12 Bun

International Journal of Nursing Studies 44 (2007) 297314
Literature review
Impact of job satisfaction components on intent to leave and
turnover for hospital-based nurses: A review
of the research literature
Billie Coomber
, K. Louise Barriball
Kings College London, London, UK
Received 12 October 2005; received in revised form 31 January 2006; accepted 10 February 2006
Abstract
Background: The United Kingdom (UK), alongside other industrialised countries, is experiencing a shortage of nurses
partly due to low retention rates. Job satisfaction has been highlighted as a contributing factor to intent to leave and
turnover, yet this is a complex area with many elements affecting its measurement.
Aim: The aim of this paper is to explore the impact of job satisfaction components on intent to leave and turnover for
hospital-based nurses in order to identify the most inuential factors.
Methods: To achieve this, a systematic search of the literature was undertaken to identify relevant international
research. Three databases (i.e. BNI, CINAHL and PsychInfo) were utilised, resulting in nine articles that met the
inclusion criteria. Four recurrent themes were identied in the literature: leadership, educational attainment, pay and
stress.
Findings: The key ndings suggest that stress and leadership issues continue to exert inuence on dissatisfaction and
turnover for nurses. Level of education achieved and pay were found to be associated with job satisfaction, although the
results for these factors were not consistent.
Conclusion: Investigating possible changes over time in sources of dissatisfaction revealed that factors related to the
work environment rather than individual or demographic factors were still of most importance to nurses turnover
intentions. The differences found to occur across work settings necessitates analysis of job satisfaction at ward level,
and the contribution of qualitative methods to develop more detailed insight is emphasised. The inconsistent ndings
over time associated with the effects of educational attainment and pay on intent to leave suggest that it is imperative
that sources of job satisfaction are reassessed in the light of ongoing changes.
r 2006 Elsevier Ltd. All rights reserved.
Keywords: Job satisfaction; Nurse turnover; Intent to leave; Nurse retention; Nurse shortage; Attrition; Research review
What is already known ?
Recruitment and retention of nurses is a contemporary
issue of concern internationally as well as in Britain.
Job satisfaction is a concept closely linked to intent to
leave and, hence, turnover within the nursing profession.
A multitude of factors can exert an effect on the job
satisfaction of nurses.
ARTICLE IN PRESS
www.elsevier.com/locate/ijnurstu
0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2006.02.004
Corresponding author. Tel.: +44 20 7274 0348.

E-mail address: billie.coomber@kcl.ac.uk (B. Coomber).
What this paper adds
Reviews international research on job satisfaction
exposing the factors most inuential on turnover.
Highlights the need to analyse job satisfaction at
individual ward level.
Considers the contribution of qualitative research
methods to develop insight.
Reconrms organisational factors (particularly stress
and leadership) as more inuential than individual
factors (or demographics) on job satisfaction and
turnover intentions.
1. Introduction
For 2003, the Ofce of Manpower Economics (OME)
(2003) reported that the rate of nursing staff leaving the
National Health Service (NHS) in Britain was 9.4%.
Given that nurses account for approximately 356,000
members of staff in the NHS, the scope of this wastage
amounts to approximately 33,500 nurses per annum.
Nursing shortages have effects on many aspects of
health care in Britain, not least constraining the effective
delivery of services (Department of Health (DH), 2001).
The problems associated with the shortage of registered
nurses are compounded by an increasing demand for
health care due to advances in medical technology,
longer life expectancy, and the subsequent number of
people living with serious illness and chronic disease
(Buchan and Seccombe, 2003). Furthermore, there are
increased demands for nurses as roles have widened to
include those responsibilities formerly undertaken by
medical staff, which emphasises the negative impact a
nursing shortage may have on the quality of patient care
(Aiken et al., 2002).
A fundamental policy shift has occurred in the British
NHS with the introduction of modernisation plans and
the implementation of strategies for improving the
working lives of health care staff (DH, 2000, 2001).
The NHS Plan (DH, 2000) acknowledges workforce
planning and effective approaches to recruitment,
retention and motivation of NHS nurses as key elements
to achieving a modernised health service. However, the
health gain targets imposed by the NHS Plan
are dependent on increasing the numbers of nurses in
the NHS (Buchan and Seccombe, 2003).
2. Background
2.1. Turnover
Turnover at an organisational level is seen to be a
major contributor to the shortage of nurses (Gauci-
Borda and Norman, 1997). Additionally, the loss of
performance and efciency on part of the leaver prior to
departure is a major consequence of turnover, and high
absence is seen as a critical problem in times of high
turnover (Cavanagh, 1989). This has the effect of
increasing pressure on, and decreasing morale of the
remaining staff, resulting in the possibility of further
turnover (Gauci-Borda and Norman, 1997). The im-
plications of this vicious cycle serve to focus attention
on retention as a means to inhibit turnover and address
the burden of shortages.
There are inconsistencies within the literature regard-
ing turnover, which may be attributable to the
uncertainty surrounding both denition and measure-
ment (Cavanagh, 1989). Turnover is generally viewed as
the movement of staff out of an organisation, yet this
consistently presents problems within turnover research
for two reasons. Firstly, the incongruent inclusion in
sample populations of staff who are retiring or are
dismissed alongside those who voluntarily leave; and
secondly, distinction between intra- (i.e. movement
between units within the same organisation) and extra-
(i.e. movement across organisations) institutional turn-
over is not made freely within the literature, which has
particular resonance for the health service. Bluedorn
(1978) viewed turnover as a two-dimensional concept,
distinguishing between the act of leaving as voluntary or
involuntary, and between the leaving and joining of an
individual to an organisation. This dened view is useful
to consider when attempting to distinguish the variables
that may have a relationship with voluntary turnover.
To promote clarity, the theorists Fishbein and Ajzen
(1975) sought to explain factors that predict actual
turnover, summarising that behavioural intention is the
primary antecedent to actual behaviour. This infers that
the cognitive process of turnover intention (intent to
leave) is an important predictor of actual turnover, a
concept that has much empirical and theoretical support
within turnover research (Mobley et al., 1978; Bluedorn,
1982; Steele and Ovalle, 1984; Prestholdt et al., 1987).
Therefore, turnover intention (or intent to leave/stay) is
consequently considered as an outcome of affective
variables (such as job satisfaction) rather than actual
turnover, which may be mediated by other variables
such as age and tenure (Hellman, 1997). Actual turnover
can thus be tested, but may not be subject to variables
that are directly predictive.
2.2. Job satisfaction
As a shortage ensues and difculties in retention are
highlighted, it follows that the reasons nurses leave their
jobs must be clearly identied if the issue is to be
successfully addressed. Job satisfaction has been cited
as a major contributory factor to intent to stay in
the international nursing literature (Cavanagh, 1992;
ARTICLE IN PRESS
B. Coomber, K. Louise Barriball / International Journal of Nursing Studies 44 (2007) 297314 298
Gauci-Borda and Norman, 1997; Strachota et al., 2003),
but job satisfaction is a complex phenomenon with many
affecting components. Its status as an important predictor
of intent to stay has the secondary effect of decreasing
turnover, with many authors concluding that a decrease in
turnover occurs when a workforce is satised (Saleh et al.,
1965; Blegen, 1993; Irvine and Evans, 1995; Hellman,
1997).
Whilst substantial literature exists regarding job
satisfaction among employees in general and within
nursing specically, there appears to be no agreed
precise denition (Cavanagh, 1992). It has been de-
scribed as an individual attitude to how well personal
expectations at work correspond to outcomes (McKen-
na, 2000). Therefore, an individuals appraisal of the
degree to which the job fulls ones own job values can
cause a positive emotional state of satisfaction or a
contrasting negative feeling of dissatisfaction.
Job satisfaction is considered within empirical studies
either as an overall (global) feeling about the job, or as a
related set of attitudes about various aspects of the job
(facet approach) (Spector, 1997). The global approach to
measurement is used when the interest is in overall attitude
to the job. However, facet approaches can determine which
particular aspects of the job are producing satisfaction or
dissatisfaction for the individual and are, therefore,
important in determining areas for improvement. Facets
of job satisfaction can involve any aspect of the job and
those frequently assessed include pay, co-workers, super-
visors, organisational factors and work environment (Smith
et al., 1969; Stamps and Piedmonte, 1986).
2.3. Concept of job satisfaction
Whilst denitions can provide a broad understanding
of what job satisfaction entails, it remains a complex
concept illustrated by the multiple variables that have
been studied in relation to it. Different theories present
differing conceptualisations of job satisfaction that
can be categorised as content or process theories
(Campbell et al., 1970). Herzbergs (1966) Motivator
Hygiene theory and Maslows (1970) Hierarchy of
Needs exemplify content theories, and attempt to
identify needs or values to be realised in order for an
individual to be satised at work. For instance,
Herzberg (1966) identied maintenance and motivating
factors related to peoples attitudes to work: main-
tenance or dissatisers such as pay and associated
benets, organisational policies and working environ-
ment; and motivating factors including recognition,
achievement and self-satisfaction. Together with deni-
tions, two main themes run through these theories: that
job satisfaction has an affective component, i.e. a feeling
of satisfaction, and a perceptual component which is an
evaluation of whether ones job meets ones needs
(Tovey and Adams, 1999). This is particularly pertinent
when appraising the reasons why different studies utilise
differing measurement approaches, and provides ratio-
nale for this occurrence.
2.4. The link between job satisfaction and turnover
According to Hellman (1997), increasing dissatisfac-
tion in employees results in a higher chance of
considering other employment opportunities. In his
meta-analysis of US studies of non-nursing workers,
the relationship between job satisfaction and intent to
leave was found to be signicantly different from zero
and consistently negative. These ndings were reiterated
in nursing research with many authors concluding that
increasing job satisfaction decreased rates of turnover
(Saleh et al., 1965; Price and Mueller, 1981; Cavanagh
and Cofn, 1992). Seccombe and Smith (1997) found
that the factors given by nurses as reasons for leaving
were centred on issues known to affect job satisfaction
such as ineffective supervisory relationships and poor
opportunities for professional development, rather than
external labour market forces of which managers would
justiably feel unable to control.
A summary of disciplinary perspectives contributing
to the understanding of nurse turnover behaviour
was provided by Mueller and Price (1990). This
included: economic research with its emphasis on
individual choice and labour market variables; socio-
logical research emphasising characteristics of the work
environment and content; and psychological research
which emphasised individual variables and cognitive
processes. Irvine and Evans (1995) developed this
concept into a model for their meta-analytical study
on job satisfaction and turnover, a summary of which
can be seen in Fig. 1.
3. Methods
3.1. Search strategy
The aim of this review was to explore the impact of
job satisfaction components on intent to leave and
turnover for hospital-based nurses. In order to extract
relevant research from the published literature to
achieve this aim the electronic databases Cumulative
Index to Nursing and Allied Health Literature (CI-
NAHL 19822004), Psychology Information (PsycIN-
FO 20002004) and British Nursing Index (BNI
19852004) were searched. Keywords were nurses,
retention and job satisfaction with synonyms and
phrases being used as appropriate (for example, the term
retention was used and combined with attrition, intent
to leave, intent to quit, propensity to leave, intent to stay
and turnover). The years 19972004 were chosen as a
limit option in order to select only recent published work
ARTICLE IN PRESS
that may hold more relevance for the nursing profession
today due to the rapidly changing nature of nursing over
recent years. Where possible, the search was globally
limited to research (e.g. within CINAHL) and manually
where electronic search limits were not possible. Specic
criteria for inclusion and exclusion (Table 1) were also
applied to ensure fullment of the aim of this review and
manual scanning of abstracts was undertaken for the
purpose of checking article suitability. While it was not
possible to retrieve a small number of papers, the
application of the inclusion/exclusion criteria resulted in
nine research articles being selected. These articles are
summarised in Table 2.
3.2. Framework for analysis
With a plethora of themes found within the chosen
literature, a decision was made to systematically identify
the most frequently cited using an adaptation of
thematic content analysis. This entailed scrutinising
each paper, logging each theme contained within each
paper and selecting those themes with the greatest
counts for analysis. The four themes with the highest
frequencies were: (1) leadership, (2) educational attain-
ment, (3) stress and (4) pay. Whilst an alternative
approach to inclusion could have been to choose the
most statistically signicant themes, this was not
ARTICLE IN PRESS
ECONOMIC FACTORS
Pay
Job market
Training
JOB
SATISFACTION
BEHAVIOURAL
INTENTIONS
STRUCTURAL FACTORS
Work environment
Work context
TURNOVER
PSYCHOLOGICAL FACTORS
Individual
Demographic
Fig. 1. Model of nurse turnover behaviour (Irvine and Evans, 1995).

Table 1
Showing criteria for inclusion and exclusion of articles
Inclusion Exclusion
Adult nurses Paediatric/mental health/learning difculties nurses
Hospital nursing Primary/community/correctional/public health/hospice/nursing
homes/NHS direct/military
Nurses in general medical and surgical units Solely specialist areas e.g. ICU, oncology, theatres, nurse
practitioners, management, nurse anaesthetists
Both job satisfaction+intent to leave/turnover a key focus of
the paper
Only job satisfaction covered
Primary or secondary research Literature reviews
possible due to the difculties in comparability of the
data and the variation in reports of each statistic.
4. Findings
4.1. Leadership
One of the problematic issues regarding leadership is
the lack of consensus regarding denition. Despite this,
some recognition that it refers to either the direct superior
or ward manager exists and that certain characteristics
pertaining to leadership are particularly pertinent in
inuencing intent to leave. Five of the nine papers used
scale measurement of leadership styles and characteristics
used in ward environments (Fang, 2001; Fletcher, 2001;
Tzeng, 2002; Yin and Yang, 2002; Larrabee et al., 2003).
Whilst leadership was dened differently in each study,
similar results were obtained with one exception.
Fang (2001) used a specically constructed super-
vision satisfaction scale consisting of ve items measur-
ing competency, fairness, recognition, communication
and collaboration (strongly disagree 1, strongly
agree 5). Regression results indicated that supervisor
satisfaction was one of the most signicant predictors of
turnover intention (coefcient standardised 0.168,
po0:05) but not turnover cognition (0.032). The study
surveyed 180 nurses in Singapore and obtained a 90%
response rate strengthening the validity of the results
although it was undertaken in a single hospital, thus
limiting generalisability.
Fletcher (2001) used a six-item scale of immediate
supervisor measuring perceived qualities such as supervisor
reliability, competency and helpfulness (very true 1,
not at all true 4), as well as the supervisory subscale
from the Job Diagnostic Survey (JDS, Hackman and
Oldham, 1975) (extremely dissatised 1, extremely
satised 7). The denition given for immediate super-
visor was generally the nurse manager, and the lowest
ratings attained were related to this subject. The lowest
individual item means for the subscale of JDS were for
supervisor support (mean 4.34) and quality of super-
vision (mean 4.46). For the Immediate Supervisor
scale the highest means (and therefore lowest ratings)
were for supervisor helpfulness (2.81) and reliability
(2.68). The low ratings were claried with written
comments from participants that were categorised into
four general themes: quality of leadership, lack of
physical presence, failure to address problems and
stafng issues. Whilst the results pertaining to intent to
leave indicated that the participants surveyed were likely
to remain in nursing, this was measured with a single
question scored on a 5-point Likert scale without further
statistical tests applied. Despite the large sample size
(n 1780 for JDS, n 509 for qualitative component)
and the number of hospitals surveyed (n 10), the
response rate for both components was low (34.5% and
28.6%). Furthermore, no report or prole of non-
respondents was provided, which may have affected the
representativeness of this US sample.
Larrabee et al. (2003) also reported associations
between leadership and intent to leave, but acknowl-
edged that this was an indirect link. Their US study
collected data (n 90, RR 60%) via nine subscales of
the Multifactor Leadership Scale (Bass and Avolio,
1995) with varying numbers of items in each subscale:
transformational leadership (5), transactional leadership
(3), non-transactional (1) and leadership outcomes (3).
Intent to leave was measured using a single item
(denitely will not leave 1, denitely will leave 5).
The results of stepwise multiple regression suggested
that leadership was not directly related to intent to leave
but indirectly related through various other predictors.
Transformational leadership style was found to predict
psychological empowerment of nurses (po0:001) which
in turn predicted an increase in job satisfaction
(po0:001) which was then a major predictor of a
decrease in intent to leave (po0:001). These ndings
illustrate the complexity involved in various perceptual
and attitudinal factors contributing to an individuals
intention to leave.
In contrast to the ndings of the studies presented
above, the results of Tzengs (2002) work suggested that
leadership style exerted no inuence on job satisfaction
and intent to leave (n 648, RR 82%). The different
method of modelling utilised by Tzeng distinguishes this
study from the others and may account for the variance
in ndings, although it is noteworthy that large p-values
(model 2, p 0:10; model 3, p 0:35) were obtained for
leadership style. This study was undertaken in Taiwan
and whilst the potential for cultural inuences to explain
the differences is acknowledged, interestingly Yin and
Yang (2002) attained opposing results in their meta-
analysis of 13 Taiwanese studies. In particular, consis-
tently signicant results were reported for experienced
turnover and potential turnover due to supervisor
dissatisfaction (ranked 5/18 and 3/16, respectively,
po0:05). The specic areas of supervisor dissatisfaction,
while measured, were not presented thus lowering the
opportunity for direct application of ndings to
practice.
4.2. Educational attainment
Conicting results were found for the effect of the
individual factor of educational attainment on job
satisfaction and on intent to leave. Six studies used
self-reported demographic data to ascertain the educa-
tional level of participants (Fang, 2001; Lu et al., 2002;
Tzeng, 2002; Yin and Yang, 2002; Larrabee et al., 2003;
Rambur et al., 2003). Three studies found positive
correlations for educational level and job satisfaction. A
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secondary analysis of US relicensure surveys by Rambur
et al. (2003) (n 4418, RR 85%) reported that job
dissatisfaction decreased with higher educational level,
and Yin and Yangs (2002) work in Taiwan conrmed
this nding, suggesting that nurses with lower educa-
tional levels are less satised with their jobs (po0:05).
This is reiterated by Tzeng (2002), whose results for the
nal ordinal regression indicated that holding a diploma
(estimate 1.790, Wald w
2
4:28, p 0:04), holding
an associate degree (1.639, Wald w
2
4:00, p 0:05)
and general job satisfaction (0.862, Wald w
2
22:89,
p 0:00) are signicant predictors of Taiwanese nurses
intention to quit. Yins and Yangs (2002) meta-analysis
of individual factors related to nurse turnover asserted a
small but stable relationship for educational attainment
(r
xy
0:09), with this relationship being one of the
strongest out of the individual factors that included
marital status, years of tenure, age and position.
Interestingly, opposing results were obtained by Lu et
al. (2002) who found a signicant association indicating
educational level to be negatively correlated with job
satisfaction (Spearmans correlation 0.101, po0:01)
and positively correlated with intent to leave the
organisation (.054, po0:05) and the profession (0.058,
po0:01) for a Taiwanese sample (n 2197,
RR 86.2%). The studies by Fang (2001) and Larrabee
et al. (2003) both concluded that there were no
signicant relationships between any demographic
factors and turnover cognition or intention. Fang
(2001) further reported that job satisfaction did not
exhibit any signicant inuence on turnover in a sample
of Singaporean nurses (coefcients standardised for
cognition 0.108; for intention 0.007). The small, non-
random sample in Larrabee et al.s (2003) study could
indicate a reason for their opposing results, with larger
studies required to conrm these as valid ndings.
Additionally, the purpose of their study did not
specically involve the investigation of demographic
variables on job satisfaction and intent to leave, so
results of statistical tests were not provided for educa-
tional attainment, thus disallowing independent assess-
ment of the effect.
Overall, there was no consensus regarding educational
attainment and its relationship with either job satisfac-
tion or intent to leave. The inconsistent, yet sometimes
signicant results allow for considerable confusion when
attempting to interpret the importance and implications
of educational attainment for retention. Similarities in
data collection methods and use of statistics across
studies further hinders the clarication of reasons
for the differences in ndings. It could be assumed from
these results that assessment of educational level is
fraught with methodological challenges, or perhaps the
samples were very distinct. Certainly the ndings are
mixed, and as such conclusions should be drawn with
caution.
4.3. Pay
Throughout the studies that measured the importance
of pay for nurses (Fang, 2001; Fletcher, 2001; Cowin,
2002; Rambur, 2003), denitions were implied as salary
or salary and fringe benets, which enhanced compar-
ability of ndings. However, the impact of salary related
to culture is difcult to determine without detailed
knowledge of the wider social and economic climate in
which it operates. In addition, several different ndings
were produced from differing methods of assessment.
Cowin (2002) measured satisfaction with pay over an
8-month period among a sample of Australian graduate
nurses (n 506 at T1, n 110 at T2) and experienced
nurses (n 528 at T1, n 332 at T2) through a
component of the Index of Work Satisfaction (IWS,
Stamps and Piedmonte, 1986) at two points in time
(T1 0 months, T2 8 months). The ndings indicated
that although the issue of pay was not ranked as the
most important, it rated as the least satisfying for
graduates (T1 and T2) and second least satisfying for
experienced nurses (T2). Furthermore, the importance
of pay increased over time for both groups (from 3/6 to
2/6). This could be attributable to other confounding
factors occurring over the 8 months of the study but not
measured, or may indicate a growing concern that has
the potential to become a considerable source of
importance. However, the specically constructed Nurse
Retention Index (NRI, 8-point forced choice Likert) was
administered to the two groups at T2, and Cowin (2002)
stated that the results of multiple regression analysis
suggest that pay was not a statistically signicant
indicator of intent to leave for either group (gures
undisclosed). Despite this, the qualitative component of
Cowins (2002) study, which consisted of written
comments, indicated that dissonance between pay and
level of responsibility may lead to retention issues. A
major source of concern for graduates and experienced
nurses was the perceived inequality of pay for high level
of responsibility. In particular, experienced nurses
compared their workloads, level of knowledge and
responsibility to their perception of less qualied
professions, resulting in expressions of disappointment
with career choice. Other comments suggested that pay
was not a primary problem for retention when enjoy-
ment of other aspects (undisclosed) of the work was
high.
Fang (2001) also found no statistically signicant
inuence of pay on turnover cognition (coefcient
standardised 0.108) or turnover intention (0.007). A
complete assessment of the importance of pay was,
however, complicated by the loading of pay into the
same factor of job satisfaction. The overlap between
these two factors was found during factor analysis and it
was therefore found to possess a lack of empirical
distinctiveness. The question asked of the sample
ARTICLE IN PRESS
relating to pay also included the element of job security.
It is possible that this multiple question could have
affected the assessment of salary satisfaction if partici-
pants were satised with the security of their position
and scored accordingly.
The inability to assess pay individually was also
evident in Fletchers (2001) study. A job satisfaction
subscale of the JDS (Hackman and Oldham, 1975) was
used to measure pay satisfaction of US nurses
(n 1780, RR 34.5%) via two items (Spearman-
Brown reliability for items on scale 0.86). The pay
items were measured with a 7-point Likert scale
(extremely dissatised 1, extremely satised 7) but
the only result presented was that of an overall score for
the subscale which consisted of 14 items. This asserted
that participants were slightly satised with their jobs
(mean 5.04, SD 0.99), but rendered specic results
for the pay items inaccessible. Written comments from
participants provided some clarity, with an expression of
similar feelings to those from Cowins Australian (2002)
study. They indicated feelings of inadequate reward for
their education, experience and expertise, and unfair-
ness of pay compared with other professions. Fletcher
(2001) argued that the sample was likely to remain in
nursing, although this conclusion was drawn on the
basis of a single question providing little insight into the
factors inuencing participants responses. Generalisa-
bility is compromised due to the low response rate
(34.5%), and a reported demographic of nurses being
represented by a bargaining unit (type of union that
negotiates salary each year) which is unrepresentative of
the nursing profession in other countries.
An interesting feature of the issue of pay and resulting
inuence for intent to leave for nurses was reported in
Rambur et als (2003) large US study. A gender
difference affecting pay satisfaction was found during
secondary analysis of self-reported data. Pay was
collapsed into the category of job dissatisfaction along
with aspects such as short stafng and poor manage-
ment. Of those intending to leave (males 23%,
females 20%), 75% of male participants were intend-
ing to leave for reasons of job dissatisfaction in contrast
to 51% of female participants (w
2
10:31, po0:01). In
addition, male participants (53%) were more likely to be
leaving due to dissatisfaction with salary than female
participants (26%) (w
2
16:31, po0:01). As no statis-
tically signicant results for gender differences were
obtained for the majority of other categories inuencing
intent to leave, gender expectations and socialisation
may play a particular role in pay.
4.4. Stress
Four studies specically investigated the effect of
stress on intent to leave, with stress consistently being
cited as a major predictor of anticipated turnover. This
had particular international signicance with studies
conducted in the US (Shader et al., 2001), Singapore
(Fang, 2001), Australia (Cowin, 2002) and Taiwan (Yin
and Yang, 2002) reporting similar results. Methods used
to measure stress were varied and included scales (Fang,
2001; Shader et al., 2001), written comments (Fletcher,
2001; Cowin, 2002) and meta-analysis (Yin and Yang,
2002).
Stress exerted the most substantial impact on turnover
cognition (coefcent standardised 0.351, po0:000)
and turnover intention (coefcient standardised 0.29,
po0:001) of all variables measured in Fangs (2001)
study. Whilst reporting that stress explained 8.5% from
a total of 41% of the variance for turnover cognition
and 4.6% from a total of 32% for turnover, the specic
causes of stress remained undifferentiated. This detracts
from the wider focus of the study, which was to identify
the most critical causes of the turnover problem in
Singapore with a view to mitigating the problem. Whilst
an indication that stress is a major cause is helpful for
directing future research, a scale identifying specic
stressors would have been helpful in ascertaining areas
requiring improvement.
Shader et als (2001) US study partly identied
particular stressors via the Job Stress Scale (Hinshaw
and Atwood, 1985), a 22-item, 4-point Likert with four
subscales. The mean job stress score was 2.06
(SD 0.39, range 14), demonstrating that nurses
reported moderate levels of job stress (n 151,
RR 63%). The Anticipated Turnover Scale consisting
of 12 items rated on a 5-point Likert measure (possible
responses undisclosed) reected individual perceptions
about the possibility of leaving their current positions
(mean score of 3.45, SD 1.06, range 17), rating their
intention to leave as moderate. Pearsons correlation
analyses were performed on all major study variables.
The main stressor was assessed to be lack of stability in
the work schedule (constantly changing rota), with the
more stable the schedule, the less work-related stress
(r 0:205, po0:001) and lower anticipated turnover
(r 0:29, po0:001). Higher job stress was also found
to lower job satisfaction through the lowering of group
cohesion (r 0:41, po0:001) which then increased
anticipated turnover (r 0:37, po0:001). A stepwise
regression model including the variables of job satisfac-
tion (0.35), weekend overtime (0.27), job stress (0.16)
and group cohesion (0.13) explained 31% of the
variance in anticipated turnover. Shader et al. investi-
gated turnover further by looking at different age groups
in relation to these factors. The ndings indicated that
low job satisfaction and job stress were signicant
predictors of anticipated turnover for 2030-year-old
nurses (R
2
16, po0:001), low job satisfaction was a
predictor for 3140-year-old nurses (R
2
0:31,
po0:001) and low job satisfaction together with low
group cohesion for 4150-year-old nurses (R
2
0:28,
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po0:001). For nurses aged 51 and over, there were
no signicant predictors of anticipated turnover. The
inference that stress is mainly a problem for
the youngest nurses of the sample may be linked to the
nding that the stressor of most importance was work
schedule as high value may be placed on control over
own time for this age group. The demographics denoted
that two-thirds of the sample had been nursing for less
than 3 years also highlighting the possible implication of
inexperience. However, job dissatisfaction as measured
by the IWS exerted an inuence on intent to leave for all
age groups of nurses implying ultimate signicance of
this factor for the study sample.
A negative relationship between stress and job
satisfaction (po0:01) was also reported as having an
important inuence on turnover in the meta-analysis of
nursing turnover conducted by Yin and Yang (2001).
Stress was inducted as one of 12 variables related to
turnover from the factors included in 13 studies under-
taken in Taiwan. The second most frequently reported
reason for leaving last nursing position was work stress
due to high workload. In contrast, stress was ranked 6th
of reasons for potentially leaving a current job. This
inconsistency in rank from experienced (2) to potential
(6) turnover is difcult to explain, as logically it would
be expected that factors would have to be important to
intent to leave in order to inuence turnover. This
occurrence could possibly be explained by mediating
factors that, perhaps, become less inuential over time.
For example, positive peer group relationships (ranked
2nd for potential turnover) within the workplace may
buffer stress only to a certain point above which stress
becomes more inuential. However, another possibility
may be that the retrospective measurement of reasons
for turnover, with consequential reliance on partici-
pants memory, could allow for inaccurate results. A
strength of the meta-analysis makes the combined
sample more representative of the population than
individual samples; however, it is possible that the
generalisability of these ndings could be limited to
hospital settings in Taiwan.
Overall, for factors relating to turnover, stress has
been consistently implicated in these studies, but
ambiguity towards the actual stressors responsible has
been shown.
5. Discussion
5.1. Limitations
It is acknowledged that some of the studies selected
for nal inclusion contained data derived from some
specialist areas due to random samples taken from the
hospital workforce. Whilst measures were taken to
reduce this occurrence, the reality of the empirical
literature precludes this as a practicality. As a conse-
quence, studies were included if the sample predomi-
nantly contained nurses working in general medical or
surgical environments. It is recognised that this may
inuence the conclusions drawn from the literature
analysed. Another limitation of this review relates again
to the selection of studies. Stricter criteria involving
intent to leave could have ensured the review focused on
intent to leave the profession rather than the organisa-
tion. This may have wider signicance for the profession
than the organisation they serve.
5.2. Key outcomes and comparison over time
In the meta-analyses of Blegen (1993) and Irvine and
Evans (1995), factors with the strongest relationships to
job satisfaction were found to be related to work content
and environment. This remains true for more recent
research ndings as can be seen by the themes high-
lighted. From the four themes discussed, three were
organisational factors (leadership, stress and pay) and
only one an individual/demographic factor (educational
attainment). This has implications for improvements in
retention as organisational changes may be more easily
addressed than those involving age, education and
tenure for nurses already employed.
5.3. Stress
In earlier studies, stress had the strongest relationship
with intent to leave, and factors such as low autonomy,
low recognition and poor communication with collea-
gues were described as the causes of this stress (Hinshaw
et al., 1987; Blegen, 1993). With the changes affecting
nursing practice over recent years and the corresponding
increase in demands on nurses, it is unsurprising that
stress is still an issue for todays profession. It is unclear,
however, what stage along the continuum of eustress to
distress is being measured, and whether the amount of
stress reported in recent work has increased or decreased
from those of earlier studies. Additionally, specic
stressors were not identied with any consensus in the
papers studied although various stressors such as
workload (Yin and Yang, 2001) and unstable work
schedules (Shader et al., 2001) were identied as
important for some samples.
In an occupation as diverse and challenging as
nursing, assessing stress is difcult (McVicar, 2003).
This, coupled with the subjective nature of stress
perception, renders the identication of specic con-
tributing factors unrealistic. However, in the light of the
consistent implication of stress inuencing turnover, an
effective reduction of stress is required to successfully
address low retention. A full understanding of the stress
phenomenon is necessary to facilitate appropriate
policies and interventions, yet the fact that nursing
ARTICLE IN PRESS
environments are not generic makes achieving this
complicated. In view of this, interventions that seek to
support the individual, such as stress-management
training, which enables individuals to utilise their most
effective coping strategies, and increasing support from
colleagues and senior staff have both been suggested as
appropriate measures to counteract stress within the
nursing profession (McVicar, 2003).
The UK Government recognises the need to address
low retention in health care, with initiatives designed to
reverse the trend in turnover. Introduction of exible
working practices are part of the Governments commit-
ment to improving the worklife balance of staff (DH,
1999). This may be particularly relevant for retention of
younger nurses who were found to perceive stress from
lack of control over work scheduling (Shader et al.,
2001). An increase in stafng levels via improved
retention is also a means to address the cited stressor
of workload (Yin and Yang, 2001). With an increase in
demand for health care, the burden of high workload
can only be ameloriated by increasing nurse numbers.
The RCN (2002) maintains this point, and adds that
recruitment efforts will produce little signicant im-
provement in workload stress in the near future and
should perhaps be seen as a medium to long-term
measure. Government initiatives designed to meet needs
of the majority is a starting point, but in view of the
individual nature of stress may not provide the answer
for all nurses (McVicar, 2003). In view of the fact that
organisational change is a recognised source of stress
(Kouzes and Posner, 2003) and that changes constantly
occur in the health services in line with modernisation
plans, this issue is unlikely to be solved imminently
within the British NHS.
5.4. Leadership
The variable of leadership, or supervisory relation-
ship, has a consistent relationship with job satisfaction
and intent to leave in both early and recent studies
(Sorrentino, 1992; McNeese-Smith, 1995; Chiok Foong
Loke, 2001; Fang, 2001; Fletcher, 2001; Yin and Yang,
2002; Larrabee et al., 2003). Nursing leadership style, or
supervisory relationship, is a phenomenon of interna-
tional relevance that is linked to the work environment.
Fletchers (2001) study suggested that job dissatisfaction
ensues when nurse managers fail to give due recognition
and support, disregard stafng issues and neglect to
address problems. Furthermore, Larrabee et al. (2003)
asserted that the main effect on intent to leave was a
decrease in job satisfaction through a lack of empower-
ment perceived by nurses to be a result of leadership
style. This suggests that when stafng levels are reduced,
as they are for todays profession, leadership that
encompasses an open, empowering approach to staff
may be able to buffer low retention. Transformational
leadership style engenders motivation of others to
pursue high standards, concentrates on creating open
communication and a willingness to embrace change
(Morrison et al., 1997; Upenieks, 2003). This would
seem most desirable for a profession that experiences
much change and that has expressed concern about
supervisory relations to a point that it negatively affects
turnover and possibly quality of care (McNeese-Smith,
1993; Davidson et al., 1997; Needleman and Buerhaus,
2003). Introduction of participative styles of manage-
ment is central to the human resource proposals of
the NHS Plan (DH, 2000), but change in leadership
behaviour may not be easily obtained if this is not placed
high on the agenda for managers (Finlayson et al.,
2002).
5.5. Pay
Nurses pay has been measured as a component on
many scales, although early studies found it to
contribute little to job satisfaction (Blegen and Mueller,
1987; Blegen, 1993; Irvine and Evans, 1995). However,
the issue of pay and its contribution to job satisfaction
increases in importance when nurses perceive discrepan-
cies between their remuneration and that of other
professions (Tovey and Adams, 1999). This was
reiterated in the written comments obtained in the
studies of Fletcher (2001) and Cowin (2002). It has also
been suggested that perceived lack of reward contributes
to role disengagement (Demerouti et al., 2000) and,
although pay was not found to exert an effect on intent
to leave in these studies, such perceptions have the
potential to become inuential. Comments from the
participants of Cowins (2002) study suggesting that pay
was not an issue only when other factors were satisfying
reiterates this possibility. It is further supported by the
dissatisfaction expressed by participants regarding the
discrepancy between the high responsibility of the job
and perceived low pay. As roles for nurses expand,
and their responsibility increases, the potential for
dissatisfaction and intent to leave could be amplied in
the UK.
Addressing pay via the Agenda for Change (DH,
2003) programme, which aims to modernise the salary
system of the British NHS by providing competency-
based pay (a variant of performance-related pay), has
been suggested as a potential source of conict for
employees expectations, norms of fairness and practice
(Grimshaw, 2000) although such a perspective has its
detractors. In a case study undertaken as a precursor to
Agenda for Change evaluation, Meerabeau et al.(2004)
found that a competency-based pay system was valued
by staff who felt that it provided structured role
development. This dissonance demands that close
attention be paid to evaluation of this system when it
is introduced nationally.
ARTICLE IN PRESS
5.6. Educational attainment
Inconsistencies were apparent in overall results for the
relationship between levels of education and job
satisfaction. However, some ndings contradicted the
earlier research of Price and Mueller (1981) and
Cavanagh (1992) by suggesting that higher educational
attainment led to greater satisfaction at work and
lowered intention to leave (Tzeng, 2002; Yin and Yang,
2002; Rambur et al., 2003). This contradiction may have
occurred as a result of changes to nursing education that
have developed over recent years in the countries where
these studies were located (i.e. Australia, Singapore,
Taiwan, US), most notably the introduction and
expansion of degree-level qualications. For example,
Rambur et als (2003) US study, elucidates that
baccalaureate education emphasises a greater under-
standing of the context of health care delivery allowing
for greater satisfaction. They suggest that it is this
enhanced understanding that empowers nurses to
inuence the macro factors impacting on their work
environment resulting in a reduction of dissatisfaction.
If so, it could have relevance for the profession in the
UK which, in an era of fast-paced change, may benet
from further expansion of degree education. However,
the inconsistent results in both early and recent studies
would suggest that educational attainment is a widely
varying factor for which conclusions cannot yet be
drawn and as such warrants further investigation.
5.7. Reection on ndings and model of nurse turnover
behaviour
The ndings of this review were found to reect the
model of nurse turnover proposed by Irvine and Evans
(1995). Although Irvine and Evans conducted their
meta-analysis in a different employment climate to that
which currently exists, the major ndings of leadership/
supervisory relationship and stress remain inextricably
linked to intent to leave. These factors comprise part of
the work environment, which was found to have a
stronger relationship with job satisfaction and intent to
leave in both their meta-analysis and the ndings of this
paper. Changes over time have occurred regarding the
effects on intent to leave for educational attainment and
pay. This suggests that it is imperative that sources of
satisfaction are reassessed in the light of changes over
time. The empirical evidence shows that stress and issues
concerning leadership consistently exert both direct and
indirect effects on job satisfaction and intent to leave.
Despite the improvement in techniques to analyse
results from nurses job satisfaction studies, the reliance
on quantitative methods for data collection has over-
shadowed qualitative investigations (McNeese-Smith,
1999). Nevertheless, some qualitative inquiry has been
used, often as a small component of a larger investiga-
tion. This is exemplied in Cowins (2002) and Fletchers
(2001) studies where additional written comments served
to clarify issues raised in results from scale measure-
ment. The information gained from qualitative inquiry
could be utilised more widely to provide a relevant data
source to complement quantitative methods. Not only
would this serve to enhance contemporary and specic
knowledge of nurses job satisfaction, but would also
assist in providing the nursing profession with a
methodology evolved from, but independent of, non-
nursing areas.
5.8. Contextual factors
Despite much research, denitive results of which
variables are statistically and consistently related to
nurses job satisfaction remain elusive (Tovey and
Adams, 1999). The demonstration of variation in the
factors inuencing job satisfaction in different levels of
the profession (e.g. of ward managers and staff nurses)
and in differing environments (e.g. hospitals, commu-
nities, geographical regions) reects the difculties faced
when searching for authoritative results. Furthermore,
there are discrepancies regarding sampling that involves
mixing data from samples of nurses whose jobs have
distinctive features such as paediatric, intensive care or
mental health, as well as the inclusion of health care
assistants. This lack of distinctiveness serves to invali-
date generalisability of results to ward-based medical
and surgical adult nurses. Similar problems exist with
geographical locations that may have differing labour
markets and population densities that may affect the
opportunities for alternative employment or workloads
respectively.
Studies undertaken in differing types of hospitals
offering different types of care (e.g. long-term or acute)
may further produce results specic only to that
environment, and therefore limit the relevance for the
wider profession. Additionally, the generalisability of
research based on theories and frameworks developed in
one culture or nation and then undertaken in dissimilar
countries has been questioned (Rosenzweig, 1994).
However, in response to this, some international
research on job satisfaction now offers comparisons
across nations, contributing to empirical generalisation
(Fang and Baba, 1993). Furthermore, the extent to
which international recruitment has occurred over
recent years and the paucity of research relating to
immigrant nurses experiences of the British NHS
necessitates the use of international data on job
satisfaction to illuminate the views of nursing staff.
5.9. Implications for research
Given the multitude of issues surrounding the study of
job satisfaction components and their effects on intent
ARTICLE IN PRESS
to leave, generalised conclusions should be drawn with
caution. The use of scales developed for use on
occupational groups other than nurses may no longer
be appropriate, as the changing nature and specicity
of work areas demand measurement approaches to be
more exclusive. Research to identify particular stressors
and effective ways of detecting stress early may be
useful to address the impact that stress has on retention,
and outcomes of the introduction of participative
management for leadership dissatisfaction should be
assessed.
The literature selected for analysis contained no UK
studies. This was unexpected and may indicate a
discrepancy between the espoused importance of reten-
tion issues and the UKs research priorities and as
such should be addressed and acted upon. Some work
is, however, being undertaken such as the development
of a tool for measuring job satisfaction in the
contemporary UK nursing profession (Murrells et al.,
2005), which will serve to accurately assess this
exigent issue.
6. Conclusion
This review set out to assess the components of job
satisfaction most inuential on intent to leave for nurses
working with adults in ward environments. In addition
to identifying these components, an exploration of how
the sources of job satisfaction may have changed over
time was undertaken. The results suggest that although
many of the same factors are being assessed within
scales, a more appropriate and relevant approach may
be to assess each environment individually. Scales,
whilst useful tools for comparability, need to evolve
within the nursing profession for maximum effective-
ness. If to be used as a means for implementing policy
change and improving the working lives of nurses, it is
essential that scales generate specic and accurate data.
When the aim is improvement of job satisfaction for
nurses, the conclusions made from this study point
strongly toward the need for analysis at ward level. As
differing results are found across work environments,
more appropriate techniques such as qualitative inter-
views or action research may be employed to gain
detailed insight into which components are of impor-
tance to particular workforces. This could be under-
taken ward-wide, for policy change at NHS Trust level,
as a nation-wide policy may not be apt given the
discrepancies shown.
Although consistent results were not always found,
the issues of leadership and stress were highlighted as
exerting particular inuence on intent to leave. The
implications of these issues remaining unresolved are
detrimental for practice and the health service.
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International Journal of Nursing Studies 44 (2007) 297314

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Fig. 1. Model of nurse turnover behaviour (Irvine and Evans, 1995).

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