During the past twenty years, nurses' job satisfaction has been studied repeatedly, in relation to various manpower and economic influences (Hinshaw & Atwood, 1984.). The nurse shortage of the 1970s made it difficult to fill budgeted nursing positions. Therefore, information was sought about nurses' job satisfaction in order to improve nurse recruitment (McCloskey, 1974). In the mid-1980s, the DRG prepayment system caused many health agencies to downsize and decrease personnel budgets. Then information about nurses' job satisfaction was needed to improve nurse retention and cut turnover costs (Hinshaw, Smeltzer, & Atwood, 1987). In the early 1990s, competition among health care providers necessitated new approaches to improve care and market services. Hence, research was implemented to explore possible linkage of nurses' job satisfaction to work productivity and client satisfaction (McDaniel & Patrick, 1992).
In the past, job satisfaction studies focused more on acute care than on long-term care nurses (Pfaff, 1987), and more on staff nurses than on nurse managers/administrators (Bunsey, Defazio, Pierce, & Jones, 1991; Scalzi, 1990). However, population aging and increasing chronic illness have increased demand for long-term care services. Information about job satisfactions in long-term care is needed to recruit and retain caregivers for the nation's aged, infirm, and disabled. The nurse administrator, who is responsible for the principal long-term care service, is expected to be a primary leader in improving care quality and controlling cost (Lodge & Pietraschke, 1986). Unfortunately, less information is available about job attitudes of nurse administrators in long-term care than their counterparts in acute care settings (Lodge, 1985).
Satisfaction of Long-Term Care Nurses
Job satisfaction is defined as degree of positive affective orientation toward one's job (Biegen & Mueller, 1987). In the few satisfaction studies published about longterm care personnel, more information is available about work satisfactions of long-term care staff nurses than long-term care nurse managers.
Job satisfaction of staff nurses in long-term care has been related to workload (Power & Sharp, 1988), autonomy (Parahoo, 1991), prestige (Riordan, 1991), scheduling (Robertson & Cummings, 1991), management style (Pfaff, 1987), and recognition from co-workers (Anderson, Aird, & Haslam, 1991). Job satisfaction of nurse managers in long-term care has been related to the supervisor's consideration behavior (Nealey & Blood, 1968), and relations with co-workers (Deckard, Hicks, & Rountree, 1986).
There are some similarities in job satisfaction of long-term and acute care nurses. As with long-term care staff nurses, satisfaction of acute care staff nurses has been related to work schedules (Biegen & Mueller, 1987), supervisor's behavior (Mottaz, 1988), and autonomy (Donovan, 1980). But satisfaction of acute care staff nurses has also been related to professional status (Johnston, 1991), method of nursing care delivery (Reed, 1988), and nurse-physician relations (Longest, 1974); and these factors have not yet been related to satisfaction of long-term care staff nurses.
Likewise, satisfactions of nurse managers in long-term and acute care are somewhat similar. As with long-term care nurse managers, satisfaction of acute care managers is related to their superior's behavior (Sims & Szilagyi, 1975). However, satisfaction of acute care managers is related to superiors' structuring behavior, while long-term care managers' satisfaction is related to superiors' consideration behavior.
Measurement of Job Satisfaction
Researchers have used many tools to measure nurses' job satisfaction. Some investigators developed their own tools, focusing on variables of interest for a particular study (Deckard, Hicks, & Rountree, 1986; Wright, McGiIl, & Collins, 1990). A few researchers used the Job Description Index, which was developed for multiple occupational groups (Reed, 1988; Weisman, Alexander, & Chase, 1980). Porter's Need Satisfaction Survey, which was developed to measure satisfaction of business and military personnel, was used in some studies (Blalack, 1986; Humphris & Turner, 1989). Some investigators used Price and Mueller's Job Satisfaction Scale, which was developed for multiple categories of health workers (Biegen & Mueller, 1987; Packard & Motowidlo, 1987). Brayfield and Roth's Index of Job Satisfaction, which was developed to measure overall job satisfaction of industrial workers, has been used in nursing studies (Riordan, 1991; Wakefield, Curry, Price, Mueller, & McCloskey, 1988). The Hinshaw and Atwood Scale, adapted for nurses from the Brayfield and Roth Tool, has been used by some researchers (Bunsey, Defazio, Pierce, & Jones, 1991; Norbeck, 1985). The HaU, Von Endt, and Parker Staff Satisfaction scale, based on Maslow's and Herzberg's motivational theories, has been used recently (Riordan, 1991; Wells, 1990). Several investigators have used Stamps and Piedmonte's Index of Work Satisfaction (IWS), which was designed to measure nurses' satisfaction with six job aspects (Baggs & Ryan, 1990; GoweU & Beverie, 1992; Johnston, 1991; Wright, McGill, & Collins, 1990). In repeated tests in different settings, Stamps and Piedmonte's Index of Work Satisfaction showed acceptable levels of reliability and validity (Stamps & Piedmonte, 1986).
The Index of Work Satisfaction consists of two parts. Part A contains 15 paired comparisons which measure a subject's opinion as to relative importance of six job aspects. Part B is a 44-item, seven-point Likert-type scale that measures a subject's satisfaction with the following job aspects: Pay, Professional Status, Task Requirements, Autonomy, Interpersonal Interactions, and Organizational Policies. The 44 items were grouped into the aforementioned subscales on the basis of factor analysis, and reliability of the subscales ranges from .52 to .81. Stamps and Piedmonte (1986) reported that the unweighted scores (Part B of IWS) are comparable to weighted scores (Part B scores weighted according to relative importance indicated on Part A).
It is difficult to compare results of published job satisfaction studies, because some researchers (Mottaz, 1988; Packard & Motowidlo, 1987) reported nurses' satisfaction with the job as a whole; whüe others (Deckard, Hicks, & Rountree, 1986; Johnston, 1991) reported nurses' satisfaction with multiple job aspects. Also, some studies used researcherdeveloped tools of unknown reliabiUty and validity (Longest, 1974; Mottaz, 1988), and few studies were replicated using samples from different units or agencies.
Interestingly, most researchers have measured nurses' job satisfaction at a single point in time. This approach is based on the assumption that a person's satisfaction does not change appreciably throughout tenure in a particular position; which would be likely if job satisfaction were more influenced by personal than agency factors. However, nonnursing and clerical personnel studied by Van Maanen and Katz (1976) reported that their satisfaction with organizational policies, interpersonal relations and job tasks changed with greater tenure in a position. Gruneberg (1979) postulated that a person's job satisfaction changes continuously, as a result of his/her adaptation to changing circumstances and acquisition of new values. This would be likely if job satisfaction results from interaction of personal characteristics with organizational factors.
A few researchers have measured nurses' job satisfaction at multiple time points. Biegen and MueÜer (1987) measured staff nurses' job satisfaction twice, at an eight-month interval, to determine the effects of multiple environmental factors, while controlling for subjects' satisfaction at Time 1. Because satisfaction levels at Time 1 and Time 2 were highly correlated, Biegen and Mueller concluded that a nurse's level of job satisfaction remains fairly stable through time.
In contrast, Humphris and Turner (1989) measured job satisfaction of long-term care geropsychiatric staff nurses and nurse managers before and after change in unit location. Nurses' satisfaction with the total job and with working conditions improved following their move to a more spacious, more attractive, better equipped unit, which suggests that satisfaction changes in response to altered external circumstances. Stillwaggon (1989) measured job satisfaction of Maternal-Child Health nurses twice: following several weeks' assignment to a flextime, managed nursing care delivery system, and four weeks after returning to a more traditional 40 hours per week nursing system. Ih Stillwaggon's study, as in Humphris and Turner's study, nurses' job satisfaction changed through time, in that satisfaction of the maternalchild nurses decreased following change from autonomous practice in a flex-time managed care system to a more regimented, traditional system.
In summary, the majority of published studies of nurses' job satisfaction have focused on measuring work-related satisfaction of acute care staff nurses at a single point in time. Job satisfaction of staff nurses and nurse managers in long-term care has received little attention. Therefore, health planners lack information needed for recruiting and retaining professional caregivers in the most rapidly expanding segment of the health industry.
This study was undertaken as one method for evaluating outcomes of an extended continuing education (CE) program for nurse managers in long-term care. Subjects' job satisfaction was measured at the beginning and end of the CE program to determine whether their level of job satisfaction had changed during the 30-month program.
Subjects were 44 nurse directors and nurse educators who participated in an extended continuing education project while being employed in a variety of long-term care agencies. (These nurse directors and nurse educators will subsequently be referred to collectively as "nurse managers.") The Geriatric Education for Nurses in Long Term Care Project (GENLTCP) (Grant #1 D10-NU25263-01, DHHS) was a three-year, multi-function continuing education project that was funded by the Division of Nursing, United States Public Health Service, and implemented by the Midwest Alliance in Nursing (MAIN). The purpose for GENLTCP was to improve care of chronically ill elders in 13 Midwestern states by increasing management knowledge and skills of directors of nursing and inservice teachers in long-term care agencies. The participating nurses were employed in nursing homes, public health nursing agencies, home nursing agencies, hospices, Veterans' Administration hospitals and homes, facilities for developmentally disabled, Indian Health Services, and colleges and universities offering undergraduate and graduate courses in geriatric nursing.
The enrolled nurse directors and educators engaged in interactive conferences and seminars that were designed to improve health care and quality of life for elders with impaired cognitive, physical, and social abilities. GENLTCP participants applied information obtained from these conferences while implementing a self-selected careimprovement project in their agency. Also, participants disseminated nursing practice innovations that they learned about in GENLTCP conferences to other nurses in their communities.
Demographic and Employment Characteristics at Sampie
Stamps and Piedmonte's Index of Work Satisfaction (IWS) was used to measure nurse managers' level of job satisfaction at the beginning and end of the Geriatric Education for Nurses in Long Term Care Project. Since IWS had been used in studies of acute care nurses, using IWS in this study facilitated comparison of GENLTCP managers' satisfaction with that of acute care nurses. Because unweighted IWS scores are comparable to weighted scores (Stamps & Piedmonte, 1986), subjects completed only Part B of IWS (the 44-item Likert-type scale).
A second instrument was a Demographic Questionnaire that requested no identifying information about the nurse participant or the long-term care agency with which (s)he was affiliated. The questionnaire included questions about participant's age, gender, race, educational preparation, years in nursing, and years in present agency; as well as agency type, ownership, and size.
GENLTCP participants were asked to complete the Demographic Questionnaire and Stamps and Piedmonte's Index of Work Satisfaction at the beginning of the first GENLTCP conference (middle of first project year) and at the end of the last GENLTCP conference (end of third project year.) Questionnaires were coded to enable researchers to link Time I and Time II questionnaires for the same subject.
Demographic data were analyzed using descriptive statistics. Total IWS scores and subscale scores were analyzed using descriptive statistics and Repeated Measures Analysis of Variance.
Of 112 nurse managers and educators who enrolled in GENLTCP, 53 (47%) filled out the IWS at the beginning and end of the three year project. For 41 nurses (37% of original group) all IWS items were answered at Time I and Time ?. Forty-four nurses (39% of original group) answered the Demographic Questionnaires at both Tune I and Tune ?, but some respondents did not answer every item on the Demographic Questionnaire.
Subjects were 96% female, with mean age of 44, an average of 21.5 years in nursing, and an average of 7.7 years in the present agency. As shown in Table 1, 19% had a diploma, 12% had an associate degree, 31% had a baccalaureate degree, 36% had a master's degree, and 2% had a doctorate.
Highest possible score for the total IWS scale is 308 (though it would be unlikely for a subject to give a score of 7 to all 44 items). Mean subscale and total satisfaction scores at beginning and end of the GENLTC project are shown in Table 2. From Time I to Time ?, there was significant change (an increase) in scores for only one subscale: Satisfaction with Organizational Policies. Mean Satisfaction with Organizational Policies increased from 29.05 at Time I to 33.44 at Time II (t=-3.14; df= 40; p=.003).
Repeated Measures Analysis of Variance was used to analyze changes in IWS scores from beginning to end of GENLTCP for: 1) type of agency, 2) agency administrative control, 3) geographical location of agency, and 4) subjects' educational level. Neither agency type nor agency managerial control was related to IWS scores.
Geographical location (rural, suburban, metropolitan) and education (diploma, associate, baccalaureate, masters) were related to IWS scores. At both the beginning and end of GENLTCP, metropolitan managers' scores on the Autonomy, Interaction, Professional Status, and Organizational Policies subscales were higher than those of rural or suburban managers. Mean scores for most IWS subscales increased from the beginning to end of GENLTCP. However, this increase was significant only for the Organizational Policies subscale, and amount of increased satisfaction with policies was similar for managers in rural, suburban, and metropolitan agencies (Table 3).
Subjects' IWS Scores Before and After GiNLTCP (N=41)
Education level was related to scores on the Task Requirements subscale. At the beginning of GENLTCP, masters-prepared managers were more satisfied with task requirements than were baccalaureate, associate, or diploma-prepared managers. Also, time interacted with education in influencing task satisfaction. From Time I to Time II, task satisfaction increased for diploma managers, decreased for AD managers, and remained fairly constant for baccalaureate and masters managers.
In this study, as in that by Deckard and associates (1986), nurse managers in long-term care experienced high levels of job satisfaction. These subjects were more highly satisfied with Interactions, Autonomy, and Professional Status than with Agency Policies, Pay, and Task Requirements. Perhaps comfortable relationships with administrators, co-workers, and clients somehow compensated these nurse managers for some of their dissatisfactions concerning job responsibilities, work conditions, and salary level.
In this study, as in that by Biegen and Mueller (1987), amount of nurse managers' job satisfaction remained fairly stable through time. Of six job aspects measured by IWS, only Satisfaction with Organizational Policies increased significantly (p=<.01) during the 30-month GENLTC program. The GENLTC project occurred during implementation of the 1989 Omnibus Budget Reconciliation Act (OBRA) and the 1991 Patient Self Determination Act (PSDA). At the beginning of GENLTCP, many participants had just received OBRA Guidelines. They were struggling to implement required patient care and nursing practice changes. When participants were invited to suggest workshop topics, most wanted information about eliminating physical restraints, preventing patient falls, managing patients' aggressive behavior, instituting patient self-administration of medications, encouraging patient self-government, and informing patients about advance care directives. These are all OBRA- or PSDArequired activities. GENLTCP staff addressed these requests by including a nurse in each conference and seminar who advised participants in implementing new federally mandated care improvements. Perhaps these discussions of OBRA and PSDA requirements decreased participants' resistance to these externally-imposed directives, and enabled them to develop more effective policies in their agencies. Participants' increased "ownership" of agency policies would explain their increasing satisfaction with organizational policies during the GENLTCP program.
Repeated Measures ANOWI for Pre/Posf IWS Scores by Geographical Location
The effect of education level on participants' task satisfaction is especially interesting. Studies have shown that nurses with more education experience less job satisfaction (Biegen, 1993). At the beginning of GENLTCP, diploma-prepared managers reported less task satisfaction than did associate degree, baccalaureate, or masters-prepared managers. However, by the end of GENLTCP, diploma-prepared managers reported greater task satisfaction than any other educational group.
The highest proportion of diploma-prepared nurse managers is found in rural areas, where baccalaureate and masters nursing programs are scarce, health care needs are growing, and health facilities are declining (Adams, 1989). Findings of this study suggest that: 1) diplomaprepared nurses can upgrade management knowledge and skills through extended continuing education (CE) programs, and 2) task satisfaction of diploma nurse managers is enhanced through continuing education. It is possible that the improved performance and increased satisfaction of CE-enhanced managers will decrease turnover in this group, leading to decreased recruitment and orientation costs.
This study should be replicated using larger samples and continuing education programs of different lengths. Further research will help to determine whether job satisfaction is stable through longer and shorter CE programs. Subsequent studies should explore the relationship of additional personal and agency characteristics to nurse managers' job satisfaction. Such agency factors as size, staff-to-patient ratio, employee unions, method of care delivery; and such personal factors as number of dependents, commuting distance, and health status may affect the job satisfaction of nurse managers in long-term care.
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Demographic and Employment Characteristics at Sampie
Subjects' IWS Scores Before and After GiNLTCP (N=41)
Repeated Measures ANOWI for Pre/Posf IWS Scores by Geographical Location