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. Author manuscript; available in PMC: 2008 Oct 1.
Published in final edited form as: Soc Sci Med. 2007 Jul 9;65(8):1708–1719. doi: 10.1016/j.socscimed.2007.05.050

Ethical Climate, Ethics Stress, and the Job Satisfaction of Nurses and Social Workers in the United States

Connie Ulrich 1, Patricia O'Donnell 2, Carol Taylor 3, Adrienne Farrar 4, Marion Danis 5, Christine Grady 6
PMCID: PMC2442035  NIHMSID: NIHMS32061  PMID: 17619068

Abstract

Nurses and social workers are fundamental to the delivery of quality health care across the continuum of care. As health care becomes increasingly complex, these providers encounter difficult ethical issues in patient care, perceive limited respect in their work, and are increasingly dissatisfied. However, the link between ethics-related work factors and job satisfaction and intent to leave one’s job has rarely been considered. In this paper, we describe how nurses and social workers in the USA view the ethical climate in which they work, including the degree of ethics stress they feel, and the adequacy of organizational resources to address their ethical concerns. Controlling for socio-demographics, we examined the extent to which these factors affect nurses and social workers’ job satisfaction and their interest in leaving their current position. Data were from self-administered mail questionnaires of 1215 randomly selected nurses and social workers in four census regions of the United States. Respondents reported feeling powerless (32.5%) and overwhelmed (34.7%) with ethical issues in the workplace and frustration (52.8%) and fatigue (40%) when they cannot resolve ethical issues. In multivariate models, a positive ethical climate and job satisfaction protected against respondents’ intentions to leave as did perceptions of adequate or extensive institutional support for dealing with ethical issues. Black nurses were 3.21 times more likely than white nurses to want to leave their position. We suggest several strategies to reduce ethics stress and improve the ethical climate of the workplace for nurses and social workers.

Keywords: registered nurses, social workers, ethical climate, ethics stress, job satisfaction, USA

The quality and safety of patient care as well as patient and family satisfaction with care are largely dependent on nurses and social workers. Both nurses and social workers help people in some of their most difficult circumstances of life and assist with nearly every facet of need, including physical and mental illness, disability, counseling, education, or simply navigating the health care system (National Association of Social Workers, 2006). By the year 2020 however, U.S. hospitals expect a 20% shortage of nurses (American Hospital Association, 2001; American Association of Colleges of Nursing, 2002; Buerhaus, Staiger, & Auerbach, 2000). Non-hospital settings also face shortages as patients discharged early need coordinated professional care. To support the complex needs of patients as they transition from hospital to home or long-term care facilities, a 30% increase in the need for social workers is expected by the year 2010 (Hecker, 2001; National Association of Social Workers [NASW], 2006).

An inadequate supply of healthcare workers impacts quality, safety, and access to healthcare. At least 1.3 billion people worldwide lack access to basic care due to these shortages (World Health Report, 2006). The severity of patient problems, paperwork, caseload size, undervalue of work and decreases in job security, staffing levels, wages, skill mix, resources, and other factors continue to affect the satisfaction and retention of healthcare providers (NASW, 2006). Urgent strategies are needed not only to recruit more nurses and social workers but also, importantly, to retain existing personnel. Economic constraints, downsizing, restructuring, and the burden of emerging and reemerging diseases on healthcare systems have created stressful working environments for many providers. Predictors of job satisfaction and intent to leave have mainly focused on demographics, work setting characteristics, and work attitudes, but little empirical attention has been given to their relationship with ethics-related issues within hospital and non-hospital practice settings and in different types of healthcare providers.

Background

Ethics Stress

Nurses and social workers encounter serious ethical problems in providing patient care services. These ethical problems in practice can result in ethics-related stress in healthcare providers. Ethics-related stress is an occupational stress that is the emotional, physical and psychosocial consequences of moral distress (i.e., knowing the morally right course of action but constrained to carry out the action) (Corley, Minick, Elswick, & Jacobs, 2005; Jameton, 1984; Raines, 2000). The consequences of ethics stress can include frustration, interpersonal conflict, dissatisfaction, physical illness, and possibly abandonment of the profession.

Ethics stress may be inherent in the professional role of nurses and social workers based on their daily interactions and care for ill persons and their relationships within a complex bureaucratic healthcare system; ethics stress is also organizationally induced. Raines (2000) describes “ethics stress” as the stress associated with ethical issues and/or dilemmas. She found that 80% of oncology nurses in her study had a stress score of 6 on a 10-point scale and identified 32 different types of ethical dilemmas they encountered within the previous year. Likewise, in a focus group analysis of ethical dilemmas and moral distress in Swedish healthcare providers, Kälvemark, Höglund, Hansson, Westerholm, and Arnetz (2004) discuss conflicts between organizational rules and regulations and providers’ caring obligations toward patients. They found that the phenomenon of moral distress is not isolated to a specific category of healthcare professional as previously indicated in U.S. literature.

Social workers and nurses have been challenged by value laden decisions related to technology, the right to live or die, the limits of interventions, patient autonomy, and quality of life issues (Raines, 2000; Reamer, 1985). Similar ethical issues that create stress among both social workers and nurses range from individual patient care conflicts, end-of-life care, advance directives, competency and surrogate decision making, informed consent, protecting patient rights and withdrawing or withholding treatment to broader work place concerns over appropriate levels of staffing, resource availability, procedural justice, autonomy, and collegiality (Black, 2004; Csikai & Bass, 2000; Egan & Kadushin, 1999; Fry & Duffy, 2001; Gellis, 2001;Mackelprang & Mackelprang, 2005; Manetta & Wells, 2001; Miller, Hedlund, & Murphy, 1998; Proctor, Morrow-Howell, & Lott, 1993; Raines, 2000; Redman & Fry, 2000; Wilkinson, 1987/88).

Ethical Climate and Job Satisfaction

Organizations declare what is of value to them through articulated goals, treatment of patients, staff, students, and community, and how conflicts and controversy are managed (Reiser, 1994). An ethical climate represents those shared perceptions of organizational practices related to ethical decision-making and reflection and includes issues of power, trust and human interactions within an organization (Olson, 1998). Improving the ethical climate may be essential for addressing ethics stress, job satisfaction, and turnover intentions (McDaniel, 1997; Raines, 2000; Shirey, 2005), yet few studies have examined the perception or importance of ethical climate to nurses and social workers.

Hart (2005) found that a negative ethical climate was associated with registered nurses’ (RNs) decisions to leave their job or to leave the nursing profession; however, the study was limited by use of a single state and the low response rate. Corley et al. (2005) examined the relationship between the ethical environment and nurse moral distress and found that 25% of nurses in their sample left a position due to moral distress. Although ethical factors were not part of their research, Aiken, et al. (2001) found that 40% of nurses are dissatisfied with their work environment and one out of three RNs under the age of 30 plans to leave their position within the next year. Nearly half (44%) of Aiken et al’s sample reported a diminished quality of care within their workplace. Similarly, social workers’ dissatisfaction and intent to leave are often influenced by personal, professional, and organizational factors including issues of respect, supportive work environments, professional development, and personal boundaries with patients and collaborative decision making (Acker, 2004; DeLoach & Monroe, 2004; Egan & Kadushin, 2004; Gregorian, 2005; Kadushin & Egan, 2001; Kadushin & Kulys, 1995).

As workplace issues continue to be seen as a major cause of the healthcare shortage (American Association of Colleges of Nursing, 2002), we hypothesized that a positive ethical climate is an important determinant of nurses’ and social workers’ job satisfaction. This study describes how nurses and social workers view the ethical climate in which they work, including the degree of ethics stress they feel, and the adequacy of organizational resources to address their ethical concerns. We examined the extent to which these factors affect nurses and social workers’ job satisfaction and their interest in leaving their current position.

METHODS

Study Sample and Design

A self-administered paper-and-pencil survey was mailed to a random sample of 3000 nurses and social workers chosen from the state licensing lists of 4 states in 4 census regions of the United States in 2004 (California, Maryland, Massachusetts, and Ohio). States were chosen for geographical diversity and based on the availability of state licensing lists for both professional groups. At the time of the study, currently certified and licensed registered nurses and social workers in each of the designated states were eligible for participation. Because social workers practice in a large variety of areas, we estimated that about a third of social workers practice in clinical/healthcare situations and over-sampled this population to ensure an adequate number of responses for our analysis. Twelve percent of our respondents were ineligible and for 3.6% the address was not valid resulting in an overall adjusted response rate of 52% (53% SWs, 52% RNs) (American Association for Public Opinion Research, 2000). The margin of error for the results from the entire sample was ± 2.8%.

The Survey Questionnaire and Procedures

A single questionnaire was designed in conjunction with the Center for Survey Research at the University of Virginia and used for both professional groups. Respondents were offered the option of either a paper-and-pencil or web-based response. Items for the questionnaire were adapted from the literature and previous ethics-related research. The questionnaire addressed the following domains: description of the workplace ethical climate, availability and type of organizational resources to assist with ethical issues, type and frequency of ethical issues encountered, ethics stress, job satisfaction and intent to leave, and socio-demographic and practice characteristics. Dillman’s Tailored Design Method (TDM) (1978, 2000) was used as a guide for the data collection procedures, with a $2 financial incentive in the initial mailing added to maximize participation. Four mailings were sent to participants.

Dependent Variables

Job satisfaction and intent to leave were the outcome variables. We adapted the 12-item Physician Job Satisfaction Scale originally developed by Williams, et al. (1999) to measure the professional job satisfaction of nurses and social workers. The instrument uses a 5-point Likert scale with item responses ranging from 1 (strongly disagree) to 5 (strongly agree). Several items are reverse scored. Three subscales comprise the measure: global job satisfaction, career satisfaction, and specialty satisfaction. The internal consistency reliability for the total scale in our study was .92 and .86, .86, and .82 for the three subscales respectively. Intent to leave was measured by a single dichotomous item worded as follows “Would you like to leave your current position?”(1= Yes, 0 = No).

Independent Variables

Independent variables included socio-demographic characteristics, ethics stress, ethical climate, and factors thought to influence retention. Socio-demographic characteristics included age, sex, race, ethnicity, income, education, type of provider (RN, SW), years in professional practice, and years in current position. An adapted Ethics Stress Questionnaire developed by Raines (2000) was used to measure the degree of ethics stress experienced by nurses and social workers. Thirty of the 52 original items were used with an internal consistency reliability of 0.89 in our study. The instrument contains items assessing confidence and powerlessness in dealing with ethical issues; job related effects that include fear of reprimand for ethical decisions, legal liabilities that affect ethical decisions in the work setting; and psychosocial effects of ethical decision making (e.g., physical symptoms, fatigue, frustration, feeling overwhelmed).

An adapted version of Olson’s 26-item Hospital Ethical Climate Scale (1998) was used to measure the influence of the workplace and organizational practices on nurses’ and social workers’ ability to engage in ethical practice and reflection and to resolve ethical issues. This instrument captures respondents’ relationships with peers, patients, physicians, managers, and their institutions (e.g., hospital). Responses to these items yielded a scale with high internal consistency with a coefficient alpha of .93. Respondents were also asked to rate on a 5-point Likert scale the extent to which each of the following factors influenced their decision to remain in their position: staffing, salary, scheduling, workload, identification with the institution’s mission, feeling like a respected and valued member of the organization, and the level of ethical conflict. Finally, using a single 5-point Likert item, respondents were asked to identify the adequacy of the resources provided by their institution to assist with ethical work issues.

Human Subjects Protection

The Offices of Human Subjects Research (OHSR) at the National Institutes of Health (NIH) and the University of Virginia (UVA) approved the study. A cover letter informed participants of the purpose of the study and that responses would be kept confidential.

DATA ANALYSIS

Data were analyzed using SPSS version 14. The multivariate model of job satisfaction was tested using linear regression and the multivariate model of intent to leave was examined using logistic regression procedures. To meet the basic assumptions for linear regression, income which was originally measured using six categories was collapsed into three categories and institutional support to assist with ethical issues at work was dichotomized into adequate/extensive resources or limited/no resources. Other transformed variables included years in practice (square root transformation), years in current position (log transformation), and the influence of feeling like a respected member of the team (log transformed). Expectation maximization (EM) was used to impute missing values for items measuring ethical climate, ethical stress and job satisfaction. Fewer than 5% of the subjects in the analyses reported here had missing values imputed. Finally, regression diagnostics indicated no evidence of multicollinearity and no influential or outlier cases.

Results

Respondent Characteristics

Respondents included 1215 nurses and social workers aged 23 to 78 years [Mean (SD), 45.9 years (10.9)] (See Table 1). Nearly 10% of the sample was under 30 years of age. The sample was predominantly female (85.3%) and Caucasian (83.3%) with nurses more likely than social workers to be female (p < .001). The majority of social workers were masters prepared (83.1%) and most reported receiving some type of ethics education while 23% of nurses reported no ethics education and only 18.3% had masters education. Respondents had a mean of 17 years of professional experience but practiced in their current position less than ten years (mean, 7.4 years), and 71.7% worked full time in both hospital and non-hospital settings. Six percent of the nursing sample and .8% of the social work sample was educated outside the US. Nurses and social workers in our sample did not differ significantly in age, sex, or race when compared to the 2000 National Sample Survey of Registered Nurses and the 2004 Licensed Social Worker Survey in the U.S (Spratley, Johnson, Sochalski, Fritz, & Spencer 2001; Stoesen & Moss, 2006).

Table 1.

Demographic Characteristics of Study Sample.

Sample (N = 1215) Nurses (n = 422) Social Workers (n = 793) P-value†
Age (years)
     Mean (SD) 45.9 (10.96) 45.9 (10.84) 45.8 (11.02) .95
     Range 23–78 23–78 24–74
Gender
     Male 174 (14.7%) 20 (4.8%) 154 (19.8%) <.001
     Female 1013 (85.3%) 393 (95.2%) 622 (80.2%)
Race
     African American 98 (8.3%) 28 (6.9%) 70 (9.1%) .06
     Caucasian 979(83.3%) 343 (84.1%) 636 (82.9%)
     Asian 37 (3.1%) 20 (4.9%) 17 (2.2%)
     Other 61 (5.2%) 17 (4.1%) 44 (5.8%)
Education
     <Master’s Degree 467 (39.3%) 335 (81.7%) 132 (16.9%) <.001
     Master’s Degree or Higher 722 (60.7%) 75 (18.3%) 647 (83.1%)
Income
     ≤ $55,000 722 (61.8%) 206 (51.2%) 516 (67.4%) <.001
     $55,001–75,000 323 (27.7%) 136 (33.9%) 187 (24.4%)
     > $75,000 123 (10.5%) 60 (14.9%) 63 (8.2%)
Years in Professional Practice
     Mean (SD) 17.1 (10.62) 19.8 (11.63) 15.6 (9.74) <.001
     Range 0.0–46 .1–58 .8–45
Years in Current Position
     Mean (SD) 7.53 (7.42) 7.7 (7.95) 7.4 (7.13) .51
     Range 0.1–58 .0–46 0–40
Institution Type
     Hospital 435 (35.8%) 253 (60.0%) 182 (23.0%) <.001
     Other 780 (64.2%) 169 (40.0%) 611 (77.0%)
Employment Status
     Full-time 858 (71.7%) 229 (67.2%) 587 (75.1%) .001
     Part-time 314 (26.2%) 112 (32.8%) 182 (25.3%)
Ever Received Ethics Education
     Yes 1025 (85.7%) 311 (75.1%) 714 (91.3%) <001
     No 171 (14.3%) 103 (24.9%) 68 (8.7%)
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*

Percentages may not equal 100 due to rounding and missing data.

†

Chi-square p-value comparing RN versus SW for categorical variables, t-tests for continuous variables.

The analytic sample included those respondents with complete data on all variables of interest after imputation of missing data. The analytic sample tended to be younger (45.0 vs. 50 yrs, p<.001) with fewer years in their profession (16.2 vs. 20.9 yrs) and fewer years in their current position (6.9 vs. 10.2 yrs), a smaller proportion had a master’s education (59% vs. 69%, p=.006), and a greater proportion worked in hospitals (32% vs. 21%), as compared with those not included in the analytic sample.

Nurses’ and Social Workers’ Attitudes toward Ethical Climate, Ethics Stress, and Job Satisfaction

The majority of respondents rated the ethical climate of their work environment to be somewhat higher than neutral, but not overtly positive with a mean score of 97.3 (median, 98; range, 35–130; SD = 14.4). When we compared our full sample item mean for the scale (3.7 with SD = 0.55), our results are comparable to Hart’s (2004) study of nurses in Missouri (3.7 with SD = 0.66). Most indicated they received support from their peers (90.6%) and managers (77%) and worked in an environment with competent colleagues (82.3%). However, only 58.3% reported that members of “my profession and physicians respect each other,” and only 55.4% indicated that there was trust among the respondent group and physicians. Moreover, 10.5% disagreed and 19.5% neither agreed nor disagreed that nurses and social workers were supported and respected in their practice setting. About one out of four respondents (23.9%) were not sure whether patients know what to expect although more than three-quarters (77.5%) said that patients’ wishes were usually respected and that safe patient care was given (78.3%). One out of four respondents (25%) did not perceive that conflict was openly addressed. Finally, 39% of nurses and social workers reported having no organizational resource or process to assist them with their ethical concerns.

The Ethics Stress scale had a mean score of 72.8 (median, 72; range, 30–129; SD = 14.2). Respondents reported fatigue (39.9%) and a sense of being overwhelmed (34.7%) when dealing with ethical problems and having to make ethical decisions. Nearly a third (32.5%) felt powerless in dealing with others about ethical issues, and 37% reported that their job has become more difficult because of these issues. Physical symptoms associated with ethical problems were reported by 22% of respondents, 52.8% reported feeling frustrated or angry when they cannot resolve an ethical issue, and 68.2% reported being upset when others avoid ethical issues. Finally, 10.8% feared reprimand for their ethical decisions and 62% stated there were some ethical issues they could do nothing about.

There were no significant differences in job satisfaction by professional group and most found their work personally rewarding (84.5%). While the majority was fairly satisfied in their present work (Median = 47; range 12–60; SD = 9.0), more than a fifth (21.9%) said their work situation was a major source of frustration and a full quarter of them would like to leave their current position. Furthermore, 21% agreed that if they were starting over again, they would not choose to be nurses or social workers and another 20% neither agreed nor disagreed about whether they would choose the same profession.

Factors Thought to Influence Retention

Being respected and a valued member of the team was reported most often by respondents as having the strongest influence on their decision to remain in their position (75%), followed by scheduling (65%) and identification with the institution’s mission (57%). Interestingly, workload and staffing patterns were not as influential. Forty-three percent responded that staffing patterns had a strong influence on their thoughts to remain in their position, 31% reported some influence, and 26% responded that staffing patterns had minimal to no influence on their thoughts to remain in their position. Finally, one out of three respondents (35%) cited their level of ethical conflict as strongly influential.

Bivariate Analyses

Table 2 presents the significant bivariate relationships of potential predictors with job satisfaction and respondents’ intent to leave their current position. Years in current position, perceived ethical climate, perceived adequacy of institutional ethics resources, the influence of feeling like a respected member of the team and of identification with the institution’s mission correlated positively with job satisfaction and negatively with intent to leave. In addition, respondents reporting more ethical stress reported a lower level of job satisfaction and a higher frequency of intent to leave their current position. Those working full-time, non-whites, and those who were younger were more likely to indicate an intent to leave. Finally, those who indicated an intent to leave reported lower levels of job satisfaction.

Table 2.

Significant bivariate relationships between predictors and dependent variables.

Dependent Variable
Predictor Job Satisfaction (n = 965) Intent to Leave1 (n = 954)
Age .97***
Race (1=White, 0=Nonwhite) .58***
Income .14***
Discipline (1=Registered Nurse, 0=Social Worker) .73*
Years in profession2 .85**
Years in current position3 .11*** .58*
Fulltime Employment Status 1.63**
Influence of work schedule on remaining in position
Influence of feeling like a respected member of the membership on remaining in position3 .24*** .21***
Influence of identification with institution’s mission on remaining in position .23*** .78***
Influence of staffing on remaining in position −.07*
Ethical Climate .43*** .95***
Perceived adequate/extensive institutional support for dealing with ethical stress .28*** .31***
Ethical Stress −.44*** 1.04***
Job Satisfaction .86***
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*

p < .05.

**

p < .01

***

p< .001

1

0=No, 1=Yes

2

Square root transformed.

3

Log10 transformed.

Note: Pearson correlation used between Job Satisfaction and continuous variables; eta used between Job Satisfaction and dichotomous variables. OR used for relationships with Intent-to-Leave.

Multivariate Analyses

Potential predictors of job satisfaction were entered into the linear regression model hierarchically using blocks of variables: demographic variables (p<.001); discipline, years in practice, and years in current position (p=.003); work setting variables (p=.70); influences on decision to remain in current position (p<.001); ethics education, ethical climate, and institutional support (p<.001); and ethical stress (p<.001). Overall the 6 blocks of variables explained 31.9% (p<.001) of the variability in job satisfaction (Table 3). Given that not all variables were significant in the full model, a stepwise procedure was used to identify a parsimonious model.

Table 3.

Stepwise linear and logistic regression results.

Dependent Variable: Job Satisfaction Intent-to-Leave
Predictor β-weight OR 95% CI
Race (1 = White; 0 = Nonwhite) .550 0.35–0.85
Income .106***
Years of practice1 .835 0.72–0.95
Full-time employment 1.540 1.00–2.36
Discipline (Nurse = 1; Social Worker = 0) .679 0.46–0.99
Salary influence on remaining in position −.062*
Influence of feeling respected on remaining in position2 .164***
Influence of staffing on remaining in position −.083**
Having received ethics education −.078**
Ethical climate .260*** .978 0.96–0.99
Institutional support for dealing with ethical stress (1 = Adequate/Extensive; 0 = Limited/None) .671 0.45–0.98
Ethical Stress −.284***
Job Satisfaction .864 0.84–0.88
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*

p < .05

**

p < .01

***

p < .001

1

Square root transformed.

2

Log10 transformed

Job Satisfaction: R2 = .319, F=19.13, p<.001

Intent to Leave: Model χ2(7) = 306.267, p<.001; Hosmer-Lemeshow χ2(8)=4.495, p=.810

Those with higher income (β = .106, p < .001), a favorable ethical climate (β = .260, p < .001), less ethical stress (β = −.284, p <.001), and who had not received ethics education (β = −.078, p = .004) were more likely to report increased job satisfaction. In addition, the extent of influence that three factors have on respondents’ intent to leave the current position or professional practice were also predictive of increased job satisfaction: staffing (β = −.083, p =.005), salary (β = −.062, p = .030), and feeling like a respected member of the team (β = −.164, p < .001). Other variables that demonstrated a significant bivariate relationship with job satisfaction failed to enter the final model, specifically years in current position, influence of identification with the institution’s mission, and perceived institutional support for dealing with ethical stress.

The first variable to enter the stepwise model was ethical stress followed by ethical climate. In controlling for climate, the relationship between ethical stress and job satisfaction decreased (β = −.439 without climate; β = −.309 with climate in the model) indicating that ethical climate partially mediates the relationship between ethical stress and job satisfaction (Sobel’s z = 7.96, p<.001).

To identify the unique contribution of ethics stress in relationship to other workrelated variables, we looked at what ethics stress uniquely contributes when controlling for all the other variables and then at what the other variables explain controlling for ethics stress. Ethics stress uniquely explained 9.8% of the variability and the other variables (i.e., those considered in Step 1 of the original analysis) uniquely contributed 9.1%. Ethics stress explained as much as the demographics, work setting, and influence-on-intent-decision (i.e., staffing, respect, valuable member of the team) variables.

When all blocks were entered into a logistic regression model for intent to leave, the model was significant [model χ2(23) = 318.17, p<.001; Hosmer-Lemeshow χ2(8)=5.07, p=.750]. A stepwise approach was then used resulting in a final model with 7 significant predictors. Whites (OR = .550, 95% CI 0.35 to 0.85), registered nurses (OR = .679, 95% CI 0.46 to 0.99), and those with more years of practice (OR = .835, 95% CI 0.72 to 0.95) were less likely to indicate an intent to leave while those employed full time (OR = 1.54, 95% CI 1.00 to 2.36) were more likely to indicate an intent to leave. In addition, a better perceived ethical climate (OR = .978, 95% CI 0.96 to 0.99) and more job satisfaction (OR = .864, 95% CI 0.84 to 0.88) were protective factors against the intent to leave as was the perception of adequate or extensive institutional support for dealing with ethical stress (OR = .671, 95% CI 0.45 to 0.98). Increased ethical stress was related to intent-to-leave in a bivariate relationship, but failed to enter the multivariate model. Results indicate that job satisfaction completely mediated the relationship between ethical stress and intent-to-leave (Sobel’s z=9.34, p<.001).

Because profession was significant in the multivariate analysis, each group (RN vs. SW) was examined individually. For the nurse sample, using the enter method, the model for intent to leave was significant (Chi-square = 128.822, p<.001) and the Hosmer-Lemeshow Test was not significant (Chi-square = 11.258, p=.188) indicating good fit. Overall 85.2% of the sample was correctly classified. Black nurses were three times more likely to indicate intent to leave (OR for blacks = 3.21, 95% CI 1.38 to 7.46), those with lower job satisfaction were more likely to indicate intent to leave (OR = 0.843, 95% CI 0.799 to 0.890), and those who indicated the place of employment provided adequate/extensive resources to help with ethical issues were less likely to indicate intent to leave (OR = 0.418, 95% CI 0.189 to 0.921). When the analysis was rerun using a stepwise approach, four variables entered the model: (in order of entry) job satisfaction (OR = 0.858, 95% CI 0.824 to 0.894), black race (OR = 3.00, 95% CI 1.40 to 6.45), extent to which schedule influences decision to remain in a nursing position (OR = 0.413, 95% CI 0.209 to 0.818), and extent to which place of employment provides adequate/extensive resources to help with ethical issues (OR = 0.858, 95% CI 0.290 to 0.996).

For the social workers, using the enter method, the model for intent to leave was significant (Chi-square = 225.197, p<.001) with Hosmer-Lemeshow Test not significant (Chi-square 6.229, p=.622). Overall 81.9% of the sample was correctly classified. Those less likely to indicate an intent to leave had fewer years of practice (OR = 0.729, 95% CI 0.564 to 0.942), higher scores on the ethical climate questionnaire (OR = 0.965, 95% CI 0.945 to 0.986), and increased job satisfaction (OR = 0.862, 95% CI 0.833 to 0.893). When the stepwise approach was used, full-time versus part-time status also was significant (OR =1.882, 95% CI 1.07 to 3.31) with those working full-time more likely to indicate an intent to leave.

Discussion

Our data show the importance of a positive ethical climate and degree of ethics stress on nurses’ and social workers’ job satisfaction and intentions to leave their positions. Improving job satisfaction among these providers requires sustainable work-related interventions to allay ethics stress, increase ethics resources, and improve the ethical climate. Open dialogue on strategies for increasing respect within the workplace and the value of a positive ethical climate is warranted.

Nearly two-thirds of our sample reported that there are some ethical issues they can do nothing about, and many reported frustration and fatigue. As our findings note, those without institutional support for handling ethical issues and stress are more likely to want to leave their jobs. Consistent with the earlier work of Aiken et al. (2001), 25% of our sample reported they would like to leave their current position, especially younger workers and those who work full time. With a plethora of career options available today, young nurses and social workers may leave a profession if they feel stress, disrespect, and dissatisfaction.

Unexpectedly, black nurses reported more ethics stress and were three times more likely to say they wanted to leave their position than Caucasian nurses. In a sample of nurses from 40 metropolitan statistical areas in 29 U.S. states, non-Hispanic black RNs were less satisfied than were their white colleagues (Kovner, Brewer, Wu, Cheng, & Suzuki, 2006). Future research should explore cultural and language variables, such as acculturation, ethnic support, employment equity, and organizational leadership behaviors as well as whether other minority nursing groups have similar levels of ethics stress and turnover intentions. With a rapidly changing U.S. racial and ethnic demography (Smelser, Wilson, & Mitchell, 2001), workplace polices must address diversity in the workplace to meet the needs of multicultural patient populations and providers. An in-depth qualitative approach may help differentiate minority concerns and articulate their experiences in the workplace.

Much of the research on job satisfaction and turnover focuses on how staffing levels affect outcomes (Davidson, Folcarelle, Crawford, Duprat & Clifford, 1997; Tai Wai Chi, Bame, & Robinson, 1996; Vahey, Aiken, Sloane, Clarke & Vargas, 2004). Our data suggest that although staffing is related to job satisfaction and factors into turnover intentions, it is not the most important factor. Being respected and a valued member of the team followed by scheduling, and identification with the institution’s mission had the strongest influence on providers’ decisions to remain in their current position. Workload, staffing patterns, and salary were not as influential. In our analysis, ethics stress has a stronger relationship to job satisfaction than does the influence of staffing on decision to leave. Because we did not measure staffing directly, more research is needed to fully understand if ethics stress is a stronger prediction of job satisfaction than nurse staffing.

The majority of our respondents reported that respect in the workplace and a belief in the institution’s mission are more important factors in retention than salary or staffing. Respect in the workplace is a measure of organizational justice, procedural fairness, and a fundamental value “that shapes what goes on in organizations.” (Laschinger, 2004, p. 355). A lack of organizational respect for professional practice is associated with negative attitudes, mental health outcomes, and work effectiveness (Colquitt, Conlon, Wesson, Porter, & Ng, 2001; Elovainio, Kwimaki, & Vahtera, 2002; VanYperen, Hagedoorn, Zeers, & Postma, 2000). Although economic models that focus on wage increases, sign-on bonuses, and mandated staffing/patient ratios may help retain providers in the short term, attention to ethical climate and an atmosphere of respect may be necessary. This is why the American Association of Critical Care Nurses’ Healthy Work Initiative (2005) that stressing the communication, mutual respect, and value recognition to establish practice environment standards for acute and critical care nurses is a step in the right direction. These standards could be applicable to other disciplines and research is now needed to determine their effectiveness.

An important overlap exists between overall work climate and ethical climate, and overall work related stress and ethics stress. Our data begin to separate these concepts. Although the Nursing Work Index is widely used when looking at the general work environment (Lake, 2002), it does not focus on ethics-related factors. As ethical concerns related to quality, cost, and access increase, augmenting the Nursing Work Index with an ethics-related subscale would be beneficial. In our analysis, a higher ethics stress score was associated with a lower ethical climate score. Ethics stress could contribute to or be the result of a poor work environment.

Interestingly, nurses and social workers with more ethics education reported more job dissatisfaction. Having some knowledge and skills to address, recognize, and articulate ethical issues in the workplace, but limited or no access to resources or a non-supportive ethical climate for practice may lead to frustration and dissatisfaction, moral distress and moral residue—emotional guilt over ethical decisions made by others or eventually forgone (Corley, 2002; Jameton, 1984; Webster & Baylis, 2000). Education alone is inadequate; efforts should also be directed to improving workplace ethical climate, reducing ethics stress, promoting autonomy, and respecting these professionals.

In our analysis, ethical climate partially mediates the relationship between ethical stress and job satisfaction and job satisfaction completely mediates the relationship between ethical stress and intent-to-leave. These findings are significant in that nurses and social workers who have support and resources for ethical concerns are more likely to endure higher levels of ethics stress and still be satisfied in their positions. Also, although our data show that nurses and social workers have ethics stress, other factors affecting job satisfaction may serve as protective factors against intent to leave. Participants from hospital settings report more ethics stress than those from non-hospital settings. Patient acuity levels and the volume, intensity, and severity of the associated ethical concerns, staffing levels, hospital size and location and other organizational characteristics may partially account for this finding; future work is needed to understand the significance of these relationships and the differences that exist.

A limitation of our study was that we did not address issues related to leadership and magnet status of institutions. Several studies support the relationship of accredited magnet hospitals, or those environments that facilitate nursing control over practice, to quality of care and job satisfaction of nurses (Aiken, Havens, & Sloane, 2000; Laschinger, Almost, & Tuer-Hodes, 2003). It is not known, however, whether nurses and social workers in magnet hospitals are more likely to view their ethical climate as positive, have and use resources to address ethical issues, or perceive less ethics stress. “The leader’s role is key in setting the standard of conduct for an ethical climate in nursing practice” and a more in-depth analysis of the nurse/social work leader’s role in translating the mission, values, and beliefs of the organization into practice behaviors is warranted (Shirey, 2005, p.63).

In sum, our data suggest that investing in institutional ethics support and resources for employees and establishing a positive ethical climate for practice might lead to more job satisfaction of nurses and social workers, and possibly reduce turnover intentions. This could in turn have a positive effect on patient care and quality outcomes at a reasonably low cost. Further study on the effect of an ethical climate, ethics stress, and ethics resources in relation to provider health, patient care and quality outcomes is now needed.

Author Comments

This research was supported by the Department of Clinical Bioethics and Department of Social Work, National Institutes of Health. We would like to acknowledge Dr. Dorrie Fontaine for earlier assistance with this project and Drs. Lois Evans and Linda Aiken for their thoughtful reviews of this manuscript, Yuen-Yen Fang and Dr. Karen Soeken for their statistical support, and Jill Smith and Ariella Kopinsky for their editorial assistance.

Footnotes

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Contributor Information

Dr. Connie Ulrich, University of Pennsylvania Philadelphia, Pa UNITED STATES

Patricia O'Donnell, Center for Ethics, Inova Health System.

Carol Taylor, Center for Bioethics, Georgetown University.

Adrienne Farrar, Department of Social Work, Clinical Center, National Institutes of Health.

Marion Danis, Department of Clinical Bioethics, Clinical Center, National Institutes of Health.

Christine Grady, Department of Clinical Bioethics, Clinical Center, National Institutes of Health.

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