample size was based on Tabachnick and Fidell's recommendation that 10 respondents per variable are needed for adequate power in linear regression.23 Assuming that 10-12 predictors would be used in the model, the sample size was more than adequate (military = 283 and civilian = 213). Data were collected, after Institutional Review Board approval at the three organizations. It was estimated that -1,173 nurses meet the inclusion criteria. The return of the questionnaire was considered implied consent. 

The eligible nurses included Navy staff registered nurses with the rank of Ensign (0-1) through Lieutenant Commander (0-4) and civilian registered nurses employed in the Federal General Schedule (GS) system in grades GS-9 through GS- 12. These employment levels were selected because they include most of the nurses who provide clinical care for inpatients. In the military, nurses in the ranks of 01 to 04 have the highest attrition rates. This is a critical group of nurses that are highly desired to be retained because of their clinical competence. 

Procedures 

Questionnaires were distributed using a modified Dillman approach.24 An e-mail was sent to all eligible nurses inviting them to participate in the upcoming survey. Two weeks later, the questionnaires were placed in each nurse's unit mail box. Two options were offered for returning the completed questionnaire. After placing the questionnaire in an envelope, the questionnaire could be placed into a designated box on the nursing unit or it could be sent via the hospital's internal mail system to the principal investigator (PI) at the hospital's research office. A reminder e-mail was sent to all nurses 3 weeks after the initial contact and a reminder postcard was placed in their mailboxes. Finally, an e-mail reminder was sent to all potential respondents 7 days before the data collection period was to end. 

Measures 

A modification of Price and Mueller's model of turnover guided the concepts examined in this study (see Figure I).7 The survey was adjusted to account for military concepts by modifying items to address specific military issues. The mapping of items to the concepts of the Price and Mueller model were maintained. Table I presents the constructs measured in the study, a conceptual definition of each, the number of items used to measure each concept, and mean and standard deviation for each scale used in the analysis. All items were measured on a 5-point Likert scale with anchors of 1 = strongly disagree and 5 = strongly agree. These items have been found to be reliable and valid in previous research.2,7,12 For example, the three items used to assess routinization were related to variety in the job, having the opportunity to do different things on the job, and repetitiveness of the job (see Price and Mueller7 for a summary of each concept and the items used to measure each concept). In the current sample, the average alpha coefficient was 0.74 for all items in the model. The survey also included open-ended questions where nurses could add comments. 

Analysis 

Data were analyzed using SPSS version 15.0. Descriptive statistics were compared to characterize the demographics characteristics of the military and civilian sample of nurses. Linear regression analysis was used to determine significant predictors of job satisfaction. Statistical assumptions of linearity and normality were tested and all assumptions were met. Multicollinearity was assessed using the tolerance test and variance inflation factor.23 Since age and rank were highly correlated with both tenure and experience, only tenure and experience were included in the models as control variables. As the focus of the study was on isolating the factors that influence satisfaction, the analysis was conducted in two steps. In step one the demographic variables were entered, followed by the Price and Mueller concepts. RESULTS 

A total of 496 usable questionnaires were returned for a response rate of 42%. Military nurses had a response rate of 35% (283/806) as compared to a 58% (213/367) response rate for civilian nurses. Table II depicts the demographic charac- teristics for the sample. More than half of the respondents were military nurses (57%). The distinct differences in Navy and civilian nurses are evident. There was a difference in age with 84% of the military nurses being between 21 and 40 as compared to only 19% of the civilian nurses. The majority of the nurses who completed the questionnaire were female in both groups although the military sample was one-third male (33%) as compared to only 7% of civilians. The military nurses represented the range of ranks whereas nearly two- thirds of the civilian nurses were in GS- 12 pay grade. All mil- itary nurses had a bachelor's degree or higher whereas 70% of the civilian sample had a bachelor's degree. Half of the civilian nurses had been working at the present organization for over 7 years as compared to the military nurses who had only 5% working in the organization for more than 7 years. This difference in tenure is expected because military nurses are changing duty stations every 2 to 4 years. The civilian nurses were also more experienced as reflected in the fact that 61% report being a registered nurse for 4 or more years whereas only 8% of the military nurses had that much experience. The military nurses were registered nurses for 6.33 years and the civilian nurses were registered nurses for 22.44 years. 

Since the purpose of the study was to compare the relative influence of factors influencing satisfaction of military and civilian nurses two demographic characteristics - tenure and years of nursing experience - were entered into the model as control variables. Regression models were fitted separately for both military and civilian nurse subgroups. As shown in Table III, the models were significant and explain a substantial portion of variance in job satisfaction for both military (51%) and civil service nurses (55%). The standardized negative coefficients indicate that routinization has the strongest negative association with job satisfaction for both military and civil service nurses. Higher levels of routinization predicted lower levels of job satisfaction, even controlling for tenure in the organization and years of experience. Promotional opportunity was a significant predictor of job satisfaction for both military and civilian nurses, although the influence was stronger for the military nurses. For military nurses, resource adequacy and supervisor support were also significant predictors of job satisfaction, although coworker support and role ambiguity were significant for civilian nurses. Increasing amounts of role ambiguity were associated with lower levels of satisfaction. 

DISCUSSION 

This study has added additional information to the knowledge concerning job satisfaction in nurses by investigating two distinct nurse populations who work in the U.S. military health sector. Moreover, the survey items were derived from a comprehensive retention model and composite scores were created on the basis of the model. 

The strongest predictor of satisfaction for both groups was routinization and it was negatively associated with job satisfaction. This indicates that the more routinization employees experience on the job the less satisfied they are. Interestingly, the mean score for the routinization items in both groups was very similar (2.58 for military nurses and 2.60 for civilian nurses) and this represents a fairly low score compared to the other concepts in the model. The significant positive relationship between promotional opportunity and job satisfaction for both cohorts was also not unexpected. Nurses who perceive opportunities for promotion are more likely to be satisfied. This relationship is consistent with the Magnet hospital force standard of professional development (http:// www.nurse credentialing.org/model/index.htm).25 On the basis of these findings, hospital and nursing administrators should consider that order and discipline are good, but more promotional opportunities are needed to ensure nurse satisfaction. 

For Navy nurses promotion offers instant benefits including public recognition (i.e., through uniform insignia), increased positional authority (i.e., through achieving a higher military rank), and increased pay. These characteristics promote higher self- worth, thus leading to increased job satisfaction. 

In contrast, the potential for promotion of the civilian nurses is quite limited in many Navy hospitals. On the basis of the narrative comments from civilian nurses, many did not feel they have an opportunity for promotion. Civilians expressed a strong sentiment that there is no clear career path available to them as there is for the military personnel. These findings may be particularly relevant to nursing administration in military hospitals because civilian nurses are playing a critical role on the military health care team. In addition to the loss of military nurses because of deployments to the combat theaters, there has been a move over the past decade to decrease the number of active duty nurses serving in the U.S. Department of Defense (and to replace them with civilian contract nurses). 

The findings also demonstrate that having adequate resources to do their job contributes to job satisfaction in Navy nurses. This finding is not surprising because to provide quality care to patients, supplies and support services must be available to the staff. This relationship is also consistent with the Magnet hospital force standard of consultation and resources (http:// www.nursecredentialing.org/model/ index.htm)25 The Navy nurses affirmed previous findings that supervisor support was a significant contributor to job satisfaction. This finding was supported by narrative comments related to concerns about leadership deficits in their supervisors. Military nurses in the early stages of their careers are likely to recognize the benefit of having more senior mentors who can guide their career. In a study of U.S. Army nurses serving in the Reserve component, nurses with less military seniority who had a mentor reported higher levels of job satisfaction and career commitment.26 Prevosto noted that mentored relationships help the novice nurse become acclimated into the military culture. 

For civil service nurses, coworker support was the second strongest predictor of satisfaction. This may be the result of civilian nurses coming into military settings, where they are not part of the military hierarchy and must rely on coworkers to clarify their role and navigate the organization. Likewise, higher role ambiguity was associated with lower satisfaction, suggesting that civilian nurses' roles are not clear. This finding is consistent with the narrative comments where both Navy and civilian nurses reported that they experienced a sense of teamwork and support from their peers. Coworker support has been identified as a crucial component in establishing a positive work environment.27 

One of the most important implications of the findings concerns civilian nurse retention in the military health sector. The current nursing shortage makes it difficult for the military to recruit and retain civilian nurses. The findings from this study have shown that there are different motivating and satisfying factors for military and civilian nurses. It would be desirable to tailor retention strategies differently for military and civilian nurses in military hospitals to enhance retention. 

At the organizational level, there may be value in integrating civilian nurses into the management structure. This might involve increased leadership opportunities and participation in governance and committee work. Civilian nurses, with their extensive years of experience are a valuable resource but based on narrative comments may be underutilized. Future research is needed to examine and test models that integrate more civilian nurses into the leadership team within the organization. 

At the hospital unit level, inclusion of more civilian nurses in management positions may add stability to operations. The findings from the study suggest a lack of coworker support and role ambiguity were related to dissatisfaction in civilian nurses. Strategies that increase teamwork and clarify civilian nursing roles may enhance satisfaction and should be examined. Finally, future research should examine the effect mentors have on both military and civilian nurses' job satisfaction. 

Several limitations of the study must be acknowledged. The satisfaction data were obtained from a convenience sample of nurses, not a random sample. Although the response rate was better than in similar nurse survey studies, there may be response bias. Data were collected at three large acute care Navy hospitals and the findings cannot be generalized to all military hospitals. As with any survey approach to data collection there is the potential for bias in self- report measures. 

The study used a well-established model and instrument to assess a large sample of Navy and civilian nurses who work side by side. The lack of significant influences of autonomy, distributive justice, and professional growth might be considered a good result since these issues have been identified as dissatisfiers by nurses in other studies. Yet, the importance of promotional opportunities, resource adequacy, and supervisor and coworker support are affirmed. Although some of the comments reported by nurses were critical in nature, the respondents also reported a strong sense of patriotism and were committed to caring for this patient population. Further investigation into factors affecting military nurses' job satisfaction and civilian nurses' job satisfaction must be explored, particularly as military operations continue overseas. ACKNOWLEDGMENTS 

This project was supported by TriService Nursing Research Program (Grant N02-031), Uniformed Services University of the Health Sciences. 

Copyright Association of Military Surgeons of the United States Jan 2009 

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