Investing in human capital: exploring causes, consequences and solutions to nurses’ dissatisfaction

Abstract

Background

Human capital (employees) is the most important asset for healthcare. However, nurses experience some of the highest rates of burnout and dissatisfaction. In 2017, the Nursing and Midwifery Council reported that, for the first time since 2008, more nurses and midwives are leaving the profession in the UK than joining it.

Aims

The aim of this paper is to explore the literature regarding the importance of human capital within healthcare sectors in the UK, with a particular focus on nurses and job satisfaction.

Methods

A literature review was conducted with the focus on the aim, as stated above. Findings and conclusions have been summarised. Potential causes, consequences and solutions to job dissatisfaction are explored.

Results

Factors related to job satisfaction include pay, respect, security, workload, recognition, responsibility, environment, autonomy, personal growth, administrative bureaucracy and caseload. Investing and promoting ‘organisational compassion’ could be a key part of the solution.

Conclusions

More research using the same validated tools for measuring job satisfaction will help with consistency and comparability across hospitals. It is hoped this could provide information aiding recruitment and retention, which is a problem within both the NHS and independent sectors.

Introduction

Intangible assets can be broadly split into three classes (Figure 1): human-, relationship- and structural capital. Human capital adds to company value by looking at the combined skills, experience and knowledge of the employees. Relationship capital is where the value lies with the strength of the bonds between employees themselves, and with suppliers, customers and other external people. Structural capital could include anything that is unique to the organisation and its processes; brand value would be included here.

Figure 1.

Types of intangible assets.

In places that are driven by human-to-human interactions, such as healthcare, the brand value (structural capital) of an organisation is closely linked to that of the people who work within it. With better brand value and a good reputation, a hospital can attract and retain a superior workforce, leading to higher productivity. Without employees you could not have human or relationship capital: they are the common denominator.

This is even more important within the healthcare sector, where quality of care, compassion, bedside manner and a range of therapies cannot be delivered other than by humans.

An analysis of healthcare by discipline shows that nurses (in particular female and of lower rank) experience the highest rates of burnout and dissatisfaction (Cacciacarne et al., 1986). Herein lies the problem. In the UK there is an acute problem with the recruitment and retention of staff, especially nursing staff, in the NHS and independent sectors.

Within the NHS in 2017, the Nursing and Midwifery Council (NMC) found that more nurses and midwives were leaving in the UK than joining the NHS for the first time since 2008. The NMC’s register has increased every year since 2013, reaching a peak of 692,556 in March 2016. However, between March 2016 and March 2017, the register reduced by 1783 registrants to 690,773. The numbers for April and May 2017 show a further reduction of 3264 registrants (NMC, 2017). These new figures show an increase in the numbers of nurses and midwives leaving the NMC’s register. At the same time, the numbers joining the register have slowed, resulting in an overall reduction in the workforce.

The Royal College of Nursing (RCN) found that in 2017 there were 40,000 unfilled posts – double the number from 3 years ago (RCN, 2017). This is placing pressure on the existing system, where there has been talk of UK nurses voting for their first ever strike.

In the UK independent sector, nurses are ‘often overlooked’ despite doing a vital job (Ledger, 2014). The RCN surveyed what is important to nurses in the independent sector; their findings are presented below (Box 1). In the same survey, 84% of all nurses in the UK independent sector who agreed that they were proud to work for their organisation also reported greater job satisfaction.

Box 1.

The 10 most important features of working life for independent sector nurses.

Convenient work location

Good relationship with your manager

Working in pleasant physical surroundings

Being well managed

Being rewarded for working unsocial hours

Good pay

Managing your own career

Using your skills fully

Being respected at work

Good job security

Source: Nurses in the independent sector: Results from the RCN membership surveys 2001/02 (Ball and Pike, 2002)

A subsequent dissemination of the RCN survey showed that one in four nurses in the independent sector were seeking a change in job, the same figure of 1 in 4 as within the NHS that year (Ball and Pike, 2007). But why do nurses leave their current job? Apart from when their place of work closes down or they are made redundant, the reasons given are presented in Box 2.

Box 2.

Reasons for nurses in the independent sector changing jobs.

Gain different experience/skills

Better prospects

Promotion

Better pay

Change in hours

Better work–life balance

Dissatisfied with previous job

Stress/workload with previous job

Distance to work

Better terms and conditions elsewhere

Personal reasons/moving/partner’s job

Family reasons

Training reasons

Bullying/harassment

Health problems

Source: Independent Sector Nurses in 2007: Ball and Pike, 2007

Could the current nursing shortage be related to Brexit? In a referendum on 23 June 2016, 51.9% of the participating UK electorate voted to leave the European Union (EU). On 29 March 2017, the British government invoked Article 50 of the Treaty on the European Union, meaning the UK is on course to leave the EU 2 years from that date.

Interestingly, in the month after Article 50 was invoked, only 46 nurses from the EU registered with the NMC to practise in the UK, which was a 96% drop compared with July 2016 (NMC, 2017). Since 2008, the majority of international nurses registering in the UK have come from within the EU. However, the recent trend in nurses from the EU leaving the UK nursing register may not be entirely related to Brexit. It is hypothesised that the recently implemented strict English language criteria set for nurses coming to the UK are acting as a barrier. As with most things, the reasons are multifactorial. A survey of 247 EU nurses who left the NMC register over the past 12 months shows that their top three reasons were that they were leaving or had already left the UK (58%), that Brexit had encouraged them to consider working outside the UK (32%), and unhappiness with working conditions (32%) (NMC, 2017).

However, overall the NMC said the downward trend had been most pronounced among UK registrants rather than EU workers. Many leavers cited working conditions leading to low job satisfaction (NMC, 2017). A meta-analysis of the literature supports this, suggesting that in nursing, job satisfaction is strongly (negatively) related to stress and commitment to the organisation (positively) (Blegen, 1993).

Sometimes a vicious cycle is set in motion. New staff are regularly trained, only for some to leave weeks or months afterwards. This results in advertisements for new unfilled nursing posts, which require further training. During the time when there are insufficient numbers of nursing staff, agency staff are paid very high rates to fill shifts. This results in the double negative of staff being extraordinarily expensive to maintain, but also, hiring staff unfamiliar with the hospital disrupts continuity of care and increases the propensity for mistakes. The loss of experienced nurses is a huge blow to an organisation. They take with them not only their expertise and clinical acumen, but their accumulation of knowledge of the hospital and its policies and procedures, which tend to vary across healthcare settings. The problems with retention are arguably the most significant for an organisation, given the effort and cost necessary to induct a member of staff into a new environment.

Happell et al. (2003) found that more than half of the total responses to their survey indicated nurses’ willingness to leave not only the hospital, but the nursing profession altogether should an opportunity arise elsewhere. This is not only worrying from a retention point of view, but should the nurses follow through with their intentions, it represents an ever-decreasing pool of nurses to then recruit from.

Aim

The aim of this paper is to explore the literature regarding the importance of human capital within healthcare sectors in the UK, with a particular focus on nurses and job satisfaction. Potential causes and consequences of and solutions to job dissatisfaction are explored.

Job satisfaction of nurses

The most widely accepted definition of job satisfaction was presented by Locke (1976), who defined job satisfaction as ‘a pleasurable or positive emotional state resulting from the appraisal of one’s job or job experiences’ (p. 1304). However, this does not capture the nuances and multitude of potential facets that comprise satisfaction, some of which are depicted in Figure 2.

Figure 2.

Facets of job satisfaction (Smith et al., 1969). Image courtesy of https://wikispaces.psu.edu/display/PSYCH484/11.+Job+Satisfaction.

The environment has been shown to have an impact on satisfaction levels, and this is not just the ‘hard’ environment of the office space, but also what others are saying about the job; whether comments are positive or negative can influence those around them (Aamodt, 2009).

A further complication is that the job satisfaction model presented in Figure 2 does not take into account beliefs about equity and fairness. For example, another employee may have the same job but higher pay, and this knowledge may well feed into lowering satisfaction.

Causes of job satisfaction and dissatisfaction

Many of the issues contained here have antecedents, and much of the research undertaken in the past still remains relevant and valid. In a literature review from 1985 to 2003, McVicar (2003) found the following causes of nurses’ stress in the workplace: workload, leadership/management style, professional conflict and the emotional cost of caring. They acknowledged there was disagreement as to the magnitude of their impact. In the paper titled ‘Job satisfaction in psychiatric nursing’ specifically looking at the UK, Ward and Cowman (2007) found that the following factors influence job satisfaction: choice of work location, work routine, teamwork and working environment. Although there was only a 43% response rate to the questionnaire, other authors appear to corroborate their findings. For example, multidisciplinary teamworking has been found to be positively correlated with satisfaction (Parahoo and Carr, 1994), whereas others report a negative relationship between nurses’ levels of satisfaction and routine (Giloran et al., 1994). Teamworking per se may not automatically equate to higher satisfaction. The team itself must be supportive and effective, and there should be team role clarity and identification with the team (Onyett et al., 1997).

Although Coomber and Barriball (2007) found work environment rather than individual or demographic factors were of greatest importance in relation to nurses’ turnover, this contradicts other work that found British nurses derive satisfaction from factors such as perceived sense of achievement, recognition for their efforts, and the degree of responsibility (Fagin et al., 1995). McVicar (2003) highlights the importance of environment and individual factors, but concedes there is ‘a lack of understanding of how personal and workplace factors interact’. In addition to this is the subjective nature of identifying the causes of stress within a complex role that continues to change within the UK (McVicar, 2003, p. 1).

Nurses working in long-term care settings were significantly more dissatisfied than those working outside this area (Carr and Kazanowsky, 1994). For psychiatric nurses, the forensic sector is particularly stressful (Kirby and Pollock, 1995), with the perceived threat of violence and actual incidents of violence contributing to this stress significantly (Parkes, 2003). Others have postulated that forensic nurses rarely see their efforts culminate in concrete results, which leads to frustration and dissatisfaction (Dickinson and Wright, 2008). An increasing number and scope of policies and regulations can contribute to nursing staff having less perceived autonomy and input in decision making, which in turn can lead to lower satisfaction (Dickens et al., 2005). Interestingly, another study of forensic mental health nurses (Jones et al., 1987) found that administrative and bureaucratic aspects of the job were actually more stressful than direct patient contact.

It is not unsurprising that workload was found to be the primary reason for nurses’ stress in hospital, as this leads to inadequate time to complete their day-to-day activities such as supporting the patients. Inadequate staffing numbers to cover a unit also leads to increased workload. Coffey and Coleman (2000) found a statistically significant association between caseload size and stress. Other pieces of evidence regarding nurses and job satisfaction consistently point towards the following as major contributors: the structure and atmosphere of an organisation, the tasks, pay, personal recognition, potential for advancement, uncertainties about the roles of different staff groups, and leadership style and effectiveness (Gillies et al., 1990; Mansen, 1993; Sainsbury Centre for Mental Health, 2000; Wells, 1990).

Consequences of job satisfaction and dissatisfaction

The notion of job satisfaction is a hugely important one, because of its close links with motivation, absenteeism, commitment, retention and ultimately productivity (Landy, 1978). Those whose expectations of the job do not match reality can experience stress and dejection (Higgins, 1999). Job satisfaction is not just for the employees’ benefit, but the organisation’s too. Employee satisfaction in the workplace drives the organisation forward into profitability or increased productivity by means of a dedicated and motivated workforce who also feel more committed to the organisation (Blegen, 1993; Syptak et al., 1999). This in turn drives up the reputation and adds to brand value. Patients within the UK are increasingly given more choice about where they would like to be treated. A happy, dedicated workforce can lead to tangible benefits in terms of increasing their customer share in an increasingly competitive field.

What happens when you do not have a happy, dedicated workforce in a healthcare setting? Coffey and Coleman (2000) found a large portion of nurses (44.3%) were experiencing burnout as a result of what they termed emotional exhaustion. Other studies back up this intuitive relationship, where job satisfaction in nurses appears to be inversely correlated with burnout (Dolan, 1987). Just as important, if not more so, quality of patient care can be affected (McKeese-Smith, 2000), quite likely as a result of nurses losing the ability to empathise with their patients – a core part of their role (Coffey, 1999).

Looking at the wider picture, one also needs to consider the employee’s personal life. Of course, the hospital has less direct impact here, but personal life issues do impact on work life and vice versa. Happier employees can focus more at work, demonstrating a heightened sense of belonging to the organisation (Dickinson and Wright, 2008).

Low job satisfaction is the most frequently cited reason for turnover in nursing, leading to the recruitment problems we see today (Mrayyan, 2005; Tovey and Adams, 1999). This is not just a UK problem, but an international challenge (Buchan, 2000).

When one asks the question from the other side – ‘What causes nursing turnover?’, the evidence still points to the same answer: satisfaction (Shader et al., 2001). In this cross-sectional study in the UK, higher satisfaction rates were predicted by evidence of a more stable work schedule, less stress, higher group cohesion and lower anticipated turnover. Even the anticipation of turnover before it actually happens can have an impact on staff morale. This reinforces the need for a harmonious group, and stresses the potentially pernicious effect of so-called water-cooler conversations that may seem so innocuous.

Discussion and potential solutions

Measuring human capital and satisfaction

Unlike tangible assets, human capital is trickier to measure. One can take Porritt’s (2005, p. 170) view at one extreme, that ‘it is clear it cannot possibly be measured in financial terms’ and ‘it’s not even possible to quantify it in any serious way’. Or one can go to the other end of the spectrum, where the Swedish financial service company, Skandia, has developed intellectual capital metrics and has been producing comprehensive financial reports to demonstrate the value of intangible assets to its shareholders (Skandia, 1997). In the evidence-based world we live in (certainly in medicine) we need to produce some way of measuring aspects of human capital, whilst appreciating we may not capture the whole picture. This can be done by a combination of quantifiable indicators such as employee turnover, recruitment and retention rates, training costs per employee, average years of service etc., and qualitative indicators such as job satisfaction.

In hospital settings, common ways of trying to measure job satisfaction include questionnaires, exit interviews with human resources (to find out reasons why the employee is leaving, and learn from this), focus groups or drop-in sessions where nursing staff can speak confidentially with managerial or senior staff on a one-to-one basis, and ‘temperature checks’ carried out on a ward-by-ward basis ascertaining information from nurses at a group level. Such approaches can result in ‘You said, we did’ posters. Ideally the results should be triangulated to identify recurring themes.

As Figure 2 demonstrates, job satisfaction encompasses so many different facets, and one has to question whether something so nebulous can actually be measured. Nevertheless one has to try, given the old adage ‘what cannot be measured cannot be managed’. Gathering quantitative data is useful insofar as one can obtain a big picture generalisation at one moment in time, and then look for trends over time if the measurements are repeated. However, this still misses out the more subjective, impressionistic feelings that are more subtle and nuanced, that are better captured qualitatively from a variety of sources. Any questionnaire must be able to gather both types of data. Evaluations of satisfaction, one has to admit that satisfaction measurements will always be part science and part art. Weatherly (2003, p. 4) puts this eloquently: ‘it should also be obvious that we can no longer fail to recognise the importance of seeking to develop, test, and refine appropriate methodologies to measure the value of what has become for all intents and purposes our primary asset’. There are already validated tools developed to use in this population (listed in Box 3). Serious consideration should be given to incorporating these in subsequent surveys to increase the validity of the results.

Box 3.

Validated measurement tools for the nursing population.

Work Environment Scale (Moos, 1994)

Occupational Stress Indicator (Cooper et al., 1988)

Mental Health Professional Stress Scale (Cushway, 1992)

Maslach Burnout Inventory (Maslach et al., 1996)

Job Satisfaction Scale of the Nurse Stress Index (Harris et al., 1998)

Satisfaction with Nursing Care Work Scale (Hallberg et al., 1994)

Some examples of general measurement tools for job satisfaction

Job Descriptive Index (Smith et al., 1969)

Global Job Satisfaction (Warr et al., 1979)

Job Satisfaction Survey (Spector, 1997)

Everett (1995) suggests the following:

1. When have I come closest to expressing my full potential in a work situation?

2. What did it look like?

3. What aspects of the workplace were most supportive?

4. What aspects of the work itself were most satisfying?

5. What did I learn from that experience that could be applied to the present situation?

However, this perhaps may serve well for self-reflection or a topic for supervision rather than for analysis in research, as the questions leave room for ambiguity and therefore may not give meaningful and consistent answers. Many people would not wish to spend their valuable time filling in such a questionnaire. A couple of short open-ended questions to gather qualitative data could possibly be better, such as those asked by the psychologist Fredrick Herzberg and his colleagues (1959) when carrying out their own pioneering work. This led to the two-factor theory (also known as Herzberg’s motivation-hygiene theory and dual-factor theory) that states there are certain factors in the workplace that cause job satisfaction, while a separate set of factors cause dissatisfaction.

His team asked employees two sets of questions:

• Think of a time when you felt especially good about your job. Why did you feel that way?

• Think of a time when you felt especially bad about your job. Why did you feel that way?

The two questions are easy to understand, do not lead the responder down any particular avenue, and could be included in future questionnaires.

Out of the theoretical models available, Herzberg et al (1959) offers a good checklist for organisations interested in satisfaction rates (Figure 3).

Figure 3.

Herzberg’s two-factor theory (Herzberg et al., 1959).

Syptak et al. (1999) agree:

While there is no one right way to manage people, all of whom have different needs, backgrounds and expectations, Herzberg's theory offers a reasonable starting point. By creating an environment that promotes job satisfaction, you are developing employees who are motivated, productive and fulfilled. This, in turn, will contribute to higher quality patient care and patient satisfaction (p. 30).

Putting theory into practice

One way to improve satisfaction rates is to address the hygiene and motivational factors described by Herzberg et al (1959) in the previous section.

Hygiene factors may not directly be linked to satisfaction, but those issues should be dealt with to create an environment for this to occur. Indeed, the Occupational Stress Indicator (Cooper et al., 1988) asks about levels of satisfaction in relation to the organisational structure, design and processes, as well as satisfaction with the job itself and with personal relationships, among other factors. Herzberg’s theory can easily be applied to the real world.

Herzberg et al (1959) also discussed the importance of company and administrative policies. They should be clear, accessible, ideally with employee input, updated and applied equally to all; if not, this can lead to frustration and dissatisfaction (Syptak et al., 1999).

Other authors (Robinson et al, 2005) point towards improving retention by enhancing supportive working relationships and caregiving opportunities for nurses, and by remedying the sources of dissatisfaction. This study in the International Journal of Mental Health and Nursing is particularly useful because it is one of the few longitudinal as opposed to cross-sectional studies. Supportive working relationships could be enhanced by means of a ‘preceptorship’ system, where a newly qualified nurse is allocated to a named person to help and support them, and by ensuring clinical supervision takes place. This could mean providing an opportunity for reflective practice, an essential tool for nurses; however, only half of respondents in the Robinson et al (2005) study stated they were satisfied with the opportunities to do so. In agreement with Robinson et al. (2005), the UK governmental body the Department of Health recognised that flexible working practices and ‘family-friendly’ policies were necessary for improving working lives (Department of Health, 1999). As for Herzberg et al's ‘working conditions’, the environment is crucial to maintaining employee satisfaction. However, all the hygiene factors described above need to be tackled, otherwise the most productive employees could potentially leave.

Moving on to Herzberg’s et al (1959) motivating factors, themes such as recognition for achievements could be incorporated into a range of activities such as staff ‘thank you’ cards personally written by the Chief Executive Officer or Hospital Director that could be given to individuals or teams, and ‘weekly briefs’ to highlight the hard work of staff. One might consider an ‘employee of the month’ scheme, where anyone can nominate other staff and then a panel decides on the outcome. These are all positive steps, the value of which needs to be measured.

One thing not mentioned by Herzberg et al (1959) is the need for a good work–life balance. This means the need for flexible working practices where possible, and looking after the personal wellbeing of the employees. Robinson et al.’s (2005) findings on work ‘life’ balance suggested that ‘employers should ensure availability of family-friendly strategies from qualification onwards’ (p. 238). Hospitals could think about gym memberships, subsidised lunches, onsite crèches, onsite yoga classes and being able to use the hospital gym if there is one. Not only would it positively affect the physical health of the workforce, and therefore make sickness less likely, but it could be a useful outlet for stress build-up. This could lead to higher productivity levels. Indeed, all the initiatives could be packaged into an ‘Above and Beyond programme’ that has been used successfully to increase satisfaction rates by other hospitals (Fields et al., 2012).

Pay

According to a Nursing and Midwifery Council survey of more than 4500 leavers (NMC, 2017), one reason for doing so was poor pay and benefits.

Nurses and midwives previously received bursaries during their studies, but the government announced it would cease the NHS bursaries system from 1 August 2017, meaning students in many healthcare fields now have to repay the cost of their degrees.

The Nuffield Trust also thinks that increased pay would help with the current crisis in the UK (Imison, 2016). The author points out that when there was a severe nurse shortage in the late 1990s and early 2000s, the Pay Review Body responded with substantial real pay increases. The NHS pay review body advises on the pay of NHS staff. It is an advisory non-departmental public body, sponsored by the Department of Health and Social Care. This appears unlikely to happen in an era of austerity following the recession. From 2010 to 2017 there has been a 0% or 1% pay cap for NHS healthcare workers. Unions claim this equates to a fall in wages of 15% in real terms. The scrapping of the pay cap was announced in September 2017. The 2017–2018 pay scales for NHS nursing staff in England range from £15,404 for the starting salary of a band 1A nurse to £48,514, the highest salary point for a band 8A nurse (www.rcn.org.uk/employment-and-pay). The RCN called in July 2017 on the government to scrap the 1% public sector pay cap as a matter of urgency to prevent more health workers leaving.

Throughout Europe, wages are a major source of nursing dissatisfaction (Aiken et al., 2013), although interestingly, England had the second lowest level of dissatisfaction regarding wages (of 46%) of all 12 European countries surveyed (Switzerland had the lowest). The highest rates of dissatisfaction were found in Sweden (80%) and Greece (83%).

What about the evidence linking pay with satisfaction? The Nobel Prize-winning psychologist Daniel Kahneman and economist Angus Deaton analysed the responses of 450,000 Americans in 2008 and 2009 (Kahneman and Deaton, 2010). They found the magic figure of US$75,000 (equivalent to £50,000 if you assume 1.5 dollars to the pound) had an impact on greater overall life satisfaction (but not on day-to-day emotional wellbeing). The survey asked respondents to place themselves on a life satisfaction ladder, from the first (lives were not going well) to the tenth rung (good as it could be). They found that for every 10% rise in annual income people move up the satisfaction ladder by the same amount, whether they are making $25,000 or $100,000. ‘high incomes buy life satisfaction but not happiness’, conclude the authors (Kahneman and Deaton, 2010, p. 16489).

Some argue that beyond the point of providing for food, shelter and safety, increases in wealth do little to improve people’s wellbeing or happiness (Kasser, 2002). Increases in gross domestic product in the UK do not seem to be linked with increases in life satisfaction rates (Donovan and Halpern, 2002).

On an individual level, although a pay increase may result in a person’s increase in satisfaction initially, this effect can wear off as that person adapts to the new circumstances or their expectations and aspirations rise. Richard Easterlin (2001) refers to this as the ‘hedonic treadmill’, in that our desire for more constantly outstrips what we already have. A pay increase for one may also reduce other workers’ satisfaction rates due to envy, and there is evidence that satisfaction rates tend to be determined by relative rather than absolute wealth and status (Donovan and Halpern, 2002). Robinson et al. (2005) found a source of dissatisfaction to be the pay in relation to responsibility, paperwork and continuing education opportunities. Although salary by itself may not simply link to satisfaction, employees do want to be paid fairly. Syptak et al. (1999) lend support to this with the notion that salary and benefits need to be comparable with other organisations, as this will raise satisfaction and reduce turnover. Coomber and Barriball (2007), in a review of the literature on job satisfaction and nurse turnover, found the results regarding wages inconsistent and stated the need for more research in this area.

Learning from others

There have been some large-scale European studies looking at why nurses are leaving their profession. The European Nurses’ Early Exit (NEXT) Study has produced some longitudinal data from over 11,000 registered nurses working in eight European countries. One study using this data found that high job strain (defined below), even for a short time, was a significant factor in nurses wanting to leave their profession in most countries (Hasselhorn et al., 2008). According to the Job Demand-Control Model (Karasek, 1979), job strain results from the interaction between two main job dimensions: work demands and control. The latter consists of two elements: the worker’s potential to influence their work and their level of skill discretion. This would suggest that lowering the strain (by decreasing the demands of the job, and by increasing the amount of influence nurses have) may have a positive impact in retaining nursing staff.

RN4CAST is a cross-sectional study of 33,659 nurses providing clinical care across 488 hospitals in 12 European countries. It is one of the largest studies ever conducted in Europe, which links features of the hospital nurse workforce to patient outcomes. Nurses’ general dissatisfaction with their jobs was expressed by roughly 1 in 10 nurses in the Netherlands; by approximately 2 in 10 nurses in Belgium, Norway, Sweden and Switzerland; by 4 in 10 nurses in England, Germany, Ireland and Spain; and by nearly 6 in 10 nurses in Greece (Aiken et al., 2013). From the same data set, Aiken et al. (2012) found that improved work environments and reduced ratios of patients to nurses were associated with increased care quality and satisfaction for both patients and nurses.

In comparison, the United States had a low patient-to-nurse ratio. The percentage of US nurses intending to leave their jobs was lower than in all 12 European countries surveyed in the RN4CAST study (Aiken et al., 2012). A 2014 report from the US Department of Health and Human Services stated that nursing supply between 2012 and 2025 is projected to outpace demand. Turning a shortage into a predicted surplus is achieved through the rapid growth in nurse training numbers; this has been supported in many states by offers of bursaries and other financial benefits.

In a review that compiled a list of the top 100 great places to work in healthcare in the United States (Fields et al., 2012), the most popular activities and incentives from the top five appeared to be:

• ‘employee development’, with the hospital providing ‘100% reimbursement for [staff] pursuing certification or degrees’;

• a company that treats all its employees to an annual picnic;

• a hospital that offers a ‘robust employee wellness programme’ that gives them access to ‘exercise equipment and spa-like amenities’;

• a company that provides ‘shared governance models that allow employees to contribute to decision making in the organisation’; and

• a medical centre that ‘installed a variety of activities to build employee engagement, including employee lunches, an employee activities committee and an “Above and Beyond” programme that recognises fellow employees’.

Indeed, the last example, Bailey Medical Centre, stated that 94% of their employees said they were ‘satisfied’ or ‘very satisfied’ with their employment. It is clear that all these organisations place great importance on human capital and going further than what is required of them legally. It is no surprise that in the UK the NHS England business plan for 2013/14–2015/16 places ‘staff feeling supported and valued in their work’ alongside ‘patient experience’ as the two most important indicators going forward, and acknowledges they are interlinked (available at http://www.england.nhs.uk/wp-content/uploads/2013/04/ppf-1314-1516.pdf). NHS England states that ‘It is these indicators that will tell us if all others are amounting to genuine quality where it matters’ (p. 6).

Organisational compassion

Investing in and promoting ‘organisational compassion’ can lead to many solutions to the issues discussed above. This is not a new term, but to the author, organisational compassion encompasses how senior managers relate to their employees and vice versa; how employees relate to each other; and how open, transparent and helpful an organisation is. Organisational compassion is an essential component for a thriving environment. It may not be a well-known term at the moment, but there has already been a great deal of research into this field by the research collaborative CompassionLab (CompassionLab.com) and the Centre for Positive Organizational Scholarship at the University of Michigan Ross School of Business (positiveorgs.bus.umich.edu/). The author believes this is where the future must lie for answers to address staff satisfaction, recruitment and retention. There are even established ways of providing an organisation’s ‘compassion score’. As can be seen from the questions in Box 4, a large proportion are linked to promoting human capital.

Box 4.

Creating a ‘compassion score’ for organisations.

*Questions that test an organisation’s compassion score include the following:

– The leaders in my organisation take time to talk and listen to people who are having a hard time.

– People in my organisation feel comfortable revealing that they’re stressed out, suffering, feeling burdened  or experiencing hardships.

– When I feel distressed, I have the sense that others at my organisation feel concerned for me.

– I hear stories in my organisation about colleagues receiving support from one another during difficult  times, such as through meals, cards, flowers or other expressions of care.

– When my organisation is looking for new members, we talk about care and compassion as part of what  makes someone fit.

– I feel that the leaders in my organisation support efforts to respond to someone who needs help or care.

– When I am in my organisation, I feel valued as a whole person.

– When people in my organisation help someone in need, they consider that individual’s unique  preferences and needs rather than responding in a more generic way.

Source: https://greatergood.berkeley.edu/quizzes/take_quiz/compassionate_organizations Note: *Each answer is scored according to a five-point Likert scale with the options Never, Rarely, Sometimes, Often and Always.

The author has created the diagram below (Figure 4) to illustrate his perception of the interactions and influences of factors leading to satisfaction, starting with employees at the centre. Here healthcare professionals can help themselves by learning and practising self-compassion, which has been shown to improve satisfaction and ameliorate burnout (Raab, 2014). In their immediate circle of influence is the team they work with, and the outer circles can exert influence on any of the inner circles. So the organisation, by looking to develop and enhance their organisational compassion and by making the environment space pleasant, can have an effect on employee satisfaction rates. But there are other circles of influence outside the organisation’s control. Governments can enforce laws on an organisation (e.g. minimum wage, legal acts on disability discrimination). Even the socio-economic system a country operates in has an influence. For example, the liberal free market capitalist system established in the UK makes it easier, and arguably more likely, for its labour force to move between organisations with relative ease compared with other models of capitalism such as the collaborative corporatist systems of Germany and Sweden (where organisations tend to have a flatter power structure). This is beyond the scope of this paper, which has instead concentrated on the other circles, all of which can be addressed by looking at organisational compassion as described above. Apart from the outermost circle, each of the inner circles could directly and easily influence satisfaction rates, and limit the turnover rates of nurses.

Figure 4.

Circles of influence on satisfaction.

There is a school of thought that perhaps a hospital would do better to target its most productive staff. Indeed, Stirling (2008) went further and wrote that 20% of engaged individuals do 80% of the work. Stirling (2008) stated ‘Therefore, it is vital to continue to cultivate job satisfaction among these highly productive individuals’ (p. 9). While this may be true, it may be misplaced for hospitals to pursue this course of action, as it would lead to a perception of inequality and therefore dissatisfaction rates would increase. Rather than risking alienating experienced nurses who are tremendously difficult to replace, all nurses at similar levels need to be treated with equity and fairness. This is backed up by Syptak et al. (1999), who argue that company policies need to be applied equally to all its employees, as this will in turn improve their attitude and decrease dissatisfaction.

Limitations of studies

Many studies looking into job satisfaction focus on individuals in isolation. Of course, in normal work life (certainly as a healthcare professional) the day is filled with interactions with others, and these can have a profound impact on mood and satisfaction rates. We tend to compare ourselves against others, and the level of satisfaction very much depends on this. We know from equity theory that if an individual gains more benefits for doing the same job, the person with fewer benefits will feel less satisfied and motivated (Huseman et al., 1987). The other criticism is that studies on satisfaction are often conducted by researchers who belong to just one field. But we know that an amorphous concept such as satisfaction transcends economics, psychology and social sciences. Simple cross-sectional studies are easier to conduct, but do not take on board the nuances of these social interactions. One potential solution methodologically would be to look at ethnographic studies observing employees interacting in their own environments. However, where you would gain in collating rich descriptive data on social interactions, you would lose in replicability and generalisability. Other limitations on the questionnaire, methodology and literature have been reported elsewhere.

There is a need for further research in this area, ideally using the same measures of satisfaction (that demonstrate validity and inter-rater reliability), and using multiple sources of collated data to triangulate information. This way, meaningful comparisons can be made, even potentially leading to league tables based on organisational compassion scores, in the same way that statistics on hospital waiting times are presented in the UK.

Key points for policy, practice and/or research

• Hospitals should focus more on improving nurses’ job satisfaction as this is one of the most important intangible assets.

• Factors related to job satisfaction include pay, respect, security, workload, recognition, responsibility, environment, autonomy, personal growth, administrative bureaucracy and caseload.

• Low job satisfaction impacts on motivation, absenteeism, commitment, retention, burnout, productivity and patient care.

• Investing and promoting organisational compassion could be a key part of the solution.

• More research using the same validated tools for measuring job satisfaction will help with consistency and comparability across different hospitals.

Biography

Neel Halder has approximately 20 years’ experience working in hospitals within both the NHS and the private sector in the UK. He has completed an MBA degree exploring intangible assets (specifically job satisfaction of nurses) within healthcare settings. He is a Research Champion for his trust, and is widely published in peer-reviewed academic journals on a range of subjects. He is on the editorial boards of the British Journal of Forensic Practice and the Royal College of Psychiatrists’ journal the BJPsych Bulletin. He has published book chapters and written a book on helping others to publish, and is a peer-reviewer for several academic journals. He is also a specialist clinical advisor for the Care Quality Commission. He has been appointed as recruitment lead for the Royal College of Psychiatrists (NW).

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.