Reasons Why Dissatisfied Acute Care Registered Nurses and Health Care Assistants Remain in Their Jobs

Saturday, 18 March 2017: 10:15 AM

Zelda Gibbs, PhD
Department of Nursing, College of Health Sciences and Human Services, Tarleton State University, Fort Worth, TX, USA

Financial challenges for hospitals demand strategies to ensure superior patient satisfaction scores. Healthcare employees face substantial challenges in their efforts to provide exceptional patient care and meet organizational expectations (Centers for Medicare and Medicaid Services, 2013; Top issues, 2016). Health care assistants (HCAs) are providing direct care for patients along with registered nurses (RNs). Yet, they are an understudied population in acute care facilities. Job descriptions for HCAs in acute care facilities are extremely diverse, and RNs feel reluctant to assign responsibilities to HCAs (Jenkins & Joyner, 2013; McKenzie & Turkhud, 2013). Stressful relationships between RNs and HCAs affect quality of care, patient satisfaction and retention of staff. Job retention, job satisfaction, commitment, and professional relationships can potentially suffer as a result. Generational differences between healthcare populations are also linked to relationship and retention issues in nursing (Hendricks & Cope, 2013; Schullery, 2013; Young, Sturts, Ross & Kim, 2013). This study explored the reasons why health care employees are embedded in their jobs, even when they are dissatisfied with the circumstances under which they work.

Job embeddedness (JE) is a construct that measures the reasons why employees stay in a job, even if they are not satisfied with this job. These reasons might be organizational or community related and are measured as fit, link and perceived sacrifices when quitting the job (Mitchell et al. 2001). JE has been linked to locus of control (Ng & Feldman, 2011), engagement, job satisfaction, commitment, job performance and intent to stay, and directly affects job retention and quality of service (Karatepe, 2013; Karatepe & Karadas, 2012; Lee, S., Lee, D., & Kang, 2012, Mitchell et al. 2001). Knowledge regarding JE of HCAs is lacking, and studies about the differences between JE of RNs and HCAs in acute care facilities could not be located.

A descriptive comparative design was used to measure: Infer differences between the total JE, organizational and community dimensions of JE, job satisfaction, intent to stay between RNs and HCAs, between three generations of RNs and HCAs, and to describe differences between the demographic data of RNs and HCAs including education, shift worked, years of experience, and hours worked per week. A convenience sample of RNs and HCAs from medical and surgical units at two Texas hospitals completed a survey of demographic data and one that measured JE variables of fit, link and sacrifice from organizational and community perspectives. Awareness of these associations combined with knowledge about the reasons why employees remain in their jobs can guide nurse managers on hiring requisites and incentives to improve retention rates.

 RQ1 - Is there a difference between RNs and HCAs on Total JE, Organizational JE Subscales, Community JE Subscales, Job Satisfaction and Intent to Stay?

Independent Samples t-tests were conducted to answer the question. The only statistically significant finding showed was that RNs valued community sacrifices as more important than HCAs [t (118) = 2.41, p = .018 with a large effect size of d = .55]. A post hoc power analyses revealed a power of .50, thus a 50% probability that rejecting the null hypothesis is wrong. Post hoc analyses on the non-significant t-tests vary between .48 and .65. Post hoc power analyses below .80 might be an indication of Type II errors. Community sacrifices was conceptualized to be costs and inconvenience associated with relocating to get another job. Financial ability of RNs to invest in their communities, while HCAs might not financially able to pay for the same investments. Due to the differences in pay between RNs and HCAs it is not surprising that the community sacrifice might be perceived differently by the higher-paid employees.

RQ2: Is there a difference between three generations of health workers in an acute care hospital on Total JE, Organizational JE subscales, Community JE subscales, Job Satisfaction and Intent to Stay?

ANOVA analysis showed a statistically significant difference [F (2, 117) = 4.813, p = .01] in the total JE scores. A post hoc analysis revealed a medium effect size of .30 and a power of 0.60, a probability of 40% that a Type II error could have been made. Post hoc analysis revealed that the increase from Millennials to Baby Boomers [-.42, 95% CI (-.74 to -.10)] was statistically significant (p = .007). The organizational links embeddedness score was statistically different between the three groups [F(2, 117) = 26.27, p < .01] with a large effect size of 0.70. The null hypothesis is rejected: There are significant differences in organizational links JE between generational groups. The post hoc power of 0.999 fully supported the decision since a Type II error rate was smaller than 0.001. Differences between all three generations on the organizational link subscale were statistically significant, as well as the difference between Baby Boomers and Millennials on total JE. Three out of the seven questions included years employed at this organization, in this position and in the hospital industry. Baby Boomers will most likely score higher on these questions than Millennials, just because they are older. However, this does not explain the significant difference between these two generations and Gen Xers. Millennials are focused on instant results and strive to thrive in their jobs. They might be more involved in committees and work teams. The average ages for RN and HCA were the same in each generation, with results showing that the mean age for healthcare employees at these two facilities falls in the Gen-Xer generation. This finding shows that attempts for improvement should be focused on generational similarities for each population.

These differences in JE between generations (although only organizational links embeddedness between all the generations, and total JE between Baby Boomers and Millennials were significant) showed that retention strategies and incentives should be focused on methods to retain staff. The differences between generations should be kept in mind because a ‘one size fits all’ approach will not deliver positive results.

RQ3: Can age, years worked, shift worked, level of education, organizational links, organizational fit, organizational sacrifice subscales predict job satisfaction?

Multiple regression was conducted and the assumptions of linearity, independence of errors, homoscedasticity, unusual points and normality of residuals were met. Independence of residuals was assessed by a Durbin-Watson statistic of 1.94. Normal distribution was verified with visual inspection of the histogram and P-P Plot. Model fit was confirmed with Adjusted R2 = .678. The ANOVA table suggested a statistically and significantly prediction of job satisfaction F (7, 115) = 37.652, p < .0005. Organizational fit, organizational sacrifice and level of education added statistical significance to the prediction, p < .05. The post hoc analysis suggested an effect size of 2.11 and a power of 1.00; thus fully supported the decision to reject the null hypothesis since a Type II error rate was smaller than 0.00.

The results revealed that RNs valued community sacrifices significantly higher than HCAs. This is a significant finding because only one other study could be located to demonstrate a positive correlation between JE and community sacrifices (Stroth, 2010) among RNs. Total JE scores between baby boomers and millennials were significantly different, while organizational links scores among all three generations showed a statistically significant difference. Organizational fit, organizational sacrifice and level of education added statistical significance to the prediction of job satisfaction.

The results from this study sketch a picture of RNs who fit well into the organizational culture and create the necessary professional links to be successful, while they also fit well in their communities and place significant value on community sacrifices. However, they scored lower on total JE, job satisfaction and intent to stay than HCAs. RNs might be well embedded in their communities (such as being, married, children in school and owning a house) but might not be embedded well enough at their particular organization or department to remain in their jobs, and might explore opportunities at other organizations or departments more freely than HCAs. In addition to this study’s results, attention to studies that showed positive results with regard to the organizational fit (Holtom, Smith, Lindsay & Burton, 2014) and community sacrifice subscales (Stroth, 2010), can reduce annual turnover and improve retention strategies significantly.

Results from this research can help administrators understand organizational and community influences on JE and the consequences that JE of RNs and HCAs have on professional relationships and quality of nursing care. Recommendations from previous studies in this context can be compared to these results and considered as strategies to improve workflow processes. Furthermore, this study provides a basis for future studies regarding the relationships between employee JE, quality of care indices, cost effectiveness and patient satisfaction.

Perceived values of HCAs to organizational sacrifices and community links can be a revelation for organizations that are striving to increase employee retention rates. Attempts to incorporate HCAs into the organization, such as offering opportunities to participate in committees, offering standardized education, certifications and a new focus on the value that this workforce brings to quality of nursing care will help to improve their organizational JE.

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