TRUST IN MANAGEMENT AND ITS RELATION TO JOB SATISFACTION AND INTENTIONS TO REMAIN FOR NORTHERN 8 0 NURSES by Heather Lynne Smith B.A., University of Northern British Columbia, 2000 THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in COMMUNITY HEALTH SCIENCE THE UNIVERSITY OF NORTHERN BRITISH COLUMBIA April 2004 © Heather Lynne Smith, 2004 1^1 Library and Archives Canada Bibliothèque et Archives Canada Published Heritage Branch Direction du Patrimoine de l'édition 395 Wellington Street Ottawa ON K1A0N4 Canada 395, rue Wellington Ottawa ON K1A0N4 Canada Your file Votre référence ISBN: 0-494-04668-6 Our file Notre référence ISBN: 0-494-04668-6 NOTICE: The author has granted a non­ exclusive license allowing Library and Archives Canada to reproduce, publish, archive, preserve, conserve, communicate to the public by telecommunication or on the Internet, loan, distribute and sell theses worldwide, for commercial or non­ commercial purposes, in microform, paper, electronic and/or any other formats. AVIS: L'auteur a accordé une licence non exclusive permettant à la Bibliothèque et Archives Canada de reproduire, publier, archiver, sauvegarder, conserver, transmettre au public par télécommunication ou par l'Internet, prêter, distribuer et vendre des thèses partout dans le monde, à des fins commerciales ou autres, sur support microforme, papier, électronique et/ou autres formats. The author retains copyright ownership and moral rights in this thesis. Neither the thesis nor substantial extracts from it may be printed or otherwise reproduced without the author's permission. L'auteur conserve la propriété du droit d'auteur et des droits moraux qui protège cette thèse. Ni la thèse ni des extraits substantiels de celle-ci ne doivent être imprimés ou autrement reproduits sans son autorisation. In compliance with the Canadian Privacy Act some supporting forms may have been removed from this thesis. Conformément à la loi canadienne sur la protection de la vie privée, quelques formulaires secondaires ont été enlevés de cette thèse. While these forms may be included in the document page count, their removal does not represent any loss of content from the thesis. Bien que ces formulaires aient inclus dans la pagination, il n'y aura aucun contenu manquant. Canada Abstract Job satisfaction and, more importantly, retention, have been at the forefront of healthcare in British Columbia and trust in management is believed to be a significant factor in both retention and job satisfaction in many areas of literature. This study examined, through survey and structured interview, the job beliefs and attitudes of 123 registered nurses working in hospitals in northern British Columbia. The results of the study showed that while job satisfaction and intentions to remain are related to nurse’s trust in management, the correlation is not as high as correlations found in other fields. This seems to indicate that further examination of trust in nursing may have to be done before the role that trust plays can truly be determined. Table of Contents Abstract Table of Contents List of Tables List of Figures Acknowledgements ii iii v vi vii 1.0 INTRODUCTION 1 2.0 LITERATURE REVIEW 2.1 Sources of Job Satisfaction 2.2 Factors Related to Retention of Nurses In Hospital 2.3 Factors Related to Intentions to Remain In Nursing 2.4 Relation Between Job Satisfaction and Intentions to Remain in Hospital 2.5 Definitions and Facets of Trust 2.6 Relationship between Trust and Job Satisfaction 2.7 Relationship between Trust and Intentions to Remain in Hospital 3 3 8 10 10 11 13 14 3.0 PURPOSE OF STUDY 3.1 Gap in Literature 3.2 Study Objectives 3.3 Study Hypotheses 16 16 16 17 4.0 METHODS 4.1 Description of Project 4.2 Sample 4.3 Initial Contact/ Recruiting Participants 4.4 Collection of Data 4.5 Participation Gift 4.6 Survey Instrument 4.7 Structured Interview - Procedure 4.8 Input of Data 4.9 Data Analysis 18 18 18 19 20 21 21 27 29 30 5.0 RESULTS 5.1 Demographics 5.2 Job Satisfaction - Central Tendencies 5.3 Intentions to Remain in Hospital- Central Tendencies 5.4 Ties in the Community - Central Tendencies 33 33 35 38 39 5.5 Intentions to Remain in Nursing - Central Tendencies 5.6 Trust - Central Tendencies 5.7 Correlations 5.8 Demographic Groupings of Variables of Interest 5.9 Types of Trust 6.0 DISCUSSION 6.1 Trust and Job Satisfaction 6.2 Trust and Intentions to Remain at Hospital and Remain in Nursing 6.3 Job Satisfaction and Intentions to Remain in Hospital 6.4 Job Satisfaction and Intentions to Remain in Nursing 6.5 Education Level 6.6 Ties In The Community/Intentions To Remain at Hospital 6.7 Does Type of Trust Matter? 6.8 Strengths of the Study 6.9 Limitations of the Study 6.10 Areas of Future Research 6.11 Conclusion 40 41 43 49 60 61 61 63 65 67 68 70 71 74 76 82 84 Reference List and Bibliography 85 APPENDIX A - Calculation of Northern BC Population Estimate APPENDIX B - Recruitment Poster APPENDIX C - Introduction Letter and Informed Consent Form APPENDIX D - Survey APPENDIX E - Structured Interview Questionnaire APPENDIX F - Coding for Structured Interview APPENDIX G - Inter-rater Reliability for Structured Interview Questions APPENDIX H - Scatter Plots for Variables of Interest 97 98 99 101 113 115 121 122 IV List of Tables Table 1 Comparison of Cl HI Data and Study Data Table 2 Central Tendencies of Job Satisfaction Variables Table 3 CentralTendencies of Variables that Contribute to Job Satisfaction Table 4 Central Tendencies of Intentions to Remain at Hospital Variable Table 5 CentralTendencies of Ties to the Community Variable Table 6 Central Tendencies of Intentions to Remain in Nursing Variable Table 7 Central Tendencies for Trust Variables Table 8 Correlation of Job Satisfaction, Sources of Job Satisfaction, and Trust Variables Table 9 Correlation between Intentions to Remain at Hospital Variables and Trust Variables Table 10 Correlations Between Intention to Remain in Nursing and Trust Table 11 Correlations Between Job Satisfaction and Intention to Remain in Hospital Table 12 Correlation Between Ties in Community and Intentions to Remain at Hospital Table 13 Correlation Between Job Satisfaction and Intention to Remain in Nursing Table 14 Demographic Grouping of Trust Variables Table 15 Demographic Groupings of Remain in Hospital and Ties in Community Variables Table 16 Demographic Groupings of Intentions to Remain in Nursing Variable Table 17 Demographic Groupings of Job Satisfaction and Sufficient Autonomy Variables Table 18 Demographic Groupings of Management’s views and Opportunities for Advancement Table 19 Demographic Groupings of Decision-making Authority and Safety Variables Table 20 Demographic Groupings of Feedback Variable Table 21 Paired T-tests of Trust-lnterview vs trust-Survey for Management V 34 36 37 38 39 40 41 44 45 46 47 47 48 53 54 55 56 57 58 59 60 List of Figures Figure 1 Theoretical model of relationships between trust, job satisfaction and Intentions to remain 4 Figure 2 Pie chart of age categories of nurses in the study. 33 Figure 3 Scatter Plot of Trust-survey vs Satisfaction 122 Figure 4 Scatter Plot of Trust-lntervlew vs Satisfaction 122 Figure 5 Scatter Plot of Trust-survey vs intentions to Remain - Hospital 123 Figure 6 Scatter Plot of Trust-lntervlew vs Intentions to Remain - Hospital 123 Figure 7 Scatter Plot of Trust-survey vs Intentions to Remain - Nursing 124 Figure 8 Scatter Plot of Trust-intervlew vs Intentions to Remain - Nursing 124 Figure 9 Scatter Plot of Intentions to Remain - Hospital vs Satisfaction 125 Figure 10 Scatter Plot of Intentions to Remain - Nursing vs Satisfaction 125 VI Acknowledgements I would like to thank the following people for their valuable contributions to this thesis: • The nurses who participated in this research project and who were so free with their valuable time. Without your participation, none of this would have occurred. • Karen, for being willing to step in and assist me with the development of this thesis. Without your willingness to be generous with your time, advice and constructive criticism, this thesis would not have gone this far. • Rick, for allowing me to work on this project with you and for your valu­ able comments and support during the writing of this thesis. • Lela, for your valuable comments on drafts of thesis that helped im­ prove the final result. • Harvey, for your help and encouragement throughout my graduate studies • Peter MacMillan for your immeasurable help with statistics and infinite patience in helping me to understand what it was that I was doing and needed to be doing. • William Zhang for your help with statistics. • My mom and dad who have supported me fully not only in this endeav­ our, but in all things that I’ve undertaken. • Alex for your support and encouragement through the frustrating por­ tions of this thesis and for sharing the joy with me as I finished it up. In addition, a huge thank you for converting the many pieces of my thesis into one beautiful PDF; you will never know how much I love you for that. • My family and friends who were not only good enough to ask how my thesis was going, throughout the process, but were also kind enough to listen to me when I actually told them. V II 1.0 INTRODUCTION The retention of nurses in Northern British Columbia and, in fact, many areas, is a major concern to health care providers at the moment (BCNU, 2001). Hospitals find themselves running short staffed, having difficulty recruiting new staff and having difficulties retaining the staff they already have (BCNU, 2001). Some of the factors contributing to the problem are external: the healthcare workforce is aging and many babyboomers are retiring, there was a lack of hiring in the 1990s, and there were reduced numbers of university students in health professions (Lowe, 2002). A shift from a 2-year diploma program to a 4-year BSN program, in the mid 1990’s, created a lag between the last diploma class and the first BSN class; as well there are a lack of spaces in universities for those wishing to pursue a nursing career In 2001/02 the numbers enrolled in first year nursing programs across the province were 915. Although no central registry exists to accurately monitor the number of applicants for each specific program, colleges and universities report that there is fierce competition for every nursing seat. Lack of physical space for nursing seats, reduction in the num­ bers of qualified instructors and educators (due to many of the same factors impacting front-line nurses), shortages of clinical placements and nurse preceptors, as well as lack of research money specifically al­ located to nursing chairs, impacts the ability to effectively carry out this strategy in the long-term (BCNU, 2001). These are factors that are beyond the control of employers. There are, how­ ever, factors that hospitals and other healthcare employers can control. In his article, Lowe (2002) notes that health professionals (compared to a variety of other oc­ cupations including university professors, clerical, skilled sales/service, skilled and unskilled manual labour, etc) have the lowest levels of trust in their employers, the lowest levels of commitment to their employers, the lowest levels of workplace com­ munication, feel they have the least influence in their workplace decisions and rate their workplace as being the least healthy and supportive. Of the areas identified by Lowe (2002), this paper will examine two of them: trust in employers and job satisfac­ tion (which is a component of a healthy, supportive workplace) as well as their rela­ tionship to intentions to remain. 2.0 LITERATURE REVIEW The relationships between trust, job satisfaction and intentions to remain are areas that have been explored in depth by a number of fields. This paper will explore the those relationships as they relate to nurses in Northern BC; these relationships are outlined in Figure 1. A number of factors directly contribute to job satisfaction; these factors include: feedback, autonomy, safety, opportunities for advancement, management’s view of nurses, and decision making authority. The literature review will discuss, in more detail, the theoretical relationships illustrated by the model and the nurses discussed in the literature are from acute care settings unless otherwise specified. 2.1 Sources of Job Satisfaction Satisfaction is defined as being the “fulfilment of a need or a desire as it af­ fects or motivates behaviour”(No author, 1989) and the definition of job satisfaction has been further refined and come to mean “how people feel about their jobs overall and about different aspects of them - the extent to which they like their jobs” (No author, 1997). Within nursing, countless measures of job satisfaction have been as­ sessed and authors have found very little evidence that the sources of job satisfaction can be narrowed down to a few key sources. Sadly, for hospitals, this means there is not one single change that can be made in order to satisfy all staff and changes made that satisfy some may cause dissatisfaction in others. Many of the sources Ties in Community Safety Autonomy Feedback INTENTIONS TO REMAIN IN HOSPITAL JOB SATISFACTION INTENTIONS TO REMAIN IN NURSING Management's Views Advancement Opportunities Decision Making Figure 1 Theoretical model of relationships between trust, job satisfaction and intentions to remain of job satisfaction are relatively intuitive such as opportunities for advancement and safety but others, like feedback and management support, are not so immediately ap­ parent. 2.1.2 Opportunity for Advancement Shields & Ward (2001), Lundh (1999), Armstrong-Stassen, Cameron & Horsburgh (1996), Cavanagh (1990) all discuss the idea that the opportunity for advance­ ment is linked to job satisfaction but they did not delve into the reason that advance­ ment leads to job satisfaction. It is plausible that the biggest payoff for job satisfaction likely comes from the employee feeling valued and that their contributions within the organizations are not only noticed but acted upon. One thing that is not discussed by any of the authors is the idea that satisfaction can come from advancement but not involve any vertical movement (e.g. becoming more specialized in a given field or learning about a different area but still doing bedside nursing and not moving up into management; “In nursing definitely [there are advancement opportunities] - at my age I am not looking for more degrees but [there are] lots of opportunities to get into dif­ ferent jobs (Structured Interview #109, 2002)”). There are nurses who are happy with doing bedside nursing and who don’t want to leave their chosen area of practice. 2.1.3 Autonomy/Decision Making Autonomy is an area that arises in most literature that discusses job satisfac­ tion, regardless of the profession in question, and nursing is not any different. Adams & Bond (2000), Grose (1999), Buchan (1994) and Cavanagh (1990) simply looked at levels of autonomy and used those as a marker to separate more successful hospitals from those with high turnover. Collins, Jones, McDonnell, Read, Jones & Cameron (2000), Carver (1998), Chiarella (1998), Pierce, Hazel & Mion (1996) and Ethridge (1987), however, delve more deeply into what autonomy means to nurses, what it would allow them to do and why it changes levels of job satisfaction. These authors found that the expanded roles that come with autonomy offer many nurses new challenges and chances to expand their skill sets. They are able to pursue in­ novative paths and have increased freedom to design care plans they feel are most appropriate for their patients. This autonomy gives nurses the ability to give good patient care, the reason most of them became nurses. Chiarella (1998) and Carver (1998) both discuss nurses taking on roles from traditional medical territory in order to offer more holistic patient care and a further continuity of care but while Chiarella (1998) feels that this increased role and autonomy can only lead to increased job satisfaction. Carver (1998) offers the caution that nurses should ensure that the roles they are taking on allow them to deliver the type of nursing care they want to give lest they find themselves with increased autonomy but deceased levels of job satisfaction. 2.1.4 Working Conditions/Safety Working conditions and their relation to job satisfaction speak to one of the basic needs of employees, the ability to feel safe at work. Zboril-Benson (2002), Greenglass & Burke (2001), Crose (1999), Wicker (1999) and Armstrong-Stassen, Cameron & Horsburgh, (1996) note that nurses want control over their working condi­ tions; they want to be able to decide appropriate nurse to patient ratios, how many RNs are needed and what they require, by way of equipment and supplies, to deliver safe, quality care. Greenglass and Burke (2001) discuss the idea that many nurses feel there has been a deterioration in their working conditions and that the deteriora­ tion is mainly due to restructuring within the hospitals and the health care system. Zboril-Benson (2002) also notes that with respect to restructuring, the deterioration of working conditions has also brought about more cases of serious injury. 2.1.5 Support from Management Downsizing is not the only area in which management is linked to satisfaction. Quine (2001), Duchscher (2001), Peltier, Boyt & Westfall (1999), Yoder (1995) and Prato (1987) discuss that the amount of support received from management directly affects levels of job satisfaction. In Prato’s article (1987), support from management comes in the form of effective orientation. Offering credit for jobs well done, estab­ lishing decision making guidelines and ensuring units are operating as smoothly as possible are part of the broader spectrum of ensuring that nurses are aware of their roles and duties within the unit. Management that does this finds they have happier and more satisfied nurses. Yoder’s article follows a similar vein, discussing the value of a career development relationship that involves mentoring, preceptoring, coaching and sponsoring (Yoder, 1995: 293). Career development relationships offer nurses a chance to share their strengths, an avenue to improve any weaknesses and also provide a support system for newer nurses. Quine’s article (2001), however, looks at the support management offers for nurses who are being bullied within the work­ place. Quine (2001) states that more nurses are bullied than any other hospital staff, that they are more likely to witness bullying and that less than one quarter of them are 8 satisfied with the outcome of dealing with the bullying. This lack of satisfaction with outcome leads to a more generalized decrease in job satisfaction and an increase in propensities to leave. Quine (2001) suggests that management would do well to deal more effectively with bullying but does not state what sort of support the nurses want or need. 2.1.6 Feedback Feedback from management and supervisors about job performance has been shown, in many areas of the literature, to be a significant predictor of job satis­ faction (Ecklund & Hallberg, 2000; Reiner & Zhao, 1999; Taylor, 1999). Kim (1999), in his study of public officials found that feedback had a significant, positive impact on job satisfaction. Orpen (1984) found there was a significant correlation between job satisfaction and feedback (r=.39, p<.05). There are other sources of job satisfaction but the ones listed above touch on many of the major areas that are necessary to fulfill the needs of an employee. Hav­ ing looked at what gives satisfaction within a job, it is also important to examine what keeps individuals in their jobs. 2.2 Factors Related to Retention of Nurses In Hospital It has been made fairly clear in the literature that one of the main factors relat­ ed to retention is job satisfaction but that is not the only factor. Friss (1982), While & Blackman (1998) and Leveck & Jones (1996) state that age and experience are fac­ tors in retention; the older a nurse is and the longer she has been at an institution, the less likely she is to leave. Shay & Stallings (1993), Fisher, Hinson & Deets (1994), Diaz (1989), Schaefer (1989), and Friss (1982) also note that there is a correlation between turnover and level of skill, education opportunities and type of occupation. Nurses who are more highly skilled and who have more education appear to be more inclined to remain at an institution. Contrarily, Price & Mueller (1981 cf Cavanagh 1990) found that nurses with undergraduate degrees were more likely to leave their jobs than counterparts who did not have degrees. Schaefer (1989), notes that critical care nurses’ levels of retention is aided with research training skills that enable them to expand their scope of practice; Diaz (1989) notes the importance of ensuring that the off-shifts (i.e. nurses who are not working when inservices are presented) have adequate opportunities to access education and the importance of doing a needs assessment to determine what education is actually important and useful to those nurses. 2.2.1 Community and Family Ties Retention issues do not always fall within the hospital’s control. Orsolits (1984) found that 27% of respondents to an exit survey stated family relationships (chil­ dren and husband’s work) as their main reason for leaving. Fisher, Hinson & Deets (1994) and Cavanagh (1990) examined a number of retention factors at not-for-profit hospitals in the US and found that kinship responsibilities played a significant role in intentions to remain (in the case of Cavanagh (1990), kinship responsibilities were the most important predictor of turnover). Examples of kinship responsibilities include: having to care for elderly parents, caring for a chronically ill spouse or child, reloca­ tion of a spouse to a new job, etc. The hospital cannot do anything to prevent kinship 10 responsibilities from arising, however, they can offer support to its staff in order to at­ tempt to temper the effects of kinship responsibilities. In addition, other studies have found that individuals choose to work in the location where they are because of family ties. In education, it was found that 35% of teachers taught in the county they were teaching in because of family ties (Chatham Education Foundation, 2001). 2.3 Factors Related to Intentions to Remain In Nursing While no literature could be found on intentions to remain in the nursing pro­ fession (rather than retention at current hospital or organization), other fields have done research in this area. The education literature discusses the fact that many teachers feel they are required to perform like experienced teachers as soon as they enter the field and do not have sufficient professional support and assistance to perform their job adequately. Special education teachers leave their profession citing reasons including: high rates of role conflict, lack of collegiality and poor school cli­ mate (Griffin, Winn, Otis-Wilborn, Kilgore, 2003). In another study, Theobega & Miller (2001) found that supervision and feedback were positively related to job satisfaction which is, in turn, related to intentions to remain in the teaching profession 2.4 Relation Between Job Satisfaction and Intentions to Remain in Hospital Armstrong-Stassen, Cameron, Mantler, Horsburgh, M.E. (2001), Chusmir (2001), Shields & Ward (2001), Zangaro (2001), Kunavikitkul, Nuntasupawat, Srisuphan & Booth (2000), Buchan (1999), Crose (1999), While & Blackman (1998), Leveck & Jones (1996), Irvine & Evans (1995). Stratton, Dunkin, Juhl & Geller (1995), Huntley (1994), Robinson & Rousseau (1994), Choi, Jameson, Brekke, Anderson, 11 & Podratz (1989), Hogan & Martell (1987) discuss job satisfaction and retention and while the source of this satisfaction differs from article to article, the common thread among them is that job satisfaction is directly correlated with intentions to remain. Armstrong-Stassen, Cameron, Mantler, Horsburgh (2001: 156) show a correlation of -.59 between job satisfaction and turnover intentions (note that this is intentions to leave, not remain hence the negative correlation). Cox (2001) shows a similar satisfaction-turnover intention with a correlation of -.57. Hogan and Martell (1987) exam­ ined the relationship between satisfaction and intent to stay and found the correlation to be .56 while Robinson & Rousseau (1994) found that satisfaction and intentions to remain had a correlation of .43 (p=.01). 2.5 Definitions and Facets of Trust A review of the literature surrounding trust reveals a wealth of articles on the subject. Trust, and its importance in organizations, workplaces and relationships has been examined from many different angles. For the purposes of this paper, the pertinent articles can be condensed into a three major themes: trust has many defini­ tions, trust is multi-faceted, and trust is related to job satisfaction and intentions to remain. In their review of trust based literature, Rousseau, Sitkin, Burt, Camerer (1998) define trust as being: “...a psychological state comprising the intention to ac­ cept vulnerability based upon positive expectations of the intentions or behavior of an­ other (p. 395).” In their cross-discipline study of trust, Rousseau et al. (1989) looked at the treatment of trust by economists, psychologists, sociologists and others and 12 tested assumptions surrounding what was known about trust. They found that while scholars may word their definitions of trust differently, fundamentally, they agree on the meaning of trust and there are different types of trust that exist within a spectrum and that the same parties may experience different types of trust depending on the task or setting. Trust is not one-dimensional, however; many characteristics contrib­ ute to the establishment and maintenance of a trust relationship. Sirdeshmukh, Singh, Sabol (2002), Pounder (2001), Tschannen-Moran (2001), Shockley-Zalabak, Ellis, Winograd (2000), Hoy & Tschannen-Moran (1999), Clark & Payne (1997) ,Deluga (1995), Hosmer (1995), and Butler (1991) describe these characteristics that contribute to trust as facets. These facets include: benevolence (self-interests are balanced with other interests), reliability (the expectation of con­ sistent and dependable behaviour in words and actions), competence (a generalized perception that assumes leadership effectiveness and the ability of the organization to survive in the marketplace), honesty and openness (the amount of information be­ ing shared and the perception of sincere efforts by leaders). Deluga (1995) describes an additional five facets that are present primarily in the trust relationship between employees and management. These include: availability (being physically present when needed), consistency (making decisions in a reliable fashion), confidentiality (keeping confidences), fairness (just and impartial treatment), integrity (honesty and moral character), loyalty (an implied agreement not to cause harm and promote the subordinate’s interests), and receptivity (being straightforward about giving and ac­ cepting suggestions) (Deluga, 1995:3-4). 13 2.6 Relationship between Trust and Job Satisfaction The role of trust in management in employees’ levels of job satisfaction is one that has been widely explored in business literature for many years. Trust plays a large role in job satisfaction; this refers not only to the global idea of trust, but to the idea of faceted trust. Each of the facets of trust may contribute differently to the lev­ els of job satisfaction. Shockley-Zalabak, Ellis, Winograd (2000), Deluga (1994) and Robinson and Rousseau (1994) all discuss the individual facets of trust and relate those to job satisfaction. Shockley-Zalabak, Ellis, Winograd (2000) also look at trust as a whole and found that trust explains 60.8% of the variance in job satisfaction. Driscoll (1978) found a correlation of .52 (p=.001) between trust and overall satisfac­ tion, Ellis and Shockley-Zalabak (2001) found that there was a strong linear relation between trust in management and satisfaction (r=.88) and Robinson and Rousseau (1994) found a correlation of .69 (p=.01) between trust and satisfaction. Fulk, Brief, Barr (1985) found a correlation of .47 (p=.05) between the employee’s trust in man­ agement and how he or she perceived the fairness and accuracy of feedback (a component of satisfaction). Barrett (2000) discusses the trust relationship between management and employees regarding safety (a component of job satisfaction). Bar­ rett (2000) notes that when employees perceive a lack of concern on the part of man­ agement regarding safety issues they subsequently do not take further concerns to management because there is no belief that those concerns will be dealt with. This leads to problems with satisfaction in other areas and the greater possibility of injuries resulting from unsafe equipment and practices. 14 There is not, however, a great deal of literature regarding the importance of the trust relationship between nurses and management in hospital settings. The litera­ ture that exists, however, does indicate that trust is an important factor in satisfac­ tion. Armstrong-Stassen, Cameron, Mantler, Horsburgh (2001) found in their paper, examining the effects of hospital amalgamations, that trust was strongly related to job satisfaction (r=.47, p=.001). In their paper examining burnout and nurses Laschinger, Shamian, Thomson (2001) found that while organizational trust (defined as trust that an employer will be straightforward and follow through on commitments) had relative­ ly low levels of direct correlation with job satisfaction, organizational trust was strongly correlated to organizational characteristics (like autonomy and decision making au­ thority; similar to what this study has defined as sources of job satisfaction) which were then, in turn, correlated strongly with job satisfaction. 2.7 Relationship between Trust and Intentions to Remain in Hospital The relationship between trust and intentions to remain is one that hasn’t been explored in the same depth as the trust and job satisfaction relationship. As the theo­ retical model shows (Figure 1), the primary linkage between trust and intentions to remain is through job satisfaction but that does not mean there are no direct relation­ ships discussed in the literature. Arnold, Barling, Kelloway (2001) found that there was a correlation of .70 between intentions to remain and trust while Robinson and Rousseau (1994) found a correlation of -.18 (p=.05) between trust and intent to leave (hence the negative correlation) and a correlation of .39 (p=.01) between trust and intentions to remain. 15 Armstrong-Stassen, Cameron, Mantler, Horsburgh (2001) found in their paper, exam­ ining the effects of hospital amalgamations, that trust was strongly related to turnover intentions (r= -.45, p=.001) 16 3.0 PURPOSE OF STUDY 3.1 Gap in Literature An apparent gap in the literature pertaining to the management-nurse satis­ faction/retention relationship, and the one this thesis will explore, is how trust factors into the picture. We have seen, in other organizations, how the trust between em­ ployers and employees leads to job satisfaction and retention but there is currently very little literature that looks specifically at how nurses’ trust in management relates to job satisfaction and retention. Given the importance of trust in other organizations, one would assume that it is likely that trust occupies an equally important place in nursing-management relationships. 3.2 Study Objectives 1) To determine the relationship between nurses’ trust in management and their job satisfaction. 2) To determine the relationship between nurses’ trust in management and their intentions to remain working in the hospital they are currently at. 3) To determine the relationship between nurses’ trust in management and their intentions to remain in nursing. 4) To determine the relationship between job satisfaction and intentions to remain working in the hospital. 5) To determine the relationship between job satisfaction and intentions to remain in nursing. 17 6) To determine the relationship between job satisfaction and the sources of job satisfaction outlined in the literature. 7) To determine the relationship between intentions to remain at the hospital and ties in the community. 3.3 Study Hypotheses 1) There is a positive relationship between trust in management and job satisfaction. 2) There is a positive relationship between trust in management and inten­ tions to remain in the hospital. 3) There is a positive relationship between trust in management and inten­ tions to remain in nursing. 4) There is a positive relationship between job satisfaction and intentions to remain in the hospital. 5) There is a positive relationship between job satisfaction and intentions to remain in nursing. 6) There is a positive relationship between job satisfaction and the sources of job satisfaction. 7) There is a positive relationship between intentions to remain at the hospi­ tal and ties to the community. 18 4.0 METHODS 4.1 Description of Project The work detailed In this paper was part of a larger study entitled “Motivators and Trust as Explanatory Factors in Northern Hospital Nurses’ Intentions to Remain and Obligation Attitudes.” The purpose of this research project was to gather data that would allow the examination and understanding of factors in the workplace that explain hospital nurses’ work attitudes. To do this effectively, it was decided that the project would have both a quantitative component and a qualitative component. The project required ethics approval due to its investigative nature and received ap­ proval from the University of Northern British Columbia and the BC Northern Health Authority. The bulk of this project began in January 2002. Interviewing of nurses was started in April 2002 and completed in October 2002 and data entry was com­ pleted by December 2002. The nurses participating in this study were from hospitals throughout Northern BC. Funding for this project was provided by the British Colum­ bia Rural and Remote Health Research Institute. 4.2 Sample To obtain a rough estimate of the population of northern BC, data from Sta­ tistics Canada (2001) was used. When the populations of all the towns that have hospitals in the north are added together, a population estimate of 258,974 is reached (see Appendix A for calculation of population estimate). This number is likely a little low because only towns that have hospitals are being used. However, census ag­ glomeration area data from Statistics Canada (2001) does include some of the small 19 villages and settlements that surround the bigger centres. According to data from the Canadian Institute for Health Information (2002), Urban BC has a nursing population of 70.6 nurses per 10,000 people. Extrapolating from these numbers, there should be approximately 1800 RNs in the North. According to the Canadian Institute for Health Information only 65.6% of these nurses are hospital nurses (the focus of the study), reducing the possible pool of nurses to approximately 1200. Given that this study sampled 123 nurses, it has sampled approximately 10% of the available pool of nurses. According to Cohen (Hurlburt, 2003), for a study with medium effect size (defined as a correlation greater than .3 but less than .5, the category into which the majority of the correlations in this study fall) and an alpha =.05, 66 pairs of observa­ tions are necessary to have a power=.8 (an 80% chance of correctly rejecting the null hypothesis). Since this study has a minimum of 110 pairs for each correlation, it more than meets this requirement. 4.3 Initial Contact/ Recruiting Participants To begin the project, contact was made with the nursing managers at the hospitals within the study area. Nurse managers were asked if they would be willing to receive a package of recruitment posters to display in their hospitals. All managers contacted were agreeable to displaying the posters. Posters were mailed out to the nurse managers with a note of thanks for their willingness to assist with the study. The recruitment posters (Appendix B) were a single 8 1/2 x 14 sheet of paper with a brief synopsis of the study, a clear explanation of where funding for the project was coming from (this seemed an important thing to specify as the health authorities 20 in British Columbia were undergoing a massive restructuring at the time and there was a wish to clarify the fact that this project was not associated with the provincial government or the hospital) and contact information. Two versions of the poster were made; the only difference between the two was that the regional poster offered a 1800 telephone number for participants to use rather than a local number. 4.4 Collection of Data Within approximately one week of the posters being displayed at the hospital participants began contacting the study. To be eligible to participate, nurses had to have worked at least 450 hours in the last 6 months and be at a head nurse/clini­ cal instructor level or registered staff nurse. The former was done to ensure that the nurses being surveyed and interviewed would be likely to have sufficient knowledge of and interaction with management. The latter was done to ensure that nurses being interviewed about “higher management” were not management themselves. When it was determined that a nurse was eligible to participate in the study, a package was mailed that included an introduction letter detailing the study, what their participation in the study would involve and what they could expect to receive for participating in the study (Appendix 0), an informed consent sheet (Appendix 0), a copy of the sur­ vey that was to be filled out before their structured interview and a copy of the struc­ tured interview. Approximately one week after mailing the package, the participants were given a follow-up call to ensure they had received their package, to ask if they 21 had any questions and to arrange a time to conduct the structured interview. The distribution of packages began in early April and distribution of packages ceased in O ctober. 4.5 Participation Gift When undertaking this study, it was recognized that nurses are busy individu­ als. This was why it was decided that the nurses would be offered a gift to thank them for their participation in the study. The nurses were given a gift worth approxi­ mately $50.00; it was felt that this amount adequately compensated the participants for the two hours of time the survey and interview portions of the study were expect­ ed to take. 4.6 Survey Instrument The survey used in this study was a combination of a number of different surveys. The first section of the survey collected demographic information as well as information about how long the participant had been nursing, how long they had been at the hospital and whether they worked full time, part time or casual. The second section of the survey dealt with ideas of commitment, job satisfaction, trust and re­ tention. This section used a Likert-style scale that was anchored with “1=strongly disagree” and “5=strongly agree” while 2, 3 and 4 were equivalent to “disagree”, “neither agree nor disagree” and “agree”, respectively. The third section dealt with obligations, both employer and employee. This section used a Likert-style scale that was anchored with “1=Not Obligated” and “5=Absolutely Obligated” while 2, 3, and 4 are equal to “Slightly Obligated”, “Fairly Obligated” and “Very Obligated”, respectively. 22 The final section dealt with the characteristics of the participant’s ideal job. The Lik­ ert-style scale for this section was anchored with “1=very unimportant” and "5=very important” while 2, 3, and 4 were equivalent to “not important”, “neither important nor unimportant” and “important” respectively. A complete copy of the survey is avail­ able in Appendix D but it is important to understand that not all questions asked in the larger study were of interest in this thesis. For the purposes of this thesis, only select sets of questions from the second section of the survey (Job Organization and Beliefs) were used. These sets of questions (detailed in the following sections) repre­ sent complete sub-scales that have been shown to be valid measures for assessing the concepts of job satisfaction, trust, intentions to remain in hospital and intentions to remain in nursing. 4.6.1 Job Satisfaction Questions dealing with job satisfaction came from Hackman & Oldham (1980:282, 305) and were inserted as written into the questionnaire. The questions asked were part of a larger job diagnostic survey but the questions used dealt specifi­ cally with job satisfaction. The questions include: Generally speaking, I am satisfied with this job; I frequently think of quitting this job (reverse scored); and I am generally satisfied with the kind of work I do on this job. The reverse scoring of the above ques­ tion was maintained in the larger survey (as were the other reverse scored variables). Reverse scored variables are used in surveys as a form of validation or “check” to en­ sure that the points on the scale that participants are picking truly represent their an­ swers and that they aren’t just answering by rote. The scale used to measure these 23 variables was shifted from a 7 point scale to a 5 point scale by collapsing points 2 and 3 and points 5 and 6 on the original scale. This was done to give the scale conti­ nuity with already existing survey questions and was anchored with strongly disagree (1) and strongly agree (5). Hogan & Martell (1987) re-examined the questions used for job satisfaction and found them to have a Cron bach's alpha (internal consistency) of .82. A fourth question, Overall, I am satisfied with my job, was developed for this project and was included in the job satisfaction questions that were asked in this study. This question is very similar to the one from Oldham & Hackman; a reliability analysis shows it to have a Cronbach’s alpha of .92 when compared to the question from Oldham & Hackman’s study. In addition, job satisfaction is also examined through the sources that contrib­ ute to it (autonomy, feedback, management’s views, decision making authority, safety and opportunities for advancement). Questions that deal with the sources that con­ tribute to job satisfaction are not taken from specific scales, but instead they opera­ tionalize the characteristics of the job characteristics model and needs theory. Auton­ omy (and decision making authority, which is a part of autonomy) and feedback come from the job characteristics model and are considered to be core job characteristics. It is widely maintained that individuals with higher levels of these characteristics tend to have higher levels of satisfaction (McShane, 2004). Needs theory, specifically the ERG theory, groups human needs into three main categories (existence, relatedness and growth); this theory maintains that these needs are instinctive and hierarchi- 24 cal and that individuals progress to or regress from higher levels depending on their fulfilment. Safety is an existence need, management’s views fall within relatedness needs and opportunities for advancement are growth needs (McShane, 2004). 4.6.2 Trust Questions that examined trust in management were taken from Mayer & Davis (1999:136). The internal consistency for these questions was evaluated by Mayer & Davis and found to have a Cronbach’s alpha of .82. The questions were altered slightly to reflect the nursing focus of the questionnaire; this condensing was done in order to help shorten the length of the overall survey to something that could be completed, by the majority of the participants, in an hour. The final questions used in the survey were: I would be willing to let management have complete control over my future in the hospital and issues that are important to me and I would be willing to give management a task or problem that was critical to me, even if I could not monitor their actions. All questions also used a five point Likert-style scale and had anchors of strongly disagree (1) and strongly agree (5). 4.6.3 Intentions to Remain Questions that measured intentions to remain were taken from Chatman (1991) These questions were adopted by Robinson (1996) and found to have an internal consistency, measured by Cronbach’s alpha, of .86. For use in this study, the questions outlined in Chatman and Robinson were modified as they were originally used in a business environment and this study was using them in a nursing environ­ ment and we believed it was important to have the questions appear as relevant and 25 specific as possible. In addition, intentions to remain questions were asked about three separate areas. The same set of questions was used to assess the partici­ pants’ intentions to remain at their hospital, in nursing and in Northern BC. The modified questions used to assess intentions to remain in nursing include: I would prefer a job other than nursing; If I have my way, I will be nursing 3 years from now; and I intend to remain in nursing. The modified questions used to assess intentions to remain in the hospital include: I would prefer a job outside the hospital. If I have my way; I will be working in the hospital 3 years from now; and I intend to remain with the hospital. The wording of the questions was also changed from “you” focussed ques­ tions to “me and my” focussed questions. This change created questions that were in keeping with the style of the other questions asked in this section of the study. All questions used the same 5 point Likert-style scale and were anchored with strongly disagree (1) and strongly agree (5). 4.6.4 Ties in the Community The ties in the community variable is also used in relation to the intentions to remain hospital questions. The questions used to assess community ties were 5 point Likert-style scales anchored with strongly disagree (1) and strongly agree (5). The ties items were not part of a published scale, instead they operationalized relat­ edness needs from needs theory (McShane, 2004). As discussed in the literature review, family and community ties may alter nurses’s intentions to remain at the hos­ pital, regardless of their feelings about the hospital itself. 26 4.6.5 Reverse Scoring Reverse scoring is a technique often used in surveys to ensure the veracity of the data collected. Items are asked in a reverse manner from the other items in a sub-scale but when using the item to calculate a mean, the results are reversed (eg on a 5 point Likert-style scale, 1 becomes 5, 2 becomes 4, 4 becomes 2, 5 becomes 1 and 3 stays as it is). Clark & Payne (1997) discuss that the means of reverse scored items are often lower that the means of other items in the sub-scale. This is often because participants answering the questions do not look closely at the actual question asked and simply answer the way they have been answering most often. In some instances, a decision may be made to remove or alter the sub-scale if the check performed by reverse scoring indicates that participants have not understood or read the question. For this study, however, the means of the reverse -scored items (I frequently think of quitting this job-job satisfaction sub-scale; I would prefer a job other than nursing, I would prefer a job outside the hospital-intentions to remain sub­ scales), while lower, do not change the composite reliability below acceptable levels for the sub-scale. The means for reverse-scored variables presented in this paper represent the scale after it has been reversed. 4.6.6 Demographic Variables Various demographic variables were used in this study to help group the par­ ticipants. Gender, age, marital status, children, education level, employment status, time in current position, time in current organization and time in nursing. Age was 27 measured in two different ways. The main survey asked participants to provide an age range while a secondary, quality of life survey provided an exact age of partici­ pants. 4.7 Structured Interview - Procedure Interviews were done at the convenience of the nurses to the greatest degree possible. The interviews were conducted in a variety of locations. Office space was made available at the university, the option of coming to the nurse’s home was given and some nurses chose to be interviewed at the hospital. Interviewing at the hospital was not originally a study option as there was a concern that nurses interviewing at the hospital would not feel that they could speak freely or that there would be con­ cerns about who overheard what they said. When this concern was shared with the nurses, however, none of them felt that they could not speak as freely in the hospital setting as they could in their own homes or a university office. For regional inter­ views, the hotel room of the interviewer or space at the hospital was generally used although some interviews were conducted at the homes of the participants. For the face to face interviews, the interview began with the collection of the survey and the assigning of a case number. Case numbers were assigned consecutively for the par­ ticipants. Once introductions were done and the survey was collected, the participant was given a chance to ask questions about anything he or she did not understand (in the survey, the structured interview, the consent form or the study as a whole) and the consent form was signed by both the participant and the interviewer. A tape recorder with a table microphone was used to record the interview onto 90 minute 28 cassette tapes. At the conclusion of the interview, the cassette tapes were labelled with the case number. In some cases, a time to do a face to face interview could not be arranged. In these cases, the interview was conducted over the phone using a recording device that hooked into the tape recorder and the telephone handset. The participant was still given the opportunity to ask questions and obtain clarification. At the conclusion of the interview, participants were asked to send in their survey and signed consent form, if they had not already done so, and the cassette tape was la­ belled with their code number. Upon receipt of the questionnaire, the informed con­ sent was signed by the interviewer, the survey was labelled with the appropriate code number and any information that could identify that survey from others was discarded (e.g. envelope, etc). 4.7.1 Structured Interview - Questions The questions in the structured interview were asked in the order they appear on the sheet (see Appendix F) and were asked exactly as printed. Follow up ques­ tions were asked, depending on the response of the participant, to help clarify and expand upon the answers given. Care was taken not to ask questions that could be considered ‘leading’ and the tapes were listened to by the non-interviewing research­ er (RT) to check for consistency in questioning and use of leading questions. The questions contained in the structured interview were developed specifically for this study. Motivational theory, in particular needs theory (the idea the people’s behav­ iour is driven by a requirement to satisfy certain needs), was used as the guideline to develop the questions (McShane, 2004). Questions from the structured interview 29 that were utilized in this study include: How much do you trust management?; What do you believe are management’s views of nurses?; Do you have sufficient autonomy in your work?; Do you have sufficient decision making authority to do your job effec­ tively?; Are there advancement opportunities either within nursing or in the hospital for you?; and Is the feedback you get on how you are doing your job sufficient and beneficial to you?. The validity of the measurement of the concepts in the structured interview has not been determined by other studies; given the broad nature of these concepts, however, it was decided that it would be more informative to have the nurses self-define the concepts in their answers. In this way, the researchers have not biased the study by introducing their own concept definitions. 4.8 Input of Data Since the questions in the survey were mainly Likert-style questions, they already contained the coding used to input them into the statistical program. A data­ base was set up in SPSS (SPSS Inc., 1999) and the input of the questionnaires was done as they were received. The demographic section was coded by simply convert­ ing a nominal answer to a number (e.g. female=1, male=2). The structured interview was more difficult to input into SPSS (SPSS Inc., 1999) as the answers were given verbally rather than in numeric form. To ensure that the interview data could be used both qualitatively and quantitatively the interview was first recorded onto paper. This was not strictly a transcription, instead simply the main points that answered the question were recorded. It became apparent, however, that some aspects of data from the structured interview would be better served through quantitative analysis. 30 To this end, a coding system (1 to 5, each with answers associated) was developed for each question (see Appendix F) and the synopsis of the question was read and matched up with the code that best matched the participant’s answer. To ensure the reliability of this coding, it was done 3 times: once by the researcher who did the synopsis transcriptions (RT), once by the researcher who did the interviews (HS) and once by a researcher who was completely independent of the project and had not heard the interviews and had only seen the synopses of the interviews (BO). The 3 answers for each question were then compared and a inter-rater reliability analysis was performed to ensure the code accurately reflected the answer given by the par­ ticipant. Inter-rater reliability, for the questions being used in this paper are detailed in Appendix G. The structured interview questions of interest showed a total agreement (where all three raters agree) of between 20 and 60% and a close agreement (where two raters agree and the third differs by only one point) of between 80 and 95%. To form the variable that would be used in analysis, the scores of the three raters were averaged to give a single number. The median of the three scores was also consid­ ered for use as variable but since the median and average scores had a correlation of .976, the average score would be used to maintain consistency with the other vari­ ables being used. 4.9 Data Analysis Data collected from the survey and structured interview was coded and en­ tered on a Dell Inspiron 3500 laptop computer. All of the statistical analysis was com­ pleted using SPSS 10.0.5 (SPSS Inc., 1999). Data from the demographic portion of 31 the survey was treated as nominal data. Data from other portions of the survey and the structured interview was more problematic. Data in these areas came from the Likert-style scales used to collect the data and while Likert-style scales are techni­ cally ordinal measures, they can and have been used successfully as interval data. Zumbo, B.D. & Zimmerman, D.W. (1993:390) concluded that there was “no need to replace parametric statistical tests by nonparametric methods when the scale of mea­ surement is not interval. As well, Jaccard and Wan (1996:4) found that, “for many statistical tests, rather severe departures (from intervalness) do not seem to affect Type I and Type II errors dramatically.” The reasoning behind using the Likert-style scales as interval data is that it allows the researcher to perform parametric tests; these tests yield more interpretable results. To assess the normality of the data used in this study, the histograms produced by the individual variables were overlayed with a normality curve and the fit of the variable within the curve was examined; all variables examined appeared near-normal. In addition, for the variables of interest, both the parametric and non-parametric tests were run to see if differing results were produced. These tests included: t-tests/Mann-Whitney U, ANOVA/Kruskal-Wallace, and Pearson/Spearman’s Rho correlations. For all parametric and non-parametric tests, p<.05 was considered to be significant. Both non-parametric and parametric tests were run as a type of sensitivity analysis; Likert-style scales, although accepted for use with parametric tests, are not truly continuous data and therefore it seemed prudent to do both types of testing to see if similar results were obtained. Similar results for all tests were obtained, therefore only the parametric results are reported. 32 Scheffe’s test was used as a post-hoc analysis for the AN OVA tests. Scheffe was chosen because it is a robust test and is able to handle unequal sample sizes (Glass, G.V. & Hopkins, K.D., 1996). Cronbach’s alpha was used to determine the composite reliability of the sub-scales. For the variables, job satisfaction, intentions to remain in nursing, intentions to remain in the hospital and trust (survey), the composite reliabil­ ity was to examined to ensure that the items in the sub-scale could be combined into a single item while still accurately reflecting the responses of the participants. The resulting composite item was then averaged so all means being compared and dis­ cussed would be on the same 5 point scale. 33 5.0 RESULTS This study recruited 123 nurses from hospitals throughout northern BC. This was slightly less than our goal of 150 participants from the study region. 5.1 Demographics Figure 2 Pie chart of age categories of nurses in the study.The majority of nurses who took part in this study were women (95.1%). Ages are shown in Figure 2 and the largest group of nurses is between 41 and 50 years old. Age of Particpants 61 and over 3 .28% 2 1 -3 0 1 0 .6 6 % under 210.00% -60 17.21% 31-40 2 6 .2 3 % 62 % Figure 2 Pie chart of age categories of nurses in the study. 34 75.4% of the nurses were married and 63.1% had children. 75.4% of nurses had a diploma while 21.3% had bachelor’s degrees and 3.3% held graduate degrees. The majority worked full time (67.2%) and 80.3% had been with their current organi­ zation more than 6 years with 61.5% having over 10 years with their current hospital. A third had been in their current job over 10 years. Half of the nurses interviewed had been nursing for more than 20 years. Table 1 shows how the data collected in this study is similar to data collected by the Canadian Institute for Health Information for urban British Columbia. The data used to calculate statistics for urban BC came from Statistics Cana­ da, by way of the Canadian Institute for Health Information. It is important to note that urban and rural data from Statistics Canada do not follow the typically understood Table 1 Comparison of Cl HI Data and Study Data Year 2000 Urban BC N =24,381 + Our Study N=122 p-value Average Age (yrs) 44.2 43.1** .279' male 4.1 4.9 female 95.9 95.1 full-time 67.9 67.2 part-time 32.1 32.8*** diploma 71.2 75.4 bachelor’s 26.4 21.3 master’s/doctorate 2.5 3.3 G ender(%) 6866* 8808* Employment Status (%) Education Level (%) Canadian Institute for Health Information, 2000: 82 **, average age of 98 participants (taken from quality of life survey) * * * ; Includes both part time and casual workers +lncludes all RNs (hospital, community, etc) ^ chi square 't test (one sample compared against Urban BC average) .4750* 35 definitions of rural and urban. For Statistics Canada purposes, urban areas are not only the large urban areas like Toronto and Vancouver (referred to as Census Met­ ropolitan Areas) but also areas that have an urban core that range from 10,000 to 99,000 people, plus the adjacent urban and rural and areas. These are known as Census Agglomeration Areas (CA). In addition to the population requirements, 50% or more of the employed labour force living in neighbouring Census Subdivisions (CSD) must commute to work in the urban core or 25% or more of the employed labour force working in neighbouring CSDs commutes to work from the urban core. A CSD is a grouping of enumeration areas and is the smallest standard geographical area for which census data has been reported. In British Columbia, this means that many of the smaller towns that are traditionally considered rural have been amal­ gamated, for census purposes, into a CA and are therefore counted in the urban BC numbers. This is why this study compare itself only to the urban BC statistics. There is not a large enough group of rural data left when CAs are removed to make a com­ parison to the rural data provided by the Canadian Institute for Health Information. In comparing the data for Urban BC and the data collected by this study, we find that there is no significant difference between the two sets of data in terms of age, gender, employment status or education level. 5.2 Job Satisfaction - Central Tendencies As discussed in the methods section, there are four different questions that at­ tempt to understand nurses’ levels of job satisfaction (Table 2). 36 Table 2 Central Tendencies of Job Satisfaction Variables Variable N Minimum Maximum Mean Std. Deviation Satisfaction-overall 122 1 5 3.83 .86 Satisfaction-general 121 1 5 3.71 .89 Satisfaction-remain 121 1 5 3.18 1.19 Satisfaction-work 122 1 5 4.06 .73 Satisfaction 121 1.25 5 3.69 0.69 Satisfaction-overall; Overall, I am satisfied with this job; Satisfaction-general: Generally speaking, I am satisfied with this job; Satisfaction-remain: I frequently think of quitting this job; (reverse scored) Satisfaction-work: I am generally satisfied with the kind of work I do on this job; Satisfaction-average: average of four job satisfaction variables. NB: Bolded variables are those being used in the theoretical model (Figure 1, p 4) When we calculate the composite reliability, through Cronbach’s alpha, of the job satisfaction sub-scale, it is found to have an alpha of .7190. The alpha is high enough that we are able to look at the combined job satisfaction sub-scale rather than the individual items. Job satisfaction has a mean of 3.69 and a standard devia­ tion of .68 with a range of 1.25 to 5. In examining the individual questions, the ques­ tion with the highest mean (4.06, sd=.73) is one that asks about satisfaction with the kind of work that is done in the job (I am generally satisfied with the kind of work I do on this job-satisfaction-work) while question with the lowest mean asks I frequently think of quitting this job (satisfaction-remain) (mean=3.18, sd=1.19). The two remain­ ing questions, dealing with job satisfaction, are both general questions that look at the job as a whole, not just the kind of work done on the job. The question, overall, I 37 am satisfied with this job (satisfaction-overall), had a mean of 3.83, sd=.B6 while the question, generally speaking, I am satisfied with this job (satisfaction-general) had a mean of 3.71, sd=.89. 5.2.1 Job Satisfaction - Contributing Variables- Central Tendencies In addition to the 4 questions that directly measure job satisfaction, there are also a number of variables that contribute to job satisfaction. The central tendencies for these variables are outlined in Table 3. Table 3 Central Tendencies of Variables that Contribute to Job Satisfaction Variable N Minimum Maximum Mean Std. Deviation Safety-feeling 121 1 5 3.09 1.13 Safety-place 121 1 5 2.96 1.09 Safety-average 120 1 5 3.02 .99 Mgmt views 116 1 5 2.38 1.08 Autonomy 113 1 5 4.07 0.95 Decision making 116 1 5 3.80 1.07 Advance 116 1 5 2.85 1.16 Feedback 116 1 5 2.70 1.02 Safety-feeling: I feel safe in my Job Safety-place: This is a safe place to work Safety-av: average of two safety variables Mgmt views: What do you believe are management’s view of nurses? Autonomy: Do you have sufficient autonomy in your work? Decision Making: Do you have sufficient decision-making authority to do your job effectively? Advance: Are there advancement opportunities either within nursing or in the hospital for you? Feedback: Is the feedback you get on how you are doing your job sufficient and beneficial to you? NB: Bolded variables are those being used in the theoretical model (Figure 1, p 4) 38 Composite reliability (as measured by Cronbach’s alpha) for the safety vari­ ables is .7395. This level of reliability indicates that the items from the safety variable sub-scale can be added together and averaged into a single safety variable. Means for the variables that contribute directly to job satisfaction ranged from 2.38 (manage­ ment’s view of nurses) to 4.07 (sufficient autonomy). 5.3 Intentions to Remain in Hospital- Central Tendencies The central tendencies of the intentions to remain in hospital variable are out­ lined in Table 4. Table 4 Central Tendencies of Intentions to Remain at Hospital Variable Variable N Minimum Maximum Mean Std. Deviation Hospital-three years 121 1 5 3.41 1.12 Hospital-prefer outside 121 1 5 3.17 1.19 Hospital-intentions 121 1 5 3.27 1.02 Hospital-average 120 1 5 3.29 0.88 Hospital-three years; If I have my way, I will be working in the hospital 3 years from now; Hospital-prefer outside: I would prefer a job outside the hospital (reverse scored); Hospital-intentions: I intend to remain with the hospital; Hospital-average; average of the three hospital items. NB: Bolded variables are those being used in the theoretical model (Figure 1, p 4) Questions dealing with intentions to remain at the hospital were asked in three different ways. The range of responses for these question was 1 to 5 and the ques­ tions had an average response of 3.29 (sd=.88). The Cronbach’s alpha (composite reliability) for the three items in the “remain at hospital” sub-scale was high enough (alpha= .6918) that they could be averaged and used as a single measure. Although 39 the computed and averaged “remain at hospital” score will be used, it is worthwhile to examine the individual questions to see how responses vary. The first question, If I have my way, I will be working in the hospital 3 years from now (hospital-three years), had the highest mean of the three questions at 3.41 (sd=1.12) followed by I intend to remain with the hospital (hospital-intentions) (mean=3.27, sd=1.02). The question I would prefer a job outside the hospital (hospital-prefer outside) has the lowest mean of the three questions (mean=3.17) but has the highest standard deviation (sd=1.19). 5.4 Ties In the Community - Central Tendencies The central tendencies for the variables dealing with ties to the community are outlined in Table 5. Table 5 Central Tendencies of Ties to the Community Variable Variable N Minimum Maximum Mean Std. Deviation Ties-personal 122 1 5 4.07 1.10 Ties-family 122 1 5 3.41 1.44 Ties-average 122 1 5 3.74 1.13 Ties-personai: I have ties to this community. Ties-family: My family ties me to this community. Ties-average: average of two ties variables. NB: Bolded variables are those being used in the theoretical model (Figure 1, p 4) The ties in community variable has a computed average of 3.74 (sd=1.13) and its composite reliability (as measured by Cronbach’s alpha) is .7281. Of the two items that make up the sub-scale, the item asking I have ties to this community had a mean of 4.07 (sd=1.10) while the item asking My family ties me to this community had a mean of 3.41 (sd=1.44). Both items as well as the averaged sub-scale had ranges of 1 to 5. 40 5.5 Intentions to Remain in Nursing - Centrai Tendencies Central tendencies for the intentions to remain in nursing variable are outlined in Table 6. Table 6 Central Tendencies of Intentions to Remain in Nursing Variable Variable N Minimum Maximum Mean Std. Deviation Nursing-prefer outside 122 1 5 3.88 1.1 Nursing-intentions 121 1 5 4.25 0.93 Nursing-three years 121 1 5 3.98 1.05 Nursing-average 120 1 5 4.04 0.87 •'Jursing-prefer outside: I wouid prefer a job outside of nursing (reverse scored); Nursing-intentions: i intend to remain in nursing; Nursing-three years; If I have my way, I will be nursing 3 years from now; Nursing-average: average of three remain in nursing items. NB: Boided variabies are those being used in the theoretical model (Figure 1, p 4) Questions dealing with the participants intentions to remain in nursing were asked in the same style as the hospital questions and simply substituted “nursing” for “hospital.” The range of responses (Table 6) seen for these questions were 1 to 5, and their average response was 4.04 (s.d.=.87). Again, the composite reli­ ability, measured by Cronbach’s alpha, of “remain at hospital” sub-scale is enough (alpha=.8019) that a single measure can be computed from the three items. The question,! would prefer a job outside of nursing (nursing-prefer outside), (mean=3.88, sd=1.10) had the lowest of the three means while the question regarding staying in nursing for an indefinite period of time (I intend to remain in nursing-nursing-inten- 41 tions) (mean=4.25, sd=.93) scored higher than the question regarding remaining In nursing for the next three years (If I have my way, I will be nursing 3 years from nownurslng-three years) (mean=3.98, sd=1.05). 5.6 Trust - Central Tendencies Central tendencies for trust variables are outlined In Table 7. Table 7 Central Tendencies for Trust Variables Variable N Min Max Mean Std. Deviation Trust-future 121 1 2 1.23 0.42 Trust-task 122 1 5 1.91 1.00 Trust-survey 121 1 3 1.57 0.61 Trust-interview 115 1 4.33 2.34 1.04 Trust-future: I would be willing to let management have complete contre over my future in the hospital and issues that are important to me Trust-task: I would be willing to give management a task or problem that was critical to me, even if I could not monitor their actions. Trust-survey: average of trust-future and trust-task items Trust-interview: inter-rater’s combined rating of trust management variable from structured interview NB: Bolded variables are those being used in the theoretical model (Figure 1, p 4) There are two different types of trust dealt with In this study; the first, through the Likert-style scale survey, deals with vulnerability and the participants willingness to let others have control over things that are Important to them ( I would be willing to let management have complete control over my future In the hospital and issues that are Important to me) and to give others a task to do, unsupervised, and trust It will be completed in an appropriate manner (I would be willing to give management a task or problem that was critical to me, even If I could not monitor their actions). In this study (Table 7), participants have a mean of 1.23 (sd=.42) for the question about 42 allowing management to have control over their future and issues that are important to them and a mean of 1.91 (sd=1.00) for the question regarding giving management an important task to do if the participant could not be there to supervise. While the means of these two questions do not differ greatly, the range of the questions do. For the former question regarding issues and future, none of the participants scored the question above a 2 (disagree) but on the later question regarding trust with a specific task, participants scored the question in the whole range of possible answers (1-5). When the two scores are averaged (Trust-survey), the mean is 1.57 with a standard deviation of .61. The second type of trust, dealt with in the structured interview, was a more general inquiry about trust. The general question from the structured interview re­ garding trust (how much do you trust management-trust-interview) was scored slightly higher, on average, by the participants (mean=2.34, sd=1.0). Nurses who indicated a low level of trust in management, however, had numerous reasons that they did not trust management. These reasons include: being lied to by management (“ [I] have been lied to and threatened, almost every nurse has been lied to”; “say one thing and do another. Never know what they are going to do until they do it. Don’t trust what they say until it actually happens”), a feeling that management was invisible (“I don’t [trust them] because I don’t know who they are. To change the level of trust they should be here and be part of the operation here”), a lack of support from manage­ ment (“I have never trusted management really. They will do what they have to do - [they] see us as worker units. The moment there is any trouble they will not sup­ 43 port you.”), a feeling that management had no understanding of nurses’ jobs (“Don’t know them - difficult to trust someone you don’t know and don’t feel they appreciate at all what you are doing”), and that there was too much changeover in management (“These guys are loose cannons - how do we know who will be here in the future?”). 5.7 Correlations Correlations offer insight into relationships between variables and the strength of those relationships but due to the cross-sectional nature of this study, it is impos­ sible to do more than speculate about possible causes for relationships between variables. For the purposes of this study, small correlations will be those where r<.3, medium correlations will be defined as those where .3 .9843 diploma bachelor’s 25 3.2667 1.1467 25 2.8800-’ 1.2167 degree Education .055 .036* graduate 4 3.5000 1.2323 3 2.3333 1.7321 Level degree 115 2.8580 1.1598 2.3913 1.0781 Total 115 57 2.7602 1.2324 2.6784 1.1144 57 small 78 2.8462 1.0454 2.5171 1.0766 full time 78 30 2.9556 1.3999 Employment 2.0556 1.0544 part time 30 .727 .137 7 2.5714 1.3840 7 2.4286 1.0313 casual Status 115 2.8580 1.1598 2.3913 1.0781 Total 115 less than 3 5 2.5333 1.5019 5 2.4667 1.1926 months 3 months to 1 13 2.8718 1.1348 12 2.2222 1.1576 Time in vear .582 .952 Current 40 3.0917 1.2987 2.4683 1.0971 42 1 to 5 years .9490 20 2.6667 19 2.4386 1.0890 6 to 10 years Position greater than 10 37 2.7477 1.0813 37 2.3243 1.0613 vears 115 2.8580 1.1598 2.3913 1.0781 Total 115 5 1.9333 1.1879 4 2.5833 1.1667 less than 1 year 17 2.7843 1.2187 1 to 5 vears 19 2.4386 1.1442 Time in 21 3.0635 1.1908 2.4921 1.2185 21 6 to 10 vears .271 .917 Current greater than 10 72 2.8796 1.1277 2.3380 1.0320 71 Organization years 115 2.8580 1.1598 2.3913 1.0781 Total 115 2 2.8333 1.6499 1 4.3333 less than 1 vear 5 2.3333 1.6833 2.5714 1.3840 7 1 to 5 years 19 3.0175 1.3765 6 to 10 years 19 2.3860 1.3253 Time in 30 3.1778 1.2495 2.4762 .8722 28 .299 11 to 20 years .405 Nursing greater than 20 .9587 59 2.6893 60 2.3000 1.0428 vears 115 2.8580 1.1598 2.3913 1.0781 Total 115 “bachelor’s degree ” for the “management’s views’’ variable 58 Table 19 Demographic Groupings of Decision-making Authority and Safety Variables Safety on Job (survey) Sufficient Decision-Making Aut hority (interview) Mean N SD Sig Sig N Mean SD Grouping Demographic 2 tail 2 tail 114 3.0307 .9895 female 109 3.7951 1.0905 .501 .837 Gender 6 2.7500 1.0840 .8861 male 6 3.8889 2.9231 13 .8623 11 3.7576 1.1934 21 to 30 years 31 2.7419 1.0398 29 3.6322 1.1421 31 to 40 years 51 3.0980 .9696 50 3.8267 1.0416 41 to 50 vears 21 3.1905 1.0183 21 3.9524 1.1019 .354 51 to 60 vears .865 Age 4 3.5000 1.0801 4 4.0000 .9428 greater than 61 years .9914 120 3.0167 Total 115 3.8000 1.0777 90 2.9889 1.0652 86 3.7597 1.1383 married 14 3.1071 .7641 13 3.7949 .9769 divorced .7583 Marital 5 3.2000 .2981 separated 5 4.1333 .897 .920 9 3.1667 .7500 single 9 3.9259 1.0773 Status 2 2.5000 .7071 2 4.1667 .2357 widowed .9914 120 3.0167 Total 115 3.8000 1.0777 75 2.8667 1.0441 71 3.6948 1.2055 Yes Have .185 3.2667 45 .8501 .032** 3.9697 44 .8159 no Children? 90 2.9222 9884 diploma 86 3.7481 1.1306 26 3.2500 .9513 .9422 bachelor’s 25 3.8800 degree Education 4 3.6250 1.1087 .153 4 4.4167 .4194 .443 graduate Level degree .9914 120 3.0167 Total 115 3.8000 1.0777 60 3.2500 .9589 57 3.9649 1.0402 small 80 3.1125 .9743 78 3.7650 1.0665 full time Employment 33 2.8485 1.0494 30 3.8444 1.2184 part time .312 .832 7 2.7143 .8591 7 4.0000 .4714 casual Status .9914 120 3.0167 Total 115 3.8000 1.0777 5 2.7000 .7583 less than 3 5 3.4667 1.2156 months 13 2.5385 .9005 13 3.6410 1.2207 3 months to 1 Time in year .374 .669 Current 41 3.0488 1.0356 1 to 5 years 40 3.6833 1.1372 20 3.1250 1.0371 20 3.8833 1.2625 6 to 10 years Position 41 3.1220 .9668 37 3.9820 .8350 greater than 10 vears .9914 120 3.0167 Total 115 3.8000 1.0777 .8944 5 2.9000 .2357 less than 1 year 5 4.3333 18 3.0000 .9075 17 3.3529 1.0637 1 to 5 years Time in 23 2.8696 .9320 .9184 21 4.0794 6 to 10 years .846 .134 Current greater than 10 74 3.0743 1.0458 72 3.7870 1.1305 Organization years .9914 120 3.0167 Total 115 3.8000 1.0777 2 3.0000 1.4142 less than 1 year 2 4.3333 .0000 6 2.6667 .9832 5 3.4000 1.4795 1 to 5 years 20 2.9500 .7931 .9990 6 to 10 years 19 3.7544 Time in 31 2.8226 1.0843 11 to 20 years 30 3.4000 1.2236 .479 .084 Nursing greater than 20 61 3.1721 .9953 59 4.0339 .9543 years .9914 120 3.0167 Total 115 3.8000 1.0777 59 Table 20 Demographic Groupings of Feedback Variable Feedback sufficient and beneficial (interview) Demographic Gender Age Marital Status Have Children? Education Level Employment Status Time in Current Position Time in Current Organization Time in Nursing Grouping N Mean SD female male 21 to 30 vears 31 to 40 vears 41 to 50 vears 51 to 60 vears greater than 61 years Total married divorced separated single widowed Total ves no diploma bachelor’s degree graduate degree Total small full time part time casual Total less than 3 months 3 months to 1 vear 1 to 5 vears 6 to 10 years greater than 10 years Total less than 1 vear 1 to 5 vears 6 to 10 vears greater than 10 years Total less than 1 year 1 to 5 vears 6 to 10 years 11 to 20 years greater than 20 years Total 109 6 11 29 50 21 4 115 86 13 5 9 2 115 71 44 86 25 4 115 57 78 30 7 115 5 13 40 20 37 115 5 17 21 72 115 2 5 19 30 59 115 2.7125 2.7222 2.7879 2.1379t 2.9667t 2.6984 3.5833 2.7130 2.7209 2.8205 2.4000 2.5185 3.3333 2.7130 2.7089 2.7197 2.5969G 317336 2.3333 2.7130 2.9006 2.8162 2.4444 2.7143 2.7130 2.3333 2.6667 2.8000 2.7667 2.6577 2.7130 2.6000 2.9216 2.6508 2.6898 2.7130 1.8333 2.4667 2.8772 2.3444 2.8983 2.7130 1.0467 .5741 1.1951 .7742 1.0196 .9304 1.2583 1.0259 1.0589 1.1435 .4346 .7474 1.4142 1.0259 1.0763 .9508 1.0073 .9959 .9813 1.0259 1.0078 1.0509 .9442 1.0079 1.0259 .9718 1.2693 1.0750 .9119 .9828 1.0259 1.3208 .9897 .9915 1.0396 1.0259 1.1785 .9603 1.1874 .8598 1.0138 1.0259 Sig 2 tail .982 .003** .802 .957 .034* .243 .888 .835 .087 and “41-50” for the “feedback” variable § Scheffe’s post-hoc test shows a significant difference (p=.045) between the means “diploma” and “bachelor’s degree” for the “feedback” variable. 60 5.9 Types of Trust Table 21 shows the results of a paired t-test for the trust means for manage­ ment. Table 21 Paired T-tests of Trust-interview vs trust-Survey for Management Variable Mean N SD trust management-interview 2.33 114 1.04 trust management-survey 1.58 114 0.62 Sig. (2tailed) .000** As mentioned in the methods section, this study deals with two different types of trust. The type of trust measured by the survey is a willingness to be vulnerable to the actions of others while the type of trust measured by the interview was interpreted in a number of different ways, by the participants, which were discussed in the meth­ ods section. The paired t-test shows a significant difference (p<.001) between the mean amount of trust indicated by the survey and the mean amount of trust indicated in the structured interview. 61 6.0 DISCUSSION 6.1 Trust and Job Satisfaction In examining Table 2, the mean of 3.69 (sd=.68) indicates that the majority of the nurses surveyed are moderately to very satisfied with their jobs, however further examination of the items within the job satisfaction sub-scale shows that the highest levels of job satisfaction are shown when nurses are asked about their satisfaction with the kind of work they do on their job rather than more general satisfaction ques­ tions. This result is mirrored in the structured interview; several nurses commented that they really liked their work and enjoyed dealing with the patients, but found other parts of the job such as “office politics” to be extremely frustrating. Trust variables for this study were near the bottom end of the scale, indicating that the majority of nurses who participated in this study did not trust management. In the trust question from the survey that dealt with a willingness to be vulnerable to the actions of management, 98% of the participants were unwilling to let themselves be vulnerable to management’s actions. In the trust question from the structured in­ terview, interpreted individually by participants, more than 50% of the participants did not trust management. The correlations between job satisfaction and the trust variables were found to be significant (p<.01). The correlation for trust (interview) and job satisfaction (r=.378) was slightly higher than the correlation for trust (survey) and job satisfaction (r=.259). Other studies on the trust-job satisfaction relationship show varying levels of correla­ tion. Armstrong-Stassen, Cameron, Mantler,Horsburgh (2001) found, in their paper 62 examining the effects of hospital amalgamations, that trust was strongly related to job satisfaction (r=.47, p=.001) while Moss and Rowles (1997) show a difference in job satisfaction levels, depending of the characteristics of management styles. ShockleyZalabak, Ellis, Wi nog rad (2000) also looked at trust as a whole (but from a business viewpoint) and found that trust explains 60.8% of the variance in job satisfaction. Driscoll (1978) (also business oriented) found a correlation of .52 (p=.001) between organizational trust and overall satisfaction. It appears that, overall, correlation num­ bers from the business literature are higher than those from the nursing literature. An interesting picture begins to form when we examine the correlations in the form of scatter plots. The scatter plots of the correlation between trust (survey) and job satisfaction and between trust (interview) and job satisfaction show relatively typical positive correlation configurations in their top quadrants as well as the lower left quadrant. Where the interest in these scatter plots lie is in the lower, right quad­ rant. Both scatter plots indicate that there are a number of nurses who have relatively high levels of job satisfaction but low trust in management. Much of the literature has shown that trust has a high, positive correlation with satisfaction yet the results of this study show a group of nurses with low trust but high job satisfaction. A partial explanation may be found when the sources of job satisfaction are considered. Job satisfaction can come from a number of areas: autonomy, feedback, safety, advance­ ment opportunities, etc. Bedside nurses tend to have a great deal of autonomy in dealing with their patients and helping patients get well, achieve stability in their health or even die a good death. These are all areas where nurses derive a lot of 63 their job satisfaction without any involvement from management at all. If we contrast this with other working environments (eg a bank or a corporate office), much of the job satisfaction in those environments would likely be derived from interactions with the employee’s management and supervisor (in the form of feedback, promotions, recognition, etc.) (McShane, 2001). In addition to the single satisfaction variable, this study also examined compo­ nents of job satisfaction that were identified by the literature. Of these components, all but opportunities for advancement showed a significant correlation with satisfac­ tion, indicating that they do, indeed, have a relation to satisfaction. The components of satisfaction, when correlated with trust, did not all have significant relationships. Of the six components detailed in the theoretical model and literature review (autonomy, decision making authority, safety, management’s views, opportunities for advance­ ment, and feedback) only feedback, safety and management’s views correlated significantly with trust. This may indicate some possible areas that management can focus on when examining their trust relationships with nurses. 6.2 Trust and Intentions to Remain at Hospital and Remain in Nursing For the purposes of this study, intentions to remain was divided into three dif­ ferent variables, two of which have been examined in this paper. Intentions to remain in the hospital had a mean of 3.29 (sd=.88) while the intentions to remain in nurs­ ing variable had a mean of 4.04 (sd=.87). This difference between the two means shows that while nurses are fairly evenly split as to whether or not they wish to remain at the hospital they are currently at, the majority of them wish to remain in nursing. 64 This result Is in keeping with comments from the structured interviews where nurses had complaints and problems at their hospitals but the majority of them, when asked about nursing as a whole, said there wasn’t anything else they could imagine them­ selves doing or that it was always what they wanted to do with their lives. The trust variables used are the same as those already discussed in section 6.1.1 but when correlated with the intentions to remain variables offer some interesting results via scatter plots. The scatter plots for the intentions to remain in hospital vs trust (inter­ view or survey) are not overly revealing. The scatter plots lack any clear arrangement of points and this is reflected in the lack of significant correlation between remaining at the hospital and trust in management (survey) and the small but significant correla­ tion between remaining in the hospital and trust in management (interview). Inten­ tions to remain in nursing vs trust in management (survey) yields a similarly small relationship while the remain in nursing vs trust in management (interview) correlation yields no significant relationship. What is different about the intentions to remain in nursing vs trust in management scatter plots is the arrangement of the points. The scatter plots for the intentions to remain in nursing variable resemble those for job satisfaction, that is while there is an indication of positive correlation on the top two and bottom left quadrants, points in the bottom right quadrant decrease the overall correlation value. Again this study has found nurses who have low trust in manage­ ment but have high levels of intentions to remain in nursing. Armstrong-Stassen, Cameron, Mantler, Horsburgh (2001) found that trust was strongly related to turnover intentions (r= -.45, p=.001) yet the numbers seen in this study are not that close to 65 those seen in the literature. Clues to this apparent dichotomy may come from the nurses themselves, particularly through the structured interview. Nurses in the struc­ tured interviews continually indicated how much they enjoyed nursing and caring for patients and their families. The current job market for nursing in Canada allows nurses a great deal of freedom as to where they wish to nurse. Nurses may feel that trust in management is not a significant concern when they consider whether or not they want to continue nursing. Given the breadth of nursing opportunities outside the hospital, nurses who have low trust in management but high intentions to remain in nursing may stay at the hospital for a variety of personal reasons such as cama­ raderie with other nurses or dedication to patients. In addition, nurses in towns with only one hospital may have few work options if their families choose to stay in a town. These nurses show loyalty to nursing as a profession, but may not have a commit­ ment towards the organization they are employed with. 6.3 Job Satisfaction and Intentions to Remain in Hospitai The results from Pearson correlation shows a correlation between job satisfac­ tion and intentions to remain in hospital (r=.465). The intentions to remain at hospital vs job satisfaction scatter plot (Appendix H) shows a more traditional, positive cor­ relation shape and this is evidenced by its higher correlation coefficient. Of interest in this plot are the points that show reasonably high levels of job satisfaction but low intentions to remain at the hospital. It is in this area that tools like the structured in­ terview become important because they help to tell the story behind the results. Why are satisfied nurses wanting to leave the hospital; possible reasons could include 66 familial commitments or a separation between their job (caring for people) and the en­ vironment they do their job in (the hospital). Consequently, a person could be happy with his or her profession, but unhappy with their environment and wish to do their job elsewhere. This, in fact, is an idea that was reflected in many of our structured interviews. The correlation between intentions to remain in nursing and intentions to remain in the hospital was .473. When the means for these two variables are exam­ ined, we find that the intentions to remain in nursing variable (mean=4.04, sd=.87) is significantly different (p=.000) than the intentions to remain at the hospital variable (mean=3.29, sd=.88). This difference demonstrates the same idea that we see in the job satisfaction/intentions to remain in nursing relationship and this is the idea that nurses want to nurse but where they do it is less important to them than getting to do it. The correlations found in this study are lower than those found in other nursing studies dealing with job satisfaction and intentions to remain. Armstrong-Stassen, Cameron, Mantler, Horsburgh (2001: 156) show a correlation o f -.59 between job sat­ isfaction and turnover intentions (note that this is intentions to leave, not remain hence the negative correlation). Cox (2001) shows a similar trust-turnover intention with a correlation o f -.57. Hogan & Martell (1987) examined the relationship between satis­ faction and intent to stay and found the correlation to be .56. The possible reasons for the difference between the correlation numbers here and those found in other studies are numerous and could range from a difference between asking the ques­ tions using “intentions to leave” and asking the questions using “intentions to remain” (earlier portions of the study have shown how reverse scored variables can differ 67 from normally scored variables trying to achieve the same answer). Another possible reason for the difference could be the difference in the sample. The differences may even go beyond the study design and sample and reflect differences in economics of the area in which the study was published as well as the structuring of the health care system in those regions. In addition to the main satisfaction variable, the components of job satisfac­ tion (autonomy, decision making authority, safety, management’s views, opportunities for advancement, and feedback) were also correlated with the intentions to remain in hospital variable. Of these, only safety and feedback had significant correlations. These correlations for the satisfaction components are smaller than the correlation between the overall satisfaction measure and intentions to remain in hospital (r=.245; .282 vs .465 respectively). This indicates that while safety and feedback are impor­ tant considerations in the satisfaction picture, with respect to retaining nurses, there may be other components of satisfaction that were not identified by this study. 6.4 Job Satisfaction and Intentions to Remain in Nursing Pearson correlation showed a correlation between job satisfaction and inten­ tions to remain in nursing (r=.3B9). The scatter plot for the intentions to remain in nursing vs job satisfaction shows points that are clustered around the centre with the majority of the points in the upper right corner, indicating higher levels of both inten­ tions to remain and job satisfaction and the single outlier with low job satisfaction and intentions to remain may actually be skewing the correlation slightly to the positive end of the scale. 68 In addition to the main satisfaction variable, the components of job satisfac­ tion (autonomy, decision making authority, safety, management’s views, opportunities for advancement, and feedback) were also correlated with the intentions to remain in nursing variable. Of these, safety, opportunities for advancement, and feedback correlated significantly. Of these variables, the advancement variable is of particular interest as it does not correlate significantly with the larger satisfaction variable but does have a relationship with the intentions to remain in nursing variable. There was no research, in the nursing literature, that could be found that dealt with the relation­ ship between job satisfaction and remaining in nursing but other areas such as edu­ cation dealt with the satisfaction/remain in profession relationship. The relationship found in this study was lower than what was seen in the education literature. 6.5 Education Level The level at which bedside nurses should be educated has long been a topic of discussion. In the last 10 years, the province of British Columbia decided to phase out the diploma nurse program and required that all nurses being trained graduate with a bachelor of science in nursing. This lengthened the nursing program training time from 2.5 years to 4 years. Diploma nurses already working in hospitals were encouraged but not required to get their bachelor’s degrees. The question that has not yet been answered is “was this a worthwhile move?’’ Are the nurses who have achieved additional degrees beyond the diploma level significantly different that those who hold a diploma? This study found that nurses with graduate degrees were more likely to trust management (interview) than nurses with diplomas while nurses with 69 bachelor’s degrees were more likely to believe management viewed them positively than diploma nurses. There are many reasons these differences could exist. These reasons include; nurses who have completed higher levels of education are exposed to more of the management practices that are taught at the bachelor’s level and grad­ uate level but only skimmed at the diploma level (this increased exposure means that these nurses may be more likely to have an understanding of where management is coming from and they may have more tools to be able to see the bigger picture of where management is going with its policy changes); nurses with degrees may have better ability to self-advocate and through this, have more self-confidence and self esteem; or perhaps diploma nurses believe they simply are not treated as well, by management, as degree nurses. Another variable grouped by education that is important is the intentions to remain variable, but unlike trust, it is important for its lack of significant differences among the categories. This finding is contrary to those of Friss (1982), Schaefer, (1989), Diaz (1989) Fisher, Hinson, & Deets (1994), and Shay & Stallings (1993) who all noted a correlation between turnover and education levels. This does not negate the importance of continuing education but it may indicate that nurses want continu­ ing education to keep their skills sharp and to learn new techniques; the acquisition of a degree beyond the diploma level may not matter to them provided they have educa­ tional opportunities given to them. 70 6.6 Ties In The Community/intentions To Remain at Hospital When the variable ties in the community is examined, five of the ten demo­ graphic groupings show significant differences among their groupings. Marital status, children, time in current position, current organization and nursing all show significant differences among their means. While, at first glance, this may not seem particularly meaningful, the importance becomes clear when the ramifications are considered. The correlation between ties in the community and intentions to remain at the hos­ pital is .455 and individuals with children, individuals who are married, divorced or separated and individuals who have spent more than one year in their current hospi­ tal or position show higher levels of ties to the community than their childless, single or “new in town” counterparts. This may indicate that hospitals need to rethink their recruitment and retention strategies. The results of this study indicate that the longer people are in an area, the more ties they have to the community, especially if they are married, separated or divorced and/or have children. Since ties to the community are related to intentions to remain at the hospital this could suggest that instead of focussing solely on bringing nurses to the hospital, hospitals need to focus on recruit­ ing families to their towns. Families who are able to develop ties are likely to have higher retention intentions than those who are unable to form ties in the community. Fisher, Hinson, & Deets (1994) discuss the idea of kinship responsibilities and these responsibilities can often play a large role in a nurse remaining at the hospital. In a resource dependent area like northern BC, people are often transient as they move to follow employment opportunities. In resource industry down times, nurses may 71 be the sole breadwinners for their families but feel that if the opportunity comes for their spouse to be employed elsewhere that they have to move their families because in the current market there is a belief that nursing jobs are “easy” to acquire. At this point, retention of nurses no longer becomes the sole responsibility of the hospital; it becomes a consideration for the entire town. Hospitals and other industries as well as the cities or towns themselves need to look at developing retention strategies that are able to attract whole families. These strategies could include: adequate course offerings at the high school level, adequate recreational activities, etc. 6.7 Does Type of Trust Matter? In their work on trust, Rousseau, Sitkin, Burt, and Camerer (1998) found that there were different types of trust that could exist and the type of trust was dependent on the task being performed and the setting. These types of trust include: deterrence based trust, calculus-based trust, relational trust and institution-based trust. Deter­ rence based trust is the belief that the sanctions for breaching trust are costly and exceed any potential benefits that could be gained from the opportunistic behaviour leading to breach of trust. Calculus-based trust is based on rational choice. The trustor observes the actions of the trustee. If the trustor perceives the trustee as performing beneficial actions and has credible information regarding the intentions or competence of the trustee then the trustor will place their trust in the trustee for that particular area. Relational trust develops through repeated interactions over time between the trustor and the trustee and is a more emotion laden type of trust. Infor­ mation available to the trustor from within the relationship itself forms the basis for re- 72 lational trust. Reliability and dependability in previous interactions leads to increased positive expectations about trust. Institution-based trust is the most nebulous of the trust types and is often seen as a bridge to developing relational and calculus-based trust. An institution’s organization and practices (eg standard human resource prac­ tices or emphasis on teamwork among employees) help to form supports for other types of trust to develop. As discussed in the literature review, the four types of trust are not mutually exclusive; trust has a bandwidth and may exist in different forms for the same people depending on the task and setting. Trust in management, as we have seen, had low means for both trust-survey and trust-interview but types of trust can be factored in here as well. One of the biggest complaints against management that arose in the structured interview was that management was “invisible.” Nurses felt that they didn’t know what management was doing for them and often didn’t feel they had enough information to know if they could trust management. According to Rousseau et al.’s (1998) trust types, it can be hypothesized that nurses at smaller hospitals likely have some relational trust with management which contributes to slightly higher trust means while nurses at larger hospitals have calculus-based trust in management and are not getting the input they need from management to make the choice to trust them. This idea did not necessarily hold true for this study, how­ ever. When examining the transcripts of structured interviews it was found that nurs­ es from all hospitals had complaints about the “visibility” of management and, in fact, nurses at smaller hospitals had more concerns about management’s visibility than those at larger hospitals. The reason for this can not be known for certain, but given 73 the climate at the time of these interviews, it can be hypothesized that nurses in the outlying regions of the Northern Health Authority had concerns that having manage­ ment centralized in one location would be detrimental for hospitals outside of central location as management would not have a clear picture of what was happening in those hospitals, nor would they be making frequent enough visits to achieve a clear picture. The facets of trust discussed by Sirdeshmukh, Singh, Sabol (2002) and oth­ ers might be a consideration when looking at the difference between the mean level of trust from the survey and the mean level of from the interview. Facets of trust can also be interpreted as how individuals define the word trust; an individual who inter­ prets trust to mean benevolence will likely answer a question differently than an indi­ vidual who uses one of the other facets to interpret trust when answering the question (e.g. reliability, competence, fairness, and honesty and openness). Individuals gener­ ally pick a facet to define trust that best reflects their own personal value set. This must be a consideration in examining trust. Either researchers must ask questions that more specifically delve into a facet of trust (e.g. questions specifically around the competence or fairness or the supervisor) or there must be an understanding that trust may not be interpreted in the same way by all respondents and thus, this may affect the results. 74 Understanding the different types of trust and how they may be reflected in the outcomes of specific variables is an important consideration for those conducting studies dealing with trust. There needs to be a decision about what type of trust is of interest to the study and what the best way is to accurately measure that trust through a survey instrument or structured interview. 6.8 Strengths of the Study 6.8.1 Structured Interviews Dixon et al. (2002), Foster & Godkin (1998), and Pulakos et al. (1996) have all found that structured interviews provide more reliable information than their non­ structured counterparts (reliability of .55-.90). Structured interviews also offer a consistency that unstructured interviews may not provide. Unstructured interviews have no formal scoring guides, making the results hard to measure and compare. Structured interviews, however, are formalized (the same questions are asked in the same order to each interviewee) and they allow for measurement and comparison as long as scoring anchors or benchmarks are provided. Dixon et al. (2002) also note that multiple raters have increased reliability over a single rater but only if the multiple raters do their rating separately. If raters rate together, there is a tendency for group think to dominate which can take away from the actual worthiness of the instrument. This study was able to gather the wealth of information that can be obtained from an interview while maintaining the structured set up that allowed for rating and compari­ 75 son of the responses given. In addition, the separate rating, by three independent raters, ensured that each participant was carefully evaluated without “group think” tak­ ing away from the validity of both the rating and the instrument. 6.8.2 Sample size and similarity to Urban BC Another strength of this study was that even though we were unable to do a random sample of our population of interest, our sample’s demographics were not significantly different from those published by CIHI regarding the urban BC nursing population. This lack of significant difference between our sample and urban 8 0 nurses indicates that the results can not only be applied to our sample, but they are likely generalizable to the hospital nursing population of British Columbia. 6.8.3 Mixed Method The mixed method of this study (using both qualitative and quantitative) is one of its strengths. By using quantitative measures, we have the ability to perform sta­ tistical analysis on the data while the qualitative measures allow for a more complete picture and add depth to the quantitative findings as well as further confirming the quantitative findings. 6.8.4 Concepts defined by participants (strength of study section) In the structured interview portion of this study, participants were asked ques­ tions about concepts such as autonomy and trust but no definition was provided for these concepts. Allowing the nurses to self-define the meanings for these concepts is a strength of this study because it means that the researchers are not narrowing down the concepts to fit their own definitions and research agendas. This idea be- 76 cornes clear when we consider the idea of trust. As mentioned in this paper, nurses self-defined trust in the way that best illustrated the idea of trust for him or her. Some nurses indicated trust to mean reliability while others indicated that trust mean con­ fidentiality or competence to them. If the concept of trust had been pinpointed to one of these concepts rather than letting nurses self define, the results may not have indicated the true picture of nurses’ trust levels. 6.9 Limitations of the Study 6.9.1 Non-random seiection As with any study, this one had certain limitations. The first was that the se­ lection of the participants was not random; instead, the participants “opted in” to the study. There are two problems with “self-selecting” samples: 1) the specific popula­ tion that had a chance of participation is unknown and thus cannot be expected to describe the population as a whole and, 2) they only include respondents who chose to participate (Zorn, E., 2003). The first problem with self-selecting samples is not that great a concern here. Since one of the requirements for participation was having worked 450 hours in the last six months, all potential participants should have been at the hospital enough to see or hear about the study through the recruitment post­ ers or through colleagues that had seen the posters and/or participated in the study. An area of concern is the two hospitals we had no response from. In those cases, it is not clear whether the information was not disseminated or if it was simply that no one at those institutions chose to participate. The second problem with self-selecting samples, however, may be of concern in this study. While a certain amount of “snow­ 77 balling” (where participants were asked if they knew anyone who had not participated in the study and were asked to encourage people in their workplace to contact the study) took place, the majority of the participants in the study were self-selected. Self-selecting samples are a source of concern in studies because of the possibility of bias towards a certain type of participant (e.g. disgruntled and wanting to complain or happy and wanting to praise). As mentioned in the above, strengths of the study, section the study population was not significantly different in make up from the urban BC nursing population as a whole. This helps to alleviate worries that this self-select­ ed sample might not offer a truly representative sample of northern BC nurses. 6.9.2 Participation gift The participation gift itself could be considered to be a limitation to this study. There is a belief that gifts beyond a certain amount could coerce participants into par­ ticipating in a study they would not normally have chosen to participate in. Given the similarity between the study group and the urban BC nursing population, it does not seem that the size of the gift adversely affected the group of individuals who self-se­ lected to be part of the study. 6.9.3 Rating of structured interview The rating of the structured interview is a possible limitation of the study. The structured interview used in this study was open (the same questions were asked to each participant but no choice of answers was given). The answers were then sub­ ject to content analysis and the rating scheme was derived from this. Having the one of the researchers define the ratings from the questions rather than giving the pos­ 78 sible choices for answers when the question was asked means that a source of bias may have been introduced. Instead of having an answer directly from the participant, the researcher had to infer the rating on the question by looking at the overall answer to the question. An attempt to ensure that the correct rating was chosen by having three raters read the participant’s response and choose the appropriate rating but the choices of the raters may not reflect the choice the participant would have made, especially where there was disagreement among the raters. Contrary to this idea, however, Culp, K. & Pilat, M (1998) feel that asking the same, open-ended ques­ tions to all the participants, especially in areas where likely responses haven’t been determined by other research, prevents limiting the respondents to a set of answers that were predetermined by the researchers. In this way, researchers would prevent introducing their own bias through the questions they asked and chose not to ask. 6.9.4 Cross-sectional nature of study Another limitation of this study was its cross sectional nature. Due to time and budget constraints it was not possible to do multiple repetitions of this study, spread out over a longer period of time. This means that the data collected, while important, can not offer an indication of causality. Those examining the data can make educat­ ed guesses as to the reasons for the correlations and relationships between variables but they will only be guesses. 79 6.9.5 Paring down of survey questions The paring down of survey questions was also a limitation of this study. Due to efforts to have the survey be answerable within the one hour allotted for it, ques­ tions that seemed repetitive or not as relevant to the overall study were removed. Care was taken to try to ensure that the ability of the instrument to measure its vari­ able of interest was not affected. In the case of the questions this paper examined, the job satisfaction instrument was shortened by two questions that dealt with how “most people felt” about their jobs, the trust instrument condensed two questions into one and removed a third question while the intentions to remain instrument removed a question that could not be answered using the methods chosen for the survey and altered the wording of the questions to make them specific to the nursing nature of the study. Though the reliability for these instruments remained high, even with the questions altered, the removal of the questions may have altered the results. These alterations may not be significant or even noticeable, but there is no way of knowing this without administering the survey both with and without the deleted questions. 6.9.6 Nursing vs Business The majority of the concepts in this thesis are taken from business literature and then applied to nursing. Given potential differences in the scope of employment and hierarchy within these organizations, information about job satisfaction, trust and intentions to remain, as well as the relationships between those concepts, taken from the business literature may not be generalizable to the nursing profession. It is important to note, however that the few nursing documents focussing on the relation­ 80 ships studied in this thesis showed different results. However, some of the concepts explored in this study, while explored by the business literature, have not yet be explored to any depth in the nursing literature. This gap in the nursing literature is a limitation because some of the results from this study can not be compared with other nursing studies. It is possible that nurses may not have conceptualized the variables of interest in the same way employees in a “business” environment. Until studies are done using these concepts to model nursing relationships, it will not be clear how generalizable the business literature is for nursing environments. 6.9.7 Concepts defined by the participants As mentioned in the above section, allowing participants to self-define con­ cepts asked in the structured interview is a strength of the study but it is also a limita­ tion. Since the nurses self-defined concepts such as autonomy, trust and manage­ ment’s views, the quantitative means for these variable can only indicate the degree of presence or absence of a problem; the means do not tell management how the nurses defined the concepts or what management can do to improve the situation. To make the means for these self-defined concepts more useful to hospitals that are focussing on job satisfaction and retention issues, the content from the qualitative portion of this study needs to be explored in more depth. By exploring the answers the nurses gave to the questions in the structured interviews, management can be made aware of where, exactly, nurses feel that the problem lies in addition to knowing that there is a problem. In-depth analysis of the structured interviews was beyond the scope of this thesis but has been addressed in areas of future research. 81 6.9.8 Cooperation with nursing council A final limitation of the study was the decision to abide by one nursing council’s request to give half of the money allotted for participant gifts to the council who would then, in turn, give the nurses who participated an hour of paid time off. While this seemed like an excellent and workable idea when presented, not all of the ramifica­ tions were clear at the time. Although participants were promised anonymity and it was made clear in both the informed consent form and verbally at the interview that their answers would never be revealed or shared with anyone but the researchers, there were some potential participants who were not comfortable with the hospital knowing that they had participated. One individual in particular contacted the re­ searchers for the express purpose of informing us that she would not be participating due to the involvement of the hospital in the study. If one potential participant felt this way, and felt strongly enough to inform the researchers of her decision not to partici­ pate, it seems plausible that there were other potential participants who did not phone to tell us of their unhappiness with the hospital’s involvement, but chose not to par­ ticipate because of it. In addition, many of the participants receiving the hour of paid time off expressed a great deal of skepticism that they would actually be able to take the hour off at any point. In future studies, it might be better to keep the hospital out of the research as much as possible, even if this means that the study does not have the same degree of support and assistance from management. 82 6.10 Areas of Future Research One area of future research would be to perform a longitudinal study. In a perfect project, the same survey and interview could be given to participants two years after their initial interview and possibly at a third point. These additional inter­ views, with the same participants, would allow researchers to track changes in spe­ cific answers as well as general trends. What would be of particular interest is that at the time of the initial study, the province of British Columbia was restructuring their health authorities. This created a great deal of unrest and uncertainty for health care workers. A study at two years and five years after the initial study and, coincidentally, two and five years after restructuring would give an opportunity to examine, at least anecdotally, how participants feel about the changes and if any of the fears that were expressed during structured interviews have come to pass. Another area of future research would be to inflate certain areas of the study and examine them in more depth. As it stands, the survey done here was a broad look at many areas and while this offers ideas as to where hospitals and nurses need to work on their relationships, it doesn’t offer the specific details that tell them “what is broken”. As we have seen, there are many factors that relate and contribute to trust, job satisfaction and intentions to remain; understanding what, in particular, has been done to decrease those numbers or is being done to improve upon them will help nurses and hospital administration target policies and programs more accurately. Possibilities for studies include: surveys that target fewer areas in more depth to try to find the root of a particular issue or focus groups that take an abstract result (i.e. trust 83 in management Is low) and try to discover the reasons behind that result (i.e. why don’t you trust management, why is your trust in management so low). It is only in understanding “why” that hospital administration and nurses will truly be able to cre­ ate effective solutions that please both parties. For the purposes of this thesis, the qualitative items were converted to a quan­ titative scale and utilised. A future area of research is to analyse the qualitative por­ tion of this study in a more thorough manner. To make the qualitative portions of this study of more use to future research, they must be transcribed and content analysis and interpretation must be done. The qualitative answers the structured interview questions will help define the concepts in this study (such as trust, autonomy, etc.) that were left to the participants to self-define. The qualitative portion of the study also helps provide information as to what exactly the problems are that were identi­ fied by the quantitative portion of the study. For example, the job satisfaction scale only gives a measure of satisfaction (or dissatisfaction). For this information to be truly useful to hospital and nurses, there needs to be an understanding of what, spe­ cifically, makes nurses satisfied or dissatisfied. These are the pieces that a thorough content analysis of the structured interview should be able to provide. A final area of future research is to examine the type of motivation that drives nurses in their jobs. Motivation has often been linked to job outcome; the idea that people are rewarded (through money, prestige, etc.) to do a job well. There is, how­ ever, debate that this long held idea may not be true for all people and situations. There is a belief that some people are intrinsically motivated (ie have a desire to per- 84 form a task for its own sake) and that rewarding these people may actually be coun­ ter-productive (Benabou, R. & Tirole, J., 2003). It has been expressed by nurses in this study that they nurse because they love nursing; they are motivated to perform their job because they enjoy the job itself (something that is reflected in the remain in nursing numbers). If nurses are indeed intrinsically motivated, as it appears they are, this presents new challenges for management. The first step in the research would be to determine if, in fact, nurses are intrinsically motivated. If this is the case, then the next step would possibly be to form focus groups to discover what the hospital management can do to augment motivation. These augmentations could take the form of increased autonomy, increasing staff so nurses have more time to spend with individual patients or simply providing the tools for the nurses to do their job to a level that satisfies them. 6.11 Conclusion Problems with job satisfaction and retention do not occur overnight; they take time to develop and they will take time to rectify. This study shows that while trust in management is related to job satisfaction and retention, it is not as highly correlated as is seen in other areas such as business and education. 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C a n a d ia n P sychology, 34, 390-399. 97 APPENDIX A - Calculation of Northern BC Population Estimate Population 25122 19980 24426 15302 85035 10285 16034 17444 2623 2576 5414 1456 1729 4956 21693 711 4188 City or Area Williams Lake (CA) Terrace (CA) Quesnel (CA) Prince Rupert (CA) Prince George (CA) Kitimat (CA) Fort St John (CA) Dawson Creek (CA) Burns Lake (UA) Chetwynd (UA) Smithers(UA) Vanderhoof (UA) 100 Mile House (UA) Mackenzie (UA) Skeena-Queen Charlotte Regional District (CD) McBride (VL) Fort Nelson (UA) 258974 'Statistics Canada, 2001) Legend CA=census agglomeration UA=urban areas CD=census division VL=village Northern BC Population (rough estimate) Bulkley Nechako Regional District Cariboo Regional District Fraser Fort George Regional District Kitimat Stikine Regional District Peace River Regional District Skeena Queen Charlotte Regional Total 40,856 65,659 95,317 40,876 55,080 21,693 319,481 Urban 16,013 28,453 71,195 27,028 31,200 14,643 188,532 For ease of calculation and a more accurate reflection of possible sample population available to this study, only the areas that had hospitals were used to cal­ culate the population estimate. In addition, this estimate does not include areas not examined by this study such as the Bella Coola region. 98 APPENDIX B - Recruitment Poster Nurses Wanted UNBCStudy on Motivation and Trust Funded by: The British Columbia Rural and Remote Health Institute Full time, part time or casual registered general duty nurses, clinical instructors and head nurses who have worked 450 hours or more in the hospital in the past 6 months are needed for a research study entitled: M otivators an d T ru st as E xp lan atory F actors in N o rth ern H osp ita l N u r se s’ In ten tio n s to R em a in an d O bligation A ttitu d es Participants w ill be compensated for their time. For additional information or to express an interest in participating please contact: Rick Tallman Assistant Professor Business Prograrn, UNBC Tel: (250)^60-^404 E-mail: nursestudy@unbc.ca 99 APPENDIX C - Introduction Letter and Informed Consent Form Faculty of Business - Research Project Information “Motivators and Trust as Explanatory Factors in Northern Hospital Nurses’ Intentions to Remain and Obligation Attitudes” Thank you for volunteering to assist us in our researeh project. Heather Smith, a UNBC graduate student, and I are conducting this project. As the title suggests, the purpose of this researeh project is to gather data that will allow us to examine and understand factors in the workplace that explain hospital nurses work attitudes. I have an interest in the questions involved because I believe nurses are critical to our healthcare system. I also believe that the vast majority of people want to work in a job that provides them with a sense of satisfaction and self-worth. It is management’s responsibility to provide the conditions that allow this to occur. This study will help us understand the conditions that exist in northern regional hospitals. There are two parts to the data collection in this project. One part involves a survey questionnaire and the other a one hour structured interview. The two sets of questions being used are attached to this letter. The first set, entitled “Survey Questionnaires” involves background information and sets of questions on a variety of work attitudes. This set is to be completed bv vou and returned to us at the time of vour interview. This will take about one hour. The second set, entitled “Structured Interview Questions”, involves questions that provide information on workplace factors and trust. You do not have to attempt to answer these questions at this time. These are the questions we will be asking in the interview with you. We are providing them so that you know what questions will be asked and you have a chance to think about them. Your answers to the questions on the survey and in the interview are confidential. Only Ms. Smith and I will have access to them. We will be tape-recording your interview. This will allow us maintain the flow of the interview without having to take notes. When we meet for the interview, we will assign you a case number. This number will be used on the survey questionnaires, on the tape-recording and in the interview. I will keep a separate list of participant names, case numbers and contact information in the event we need to ask a clarifying question during data analysis. Within six months of our data collection, this list will be destroyed. The tape-recording and survey questionnaires will be destroyed after two years. There are no risks to you or other participants. Your participation is completely voluntary and you can choose to not continue at any time. If you have any questions, you are welcome to call me at or through e-mail at . If you should have any complaints about this study, they should be directed to the Office of Researeh, UNBC, i , Results of this study should be available about six months after collection of the data. If you want a copy of the study results, you can request them via telephone or e-mail. It is important that you answer each question to the best of your ability even if you think the answer to the question is obvious or you are not sure you understand the question. Even one incomplete answer means that we cannot use some portion of your data. There are no right or wrong answers. Different answers only indicate that people are different and have different beliefs. You will be compensated for your time through a $25 gift certificate and one hour of paid time off from your job. Please keep this letter for future reference. Rick Tallman Assistant Professor Faculty of Business 100 Informed Consent Form Do you understand that you have been asked to be in a research study? Yes No Have you received and read a copy o f the research project inform ation sheet? Yes No Do you understand that the research interview w ill be recorded? Yes No Do you understand the benefits and risks involved in participating in this study? Yes No Have you had an opportunity to ask questions and discuss this study? Yes No Do you understand that you are free to refuse to participate or to w ithdraw from the study at any time? You do not have to give a reason. I f you should choose to withdraw, any data provided w ill not be used. Yes No Do you understand the issue o f confidentiality and who w ill have access to the inform ation you provide? Yes No As a way to com pensate you for any inconvenience related to your participation, you w ill be given an honorarium having a value o f approxim ately $50. It is im portant to know that it is unethical to provide undue com pensation or inducements to research participants and, if you agree to be a participant in this study, this form o f com pensation to you m ust not be coercive. If you would not otherw ise choose to participate if the com pensation was not offered, then you should decline. I agree to take part in this study. Signature o f Research Participant Date Printed Name I believe that the person signing this form understands w hat is involved in the study and voluntarily agrees to participate. Signature o f the Investigator Date 101 APPENDIX D - Survey Faculty of Management The University of Northern British Columbia Dem ographics and W ork Experiences Please tell us something about yourself. This w ill provide us with inform ation on the people who have helped complete the questionnaires and any difference that may appear in the responses. Please m ark the following w ith a check in the appropriate slot. W hat is your gender? F em ale:_______ , M a le :________ W hat is your present age? U nder 20 y e a rs , 21 to 30 y e a rs 41 to 50 y e a rs , 51 to 60 y e a rs , greater than 61 y e a rs ______ D o you hold: a nursing dip lo m a , a bachelors d e g re e , 31 to 40 y e a rs , , a graduate degree______ A re you m a rried ,_______ , divorced_________ ,_sep arated _________ , or_s in g le________ D o you have children living at home? Y e s_________,N o _________ How long have you been in your current position? Less than 3 m o ._______ , 3 mo. to 1 year , 1 to 5 y e a rs , 6 to 10 y e a rs _______ , over 10 y e a rs_______ N ature o f your position? Full tim e _______ , p art tim e , c a su a l_________ I f your position is part time or casual, approxim atelv how many hours have you worked in the past 6 m o n th s______________? How long have you been w ith this organisation? Less than 1 y e a r , 6 to 10 y e a rs , greater than 10 y e a rs ______ , 1 to 5 years How long have you been employed in nursing? Less than 1 y e a r , 1 to 5 y e a rs _____ _, 6 to 10 y e a rs , 11 to 20 y e a rs , greater than 20 y e a rs ______ 102 Job and O rganization Beliefs > > > We are interested in how you personally feel about aspeets of your job. Each of the statements below is something that a person might say about his or her job. You are to indicate your own personal feelings by marking how much you agree with each of the statements. > Circle the number which best describes your feelings. 1. - Strongly Disagree 2. - Disagree 3. - Neither Disagree nor Agree 4. - Agree 5. - Strongly Agree Strongly Disagree Disagree Neither Agree Strongly Agree Overall, I am satisfied with my job 2 3 4 5 I would prefer a job other than in northern B. C. 2 3 4 5 I do not feel any obligation to remain with my current employer 2 3 I would prefer a job other than nursing 2 3 When union leaders speak publicly about nursing issues they speak for me 2 3 I have ties to this community 2 3 I really feel as if this organization’s problems are my own 2 3 Too much in my life would be disrupted if I decided I wanted to leave my organization now 2 3 4 The policies of this organization are fair and just 2 3 4 Even if it were to my advantage, I do not feel right to leave my organization now 2 3 4 I would be very happy to spend the rest of my career with this organization I would be willing to let the nurses I work with have complete control over my future in the hospital and issues that are important to me It would be very hard for me to leave my organization right now, even if I wanted to 103 strongly Disagree Disagree Neither Agree I would be willing to let the doctors I work with have complete control over my future in the hospital and issues that are important to me Generally speaking I am satisfied with this job 2 4 The hospital is obligated to provide day-care facilities for staff 2 4 I frequently think of quitting this job 2 4 I feel safe in my job 2 4 I intend to remain in northern B. C. 2 4 I do not feel like part of the family at this organization 2 4 I believe the union helps me in my career 2 4 I would feel guilt if I left my organization now 2 4 I intend to remain in nursing 2 4 I would prefer a job outside of the hospital 2 4 If I have my way, I will be working in the hospital 3 years from now I would be willing to let my supervisor have complete control over my future in the hospital and issues that are important to me I would be willing to give the nurses I work with a task or problem that was critical to me, even if I could not monitor their actions Right now, staying with my organization is a matter of necessity as much as desire I would be willing to let management have complete control over my future in the hospital and issues that are important to me I feel that I have too few options to consider leaving this organization I would be willing to give the doctors I work with a task or problem that was critical to me, even if I could not m onitor their actions Strongly Agree 104 strongly Disagree Disagree Neither Agree Strongly Agree I am generally satisfied with the kind of work I do on this job 2 My family ties me to this eommunity 2 4 5 I do not feel emotionally attaehed to this organization 2 4 5 This organization deserves my loyalty 2 4 5 This is a safe place to work 2 4 5 If I have my way, I will be nursing 3 years from now 2 4 5 I would be willing to give my supervisor a task or problem that was critical to me, even if I could not monitor her/his actions 2 4 5 I owe a great deal to my organization 2 4 I intend to remain with the hospital 2 4 I do not feel a strong sense of belonging to my organization 2 4 This organization has a great deal of personal meaning for me The hospital should provide child-eare for staff 24 hours/day One of the few negative consequences of leaving this organization would be the scarcity of available alternatives If I had not already put so much of myself into this organization, I might consider working elsewhere I would not leave my organization right now because I have a sense of obligation to the people in it I would be willing to give management a task or problem that was critical to me, even if I could not monitor their actions If I have my way, I will be working in northern B. C. 3 years from now The union is an important part of my well-being 105 Employee Obligations > > > > Employment involves obligations between employees and their employers. Consider the list below of potential obligations you might have to your employer To what extent do you believe you are obligated to do these things as an employee. Please circle the number that applies next to the statement. 1 = Not Obligated, you have no obligation to do this at all 2 = Slightly Obligated, you should do this from time to time 3 = Fairly Obligated, you should do this about half the time 4 = Very Obligated, you should do this most of the time 5 = Absolutely Obligated, you must do this, without fail, all of the time Not How obligated are you t o ...... Very Slight Fairly Oblig. 1. Work extra time. 2. 3. ^ Oblig. Oblig. Oblig, Absol Oblig, 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 Contribute beyond your job requirements. Attend work and be on time. 1 4. Be loyal to your employer. 5. Trust your employer. 6. Refuse to support competitors. 7. Be active in your workplace social community. 8. Show respect to and follow the instructions of your supervisor and managers. 1 2 3 4 5 Place the benefits and needs of the organization ahead of your own. 1 2 3 4 5 10. Control my emotions and respect co-workers and customers at all times. 1 2 3 4 5 11. Follow instructions even though they do not make sense to you. 1 2 3 4 5 2 3 4 5 9. 12. Be open and honest in your workplace. 13. Do things that make their supervisors job easier. ^ 106 How obligated are you t o ...... Not Oblig, Slight Oblig. Fairly Oblig, Very Oblig, Absol Oblig. 14. Contribute to workplace improvements. 1 2 3 4 5 15. Adapt and share the workplace culture. 1 2 3 4 5 16. Represent the workplace favorably to outsiders. 1 2 3 4 5 17. Know and follow the unwritten rules of the workplace. 1 2 3 4 5 18. Maintain the privacy and security of information in the workplace. 1 2 3 4 5 19. Be sensitive to the effects of “office politics”. 1 2 3 4 5 20. Act professionally inside and outside of work. 1 2 3 4 5 21. Do your work to the best of your ability. 1 2 3 4 5 22. Do work that is not part of your job including covering the workload of absent employees. 23. Use your work time well. 1 2 3 4 5 1 2 3 4 5 24. Make due with what you have available 1 2 3 4 5 25. See what needs to be done and do it. 1 2 3 4 5 26. Be flexible in your job. 1 2 3 4 5 27. Do work that you are not qualified to do. 1 2 3 4 5 28. Use management’s presentation and reporting style. 1 2 3 4 5 29. Be a team player. 1 2 3 4 5 30. Accept all workplace hazards. 1 2 3 4 5 31. Continually upgrade your skills and knowledge. 1 2 3 4 5 32. Maintain your physical fitness. 1 2 3 4 5 33. “Butter-up” your supervisor and management. 1 2 3 4 5 34. “Go the extra mile” at work 1 2 3 4 5 107 How obligated are you t o ...... Not Oblig, Slight Oblig. Fairly Oblig. Very Oblig. Absol Oblig. 35. Use good judgement in making decisions. 1 2 3 4 5 36. Learn the job as you work. 1 2 3 4 5 37. Solve unusual problems. 1 2 3 4 5 38. Communicate effectively. 1 2 3 4 5 39. Supervise and direct the work of others. 1 2 3 4 5 40. Act independently. 1 2 3 4 5 41. Plan and organize the work of yourself and others. 1 2 3 4 5 42. Accept your workplace values as your own. 1 2 3 4 5 43. Provide advance notice if taking a job elsewhere. 1 2 3 4 5 44. Accept a transfer. 1 2 3 4 5 45. Spend a minimum of two years in the organization. 1 2 3 4 5 108 Employer Obligations > > > > Employment involves obligations between employees and their employers. Consider the list below of potential obligations your employer might have to you To what extent do you believe you employer is obligated to provide these things to you? Please cirele the number that applies next to the statement. 1 = Not Obligated, the employer has no obligation to do this at all 2 = Slightly Obligated, the employer should do this from time to time 3 = Fairly Obligated, the employer should do this about half the time 4 = Very Obligated, the employer should do this most of the time 5 = Absolutely Obligated, the employer must do this, without fail, all of the time How obligated is your employer t o ..... Not Oblig. Slight Oblig. Fairly Oblig. Very Oblig. Absol Oblig. 1. Help people get along at work. 1 2 3 4 5 2. Treat everyone the same. 1 2 3 4 5 3. Help me when my job is stressful. 1 2 3 4 5 4. Provide good benefits. 1 2 3 4 5 5. Make sure your supervisor is on your side with higher management. 1 2 3 4 5 6. Let you be part of the decisions that affect you. 1 2 3 4 5 7. Not ask you to do anything wrong or illegal. 1 2 3 4 5 8. Reward extra work 1 2 3 4 5 9. Reward hard work. 1 2 3 4 5 10. Reward performance based on fair evaluations 1 2 3 4 5 11. Keep employees informed about goals, policies and changes. 1 2 3 4 5 12. Let employees know what is going on in the workplaee. 1 2 3 4 5 13. Keep its promises. 1 2 3 4 5 109 Not Slight Oblig. Fairly Oblig. Very Oblig. Absol Oblig. 14. Support your job-related actions. 1 2 3 4 5 15. Follow the labour code and workplace policies. 1 2 3 4 5 16. Recognize that your family comes tirst. 1 2 3 4 5 17. Have reasonable expectations about the job. 1 2 3 4 5 18. Provide enough training. 1 2 3 4 5 19. Provide you with everything you need to do your job. 1 2 3 4 5 20. Respect your right to join a union. 1 2 3 4 5 21. Make sure your supervisor treats you with respect. 1 2 3 4 5 22. Respect your privacy. 1 2 3 4 5 23. Make you feel safe at work. 1 2 3 4 5 24. Allow you to speak your mind. 1 2 3 4 5 25. Allow you the freedom to do things as you see tit. 1 2 3 4 5 26. Tell you when you have gone as high as you can in the 1 2 3 4 5 27. 1 2 3 4 5 28. Place you in a job in which you can be true to your 1 2 3 4 5 29. Premie opportunities for promotion. 1 2 3 4 5 30. Provide good pay. 1 2 3 4 5 31. Base my pay on my performance. 1 2 3 4 5 32. Provide job security. 1 2 3 4 5 33. Provide career development. 1 2 3 4 5 34. Support me when I have personal problems. 1 2 3 4 5 How obligated is your employer t o .... membership costs related to your work. 110 Not Oblig. Slight Oblig. Fairly Oblig. Very Oblig. Absol Oblig. 35. Provide a sense of meaning and purpose in the job. 1 2 3 4 5 36. Provide opportunities for personal growth. 1 2 3 4 5 37. Provide interesting work. 1 2 3 4 5 38. Provide challenging work. 1 2 3 4 5 39. Provide responsibility in the job. 1 2 3 4 5 40. Provide recognition for good work. 1 2 3 4 5 41. Provide status and prestige in the job. 1 2 3 4 5 42. Provide an organized workplaee. 1 2 3 4 5 43. Provide regular feedback and evaluations. 1 2 3 4 5 44. Provide support for work related problems. 1 2 3 4 5 45. Provide regular pay raises 1 2 3 4 5 How obligated is your employer t o ..... 111 Im portant Aspects of Your Ideal Job The purpose of this questionnaire is to find out what you consider important or unimportant to have in your ideal job. Please answer the following statements in terms of how important or unim portant it is to you in determining an ideal job. Circle the number next to each statement that best describes how important or unimportant it is to you. 1 = Very Unimportant, not at all essential to an ideal job, you can easily do without it. 2 = Not Important, not essential to an ideal job 3 = Neither Important nor unimportant to an ideal job 4 = Important, it is essential to an ideal job 5 = Very Important, absolutely essential to an ideal job, you cannot do without it. On my ideal job, how important is it that.... Very Unimpt, Not Impt. Neither Impt. 1.The job has good working conditions. 4 2. My pay would compare well with that of other employees. 4 3. I could feel secure about the job and my future in the organization. 4 . 1 could have variety in my work. 2 4 5 . 1 could supervise or direct other people. 2 4 6 . 1 could do work that is well suited to my abilities. 2 4 7. The job would give me importance in the eyes of others. 2 4 8. The company would have good policies towards its employees. 2 4 9. My supervisor and I would understand each other and have good personal relations. 2 4 10.1 could be active and busy much of the time. 2 4 II. I could do things that don’t go against my beliefs and values. 2 4 12.1 could be responsible lor planning and making decisions related to my work. 2 4 13.1 would be noticed and be recognized when I do a good job. 2 4 14. The job could give me a feeling of accomplishment. 2 4 15. The job would provide an opportunity for advancement. 2 4 16. My supervisor would have a lot of “know-how” and provide help with hard problems Very Impt. 112 On my ideal job, how im portant is it th a t .... Very Unimpt. Not Impt. Neither Impt. very Impt. 17. The people I work with would be eooperative and friendly. 1 2 3 4 5 18.1 could be of service to or help other people. 1 2 3 4 5 19.1 could do new and original things or try my ideas on my own. 1 2 3 4 5 2 0 .1 could work independently of other people. 1 2 3 4 5 113 APPENDIX E - Structured Interview Questionnaire We are eonducting a structured interview to ensure we ask all nurse participants the same questions. This will allow us to code your answers and create a quantified database for statistical analysis. We will also be asking you to expand on your answers from time to time. This will help provide greater meaning and depth to your answers. I f during the interview you wish to expand on an answer, please feel free to do so. At the same time, we have a lot o f questions to cover and it is important we get through them all within the one-hour allotted. I f there are areas which you or the researcher feel could use additional elaboration, we will return to those areas at the end of the interview. At times, you may feel you should answer a question in a way that might be considered socially or politically correct. It is important that you do not do so. For this study to be meaningful it is important you answer the questions based on how you feel. First, we would like to know your views of nursing and how you feel others view nurses and nursing. 1. How personally satisfying, enjoyable and challenging do you find nursing? 2. Do you feel our society and the general public recognizes the value o f nurses? 3. To w hat extent do you believe the general public view nurses as professionals? 4. W hat do you believe are m anagem ent’s view o f nurses? 5. W hat do you believe are doctors’ views o f nurses? Next, we would like to know your views of your job. 1. How personally satisfying, enjoyable and challenging do you find your present job? 2. To w hat extent do you feel a positive sense o f anticipation about going to work? 3. Do you feel you are sufficiently recognized and appreciated for w hat you do in yourjob? 4. Do you have sufficient decision-m aking authority to do your job effectively? 5. Do you have sufficient autonomy in your work? 6. Do you feel the w ork you do m akes a m eaningful contribution tow ard restoring a patient to health or is it a relatively small portion o f what is done? 7. Is the feedback you get on how you are doing your job sufficient and beneficial to you? 8. Does your job allow you to fully utilize your knowledge and abilities? 9. Do you feel you have grow n in knowledge, abilities and/or professionally over the past several years? 10. Are there advancem ent opportunities either w ithin nursing or in the hospital for you? 11. Do you feel that those w ith whom you come in contact in your current job treat you as a professional? 12. Are there any childcare or fam ily issues that im pact on your job? 114 Next, we would like to know about your relations with your co-workers. 1. How well are you treated by your co-workers? 2. W hat do you like and dislike the m ost about your co-workers? 3. Have there been any particular incidents w here your eo-workers have m ade your job easier or harder? Now, we would like your views of your supervisor and management. 1. W hat is your opinion o f your supervisor? 2. How does your supervisor treat you? 3. Are there things your supervisor does that make your job easier or harder? 4. W hat is your opinion o f management? 5. How does m anagem ent treat you? 6. W hat does m anagem ent do that m akes your job easier or harder? Now, we would like to know your views of doctors 1. W hat is your opinion o f doctors? 2. How do doctors treat you? 3. A re there things that doctors do that make your job easier or harder? Finally, we would like to know the extent that you trust the people you work with 1. How much do you tru st the nurses you work with? 2. How much do you tru st the doctors you w ork with? 3. How m uch do you tru st your supervisor? 4. How much do you tru st m anagement? 5. Have there been any particular incidents that have affected your level o f trust? Are there any other issues that you feel are important in understanding what is happening in the hospital or that affect your desire to remain there? Are there any issues from the questions asked in this interview that yon would like to elaborate upon? Thanks for your help w ith this research study! ! 115 APPENDIX F - Coding for Structured Interview 1.How personally satisfying, enjoyable and challenging do you find nursing? 1 no on all 2 very little, yes on 1, no on 2 3 somewhat 4 quite a bit, 2 o f 3 fairly strong 5 very much, all yes 2. Do you feel our society and the general public recognizes the value o f nurses? 1 strong no 2 majority do not 3 some do some don’t, don’t know 4 majority do 5 strong yes 3. To what extent do you believe the general public view nurses as professionals? 1 strong no 2 majority do not 3 some do some don’t, don’t know 4 majority do 5 strong yes 4. W hat do you believe are m anagem ent’s view o f nurses? 1 very negative view, no respect, view nurses as a com modity 2 somewhat negative view, little respect, don’t understand w hat we do 3 not sure, neutral 4 somewhat positive, nursing m anagers have positive view other m anagers m ay be more negative 5 very positive 5. W hat do you believe are doctors’ views o f nurses? 1 very negative, no respect, nurses are handm aidens 2 somewhat negative, little respect, m any th in k nurses are handm aidens 3 neutral, some have respect some don’t 4 somewhat positive, m any think nurses are o f value 5 very positive, great deal o f respect, value nurses 116 6. How personally satisfying, enjoyable and challenging do you find your present job? 1 no on all 2 very little, yes on 1, no on 2 3 somewhat 4 quite a bit, 2 o f 3 fairly strong 5 very much, all yes 7. To what extent do you feel a positive sense o f anticipation about going to work? 1 dread going to work, don’t w ant to go to work 2 many tim es dread going to work 3 neutral, don’t dread nor look forw ard to going to work, sometimes dread sometimes enjoy 4 generally look forward to going to work 5 really like to go to work 8. Do you feel you are sufficiently recognized and appreciated for w hat you do in your job? 1 no by anyone 2 not much but by a few 3 neutral, some recognize and appreciate me some don’t 4 most recognize and appreciate me but some don’t 5 yes by all 9. Do you have sufficient decision-making authority to do your job effectively? 1 strong no 2 some but not in m ost cases 3 neutral, not sure 4 pretty much yes 5 strong yes 10. Do you have sufficient autonomy in your work? 1 strong no 2 some but not in m ost cases 3 neutral, not sure 4 pretty much yes 5 strong yes 117 11. Do you feel the work you do makes a m eaningful contribution tow ard restoring a patient to health or is it a relatively small portion o f w hat is done? 1 strong no 2 some but not in m ost cases 3 neutral, not sure 4 pretty much yes 5 strong yes 12. Is the feedback you get on how you are doing your job sufficient and beneficial to you? 1 strong no, get no feedback form ally or inform ally 2 some but not sufficient, either no form al or no inform al 3 neutral, not sure, may not get form al but fairly good inform al from most 4 pretty much yes, inform al good, some formal 5 strong yes inform ally and formally 13. Does your job allow you to fully utilize your knowledge and abilities? 1 strong no 2 some but not in m ost cases 3 neutral, not sure 4 pretty much yes 5 strong yes 14. Do you feel you have grow n in knowledge, abilities and/or professionally over the past several years? 1 strong no 2 some but not much 3 neutral, not sure 4 pretty much yes 5 strong yes 15. A re there advancement opportunities either w ithin nursing or in the hospital for you? 1 strong no 2 some but not much 3 neutral, not sure, could be but don’t w ant them 4 pretty much yes 5 strong yes 118 16. Do you feel that those w ith whom you come in contact in your current job treat you as a professional? 1 strong no 2 some do but m ost don’t, not much 3 neutral, not sure, some do some don’t 4 pretty much yes, m ost do 5 strong yes, all do 17. A re there any childcare or family issues that im pact on your job? 1 yes, a lot 2 quite a bit 3 a fair bit 4 some but not much 5 no, not at all 18. How well are you treated by your co-workers? 1 very poorly by all 2 somewhat poorly 3 neither good nor bad 4 fairly well 5 very well 18a. W hat do you like and dislike the m ost about your co-workers? No scoring, use to help decide on scoring for 18 18b. Have there been any particular incidents w here your co-workers have m ade your job easier or harder? No scoring 19. W hat is your opinion o f your supervisor? 1 is very poor, not nice, and/or incom petent 2 is somewhat poor, not nice and/or incom petent 3 is okay 4 is good 5 is very good, exceptional 119 20. How does your supervisor treat you? 1 very poorly 2 somewhat poorly 3 neither good nor bad 4 fairly well 5 very well 20a. A re there things your supervisor does that m ake your job easier or harder? No scoring, can be used to help assess 19 or 20 21. W hat is your opinion o f management? 1 is very poor, not nice, and/or incom petent 2 is somewhat poor, not nice and/or incom petent 3 is okay, no opinion, don’t know 4 is good 5 is very good, exceptional 22. How does m anagem ent treat you? 1 very poorly 2 somewhat poorly 3 neither good nor bad, no opinion, don’t know 4 fairly well 5 very well 22a. W hat does m anagem ent do that makes your job easier or harder? No scoring, can be used to assess 21 & 22 23. W hat is your opinion o f doctors? N ot asked o f many. Use 24 to score. We may not use this. 1 is very poor, not nice, and/or incom petent 2 is somewhat poor, not nice and/or incom petent 3 is okay, no opinion, don’t know 4 is good 5 is very good, exceptional 120 24. How do doctors treat you? 1 very poorly 2 somewhat poorly 3 neither good nor bad, no opinion, don’t know 4 fairly well 5 very well 24a. A re there things that doctors’ do that make your job easier or harder? No scoring, can be used to assess 23 and 24 25. How much do you trust the nurses you w ork with? 1. don’t tru st them at all 2. tru st a couple quite a lot but not most, tru st then a bit 3. neither tru st them nor don’t tru st them , some I do some I don’t 4. tru st m ost a lot but not all 5. trust them all in all things 26. How much do you trust the doctors you w ork with? 1. don’t tru st them at all 2. trust a couple quite a lot but not most, tru st them a bit 3. neither tru st them nor don’t tru st them , some 1 do some I don’t 4. trust m ost a lot but not all, tru st them on m ost things but not completely 5. trust them all in all things 27. How much do you tru st your supervisor? 1. don’t trust him /her at all 2. tru st somewhat on certain things but not a lot on m ost things 3. neither trust nor don’t trust him /her, tru st on some things not on others 4. trust on m ost things but not completely 5. trust him /her on all things 28. How m uch do you tru st m anagement? 1. don’t tru st them at all 2. tru st them a bit but not all that much 3. neither tru st them nor don’t tru st them, some I do some I don’t, don’t know 4. tru st m ost a lot but not all, tru st them on m ost things but not completely 5. tru st them all in all things 121 APPENDIX G - Inter-rater Reliability for Structured Interview Questions Structured Interview Variable % close agreement % total agreement Management’s Views 81.96 29.51 Sufficient Autonomy 95.08 42.62 Sufficient Decision Making 89.34 50.00 Opportunities for advancement 85.25 36.89 Sufficient Feedback 82.79 23.77 Trust in Management 90.00 60.00 NB total agreement is where all three raters agree, close agreement is where two raters agree and the third differs by 1. 122 APPENDIX H - Scatter Plots for Variables of Interest 3.5 ♦ î 3 (0 ♦ ♦ ♦ ♦ ♦ ♦ ♦ 2.5 c ♦ ♦ ♦ ♦ ♦ 2 ♦ ♦ ♦ ♦ ♦ c 0) I... c ^ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ 1 » 0.5 0 1 2 3 4 5 Intentions to Remain in Nursing Figure 7 Scatter Plot of Trust-survey vs Intentions to Remain - Nursing ? ^ 5 4. E ♦ ♦ ♦ ♦ I 3. ♦ I. 0) O) (0 s 1 ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ 3 4 ♦ ♦ 3 0 1 2 5 Intentions to Remain In Nursing Figure 8 Scatter Plot of Trust-interview vs Intentions to Remain - Nursing 125 0 1 Job Satisfaction Figure 9 Scatter Plot of Intentions to Remain - Hospital vs Satisfaction .5 6 Î2 3 r- ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ C 4 're E q ♦ (I) o ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ 5 2 (/) ♦ l o 0 1 2 3 4 5 Job Satisfaction Figure 10 Scatter Plot of Intentions to Remain - Nursing vs Satisfaction