Original articleThe role of job satisfaction, work engagement, self-efficacy and agentic capacities on nurses' turnover intention and patient satisfaction
Introduction
In recent years, public hospitals have had to cope with numerous challenges including increasing competition and the exponential increase of demand in terms of quantity and quality (Counte and Meurer, 2001, Zweifel, 2016). The financial cutbacks in public funding and the increasing number of patients (Aiken, Clarke, & Sloane, 2002) have highlighted the urgency to improve the quality of service and, at the same time, to reduce the costs of healthcare. This entails an increase in workload and pressures for the operators that are over-exposed to psychosocial risks (Bernal et al., 2015), which scientific research must take into account.
Healthcare workers' well-being is an interesting topic given its influence on service quality in hospitals. Many studies have demonstrated the association between employee psychological well-being and job performance (Cropanzano and Wright, 1999, Wright et al., 2007), including the health sector (Ferrara et al., 2013, Lundstrom et al., 2002). To achieve the aim of continuous improvement of service quality, healthcare organisations must constantly monitor and promote the health and satisfaction of all the people who are involved in the care process (Al-Abri & Al-Balushi, 2014).
Nursing care is crucial for the realisation of healthcare outcomes (Cho, Ketefian, Barkauskas, & Smith, 2003). Indeed, nurses provide continuous assistance to hospitalised patients (Tourangeau et al., 2006) responding to their physical and emotional needs (Henderson, 2001). Specifically, nurses assist patients, helping them in daily activities to maintain or improve their health and lead them to achieve independence as soon as possible (Henderson, 2006). To reach these aims it is important that nurses establish a helping relationship with patients. An empathic attitude with patients aids in offering adequate treatment to address the real needs of those assisted and to make them feel more satisfied with the care process (Dal Santo et al., 2014, McQueen, 2004).
Often nurses' work demands exceed their personal and job resources and this exposes them to psychosocial risks with negative consequences on their physical and psychological health (Bernal et al., 2015, Fillion et al., 2007). A possible effect of nurses' malaise is voluntary turnover that exacerbates the shortage of nursing staff (Flinkman, Isopahkala-Bouret, & Salanterä, 2013). International data indicates that the shortage of nurses is a worrying global phenomenon (Buchan and Aiken, 2008, Johnson et al., 2016). In the USA, researchers and government organisations have estimated that there will be a shortage of nurses anywhere from 300,000 to 1 million in 2020 (Juraschek, Zhang, Ranganathan, & Lin, 2012). Compared to the European average of 8.4, Italy ranks lower with 6.2 nurses per thousand residents in 2014 (OECD, 2016). Quantitative and qualitative demand for nurses will probably continue to increase because of the growing life expectancy and ageing workforce (Germini et al., 2010, Juraschek et al., 2012, OECD, 2016). At the same time nursing turnover rates are alarming in many countries (Duffield et al., 2014, Hayes et al., 2006, Hayes et al., 2012). One study, which involved seven European countries, showed that Italy, along with France and Germany, have nurses with higher levels of intention to leave their profession (Li, Galatsch, Siegrist, Müller, & Hasselhorn, 2011). An Italian study (Ambrosi et al., 2011) found that 34.4% of nurses planned to leave the hospital within one year after hiring and 43.8% of them had already sent a hospital transfer request. It seems clear that understanding the reasons why nurses want to carry out turnover behaviour is crucial to face the shortage of nurses.
The literature showed that the intention to leave is the main predictor of real turnover behaviour (Griffeth et al., 2000, Takase et al., 2008). According to Takase (2010), turnover intention is a complex process that arises from a negative psychological response to specific occupational or organisational conditions and this response evolves either into the decision to leave or unfolds into withdrawal behaviours that may entail voluntary abandonment of the current job or actions to achieve better job opportunities. Nursing turnover includes nurses moving to another ward within the same hospital or leaving the organisation or profession (Ambrosi et al., 2013, Hayes et al., 2006, Hayes et al., 2012). High voluntary turnover rates among nurses often lead to dysfunctions at an organisational level causing an increase in costs and the workload of nurses on duty (Hayes et al., 2006, Wagner, 2010). This situation has a negative impact on nurses' well-being and performance, as well as on the quality of patient care (Aiken et al., 2012).
Moreover empirical research has found a relationship between nurses' occupational health and the quality of care perceived by patients (Coomber and Barriball, 2007, Ferrara et al., 2013, Garman et al., 2002, Janicijevic et al., 2013, Leiter et al., 1998). This relationship has been extensively analysed in the international literature (Coomber and Barriball, 2007, Garman et al., 2002, Janicijevic et al., 2013, Leiter et al., 1998), but is still underexplored in the Italian context (Argentero et al., 2008, Ferrara et al., 2013). Considering the alarming turnover data in Italy (Ambrosi et al., 2011, Li et al., 2011, OECD, 2016), scientific research investigating which dimensions impact voluntary turnover is needed, in part to suggest useful interventions for healthcare organisations to prevent this phenomenon and retain nurses.
Based on social cognitive theory (Bandura, 1986) which views people as active agents in their own environment, this study investigated the role of specific dimensions, such as job satisfaction and other less studied constructs in relation to this topic such as self-efficacy, agentic capacities and work engagement, as potential antecedents of hospital turnover intention among nurses. The main contribution of the present research is to analyse both the relationships between possible determinants of hospital turnover intention among nurses, in order to expand the knowledge on this issue, and the relationship between nurses' job satisfaction, work engagement, self-efficacy, agentic capacities, turnover intention and patient satisfaction, which is increasingly used in many healthcare organisations as a quality performance indicator (Al-Abri & Al-Balushi, 2014). The findings of this study can highlight dimensions to focus upon in order to improve organisational strategies useful to reduce volunteer turnover behaviours among nurses. The research offers interesting insights for healthcare organisations to act to retain their staff, consequently prevent turnover, and to insure good quality nursing care.
The paper is organised as follows. Firstly, it illustrates the theoretical framework of this study focusing on dimensions of job satisfaction, work engagement, self-efficacy and agentic capacities in relation to nurses' turnover intention and patient satisfaction. Secondly, it describes the research methodology and the data gathered in the study. Finally, we discuss the principle findings of this research within the previously outlined theoretical framework and their implications for theory and practice.
Section snippets
Specific predictors of nurses' turnover intention: the role of job satisfaction, work engagement, self-efficacy and agentic capacities
Several researchers have studied turnover intention as a main predictor of turnover behaviour (Griffeth et al., 2000), and specifically among nurses (Takase et al., 2008). Turnover intention has been identified as the principal predictor of turnover intention and job satisfaction (Zaghloul, Al-Hussaini, & Al-Bassam, 2008). Other variables analysed in relation to turnover intention are work engagement (De Simone and Planta, 2017, Laschinger, 2012, Shahpouri et al., 2016, Simpson, 2009) and
Patient satisfaction: a quality performance indicator
People who use health services can be considered as both consumers and co-producers of the service because patients are not just passive users but have an active role in healthcare (Vincent & Coulter, 2002). There is a growing recognition of the relevance of embracing patient-centred care approaches in healthcare services by international organisations (International Alliance of Patients' Organizations, 2007, OECD, 2016, The Health Foundation, 2014, World Health Organization, 2000) since it
Method
The present study was conducted in two public hospitals in southern Italy. Healthcare directors of the organisations were informed about the study and, after they agreed to participate, all nurses were informed about the study through specific meetings with researchers and management. We explained the procedures of the study and assured them that their responses would be confidential. Informed consent was obtained from all individual participants included in the study.
The research data was
Nursing staff survey
The self-report questionnaire, accompanied by a presentation letter describing the research project, was delivered to the nursing staff coordinators, from each ward, who distributed it to their colleagues during working hours. Questionnaires, once completed, were placed in a sealed box that was prepared for each ward in order to respect privacy and anonymity. Of 389 nurses, 194 returned the questionnaire filled out correctly, with a 50% response rate. Nurses were distributed in different
Nurse measures
The booklet completed by nurses contained a section for the collection of socio-demographic and job information (gender, age, level of education, professional and organisational seniority) and the following scales.
Patient survey
The questionnaire, along with a brief presentation of the research project, was delivered by the nursing staff coordinators to patients the day before discharge, including only those of age, hospitalisation of two nights or more and absence of psychophysical disorders to allow for the independent completion of the questionnaire. Once the patients completed the questionnaire and inserted it in the urn, the research team proceeded to collect them from each ward.
Of the 181 participants, 104 were
Patient measures
Patient satisfaction was measured using the Italian version (Piredda et al., 2015) of NSNS (Thomas et al., 1996). The patients responded to 17 items (e.g., “How willing nurses were to respond to your requests”) on the response scale from 1 to 5 (1 = not satisfied, 5 = completely satisfied). Each individual score was then added and transformed to obtain an overall satisfaction score which can range from 1 to 100, where 100 represents the highest level of satisfaction with the nursing care received.
Data analysis
Descriptive analyses of participants' sociodemographic data were calculated using means and standard deviations. Cronbach's reliability alphas were utilised for all measures. To verify associations between job satisfaction, work engagement, self-efficacy, agentic capacities and turnover intention we used Pearson's correlation.
To test the association between nurses' job satisfaction, work engagement, self-efficacy, agentic capacities, turnover intention and patient satisfaction, we utilised
Results
We conducted a correlation analysis using Pearson's r coefficient to clarify the relationships among the variables for the nurses. As shown in Table 1, job satisfaction, work engagement, self-efficacy and agentic capacities were positively related. These dimensions were inversely correlated with turnover intention. Job satisfaction had the highest correlation with turnover intention among other dimensions (r = − 0.38). Not all agentic capacities correlated with turnover intention. We found a
Discussion
The purpose of this research was to study both the relationship between job satisfaction, agentic capacities, self-efficacy and work engagement and the role played by these variables in hospital turnover intention among nurses. Furthermore, we analysed the relationship between nurses' job satisfaction, work engagement, self-efficacy, agentic capacities and patient satisfaction.
Overall the hypotheses of this study were partially confirmed. The first hypothesis, that considered job satisfaction
Limitations and further directions
This study has some limitations which may be overcome with further research development. First, the small sample size and the voluntary participation of nurses and patients do not allow us to determine how the results can be generalised. This research project could be replicated expanding the sample and comparing nurses and patients in different public or private healthcare organisations.
A second limitation is attributable to the exclusive collection of subjective data, using self-report
Conclusion and practical implications
This study contributed to expanded knowledge of the factors associated with hospital turnover intention and confirmed the importance of monitoring nurses' job satisfaction, work engagement, self-efficacy, self-regulation, anticipation and turnover intention to improve patient satisfaction with nursing care. The presented results provide practical implications for healthcare services.
Job satisfaction is the most promising dimension on which healthcare organisations should act to reduce hospital
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