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Title:
Exploring the relationships among work-related stress, quality of life, job satisfaction and anticipated turnover on nursing units with clinical nurse leaders
Physical Description:
Book
Language:
English
Creator:
Kohler, Mary
Publisher:
University of South Florida
Place of Publication:
Tampa, Fla
Publication Date:

Subjects

Subjects / Keywords:
Clinical Nurse Leader
Job satisfaction
Quality of life
Nursing work related stress
Anticipated turnover
Dissertations, Academic -- Nursing -- Masters -- USF   ( lcsh )
Genre:
non-fiction   ( marcgt )

Notes

Abstract:
ABSTRACT: The purpose of this study was to explore the relationship of the Clinical Nurse Leader (CNL) (AACN) role with the variables of work related stress, quality of life, job satisfaction and anticipated turnover of acute care nurses. Participants included registered nurses (RNs) (N= 94) in Florida recruited from 3 (not for profit) Magnet hospitals in the Tampa Bay Florida area. An ex post facto design was used to test the hypotheses of this study; independent t-tests compared RN's responses on survey tools measuring work-related stress, quality of life, job satisfaction, and anticipated turnover. Multiple regression analysis was used to examine the interrelationships among these variables. RNs (N=94) completed five survey instruments, including a researcher-developed demographic form. The results of the study showed Aim1 which explored work- related stress did not show any statistical difference between the two groups. Aim 2 which explored job satisfaction and quality of life did not show a difference in the two groups when total scores were analyzed. However, the mental health subscale of the Sf-36(quality of life) was significant (p=.021), and the general health subscale of the Sf-36 trended toward the CNL group reporting better general health (p=.080). This study revealed that Aim 3 which explored anticipated turnover was statistically significant (p=.047). Standard multiple regression showed a significant relationship existed between CNLs, work related stress and anticipated turnover. The significance of implementation of the CNL role in decreasing turnover through a relationship with these variables may have an important impact on the nursing profession. Specifically, economic implications vii in reducing turnover that bear further exploration and improving the nursing work environment. This research is the first study to explore the CNL role in relation to these variables.
Thesis:
Dissertation (PHD)--University of South Florida, 2010.
Bibliography:
Includes bibliographical references.
System Details:
Mode of access: World Wide Web.
System Details:
System requirements: World Wide Web browser and PDF reader.
Statement of Responsibility:
by Mary Kohler.
General Note:
Title from PDF of title page.
General Note:
Document formatted into pages; contains X pages.

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usfldc handle - e14.4691
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ABSTRACT: The purpose of this study was to explore the relationship of the Clinical Nurse Leader (CNL) (AACN) role with the variables of work related stress, quality of life, job satisfaction and anticipated turnover of acute care nurses. Participants included registered nurses (RNs) (N= 94) in Florida recruited from 3 (not for profit) Magnet hospitals in the Tampa Bay Florida area. An ex post facto design was used to test the hypotheses of this study; independent t-tests compared RN's responses on survey tools measuring work-related stress, quality of life, job satisfaction, and anticipated turnover. Multiple regression analysis was used to examine the interrelationships among these variables. RNs (N=94) completed five survey instruments, including a researcher-developed demographic form. The results of the study showed Aim1 which explored work- related stress did not show any statistical difference between the two groups. Aim 2 which explored job satisfaction and quality of life did not show a difference in the two groups when total scores were analyzed. However, the mental health subscale of the Sf-36(quality of life) was significant (p=.021), and the general health subscale of the Sf-36 trended toward the CNL group reporting better general health (p=.080). This study revealed that Aim 3 which explored anticipated turnover was statistically significant (p=.047). Standard multiple regression showed a significant relationship existed between CNLs, work related stress and anticipated turnover. The significance of implementation of the CNL role in decreasing turnover through a relationship with these variables may have an important impact on the nursing profession. Specifically, economic implications vii in reducing turnover that bear further exploration and improving the nursing work environment. This research is the first study to explore the CNL role in relation to these variables.
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Exploring the Relationships among Work Related Stress, Quality of Life, Job Satisfaction, and Anticipated Turnover on Nursing Units with Clinical Nurse Leaders b y Mary Kohler, RN, MSN A dissertation submitted in partial fulfillment of th e requirements for the degree of Doctor of Philosophy College of Nursing University of South Florida Major Professor: Cecile A. Lengacher, Ph.D. Jeffery Kromrey Ph.D. Lois Gonzalez, Ph.D. Versie Johnson Mallard, Ph.D. Date of Approval: October 28, 2010 Keywords: Clinical Nurse Leader, job satisfaction, quality of life, nursing work related stress, anticipated turnover Copyright 2010, Mary E. Kohler

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Acknowledgements The writing of this dissertation has been the most challenging encompass ing, and exciting part of my doctoral education process I thank my advisor, mentor, Dr. Cecile Lengacher, for her valued confi dence and patient encouragement, without Dr. Lengachers support I would have been unable to succeed in this endeavor. She posed questions that constantly, challenged me to express my thoughts and ideas clearly. Patiently, she guided me through the dissertation process while always demanding my best effort. Special thanks to Dr Jeffrey Kromery for his statistical guidance and gent le demeanor. He is responsible for helping me to understand and embrace statistics as an important part of research. I am also very grateful to Drs. Lois Gonzalez and Versie Johnson Mallard for their insight and valuable support of my research. Addition ally, I am very grateful to everyone who has read any part of th is manuscript. In addition to my committee I would like to thank the faculty and staff of the College of Nursing who all have contributed to my educational growth and development in the docto ral pr ogram I have learned valuable lessons f rom each and every one of them I extend a heartfelt than k you to my family and friends whose belief in me far exceeded my belief in myself and have sustained me in the most difficult times I also want to tha nk God for leading me on this path and walking with me through this and every other part of my life.

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i Table of Contents List of Tables ................................ ................................ ................................ ...................... ii List of Figures ................................ ................................ ................................ .................... i ii Abstract ................................ ................................ ................................ .............................. vi Chapter One Introduction ................................ ................................ ................................ .... 1 Work related Stress ................................ ................................ ................................ .. 1 Quality of Life ................................ ................................ ................................ .......... 5 Anticipa ted Turnover ................................ ................................ ............................... 6 Clinical Nurse Leader ................................ ................................ .............................. 6 Statement of the Problem ................................ ................................ ......................... 8 Purpose of the Study ................................ ................................ ................................ 9 Research Hypotheses ................................ ................................ ............................... 9 Definition of Terms ................................ ................................ ................................ 1 0 Delimitations ................................ ................................ ................................ .......... 1 1 Limitations ................................ ................................ ................................ ............. 1 1 Significance of the Study ................................ ................................ ....................... 11 Chapter Two Literature Review ................................ ................................ ......................... 13 Work Related Stress ................................ ................................ ............................... 14 Qu ality of Life ................................ ................................ ................................ ........ 25 Job Satisfaction ................................ ................................ ................................ ...... 31 Anticipated Turnover ................................ ................................ ............................. 3 5 Summary ................................ ................................ ................................ ................ 3 7 Chapter Three Methods ................................ ................................ ................................ ...... 37 Design ................................ ................................ ................................ .................... 37 Logic Model ................................ ................................ ................................ ........... 3 9 Sample/Settings ................................ ................................ ................................ ...... 40 Setting ................................ ................................ ................................ ........ 40 Sample ................................ ................................ ................................ ........ 40 Inclusion Criteria ................................ ................................ ....................... 4 1 Exclusion Criteria ................................ ................................ ...................... 4 1 Instruments ................................ ................................ ................................ ............. 41 Nursing Stress Scale ................................ ................................ .................. 41 NSS Validity ................................ ................................ .................. 4 2 NSS Reliability ................................ ................................ .............. 4 3 Nursing Work Index Revised (NWIR) ................................ ...................... 4 3 NWIR Validity ................................ ................................ ............... 4 4

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ii NWIR Reliability ................................ ................................ ........... 44 Medical O utcomes Inventory Short Form (SF36 ) ................................ ..... 44 SF 36 Validity ................................ ................................ ................. 4 6 SF36 Reliability ................................ ................................ .............. 47 Anticipated Turnover Scale ( ATS) ................................ ............................ 4 7 ATS Validity ................................ ................................ .................. 4 7 ATS Reliability ................................ ................................ .............. 4 7 Demographic Data Form ................................ ................................ ............ 4 8 Procedures ................................ ................................ ................................ .............. 4 8 Approvals ................................ ................................ ................................ ... 4 8 Recruitment/ Data Collection ................................ ................................ .... 4 9 Data Analysis ................................ ................................ ............................. 5 1 Data Management ................................ ................................ ...................... 52 Chapter Four Results ................................ ................................ ................................ .......... 5 3 Sample ................................ ................................ ................................ .................... 5 4 Research Hypothesis One ................................ ................................ ...................... 5 9 Research H ypothesis Two ................................ ................................ ...................... 6 1 Research Hypothesis Three ................................ ................................ .................... 7 2 Research Hypothesis Four ................................ ................................ ..................... 7 3 Chapter Five Discussions, Conclusions and Recommendations ................................ ....... 7 5 Summary of the Study ................................ ................................ ........................... 7 5 Discussions and Conclusions ................................ ................................ ................. 7 6 Implications ................................ ................................ ................................ ............ 8 2 Recommendations for Future Research ................................ ................................ 8 5 Ref erences ................................ ................................ ................................ .......................... 8 6 Appendices ................................ ................................ ................................ ....................... 1 0 0 Appendix A: USF IRB Approval ................................ ................................ ......... 101 Appendix B : USF IRB Modification Approval ................................ ................... 103 Appendix C : Informed Consent ................................ ................................ ........... 105 Appendix D : Demographic Data Form ................................ ................................ 109 Appendix E: Medical Outcomes Inventory Short Form: SF (36) ........................ 1 11 Appendix F : Nursing Work Related Stress Scale ................................ ................ 116 Appendix G : Nursing Stress Scale ................................ ................................ ....... 118 Appendix H: Anticipated Turnover Scale ................................ ............................ 1 27 Appendix I: Recruitment Poster ................................ ................................ ........... 12 8 About the Author ................................ ................................ ................................ ... End Page

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iii List of Tables Table 1 Instrument Means and Standard Deviation Effect Size ............................ 4 0 Table 2 Frequency and Percentage of gender by group ................................ .......... 5 5 Table 3 Frequency and Percentage of Marital Status by Group ............................. 5 5 Table 4 Frequency and Percentage of Ethnicity by group ................................ ...... 5 6 Table 5 Frequency and Percentage of Edu cational preparation by g roup .............. 57 Table 6 Range and means for length of employment in the Nursing Profession, in the current hospital and on the individual unit .................... 59 Table 7 Frequency and Percentage of work status by group ................................ .. 6 0 Table 8 Sample Means and Standard Deviations for Nursing Work Related Index ................................ ................................ ................................ .......... 6 0 Table 9 Results of Independent t t est for Nursing Work Related Stress ................. 6 1 Table 10 Sample Means and Standard Deviation for Job Satisfaction ..................... 6 2 Table 11 Results of Independent t t est for Job Satisfaction ................................ ...... 6 3 Table 12 Mean and Standard de viation for Job Satisfaction subscales .................... 6 4 Table 13 Results of Independent t t est for Job Satisfaction subscales ...................... 6 5 Table 14 Sample means and standard deviation for overall scores of Quality of Life ................................ ................................ ................................ ........ 6 6 Table 15 Results of Independent t t est for overall sco res of Quality of Life ............ 6 6 Table 16 Means and standard deviation for Physical Health Summary Scale .......... 67 Table 17 Results of Independent t t est for Physical Health Summary Scale ............ 67

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iv Table 18 Means and Standard Deviation for Physical Health Subscales ................. 68 Table 19 Results of Independent t t est for Physical Health Subscales ..................... 69 Table 20 Means and Standard deviation for Mental Health Score ........................... 7 0 Table 21 Results of Independent T Test for Mental Health Summary Sc ale ........... 7 0 Table 22 Means and Standard Deviation for the Ment al Health Subscales .............. 7 1 Table 23 Results of Independent T Te st for Mental Health Subscales ..................... 72 Table 24 Sample Means and Standard Deviation for Anticipated Turnover ............ 73 Table 25 Results of Independent T Test f or Anticipated Turnover .......................... 73 Table 26 Summary of Reg ression Analysis for Predicting Anticipated Turnover ................................ ................................ ................................ ..... 75

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v List of Figures Figure 1 Hypothesized Logic Model ................................ ................................ ........ 39

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vi A bstract T he purpose of this study was to explore the relationship of the Clinical Nurse Leader (CNL) (AACN) role with the variables of work related stress, quality of life, job satisfaction and anticipated turnover of acute care nurses Participants included r egistered nurses (RNs) (N= 9 4 ) in Florida recruited from 3 (not for profit) Magnet hospitals in the Tampa Bay Florida area An e x post facto design was used to test the hypotheses of this study ; independent t measuring work related stress, quality of life, job satisfaction, and anticipated turnover Multiple regression analysis was us ed to examine the interrelationships among these variables. RNs (N=94) complete d five survey instruments, including a researcher developed demographic form The results of the study showed Aim1 which explored work related stress did not show any statist ical difference between the two groups. Aim 2 which explored job satisfaction and quality of life did not show a difference in the two groups when total scores were analyzed. However, the mental health subscale of the Sf 36(quality of life) was significa nt ( p =.021), and t he general health subscale of the Sf 36 trended toward the CNL group reporting better general health ( p =.080). This s tudy revealed that Aim 3 which explored anticipated turnover was statistical ly significant ( p =. 04 7 ). Standard multiple r egression showed a significant relationship existed between CNLs, work related stress and anticipated turnover. The significance of implementation of the CNL role in decreasing turnover through a relationship with these variables may have an important imp act on the nursing profession Specifically, economic implications

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vii in reducing turnover that bear further exploration and improving the nursing work environment. This research is the first study to explore the CNL role in relation to these variables.

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1 Chapter One Introduction W ork related stress, quality of life, and job satisfaction are the factors that greatly affect turnover for registered nurses (RNs) in the acute care setting. These variables have global implications. Further research is needed on the factors related to nurse turnover. This study explore d the relationship between the Clinical Nurse Leader (CNL) role and work related stress, quality of life, job satisfaction, and anticipated turnover of acute care nurses. Work Related Stress Rese arch on work related stress has been explored for over two decades and has been found to be a major factor related to nurse turnover. Rick and Perrewe (1995) define work related stress as a conflict resulting from a disconnect ion between an erception of the demands of the position and the ability or inability to meet those demands Stickler (2009) found that the literature is extensive on the effects of the work environment on stress levels, collaborative practice, work load job con flict, and job satisfaction and anticipated turnover. The effects of work related stress are low job satisfaction, high turnover, and poor patient outcomes resulting in large numbers of nurses leaving the profession entirely (Aiken, 2001; Hayes, 2005) Seve re distress has been linked to staff absenteeism and even ill health (Healy & McKay, 1999; McGowan, 2001; Shader et al., 2001) Several factors have been identified in relation to stress in acute care settings: ( 1) workload; ( 2) organizational support; ( 3) social support; ( 4)

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2 autonomy; ( 5) relationships with colleagues; ( 6) communication ; and ( 7) rewards ( Attree, 2005; Begat, 2005; Boyle, 2004; Chang, 2006; Coffman, 2002; Fletcher, 2001; Geibert, 2006; Gray Toft, 1985; Hall, 2004; Hayes, 1999; Khowaja,2004; Lam bert, 2004; McNeely, 2005; McVicar, 2003; Reineck,2005; Oloffson 2003; Strader, 2001 ; Stichler, 2009; Sveinsdotter, 2005; Weyer, 2006; Zeytinoglu, 2005). Nurses describe t he first factor, workload as resulting from inadequate resources and an inability to deliver high quality patient care Specifically, they report that heavy workloads are caused by poor staffing ratios and high patient acuity (Fletcher, 2001) California is the only state that has enacted legislation to mandate staffing ratios Althoug have had mixed success (Coffman, Seago, & Spetz, 2002) Addressing unsatisfactory staffing ratios may reduce stress levels to some degree but other workload factors may also be involved. Inefficiencies in healthcare delivery also are reported to impact workload for the average nursing care provider Nurses spend an inordinate amount of time documenting care, with many redundancies in the process (Reineick, 2005) One reported inefficiency is implementation of computer documentation related to patient safety. An unintended consequence of computerized documentation is an increased burden on nurses who take more time to document patient care with the new technology than with the former protocols Nurses are often not provided with sufficient training and support during the equipment dissemination process and have little time to master the new technology while they practice nursing (Geibert, 2006) Therefore, efforts to increase efficiency through

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3 the use of technology have often had the opposite, deleterious effect of increasing workload The second factor noted a lack of organizational support in particular ancillary s taff resulting in highly trained RNs providing care that could be safely provided by less educated, and thus less costly, caregivers (Khowaja, Merchant, & Hirani, 2004) Additionally, lack of organizational support occurs when nurse managers and directors do not exercise the necessary skills for leadership posi tions, the staff is left feeling that administration is unsupportive In turn, lack of support leads to situations in which nurses are more likely to leave their positions (Fletcher; Zeytinoglu, 2005). Third, the demands of nursing and a lack of social su pport seem to cause emotional exhaustion and increased stress levels (Janssen, 1999) Social support from colleagues decreases stress and positively affects job satisfaction (Begat, 2004) Nurses reported that strong social support helped them experience d less stress and have a higher level of job satisfaction; this in turn contributed to enhancing quality of patient care (AlArub, 2004) Nurses believed that their psychosocial work environment improved when they were able to discuss their problems with t heir colleagues (Begat, 2005) Chang (2006) found that enhancing social support through engaging in social activities helped cope with work related stress According to Shader (2001), social support and group cohesion decreased stress, burnout, and absen teeism and improved job satisfaction and decreased the likelihood of nurses leaving the profession The fourth factor that nurses identified as a contributor to increased work related stress was lack of autonomy or low control over their nursing practice ( Attree, 2005) Nurses who perceived such a lack of control stated that they had no influence over work

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4 related matters and that they were not taken seriously; they felt powerless When nurses did not feel empowered, they were more likely to have higher s tress levels than nurses who had a strong sense of autonomy (Attree 2005 ) T he fifth factor, attributed to increase work related stress is relationships with colleagues. N urses reported conflict with either physicians or other nursing staff as largely r esponsible for the stress they experienced at work. When nurses were able to discuss problems with colleagues, they reported that their levels of stress diminished (Begat, 2005). On the other hand, they reported that verbal abuse by physicians, patients, families, and colleagues increased their stress (Rowe, 2005). Gray Toft (1985) found that forming supportive, cohesive work groups effectively reduced both conflict and stress. A sixth contributing factor in work related stress involves communication. High stress levels led to negative communication, lack of teamwork, and a feeling that colleagues were unresponsive (Oloffson, 2003). Negative communications may be received not only from other healthcare professionals, especially doctors, but also from patients and families (Hall, 2004) When effective communication broke down, nurses tended to withdraw from the situation and to focus on when the shift would end or resigned to a situation that they believed would not change ( Begat 2005) This study als o found that when nurses received adequate information, there was improved collaboration and decreased stress and n egative communication, such as discourtesy or anger. research (2004) shows not only that communication can be improved but also that better communication improves job stress, job satisfaction, and patient outcomes.

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5 T he seventh factor of work related stress explored in this review is rewards. Healthcare organizations often try to recruit or retain nurses by offering competitive rewar ds; however reward or lack of reward is seldom a significant cause of work related stress, poor job satisfaction, or a reason to leave the profession More often, the significant cause is a perceived lack of respect and acknowledgement (McVicar, 2003) Weyer (2006) found a more nuanced relationship: Chronic psychological work related stress resulted from a lack of reward proportionate to occupational effort Quality of Life According to Chang (2000), quality of life is a self reported or perceived meas ure of physical and mental health In the study of the effects of long term stress on individual physical and psychological health, researchers found that nurses experienced increased stress in situations of greater workloads and ethical and moral conflic ts in the workplace which resulted in poor perception of overall health (Begat, 2004; Stacciarini, 2004; Chang, 2006) Job Satisfaction Price (2001) defined job satisfaction as an attitude an employee has toward his or her work A causal model examined nurse practice environment, burnout, job outcomes and quality of care was examined in Belgian nurses The researchers found that poor organizational environments lead to increased burnout which in turn reduced job satisfaction, and increased likelihood of turnover from the organization or profession (Van Bogart, Meuelmens, Clarke, Vermeyen, Van de Heying, 2009) Low job satisfaction resulting from work related stress and declining physical functioning have played a significant role in attrition from nursing ( Blegen,1993 ).

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6 A study by Kuhar (2004) showed that implementation of specific retention into three categories: people, process, and technology (people being social interaction, process referring to workflow, and technology which address the advent of scientific growth). Implementation of these strategies decreased the likelihood of nurses leaving their current positions or the profession entirely Anticipated Turno ver Increased job stress and less teamwork resulted in lower job satisfaction and a higher anticipated turnover (Schader, 2001) Studies have shown a significant correlation between job satisfaction and intention to leave the profession (Lu, 2002) Nurse s leave the profession for diverse reasons; however, the current research indicates that certain interventions may decrease the likelihood of leaving the profession (Wilson, 2005) This research study examine d what, if any, role the Clinical Nurse Leader (CNL) might play in decreasing stress, improving quality of life, improving job satisfaction and decreasing anticipated turnover among nursing staff. Clinical Nurse Leader In an effort to address the problems described above, the American Association of th e Colleges of Nursing (AACN) aimed at keeping caregivers at the bedsides of patients (CNL, 2003) The Clinical nurse leader role was developed to: ( 1) implement evidence based practice in a timely fashion, ( 2) provide lateral integration of collaborative care, ( 3)collect and evaluate patient outcomes, ( 4) assess cohort risk and change plans of care when necessary(AACN, 2007).

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7 prove patient care and to provide a more efficient work environment for all members of the healthcare team (CNL, 2003) In response to changes in healthcare and the role in those changes, the AACN established an exploratory committee to investigate issues related to the nursing workforce and education Input from two studies conducted by the Institute of Medicine (IOM), Crossing the Quality Chasm (2001), as well as a follow up report, Health Professions Education: A Bridge to Quality (2003), served as a starting point for identifying a new curriculum to prepare nurses to practice in the role of CNL ( CNL 2003) This curriculum takes into account the Joint Commission on accreditation of Healthcare in Crossroads: Strat egies for Addressing the Evolving Nursing Crisis (2002) Workforce for Hospitals and Health Systems report, In Our Hands: How Hospital Leaders Can Build a Thriving Workforce (2002) and a 2002 report by the Robert Wood Johnson Foundation American N ursing S hortage These reports examined multiple, complex factors behind the inability to recruit and retain qualified nurses at the bedside Although the studies identified many factors, they recommended two act ions: ( 1) to concentrate on the needs of a new generation of nurses in the workforce; and ( 2) to create a professional role that would attract and retain the highest quality of personnel in the profession of nursing.

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8 Statement of the Problem Research on wo rk related stress factors, job satisfaction, and overall perception of health in nursing shows a relationship among these factors and the retention of nurses in the profession (Aiken, 2001; Hayes, 2005) This is an important area of research due to the sh ortage of nurses in the United States hospital practice The Bureau of Health Professions projects that the current nursing shortage will worsen over the next 20 years, possibly becoming a shortage of 800,000 nurses by the year 2020 (Spetz & Given, 2003) Relatively recently, poor working conditions have resulted in low job satisfaction and/or have caused a large number of nurses to leave the profession entirely Currently, nearly half a million registered nurses do not practice in the nursing profession b etween 1996 and 2000, the number of licensed registered nurses not employed in nursing grew from 52,000 to over 490,000 (DHHS, 2002) Current research has shown that due to the economic downturn, the shortage of nurses has decreased more than anticipa ted due to the attractiveness of employment opportunities and the ability of nurses to provide a livable wage (Buerhaus, 2010 ). The advent of current legislation HR: 4872, Reconciliation Act of 2010 proposes providing 34 million currently uninsured persons with much needed access to healthcare resources thus raising two question s ; ( 1) is the current nursing workforce positioned to provide the needed care ( 2) c an the already burdened healthcare system provide good, safe, quality care for patients and suppor tive, healthy work environments for nurses? Research by Aiken et al (2001) has demonstrated that increased morbidity and mortality for patients in acute care settings can be attributed to inadequate numbers of caregivers at the bedside The effects of inc reased work related stress, low job

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9 satisfaction, and poor quality of life on nurses can negatively affect patient outcomes In addition, these same three factors have greatly reduced the number of nurses who remain in nursing (Aiken et al.; Hayes, 2005) Therefore, exploring how the role of the CNL may influence these factors may provide an understanding of the negative effects of work related stress, job dis satisfaction, and quality of life, thus resulting in future retention of nurses at the bedside. Purpose of the Study The purpose of this study was to explore the relationship of the newly created CNL role with work related stress, quality of life, job satisfaction, and anticipated turnover of acute care nurses In addition, this research examine d t he interrelationships among work related stress, quality of life, job satisfaction, and anticipated turnover. Research Hypotheses Aim 1: To explore the effect of the CNL role on reducing work related stress among nurses, as measured by the Nursing Stress Scale (NSS) (Gray Toft, 1981). Hypothesis 1: Nurses practicing on units with a CNL will exhibit a decrease in work related stress compared to nurses practicing in units without a CNL. Aim 2: To explore the effect of the CNL role on job satisfaction as me asured by the Nursing Work Index Revised (NWI R) and perception of overall well being among nurses, as measured by the Medical Outcomes Study Short Form 36 (SF 36). Hypothesis 2: Nurses practicing in units with a CNL will exhibit increased job satisfactio n and improved perception of quality of life compared to nurses practicing in units without a CNL.

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10 Aim 3: To explore the effect of the CNL role on turnover as measured by the A nticipated Turnover Scale (ATS) for nurses. Hypothesis 3: Nurses practicing on units with a CNL will exhibit decreased anticipated turnover compared to nurses practicing on units without a CNL. decreased work related stress, improved job satisfacti on, improved quality of life, and decreased quality of life anticipated turnover (ATS) Hypothesis 4: The CNL is a predictor of decreased turnover, improved work related stress, increased job satisfaction, and improved quality of life Definition of t er ms For the purposes of this study the following terms were used: 1. Clinical Nurse Leader: Masters degree program developed by the American Association of Colleges of Nursing (AACN, 2007) 2. Work related stress: The conflict an individual experiences from a disconnect ion between perception of the demands of the position and the inability to meet those demands (Rick & Perrewe, 1995) 3. Quality of life: A self report measure of physical and mental health status (Chang, 2000) 4. Job satisfaction: An attitude an empl oyee has toward his or her work (Price, 2001) 5. positions (Shader, 2001)

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11 6. Autonomy: Self governance (Webster, 2002) Delimitations The sample included registered nurses (RNs) currently practicing on nursing units employing CNLs. The sample included the following parameters for RNs: 1. Licensed in the State of Florida 2. Primary employment in the hospital setting 3. Able to read, write, and speak English Limitations The sample did no t include Nurse Directors, Managers, Licensed Practical N urses or ancillary personnel : 1. T he CNL is a relatively new professional role; the number of CNLs in practice is limited 2. The CNL is an initiative currently in the United States, thereby making infe asible extrapolation of the results to other countries Significance of the Stu dy In 2003, the AACN responded to the growing nursing shortage and changes in healthcare with a white paper, The Role of the Clinical Nurse Leader The AACN white paper argue s the need for a new hospital role, a care and improve s healthcare systems Furthermore, the paper proposes that the CNL coordinate s and plan team activities and functions Core skills for the CNL role are delegati ng, supervising, evaluating, and supporting healthcare team members Th is CNL proposal

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12 As the CNL role in nursing is implemented, how it affects the factors of work related stress, job satisfaction, quality of life, and anticipated turnover deserve exploration This study investigate d whether the CNL decrease d work related stress nurses and a nticipated turnover, satisfaction and their perception of quality of life The desired result is to decrease the number of nurses expressing a desire to leave the profession A decrease c ould help alleviate the nursing shortage and retain qualified nurse s at the bedside.

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13 Chapter Two Literature Review This chapter first presents a review of the empirical literature related to these factors, factors that contribute to increased workplace stress, poor quality of life, low job satisfaction and the lik elihood of nurses leaving the profession of nursing These factors are demonstrated in the literature review has having global consistency. Finally a summary is provided of the potential effectiveness of initiatives to reduce stress and improve quality o f life and job satisfaction as well as a description of further areas for research Review of the literature reveals that work related stress can contribute to low job satisfaction, poor quality of life and increased likelihood of nurses leaving the profe ssion Work related stress is well documented but no studies have been done to address the relationship of the newly created CNL on this stress phenomenon. The literature is replete with references to the effects of work environment on nursing work rela ted stress, quality of life, job satisfaction and anticipated turnover (Stichler, 2009) The review of the literature took an international focus to demonstrate the global issue of nursing work related stress. Work related stress, quality of life, job s atisfaction and anticipated turnover for acute care nursing has been widely investigated in many cultures and countries The succeeding section is a review of empirical literature on the factors contributing to work related stress, perceptions of quality of life, job satisfaction

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14 and anticipated turnover in In conclusion a summary of the empirical literature is discussed. Work R elated S tress The work of nursing varies from hospital to hospital and country to country and yet nurses repeatedly report in creased levels of stress (AlArub 2004, Begat 2005, Boyle 2004, Bruyneel 2009, Chang 2006, Coomber 2006, Fletcher 2001, Golubic 2009, Hall 2004, Hayes 2006 Janseen 1999, Lambert 2004, Makinen 2003 McGowan 2001, M Neely 2005, McVicar 2003, Metzenthun 2009, O loffson 2003, Piko 2006, Santos 2003, Ruggerio 2005, Sveinsdotter 2005, Zeytinoglu 2005). Work related stress is an ongoing area of research in the nursing profession Recently, Golbubic et al. (2009) cited six major groups of occupational stressors in a study of Croatian nurses A cross sectional study of 1086 (response rate 78%) nurses identified organization of work and financial issues, public criticism, hazards in the work place, interpersonal conflict, shift work and professional and intellectual d emands as contributors to increased work stress Specifically, organization of work and financial issues that were significant was: insufficient number of co workers ( p < 0.08), unexpected situations ( p <0.01 ), and paperwork ( p <0.0 6) Public criticism show ed significance in conflicts with patients ( p < 0.02 ), patie p <0.0 1) and professional and private life stress ( p <0.01 ) In the areas of hazard in the workplace and shift work all variables showed statistical significance ( p <0. 0 1) The researcher concluded that in Croatian nurses with higher education there were substantially decreased levels of low workability 37% in those with secondary education versus 30%

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15 with higher education indicating a need to further investigate the role higher education plays in decreasing factors causing work related stress. A recent clinical study conducted by Metzenthin et al. (2009) measured salivary cortisol levels in conjunction with a subjective stress tool in 82 pediatric and critical care nu rses in Switzerland The research revealed a statistically significant increase in cortisol levels when compared to sub jective reported stress ( p =0.04 ) Additionally, objective stress measured through a standardized hospital management tool did not show a statistical relatio nship to cortisol levels ( p =.5 6). A recent study sponsored by the N ational Institute of Health examined the predictive validilty of the International Hospital Outcomes study This study served as pilot research for the RN4CAST consort itium which consists of 15 member nations that will indicate the effect of the nursing work environment and nursing staff deployment on recruitment, retention and productivity and on patient outcomes in the 11 participating countries (Bruyneel 2009) A Norwegian study by Begat (2005) surveyed 71 nurses on how the stress levels they experienced at work correlated with job satisfaction and perception of psychosocial work environment Begat (2005) found through factor analysis that there were six factors t hat had a high correlation to job stress and anxiety Factor 1 measured job stress/anxiety which accounted for (15.05%) o f the overall correlation with =.83 ), and factor one attributed increased stress to nurses feeling they had to o m uch to do ( =.90) and being stressed out on the job ( = .87) Factor 2 explored relationships with colleagues resulting in an overall correlation of (13.66%, = .63) Specifically, nurses identified a need to discuss problems ( =.80) responsiveness o f subordinates (

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16 =.77), colleagues openness to new ideas ( =.75) and the ability to get information ( =.64). In Factor 3 collaboration/communication was responsible for (11.2%) overall with an alpha of 0 .72 The nurses reported a positive relationsh ip when the y belonged to fellowship ( =.88) and when they were able to collaborate with others ( =.84). Factor 4 (10.7%, = .74) showed nurse felt more job motivation when they were engaged at work ( =.81) and found the work interesting and stimulating ( =.75) Factor 5 looked at work demands (7.8%, =.64) specifically planning and noted a correlation between stress and no job description ( =.79) and lack of planning or routines ( = .78) Lastly, Factor 6 found a positive correlation with profes sional development (5.9%) and nurses being encouraged to develop new skills ( =.85) Overall, these 6 factors explained 64.3% ( = .75) of the principal components of nurses perceptions of their psychosocial work environment (Begat, 2005) A second desc riptive study by Begat (2004) compared the responses of Japanese and Norwegian nurses on perceptions of work and moral sensitivity This study revealed that both Japanese nurses ( p <0.00) and Norwegian nurses ( p <0.001) showed a significant correlation betw een work environment and moral sensitivity The Japanese nurses showed a mild correlation to work demands and lack of time ( p <0.05) a mild correlation with moral conflict ( p <0.05) and a moderate correlation with job stress and anxiety ( p <0.01) The Nor wegian nurses also showed a moderate significance for job stress and anxiety ( p <0.01), independency ( p <0.01), as well as patient centered orientation ( p <0.01) The results demonstrated that both groups of nurse displayed moral stress in their work environ ment The Japanese nurses had a higher correlation to work

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17 demands and lack of time while the Norwegian nurse had a stronger correlation to independency (Begat, 2004) A survey of 1780 nurses in Michigan found that nurses believed they were being asked t o provide more care with less staff and that patients had unrealistic expectations of the level of care (Fletcher, 2001) The respondents rated their mean professional stress compared to other health professions as high correlation ( R = .90) indicating tha t most nurses experienced some level of work related stress Additionally, the nurses rated their job satisfaction as 5.04 on a scale from 1 to 7 concluding that they were somewhat satisfied with their job and they rated their likelihood of leaving the p rofession as 4.08 on a scale from 1 to 5 indicating a low likelihood of leaving the profession (Fletcher, 2001). A qualitative exploratory study looked at work related stressors and coping mechanisms in hospital registered nurses (Hall, 2004) The researc her interviewed 10 nurses in Kentucky and found that they believed that a shortage of skilled labor and polychronicity was responsible for their increased stress levels The nurses identified categories that they felt were responsible for their stress and among them system barriers, self expectations, shortage of skilled labor care The study also found that negative communication includ ing anger and discourtesy experienced in interactions with other health care professional doctors, and patients and families was a source of stress When effective communication broke down nurses tended to withdraw f ro m the situation and focus on when their shift would end or resign themselves to a situation they believed would not change (Hall, 2004)

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18 British literature from 1985 until 2003 was reviewed to identify work related stress factors ; this resulted in 21 primary research studies being included in the review (McVicar, 2003) After c ollecti ng the evidence the common factors were determined to be : (1) workload (2) inadequate staff (3) time pressure, (4) relationships with other clinical staff, (5) leadership style (6) poor locus of control (7) lack of supervisory support, (8)coping with death and dying,(9) shift work and (10) lack of rewards (McVicar, 2003) In conclusion the researcher suggest ed a need for ensuring professional, emotional and social support in the workplace as a stress prevent ative measure (McVicar, 2003) A second review of the British literature from 1997 until 2004 was conducted by Comber and Barriball (2006) which explored job satisfaction and intent to leave for hospital based nurses Nine articles were identified meetin ; this review, like previous reviews, confirmed four major themes that impact job satisfaction and intent to leave : (1) leadership ; (2) educational attainment ; (3) stress ; and (4) pay The researchers concluded that the componen ts of job satisfaction and intent to leave have been consistent over time They recommend ed that additional research at the unit/ward level be conducted and that tools for comparability need ed to evolve A study of 247 U.S. nurses by Ruggerio (2005) rev ealed there was no significant difference in the level of stress nurses experienced on a particular shift However, further analysis on job satisfaction revealed several statistical ly significan t relationships with global sleep quality ( p < 0 .54), depressio n ( p < 0 .15), emotional distress ( p < 0.05), and number of weekends off a month ( p < 0 .04) having a negative impact on all shifts Santos (2003) studied 694 nurses and found that increased stress was related to responsibility and physical work environment In particular, this study found that Baby

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19 Boomers experienced significantly higher stress levels regarding responsibility These stressors included role overload ( p = 0 .43), role insufficiency ( p < 0 .01), role ambiguity ( p = 0 .03) and role boundary ( p < 0 .02) A c ross sectional survey study conducted in Iceland looked a the differences among occupational stress job satisfaction and the working conditions in nurses practicing in the hospital setting and nurses in other settings ( Sveinsdotter, 2005) A random sam ple of N=522 participants yielded a response rate of 42% ( n =219) The researcher found that both hospital nurse s and non hospital nurses experienced high stress related to their working environment ( t =0.75 p =0.45) and job satisfaction for the two groups was correlated moderately with occupational stress( r =0.41; p <0.01) The nurses working in hospital settings scored higher on variables related to strenuous working conditions On average the hospitals nurses worked 39.4 hours weekly compared to the non hospital nurse who worked 36.3 hours weekly ( p < 0.03) and hospital nurse provid ed 1.2 hours more direct patient care ( p < 0.03) ( Sveinsdotter, 2005). Different healthcare structures utilize different nursing models. To identify whether a specific mode/mode l of nursing was more prone to increase stress levels Makinen et al. (2003) sampled 677 Finnish nurses on 30 wards After distributing self report questionnaires the response rate was 84% ( N =568) from 27 of the 30 units Bivariate correlations showed s pecific components of organizing care and work overload as interrelated, specifically, work grouping ( p = 0 .13), work allocation( p = 0 .94 ), duty rotatio n( p = 0 .18), accountability ( p = 0 .79 ), writing nursing notes ( p = 0 .91 ), and relationsh ips with other disciplines ( p = 0 .75 ) The authors studied primary, modular, team and functional nursing and found no significant difference in stress levels that could be

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20 attributed to the mode /model of nursing ( Makinen et al 2003) Throughout th e study nurses attribute d these fact ors as contributing to their inability to deliver safe, quality patient care (Makinen, et al, 2003) In the international community nursing practice varies in part due to cultural differences and also because of a differing societal way of financing heal thcare In Japan ; however Lambert ( 2004) determined that the work place stressors in both eastern and western nursing environments are the same A study of 310 Japanese nurse s found a strong positive correlation between work place stressors and workload as well as likelihood of leaving the profession Workload ( p =0.01) showed a strong positive correlation with workplace stressors in particular conflict with physicians ( p = 0 .5 2), death and dying ( p = 0 .47), conflict with other nurses ( p = 0 .34), lack of support ( p = 0 .34), inadequate preparation ( p = 0 .46), and uncertainty of treatment ( p = 0 .54) A cross sectional study on poor work environment and nurses inexperience and their relat ionship to burnout job satisfaction and quality defects conducted in Japan in 2008 by Kanai Pak et al. surveyed 5956 Japanese nurses on 302 units in 19 acute care hospitals The results showed that 56% of nurses scored high on burnout, 60% were dissatis fied with their jobs and 59% rated the quality of care as fair or poor Seventy two Irish nurses identified a strong negative correlation between job satisfaction and stress, specifically managing workloads ( r = .40, p < 0.01), dealing with patients and fa milies( r = .37, p < 0.03) as well as management of unresponsiveness ( r =0.56, p < 0 .0 0) (McGowan, 2001).

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21 Additional research identified two levels of support including social support from colleagues and organizational support from management or leadership as i mportant factors that decrease stress. In another study, t wo hundred sixty three Jordanian nurses felt that when they had strong social support they experienced less stress and had a higher level of job satisfaction (AbuAlRub, 2004). Upon analysis of t his data the researcher demonstrated that the nurses who felt supported provided an enhanced quality of patient care The study tested four hypotheses Hypothesis 1 postulated that nurses with increased social support would experience decreased stress and this was supported with a negative correlation ( r = .10, p < 0 .01) Hypothesis 2 tested whether increased job stress would decrease job performance ; this demonstrated a negative correlation that was not significant ( r = .10, p = 0.09 ) The third hypothesis looked at the impact high social support had on job performance ( r = .17, p < 0 .01) and was supported Hypothesis 4 tested to see if increased stress was less for nurses with high social support and the effect of increased stress on job performance The re searcher determined this was not significant and required more research (AbuAlRub, 2004). A literature review conducted in the United States included 15 empirical articles that were grouped into three themes : empowerment, job strain and motivation T he re search was shown to have a link to social support and stress in the work environment The findings determined that social support was a main, moderating or mediating effect and was able to decrease stress, burnout, and absenteeism and improve job satisfac tion (Shirey, 2004)

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22 A study in the United Kingdom by Attree (2005) used a qualitative grounded practice Utilizing semi structured interviews the researcher found a core category of professional dissonance which then divided into three subcategories The study showed that professional discrepancies, professional discontent, and professional dilemmas or decisions led nurses to a perception of a lack of governance, increase d stress, higher turnover and low moral e. In conclusion, the study indicated that further investigation A comprehensive review of the literature examined common causative f actors for nurse turnover in the U.S., Canada, England, Scotland and Germany (Hayes Pallas, Duffield, Shamian, Buchan, Hughes, Spence Laschinger, North, Stone, 2006).Thirty seven studies reported measures of turnover or turnover intent, and five s tudies examined the consequences The determinants for nurse turnover found by this review were job satisfaction and organizational characteristics Organizational characteristics; workload, stress, burnout, management style, autonomy, advancement opport unities work schedules and economic factors were found to be moderating effects In summary, the researchers concluded that administrative interventions to improve the quality of work life were necessary to effectively reduce turnover (Hayes et al 200 6) Gray Toft and Anderson (1985) developed a model to diagnosis and predict organizational stress The researchers used measures of organizational climate, supervisory practices and work group relations as predictors of role ambiguity and role conflic t Nurse stress was viewed as a direct cause of low job satisfaction and an indirect cause of absenteeism The model was validated with data from 158 registered nurses,

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23 licensed practical nurses and nursing assistants on seven nursing units in a large p rivate teaching hospital The results of the study confirmed that role conflict, role ambiguity and stress are inherent in nursing Administration was found to have a negative effect on role conflict ( r = 0.19) Communication was found to have a negativ e effect on role ambiguity ( r = 0.51) as was supervisory style ( r = 0 .16) and work group relations ( r = 0.22 ) Job satisfaction was correlated negatively to conflict ( r = 0 .16 and stress( r = 0 .18) and resulted in absenteeism ( r = 0.05).The authors determ ined that staff are more satisfied and perform more effectively when they are in a supportive work environment that allows for open participation in decision making regarding policies and procedure which in turn helped alleviate role ambiguity and decrease stress (Gray Toft Anderson 1985). of respect and organizational justice in hospital settings was developed by Spence Laschinger (2001) A random sample of 285 nurses (respon se rate 52%) from an Ontario Canada hospital were surveyed on interactional justice, structural empowerment, perceived respect, work pressures, emotional exhaustion and work effectiveness Interactional justice proved to be the strongest antecedent of re spect ( r 2 = 0 .72) followed by structural empowerment ( r 2 = 0 .47) (adequate resources and support) and overall empowerment ( r 2 = 0 .47) Negative antecedents were stress from lack of recognition ( r 2 = 0 .38) poor work relationships ( r 2 = .58 ), and heavy workload ( r 2 = 0 .24) The positive consequences of respect showed the strongest relationship between respect and job satisfaction ( r 2 = 0 .52) and trust of management ( r 2 = 0 .42) and noted a negative relationship between respect and intention to leave ( r 2 = 0 .24), emoti onal exhaustion ( r 2

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24 = 0 .35), and depressive state of mind ( r 2 = 0 .21) (Spence Laschinger 2001).The researcher concluded that a positive work environment contributed to nurses feeling respected/empowered and that respect was able to mediate stress in the work environment( Spence Laschinger, 2001) Two hundred thirteen RNs and licensed practical nurses were queried at a larger Philadelphia trauma hospital on verbal abuse and increasing stress levels The study reported nurses experienc ing verbal abuse most frequently by other nurses (27%) followed by families (25%) physicians (22%), patients (17%), and other co workers (9%) (Rowe, 2005) The research concluded that nurses who experienced regular verbal abuse were more stressed and less satisfied with thei r jobs and more likely to deliver ineffective care for their patients (Rowe, 2005) In an interventional study conducted by Boyle (2004) made an effort to improve collaborative communication between physicians and nurses in the intensive care setting T he participants were instructed in modules on ways of improving communication Aim an ICU setting Attendance was measured with a majority of participants attending 91% of the time Aim 2 investigated the effects of the intervention and post test scores showed a significant change in communication ( t =2.81 p = 0 .02) but no significant change in relationships ( t = 0.18 p = 0 .86) Aim 3 explored the sustained effect o f the intervention after 6 months All variables showed a change although they were not significant (MANOVA=0.31, p = 0 .13) This study showed that communication could be improved and that in doing so patient outcomes, job stress and job satisfaction could improve

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25 In summary the literature reveals that work related stress factors affect hospital nurses in many countries and cultures The effects of work related stress can result in low job satisfaction, high turnover and poor patient outcomes (Aiken, 2 001) Severe distress is linked to staff absenteeism and even ill heath (Healy, McKay 1999, McGowan 2001, Shader et al, 2001) The literature review has supported the fact that these variables are present globally. In this time of an ever increasing nu rsing shortage the international related stressors and improve the work environment for hospital nurses and by doing so hopefully retain ing nurses at the bedside. Quality of Lif e There physical and psychological heath Psychological and physical functioning is directly related to perception of quality of life. A systemic review of the literature conducted in the United States (Gershon, Stone, Zeltzer, Faucett, Macdavitt, Chou, 2007) focused on understanding the effect of organizational climate on nurse health outcomes The literature from 1997 2007 was explored and 1414 articles met the researchers criteria for inclusion They examined the association between quality of work life and themes : (1) blood and body fluid exposure ; (2) musculoskeletal disorder ; and (3) burnout The systematic review provides growing evidence of research that demonstrates that hospit al quality of work life can negatively

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26 D atabase was established in 1976 and included 121,700 married female RNs. Every two years questionnaires on medical history and lifestyle are sent to the entire c ohort In 1992 the Medical Outcomes study short form 36 (SF 36) was included in the mailing A study by Michael, Colditz, Coakley & Ichiro (2000) us ed the SF 36 results to look at domains of physical functioning, emotional functioning and social network s Initially 75,434 women completed the survey ; however, the researchers excluded respondents with coronary heart disease, cancer and stroke diagnosis and incomplete surveys resulting in a response rate of (73%) N =54,868 The study examined the relativ e impact of health behaviors on functional status as measured by the subscales of physical functioning, bodily pain, vitality, and role function Normal body mass index (BMI), regular exercise, no alcohol consumption and not smoking proved to correlate p ositively to physical functioning ( r 2 =0.19 ), bodily pain ( r 2 = 0.15), and vitality ( r 2 = 0.12 ) in women under 65(Michael et al 2000) Next, the researchers e xamin ed the effect of social networking on the group and found that having three to five close fri ends, weekly participation in religious services and group participation had a positive relationship with physical functioning ( r 2 =0.17 ), bod il y pain ( r 2 = 0.14 ),) and vitality( r 2 = 0.14 ) in women under 60 (Michael et al 2000) In summary the study sugge st ed that modifying health behaviors and establishing social networks are key A second SF participants and further research was conducted by the Department of Health and Social behavior at Harvard School of Public health (Cheng, Kawachi, Coakley, Schwartz & Colditz, 2000) The researchers obtained a sample from the original respondents and

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27 excluded those who were no longer in the workforce as well as anyone with coronary disease, cancer or stroke which resulted in ( N= 21,290 ) (76.5%) nurses Their conclusions propose d that adverse work conditions are important predictors of poor functional status and its decline over time leading us to believe that a positive work environment affects health as well as quality of life (Cheng et al 2000) Other research 14 of research and determined that over time nurses who experienced minimal to high s tress levels at work or at home were five times more likely to commit suicide (Feskanich, Hastrup, Marshall, Colditz, Stampfer, Willett & Kawachi, 2002) This study prospectively examined the association between self perceived stress, diazepam use and de ath from suicide in 94,110 nurses Analyses showed that 73 suicides occurred and that participants with severe stress at work or home had higher relative risk (RR) for suicide (RR=3.7, 95% CI 1.7to 8.3) (Feskanich et al., 2002) A cross sectional Danish study used and effort reward model to test the association with psychological health and poor self rated health (Weyers, Peter, Boggild, Jeppesen, Siegrist, 2006) Three hundred sixty seven participants were included in the study with an overall respons e rate of 67.7% Nurses were at risk of reporting poor health in relationship in two components of the proposed model, effort reward ratio imbalance and over commitment T he study revealed five of the six indicators of effort reward imbalance and over co mmitment associated with poor self rated health Study results demonstrated statistical significance for overall poor general health ( p poor psychological well being ( p p

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28 cardiovascular complaints ( p and musculoskeletal complaints (Weyers, et al, 2006) An article by McNeely (2005) looked at the implications of job stress on nu health The author identified that nurses felt a lack of control over their practice resulting in feeling powerless They stated that they had no influence over work related matters and that they were not taken seriously and therefore they experie nced higher stress levels and in some cases reported an overall decrease in perception of health The author suggest ed that additional research is needed to explore the relationship between nurses work, chronic job stress and career and health trajectorie s and that interventional studies be done on work reorganization to improve the health of nurses(McNeely, 2005) Olofsson (2003) conducted a grounded theory study that identified that negative stress was triggered in four Swedish nurses when they lacked co nfidence in their ability to deal with the demands of the job Results showed nurses had an absence of response ; this core category is described as an inability to respond or be receptive to people or sensations leading to feeling inadequate, powerless, f rustrated and hopelessness When these feeling are unaddressed over time they may have both psychological and physical effects (Olofsson, 2003). Australian researchers Healy and McKay (2000) demonstrated a positive correlation between workload and stressi ng for N = 128 nurses The Nursing Stress Scale (NSS) factors accounted for 15% of the variance on Profile of Mood Scale (POMS) ( p <0.0 1) with workload being the only significant predictor of mood disturbance. Australian researchers Chang, Daly, Hancock, Bid ewell, Johnson, V.Lambert and C Lambert (2006) surveyed 900 nurses with a response rate of N =320 (36%).The results

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29 showed a negative relationship both physically and mentally between stress and four factors : workload ( p = 0 .20/ p = 0 .32), death and dying ( p = 0 .17/ p = 0 .19), uncertainty about treatment ( p = 0 .21/ p = 0 .28), and conflict with physicians ( p = 0 .18/ p = 0 .31) Additionally, the research demonstrated that physical health was only correlated to age and that mental health scores were higher for nurses who had good coping skills and experienced work place support (Chang, et al 2006). A study examining the occupational and non occupational variables predictive of job satisfaction and psychological distress of nurses utilized a convenience sample of 658 nu rses at an urban university hospital resulting in a response rate of 436 (66%) ( Decker, 1997) Included in the study were 376 female, fulltime nurses Six variables were found to have significance in predicting job satisfaction ( p 0 .05) : head nurse, job/non job conflict, coworkers, unit tenure, physicians and other departments Eight variable s were statistically significant for psychological distress ( p 0 .05) : anxiety trait, unit tenure, social integration, experience, head nurse, job/non job conflict, level and physicians Overall, Decker (1997) demonstrated that occupational role relations were more predictive of job satisfaction than psychological distress and that implementing nurse manger interventions could have a po sitive response on both job satisfaction and decreasing psychological distress In Finland researchers examined the justice of decision making procedures and interpersonal relationships as psychological predictors of self rated health in hospital employee s (Elovaino, Kivimaki, Vahtera, 2002) They sampled 5342 employees in seven hospitals in one healthcare district in Finland resulting in 4076 (76%) of the questionnaires completed Ninety three percent of the nurses were women and fifty percent of the p hysicians were me n. The data was analyzed to identify

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30 the odds ratio (95% CI) of poor self rated health in men (OR= 1.21 95% CI 0.48 to 3.07) and women (OR= 1.76, 95% CI 1.32 to 2.35) and the association with procedural justice They also looked at the im pact of organizational justice on minor psychiatric disorders in men (OR= 2.35 95% CI 0.92 to 6.01) and women (OR= 1.32 95% CI 1.01 to 1.73) Lastly the research looked at the association with procedural justice and the incidence of absences in men (OR= 1.6 1 95%CI 1.12 to 2.32) and women (OR= 1.19 95%CI 1.08 to 1.32) The study showed that organizational justice was associated with health in both men and women and that it was a stronger predictor of absence in men (Elovaino et al 2002). One randomized con trol trial was found testing the effects of stress on natural killer cells in nurse from Japan The researchers found that quantitative workload was the strongest predictor for natural killer cell function as well as burnout Salivary cortisol levels wer e correlated with a self reported measure of perceived stress (Morikawa, 2005) Piko (2005) found 201 Hungarian healthcare staff experienced burnout when they had prolonged exposure to chronic job related stress Nurses and other healthcare staff in two hospitals in Hungry were sampled with 112 nurses returning completed questionnaires ( response rate of 44.6% ). The results showed that burnout particularly emotional exhaustion was strongly related to job satisfaction ( p < 0.0 1) and that role conflict co ntributed positively to both emotional exhaustion ( p < 0 01) and depersonalization ( p < 0 .01) This study also noted an increase in psychosomatic illness in nurses that experienced burnout and role conflict (Piko, 2005). A Brazilian study of 461 nurses was done to describe occupational stress, job and

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31 coping methods The study report ed a strong inverse relationships between global constructive thinking and psychological ill health ( r = 0.67) occupational stress ( r = 0.34) and physical ill health ( r = 0.27) (Stacciarini, Troccoli, 2004) Occupational stress was found to be significantly associated with psychological ill health ( r = 0.50) and physical health( r = 0.4 3) and inversely associated with job satisfaction ( r = 0.26) ; psychological health w as correlated with physical ill health ( r = 0.66) This study demonstrate d that increased work related stress is positively correlated to decreases in perceived health ( Stacciarini,Troccoli 2004) Few studies have implement ed interventions to alleviate work place issues Mimura (2002) completed an evidence based review of the literature on current approaches to workplace stress management Seven randomized control tr i als and three prospective cohort studies were found The researcher acknowledged that both the quantity and quality of the studies were weak. In summary, a need for research that studies the relationship between healthy nursing work and productive, afford able, and safe healthcare systems was identified Work environment is also noted to have an effect on job satisfaction Job Satisfaction In a study by Aiken (2002) the correlation between staffing levels and patient mortality, nurse burnout and job sa tisfaction were measured A cross sectional analysis of 10,184 nurses measured self reported job satisfaction and job related burnout Analysis of the data collected showed that an increased patient to nurse ratio resulted in a 23% (95% CI, OR 95% CI 1.1 3 to 1.34) increase in burnout and job dissatisfaction and had an effect on patient outcomes (Aiken, 2002) In this study the researchers measured

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32 the effect on specific variables when the patient to nurse ratio w as increased The authors found that the h igher patient load for nurse s directly correlated to a decrease in job satisfaction, an increase in work related stress or burnout and negative patient outcomes Aiken (2002) suggested that improving staffing ratios may reduce nursing attrition improve job satisfaction and provide safer patient care In a meta analysis of nurses job satisfaction by Blegen (1993) 200 published and 50 unpublished studies were reviewed Forty eight of the articles were included in the meta analysis The strongest rel ationship with job satisfaction was stress ( r 2 = 0 6 9) Commitment had a positive correlation ( r 2 = 0 .53 ) as did communication with supervisor ( r 2 = 0.45 ), autonomy ( r 2 = 0.42 ), recognition ( r 2 =0.42 ) communication with peers ( r 2 = 0.36 ) and fairness ( r 2 = 0 .29) Also noted in this review were weaker negative correlations of age ( r 2 = 0 28) and education ( r 2 = 0.70) The remaining variables only showed a small correlation (i.e. locus of control, age, years of experience and professionalism ) A study done a t Ohio University School of Health Sciences surveyed the influence of organizational citizenship on job satisfaction (Bolon, 1997) The authors looked at the relationships between three organizational commitment components of organizational citizenship be haviors and job satisfaction In this study organizational citizenship behavior was defined as: Behavior that is discretionary, not directly or explicitly recognized by the formal reward system and that in the aggregate promotes the affective functioning of the organization Nurses were 78% of a sample of 202 healthcare workers studied in a tertiary health care setting Results showed job satisfaction was significantly and positively

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33 related ( r = 0 22, p < 0 01) with organizational citizenship behaviors Kn oop (1995) looked at the relationship between job involvement, job satisfaction and organizational commitment for nurses One hundred and seventy one nurses were sampled in 11 hospitals R esults revealed that job involvement was significantly related to job satisfaction ( r = 0 33, p < 0 01) Commitment was also show n to significantly relate to job satisfaction ( r = 0 64, p < 0 01). L eadership style is another variable that is noted to have influence on job satisfaction among nurses In an article by Morrison ( 1997) the relationship between leadership style and empowerment and the effect on job satisfaction was explored Four hundred forty two nurses were included in the survey, which yield ed 275 useable survey responses Results revealed a positive correlat ion between job satisfaction and transformational leadership ( r =0.64, r = 0.35) respectively. Several studies looked the relationship between organizational commitment and job satisfaction Alpander (1990) sampled 150 nurses in a general hospital Nurses were asked to score skill variety, task completion task, autonomy, task significance and feedback on the job using a 5 point likert scale correlated positively and significantly with ( r > 0 49) d emonstrating th at nurses identification with the institution plays a significant role in their feelings and how motivated they are toward their job. The relationship between o rganizational commitment relationship and job satisfaction was again studied in 2002 by Ingers oll In this study questionnaires were sent to 12,000 nurses in the Central Finger lakes region of New York and a sample of

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34 4,000 was achieved to produce sufficient power ( 0 .98) to detect statistical significance ( p < 0 05) Variables found to be signific ant ( p < 0 01) were commitment, autonomy, interaction, organizational policies, pay, professional status and task requirements The impact of these variables on job satisfaction was looked at as having an impact on nurses stay in the profession at one yea r and five years Organizational commitment and the relationship to primary nursing have also been studied Nelson ( 2001) surveyed 325 nurses and found that a primary nursing model was shown to increase autonomy and be statistically significant ( p < 0 01) In addition to commitment, perceived work environment has been noted to have an impact on job satisfaction of hospital staff nurses Tumulty (1994) explored the relationship between work environment and job satisfaction N urses at two acute care hosp itals in the southeast were asked to complete a questionnaire One hundred fifty nine surveys were returned and eligible for inclusion in the study Analysis of the data showed that highly satisfied nurses were more positive with the overall work environ ment than their unsatisfied coworkers Analysis of variance showed that overall satisfaction ( F =0.04), satisfaction with pay ( F =0.87), and status ( F =0.36) varied according to clinical specialty, employment status, professional education and management st atus In the 12 years of research reviewed nine factors have most often been cited as having statistically significant relationship with nursing job satisfaction They are as follows: pay, status, commitment, autonomy, task, policies, interaction/suppo rt, communication and control

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35 Anticipated Turnover Work related stress, poor job performance are often identified in the literature as reasons nurses choose to leave the profession. A cross sectional survey was administered to 390 nurses on 12 nursi ng units in a large university hospital in the southeastern U.S (Shader, Broome M, Broome C, West, Nash, 2001) This yielded a sample of 241 useable questionnaires ( 63% response rate ). The investigators looked at the relationship between job stress, grou p cohesion, and stability of work schedule and anticipated turnover Findings showed that more job stress resulted in lower group cohesion ( r =0.41, p <0.0 1), lower work satisfaction ( r =0.51, p =0.0 1) and higher anticipated turnover ( r =.37, p <0.0 1) Conve rsely, higher job satisfaction resulted in the higher group cohesion ( r =0.42, p <0.0 1) and lower anticipated turnover( r =0.47, p <0. 01) Additionally the research found that a stable work schedule resulted in less stress ( r = 0.20, p <0. 01), lower anticipa ted turnover ( r = 0.29, p <0.0 1), higher group cohesion ( r =0.43, p <0. 01) and higher job satisfaction( r = 0.44, p <0. 01) In summary the study concluded group cohesion and good social support were responsible for increased job satisfaction and decreased ant icipated turnover (Shader et al 2001). In 2002 the Pacific Northwest Nursing Leadership I nstitute (PNNLI) developed a program which consisted of 2 day retreat style workshop and seven additional 1 day modules (Wilson, 2005) Pre and p ost testing of the participants revealed anticipated turnover (ATS) was significantly reduced post program A study in Taiwan showed that there was a significant correlation between job satisfaction and intention to leave the profession (Lu, 2002) A descriptive explora tory study in the Netherlands administered a self report questionnaire to 175 nurses with an

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36 89% response rate ( N =156) (Janssen, 1999) This study showed a positive relationship between job contentment, support of colleagues ( p = 0.03 ) and job motivation ( p =0.28) A negative relationship occurred with job contentment, unmet career expectations ( p = 0 .0 9 ) and turnover intention ( p = 0.27) The research also revealed a strong relationship between mental work overload and emotional exhaustion (p=0.45), unmet career expectations ( p = 0 .01) and turnover intention ( p = 0 .50) The research determined that the demands of nursing and a lack of social support contributed to emotional exhaustion increased stress levels and an increased likelihood of leaving the profes sion (Janssen, 1999). Canadian nurses were surveyed at three large teaching hospitals in Ontario, Canada in order to examin e the effects of job preference, unpaid overtime, importance of earnings and stress on retention in hospitals and the profession (Ze ytinoglu, Denton, Davies, Baumann, Blythe, Boos 2005) Multiple surveys were mailed yielding 1396 responses with a 52% response rate. The results showed a high propensity of leaving the hospital and leaving the profession with a positive correlation ( r = 0 .47, p 0 .01) Stress had the strongest positive correlation with a high propensity to leave the hospital ( r = 0 .3 7 p 0 .01) and leave the profession ( r = 0.25 p 0 .01) and preference for a different job status also showed a positive correlation with lea ving the hospital ( r = 0 .16, p 0 .01) and leaving the profession ( r = 0.06 p 0 .01) T he importance of income had a negative correlation with leaving the hospital ( r = 0.0 9, p 0 .01) and leaving the profession ( r = 0.07 p 0 .01) (Zeytinoglu et al 2005) The researchers concluded that attention needs to be paid to stress, job preference, importance of earnings and use of unpaid overtime in efforts to retain nurses both in hospitals and in the profession (Zeytinoglu et al 2005)

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37 Summary A global pers pective, of nursing care varies but the variables related to increased stress levels are consistent The literature review reveal s that the stress of working as a nurse can contribute to poor job satisfaction, poor patient outcome, and poor perception of psychological and physical health and in extreme cases suicide The reasons nurses leave the profession are diverse ; however the current research leads us to believe that there are interventions that could be implemented that may decrease the likeliho od of leaving the profession This research examine d what role the CNL might play in improving job satisfaction and decreasing anticipated turnover in the United States The documentation of work related stress is one step; the next step needs to invol ve developing ways of reducing stress The fact that there are very few interventional studies looking at ways of reducing work related stress show an area for future research Some research has been done to explore this through qualitative research gather ing nurses opinions on why they experienc e an increase in stress.

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38 Chapter Three Methods Chapter three outlines the research methods and the procedures for this study. First, the research design is discussed. This is followed by a description of the sample and setting, inclusion and exclusion criteria, instrumentation, procedures, approvals, and informed consent. Finally, the data analysis procedures are presented. Design An ex post facto design was used to test the hypotheses of this study. This study was designed to explore the relationship of the CNL role with work related stress, quality of life, job satisfaction, and anticipated turnover of acute care nurses. In addition, the study examined the interrelationships among work related stress, q uality of life, job satisfaction, anticipated turnover and the Clinical Nurse Leader role. The following Logic model developed from the Logic Model for Psychosocial Research (Evans 1992) was used to guide the study design. This logic model depicts the r esearch hypothesis, that the role of the Clinical Nurse leader has a relationship with nursing work related stress, quality of life, job satisfaction and anticipated turnover. This is depicted in Figure 1.

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39 INPUTS WORK ENVIRONMENT FAC TOR OUTCOMES Figure 1. Hypothesized Logic Model. Work related stress Clinical Nurse Leader Increased Job Satisfaction Decreased Work related stress Job Satisfaction Quality of Life Increased Quality of Life Decreased Anticipated Turnover Anticipated Turnover

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40 Setting and Sample Setting Three acute care hospitals that utilize the CNL role in the Tampa Bay area on the West Coast of Florida were chosen in order to pr ovide consistency in this s tudy. T he sample was sought from these institutions because they were among the first to implement the role The units that were surveyed included Medical Telemetry, Urology, Orthopedics and Medical Surgical units with a f acilities without CNLs. Sample. The number of subjects required for a power of .80; assuming a medium effect size .50 ; and an alpha level of .05 was estimated at 63 per gr oup for a total of 126 (Polit& Hungler, 1999). Table 1 displays the figures for rep orted means and standard deviations as well as the magnitude of the differences for the power of two sided independent t tests with significance levels of 0 .05 and a power of 80%. Table 1 Instrument Means and Standard Deviation and E ffect S ize Instrument ID n M SD ES Nursing Stress Scale CNL Non CNL 46 48 83.456 83.979 11.407 12.853 0.0 4 Nursing Work Index Revised CNL Non CNL 46 48 110.021 108.666 21.750 23.038 0.0 6 Medical Inventory Short Form CNL Non CNL 46 48 115.630 115.729 9. 641 9.886 0.01 Anticipated Turnover S cale CNL Non CNL 46 48 47.326 44.708 4.971 7.351 0.46

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41 Inclusion criteria Inclusion criteria for participants included: (1) RNs from s; (2) RNs from units with CNLs and RNs from similar units without CNLs; (3) RNs who speak and read English (4) CNLs must have graduated from a program of study in accordance with the American Association of Colleges of Nurses (AACN) guidelines for CNL edu cational preparation. Exclusion criteria Exclusion cri teria for participants included: 1) Nurses from other than the selected hospital units ; 2) nurse managers, CNLs, LPNs an d nursing assistive personnel; 3) RNs who do not speak or read English. The rea son for this third exclusion is that the survey instruments are written in English, and the primary investigator does not speak or read Spanish, the language other than English likely to be prevalent in Florida. Instrumentation The following instruments were utilized: t he Nursing Stress Scale (NSS) (Hinshaw, 2000) (Appendix A ); the Medical Outcomes Inventory Study Short Form (SF 36) (Hayes, 1998) (Appendix B ); the Nursing Work Index Revised (NWI R) (Aiken, 2001) (Appendix C ; and the Anticipated Turnover S cale (ATS) (Gray Toft, 2000) (Appendix D ) and a demographic data tool (Appendix E ). Nursing Stress Scale The Nursing Stress Scale (NSS) consists of 40 questions using a 4 point Likert scale to identify how frequently a nurse found individual situations str essful (Gray Toft, 1981). Four response categories are provided for each item: never (1), occasionally (2), freq uently (3), and very frequently (4).

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42 A total score measures the overall frequency of stress experienced by a nurse and can be created by addin response indicates a nurse experienced more frequent episode of stress as related to individual questions of stress experienced in the physical environment, psychological environment and ph ysical environment. The lower scores indicate that a nurse experiences less frequent stress regarding the same situations. Total scores range from 0 to 102, with higher scores indicating more frequent stress (Gray Toft, 1981). Validity of the NSS Fac tor analysis revealed seven factors comprise the NSS. Factor I measures stressful situations resulting from the suffering and death of patients. Four of seven items that loaded on this factor are related to the death of a patient. Two additional items ar e associated with patients who fail to improve or who suffer. The Factor II deals with c onflict with physicians, especially stressful situations that arise from are criticism by a physician and conflict with a physician. The other items pertain to the disagreement concerning treatment. Factor III measures i nadequate p reparation, s pecifically feeling inadequately prepared to deal with the emotional needs of patients, families. Factor IV measures the lack of support nurses felt they had to vent negative, angry or frustrated feelings. Factor V identifies c onflict with o ther n urses an d s upervisors as a stressor. The items that load on this factor are associated with difficult situations that arise between nurses and supervisors. Two of the items involve conflict with or criticism by a supervisor; the other three items have to do with conflict with nurses on the same or other hospital units. Factor V relates to the physical environment, t

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43 work load staffing and scheduling problems, and inadequate time to comple te nursing tasks and to support patients emotionally. Factor VII identified nurses facing u ncertainty c oncerning tr eatment as a contributing factor The items that load heavily on this are situations when the physician fails to adequately communicate to the nurse information concerning a (Gray Toft, 1981). Reliability of the NSS Test retest reliability for a two week period with a sample ( N = 31) resulted in an alpha of 0 81 Four me asures of i nternal consistency reported by the researchers resulted in a Spearman Brown coefficient of 0 .79 a Guttman split half coefficient of ,0 .79, and a coefficient alpha 0 .89. Internal consistency measured for five of the seven subscales resulted in an alpha >0.70, two subscales conflict with physicians resulted 0.68 and lack of support 0.65. This instrument demonstrates good overall reliability (Gray Toft, 1981). Nursing Work Related Index Revised The NWI R is a self report of nursing situations that commonly occur on hospital units (Aiken & Patrician, 2000). The NWI R consists of four subscales with 57 items on a 4 point Likert scale. The scores range from 1 strongly agree to 4 strongly disagree, with lower overall scores indicating higher leve ls of job satisfaction The NWI R was derived from the 65 item Nursing Work Index (NWI) developed by Kramer and Hafner (1989) and associated with early research on magnet hospital characteristics. The NWI R was modified to focus on the characteristics of the nurses rather than on those of the organization. Of the 65 items on the NWI, 55 were retained, one was modified, and one added. The 57 items were then divided into four subscales measuring: autonomy; control

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44 over practice; nurse physician relationshi ps; and organizational support (Aiken & Patrician, 2000). Validity of NWI R. Validity was determined in two ways: First, content validity was evidenced by the fact that magnet hospital characteristics were used as the basis for NWI development. The ori ginal researchers, attested to the content validity. Secondly, criterion related validity was supported by correlation of NWI R scores with certain organizational measurements associated with better outcomes. In particular, both higher NWI R scores and p atient satisfaction scores were found in magnet hospitals (Aiken & Patrician, 2000). Reliability of the NWI R. The overall NWI R reliability resulted in a 0.79; nurse physician relationships, 0.76; organizational support, 0.84. After aggregation of individual nurse scores, the alpha subscales were 0.85 for autonomy; 0.91 for control over practice; 0.84 for nurse physician relationships; and 0.84 for organizational supp ort: These figures demonstrate good internal consistency, reliability (Aiken & Patrician, 2000). Medical Outcomes Inventory Study Short Form ( SF 36 ) The Medical Outcomes Inventory Study Short Form (SF 36) is a self report measure of health related qualit y of life. The survey instrument includes eight subscales which are divided into two summary measures Physical and Mental health. The Physical health summary consists of ; P hysical functioning (PF) which measures physical limitations such as ability to p erform activities, lifting, carrying, climbing stairs, bending, kneeling walking and bathing dressing. R ole physical (RP)

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45 refers to limitations of activity. The B odily pain (BP) scale which measures pain intensity and interference with normal activities. The perception of G eneral health (GH) measures self ass es sment regarding overall health as compared to others and health expectations. The Mental health summary consists of the Vitality (VT) subscale which asks participants to rate their level of energy. The S ocial functioning (SF) scale which assesses the extent physical and emotional health have impacted the ability to engage in social activities the role emotional (RE) scale which asks to what extent have emotional problems limited your work or daily activity. The mental health (MH) scale uses a 4 week period to gauge the way a participant has been feeling (Ware et al., 1993) The summary scores for mental and physical health as well as the subscales measure self perceptions of quality of life. Or iginally developed as a multipurpose health survey instrument, SF 36 has been translated in more than 50 countries has become the most extensively validated and used generic instrument for measuring quality of life. It has extensive applications for health surveys, measuring physical and mental health across groups of diverse populations (Contopoulos Ioannidis DG, Karvouni A, Kouri I, Ioannidis JP, 2009) The SF 36 has been administered in various population surveys in the U.S. and other countries (Ware, K eller, Gandek, Brazier, & Sullivan, 1995), as well as to young and old adult patients with specific diseases (Ware et al., 1993; McHorney et al., 1994). There is little research that uses the SF 36 survey to measure the physical and mental health of nursin g populations. Validity of the SF 36. Research to test the factorial validity of the SF 36 with health system employees as part of a study of health status was conducted in 1995 and

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46 1996(Reed, 1998). Confirmatory factor analysis and structural equation modeling techniques were used to evaluate the data. The results of this study suggest that Mental Health and Physical Health are not independent; Mental Health cross loads onto Physical Health and general health loads onto Mental Health instead of Physic al Health. This study supports the second order factorial structure of the SF 36. Adding the covariance path between the variables Physical Health and Mental Health improved model fit. Health perception was influenced by Mental Health rather than Physic al Health, and mental health was influenced by both Mental Health and Physical Health. This cross loading suggests that the perception of Physical Health greatly affects mental health. This study indicated that a comparison of mean scores or summary scores is inappropriate due to instabilities in subscales. Data interpretation can be improved if multi groups structural equation modeling is used (Reed, 1998). Research in Greece, specifically aimed at health care workers demonstrated that Medical doctors a nd technical personnel reported better health status than nurses; women reported poorer health status than men on all eight SF 36 dimensions; younger employees reported poorer health status than their older counter partners. Moreover the mean scores on al l SF 36 dimensions reported by the participants on this study were considerably lower than the U.S and many European national norms. The study results constitute an indication of the SF 36 construct validity (Tountas, 2003). Reliability of the SF 36. T he subscales have been repeatedly tested for validity and reliability. The following are the eight dimensions of the instrument; have a demonstrated reliability reported as physical functioning (PF) role physical (RP) .89 bodily pain (BP) 90 s elf asses ses perception of general health 81, vitality (VT) 86,

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47 social functioning (SF), 68, role emotional (RE), .80 and mental health(MH) ( Ware et al., 1993; Ware et al., 1994) A study of 225 nurses, demonstrated alpha reliability coefficients for each of th e subscales as follows: general health .85; vitality .85; bodily pain .82; physical functioning .83;role physical .84; role emotional .80, mental health .80; and social functioning .83 (Budge, 2003). The SF 36 was determined to be both a valid and reliab le measure of both physical and mental health. Anticipated Turnover Scale positions. Self administered the ATS uses 12 items on a 7 point Likert scale; with 1 representing agrees strongly ranging to 7 disagrees strongly. The higher scores indicate The lower scores indicate less likelihood of nurses leaving their current position. Validity of the ATS The ATS was validated through an assessment of convergent and discriminate validity (Atwood, Hinshaw, 2003). Principal components factor analysis yielded a two factor solution that explained 55% of the variance. Additional construct validity was estimated by predictive modeling techniques (De Groot, 1998). Reliability of the ATS The researchers that developed this instrument report a Coefficient alpha reliability as.84 ( N = 1525) (Hinshaw & Atwood, 1984). A cross sectional study of randomly selected registered nurses ( N =463) in Missouri, yielded an estimated a reliability of .94 (Hart, 2005).

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48 normal range of values is .00 and +1.00, and a higher value reflects a higher degree of internal consistency (Polit, Hungler, 1999). Demographic Data Form The demographic data form, developed by the primary investigator, measured both work history and individual variables of the participants. The specific items examined w ere ; age, gender education preparation, length of employment in nursing, at the hospital and unit level, work status, marital status, number of children and ethnicity. Procedures Approvals Permission to use the NSS, ATS, and NWI R were not needed as re production of these instruments for noncommercial use does not require permission from the authors. Permission to use the SF 36 was purchased. Approval for this study by the Institutional Review Board (IRB) of the University of South Florida (See Appendi x F ), as well as the IRB of Informed consent from the participating hospital system (See Appendix G) was obtained. Additionally a modification of the original IRB approval was obtained due to changes in the recruitment procedures and informed consents (Ap pendix H ). Recruitment and Data Collection The primary investigator contacted the three hospital system to initiate research after receiving their IRB approval. The principal investigator then posted signs inviting registered nurses to participate in in formational session in team member lounges on the selected units announcing dates and times for the sessions regarding the study (See Appendix I ). Potential study participants were approached by the PI and asked to take

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49 part; only individuals who met the inclusion criteria on the selected units were invited to process, the informational sessions at each hospital were held at times and locations convenient for particip ant attendance. During the informational sessions the investigator explained the study purpose and intent to use the data to describe the CNL role as related to the variables of nursing work related stress, quality of life, nursing job satisfaction and an ticipated turnover. It was clearly stated that participation was voluntary and anonymous. Those who agreed to participate signed an IRB approved informed consent form and were given a copy of the signed consent form. Survey packets were distributed wit h instructions on completion and participants were given the option of completing the surveys and returning them to the PI or forwarding them via a stamped addressed mailer. Specifically, the RNs were asked to complete five survey instruments, including a researcher developed demographic form. The four other surveys were used to measure the variables: work related stress, job satisfaction, quality of life, and anticipated turnover. The PI then collected the surveys and screened them for completeness. N ext, the surveys were coded by group, identifying the nurses on units with CNLs and the RNs on units that did not work with CNLs. No personal identifying data was attached to the surveys. The data was collected and analyzed to examine any associations be tween participant characteristics and the variables of significance.

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50 Demographic data was collected from the participants to allow for description of the sample. Demographics included the following : age, gender education preparation, length of employment in nursing, at the hospital and unit level, work status, marital status, number of children and ethnicity. Each participant was given instructions to mark the surveys with a code known s research study are reported only as aggregate data. Data from the surveys was used to determine whether the CNL role has a r related stress, quality of life, job satisfaction, and anticipated turnover The aims were designed to explore specific constructs of the theoretical framework and are as follows. Steps 1, 2, and 3 were aimed at exploring the role the CNL had in decreasing work related stress, improving quality of life, increasing job satisfaction and decreasing anticip 1. (Aimed at exploring the potential of the CNL role as a means of decreasing nursing work related stress). To measure the levels of nursing work related stress using the NSS, nurses were asked to rate the f requency that they experienced stress on their nursing unit by depicting specific situation. Areas explored included patient situations, interactions with colleagues, supervisors and physicians, and overall work environment. 2. (Aimed at exploring whether t To determine self reported quality of life via the SF 36 the nurses were questioned on perceptions of physical, emotional and social health.

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51 3. isfaction and decreased anticipated turnover). Using the NWI R, RNs were asked to answer questions pertaining to satisfaction, autonomy, organizational support and nurse physician relations. Using the ATS nurses were asked questions regarding the likelih ood of leaving their current nursing job. 4. units decreased work related stress, improved job satisfaction, improved quality of life, and decreased anticipated turnover). Using t he cumulative score of each of the prior instruments multiple regressions holding each variable as a constant were used to determine if the CNL role was a predictor. Data Analysis Statistical analysis tested four hypotheses. The following section prese nts the hypotheses tested and the data analysis procedures. The following three hypotheses were tested using independent t tests. H 1 : Nurses practicing in units with a CNL will exhibit a decrease in work related stress compared to nurses practicing in units without a CNL. H 2 : Nurses practicing in units with a CNL will exhibit improved perception of quality of life compared to nurses pr acticing in units without a CNL H 3 : Nurses practicing in units with a CNL will exhibit increased job satisfaction, an d decreased anticipated turnover compared to nurses practicing in units without a CNL. The fourth hypothesis was tested using multiple regressions.

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52 H 4 : The CNL role is a predictor of decreased anticipated turnover, improved work related stress, increased job satisfaction, and improved quality of life. To be confident the PI assured (1) Independence; (2) Normality, was achieved as this sample size was >20; and (3) Homogeneity of variances were assured with equal sample sizes. Hypothesis four was tested by multiple regressions to determine if the CNL role is a predictor of decreased anticipated turnover, improved work related care nursing units. The assumptions of the regres sions are that the predictor variable is fixed and measured without error. The data was observed for linearity, homoscedastcity of errors, the errors were normally distributed, independent of one another, and errors were independent of predictor variable. Data Management A Statistical Package for the Social Sciences (SPSS) Verizon 17.0 was used for data entry and analysis. This program was password protected to secure confidentiality for data entry, management, and analysis. Each participant was given a n umber that was recorded on a master list of participants and kept in a locked file in the investigators home office. The c ompleted study questionnaires and forms were secured in a locked area in the investigators home office. Results are reported as aggre gate data only. No individuals can be identified by any demographic data including hospital or work unit as this was a specific concern of participants fearing retribution for reporting possibly negative data regarding leader ship.

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53 Chapter Four Resul ts This chapter first presents the results of this study related to the differences in work related stress, quality of life, job satisfaction and anticipated turnover on nursing units with CNL and those without This is followed by a presentation of the r esults according to each research hypotheses. Sample One hundred twenty eight RNs from three research sites expressed an interest in participating in the study. Thirty four surveys were not included Twenty two surveys were not returned and twelve were r eturned partly completed survey forms. Participants were designated as those units without Nursing Stress Scale, the Nursing Work Rela ted Index Revised, the Medical Outcomes Short Form and the Anticipated Turnover Scale. D emographic data was collected and included age, gender, marital status ethnicity, educational nursing preparation number of years in nursing, length of employment at hospital, length of employment on unit work status, presence of children/ number, and nursing certification All participants ( N =94) completed the demographic data form. The mean age for this group of registered nurses was 41.9 years ( SD =9.75). Their a ( n =46)

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54 mean was 43.6 years ( SD group (Group 2) ( n =48) mean was 40.6 ( SD =9.77). The participants gender is reported as 90.4% female ( n =86), male as 8.5% ( n =8). CNL had 82.2% ( n =38) females and 17.8% ( n =8) males. Non CNL had 100% ( n =48) female. Table 2 displays the gender by frequency and percentages. Table 2 Frequency and Percentage G ender by CNL and Non CNL G roup Gender CNL Non CNL n % Female 38 48 86 90.4 Male 8 0 8 8.5 Fifty six (59.6%) of participants were married, 11.7% ( n =11) reported being single, and 27.7% ( n =26) divorced. The marital status of the groups differed with a much higher percentage of th e non CNL group being married (non CNL= 72.9%, CNL= 46.7%) The CNL sample had a higher rate of single (CNL = 15.1%, non CNL=8.3%) and divorced participants (CNL= 37.8%, 18.8%). Table 3 depicts the frequency and percentage of marital status by group. Ta ble 3 Frequency and Percentage of Marital Status by CNL and Non CNL G roups Marital Status CNL Non CNL n % Single 7 4 11 59.6 Married 21 35 56 11.7 Divorced 17 9 26 27.7

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55 Table 4 displays the ethnicity of the participants. The majority were white, non Hispanic 80.9% ( n= 76), white Hispanics made up 9.6% ( n =9) of the population, 6.4% ( n =6) were Filipino, 2.1%, were b lack non Hispanic ( n =2), and 1% ( n =1) reported ethnicity as other. The ethnic diversity of the sub groups was similar with predominately white, non Hispanic participants; ( CNL had 82.2% and the non CNL 79.2% ) The CNL group had a higher percent of Hispanic participation at 13.4% versus the non CNL group at 6.3% The non CNL group had a higher portion of the sample from the black and other categories (4.2%, 2.1%).Filipino study participants accounted for 8.4% in the non CNL group and 4.4% in the CNL. Table 4 Frequency and Percentages of Ethnicity by CNL and Non CNL G roups Ethnicity CNL Non CNL n % White Non Hispanic 37 38 75 79.8 White Hi spanic 6 3 9 9.6 Black Non Hispanic 0 2 2 2.1 Filipino 2 4 6 6.4 Other 0 1 1 1.1

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56 Table 5 displays the frequency and percentages of educational preparation by group. The majority of the sample 56.4% (n=53) received Associates level education. f ollowed by 26.6% (n=25) receiving Bachelorette preparation, an additional 14.9% ( n =14) were educated in Diploma programs and 1% ( n =1) were Masters prepared. Group1 reported 57.8% ( n =26) as Associates degree nurses, 22.2% ( n =10) Bachelors prepared, 20.0% ( n =9) as Diploma graduates and no Masters prepared nurses. Group2 consists of 56.3% ( n =27) Associate degree nurses, 31.3% ( n =15) bachelors degree nurses, 10.4% ( n =5) Diploma graduates and 2.1% ( n =1) masters prepared nurses. In this study there were no doctoral pr epared nurses and degrees outside of nursing were not explored. Table 5 Frequency and Percentage of Educational Preparation by CNL and N on CNL G roup s Education CNL Non CNL n % Diploma 9 5 14 14.9 Associates 26 27 53 56.4 Bachelors 10 15 25 26.6 Masters 0 1 1 1.1

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57 Table 6 displays the range and means for length of employment in the nursing profession, the current hospital and the individual unit by group. The overall sample consists of RNs in practice ranging from 9 months to 44 years with a mean o f 12.9 years of experience in the profession. The CNL group ranged from 2 years to 44 years with a mean of 14.6 years in nursing, and the n on CNL group ranged from 9 months to 42 years and had a mean of 11.4 years in nursing. The overall sample of nurses had been employed at the current hospital ranging from 2 months to 28 years with a mean of 7.9 years. The CNL g roup showed employment with the hospital ranging from 3 months to 28 years with a mean of 7.0 years. The n on CNL g roup showed current hospital employment ranging from 3 months to 28 years with a mean of 8.6 years. The nurses reported working on the current unit with a range of 2 months to 25 years and a mean of 5.7. Group 1 showed unit tenure as ranging from 3 months to 13 years with the mean be ing 4.1 years. Group 2 reported employment on the current unit they were working on at the time of the study ranging 2 months to 25 years with mean of 6.5 years

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58 Table 6 M eans and Standard Deviation for L ength of E mployment in the N ursing P rofession, in the C urrent H ospital and on I ndividual unit by CNL and Non CNL G roup s Nursing Profession M SD CNL 12.9 years 10.87 Non CNL 14.6 years 11.01 Hospital CNL 7.04 years 6.55 Non CNL 8.6 years 6.95 Unit CNL 4.1 years 3.30 Non CNL 6.5 years 5 .43 Table 7 displays t he work status was reported as full time, part time, per diem/ pool, agency, or seasonal contract by group. Overall, nurses in this study reported 75.5% ( n =71) worked full time, 17% ( n =16) worked part time, 2.6% ( n =3) were worki ng on seasonal contracts, 2.3% ( n =3) worked per diem/pool, and 1% ( n =1) worked agency

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59 Table 7 Frequency and Percentage of Work Status by CNL and Non CNL G roup s Work Status CNL Non CNL n % Full time 32 39 71 75.5 Part time 10 6 16 17.0 Seasonal Cont ract 2 1 3 2.6 Per Diem/ pool 0 2 2 2.3 Agency 1 0 1 1.1 Research Hypothesis Number One Nurses practicing in units with a CNL will exhibit a decrease in work related stress compared to nurses p racticing in units without a Means and standard deviations for the dependant variable of the presence of the CNL in decreasing work related stress are presented in Table 8 There is a variance in sample size with the CNL ( n =4 6) and Non CNL ( n =48). The M for the two groups are CNL (M= 83.45 SD 11.45), Non CNL (M= 83.97 SD 12.85). Table 8 Sample Means and Standard Deviations for Nursing Work Related Stress Group N M SD CNL 46 83.45 11.40 Non CNL 48 83.97 12.85

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60 Table 9 reports the results o n the independent t tests regarding the variable nursing work related stress. The level of nursing work related stress experienced was not significantly different ( t = 0 .208, p = 0 83 ) between the two groups. This indicates no signific ant difference with the presence of the CNL on the nursing unit on the level of work related stress experienced by the nurses. Table 9 Results of Independent t test for Nursing Work R elated Stress Work related Stress N t p Equal variances assumed 94 0 .208 .836 In summary, nurses working on units that employ Clinical Nurse Leaders experie nce equivalent levels of work related stress to nurses who work on units that do

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61 Research Hyp othesis Number Two To test hypothesis two, Nurses practicing on units with a CNL will exhibit improved Job Satisfaction and self perception of Quality of life compared to nurses practicing on units without a CNL independent t test were used to test the difference. Job Satisfaction was the firs t variable investigated the results are reported below. Table 1 0 presents the means and the standard deviation for the variable job satisfaction. There is a variance in sample size the CNL ( n =46), Non CNL ( n =48). The group means for the two groups CNL ( M= 110.02, SD 21.75), Non CNL (M= 108.66, SD 23.03) Table 1 0 Sample M eans and Standard Deviations for Job Satisfaction Group n M SD CNL 46 110.02 21. 75 Non CNL 48 108. 66 23.03 Table 1 1 reports the results of independent t tests. Based on the resu lts of the independent t test there was no statistical significance (t = 0 .293, p = 0 .77 0 ) between the two groups when measured for job satisfaction. Job satisfaction did not demonstrate a statistically significant differ ence between the groups due to the pr esence of the CNL.

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62 Table 1 1 Results of Independent t test for Job Satisfaction Job Satisfaction N t p Equal variances assumed 94 0.293 770 In addition to the overall scores the subscales for job satisfaction autonomy, control over practice, physicia n nurse relations and organizational support were examined. Table 1 2 displays the means and standard deviations for the job satisfaction subscales. There was a variance in the sample the CNL ( n =46), Non CNL ( n =48). The autonomy subscale was CNL (M= 9.93 SD 3.10), Non CNL (M= 9.33, SD 2.66) ; t he control over practice subscale CNL (M= 14.97, SD 4.70), Non CNL (M= 14.50, SD 4.10). The means for physician nurse relations for the two groups CNL (M= 115.63, SD 9.64), Non CNL (M= 115.72, SD 9.88). and t h e organizational support subscale was reported as CNL (M= 4.21, SD 1.88), Non CNL (M= 4.41, SD 2.23).

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63 Table 1 2 Means and S tandard D eviations for J ob S atisfaction S ubscales Job Satisfaction Subscales n M SD Autonomy CNL 46 9.93 3.10 Non CNL 48 9. 33 2.66 Control over Pra c tice CNL 46 14.97 4.70 Non CNL 48 14.50 4.10 Physician nurse relations CNL 46 4.21 1.88 Non CNL 48 4.41 2.23 Organizational Support CNL 46 20.84 6.26 Non CNL 48 20.25 5.27 Table 1 3 displays the independent t test results on the job satisfaction subscales and the results are: Autonomy ( t = 0 1 00, p =.597), Control over practice ( t = 0 .526, p =.655), physician nurse relations ( t = 0 .486, p = .283) and organizational support ( t = 0 .505 p =.615). There were no signifi cant differences between the two grouped in the job satisfaction subscale

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64 Table 1 3 Results of Independent t test for the J ob S atisfaction S ubscales Job Satisfaction N t p Autonomy 94 0 .1 00 597 Control over practice 94 0 526 655 Physician nurse relat ions 94 0 505 .283 Organizational support 94 0.505 615 In summary there was no statistical difference between the two groups on the overall job satisfaction or the job satisfaction subscales

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65 Quality of Life Table 1 4 presents the sample, means and the standard deviation for the overall scores on self perceived Quality of life. There is a variance in the sample the CNL ( n =46), Non CNL ( n =48). The means for the two groups were CNL (M= 115.63, SD 9.64), Non CNL (M= 115.72, SD 9.88). Table 1 4 Sample M eans and S tandard D eviations for O verall S cores of Quality of Life Group n M SD CNL 46 115. 63 9.64 Non CNL 48 115.72 9.88 Table 1 5 reports the results of independent t tests on the variable self perceived Quality of life. The independent t test fo und no statistical significance in the overall quality of life scores ( t = 0 .049, p = 0 961 ) between the two groups. The overall scores for self perceived quality of life did not reveal a difference in the two groups. Table 1 5 Results of Independent t test for O verall S cores of Quality of life Quality of Life N t p Equal variances assumed 94 0 .0 49 0 961 In addition to the overall scores the two summary scores physical health (PH) and mental hea lth (MH) are reported. Table 1 6 reports the mean and sta ndard deviation for the first summary scale physical health (PH) as Group1 CNL M =64.02, ( SD 7.48) and Group 2 Non CNL mean and standard deviation are M =65.04, ( SD 4.84).

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66 Table 1 6 Means and Standard D eviation for Physical Health Summary Scale Group n M S D CNL 46 64.02 7.48 Non CNL 48 65.04 4.84 Table 1 7 reports the scores of independent t tests for the summary scales physical health and mental health by group. No statistically significant difference was found for the overall P hysical H ealth summary Scale ( t = 0 .7 9 p = 0 43 ). Table 1 7 Results of Independent test for Physical Health Summary Scale Physical Health Summary Scale N t p Equal variances assumed 94 0 .7 9 0 43 Means and standard deviation as well as independent t tests are reported on a ll physical health subscales. The subscales that comprise the Physical Health summary scores are; P hysical F unctioning (PF), R ole P hysical (RP), B odily P ain (BP), and G eneral H ealth (GH). Table 1 8 displays the means and standard deviation for the Physic al H ealth subscales for CNL ( n =46); P hysical F unctioning M =28.01, ( SD 5.81), R ole P hysical M =17.17, ( SD 3.84), B odily P ain M =4.21, ( SD 1.88),and general health M =14.52, ( SD 2.47). Non CNL ( n =48) means and standard deviation are;

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67 P hysical F unctioning M =27.91 ,( SD 4.27), R ole P hysical M =17.29, ( SD 2.55), B odily P ain M =4.41, ( SD 2.23),and G eneral H ealth M =15.41, ( SD 2.43). Table 1 8 Means and Standard D eviation for Physical Health Subscales Physical Health n M SD Physical F unctioning CNL 46 28.01 5.81 Non CNL 48 27 .91 2.47 Role Physical CNL 46 17.17 3.84 Non CNL 48 17.29 2.55 Bodily Pain CNL 46 4.21 1.88 Non CNL 48 4.41 2.23 General Health CNL 46 14.52 2.47 Non CNL 48 15.41 2.43

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68 Table 19 displays the results of independent t tests for the subsc ales of the Physical Health summary score. Physical F unctioning ( t = 0.18 p =. 85 ), Role P hysical ( t = 0.1 8 p =. 86 ), Bodily P ain ( t = 0 .4 7 p = 64 ) and General Health ( t = 1.77 p = 08 ). None of the physical health subscales showed and statistically signifi cant difference between the two groups. Table 19 Results of Independent T Test for Physical Health subscales Physical Health N t p Physical Functioning 94 0 .18 85 Role Physical 94 0 .17 86 Bodily P ain 94 0 .48 64 General Health 94 1.77 08 In summary, the overall Physical Health summary scores did not reveal any difference in the two groups The individual subscales of Physical Health did not reveal an y individual subscale as statistically significant between the two groups. General H ealth tr ended toward the CNL group reporting better health than the Non CNL group.

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69 20 CNL was reported M =48.78, ( SD 4.99), and the Non CNL M =47.95 ,( SD 8.65) Table 2 0 Means and S tandard D eviation for Mental Health Summary Score Table 2 1 displays independent test for the Mental health summary scores the results were ( t = 0 .56, p = 0. 57 ) and not found to have a significant difference between the two groups. This indicates that the CNL did produce a difference in the overall mental health of nurses. Table 2 1 Results of Independent t t est for Mental Health Summary Scores Mental Health Summary Sc ore N t p Equal variances assumed 94 0 56 0. 57 The subscales that comprise the Mental Health summary score are; v itality (VT), social Functioning (SF), Role emotional (RE), mental health (MH). Table 2 2 displays the means and standard deviations for the subscales of the two group s CNL ( n =46) vitality M =11.65, ( SD =1.64), social functioning M =5.82, ( SD =.768), role e motional M = 13.42, ( SD =2.28), and mental health M =17.86, ( S D= 2.32). Non CNL ( n =48) vitality M =11.75, ( SD =2.28), social functioning M =6.00, ( SD =1.33), role emotional M = 13.45, ( SD =8.23), and mental health M =16.75, ( SD =2.32) Group n M SD CNL 46 48.78 4.99 N on CNL 48 47.95 8.65

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70 Table 2 2 Means and Standard Dev iation for the Mental Health Subscales Mental Health n M SD Vitality CNL 46 11.65 1.64 Non CNL 48 11.75 2.28 Social Functioning CNL 46 0.77 0 .11 Non CNL 48 1.33 0 .19 Role Emotional CNL 46 13.43 2.28 Non CNL 48 13.45 8.23 Mental Health CNL 46 17.86 2.32 Non CNL 48 16.75 2.31 Table 2 3 displays the results of independent t tests for the subscales of the Mental Health summary score. The results of Vitality ( t = 0.24 p = 0 81 ), Social functioning ( t = 0.77 p = 0. 44 ), Role emotional ( t = 0.02 p = 0 98 and Mental Health ( t = 2.34, p = 0 021 ). Of the mental health subscales only mental health showed a statistically significant difference between the two groups.

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71 Table 2 3 Results of Independent t test for Mental Health Subscales Menta l Health N t p Vitality 94 0.24 81 Social Functioning 94 0.77 .14 Role Emotional 94 0.02 .23 Mental Health 94 2.34 02 In summary, in this group, the presence of the CNL did not increase job satisfaction, nor did it improve Quality of life for n urses. Of interest, the Physical H ealth summary sc ale did not show statistical significance however; the CNL group was more likely to report better general health Additionally the M ental H ealth summary scale did not identify a statistical difference in the two groups The mental health subscale was significantly different between the two groups indicating the CNL group was happier and less depressed than the Non CNL group. The overall scores did not support hypothesis two. It is important to note that the CNL group showed a perception of better general health a nd a statistically significant difference on the mental health subscale indicating the CNL group had a propensity to be happier and less depressed.

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72 Research Hypothesis Number Three To test hyp Nurses practicing in units with a CNL will exhibit a decrease in anticipated turnover compared to nurses practicing in units without a CNL Table 2 4 reports the sample, the means and the standard deviati on for anticipated turnover. There is a variance in sample size with the CNL ( N =46), Non CNL ( N =48). The group means for the two groups CNL (M= 47.32, SD 4.97), Non CNL (M= 44.70, SD 7.35) Table 2 4 Sample Means and Standard Deviations for Anticipated Turnover Group n M SD CNL 46 47. 32 4.97 Non CNL 4 8 44. 70 7. 35 Table 2 5 reports the results of independent t tests on anticipated turnover. Independent t test results identified a statistical ly significance difference ( t =2.01, p = 0 .0 47 ) between the tw o groups . This i ndicat es the presence of the CNL role on the nursing unit decreases anticipated turnover. Table 2 5 Results of Independent t test for Anticipated Turnover Anticipated Turnover N t p Equal variances assumed 94 2.01 047 In summary, incidence of anticipated turnover which supports hypothesis three.

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73 Research Hypothesis Number Four To test the fourth h ypothesis A significant relationship exists between anticipated turnover and work related stress, job satisfaction, and quality of life multiple regression was utilized to determine how well the independent variables of work related stress, quality of life and job satisfaction explain the variance in anticipated turnover. Statis tics examined included the standardized regression coefficients ( values). The F statistic value and statistical significance of F was also examined. Preliminary screening of the data set including checks for normality in variable distributions, outliers, and multicollinearity were discussed earlier in this chapter and will not be repeated here. Table 2 6 contains the summary obtained from standard multiple regression analysis of regressing on the independent variable of anticipated turnover and reports the relationship through a multiple regression on the resea rch vari ables anticipated turnover with group and the variables of job satisfaction, quality of life and nursing work related str ess

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74 Table 2 6 Summary of Regression Analysis for Predicting Anticipated Turnover Variables b t p Constant 53.56 5.58 .000 Group 2. 50 0 .196 2.00 .0 48 Work Related Stress 0 166 0 314 3 14 .0 02 Quality of Life 0 .0 63 0 096 0 96 339 Job Satisfaction 0 .02 6 0 .0 90 0 88 380 Note: Dependent variable: Anticipated Turnover. Multiple regressio n reveal ed, when controlling for the variables of work related stress, quality of life and job satisfaction that was a statistically significant relationship between group CNL( p =.048), anticipated turnover work related stress ( p =.002. Therefore hypothesi s four was supported. In summary hypotheses one, and two were not supported however hypothesis three was significant Additionally, work related stress and the CNL group were strong predictors of a signific ant relationship with Anticipated Turnover.

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75 Chapter Five Discussion, Conclusions, and Recommendations This chapter presents the summary of the study, discussion of the findings, conclusions, implications and recommendations for future research. This study attempted to explore the relationship that implementation of the Clinical Nurse Leader role has with the nurses working on acute care nursing units. In particular, the study sought to answer the question; does utilization of the CNL role decrease nursing work related stress, improve job satisfacti on, quality of life and decrease anticipated turnover ? This research also investigated the relationships among the variables. Summary of the Study This study was a quasi experimental design. The sample of 94 met the criteria for participation. Part icipants were working on selected units that were chosen by the PI as either employi ng a CNL or not employing a CNL. Additionally, they were able read, write and speak the English language. All participants were designated by group Group1 consisted of n u rses employed on units with CNL s Group 2 w ere nurses on units without CNL s. Ninety four participants (N=94) completed demographic data forms as well as the Nursing Stress Scale, the Nursing Work related Index Revised, the Medical Outcomes Survey shor t form (SF 36) and the Anticipated Turnover Scale. Descriptive data for the sample w ere obtained with frequencies, percentages, means, standard deviations and ranges. The sample included 46 (49%) in Group 1 with CNLs, and 48 (51%) nurses on units withou t CNLs in Group 2 The sample

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76 predominately represented w hite (79%) m arried (47%) and f emale (82%) nurses. Their they worked full time. The mean age of respondents was 42, the mean number of years practicing as nurse was12 years with 7 years being the mean time at the current hospital and 5 years being the mean time on the current nursing unit. To determine if there was any relationship with the CNL role and work r elated stress, job satisfaction, quality of life and anticipated turnover three hypotheses were proposed. Independent t t ests were used to examine these hypotheses. Additionally, a fourth hypothesis was proposed to identify if any relationship exists bet ween the variables of anticipated turnover, work related stress and job satisfaction, quality of life and the presence of the CNL. Multiple regression analysis was used to determine if any relationship exists. Discussion and Conclusion s The following i s a discussion of the findings according to the four research hypotheses in the study. Conclusions that might be drawn from this research are presented in this section. In the American Hospital Associations committee report, In Our Hands: How Hospital L eaders can build a thriving Workforce (2002) ,one recommendation was to create a professional role for retaining nurses, that would keep the most qualified nurses at the bedside. This report was cited in the original white paper from AACN used for creatin g the curriculum for the role of the CNL (CNL, 2003). An important problem to be investigated was how the role of t he Clinical Nurse Leader related to work related stress, quality of life, job satisfaction and anticipated turnover on acute care nursing uni ts. This

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77 research also examine d the relationship of the CNL role the variables and RNs on acute care nursing units. Additionally, this research examine d the variable of work related stress, job satisfaction, and quality of life to identify if they were predictors of anticipated turnover. This research is unique because it is one of the few studies on the CNL role, which was developed by the American Association of Colleges of Nursing (AACN) in response to needed changes in the practice of nursing in the acute care setting The participants in this research were 94 RNs practicing on acute care nursing units in three non profit hospitals. The demographics demonstrated the sample to be predominately female, white, and married RNs The demographics of this study were similar to the preliminarily result s from the 2008 National Sample Survey of nurses performed by the federal division of Nursing. The national sample reported an average age of 47 year s primarily female nurses (HRSA, 2010) This study was pur poseful because the University of South Florida was one of the early educational institutions to graduate students from this curriculum and the study hospitals were some of the first in the Tampa, Florida area to utilize the role on nursing units. This al so is one of the first research studies to examine this role in relationship to very important outcomes The first hypothesis stated that nurses practicing on units that employ CNL will have lower levels of work related stress. This was tested using indep endent t t ests to examine the relationship of nursing work related stress (NSS) and the CNL role. The results of the N ursing S tress Scale tool did not demonstrate the addition of the role of CNL statistically changed the level of stress of nurses on these units. This study did not demonstrate any statistical significance in work related stress on the units employing

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78 CNLs Interesting to note, the mean score on the Nursing Stress Scale f or the CNL group w as 83.45 out of a possible 102 and for the Non CNL group the mean w as 83.97. While there is no statistical significance between the groups, the means demonstrate that both groups experienced a high level of stress related to nursing work. However, the CNL group stress level was slightly less than the N on CNL group. The findings of this study are co nsistent with previous literature which is replete with examples of s tress in acute care nursing settings (Begat, 2005; Chang, 2006; Fletcher, 2001; Hall, 2004; Hayes, 1999; Lambert, 2004; McNeely, 2005; McVica r, 2 003; Oloffson 2003; Piko, 2006; Ruggerio, 2005 ; Santos, 2003; Stichler, 2009; Sveinsdotter, 2005; Zeytinoglu, 2005). Therefore the first h ypothesis that states nurses practicing on units with a will exhibit a decrease in work related stress compared to nurses practicing in units was not supported. The second hypothesis used independent t t ests to explore two of the variables; job satisfaction (NWIR) an d self perceived quality of life (SF 36) Specifically, what e ffect is experienced by the presence of the CNL? Job satisfaction was the first variable explored. In research by Aiken(2000) utilizing the NWIR the four subscales ( ,1) autonomy, ( 2) control ov er practice, ( 3) nurse physician relations, and ( 4) organizational support were identified as factors that influence job satisfaction. In another study using meta analysis nurses job satisfaction showed a strong relationship between job satisfaction and autonomy (Blegen, 1993 ). In this current study the NWIR subscales of job satisfaction, autonomy, control over practice and organizational support did not reveal any statistical difference between the two groups. It was expected that job satisfaction would be higher in the CNL group. However, job satisfaction scores were

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79 similar between the CNL and Non CNL groups and did not demonstrate any statistical significance. The second variable examined in hypothesis two; was quality of life. Independent t t ests o n overall quality of life scores did not report a difference in the two groups. It was hypothesized that quality of life scores for the CNL group might be higher due to the presence of the CNL T otal summary scores for the physical and mental health scale s did not show a statistical difference between the two groups. Analysis of the subscales did, however, reveal a statistical difference in mental health with CNL group reporting they were happier and calmer when compared with the Non CNL group. The diffe rences in scores on general health subscale were not statistically significant between the CNL and the Non CNL groups, although the scores trended toward the CNL group reporting a better perception of health Previous r ealth Study Database and the Medical Outcomes study short form(SF 36) concluded that modifying health behaviors and establishing social networks were keys elements in improving individual nurses perception of quality of life (Michael, 2000). This research does not examine health behaviors or social networking However, one possible explanation for the difference in perception of general health and the significant difference in mental health scores may be the social support the CNL role provides on the nur sing unit This i s supported by current research by Shader(2001) who report ed that social support and group cohesion decreased stress, improved jo b satisfaction and decrease d turnover. One study on healthy working environments reported that healthful workplaces created healing environments for patients and impacted provider outcomes of health, stress, satisfaction, organizational commitment and turnover (Stichler, 2009). T he role of

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80 the CNL is supportive and may be viewed as additional social support that fosters a healthy work environment Overall, the results of the analysis of hypothesis two, n urses practicing in units with a CNL will exhibit increased job satisfaction and improved perception of quality of life compared to nurses practicing in units without a CNL was not supported. Therefore in this study the two parts of hypothesis two were not supported. The third hypothesis was also tested using independent t t est s The third h ypothesis explored whether n urses practicing on units with a CNLs exhibit ed a decrease in anticipated turnover when compared with nurses practicing on units without a CNL The overall mean scores for the Anticipated Turnover Scale revealed a si gnificant difference indicating that the n on CNL group members were more likely to leave nursing. This is consistent with previous research conducted by Janssen ( 1999 ) showing a positive relationship between job contentment, support of colleagues and job motivation Consequently, the role of the CNL may be a factor influencing the nurses feeling of support from colleagues that in turn results in a decrease in anticipated turnover. Organizational participation in employment of the CNL role was explored in a grounded theory study conducted by Sherman (2008). In this study f ive major factors were identified as e ffecting chief nursing decisions to engage in the CNL project. The five factors included ;( 1 ) organizational needs ( 2) opportunity to re design c are delivery ( 3), desire to improve p atient care, ( 4) enhance ment of physician nurse relationships ; and ( 5) promoting professional development. This research demonstrates that organizational support is a necessary component of decreased turnover. This has significant economic implications for hospitals that employ CNL

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81 The fourth hypothesis of this research explore d whether work related stress, job satisfaction, and quality of life have a relatio nship with anticipated turnover. Standard multiple re gression was used to analyze this data. The results of the multiple regression analyses revealed that a significant relationship existed between anticipated turnover and nursing work related stress and the presence of the clinical nurse leader. This is c onsistent with previous literature by Aiken and Hayes (2001, 2005) which determined that t he effects of work related stress are low job satisfaction, high turnover, and poor patient outcomes and these are factors contributing to increased turnover. Theref ore the fourth hypothesis was supported. In summary, the logic model (Figure 1) reported in the third chapter of this research proposed that the presence of the CNL on the nursing unit would decrease work related stress and anticipated turnover while incre asing job satisfaction and self perceived quality of life. While there was no statistically significant difference in the two groups related to work related stress, standard multiple regression revealed a significant relationship exists between the presenc e of the CNL and work related stress as well as anticipated turnover. Anticipated turnover showed a significant difference between the two groups. However, the research did not find any significant difference in job satisfaction and quality of life that is attributable to the presence of the CNL.

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82 Implication s for Nursing The implications drawn from this quasi experimental study is presented in this section. The findings of this study have implications for nurses, nurse educators, and for further research. In chapter two the literature demonstrated there is evidence of increased stress, decreased job satisfaction and quality of life as well as e increased anticipated turnover. However, there is a lack of research on implementation of studies to alleviate t hese negative factors affecting the profession of nursing. This research is intended to determine if the CNL role could in anyway be positive influence in the acute care setting. While t his study cannot definitively be used to show the role as affecting t he negative variables it does propose that additional research in to the CNL role would prove beneficial. The nursing profession has had periodic shortages of nurses practicing at the bedside over the last several decades. Often economic factors have i return to the bedside only to have the shortage recur when economic circumstances change (Buerhaus, 2009). The factors that precipitate an leave the bedside have not changed. In order for the profession t o stop the cyclic shortages from reoccurring, more research that is needed to identify factors that support bedside acute care nursing. The AACN curriculum for the CNL used research to support implementation of this curriculum (CNL, 2003) As additional research is completed related to the efficacy of the role, the AACN will need to consider the results of subsequent research in supporting and redefining the CNL curriculum in the future.

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83 A healthcare reform billed was recently signed into legislation ( HR: 4872 ) Reconciliation Act of 2010 which provides increased accessibility of health care to the currently uninsured This bill challenges the profession of nursing to explore opportunities to support the existing nursing workforce and to provide additional resources to accommodate the needs of both patients and nurses. Research conducted regarding the impact of healthcare reform proposes a mechanism for supporting and promoting nursing through improving t he environments in which work. Politicians h ave a plan to improve workplace conditions for nurses through federal challenge grants to support magnet hospitals with better work environments. A shortage of acute care bedside nurses is reported to be related to burnout, stress, and fatigue associated w ith an unfavorable nursing practice environment and has been well documented ( McHugh Aiken, Cooper, 2008). T he CNL role may be one of the venues the nursing profession chooses to advocate as a tool to decrease the rate at which nurses leave the professi on Nursing has a responsibility at this time to look introspectively at the needs of the current workforce, among them the nurses in the acute care setting who are struggling on a daily basis to provide safe quality care There needs to be a collectiv e professional assessment to identify the needs of the current nurses and a prospective plan for future nurses to e nsure that the care givers interacting with patients on a daily basis are able to have their needs meet in order to be able to meet the needs of the patients Through this study it has been consistently demonstrated that the acute care nursing environment is stressful, there are many factors that can be attributed to the causation However, also apparent in the literature review while these factors have been

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84 repeatedly studied very little research has been produced on ameliorating interventions to assist with turnover and work related stress. While this research certainly cannot claim to be a demonstration of an intervention that has the ability to fix any of the clearly defined factors of work related stress, job satisfaction, and quality of life and anticipated turnover t his researcher believes it is crucial for the nursing profession to engage in this type of introspection and make bol d attempts at interventions like implementation of the CNL role to address the current state and the future state of nursing The CNL role in this study showed that it may be influential in improving the work related stress and the turnover on nursing un its The continued study of the CNL role is essential for nursing, for patient care and the overall quality of healthcare provided in our nation.

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85 Recommendation for Future Research Based on the review of the literature and this research study, the followin g recommendations are made for future research. 1. Potential areas for future study include replicating this study using a larger sample, in multiple demographic populations. Additionally, expanding the sample to specialty nursing units; in particular critica l care. 2. Further investigation of the CNL role and identifying the individual unit characteristics to determine if a specific type of acute care nursing unit plays a factor in the research findings 3. Continued development and refinement of instruments that address the impact of the CNL role on work related stress and job satisfaction. 4. Investigation of the CNL specific attributes that may be predicting factors for decreasing turnover. Additionally, qualitative research would be useful to identify the themes surrounding the variables 5. Further study that identifies the specific characteristics of anticipated turnover and work related stress that the CNL role effects 6. Further study in the area of anticipated turnover. Further research in this area may assist in e xplaining the role demands that are influencing the decision to leave a unit or the role of nursing. 7. Further research in this area should attempt to expand on these findings by examining the major sources of work related stress, low job satisfaction, nurse perception of overall quality of life and intention to leave the role.

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86 References AbuAlRub, R. F., & Al Zaru, I. M. (2008). Job stress, recognition, job performance and intention to stay at work among J ordanian hospital nurses. Journal of Nursing Man agement, 16 (3), 227 236. doi:10.1111/j.1365 2834.2007.00810.x Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA : The Journal of t he American Medical Association, 288 (16), 1987 1993. Aiken, L. H., & Patrician, P. A. (2000). Measuring organizational traits of hospitals: The revised nursing work index. Nursing Research, 49 (3), 146 153. Alpander, G. G. (1990). Relationship between com mitment to hospital goals and job satisfaction: A case study of a nursing department. Health Care Management Review, 15 (4), 51 62. Attree, M. (2005). Nursing agency and governance: Registered nurses' perceptions. Journal of Nursing Management, 13 (5), 387 396. doi:10.1111/j.1365 2834.2005.00553.x Atwood, J. R., & Hinshaw, A. S. (1993). Re: Assessment of convergent and discriminant validity. Research in Nursing & Health, 16 (3), 231 234. Begat, I., Ellefsen, B., & Severinsson, E. (2005). Nurses' satisfactio n with their work environment and the outcomes of clinical nursing supervision on nurses' experiences

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99 RT Journal A1 Bloom, Bernard S. T1 Crossing the Quality Chasm: A New Health System for the 21st Century JF JAMA: The Journal of the American Medical Association JO JAMA YR 2002 FD February 6 VO 287 IS 5 SP 646 a OP 647 DO 10.1001/ Ann C. Greiner, Elisa Knebel, Editors, Committee on the Health Professions Education Summit : Health Pro fessions Education: A Bridge to Quality ISBN: 978 0 309 08723 0, Health Care at the Crossroads : Strategies for Addressing the Evolving Nursing Crisis. www.aacn.nche.edu/media/pdf/JCAHO8 02.pdf H.R.4872. 111 th Cong. 2 nd s. Health Care and Education Reconciliatio n Act of 2010. An Act t o provide for reconciliation pursuant to Title II of the concurrent resolution on the budget for fiscal year 2010 (S. Con. Res. 13 ).

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100 Appendices

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101 Appendix A : IRB Approval

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102 AppendixA : IRB Approval (continued)

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103 AppendixB : IRB M odification

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104 Appendix B : IRB Modification (continued)

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105 Appendix C : Informed Consent

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106 Appendix C : Informed Consent (continued)

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107 Appendix C : Informed Consent (continued)

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108 AppendixC :Informed Consent (continued)

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109 Appendix D : Demographic Data Form Demographic Data Please fill in blank or circle most appropriate answer UNIT__________________ 1. Age _____ 2. Sex a. Male b. Female 3. Number of years in nursing _________ 4. Education in Nursing a. Diploma b. Associates c. Bachelors d. Masters e. Other ________ 5. Nursing Certification(s) ____________________ 6. Length of employment at this hospital _______ 7. Length of employment on this unit _________ 8. Work Status a. Full time b. Part time c. Per diem or pool d. agency e. seasonal

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110 Appendix D: Demographic Data Form (co ntinued ) f. Other __________ 9. Marital Status a. Married b. Single c. Divorced d. Widowed e. Other ____________ 10. Children a. Yes b. No 11. Number of Children _______ 12. Ethnicity a. White, not Hispanic b. White, Hispanic c. Black, not Hispanic d. Black, Hispanic e. Chinese f. Japane se g. Filipino h. Native American, Eskimo or Aleutian i. Hawaiian j. Korean k. Vietnamese l. Don't Know m. Other ____________

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111 Appendix E : Multiple Outcomes Short Form Inventory (SF 36)

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112 Appendix E: Multiple Outcomes Short Form Inventory (SF 36) (continued)

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113 Appendix E: Multiple Outcomes Short Form Inventory (SF 36) (continued)

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114 Appendix E : Multiple Outcomes Short Form Inventory (SF 36) (continued)

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115 Appendix E : Multiple Outcomes Short Form Inventory (SF 36)

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116 Appendix F: Nursing Work Index Revised

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117 Appendix F: Nu rsing Work Index Revised (continued)

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118 Appendix G : Nursing Stress Scale

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119 Appendix G : Nursing Stress Scale (continued)

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120 Appendix G : Nursing Stress Scale (continued)

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121 Appendix G : Nursing Stress Scale (continued)

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122 Appendix G : Nursing Stress Scale (continued)

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123 Appendix G : Nursing Stress Scale (continued)

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124 Appendix G : Nursing Stress Scale (continued)

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125 Appendix G : Nursing Stress Scale (continued)

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126 Appendix G : Nursing Stress Scale (continued)

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127 Appendix H : Anticipated Turnover Scale

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128 Appendix I : Recruitment P oster

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129 About the Author Mary Kohler was born and raised in New York. Mary received her Associate of Applied Science in Nursing from Salem College Salem West Virginia. She received her iversity in Boca Raton, Florida. Her research interest is in the area of the Nursing work environment. In particular Satisfaction and Anticipated Turnover on Nursing Units with C linical Nurse Leaders Mary Kohler is a member of the international nursing honor society; Sigma Theta Tau and a member of the Southern Nursing Research Society. She is a member of the Florida Organization of Nurse Executives as well as the Tampa Bay O rganization of Nurse Executives. She has served a research mentor for FONE. In March of 2010 she attended and was inducted into the Inaugural Student Health Policy Institute of the American Association of Colleges of Nurses.