Job satisfaction among intensive care nurses as related to professional growth needs and performance appraisal systems

Nursing service administrators strive to provide quality patient care through retention of competent, motivated nurses. Nurse job satisfaction is essential to retention and critical in Intensive Care Units (ICUs). Although there are many variables contributing to nurse job satisfaction, this study examined ICU staff nurse job satisfaction in relationship to performance appraisal systems, frequency of feedback and certain demographic characteristics. ICU staff nurses from three private hospitals responded to the study by completing a Personal Satisfaction Inventory instrument, a question on frequency of feedback and demographic questionnaire. An expert panel, instructed in motivational theory, examined the three hospitals' job descriptions/performance evaluation instruments for congruence and motivational design. Consensus of the panel was numerically translated on a Likert scale to allow statistical analysis with job satisfaction scores. Frequency of feed back and marital status achieved significant correlations with job satisfaction. No significant relationship was found with congruence/design of performance appraisal systems.

JOB SATISFACTION AMONG INTENSIVE CARE NURSES AS RELATED TO PROFESSIONAL GROWTH NEEDS AND PERFORMANCE APPRAISAL SYSTEMS by Anna S. Kontas A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science College of Nursing The University of Utah March 1985 THE UNIVERSITY OF UTAH GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Anna S. Kontas This thesis has beell read by each member of the following supervisory committee and by m~i()ritv vote has been rOll Ild to be satisfactory. - 'L7- ~/ t9~ /- -- I - 7 - Be ~Q.~- Mildred Brown THE U~IVERSITY OF UTAH GRADUATE SCHOOL FINAL READING APPROVAL To the Graduate Council of The University of Utah: I have read the thesis of Anna S. Kontas In Its final form and have found that (I) its format. citations. and bibliographic style are consistent and acceptable; (2) its illustrative materials including figures. tables. and chans are in place; and (3) the final manuscript is satisfactory to the Supervisory Committee and is ready for submission to the Graduate School. Dale ~c.tL~ J y • Clausen \'1ember. Supeni~o~' Commiw:e Linda K. Amos Chairman Dean Approved for the Graduate Council Copyright (S) 1985 Anna S. Kontas All Rights Reserved ABSTRACT Nursing service administrators strive to provide quality patient care through retention of competent, motivated nurses. Nurse job satisfaction is essential to retention and critical in Intensive Care Units (rCUs). Although there are many variables contributing to nurse job satisfaction, this study examined ICU staff nurse job satisfaction in relationship to performance appraisal systems, frequency of feedback and certain demographic characteristics. rcu staff nurses from three private hospitals responded to the study by completing a Personal Satisfaction Inventory instrument, a question on frequency of feedback and a demographic questionnaire. An expert panel, instructed in motivational theory, exam­ined the three hospitals' job descriptions/performance evaluation instruments for congruence and motivational design. Consensus of the panel was numerically trans­lated on a Likert scale to allow statistical analysis with job satisfaction scores. Frequency of feedback and marital status achieved significant correlations with job satisfaction. No sig­nificant relationship was found with congruence/design of performance appraisal systems. I dedicate this thesis to: Kathy and Kim, my wonderful daughters, who, out of love, shared in the joy and pride of this accomplishment, and likewise, shared in the pain. Beatrice Schoenberger, my mother, whose continuous prayers gave me confidence and encouragement. Mary Ellen, Frances, and Alice, my sisters, whose understanding of my time and pressures contributed to the completion of this thesis. Albert and George, my brothers, who believed in my ability. Naoma, my friend, whose generosity and love were inspirational throughout this project. CONTENTS ABSTRACT . • • • .iv LIST OF TABLES • •• viii ACKNOWLEDGMENTS • • • ix Chapters I. PROBLEM STATEMENT · . 1 Purpose of the Research • • • • • •• •• 5 Review of Literature and Conceptual Framework • • • • • .••.••• • 6 Research Questions .••••••••••••• 35 Definition of Terms. • • • • • • •• 36 Assumptions • • • • . • •••• 39 II. METHODOLOGY Setting and population. . • • • • • • Sample . • • • . • • • • • • • • Operational Definitions of Variables. Job Satisfaction Instrument • • • • • Data Collection Procedures • • • • . .42 • • • .44 • • • .46 • .47 • .53 • • • .55 III. ANALYSIS OF DATA AND DISCUSSION OF FINDINGS .59 IV. SUMMARY AND IMPLICATIONS • • .87 Implications for Research • · .98 Appendices A. INFORMED CONSENT FORM • • 102 B. QUESTIONNAIRE: SECTION I · • 104 C. QUESTIONNAIRE: SECTION I I. • • • • 107 D. ANALYSIS OF INTERNAL CONSISTENCY. • 114 E. ICU NURSE FOLLOW-UP LETTER . . · · · · 118 F. INSTRUCTIONAL OUTLINE FOR PANEL MEMBERS · · 121 . G. PERFORMANCE EVALUATION: HOSPITAL B · · · · 123 H. PERFORMANCE EVALUATION: HOSPITAL C · · 139 I. PERFORMANCE EVALUATION: HOSPITAL A · · 156 SELECTED BIBLIOGRAPHY . . . . . . . . . . . · · · · 166 vii LIST OF TABLES 1. Distribution by Number and Percent for Selected Demographic Characteristics of Sample •••••• 48 2. Means, Medians, Standard Deviations and Ranges for Select Characteristics of Sample •••••• 50 3. Correlation of Coefficients Between Job Satisfaction Scores and Selected study Variables. • • • • • • • • • • • • • ....66 4. A Comparison of the Three Hospitals' Mean Job Satisfaction with Congruence/Design ••••• 66 5. Significant Data from Kruskal-Wallis One-Way Analysis of Variace • • • • • • • •. • •• 72' 6. Correlation Matrix for Study Variables. • .78 7. Recordings for Categorical Variables Used in Correlation and Regression Analysis Procedures .80 8. Step-wise Multiple Regression Analyses for Dependent Variables Nurse Job Satisfaction Score with Independent Study Variables ••••• 81 9. Analysis of Internal Consistency of Job Satisfaction Items Using Cronbach's Alpha •• 115 ACKNOWLEDGMENTS It is with sincere appreciation that I acknowledge the contributions of the following: - JOy C. Clausen, Ph.D., for her support and guidance as Chair of my Thesis Committee: - Mildred A. Brown, M.S.N., for her assistance as a committee member, mentor and friend: - Joseph C. Bentley, Ph.D., for his expertise and assistance as a committee member: - My expert panel: Margaret M. Andrews, R.N., ph.D. Adjunct Assistant Professor University of utah, College of Nursing Lynn O. Boag, R.N., M.S. ACNS/Mental Health V.A. Medical Center Salt Lake City, Utah Patricia A. Hanson, R.N., M.S. ACNS/Geriatrics V.A. Medical Center Salt Lake City, Utah Patricia S. Hartley, R.N., M.S. Assistant Director of Nursing St. Mark's Hospital Salt Lake City, Utah Janice J. Hulbert, R.N., B.S.N. Community Health Nurse Coordinator V.A. Medical Center Salt Lake City, Utah Laura Ellen Ludwick, R.N., M.S. Staff Development St. Mark's Hospital Salt Lake City, utah I would like to acknowledge the special contribu-tions of Joanne Rolando, R.N., M.S. Joanne's individual efforts helped me gain an understanding of, and apprecia-tion for, statistical analysis in the research process. ix CHAPTER I PROBLEM STATEMENT Nurse satisfaction with resultant retention of com­petent and qualified nurses is a goal of nursing service administrators throughout the country, inasmuch as nurse retention is cost effective and qualified nurses posi­tively impact the quality of care given in the nursing organization. Conversely, nurse dissatisfaction, resulting in high turnover rates, is a source of frustration to nursing ad­ministrators, because of the recruitment and orientation costs, and because of the negative impact on quality care due to the influx of inexperienced personnel. Albeit that some degree of turnover is healthy in any organiza­tion, nursing turnover rates of up to 70% (Gauerke, 1977) are neither healthy nor cost effective in nursing service organizations. 'A second source of frustration to nursing service administrators is absenteeism. Seybolt and Walker (1980) reported it has been well documented that dissatisfied employees require more time off, are less committed to their work organization, and are often more prone to 2 illness, both physical and mental. Unplanned absences impinge on the workload of other nursing staff, impact on the quality of care the remaining staff can provide, and may give rise to "pulling" of staff from other areas. A lack of adequate nursing staff to meet patient care needs on one unit, due to unplanned absences of personnel, fre­quently results in "pulling" of staff from other units. This management practice of "pulling" is disruptive to the autonomy and integrity of nursing units and inter­feres with the ability of head nurses to plan educational offerings for their staff or additional patient related duties that have been neglected during staffing shortages. These factors, namely "pulling" practices and lack of administrative support for unit autonomy, have been identified by nurses as reinforcing their belief that nursing administration does not value direct patient care responsibilities, and as contributing to their dis­satisfaction (Wandelt, Pierce & Widdowson, 1980). A number of studies have shown correlations between psycho­logical states and bodily functioning (Burke, 1969, 1970; Chadwick-Jones, 1969; Herzberg, Mausner & Snyderman, 1959; Locke, 1976; Sales & House, 1971; Whyte, 1955). Thus, initial absenteeism of nursing personnel may be re­lated to job dissatisfaction, and the impact of absences on remaining staff may produce physical symptoms and ad­ditional absenteeism. Job dissatisfaction promotes ab- 3 senteeism which leads to turnover (Gauerke, 1977). A third frustration confronting nursing service ad­ministrators is ~ lack of employee motivation. Although two content theorists have provided the framework for em­ployee motivation -- Maslow (1954) in his Need Hierarchy Theory and Herzberg (1968) in his Dual-Factor, Motivator­Hygiene Theory -- there has been a lack of evidence in the past that these or any other theories have been the basis for job descriptions or performance evaluations for nurses. Traditionally, managers, supervisors and em­ployees have looked forward to performance appraisals with trepidation and fear. Although feedback is an es~ sential component in motivating employees to improve their performance, evaluations have been used as controls rather than motivational tools, and thus have been a losing experience, not only for employees but for organi­zations, as indicated by a higher turnover, lower job sa­tisfaction and lower productivity (Kaye & Krantz, 1983). In order for nurse performance appraisal systems to become motivational forces rather than controlling de­vices, it is essential to employ a systems approach to appraisal systems. Rather than looking at job descrip­tions and performance evaluations as separate, unrelated entities and a source of confusion and irritation to nur­ses, a cybernetic framework of input, throughput, and output can be used effectively as the appraisal systems' 4 model. The input represents the nurse's orientation to a clear job description, which is based on opportunities for professional growth; the throughput represents the frequent feedback provided the nurse by the supervisor. The feedback is designed to modify and/or direct the nurse's behavior towards attaining the functions con­tained in the job descrition. The output represents an appraisal of the nurse's performance, evaluating how well the nurse is me'eting the functions described in the job description (Stevens, 1980). In order for the appraisal system to be effective, the job description and perform­ance evaluation must be congruent, and the feedback con~ sistent. In order for the process to be a motivational influence, the congruent appraisal system must also be based on growth needs (Seybolt, Pavett & Walker, 1978). According to Herzberg (1968), motivators are driving forces that increase knowledge, individuality, under­standing and creativity; allow for ambiguity in decision making and promote growth. From 12 investigations, Herzberg (1968) reported that motivators were the primary cause of satisfaction among the variety of employees stu­died. He listed these motivators as achievement, recog­nition, the work itself, responsibility, advancement and growth. 5 Purpose of the Research Based on the literature review, the purpose of this study was to compare, for congruence, the job descrip­tions/ performance evaluation instruments of reu staff nurses at three hospitals located in northern Utah. rn addition, these job descriptions were examined to deter­mine if they had been developed so as to motivate the nurses to increase their clinical skills and proficiency and thus enhance their professional growth. This study investigated the relationship between the reu staff nurses' job satisfaction and their respective performance appraisal systems (i.e., congruent job descriptions/per~ formance evaluation instruments, job descriptions based on motivators and frequency of feedback). This study al­so investigated the relationship between the reu staff nurses' job satisfaction and certain demographic vari­ables. The findings from this study will add the dimension of performance appraisal systems and reu staff nurse job satisfaction to the existing repertoire of nurse job sa­tisfaction studies contained in the literature. By incorporating this systematized approach in administering performance appraisal programs, nursing administrators will increase the motivation and job satisfaction of their nurses, thus decrease costly turnover rates and ab­senteeism which leads to "pulling" practices, a lack of unit autonomy and nurse job dissatisfaction. Review of the Literature and Conceptual Framework Job Satisfaction Studies outside of Nursing 6 Research efforts concerning fatigue reduction and environmental factors affecting fatigue were conducted during World War I and into the 1930s in Great Britain, Germany, and the United States. The Hawthorne studies (Roethlisberger & Dickson, 1939) in 1939, however, were the first to stress the role of the informal work group and supervisory practices on employee attitudes and per-formance. The first intensive study of job satisfaction was published by Hoppock in 1935, but it was the Haw-thorne studies that established the trend in psycho-logical research over the next two decades. An outgrowth of the Hawthorne studies along with studies concerning leadership, which were stimulated by the United States' armed forces during World War II, resulted in the "Human Relations" movement. In postwar years, industrial socio-logists such as Homans in 1950 and Whyte in 1955, and psychologists such as Halpin and Winer in 1957, Likert in 1961, Marrow, Bowers and Seashore in 1967 and Fleishman in 1972, became the leaders of this movement focusing on the impact of leadership and supervisory practice on em-ployee attitudes and performance. A change in focus had occurred, however, in 1959 as 7 a result of the publication by Herzberg, Mausner and Sny­derman, The Motivation to Work. The publication redirec­ted attention to the work itself, and emphasized vertical rather than horizontal job enlargement, claiming that sa­tisfaction can be attained through growth in skill, effi­ciency and responsibility, which is possible through men-tally challenging work. Herzberg's theory regarding the work itself as a motivational influence gained popularity during the next decade, and a major report was published in 1969 by Ford and another in 1971 by Maher. An outgrowth of the Human Relations movement in­cluded a variety of investigations related to the work­environment. Some studies included the events or condi­tions affecting the work environment such as the variety of the work assignment, opportunities for learning, chances for success, managerial controls over time, pace, and methods; pay, including fairness and method of pay­ment; promotions; recognition; benefits; and working con­ditions, such as hours of work, rest breaks, equipment, ventilation, humidity, and other environmental factors. Other studies focused on the agents affecting the work environment, such as supervision, including one's super­visory style, interpersonal relationships' skill, admin­istrative and technical skill; company and management policies and procedures including a demonstration of con­cern for the employee; and social relationships among 8 peers and subordinates as a result of the work environ-mente Two causal models of job satisfaction evolved from these studied. The first model identified by Campbell, Dunnette, Lawler and Weich (1970) is the process theory. In this model, an attempt is made to specify the causal relationship between classes of variables necessary for job satisfaction, as well as a combination of these variables. The variables include physical and psycholo-gical needs, perceptions based on previous experience, values, beliefs, personal goals, competencies, and expec-tations. The second model is a content theory. This mo-del attempts to identify and describe the actual factors or the specific values or needs most conducive to job sa-tisfaction and motivation. The two most distinguished content theorists are Herzberg and Maslow (Locke, 1976). Maslow (1954) identified and described five needs which he arranged hierarchically and which he proposed are satisfied in sequence. In ascending order these needs are: a} physiological needs such as food and water; b} safety needs; c} belongingness and love: d} esteem, and e} self-actualization. Maslow proposed that each se-quential need must be satisfied before the next ascending need becomes a motivational force. In other words, the basic needs related to survival must be met before an in­~ dividual can be motivated to attai~ higher level 9 needs. Herzberg (1969) identified and described a Dual-Fac­tor Theory in which he argued that job satisfaction and dissatisfaction are the result of two separate and dif­ferent causes; satisfaction is dependent on motivators while dissatisfaction is the result of hygiene factors. Motivators include work itself, achievement, recognition, responsibility and the opportunity for growth and ad­vancement. Hygiene factors, although they do not moti­vate, can prevent the development of negative feelings and dissatisfaction. These hygiene factors he identified as supervision, company policies and administration, working conditions, interpersonal relationships, job se­curity and pay. Other important studies related to job satisfaction include Vroom's (1964) expectancy/valence theory of moti­vation. Vroom proposes that workers who are highly at­tracted to their jobs are subject to motivational forces to remain in them, with these forces manifesting them­selves in increased tenure and higher rates of atten­dance. An individual will be motivated to produce at a high level if efforts result in successful performance and if this successful performance results in desired re­wards. Based on the concept that autonomy is an important motivational force in the job setting, Turner and 10 Lawrence (1965) studied the degree to which workers feel . personal responsibility for their work outcomes. They found that in jobs which measured high on autonomy, workers tended to feel that they owned the outcomes of their work; in jobs low on autonomy, workers tended to feel that successes were due to the good work of co-workers and supervisors and failures were likewise the result of incompetence among co-workers and supervisors. Schneider and Locke's (1971) theory utilizes an event/agent classification system to measure job satis-faction. Factors influencing job satisfaction are placed in one of two categories: the events or happenings and the agents, those who made it happen. Events include the work itself, rewards and working conditions. Working conditions include the interpersonal atmosphere, physical working conditions and a miscellaneous category which in-cludes such things as accidents. The agent category includes all individuals with whom the employee interfaces and interacts during the course of the job; both self and others. With respect to agents, Schneider and Locke's data demonstrate that self is credited more often for satisfying events than for dissatisfying events as compared to nonself agents. Hackman and Lawler (1971) obtained positive rela-tionships between four core dimensions, namely variety, autonomy, task identity, and feedback, and the dependent 11 measures indicative of motivation, satisfaction, per­formance, and attendance. They found that the four most important satisfaction items that relate to the core di­mensions are, in descending order: a) the opportunity for independent thought and action in the job; b) the feeling of worthwhile accomplishment in the job; c) the opportunity for personal growth and development in the job; and d) the self-esteem and self-respect a person gets from being on the job. Likewise, they found that the four items that related least strongly to the core dimensions are, in ascending order: a) pay for the job: b) the opportunity to develop close friendships on the job: c) the opportunity for promotion; and d) the amount of respect and fair treatment received from the super­visor (Porter & Steers, 1973). There are four notable studies cited in the litera­ture that pertain to job dissatisfaction related to role ambiguity. An early study by Weitz (1952) demonstrated that prior knowledge and understanding of the role re­quirements on a job were significant factors in job sa­tisfaction and retention. Using variations of Weitz' de­sign, Macedonia (1959) and Youngberg (1963) arrived at similar conclusions. Youngberg also found that if the job expectations became a reality, job satisfaction on that job was significantly higher. Kahn, Wolfe, Quinn, Snoek, and Rosenthal also demon- 12 strated that role ambiguity is related to psychological and physical withdrawal. These authors suggested that there are three conditions that may lead to role ambigui-ty: a) rapid organizational change; b) increased com-plexity of the organization; and c) managerial philoso-phies concerning communication. Lyons (1970) in a questionnaire survey of staff nurses, found a positive relationship between role clari-ty and nurses choosing to remain on their jobs, a de-crease in job tension, and work satisfaction. Based on these studies, job clarity seems to be a significant con-sideration for job satisfaction (Porter & Steers, 1973). Job Satisfaction Studies in Nursing Nurses have been a target population for job satisfaction studies within the health field. Job satisfaction has been studied in relation to turnover rate and to unionization; Herzberg's, Hoppock's and Maslow's theories have been applied to nurse populations to determine the extent to which nurse responses are similar to the responses found in other working groups; and personality studies have been conducted on nurses to determine what type of person is attracted to the nursing profession (Slavitt, Stamps, Piedmont & Haase, 1978). In a review of the literature concerning job satis-faction among nurses, Slavitt et al. (1978) identified 13 six components reported frequently in a variety of stu­dies that were found to be the most significant for pro­fessional nurses in health care settings. They identi­fied the components as: a) pay -- the dollar figure re­ceived as well as the fringe benefits provided for work completed: b) autonomy -- the amount of independence, freedom and initiative either permitted or required in the daily activities of the job: c) task requirements -­the tasks required by a particular job; d) organizational requirements -- limits and/or constraints imposed on nurses by administration in relationship to their functions and job ativities: e) interaction -- the oppor­tunity and requirements for both formal and informal so­cial contacts during working hours: and f) job pres­tige/ status -- nurses' perception of the importance of their role, both personally and as it relates to the or­ganization. Using the six components found to be the most signi­ficant for professional nurses as described above, Stamps, Piedmont, Slavitt and Haase (1978) tested an in­strument on: a) a group of nurses in a hospital setting in the summer of 1972 using a sample population of 246 nurses; b) 42 hospital staff members (physicians, nurses and support staff) of a private, fee-for-service ambula­tory group practice in the Spring of 1974; and c) another 450 nurses in a different hospital setting in the summer 14 of 1974. This instrument was designed to measure the level of job satisfaction among these hospital staff mem-bers as related to pay, autonomy, task requirements, or-ganizational requirements, interaction, and job pres-tige/ status. Although there were significant differences in the importance of the six components among the physi-cians, support staff and nurses, the three different nurse populations consistently rated job status as being most important, interaction as the second most important, and autonomy as the third. There were variations among the components of organizational requirements, task re-quirements, and pay among the three groups of nurses. Godfrey, Adams, Addison, Bagley, Copley, Frantz, Galdys, Geels, McConnel, Spitz, Sweetwood and Vader (1978) reported the responses obtained from 17,000 nurses to the Probe Questionnaire on Job Satisfaction published in the September issue of Nursing 77. The following were the major dissatisfactions identified by the nurse re-spondents: Unsafe practices: -Dangerous understaffing -Toleration and retention of incompetent nurses -Alcoholic doctors "practicing" medicine -Patients stacked in hospital halls like so many sausages (p. 90). Poor leadership: -Head nurses who use scheduling as a weapon -Inflexible supervisors determined to preserve the status quo -Nursing directors who have not laid a hand on a patient in 20 years 15 -Authoritarian administrators concerned only with cutting costs -- at any price (p. 90.) Communication breakdown: -Learning about vital changes in the hospital -­from the newspaper -Being transferred to a different unit without being forewarned -Going through channels to relay important messages and getting no response whatsoever -Having supervisors verbally promise something (more help, a raise), then having them "forget" the conversation entirely (p. 90). In addition to the major dissatisfactions listed above, the respondents identified several factors leading to job satisfaction. These factors are: prestige and recognition; work itself; well-defined job descriptions; immediate supervisors' feedback; patients' feedback; nursing administration's and hospital management's feedback; and involvement in the planning and decision making of the institution. In response to the 17,000 nurses who identified dissatisfiers and satisfiers in their work settings, Baldonado (1980) stated that nursing administrators must develop coping strategies that will significantly increase job satisfaction among nurses. She incorporated a number of changes in her administrative practice aimed at providing supervisory support to promote staff nurse autonomy in decision making, in extending care, and in utilizing knowledge as power in an effort to increase job satisfaction among her nursing staff at a Catholic 16 Hospita~ in Chicago. Araujo (1980), in her role as a nursing administra­tor at Mercy Hospital and Medical Center in Chicago, has likewise made some innovative changes in her administra­tive practice to impact nurse retention. She contends that nursing service administrators can positively in­fluence nurse retention by creating a work experience in which professional growth is enhanced and problem-solving by staff nurses encouraged. A newly appointed director of nursing services at Stanford University Medical Center utilized an attitude survey to determine the nursing staff's attitudes and opinions concerning their work and feelings about the hospital. Of the survey respondents, 56% indicated dis­satisfaction with the lack of career and promotional op­portunities: 26% were dissatisfied with opportunities to develop skills and abilities; and 17% were dissatisfied with opportunities to learn new things. The data collec­ted in the survey were fed back to the nursing staff and the nursing director began to involve the staff in making plans to deal with the issues found to be problematic by the survey. Several programs were planned and implemen­ted but the staff involvement was the critical link in the project (Seybolt & Walker, 1980). Wandelt, Pierce and Widdowson (1980) studied ·Condi­tions Associated with Registered Nurse Employment in 17 Texas,". and reported their findings to the Texas Senate Special Committee on Delivery of Human Services. The concern at the time of the study was that some hospital beds in Texas could not be used because there were not enough nurses to care for the additional patients, even though there were about 18,000 registered nurses licensed to practice who were not working in the nursing profes-sion. These researchers sought opinions, feelings, and ideas about nursing from nurses themselves. Through a questionnaire and small-group interviews, 3500 nurses re-sponded in the study. The questionnaire elicited opinions from both employed and unemployed licensed reg-istered nurses about a variety of factors associated with nursing as a job. The ten job conditions, ranked in or-der of importance by employed nurses in the study and which were considered to be dissatisfiers,were: 1. Availability [sic]* of adequate salaries 2. The amount of paperwork 3. Lack of hospital administration support 4. Lack of opportunity for continuing education 5. Inadequacy of laws regulating the practice of nursing in Texas 6. Lack of nursing administration support 7. Unavailability of acceptable child-care facilities 8. Unavailability of inservice education 9. Unavailability of fringe benefits 10. Incompetent, nonregistered nursing staff(p. 73). *Should read unavailability. A high percentage of nonemployed nurses listed many of the same items as their reasons for leaving nursing. 18 Additional highly ranked items included: 1. Family responsibilities 2. Unavailability of desired work schedules 3. Environment that does not provide a sense of worth as a member of the health care team 4. Lack of positive professional interactions with physicians 5. No emphasis placed on individualized patient care (p. 74). A California study reported by Cunningham (1981) suggested that nursing education programs may be way off the mark in preparing nurses for the realities of hospi-tal service. The study was conducted by MacDonald, who reported that clearly there is an existing education-ser-vice gap. Conclusions from this study for change in ad-ministrative practice included the need to improve recog-nition and appreciation for nurses; opportunities for education and advancement; and work schedule options. Lesser priorities should address the needs of nurses for independent action, intellectual stimulation, work satis-faction and income. Kleinknecht and Hefferin (1982) identified a model that provides a framework for career development programs within the nursing structure. This model can assist nurse administrators in identifying opportunities for re-structuring nurses' work experiences to make the work en-vironment more interesting and challenging. Based on a number of job satisfaction studies re-lated to nurses, the authors developed a model aimed at developing programs that will specifically address the 19 issue of professional growth opportunities for nurses. The career planning program model developed considers the needs and goals of both the institution and the indi­vidual professional nurse and identifies their respective responsibilities related to the program. Subsequent to implementation at the Veteran's Administration Medical Center in Wadsworth, California, job attitude studies among staff nurses, head nurses, and supervisors have shown an increased awareness of the nursing service ad­ministrator's concern for the nurses' professional growth and well-being. Surveys have also shown a marked in­crease in the proportion of nurses who feel that their present work assignments are closely related to their career goals and those who report being satisfied and happy in their jobs. Although retention of nurses in the work force con­tinues to be a significant problem in the health care system, the severity of the problem is compounded when highly skilled intensive care nurses (lCU) leave their positions. When turnover among lCU nurses is high, hos­pitals are faced with replacement costs involving the teaching of specialized techniques, as well as the cost of closely monitoring the clinical practice of inexper­ienced lCU nurses. A recent study conducted by Dear, Weisman, Alexander and Chase (1982) compared job satisfaction and turnover 20 between leu nurses and non-leU nurses over a period of 1 year. The purpose was to investigate the relative im­portance of leU/non-leU status in predicting job satis­faction and turnover. The previous literature suggested that problems that are presumed to contribute to the po­tential for high turnover among leu nurses are related to fast-changing patient situations, the presence of death, worried and anxious families, and demanding physicians and nurse peers. Rigorous patient care requirements, communication difficulties, and the need for expanded knowledge were identified as significant problems in re­tention of leu nurses. Analysis of the data from the study by Dear et ale revealed that leu nurses expressed job satisfaction gen­erally equal to that of their non-leU counterparts, sug­gesting that despite the stress in critical care nursing, the leu nurses felt a similar sense of job satisfaction. The turnover rates for both leu and non-leU nurses were comparable. The implication of this study for nursing service administrators is to consider changes within hos­pital nursing that will build on the present job satis­faction of all nurses while retaining them within the work setting. A more recent study on nurses' job satisfaction fo­cused on the reasons nurses remain in their jobs and the specific factors that contribute to the retention of 21 registered nurses in hospital settings. In this study, Magnet Hospitals (1983) task force members on nursing practice in hospitals interviewed directors of nursing and staff nurses. The investigators believed that these individuals are in the best position to identify factors that contribute to nurse job satisfaction and retention in their hospitals. Although there were some differences in perspective among the two groups, there were similari­ties in values. The staff nurses tended to identify cer­tain behaviors and attitudes of physicians and support personnel that were important in contributing to their job satisfaction. The identified behaviors and attitudes tended to parallel some of the programs and practices identified by the directors. Some similar values in­cluded adequate and competent colleagues, flexibility in scheduling and educational programs that allow for pro­fessional growth and recognition as individuals. Other similarities between both groups of respondents included the need for nursing service administrators to respect the staff, to be open and honest in relationships, to keep the channels of communication open, and to strive for integration of individual and organizational goals. The staff nurses identified autonomy as an important ingredient in retention. The nurses have an image of themselves as influencing decisions and being in relative control of their own practice. They see themselves as 22 having rights as well as responsibilities, possessing a body of knowledge and expertise of significance to the organization, and expecting support in carrying out their legitimate role. The staff nurses identify this support as being twofold: a) a philosophical support by the chief executive officer and the director of nursing that the purpose for nurses should be patient care delivery, which supports the hiring of sufficient ancillary ser-vices in order to operationalize the nurses' purpose; b) support of nurses' quality care delivery through consis-tent feedback aimed at recognizing achievements, in-creasing staff nurse responsibility and opportunity for growth and advancement. Directors perceived that they have a power base that develops because of their leader-ship approach. Both groups identified the need for a complementary "fit" between the chief executive officer and the director of nursing, based on the fact that un-less there is a meeting of the minds with the executive officer, the director of nursing will lack the influence and ability to effect change. In the magnet hospitals, the hospitals that attract and retain nurses, it is a combination of elements that makes for a positive prac-tice environment. Performance Appraisal System Studies Throughout the literature review on job satisfaction among nurses, one common theme prevails. The theme, 23 although stated in many ways, is that nurses want to be competent in their practice so that they can earn the respect, autonomy, recognition and pay they deserve for delivering quality care to patients. The method employed by institutions to develop and evaluate the competency of nurses is a performance appraisal system. Gauerke (1977) referred to Herzberg's work in demon­strating that motivators are the primary factors in job satisfaction and in motivating employees towards job en­richment. Since job enrichment is a continuous process, performance appraisal should also be a continuous pro­cess. There are esentially two types of evaluations: the formal evaluation consisting of completion of the evalua­tion form and an interview with the individual being ap­praised; and the informal evaluation, which should be a continuous, day-to-day process whereby the supervisor in­forms empoyees about their work performance. This pro­cess, Gauerke claims, will not only lead to retention of employees but also to motivation for improved perform­ance. South (1978) states that professional development and growth do not always result from the postappraisal review commonly used when evaluating nurses' performance. He has, therefore, created a performance profile tech­nique as a method to measure effective nurse performance 24 apprai~als. This method shifts the emphasis from evalua­tion per se to development, assists the supervisor in coaching each staff nurse, assists in the analysis of a nurse's performance, and can be an administrative aid in planning and upgrading personnel. Council and Plachy (1980) suggest that performance planning and appraisal should be a cooperative venture between supervisor and employee, based on a genuine con­cern for one another's success. The authors advise super­visors to design a performance appraisal system that will encourage employee participation and goal achievement. Lovrich, Hopkins, Shaffer and Yale (1981) reported a study conducted in which three control agencies were se­lected for the assessment of a new participative per­formance appraisal system. The authors developed the participative performance appraisal system as a moti­vating device for their employees as well as for the tra­ditional use of evaluating employee performance. Not on­ly was the system used in the three control agencies to compare achievements of employees with performance stan­dards and goals, but it was also used as a tool for indi­vidual goal setting and growth in career development. Comparisons of pre- and posttest data for both the pilot study and the statewide implementation of the participa­tive appraisal process demonstrated improvements with re­spect to job satisfatioo, agency climate, and work values 25 among those employees who experienced the new evaluation process. Lerch (1982) stated that the objectives of a per­formance appraisal system are to serve as a clear and ef­fective tool in measuring current performance and in de­veloping future performance. She described a change in the performance appraisal format at St. Luke's Hospital in Richmond, Virginia as a challenge to comply with the 1980 Joint Commission on Accreditation of Hospitals' standard for criteria based performance appraisal sys­tems. The first step, according to Lerch, in the re­vision was to redesign the job descriptions for all clas­sifications in the nursing service. The nursing service administrative staff decided on a process-oriented for­mat, which served to clarify the role and function of nursing. The administrative staff established standards of performance specific to each classification and cited criteria relative to, and supportive of, each standard. The criteria for measurement of performance were defined in terms of the goals of the job itself. Standards of performance were clearly stated, measurable and within the control of the employee. Progression to the per­formance appraisal format followed in which each classi­fication exactly copied the job description. To remove some subjectivity, a simplified three-point format was designed for measuring performance against a given cri- 26 terion. The number three rating provided for recognition of exceptional performance in a given area. The new objectives developed as a result of revision in the performance appraisal system at St. Luke's Hospi­tal are: to measure employee contribution against clear­ly specified and job-related standards of performance: to provide a method for employee input and feedback; to pro­vide direction for improvement of future performance; and to provide supportive documentation for any recommended salary increase based strictly on merit. An article by Clark (1982) offers principles for ef­fectively linking salary increases to performance. Un­like the traditional automatic step increase program, Clark recommends an alternative approach, a true pay-for­performance system. He recommends use of an effective measuring device, in that the more precisely the system allows employees to be rated on criteria directly related to their duties and responsibilities, the greater the system's defensibility, validity, and acceptability will be to the employees. Each position should have measures and standards unique to the duties performed. The most effective performance appraisal systems have individual­ly- tailored objectives within a standard format. Clark concludes that the effort required to overcome initial problems and implement a pay-for-performance salary ad­ministration system will be rewarded by improved communi- 27 cation, productivity, and recognition of individual per­formance. In a study described by Frost (1983), it was hy­pothesized that behaviors associated with subordinates' role perceptions affect the relationship between subordi­nates' ability and their performance. The relationship between role ambiguity and behavior of the immediate su­pervisor was investigated. A review of the literature indicated that role ambiguity should increase the proba­bility of employee role dissatisfaction and anxiety and decrease employee efficiency. It was also hypothesized that role conflict (situations in which a person is asked to comply with inconsistent or impossible demands) would have negative relationships with job satisfaction and performance. Results support the conclusion that role conflict, and to a lesser degree, managerial behavior leading to role conflict, affects the relationship be­tween ability and performance for first-level super­visors. Frost concluded that lower level supervisors are more greatly affected by role conflict than by role ambi­guity. This investigation further demonstrated that role stress is a moderating variable that links formal organi­zational practices and behavior of the supervisor to such outcomes as subordinate job satisfaction, the propensity to leave the organization, and organizational effective­ness. Thus, clarification of role and job-related re- 28 sponsibilities are important considerations in affecting turnover rates and improving employee performance. Feeney (1982-83) offers a systemized performance improvement approach that uses principles of behavior modification to provide a system of feedback and reward to effect positive changes in human behavior. He states that if we want good performance from employees the following conditions must exist: 1. Employees must know specifically what is expected of them, which is accomplished by establishing measurable job standards and communicating the standards to employees; 2. Employees must be given feedback on performance; and 3. Good performance must have rewarding consequences, either intrinsic or extrinsic. Consequently, a management plan must contain the following criteria: 1. Rewards must be linked to the desired behavior. Likewise, to be effective, rewards should be removed if performance is out of line with desired behavior. 2. The desired behavior must be reinforced frequently. Therefore, every small improvement toward the desired behavior should be rewarded. 3. All rewards must be given in a timely fashion. The more timely the reward, the smaller that reward need be. Delayed rewards must be larger to have the same impact. 29 An article by Riley (1983) outlined three steps that make an employee performance review system more effec­tive. She stated that a performance review should be de­signed to improve employee performance, improve the working relationship between employee and supervisor, and increase employee satisfaction with the job and the in­stitution. The three steps essential to effective em­ployee performance reviews are clearly written and commu­nicated job descriptions; employee recognition for skills performed well; and realistic, attainable, measurable goals. Ginsburg (1983), in an article concerning management in the 1980s, concluded that effective managers of the 1980s will be those who recognize the need for change and are committed to its implementation. He stated that American values are changing and management must be aware and supportive of them. Recent research documents these values to be: 1. Individuals value a clear understanding of their roles, and the degree of authority they are given to perform their duties. 2. Individuals value the opportunity to participate in the negotiation of the performance expectations of their roles. 30 3. Individuals value the encouragement to utilize their skills and creative potentials. 4. Individuals value the respect, trust, and confidence of their managers. 5. Individuals value a regular and constant flow of information; to be informed in advance of changes which impact their relationship with the organization and the performance of their duties. 6. Individuals value timely and honest feedback; to be appraised of their performance and to share in the successes and failures of their units. Individuals value a reward system which recognizes accomplishment in an objective and understood manner. 7. Individuals value a development program which prepares them adequately to perform their responsibilities. A number of additional articles reflect the ability of performance appraisal systems to act as motivators towards improving performance (Bernardin & Cardy, 1983; Cascio, 1983; Edwards, Wolfe & Sproull, 1983; Hyde & Smith, 1983; Miller, Campbell & Sherman, 1983; Schoen­hard, 1978; Walther & Taylor, 1983; Weihrich, 1982). conceptual Framework There has been a great deal of research and scholar­ly activity in the area of job satisfaction over the years, as reflected in the review of the literature. 31 Each scholar has made a significant contribution to the understanding of the many aspects particularly peculiar to job satisfation. From the literature review, the work of Herzberg has been identified as the most beneficial in conceptualizing the research outlined herein. The impact of Herzberg et ale on psychological re­search has been significant since their publication, The Motivation to Work (1959). Their theoretical framework was instrumental in redirecting research attention from environmental factors and supervisory practices on em­ployee attitudes and performance to the work itself. In his motivational theory, Herzberg (1969) emphasized ver­tical rather than horizontal job enlargement and argued that satisfaction can be attained through growth in skill, efficiency and responsibility, and is attainable through mentally challenging work. In his Dual-Factor Theory, Herzberg argues that job satisfaction and dis­satisfaction are the result of two separate and different causes; satisfaction is dependent on motivators while dissatisfaction is the result of hygiene factors. Moti­vators include work itself, achievement, recognition, re­sponsibility and the opportunity for growth and advance­ment. Hygiene factors, although they do not motivate, can prevent the development of negative feelings and dis­satisfaction. He identifies the hygiene factors as su­pervision, company policies and administration, working 32 conditions, interpersonal relationships, job security and pay. As a potential nursing service administrator, the author of this thesis is interested in retaining compe­tent and qualified nurses who are satisfied and motivated and who will positively impact the quality of patient care delivered. Nurse retention is cost effective. In­herent in the administrative role is the responsibility administrators have for identifying those hygiene factors perceived by the nursing staff as being dissatisfiers and affecting whatever changes are necessary to eliminate the dissatisfaction component, while creating a climate that capitalizes on the motivators as defined by Herzberg. In reviewing the literature on nurse job satisfac­tion studies, it is apparent that nurses have left the profession primarily because administrative action was not taken to change or alter factors leading to nurse dissatisfaction, the factors Herzberg terms hygiene fac­tors. However, in the Magnet Study (McClure, Poulin, Sovie & Wandelt, 1983), not only were the hygiene factors being met satisfactorily, but nursing administrators met the motivational needs of nurses through creative, inno­vative models and support from the hospital's chief executive officer. Since job descriptions provide the framework for nurses' roles and functions, job descriptions are an ap- 33 propriate mechanism for providing fulfillment of growth needs essential for nurse motivation. Role clarity also has a positive relationship on nurse retention and work satisfaction, while role ambiguity is related to psycho­logical and physical withdrawal. It is essential, there­fore, to design job descriptions for nurses so as to meet their motivational (growth) needs. Likewise, frequent feedback on performance is an essential component for ei­ther rewarding desired or altering undesirable behavior. The missing link to an effective performance ap­praisal system is the performance evaluation tool. The evaluation instrument must be congruent with the job des­cription and must be the basis on which feedback is given consistently. As the literature suggests, not only should the appraisal system provide role clarity but it should be a cooperative venture between supervisor and employee based on a genuine concern for one another's success. Likewise, good performance must have rewarding consequences, either intrinsic or extrinsic. Based on the review of the literature and theoreti­cal framework, Figure 1 illustrates the conceptual model used in this study. In this systems model, the input is a clearly defined job description based on motivators, which are opportunities for nurses to attain professional growth and advancement through mentally challenging work, opportunities for increased responsibility, recognition ...--- - "-. INPUT '" OUTPUT Frequent Feedback Performance Evaluation Instrument Cost 0 / THROUGHPUT FrequenGif ... D Staff Effective .. III. Job Descr i~tion Based on Moti-~ vators (oppor­tunities for professional growth and achievement). Feedback / Performance Evaluation ---Instrument ... Job Description Nurse Quality -...JOb :----JII. Patient Satisfaction Care De 1 i ve ry Figure 1. A systems model for an effective performance appraisal system for nurses leading to quality patient c~re delivery. w "j::::.. 35 and achievement. The throughput represents the frequent feedba~k provided the nurses by their respective super­visors, concerning their performance in meeting the standards outlined in the job description. The two-way arrow in the throughput illustrates that the feedback provided the nurses is on-going and ties the nurses' per­formance to the job description standards. The output represents the performance evaluation instrument used to measure the nurses' performance. The "fit- between the job description and performance evaluation instrument represents a congruent performance system (i.e., the per­formance evaluation instrument is designed to specifical­ly measure the standards outlined in the job descrip­tion). This effective performance appraisal system leads to staff nurse job satisfaction that leads to cost-effec­tive, quality patient care delivery, which is the goal of nursing administration. Research Questions Based on the literature review and conceptual framework, this study addressed the following questions: 1. Are the job descriptions for Intensive Care Unit staff nurses congruent with the performance evaluation instruments used in the hospitals studied? 2. Do the job descriptions in the hospitals allow opportunities for the nurses to meet their professional growth needs (i.e., do the job descriptions contain motivators)? 3. What is the relationship between ICU staff nurses' job satisfaction as measured by the Personal Satisfaction Inventory instrument and the performance appraisal system used in the institution? 36 4. What is the relationship between ICU staff nurses' job satisfaction and the demographic variables? Definition of Terms Congruence Congruence is the extent to which the ICU staff nurses' evaluation instruments, at the three hospitals, correspond to the functions and activities or standards of the job, as stated clearly in the respective job descriptions. Frequency of Feedback The frequency of feedback is the amount of informa­tion given the staff nurses either formally or informally by their supervisors, concerning the staff nurses' per­formance, in relationship to standards of practice de­fined in respective job descriptions. ICU Staff Nurses ICU staff nurses are nurses working in an Intensive Care Unit who deliver direct patient care around the clock. ICU staff nurses are specially trained in criti- 37 cal care management of patients, with emphasis on judgmen~, assessment skills and technological competence in a highly stressful environment. Job Description A job description is a clearly written document describing the functions and activities inherent in the job, based on standards of performance that are measurable and within the control of the employee. Job Satisfaction Job satisfaction is the individual nurse's contentment with present employment and assignment as measured by the Personal Satisfaction Inventory instrument. Motivators Based on Herzberg's theoretical framework, motivators are achievement, recognition, work itself, responsibility, advancement and professional growth. Achievement is accomplishing a desired result in the . work setting through challenging opportunities. Recognition is acknowledgment of a nurse's contributions to providing quality patient care, and/or demonstrating leadership in the profession. Work itself is a meaningful, mentally challenging assignment whereby the nurse can increase knowledge, exercise creativity and individuality and attain 38 professional growth. Responsibility is allowing nurses freedom and initiative in their nursing practice and holding them accountable and answerable for results of their nursing care delivery. Advancement is being upgraded based on demonstrated competency in patient care delivery or promoted to a higher position within the framework of the nurse's career goals. Professional growth is the opportunity for nurses to increase their clinical knowledge, technical competence and proficiency in caring for patients through mentally challenging work assignments in which the nurses exercise independence, initiative and accountability for their practice: and the opportunity for the nurses to increase status in the profession of nursing through education, achievement, advancement or responsibility. Performance Appraisal System A performance appraisal system is the operational method used by an institution to evaluate the performance of nurses employed vis-~-vis a measurable job descrip­tion. In order for the system to be effective, the job description and performance evaluation instrument must be congruent. In order for the system to be a motivational device, the job description must be designed to meet the 39 nurse's professional growth needs, and the nurse must be provided frequent and consistent feedback concerning ac­complishments towards meeting the job description standards. Performance Evaluation Instrument The instrument used by each of the three hospitals to document measured performance of their ICU staff nurses against given standards, at a designated period of time, is the Performance Evaluation Instrument. Personal Satisfaction Inventory Instrument The questionnaire used to determine the degree tQ which the sample of ICU staff nurses are satisfied with the patient care they provide and progress towards attaining individual career goals is the Personal Satisfaction Inventory. Assumptions Certain assumptions were made prior to initiation of the study. It was assumed that the Personal Satisfaction Inventory instrument would measure the ICU staff nurses' job satisfaction with the patient care they deliver and with their progress toward individual career goals. It was further assumed that an effective performance ap­praisal system includes the following components: a} there is a clear, behaviorally measurably job description for the leu staff nurses based on motivators that are 40 aimed at increasing the nurses' professional growth; b) nurses are provided frequent and consistent feedback relative to their performance in meeting the job descrip­tion standards; and c) nurses are given at least an an­nual written performance evaluation that is congruent with the functions contained in the job description. Based on this assumption, it was concluded that nurses employed in a hospital that has an effective performance appraisal system operationalized would demonstrate a higher level of job satisfaction than in a hospital that employs a less effective or ineffective system. It was also assumed that differences in the performance ap­praisal systems would be found among the three hospitals, as well as differences in nurse job satisfaction. Six expert nurses were contracted with to examine the job descriptions of leu staff nurses at the three hospitals and to determine the degree to which the job descriptions act as motivators for the leu staff nurses to meet their professional growth needs. The experts were chosen based on their recent involvement in nursing administration. It was assumed that the six nursing ex­perts would be able to compare the job descriptions for leu staff nurses in each hospital with their respective performance evaluation instruments and determine if the two instruments were congruent; and then rank the three hospitals' job descriptions in order of the job descrip- 41 tions' ~otivational design. Finally, it was assumed that the respondents would answer the questionnaires honestly because of the confidentiality assured by the investiga­tor. LIBRARY CHAPTER II METHODOLOGY A qualitative, descriptive design was utilized to answer Research Questions 1 and 2 while a quantitative, correlational design was employed to address Research Questions 3 and 4. The investigator, through the use of a panel of six experts, compared the job descriptions of ICU staff nurses at each of the hospitals studied with their respective performance evaluation instruments and evaluated the level of congruence between the two. Likewise, the investigator, through utilizing the same expert panel, analyzed the job decriptions of ICU staff nurses at the three hospitals and evaluated the extent to which the job descriptions may act as motivators for the ICU staff nurses to increase their clinical skills and enhance their professional growth. The panel consisted of six nurses considered to be experts due to their recent exposure to administrative and management principles through academic studies, or because of their past and present experiences as nursing managers. The panel was comprised of the following: a) four graduates from the University of Utah College of 43 Nursing master's degree program, three of whom graduated - during the past year with two of the three specializing in Nursing Administration, one in Gerontological Nursing and the fourth a 1980 graduate in the Physiological Nursing pathway but whose experience has been in admin-istrative assignments; b) one Physiological Nursing Specialist who graduated from the University of Buffalo, New York, who has had several administrative assignments; and c) one master's level graduate student enrolled in Brigham Young University's Community Nursing Program, but who previously completed the coursework for the Nursing Administration Program, and who has had recent management experience. The method utilized to educate the expert panel concerning how to compare the job descriptions/per-formance evaluation instruments for congruence and how to determine if the job descriptions contained motivators is described in the Data Collection Procedures section later in the chapter. To obtain the job satisfaction scores, leu staff nurses at the three hospitals were asked to complete a Personal Satisfaction Inventory instrument. An "Informed Consent" accompanied the instrument explaining the purpose of the study and assuring the ICU staff nurses confidentiality in their responses (see Appendix A). To consider factors that may be related to the leu staff nurses' job satisfaction, a correlational analysis 44 investigated the relationship between job satisfaction and the following variables: congruence of job descrip­tion/ performance evaluation instrument; design of job description (i.e., is the job description designed as a motivational instrument?); and the frequency of feedback on performance provided the rcu staff nurses by their re­spective supervisors. Correlational analysis was simi­larly used to determine the relationship between rcu staff nurse job satisfaction and the nurses' demographic characteristics. The study was approved by the University of Utah Review Committee for Research with Human Subjects after the investigator received written permission from the Directors of Nursing at the three hospitals to conduct the study with their nursing staffs. Setting and Population Three private hospitals in the northern part of the state of Utah were the clinical settings for the study. Hospitals A and C were located in Salt Lake City, while hospital B was located in Ogden. Hospital A is a 300 bed tertiary facility with a full complement of medical and surgical services. A 2S-bed intensive care wing is di­vided into medical and surgical intensive care units. The unit has full ECG monitoring capabilities and cardiac resuscitation equipment with relay screens and printoff 45 equipment in the nurses' station. It is spacious and has aesthetic modern decor. The unit is staffed with 60 full and part-time RNs and a number of LPNs to facilitate the delivery of intensive nursing care. All nurses periodi­cally rotate through both units. During the critical phase of a patient's illness, the nurse/patient ratio is 1:1; however, as the patient's condition stabilizes, the nurse/patient ratio becomes 1:2. Hospital C is a 306 bed tertiary facility which of­fers medical and surgical services comparable with hospi­tal A. The intensive care wing has 17 beds and is di­vided into medical and surgical units. Hospital C con­tains the same modern technological equipment and the pa­tient ratio is comparable to hospital A. The unit is staffed with 40 full and part-time RNs as well as a num­ber of LPNs. Both hospitals A and C draw on patients from the Salt Lake City area of about 750,000 population and from surrounding small towns and rural areas. Both facilities have a religious affiliation; hospital A is Catholic and Hospital C is Episcopalian. Hospital B is a 230 bed tertiary facility located in Ogden, utah. It offers a full complement of medical and surgical services, comparable to hospitals A and C. It has two 6-bed intensive care units; one is the coronary care unit and the other is the medical/surgical intensive 46 care unit. Nurse/patient ratios are similar to the other two facilities; the CCU having 18 full and part-time RNs plus a number of LPNs, and the ICU having 13 full and part-time RNs and several LPNs to complement the staffing. Hospital B is a Catholic hospital and draws patients from the Ogden area of about 500,000 people and from the surrounding small towns and rural areas. The units con­tain comparable modern technological and resuscitation equipment as found in hospitals A and C. The majority of patients from all three hospitals are from the middle and upper-middle class of society. Sample The sample consisted of 85 respondents: 34 (40%) from hospital Ai 22 (26%) from hospital B: and 29 (34%) from hospital C. To obtain a homogeneous sample, the study was limited to full and part-time ICU staff nurses. Intensive care staff nurses are specially trained in critical care management of patients, with emphasis on judgment, assessment skills and technological competence, in a highly stressful environment. ICU staff nurses include all of the nurses on the day, evening and night shifts who provide direct patient care in this setting. Head nurses, nurses practicing in expanded roles and LPNs were excluded from the study. It was the investigator's belief that the skill levels of the ICU staff nurses 47 studied were comparable, recognizing that all Ieu nurses are expected to possess a certain level of knowledge and technical expertise in order to function safely in an intensive care setting. The supervisory controls for the subjects were similar in that the nurses were accountable for a designated level of performance to their immediate supervisor, the Head Nurse. Table 1 lists the demographic characteristics of the sample. The subjects ranged in age from 23 to 59 years; however, 51% were age 30 or younger. Of the sample, 93% were female, 64% were married, 51% had a BSN degree, 79% had been an RN for 1 to 10 years, 48% had been employed as an RN for 4 months to 3 years, 45% had been in their current assignment for 28-72 months and 64% were employed full-time. According to Table 2, although the nurses studied ranged in age from 23 to 59 years, the mean age of the nurses was 32 while the median was 30 years, the mean number of years as an RN was 8, while the median was 6 years; the mean years of employment as an RN was 5 and the median 4 years and the mean number of months in current assignment was 38 while the median was 30 months. Operational Definitions of Variables The study variables were classified into four groups: demographic, job satisfaction, congruence and Table 1 Di~tribution by Number and Percent for Selected Demographic Characteristics of Sample Variables Age 23-24 25-30 31-35 36-40 41-50 51-59 Sex Female Male Marital Status Married Divorced Never Married Education Associate Degree Diploma B.S.N. Master's Nursing Years as RN 1-5 6-10 11-17 18-30 Years Employed as RN 4 months - 1 year 1.5 years - 3 years 4 years - 8 years 9 years - 30 years Months in Current Assignment 2 - 12 months 14 - 24 months 28 - 72 months 78 - 186 months Sample (N=85) N - % 5 6 38 45 25 29 10 12 5 6 2 2 79 93 6 7 54 64 11 13 20 23 18 21 19 22 43 51 5 6 32 38 35 41 12 14 6 7 17 20 24 28 32 38 12 14 20 20 37 8 23 23 45 9 48 Table 1 (Continued) Variables Present Employment Status Full-time Part-time Sample (N=85) N - % 54 64 31 36 49 50 Table 2 Means, Medians, Standard Deviations and Ranges for Select Characteristics of Sample - Sample (N=85) Variable X Median S.D. Range Age 32 30 6.58 23 - 59 Years as RN 8 6 5.69 1 - 30 Years employed as RN 5 4 4.68 .33 - 30 Months in current assignment 38 30 33.34 2 - 186 51 design_of performance appraisal system and frequency of feedback. Demographic Data Information regarding the subjects' age, sex, mari­tal status, RN education, number of years employed as an RN, current assignment in months and employment status either full or part-time was requested by the investiga­tor from each of the subjects in the study. This request for demographic information was titled "Section I" and was affixed to a Personal Satisfaction Inventory for each subject (see Appendix B). Job Satisfaction Data about job satisfaction were obtained by re­questing completion of the Personal Satisfaction Inven­tory by each of the subjects (see Appendix C). It was designated as "Section II" and was affixed to "Section I," the Demographic Data section. The purpose of the Personal Satisfaction Inventory was to determine the de­gree to which the nurses in the study were satisfied with the job itself (i.e., satisfaction with their abilities to be recognized and assume responsibility for the patient care they give and their satisfaction toward meeting their individual career goals. The Job Satisfaction score for each subject was obtained by ad­ding the scores given each response (question 1 through 52 41, omitting questions 12 and 13 because the significance of the response to these questions goes in the opposite direction from the responses of the other questions; then adding the responses to questions 12 and 13 and subtrac-ting that sum from the sum of the total of the other re-sponses). The highest score possible, indicating the highest level of job satisfaction, was 191. Congruence and Design of Performance Appraisal System A panel of six expert nurses was contracted with to compare the job descriptions of rcu staff nurses at the three hospitals with their respective performance evalua-tion instruments and determine the level of congruence between the two. Likewise, this panel analyzed the three job descriptions and evaluated the extent to which the job descriptions might act as motivators for the rcu staff nurses to increase their clinical skills and en-hance their professional growth. The panel of expert nurses was selected because it was the investigator's be-lief that nurses could best assess motivational forces for nurses. (See Data Collection Procedures Section for a description about how the panel was prepared to accomplish this task). 53 Freguency of Feedback Data about Frequency of Feedback were obtained by in­cluding a question on "Frequency of Feedback on Perform­ance" with the demographic information, section I that was affixed to a personal Satisfaction Inventory for each subject (see Appendix B). The subjects were asked to choose the appropriate response from the following choices: a) yearly, during my performance evaluation, b) two or three times a year; c) at least monthly; d) at least weekly; or e) at least daily. Job Satisfaction Instrument The Personal Satisfaction Inventory Instrument uti­lized and adapted for this study to measure the job sa­tisfaction of ICU staff nurse subjects, was designed by Dyer, Monson and Cope for use in a study published in Nursing Research (1975). The authors of the Personal Sa­tisfaction Inventory (PSI) developed the tool for use with four other instruments in their study entitled, "In­creasing the Quality of Patient Care through Performance Counseling and Written Goal Setting." Their study was completed in seven veterans Administration hospitals throughout the cbuntry. The Personal Satisfaction Inven­tory aims at determining satisfaction with: a) choice of nursing as a career; b) professional role and use of pro­fessional abilities; c) progress toward career goals, and d) quality of patient care given in the hospital (Dyer et 54 al., 1975). The original instrument allowed a choice of five re­sponses for each question: 1 representing liTo a great ex­tent" and 5 representing "Little if at all." In an in­terview with Dr. Dyer, Dean BYU College of Nursing, the investigator obtained Dr. Dyer's permission to transpose the responses from their original sequence to an as­cending order (i.e., with 1 representing "Little if at all" and 5 representing "To a great extent"). Permission was also obtained to add question #41 to the original in­strument to determine the relationship between the total PSI score and the nurse's overall job satisfaction. However, since a statistical correlation was not found, it was the recommendation of the investigator's statis­tician that the response to question #41 by subjects be added to their total PSI score to obtain the total job satisfaction score for each respondent. Validity of the Instrument Content validity of the original Personal Satisfac­tion Inventory (PSI) instrument was obtained by having the questions reviewed by 301 nurses and three measure­ment psychologists for clarity, specificity, completeness and indicators of job satisfaction (Refer to Dyer et al., 1975 for a complete description of how validity of the PSI was established). 55 Reliability of the Instrument - "Retest reliability after 4 to 6 weeks in seven hos-pitals ranged from .68 to .94. Subjects ranged from 6 to 35 nurses" (Dyer et al., 1975). In a personal interview, Dr. Dyer informed the investigator that although the range was from .68 to .94, most of the retest reliabili-ties were in the high .80s. Using the Cronbach coefficient alpha, reliability of the revised questionnaire utilized in this study was com-puted. The internal consistency reliability coefficient for the items contained in the Personal Satisfaction In-ventory instrument was .91 (see Appendix D). Data Collection Procedures Following written confirmation from the three Direc-tors of Nursing to the Chairman of the Review Committee for Research with Human Subjects, the investigator was given approval to conduct the study at the three hospi-tals. The investigator was requested to work through a liaison at each hospital, who, in each case, was the Head Nurse of the respective Intensive Care Unit. The investigator requested an invitation from each Head Nurse to attend a Staff Nurses' meeting to discuss the study, request participation from staff nurses and to disseminate individual packets containing the Informed Consent (Appendix A), the Demographic Questionnaire (Ap- 56 pendix B), the Personal Satisfaction Inventory instrument (Appendix C), and a self-addressed, stamped envelope for return of the completed questionnaire to the investiga­tor. The investigator was invited to attend staff nurses' meetings and disseminate the packets during the months of April and May, 1984. In the "Informed Consent," it was stated that par­ticipation was voluntary and responses would be kept con­fidential. Nurses were requested not to place their names on the Personal Satisfaction Inventory or Demo­graphic Questionnaires and were advised that the numbers on the Demographic Questionnaire and Personal Satisfac­tion Inventory were merely the numbers identifying a par­ticular hospital as one of the three in the study. The investigator was advised of the number of full­and part-time staff nurses on the ICU units, by the re­spective Head Nurses. Because of the numbers of staff nurses assigned, the investigator was advised to take 60 packets to hospital A, 31 to hospital Band 40 to hospi­tal C. Copies of a reminder letter dated May 28, 1984, 2 weeks after the last questionnaires were distributed in the final staff nurses' meeting, were taken by the inves­tigator to the respective ICU units. Head Nurses were requested by the investigator to make these reminder let­ters available to their staffs. In this letter, ICU 57 nurses who had not previously participated were again in­vited to participate and a cut-off date for return of questionnaires was listed as June 8, 1984 (see Appendix E). Of the 131 possible respondents, 85 questionnaires were returned, which is a 65% response rate. In July 1984, the expert panel convened at the re­quest of the investigator. Instruction was given the six panel members by the investigator to prepare them for the task of evaluating the job description/performance evaluation instrument at each hospital for congruence; and for evaluating each job description for its ability to act as a motivator for nurses to increase their clini­cal skills and enhance their professional growth. The instruction given the expert panel was on "Moti­vation and Management," from Motivational Dynamics, Part I, block 3 (see Appendix F for instructional outline). The objective of the instruction was to have the six ex­pert nurses develop a common theoretical framework con­cerning Herzberg's "Two Factor Theory" and its relation­ship to Maslow's "Hierarchy of Human Needs" theory. Fol­lowing the motivational Dynamics format, exercises were given in which the six nurses participated. Increased understanding of the principles was evidenced by the panel members with each continued exercise. At the conclusion of the instruction, each member of the panel members were given a copy of the three hospi- 58 tals' job descriptions and respective performance evalua­tion instruments. The names identifying the respective hospitals were omitted to prevent the possibility of bias by the panel members. The panel was given instruction for completing their task that will be described in Chap­ter III. CHAPTER III ANALYSIS OF DATA AND DISCUSSION OF FINDINGS This thesis addressed specific research questions about job satisfaction so as to broaden the knowledge base in the area of nursing administration. The specific purpose of the study was to explore and describe the relationship between ICU staff nurses' job satisfaction and the variables: a) congruence and design of performance appraisal systems; b) frequency of feedback; and c) selected demographic data. The first research question asked was: Are the job descriptions for ICU staff nurses congruent with the performance evaluation instruments used in the hospitals studied? To address this question, a panel of expert nurses, des-cribed in Chapter II, was employed. These six nurses were considered to be expert because of their recent exposure to administrative and management principles through aca-demia and/or experience. Job descriptions and perform-ance evaluation instruments for the ICU staff nurses at the three hospitals in the study had been obtained from the Directors of Nursing by the investigator. Following 60 instruction of the panel members, as described in Chapter II, they were asked to rate the job descriptions/per­formance evaluation instruments as most congruent, mod­erately congruent and least congruent. On the first evaluation, the panel members independently reached 100% consensus that Hospital B's appraisal system was the most congruent, Hospital Cas moderately congruent and Hospital A's least congruent. The design of Hospital B's job description/perform­ance evaluation instrument was the major factor that was found by the expert panel to influence the level of con­gruence between the two. The job description and per-' formance evaluation instrument was one document (see Ap­pendix G). The behaviors or expected standards were des­cribed on the left side of every page and the evaluation of each performance standard was on the right. For Hos­pital Bls performance appraisal system, there were no hidden agendas. The system was straightforward and found to be totally congruent. Hospital C's job description/performance evaluation instrument was found to be congruent in most areas assessed because the personal and performance factors were defined and became the basis on which performance evaluations were completed for the nurses. Additional requirements/expectations of an ICU nurse were also defined and became the basis for evaluating the nurse's 61 performance in meeting expected standards in the leu setting. Hospital els evaluation instrument, however, contained an element defined as "Specific Job Factors." Although it was assumed by the expert panel that this element referred to the clinical, educational, administrative and research expectations, this element was unclear and affected the congruence of the job description/performance evaluation instrument (see Appendix H). Hospital A's job description/performance evaluation instrument was found to be the least congruent because although the expectations/standards of the job were clearly defined in the job description, the evaluation tool was not designed to specifically measure those defined standards. Hospital A's evaluation instrument was found by the expert panel to be a generic design measuring such elements as clinical performance, judgment, adaptability, leadership, organizational skill, etc., instead of measuring standards defined in the job description such as assessment skill, planning, implementation, teaching, etc. (see Appendix I). The second research question asked was: Do the job descriptions in the hospitals allow opportunities for the nurses to meet their professional growth needs (i.e., do the job descriptions contain motivators)? To address this question, the same expert panel was 62 utilized. The panel members were requested to examine each of the three hospitals' job descriptions and list the motivators and hygiene factors inherent in each. The instruction previously provided the panel members by the investigator became the reference for clarifying issues and questions posed in accomplishing this assigned task. However, since the panel found that each of the three job descriptions was based on the nursing process, which was believed to be a motivational influence, the answer to this question was considerably more difficult to derive than Research Question one. When the investigator determined that the instruc­tions were clear, further discussion was deferred to al­low panel members independence in rating the job descrip­tions based on the number of motivators and hygiene fac­tors found in each hospital's job description. At the conclusion of the first independent evaluation, there was 66% agreement that Hospital B's job description contained more motivators; while 34% found more motivators in the job description of Hospital C. All members found Hospi­tal A's job description to have the least amount of moti­vators because it lacked standards involving research. Following this first evaluation, discussion was en­couraged by the investigator to allow panel members to defend their independent decisions, thus provide clarity and increased understanding to other panel members. Fol- 63 lowing a lengthy discussion, the investigator requested a second independent evaluation, asking panel members to rank the three job descriptions in order of their motiva­tional influence. At the conclusion of this effort, the investigator tallied the results. There was 83% agree­ment by the panel that Hospital Bls job description con­tained the most motivators while 17% identified more mo­tivators in the job description of Hospital C. The 83% who found more motivators in Hospital Bls job description argued that the personal factors contained in Hospital CiS job description (e.g., attendance, punctuality, ap­pearance, dependability, etc.), diluted its motivation~l influence even though more motivators were found in the areas of clinical, education, administrative and research than in Hospital Bls job description. The panel members comprising the 83% further stated that personality char­acteristics should be excluded from performance appraisal systems and dealt with through the mechanism of coun­seling so that these characteristics do not ultimately influence the supervisor's perception of performance, and the 17% agreed. Therefore, on the third and final vote, 100% consensus was reached that Hospital Bls job descrip­tion was based primarily on motivators, Hospital C's was second, and Hospital A's was designed with the least num­ber of motivators. At the conclusion of the expert panel's assignment, 64 Research Questions 1 and 2 had been addressed. The panel had reached consensus that Hospital B's job descrip-tion/ performance evaluation instrument was the most con-gruent and Hospital B's job description contained the most motivators; Hospital e's performance appraisal sys-tern was mostly congruent and the job description was judged to be second in its ability to act as a motiva-tional influence; and Hospital A's performance appraisal system was rated the least congruent and its job descrip-tion was found to contain the least number of motivators. The need to provide a numerical value to the above findings, in order to statistically compare the variable congruence and design of performance appraisal systems with Ieu staff nurse job satisfaction scores, was ap-parent. Therefore, the investigator consulted a statis-tician. Upon the recommendation of the statistician, Hospital B was arbitrarily assigned a "5" on a Likert scale for the variable congruence and design of perform-ance appraisal systems, Hospital e was assigned a "3" and Hospital A was assigned a "1". The third research question asked was: What is the relationship between Ieu staff nurses' job satisfaction as measured by the Personal Satisfaction Inventory instrument and the performance appraisal system used in the institution? To answer this question a correlational analysis was used. The research question was nondirectional and 65 therefore a E~.05 was required using a two-tailed test of significance. To determine if there was a relationship between staff nurse job satisfaction scores from the Personal Satisfaction Inventory instruments and performance appraisal systems, Pearson product moment correlation coefficients (Pearson E) were obtained for nurse satisfaction scores and the variables congruence/design of performance appraisal systems and frequency of feedback. The Pearson r statistic was used because as a decriptive statistic, it summarizes the magnitude and direction of a relationship between two variables (Polit & Hungler, 1983). According to Table 3, no significant relationship was found between job satisfaction and congruence/design of performance appraisal systems (r=-.02). As Table 4 illustrates, there was little variance in the mean job satisfaction scores of the three hospitals: Hospital B, judged to have the most congruent performance appraisal system, had a mean job satisfaction score of 125 as did Hospital A, which was judged to be the least congruent; while Hospital C, which was judged to be mostly congruent, had the highest mean job satisfaction score of 128. This small degree of variance between the job satisfaction scores of the three hospitals is one explanation for why a significant relationship was not found between the variables job satisfaction and congruence and design of Table 3 Correlation Coefficients Between Job Satisfaction Scores and Selected Study Variables Job Satisfaction Variable Congruence/Design Frequency of Feedback Note. ***E~.OOl. Table 4 Correlation -.02 .65*** A Comparison of the Three Hospitals' Mean Job Satisfaction Score with Congruence/Design 66 Congruence/Design Mean Job Satisfaction Score Most congruent (Hospital B) 125 Moderately (Hospital C) 128 Least (Hospital A) 125 67 performance appraisal systems. At the onset of this study, it was assumed that the Personal Satisfaction Inventory instrument would be an effective tool for measuring the leu staff nurses' job satisfaction. It was further assumed that differences in nurse job satisfaction would be found among the three hospitals. With the small amount of variance actually found in the mean job satisfaction scores of the three hospitals, it is possible that the Personal Satisfaction Inventory instrument was not as discriminate as the au­thor of this thesis had hoped it would be. It is like­wise possible that in an effort to select a homogeneous sample, that the hospitals were similar even to the level of job satisfaction identified by the leU staff nurses in the three hospitals. An additional explanation for this finding is in­herent in the process used by the investigator to obtain the variable congruence/design of performance appraisal systems. Without a valid and reliable instrument for use by the panel members to identify both congruence of job descriptions/performance evaluation instruments and to identify specific motivators in the individual hospitals' job descriptions, the subjective evaluation by the panel members was arbitrarily discriminate and may have affec­ted the study results. The mean job satisfaction scores of the three hospi- 68 tals,however, indicate that the respondents were more sa­tisfied than less satisfied. The highest score possible was 191; therefore any score above 95.5 indicates job sa­tisfaction in a positive direction. Likewise, the mean job satisfaction scores indicate that the respondents from Hospital C were 67% satisfied with the patient care they deliver and with their progress toward attaining in­dividual career goals, while Hospitals A and B were 65% satisfied. Because only a small degree of variance was found between the mean job satisfaction scores of the three hospitals, additional statistical analysis was employed to determine if significant differences existed in the way respondents from each hospital answered individual questions on the Personal Satisfaction Inventory instrument. To obtain this information, a Kruskal-Wallis one-way analysis of variance was utilized. This is a nonparametric test that examines medians rather than means and reports the sum of the rank scores of the ordinal data examined. The analysis of variance obtained is similar to a chi-square (Hull & Nie, 1981). In utilizing the Kruskal-Wallis test, the various hospitals' responses to six questions on the Personal Satisfaction Inventory were found to be significant at the .01 - .05 level. These questions were 12, 16, 21, 29, 35 and 37. 69 Question #12 on the Personal Satisfaction Inventory was one of the two questions in which the direction indi-eating a higher level of job satisfction was reversed from the other questions. Question #12 asks: Do you perform many tasks on your job which you consider relatively unimportant or unnecessary? Hospital C, which had the highest mean job satisfaction score, received a sum rank score of 34.33, while Hospi-tal Bls sum rank score was 43.70, and Hospital Als was 49.94. Sixty-six percent of Hospital CiS respondents an-swered to a limited extent they performed many tasks which they considered relatively unimportant or unnece~- sary; while 50% of Hospital Bls respondents answered either to a moderate or considerable extent; and 56% of Hospital A's respondents likewise answered to a moderate or considerable extent. Question #16 on the Personal Satisfaction Inventory instrument asks: Are you free to adapt your working hours to meet patient care needs? Forty-eight percent of Hospital C's respondents replied that to a considerable extent they were free to adapt working hours to meet patient care needs; while 59% of Hospital B's respondents answered little if at all or to a limited extent; and 65% of Hospital A's respondents similarly responded little if at all or to a limited extent. The sum rank scores for this question were: 70 Hospital C = 52.29; Hospital B = 37.57; and Hospital A = 38.59. Question #21 asks: Does your supervisor expect you to make a significant contribution in the nursing profession? The sum rank scores for this question were: Hospital C = 40.71; Hospital B = 49.26; and Hospital A = 33.34. In answering this question, 50% of the respondents from Hospital B answered to a considerable extent and 35% from Hospital C answered the same way. Only 24% of Hospital A's respondents answered to a considerable extent; while 57% from Hospital A responded to a limited or moderate extent. Question #29 asks: Are you well-prepared for nursing in comparison with nurses having similar educational preparation? The reported sum rank scores for this question were: Hospital C = 40.31; Hospital B = 33.32; and Hospital A = 51.56. In examining the responses from each hospital, 91% of the respondents from Hospital A answered to a considerable or great extent; 76% from Hospital C and 64% from Hospital B. Question #35 asks: How satisfied are you with your career choice to be a nurse? The sum rank scores for this question were: Hospital C = 48.50: Hospital B = 48.41; and Hospital A = 33.29. The 71 respondents from both Hospitals Band C were more satis-fied with their career choice than the respondents from Hospital A. Seventy-nine percent of the respondents from Hospital C answered either satisfied, but would also be happy working in another career, or completely satisfied, would make the same choice again, and 77% of the re-spondents from Hospital B responded similarly; while only 56% from Hospital A responded in this way. Question #37 asks: Because of the manner in which your supervisor discusses your work performance with you, which of the following most nearly describes your . reaction to the discussions? The sum rank scores for this question were: Hospital C = 48.94; Hospital B = 43.02; and Hospital A = 34.39. In answering this question, 52% of the respondents from Hos-pital C answered "Encouraged," and 17% answered "Stimu-lated and eager to improve;" while 41% from Hospital B responded "Encouraged," and 18% "Stimulated and eager to improve." Only 35% of the respondents from Hospital A answered "Encouraged," and 6% answered "Stimulated and eager to improve." Table 5 more clearly depicts the chi-square statistic, significance, sum rank scores and per-centage of numerical responses to these significant six questions. It is interesting to note that Hospital C, which had the highest mean job satisfaction score, had a signifi- Question No. 12 16 21 29 35 Table 5 Significant Data from Kruskal-Wallis One-Way Analysis of Variance Question Significance Ch square You perform many tasks .03* 6.91 on your job which you consider relatively un-important or unnecessary. Are you free to adapt .04* 6.68 your working hours to meet patient care needs? Does your supervisor .04* 6.62 expect you to make a significant contribution in the nursing profession? You are well-prepared for .01** 8.98 nursing in comparison with nurses having similar educational preparation. How satisfied are you with .01** 8.57 your career choice to be a nurse? Sum of the Rank Scores by Hospital A = 49.94 B = 43.70 C = 34.33 A = 38.59 B = 37.57 C = 52.29 A = 33.34 B = 49.26 C = 40.71 A = 51.56 B = 33.32 C = 40.31 A = 33.29 B = 48.41 C = 48.50 % by Hospital Numerical Response 27% responded 2 27% responded 2 66% responded 2 12% responded 4 14% responded 4 48% responded 4 24% responded 4 50% responded 4 35% responded 4 91% responded 4/5 64% responded 4/5 76% responded 4/5 56% responded 4/5 77% responded 4/5 79% responded 4/5 .......,J tv Question No. 37 Table 5 (Continued) Question Significance Chi-square Because of the manner in .04* 6.49 which your supervisor dis-cusses your work performance with you, which of the following most nearly describes your reaction to the discussions? Note. *Significant .05 level; **Significant .01 level. Sum of the Rank Scores by Hospital A = 34.39 B = 43.02 C = 48.94 % by Hospital Numerical Response 35% responded 4 6% responded 5 41% responded 4 18% responded 5 52% responded 4 17% responded 5 -...J W 74 cantly Ipwer sum rank score on question 12 than the other two hospitals~ had a significantly higher score on ques­tion 16~ had a slightly higher score than Hospital Band a significantly higher score than Hospital A on question 35; and had a significantly higher sum rank score on question 37, with 69% of the respondents being either en­couraged or stimulated and eager to improve their per­formance because of the manner in which their supervisor discussed their work performance with them. It is also interesting to note that the leU staff nurses from Hospital A, with a mean job satisfaction score of 125 equal to that of Hospital B, perceived them­selves as being well-prepared for nursing in comparison with nurses having similar educational preparation. This factor is evidenced by the responses to question 29 in which 91% of the nurses from Hospital A responded either "to a considerable extent" or "to a great extent" as com­pared to Hospital B with 64% and Hospital C with 76%. According to Table 3, a significant relationship was found between job satisfaction scores and frequency of feedback. Nurses who received frequent feedback on performance and/or professional growth by their super­visors had significantly higher job satisfaction scores (£=.47), than those who did not. The results of this study support the conclusions of Walther and Taylor (1983) who found that "feedback on performance is essen- 75 tial in maintaining the job satisfaction of women in technical occupations." The supervisor can create a working environment conducive to improved job performance through the use of effective feedback. The payoff for the supervisor is predictable in that the time invested in feedback will have a positive effect on the employee's job satisfaction, performance and organizational commit­ment. Effective feedback serves three important functions: a) it relieves productive employees from wor­rying needlessly about their job performance and the se­curity associated with satisfactory performance; b) it helps marginal employees to improve their performance to specified standards; and c) it provides systematic docu­mentation in case of dismissal (Walther & Taylor, 1983). Thus, it is not surprising that in this study, fre­quency of feedback was the major variable in predicting Ieu staff nurse job satisfaction. Many organizations have experienced significant increases in employee pro­ductivity and job satisfaction through utilization of a performance improvement system that keeps employees in­formed of their performance in relationship to specified job standards, and rewards them for excellence in per­formance (Feeney, 1982-1983). As Godfrey et al. (1978) discovered from the re­sponses obtained from 17,000 nurses, feedback leads to job satisfaction. The nuress identified several factors leading to job satisfaction among them being immediate supervisors' feedback, patients' feedback and nursing administration's and hospital manage­ment's feedback. The fact that feedback is an im­portant factor in nurse job satisfaction is typified in the study, Magnet Hospitals (McClure et al., 1983). Nurses remained in those hospitals that em­phasized open communication and frequent feedback. The nurses likewise demonstrated a high level of com­mitment and loyalty to the institutions resulting in quality patient care delivery. 76 The importance of feedback cannot be overestimated. The feedback process in which information is given on the consequences of certain actions is central to any human relationship in which learning is desired or necessary. Likewise, in order for anyone to improve performance, please another, or change self-defeating behavior, it is necessary to be aware of the impact one may be having on another (Cohen, Fink, Gadon & Willits, 1980). Feedback, both formal and informal, can be the motivational influence leading to nurse job satisfaction. Feedback can be the driving force for nurses to increase knowledge, to develop individuality, understanding and creativity, and to attain professional growth. Feedback can also take the form of the recognition given nurses leading them to professional achievement, increased 77 responsibility and ultimate professional advancement • . Results from this study also suggest that frequent feedback can serve as a buffer between incongruent job descriptions/performance evaluation instruments and job satisfaction. Because this study only looked at fre-quency of feedback, further research is needed, however, to investigate feedback in terms of content, its actual motivating influence, timing and the supervisory skills essential to providing quality feedback. The fourth research question asked was: What is the relationship between leU staff nurses' job satisfaction and the demographic variables? To answer this question, a correlational analysis was used. The research question was nondirectional and therefore a £~.05 was required using a two-tailed test of significance. Pearson product moment correlation coefficients were obtained for nurse satisfaction scores and the demographic variables identified. According to Table 6, marital status was the only demographic variable that correlated significantly with job satisfaction. However, as Table 6 further illustrates, several study variables were intercorrelated and therefore, a regres-sion analysis using step-wise procedures was used to de-termine the contribution of each study variable to the variance of nurse job satisfaction. The step-wise proce-dure selected the set of variables which best predicted 78 Table 6 . Correlation Matrix for Study Variables Age Sex Marital status Education Years as RN Years Employed Feedback Sex M.S. -.05 -.15 -.14 study Variables Ed. Yrs. RN Yrs. Emp • F.F. Job Sat. .15 • 64*** .45*** -.15 -.14 .06 -.17 -.19* -.06 -.10 .05 .06 .04 .70 .46*** .13 .15 .02 .19* -.05 -.29***-.01 -.35***-.08 Frequency .47*** Note. M.S. = Marital Status; Ed. = Education; Yrs. R.N. = Years since graduation as an RN; Yrs. Emp. = Years employed as an RN; F.F. = Frequency of Feedback; Job Sat. = Job Satisfaction. 79 nurse job satisfaction while eliminating those that were superfluous. It is important to note, however, that the purpose of the study was not to be able to predict job satisfaction, but rather to examine relationships between job satisfaction, congruence/design of performance ap­praisal systems, feedback and selected demographic vari­ables, in an effort to formulate hypotheses to guide fu­ture research, once a significant relationship had been found and reliable and valid tools for measuring vari­ables had been developed. In the regression equation, the optimal predictor set was defined as the combination of variables that predicted nurse job satisfaction with the minimum standard error of the estimate. Categorical variables were entered in the regression equation as dichotomous dummy variables. By arbitrarily assigning metric values to each category of a given variable, dummy variables allow data to be treated as interval data and entered in­to the regression equation. According to Nie, Hull, Jen­kins, Steinbrenner and Bent (1975), multiple correlation from dummy regression is equivalent to conventional eta (correlation ratio) and can be interpreted as a measure of strength of association between Y and the categorical variable. Recordings of the categorical variables used in the regression analysis are listed in Table 7. According to Table 8, using the regression analysis Table 7 Recordings for Categorical Variables Used in Correlation and Regression Analysis Procedures Category Original Variable Recorded Variable for Analysis Demographic V5 = Sex Sex = (1 = Female 2 = Male) V6 = Marital Status M S = (1 = Married 2 = Divorced 3 = Separated 4 = Widowed 5 = Never Married) V7 = RN Education ED = (1 = Associate Degree 2 = Diploma 3 = B.S.N. 4 = Masters not in Nursing 5 = Masters in Nursing 6 = ph.D.) VII = Employment (1 = Part-time Status 2 = Full-time) V12 = Feedback Frequency (1 = Yearly 2 = 2-3/ Year 3 = Monthly 4 = Weekly 5 = Daily) co 0 Table 8 step-wise Multiple Regression Analyses for Dependent Variable Nurse Job satisfaction Score with Independent study Variables Independent Increase Step Variable R2 SE Number Entered R R2 Adjusted Adjusted Estimate Beta F 1 Feedback .47 .22 .22 16.60 .65 26.17*** 2 3 4 5 6 7 8 Note. Frequency Marital Status .54 Sex .56 Years Employment .57 Since Graduation as RN Age .60 Years Employed as .61 RN Employment Status .63 Education .63 .29 .31 .33 .36 .38 .39 .39 .07 .03 .01 .03 .02 .01 .00 16.01 -.33 9.05* 15.83 -.19 2.45* 15.78 .09 .28 15.53 -.29 3.98* 15.42 .22 1.76 15.38 .12 1.22 15.47 -.06 .33 The dashed line appearing after step 7 indicates an increase in the standard error of the estimate negating any explained variance. *£< .05; **£< .001. co I--' 82 procedure, feedback frequency and marital status signifi-cantly predicted nurse job satisfaction, accounting for 29% of the explained variance. The amount of increase in 2 R after marital status was entered in the equation was small (.03); even though the "F" ratios of the beta weights for the demographic variables sex and age achieved significance (E~.05). (Beta weights are the standardized regression weights for the independent variables [Polit & Hungler, 1983]). While the variables sex and age were found to be significant predictors of job satisfaction, their amount of explained variance was miniscule, accounting for only 6%. Also, since a random sampling technique was not employed, the sample was skewed in both the variables sex and age; 93% of the sam-pIe being female and 51% being age 30 or younger. This skewed, nonrandom sample is a likely explanation for why the variables sex and age achieved beta weight signifi-cance, but will not be addressed because a significant correlation was not found between these variables and job satisfaction (See Table 6). The two variables therefore found to be significant predictors of job satisfaction and that correlated significantly with job satisfaction were frequency of feedback and marital status. Nursing studies described earlier (Godfrey et al., 1978; McClure et al., 1983) support the conclusion that frequency of feedback is a strong predictor of nurse job 83 satisfation. However, no studies were found in the lit­erature to support the finding that married nurses are more satisfied with their jobs than are single nurses. The literature is also inconclusive in supporting the hy­pothesis that married women in the work force are more satisfied than single women. A number of studies, how­ever, have demonstrated a significant relationship between job satisfaction and life satisfaction (Haavio-Mannila, 1971: Gannon & Hendrickson, 1973: Sell, Brief & Aldag, 1979; Wright, 1978). other studies aimed at examining the psychological well-being of married women in the job force versus married women unemployed, have found that work can reduce the effect of some marital stressors and reduce the symptoms of depression that are heightened among housewives (Brown & Harris, 1978: Gove & Tudor, 1973: Kessler & McRae, 1982: Krause, 1984). Another possible explanation for this finding is that married nurses may not have an economic basis for their employment. They may be working because of a pro­fessional desire, while among single nurses, economics would be a primary reason for employment. Still another explanation for this finding is that a central and pre­vailing theme among the population in utah is "the impor­tance of the family." It is possible that this theme af­fects life satisfaction that has been demonstrated to be significantly related to job satisfaction. In any event, 84 further research is needed exploring married versus non­married nurses' job satisfaction in different settings within this geographic location, before any definitive conclusions can be drawn. In discussing the findings, it is important to note that this study was not without its limitations. Some of these limitations may have affected the study results, so will be addressed. In examining the job descriptions of the three hos­pitals in the study for their motivational influence, the expert panel determined that each was based on the nursing process, which had become a standard of the Joint Commission on Accreditation for Hospitals in 1980. Im­plementation of the nursing process was considered to be a motivational force by the expert panel, because the steps in the nursing process are based on nurses' con­tinuing growth needs. The significant differences in job descriptions, therefore, as identified by the panel, were the additional behaviors or personal factors contained in the job descriptions. Since an objective measurement in­strument had not been developed for use by the panel, the subjective evaluation for determining the variable, con­gruence and design of performance appraisal systems, was arbitrarily discriminate and may have affected the study results. An instrument that could have objectively measured the three hospitals' job description/performance 85 evaluation instrument for congruence and motivational de­sign, would have been a more reliable and valid as­sessment. Another limitation involved the fact that the vari­able frequency of feedback was the respondent's subjec­tive appraisal but not a direct measurement of the quali­ty, motivational influence, or amount of feedback actual­ly received from the respondent's supervisor. Likewise, the question asked on the questionnaire to obtain this variable did not take into account the supervisor's in­terpersonal skill in providing feedback to the respondent: therefore these variances were uncontrolled. Specific questions involving the supervisor's inter­personal skill and the motivational influence of the feedback received may have enhanced the study. To be assured of an adequate sample size, all re­spondent questionnaires were utilized in the study, ra­ther than employing a random sampling technique. Also, having to leave questionnaires for those staff nurses unable to attend staff nurses' meetings was considered to be a limitation of the study. Because income was not a study variable, it is im­possible to know whether the married nurses were employed due to economics or as a career choice; therefore a ques­tion related to income may have been valuable in discus­sing the study results. 86 Finally, the study was initiated and completed during a time of economic strain for private hospitals within the northern part of the State of utah. It is im­possible to predict how unidentified extraneous variables surrounding job security may have impacted the study re­sults. CHAPTER IV SUMMARY AND IMPLICATIONS This study explored Intensive Care staff nurses' job satisfaction in relationship to congruence and design of performance appraisal systems, feedback, and selected demographic variables. Although nurses have been a tar­get population for job satisfaction studies within the health field, this study aimed specifically at deter­mining the degree to which the nurses studied were satis­fied with the job itself (i.e., satisfaction with their abilities to be recognized and assume responsibility for the patient care they provide and their satisfaction with progress toward meeting their individual career goals). In reviewing the literature it became apparent that the work itself is a vital component in affecting nurses' job satisfaction. Herzberg et al. redirected the focus of job satisfaction studies in 1959 as a result of 'their publication The Motivation to Work. They emphasized vertical rather than horizontal job enlargement, claiming that satisfaction can be attained through growth in skill, efficiency and responsibility, which is possible through mentally challenging work. Herzberg (1968) iden- 88 tified and described a Dual-Factor Theory in which he ar­gued that job satisfaction and dissatisfaction are the result of two separate and different causes; satisfaction is dependent on motivators while dissatisfaction is the result of hygiene factors. Motivators include work it­self, achievement, recognition, responsibility and the opportunity for growth and advancement. Hygiene factors, although they do not motivate, can prevent the develop­ment of negative feelings and dissatisfaction. These hy­giene factors he identified as supervision, company poli­cies and administration, working conditions, interper­sonal relationships, job security and pay. other studies supported various aspects of Herzberg's findings. Turner and Lawrence (1965) found that responsibility for work outcomes is an important mo­tivational influence; Hackman and Lawler (1971) found that a positive relationship exists between: a) the op­portunity for independent thought and action in the job; b) the feeling of worthwhile accomplishment in the job; c) the opportunity for personal growth and development in the job; and d) the self-esteem and self-respect a person gets from being on the job, and the variables motivation, satisfaction, performance and attendance. Weitz (1952) demonstrated that prior knowledge and understanding of the role requirements on a job were significant factors in job satisfaction and retention. 89 Other studies obtained similar conclusions: Macedonia (1959),. Youngberg (1963), and Lyons (1971). Godfrey et ale (1978) reported the responses ob­tained from 17,000 nurses to the Probe Questionnaire on Job Satisfaction published in the September issue of Nursing 22. In addition to major dissatisfactions, the nurse respondents identified several factors leading to job satisfaction. These factors are: prestige and recognition; work itself; well-defined job descrip­tions; feedback from immediate supervisors, patients, nursing administration and hospital management and in­volvement in the planning and decision making of the, institution. In a recent nursing study on job satisfaction, Mag­net Hospitals (1983), specific factors contributing to nurse retention was the focus. Among the factors identi­fied by staff nurses as contributing to their job satis­faction and retention were educational programs that al­low for professional growth and recognition as indi­viduals; open communication and the opportunity for in­volvement in decision making; and support in patient care delivery as well as support through feedback aimed at recognizing achievements, and increasing staff nurse re­sponsibility (McClure et al., 1983). Since job enrichment, as defined by Herzberg (1969), is a continuous process, performance appraisal of the 90 individual nurse's performance should also be a con­tinuous process. South (1978) suggests that the emphasis in nurse performance appraisals should be from evaluation to development. Council and Plachy (1980) suggest that performance planning and appraisal should be a coopera­tive venture between supervisor and employee, based on a genuine concern for one another's success. Lovrich et al. (1981) developed a participative performance ap­praisal system for use not only for the traditional mechanism of evaluation of employee performance but also as a tool for individual goal setting and growth in career development. Lerch (1982) states that the objec­tives of a performance appraisal system are to serve as a clear and effective tool in measuring current performance and in developing future performance. Feeney (1982-83) offers a systemized performance improvement approach that uses principles of behavior modification to provide a system of feedback and reward to effect positive changes in human behavior. Ginsburg (1983) states that American values are changing and management must be aware and supportive of them. He identified these values as: a) individuals value a clear understanding of their roles and the degree of authority they are given to perform their duties; b) individuals value the opportunity to participate in the negotiation of the performance expectations of their 91 roles; c) individuals value the encouragement to utilize their skills and creative potentials; d) individuals value the respect, trust and confidence of their managers; e) individuals value a regular and constant flow of information; f) individuals value timely and honest feedback and a reward system that recognizes accomplishment in an objective and understood manner; and g) individuals value a development program that prepares them adequately to perform their responsibilities. Based on the research and scholarly activity in the area of job satisfaction over the years, as reflected in the review of the literature and especially based on the contributions of Herzberg, the focus of this study was on reu staff nurse job satisfaction in relationship to per­formance appraisal systems. The conceptual model used in this study is a systems model (see Figure 1). The input represents a clearly defined job description based on mo­tivators, which are opportunities for nurses to attain professional growth and advancement. The throughput rep­resents the frequent feedback provided the nurses by their respective supervisors to improve their performance and enhance their professional growth. The output repre­sents the performance ,evaluation instrument used to measure the nurses' performance. The "fit" between the job description and performance evaluation instrument represents a congruent performance appraisal system. 92 This system leads to staff nurse job satisfaction that leads to retention of qualified nurses to insure quality patient care delivery, which is the goal of nursing ad­ministration. Three private hospitals in the northern part of the state of utah were the clinical settings for the study. Hospitals A and C were located in Salt Lake City, while Hospital B was located in Ogden. To obtain a homogeneous group, Intensive Care Nurses at the three hospitals were studied. The sample consisted of 85 respondents: 34 (40% from Hospital A; 22 (26%) from Hospital B; and 29 (34%) from Hospital C. The sample subjects ranged in age from 23 to 59 years of age; however, 51% were age 30 or younger. Of the sample, 93% were female, 64% were mar­ried, 51% had a BSN degree, 79% had been graduated as an RN for 1 - 10 years, 48% had been employed as an RN for 4 months to 3 years, 45% had been in their current as­signment for 28 - 72 months and 64% were employed full­time. Data about job satisfaction were obtained by re­questing completion of a Personal Satisfaction Inventory by each of the subjects. This instrument was designed by Dyer et al. for use in a study published in Nursing Re­search (1975). The Personal Satisfaction Inventory aims at determining satisfaction with: a) choice of nursing as a career; b) professional role and use of professional 93 abilities; c) progress toward career goals; and d) quali­ty of patient care given in the hospital. Content validity of the Personal Satisfaction Inventory instru­ment was obtained by having the questions reviewed by 301 nurses and three measurement psychologists for clarity, specificity, completeness and indicators of job satisfaction (Dyer et al., 1975). Retest reliabilities of the instrument ranged from .68 to .94 after 4 to 6 weeks in seven hospitals (Dyer et al., 1975). Demographic data were requested by each of the respondents as well as the response to a question concerning frequency of feedback. The research questions addressed in this study were: 1. Are the job descriptions for Intensive Care Unit staff nurses congruent with the performance evaluation instruments used in the hospitals studied? 2. Do the job descriptions in the hospitals allow opportunities for the nurses to meet their professional growth needs (i.e., do the job descriptions contain motivators)? 3. What is the relationship between ICU staff nurses' job satisfaction as measured by the Personal Satisfaction Inventory instrument and the performance appraisal system used in the institution? 4. What is the relationship between leU staff 94 nurses' job satisfaction and the demographic variables? To address research questions 1 and 2, a panel of expert nurses was employed. These six nurses were con­sidered to be expert because of their recent exposure to administrative and management principles through academia and/or experience. Job descriptions and performance evaluation instruments for the leu staff nurses at the three hospitals in the study had been obtained from the Directors of Nursing by the investigator. Instruction was given the panel members by the investigator to pre­pare the six nurses, comprising the expert panel, for the task of evaluating the job description/performance evaluation instrument at each hospital for congruence and for evaluating each job description for its ability to act as a motivator for nurses to increase their clinical skills and enhance their professional growth. The instruction given the expert panel was on "Moti­vation and Management," from Motivational Dynamics, Part I, block 3 (see Appendix F). The objective of the in­struction was to have the six expert nurses develop a common theoretical framework concerning Herzberg's "Two Factor Theory" and its relationship to Maslow's "Hier­archy of Human Needs" theory. Following the Motivational Dynamics format, exercises were given in which the six nurses participated. Increased understanding of the principles were evidenced by the panel members with each 95 continued exercise. At the conclusion of the instruction, each member of the panel was given a copy of the three hospitals' job descriptions and respective performance evaluation in­struments. The names identifying the respective hospi­tals had been omitted during the copying to prevent the possibility of bias by the panel members. The six panel members were asked to rate the job descriptions/performance evaluation instruments as most congruent, moderately congruent and least congruent. On the first evaluation, the panel members independently reached 100% consensus that Hospital B's appraisal system was the most congruent, Hospital CiS was moderately con­gruent and Hospital A's was the least congruent. To obtain the variable "Design of Job Description," the panel members were assigned the task of examining each of the three job descriptions and listing the motivators and hygiene factors inherent in each. At the conclusion of the first independent evaluation, there was 66% agreement that Hospital B's job description was based primarily on motivators; while 34% felt that Hospital CiS was a more motivating tool. A lengthy discussion ensued whereby the panel members verbalized defense of their independent decisions. The investigator requested a second independent evaluation and on this count 83% agreed that Hospital B's job description contained more 96 motivatqrs while 17% identified more motivators in the job description of Hospital C. There was additional discussion followed by a final evaluation. On the third vote, there was 100% consensus that Hospital B's job description was based primarily on motivators, Hospital CiS was a close second and Hospital A's was the least designed as a motivational influence. Since consensus had been reached by the panel that Hospital B's job description/performance evaluation in­strument was the most congruent and Hospital B'S job des­cription was the most motivational in its design, Hospi­tal B was arbitrarily assigned a "5" on a Likert scale for the variable, Congruence and Design of Performance Appraisal Systems. Hospital C had been found to be mod­erately congruent and second in motivational design, so was assigned a "3" on the scale: and Hospital A, which had been found to be the least congruent and least based on motivational design, was arbitrarily assigned a "1" for this variable, for the purpose of statistical analy-sis. Correlation and regression analyses were used to an­swer research questions three and four. The research questions were nondirectional and therefore a £<.05 was required using a two-tailed test of significance. To de­termine if there was a relationship between nurse job sa­tisfaction scores and performance appraisal systems, 97 Pearson Product-moment coefficients were obtained for nurse satisfaction scores and the variables feedback fre­quency and congruence/design of performance appraisal systems. Nurses who received more frequent feedback had significantly higher job satisfction scores (r=.47). No significant relationship was found between job satisfac­tion scores and congruence/design of performance ap­praisal systems (r=-.02). There was very little range in mean job satisfaction scores for the three hospitals. Hospital B, judged to have the most congruent performance appraisal system, had a mean job satisfaction score of 125, as did Hospital A, while Hospital C had a mean job satisfaction score of 128. Because of the small degree of variance found be­tween the mean job satisfaction scores of the three hos­pitals~- Hospital A and B = 125, Hospital C = l28--addi­tional statistical analysis was employed to determine if significant differences existed in the way respondents from each of the hospitals answered individual questions on the Personal Satisfaction Inventory instrument. To ob­tain this information, a Kruskal-Wallis one-way analysis of variance was utilized. Results indicated that respon­ses to six questions on the Personal Satisfaction Inven­tory were significant at the .01 - .05 level. These questions were 12, 16, 21, 29, 35, and 37. In answering research question 4, correlation coef- 98 ficients-were obtained for nurse satisfaction scores and the demographic variables identified. Marital status was the only demographic variable that correlated signifi­cantly with job satisfaction (p~.19); however, several study variables were intercorrelated. Because of the intercorrelation found betwe