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Journal of Neuroscience Nursing:
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Job Satisfaction Among Multiple Sclerosis Certified Nurses

Gulick, Elsie E.; Halper, June; Costello, Kathleen

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Author Information

Questions or comments about this article may be directed to Elsie E. Gulick, PhD RN FAAN. She is a professor emerita for the College of Nursing at Rutgers University, Newark, NJ.

June Halper, MSCN ANP FAAN, is the executive director for the Multiple Sclerosis Center at Holy Name Hospital, Teaneck, NJ.

Kathleen Costello, MS CRNP MSCN, is the program director for the Maryland Center for Multiple Sclerosis at the University of Maryland, Baltimore, MD.

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Abstract

Several studies document high levels of job satisfaction among certified nurses, but no study has examined job satisfaction and factors influencing job satisfaction of certified multiple sclerosis (MS) nurses. This study tested a theoretical model proposing that two organizational factors, colleague relationships and benefits, will predict job satisfaction. Job satisfaction was represented by four factors: autonomy, professional status, professional growth, and time efficiency. Participants included MS nurses certified for 6 months or more practicing mostly in three countries (Canada, Great Britain, and the United States) who anonymously completed the Misener Nurse Practitioner Job Satisfaction Scale, an overall job satisfaction rating, and demographic information. Findings indicate that colleague relationships and benefits significantly estimated organization structure and that autonomy, professional status, professional growth, and time efficiency significantly estimated job satisfaction; furthermore, organization factors such as colleague relationships and benefits significantly predict job satisfaction. Among the countries, several statistically significant differences were observed between job satisfaction factors as well as items in both organization and job satisfaction subscales. Average factor scores among the countries were mostly rated satisfactory. The International Organization of Multiple Sclerosis Nurses Executive Board plans to use the study findings to see how it needs to focus efforts as an organization toward enhancing and standardizing MS care and develop MS nurse professionalism worldwide.

Certification for nurses is one measure of competence in specialty areas of practice (Smolenski, 2000). Nurse certification is available to registered nurses through examination within the United States (Smolenski) and in countries outside the United States (Daly & Carnwell, 2003). Certification promotes quality and effective patient care through expert knowledge and clinical skills as well as role satisfaction. Recently, certification has become available to nurses who provide specialized care to persons with multiple sclerosis (MS) and their families through the Multiple Sclerosis Nurses International Certification Board (MSNICB). MSNICB certification is highly valued by both employers and MS patients and provides formal recognition of basic MS nursing knowledge (MSNICB, 2005).

Although numerous studies document high levels of job satisfaction among certified nurses, no published study has examined job satisfaction among MS certified nurses (MSCNs) and factors that influence job satisfaction as an MSCN. MS nursing includes concepts underlying clinical practice that incorporate assessment, interventions, advocacy, education, and research. Practice settings may include rehabilitation centers, hospitals, MS centers or clinics, home or community care settings, nursing homes, pharmaceutical or other commercial facilities, and educational and research facilities (MSNICB, 2005).

Certification in a specialized area of nursing supports one's knowledge base and reflects competence, professional commitment to lifelong learning through required continuing education and recertification, and documented experience in a given specialty (Stromborg et al., 2005). Certified nurses possess increased knowledge and technical skills and feel more confident in their ability to detect and initiate early and prompt interventions when signs and symptoms of complications appear in their patients, leading to enhanced patient outcomes, health, and satisfaction. A study conducted by the Nursing Credentialing Research Coalition in North America indicated that certified nurses reported fewer adverse events and errors in patient care than before they were certified (Henley, 2000). In a systematic review of randomized clinical trials and observational studies of primary patient care, certified nurses, compared to physicians, were rated better on communication skills, completeness of the medical record, and advice on self‐management (Horrocks, Anderson, & Salisbury, 2002). Continence nurse specialists practicing in Great Britain, who had received a 3‐month training program on assessment procedures and evidencebased practice protocols, were rated by their patients as having excellent interpersonal skills (friendly, respectful, sensitive, trusting), technical‐care skills (competent, thorough), and information‐giving skills (Shaw, Williams, & Assassa, 2000). Certified nurses reported more personal growth and job satisfaction, increased consultation within their organization, higher participation in leadership activities, and greater financial benefits (Henley, 2000). MS certification provides a standard of knowledge that assists the employer, public, and members of the health professions in the assessment of nurses involved in MS care (MSNICB, 2005). Certification is an attempt to unite MS nurses worldwide through standard practices (Uccelli, Fraser, Battaglia, Maloni, & Wollin, 2004). MS nurses face similar issues when assisting people with MS in terms of treatments aimed at modifying the disease course, treating exacerbations, and managing symptoms. This leads to the rationale for establishing an internationally relevant and recognized standard of MS care through Internet resources, publications, and on‐site programs.

The goal of this study was to determine the extent to which certification for MS nurses increased one's overall job satisfaction and to identify specific areas of satisfaction. Stromborg and colleagues (2005) reported that specialty certification among nurses enhanced job satisfaction and is associated with increased knowledge and skills, autonomy, sense of accomplishment, and collegiality (Tri, 1991). Increased job satisfaction resulted in improved patient perceptions of quality of care (Atkins, Marshall, & Javalgi, 1996).

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Background Literature

To date, no studies have evaluated MSCN job satisfaction and factors that influence it. Studies are available that examine job satisfaction and influencing factors among other certified nursing specialty areas and advanced practice nurses (APNs). Studies that examined predictors of nurse job satisfaction frequently include noncertified nurses, certified nurses, and APNs but failed to report specific differences between these groups in terms of job satisfaction (American Board of Nursing Specialties [ABNS], 2006; Kovner, Brewer, Wu, Cheng, & Suzuki, 2006). Thus, there is a need to determine if job satisfaction of nurses holding a single license or certification differs from that of those who hold multiple certifications and/or licenses.

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Distinctions Between Certified Nurses and Advanced Practice Nurses

According to the American Nurses Credentialing Center (2006), certification is based on formal educational preparation and experience in a specialty area that recognizes nurses' knowledge, skills, and abilities or competence. Eligibility requirements for MS nurse certification include a recommendation that candidates have at least 2 years of experience in MS nursing and current registered nurse (RN) licensure or the equivalent from other countries (MSNICB, 2005). MS nursing may cover clinical practice, concepts underlying clinical practice, assessment and interventions in clinical practice, advocacy, and education and research in diverse practice settings, such as rehabilitation, MS centers and clinics, hospitals, and home or community care (MSNICB, 2005).

Advanced practice nurse is a term given to a registered nurse who has met advanced educational and clinical practice requirements beyond the 2‐4 years of basic nursing education. It includes nurse practitioners (NPs), clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), and certified nurse midwives (CNMs; American Nurses Association [ANA], 2006). NPs and CNSs have formal clinical preparation leading to a master's degree; both CRNAs and CNMs fulfill educational preparation through post‐RN certificate programs that may occur through a master's degree program (ANA). Nursing roles for APNs generally include clinical care, counseling, and patient education in their respective clinical specialties and populations. In addition, APNs may or may not prescribe medication; other roles may also include administration, research, and policymaking (ANA).

Many certified nurses hold certification in more than one area and may also hold APN licensure. There appears to be general agreement that core competencies underlie roles of certified and APN nurses, but each specialty has a unique practice environment, principal practice focus, and practice characteristics (American Nurses Credentialing Center, 2006; Daly & Carnwell, 2003).

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Conceptual Framework

The study was conceptualized within the quality‐ofcare assessment model postulated by Donabedian (1966, 1988). Donabedian identified three categories that influence quality of care, namely, structure, process, and outcome. Aspects of Donabedian's model are present in Herzberg's (1973) two‐factor model of employee satisfaction, also called the Motivator‐Hygiene model. Herzberg theorized that job satisfaction is enhanced by factors called satisfiers that include achievement, recognition, the work itself, responsibility, and advancement. Satisfiers motivate individuals to aspire to superior performance, effort, and self‐actualization. Dissatisfaction occurs when environmental conditions consisting of organizational policy and administration, interpersonal relations, and working conditions are negative, all of which are referred to as dissatisfiers (Herzberg). According to Herzberg's model, positive features of organizational structure enhance provider satisfaction. Together, Donabedian's and Herzberg's theoretical models postulate that a good structure (organization) increases the likelihood of good process (job satisfaction), and good process increases the likelihood of a good outcome (patient satisfaction). This study investigated structure and process factors as depicted in Figure 1.

Fig 1
Fig 1
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Support for continued professional growth is important for promoting job satisfaction as well as clinical care performance.

Structure refers to attributes of the healthcare setting, such as facilities, organizational policies, and methods of reimbursement (Donabedian, 1988). Good collegial relationships with coworkers are important within an organization where one feels valued and respected (Nolan, Nolan, & Grant, 1995). Job satisfaction is enhanced when nurses are able to perform the expanded role for which they were prepared and not inappropriately limited by physician supervisors' regulations (Keith, Coburn, & Mahoney, 1998) and when they receive adequate compensation (Koelbel, Fuller, & Misener, 1991; Tri, 1991). These studies, together with Donabedian's theory of structure, process, and outcome, suggest that organizational factors including colleague relationships and benefits affect both provider satisfaction and patient outcomes. Certification empowers nurses by establishing a knowledge base for true collaborative practice with other members of the healthcare team (Uccelli et al., 2004) that in turn contributes to job satisfaction (Stromborg et al., 2005) and better patient outcomes (Neale, 1999).

Process refers to what is actually done in giving care and includes making a diagnosis and recommending or implementing treatment (Donabedian, 1988). Aiken, Sochalski, and Lake (1997) theorized that organizations that promote greater nurse autonomy, more control by nurses of resources at the unit level, and better relations between nurses and physicians will yield better patient outcomes. Autonomous nursing roles are significant predictors of nurses' job satisfaction in primary (Byers, Mays, & Mark, 1999; Chung‐Park, 1998; Tri, 1991) and acute (Kovner et al., 2006) care settings. Studies of nurses have shown that respect for one's professional status (Armstrong‐Stassen & Cameron, 2005; Calgary Health Region, 2005; Nolan et al., 1995) and opportunities for professional growth (Kingma, 2001; Nolan et al.) enhance one's job satisfaction. Another area of increased job satisfaction is derived from patient care involving the provision of education, counseling, and preventive services (Moser & Armer, 2000). Having adequate time to complete work, especially time spent in patient care (Armstrong‐Stassen & Cameron; Chung‐Park) and time to discuss complex patient cases with colleagues (Best & Thurston, 2004), influences the nurse's job satisfaction. It is the qualities of autonomy, professionalism, and time efficiency identified in these studies that promote job satisfaction in both certified and advanced practice nurses and in turn promote quality patient care.

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Job Satisfaction Among International Nurses

Issues pertaining to job satisfaction among certified and noncertified nurses are reported worldwide (Aiken et al., 2001). Organizational factors, including colleague relationships and job benefits, are major sources of satisfaction or dissatisfaction.

Colleague relationships includes communication with peers and members of other health disciplines to share patient information, ability to provide input into organizational policy, respect for one's opinion, and suggestions for change in clinical practice. In a national sample of 1,538 RNs in the Unites States (46% baccalaureate or higher, 27% with advanced certification), nurses working in hospitals, nursing homes, nursing educational programs, home healthcare settings, ambulatory care settings, and other settings reported their job satisfaction was positively related to supervisor support and work‐group cohesion, but they were dissatisfied in situations with organizational constraint (Kovner et al., 2006). The 2004 Nursing Worklife Satisfaction survey of Calgary Health Region RNs (certification status was not requested) noted increases in job satisfaction, particularly in the areas of interaction with colleagues, compared with a 2002 survey (Calgary Health Region, 2005). A comparison of colleague relationships among British and Australian nurses (diploma and college trained) working in hospitals in their respective countries indicated that British nurses were more dissatisfied than Australian nurses. British nurses were more concerned about the lack of communication between nurses and doctors and felt less respected by other allied health professionals, hospital administrators, and doctors than Australian nurses (Adamson, Kenny, & Wilson‐Barnett, 1995). A survey of job satisfaction and morale among nurses, midwives, and health visitors in one health district in Wales indicated that good collegiate relationships with coworkers was rated most important to job satisfaction; feeling valued and respected were also important (Nolan et al., 1995). Job satisfaction among nurses in England, based on a nationally representative sample of nurses working in hospitals, was significantly related to the degree of cohesion existing among ward nurses, the degree of collaboration with medical staff, and perceptions of staff organization (Adams & Bond, 2000). These studies clearly illustrate the importance of colleague relationships marked by open communication and respect for one another.

Benefits includes perception of receiving an adequate salary, retirement plan, and leave policy for one's job. Aiken and colleagues (2001) reported that among nurses working in acute care hospitals in five countries more than 75% of British nurses felt that their salaries were inadequate compared with 60% of U.S. nurses and 70% of Canadian nurses. Several studies of American nurses indicated that paid time off, performance rewards (Kovner et al., 2006), salary, and benefits (Ellenbecker & Byleckie, 2005) were sources of considerable job dissatisfaction. Public health nurses in British Columbia, Canada, also reported dissatisfaction with their salary. Dissatisfaction with salary and benefits is widespread throughout nursing regardless of the country.

Indicators of job satisfaction include autonomy, professional status, professional growth, and time efficiency. Autonomy is control of one's scope of nursing practice for which one has been academically and clinically prepared and includes meeting challenges, displaying flexibility in practice protocols, and being able to deliver quality care. Autonomous nursing practice, a characteristic of certified nurses (Stromborg et al., 2005), has been shown to be a major aspect of job satisfaction among nurses working in all healthcare settings in the United States (Aiken et al., 2001; Ellenbecker & Byleckie, 2005; Kovner et al., 2006) and in Canadian provinces (Betkus & MacLeod, 2004; Calgary Health Region, 2005).

Professional status includes recognition and respect from one's peers, other disciplines, and the community as well as pride in one's work. Pride in work was found to increase job satisfaction among American nurses (Ellenbecker & Byleckie, 2005). Public health nurses in British Columbia, Canada, reported that professional status was one of the most satisfying aspects of the nursing job (Betkus & MacLeod, 2004). British nurses perceived their professional status to be lower than Australian nurses. Ostensibly, a positive view of one's professional status enhances one's job satisfaction.

Professional growth is the opportunity to expand one's scope of practice, time to seek advanced education, and opportunity for job promotion. Opportunity for promotion was important to American nurses' job satisfaction (Kovner et al., 2006). The opportunity for education beyond the minimum requirements to facilitate adoption of new ideas and new practices was reported as important to British and Canadian nurses (Best & Thurston, 2006; Nolan et al., 1995). Support for continued professional growth is important for promoting job satisfaction as well as clinical care performance.

Time efficiency refers to adequate time to perform one's nursing role and exclusion of nonnursing tasks. Many nurses working in hospitals in countries including the United States, Canada, England, Scotland, and Germany reported spending time performing functions that did not require their professional training when care activities that required their skills and expertise were often left undone (Aiken et al., 2001). Canadian community health nurses reported concern about reduction in time available for each client and a decrease in number of visits because of inadequate resources to do the job (Armstrong‐Stassen & Cameron, 2005). Time constraints often lead to job dissatisfaction and may jeopardize needed patient care.

Donabedian's (1966; 1988) theory of quality care and Herzberg's (1973) two‐factor (or Motivator‐Hygiene) model of employee satisfaction both propose that organizational structure (colleague relationships and benefits) influences the job satisfaction process (autonomy, professional status, professional growth, and time efficiency). Colleague relationships between nurses and members of other health disciplines are characterized by respect and work‐group cohesion, whereby talents and expertise are shared among the group to enhance patient outcomes and job satisfaction (Adams & Bond, 2000; Kovner et al., 2006; Neale, 1999).

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Hypotheses

This study considered the following hypotheses:

1. Colleague relationships and benefits are indicators of the healthcare system's organization.

2. Autonomy, professional status, professional growth, and time efficiency are indicators of MSCN job satisfaction.

3. The healthcare system's organization is related to MSCN job satisfaction.

Several research questions were also examined:

1. Are there differences among participating countries with regard to the organization and MSCN job satisfaction factors?

2. Are there differences among participating countries with regard to specific items within the organization and MSCN job satisfaction factors?

3. Is there a difference in organizational structure and job satisfaction factors between nurses who only hold MS certification compared with nurses who hold MS certification and additional certification in another specialty or APN licensure?

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Method

Design

This study used a correlation design consisting of two latent variables (Fig 1): organization (structure) and MSCN job satisfaction (process). Organization was represented by two factors: colleague relationships and benefits. MSCN job satisfaction was represented by four factors: autonomy, professional status, professional growth, and time efficiency.

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Sample

All MS nurses certified through the MSNICB for at least 6 months (N = 414) were invited to participate through e‐mail announcements and postal mail. Approximately 75% of all MSCNs are members of the International Organization of Multiple Sclerosis Nurses (IOMSN). Of the available MSCN pool of potential respondents, 170 responded. Two respondents who were no longer engaged in direct care of MS patients were removed, resulting in 168 (41%) usable responses. The sample included nurses engaged in MS patient care from the United States (n = 127), Canada (n = 27), Great Britain (n = 7), Australia (n = 3), New Zealand (n = 2), Sweden (n = 1), and Israel (n = 1).

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Measures

The study used the Misener Nurse Practitioner Job Satisfaction Scale (MNPJSS; Misener & Cox, 2001) to measure organization and job satisfaction factors. Items contained in the MNPJSS are consistent with activities performed by MS certified nurses. Respondents were instructed to leave an item unmarked if they were unable to rate it.

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Organization

Organization was measured by two factored subscales from the MNPJSS based on Herzberg's (1973) two‐factor theory of job satisfaction (Misener & Cox, 2001). The first, colleague relationships (14 items), is a measure of organizational policies of the health center that include respect for one's opinion and administrative support. The second, benefits (3 items), is a measure of employee benefits, retirement plan, and leave policy. The respondents rated items in the subscales using a 6‐point, Likert‐type scale ranging from 1 (very dissatisfied) to 6 (very satisfied). Scoring entails adding the items contained in each respective subscale and dividing the total by the number of subscale items to yield a score range for each respective subscale between 1 and 6. Content validity is suggested based on several reviews and slight revisions made by expert general nurse practitioners. Construct validity is suggested by being factored from a pool of 77 items. Cronbach's alpha reliability estimates for colleague relationships and benefits were .94 and .79, respectively (Misener & Cox); for the current study, reliability was, .92 and .73, respectively.

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Multiple Sclerosis Certified Nurses Job Satisfaction

Job satisfaction was measured by four factored subscales from the MNPJSS (Misener & Cox, 2001). The first, autonomy (10 items), is a measure of autonomy, challenge, flexibility in practice protocols, and ability to deliver quality care. The second, professional status (8 items), is a measure of professional interaction with other disciplines, status in the community, peer recognition, and acceptance by physicians outside of one's practice. The third, professional growth (5 items), is a measure of opportunities to expand one's scope of practice, support for continuing education, service on professional committees, and involvement in research. The fourth, time (4 items), is a measure of time for review of laboratory work, answering messages, and seeing patients. Items for the subscales are rated on a 6‐point, Likert‐type scale ranging from 1 (very dissatisfied) to 6 (very satisfied). Scores were determined by adding the items in each respective subscale and dividing the total by the number of subscale items to yield a score range between 1 and 6 for each respective subscale. Content validity was suggested based on several reviews and slight revisions made by expert certified general nurse practitioners. Construct validity is suggested by being factored from a pool of 77 items. Cronbach's alpha reliability estimates for the subscales of autonomy, professional status, professional growth, and time were 0.84, 0.86, 0.83, and 0.79, respectively (Misener & Cox), and for the current study reliability for these factors was .88, .70, .87, and .81, respectively.

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Overall Job Satisfaction

Overall job satisfaction was measured by a single item that asked respondents to rate their overall satisfaction as a certified MS nurse by putting a circle around a number ranging from 1 (very dissatisfied) to 10 (very satisfied). Global single‐item indicators require that subjects consider all aspects of a phenomenon and ignore aspects that are not relevant to their situation to provide a single rating (Youngblut & Casper, 1993). Single‐item indicators have been shown to be reliable and valid measures of the phenomenon under study.

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Demographic Information

Demographic information included age, educational level, gender, ethnicity, country, nurse certification specialties, and average MS patient visits per day.

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Data Analysis

Descriptive statistics were used to examine score distribution of demographic variables and all observed and latent variables. One‐way analysis of variance with Bonferroni post hoc comparison tests were used to determine organization and job satisfaction factor differences among participating countries with a sample of at least five participants. Mann‐Whitney U tests were used to determine organization and job satisfaction differences among organization and job satisfaction items for participating countries. Correlations among factor scores within the latent variables reveal absence of multicollinearity by demonstrating intercorrelations below .85 (Polit, 1996). However, the correlation between colleague relationships and autonomy approaches the cutoff for multicollinearity with an r of .84. Bivariate scatterplots of factors within the latent variables suggest the assumptions of linearity and homoscedasticity were met (Kline, 1998).

Structural equation modeling (SEM) was used to test the hypotheses. SEM provides a unique analysis that simultaneously considers questions of both measurement of the factors (Fig 1, nonbold arrows) and predictive relationships among the latent variables (Fig 1, bold arrow; Kelloway, 1998). Tests of the model fit included the chi‐square test, which is used to specify a model that reproduces the original covariance matrix; the root mean squared error of approximation (RMSEA), which is used to analyze residuals; and the adjusted goodness‐of‐fit index (AGFI), which provides a ratio of the sum of the squared discrepancies to the observed variances with adjustment for degrees of freedom in the model (Kelloway). A good model fit to the data is suggested when the chi‐square value is nonsignificant, the RMSEA value is less than 0.10, and the AGFI value is greater than 0.9.

Missing data resulting from unanswered items in the MSCN Job Satisfaction Scale because of lack of relevance to the MSCN's job situation were addressed by adding all answered items and dividing by the number of answered items in the respective scales. Sample size is considered adequate when there are 10 subjects for each estimated model parameter (Kelloway, 1998). The current model has 14 parameters to be estimated and required at least 140 subjects.

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Procedure

Following study approval from the Institutional Review Board for Protection of Human Subjects by the first author's university, English‐speaking subjects were recruited by mail and an e‐mail announcement was sent to members of the IOMSN. The announcement described the purpose and respondents' anonymous involvement in the study. Packets consisting of the study description, questionnaires, and either a stamped addressed return envelope (for U.S. respondents) or an addressed return envelope (nonstamped) with a $5.00 calling card (for non‐U.S. respondents) in lieu of return postage were mailed to all MSCNs. Respondents were asked to omit names and any identifying information on the questionnaires and return envelope. Postcard reminders were sent 2 weeks after the initial packet mailing, and e‐mail reminders were sent 2 weeks and 2 months after the initial mailing to thank those who returned the study materials and to remind nonresponders of the study's importance and to encourage them to return the completed questionnaires to the first author.

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Results

The sample is largely comprised of 40‐year‐old, well‐educated, Caucasian women (Table 1). More than half (55.7%) of the respondents reported having additional certifications or licensure as APNs, NPs, or CNSs in diverse specialty areas (e.g., neuroscience, rehabilitation, oncology, orthopedics, community health, and psychiatric and mental health). Additional certification in MS nursing provided validation to these nurses, their colleagues, and their patients of the expert knowledge and clinical skills specific to expanded nursing roles required in the care of persons with MS.

Table 1
Table 1
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The influence of factors such as educational level, additional certification, and age on organization and MSCN job satisfaction factors is not statistically significant. Bivariate correlations between organization and MSCN job satisfaction factors and overall job satisfaction are shown in Table 2. The proposed model (Fig 1) was tested and results indicate that the model could be improved by adding a path (Ψ = 0.09, p < .01) between colleague relationships and autonomy, shown by the double arrow between colleague relationships and autonomy (Fig 2). The relatively high correlation between colleague relationships and autonomy suggests that these factors are related. Testing of the revised model demonstrated that all paths are statistically significant (Fig 2). The latent variable organization depends on two factors: colleague relationships (λ = 0.86, p < .001) and benefits (λ = 0.45, p < .001). The latent variable MSCN job satisfaction depends on four factors: autonomy (λ = 0.61, p < .001), professional status (λ = 0.51, p < .001), professional growth (λ = 0.94, p < .001), and time efficiency (λ = 0.46, p < .001). However, the variance in autonomy is also shared with colleague relationships. Organization is a statistically significant predictor of MSCN job satisfaction (γ = 0.96, p < .001). With the added path to the hypothesized model, there is a good fit of the model to the data with Χ2 = 11.55, degrees of freedom (df) = 7, and p = 0.12; RMSEA p = .065; and AGFI = 0.93. The model explains 91% of the variance in MSCN job satisfaction.

Table 2
Table 2
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Fig 2
Fig 2
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Comparison of three countries (United States, Canada, and Great Britain) using one‐way analysis of variance demonstrated general group differences for overall job satisfaction and all factors except time efficiency. However, when Bonferroni post hoc comparison testing was done, only two job satisfaction factors demonstrated significant differences—autonomy is significantly higher among American nurses compared with British nurses but not Canadians, and professional growth is significantly higher among American nurses compared with Canadian nurses but not British nurses (Table 3).

Table 3
Table 3
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A number of items within the organization and job satisfaction factors demonstrated statistically significant differences between countries. As shown in Table 4, differences existed among countries with regard to colleague relationships, benefits, autonomy, professional status, and time efficiency. Median scores between countries ranged between 2 (dissatisfied) and 5 (satisfied), with most being between 4 (minimally satisfied) and 5 (satisfied).

Table 4
Table 4
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Countries with fewer than 5 respondents demonstrated similar ratings as the United States, Canada, and Great Britain on the organization and job satisfaction factors, with a few exceptions. New Zealand's two respondents reported considerable dissatisfaction with colleague relationships, and the single Swedish respondent reported considerable dissatisfaction with time efficiency.

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Discussion

The finding that colleague relationships and benefits, aspects of organizational structure, influence MSCN's job satisfaction is consistent with Herzberg's (1973) two‐factor (Motivator‐Hygiene) model of employee satisfaction and is supported in the literature. Neale (1999) stated that collaboration through sharing talents and expertise with physician colleagues serves to further enhance a professional relationship by focusing energies of both disciplines toward better patient outcomes, health, and well‐being. Similarly, Arford (2005) found that the communication between nurses and physicians is a cornerstone of safe, efficient, and effective patient care. Nurses who used an attentive, listening, and empathetic communication style with physician colleagues reported enhanced collaborative relationships, increased satisfaction with the interaction, and improved quality of patient care (Coeling & Cukr, 2000). Good collegiate relationships with coworkers within an organization where one feels valued and respected are important (Nolan et al., 1995). Aiken and colleagues (2001) reported that colleague relationships were relatively positive and nonproblematic in an international sample of American, Canadian, and British nurses who worked in acute care hospitals. In contrast, the current study results for nurses in the same countries indicate an average rating of minimally satisfactory (4/6). In particular, specific items pertaining to supervisor and administrative support and recognition demonstrate differences—American nurses are more satisfied than Canadian and British nurses. Colleague relationships through supervisor support and work‐group cohesion were noted to be significant predictors of job satisfaction in a national sample of nurses employed in diverse healthcare settings in the United States (Kovner et al., 2006).

Although the average benefits score did not differ among the three countries, satisfaction with the benefit package on post hoc comparison testing was higher for American nurses than for Canadian and British nurses. Considerable dissatisfaction with benefits and pay has previously been reported among Canadian community health nurses (Armstrong‐Stassen & Cameron, 2005; Betkus & MacLeod, 2004) and among British nurses working in an acute National Health Service hospital (Tovey & Adams, 1999). Studies report that benefits, particularly pay, is one of the most frequently reported incentives for nurses to migrate to other countries (Kingma, 2001).

The finding that MSCN job satisfaction depends on the presence of autonomy, professional status, professional growth, and time efficiency is consistent with Herzberg's (1973) theory proposing that job satisfaction is enhanced when satisfying factors that include achievement, recognition, work itself, responsibility, and advancement are present. In the current study, autonomy was shown to be significantly higher among American nurses than British nurses. In particular, “having a sense of value for what one does,” an aspect of autonomy, was more prevalent among American nurses than British nurses. Consistent with the current study, autonomous nursing roles were shown to be significant predictors of nurses' job satisfaction in primary care settings (Byers et al., 1999; Chung‐Park, 1998; Tri, 1991) and in acute care hospitals (Kovner et al., 2006).

Results demonstrate significant mean score differences in professional status between American and Canadian nurses. American nurses rated “Social contact at work” and “Status in the community” significantly higher than Canadian nurses. Of note is a Nursing Worklife Satisfaction survey conducted in 2004 among nurses in the Calgary Health Region of Canada that indicated an increase in areas of professional status, interaction with colleagues, and autonomy over the 2002 survey (Calgary Health Region, 2005). Similarly, Betkus and MacLeod (2004) reported that public health nurses working in rural British Columbia were most satisfied with their professional status and professional interaction. American nurses also rated “Quality of assistive personnel” higher than British nurses. A study of British nurses indicated that job satisfaction was enhanced when they felt valued, respected, and given opportunities for professional growth (Nolan et al., 1995). Professional status for nurses in many countries is increasing, but further attention to this area may be warranted in some regions of some countries.

In the present study, no statistically significant differences in time effeciency were evident among or between the countries. However, examination of items in the scale reveals that American nurses were more satisfied with “Time to review lab and other test results” than British nurses. If, as some British nurses report, there is insufficient time to give a good standard of care to their patients (Nolan et al., 1995), it is understandable that time to review laboratory and other test results may also be unsatisfactory. Lack of adequate time for some Canadian nurses was shown by experiencing a reduction of time spent for each patient, decreased number of follow‐up community visits, and decreased job satisfaction (Armstrong‐Stassen & Cameron, 2005). Conversely, adequate time to complete work, especially time spent in patient care, was associated with job satisfaction among certified navy nurses (Chung‐Park, 1998).

More than one‐third (38%, 8.5 years) of the average number of years spent in nursing practice (22.5 years) by MSCN respondents was spent caring for MS patients and their families. More than one‐third of the years spent caring for MS patients and families included being MS certified. The movement toward care of MS patients and families is probably due to the general movement toward specialized nursing and to the increased nursing needs of MS patients arising from an increased understanding of the disease and symptom management (Halper, 2001).

Finding no statistically significant differences between level of nurse education and both organization and job satisfaction factors is similar to that of home health nurses in the United States (Ellenbecker & Byleckie, 2005). Similarly, the current study showed no significant differences between nurses holding just the MSCN certification and several specialty nurse certifications or APN licenses. Nurses at all educational and practice levels who care for MS patients have vast opportunities for continuing education through a number of publications from the Consortium of Multiple Sclerosis Centers, IOMSN, various pharmaceutical companies, and Internet resources; all resources provide state‐of‐the‐art information on all aspects of MS and best healthcare practices.

The study also sought to identify organizational factors that are supportive or unsupportive to the MSCN role in clinical practice, advocacy, education, and research. This information may be helpful to the IOMSN in its goal to serve as a forum for discussion and collaboration on issues that concern certified and noncertified MS nurses (IOMSN, 2006). The IOMSN Executive Board plans to use the study's findings to develop an organizational focus over time. In addition, this information may be helpful to physicians and group practices that care for patients with MS. It may also provide material for educational programs that prepare MSCNs, healthcare organizations that employ them, and third‐party payers by developing an awareness of the relationships between organization and job satisfaction factors among MS certified nurses.

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Limitations

Limitations of the study include a response rate below 50% of MSCNs. The response rate in the current study was similar (41%) to a mailed survey conducted in Great Britain (Nolan et al., 1995) and higher than the 38% response rate reported among home health nurses in the United States (Ellenbecker & Byleckie, 2005). Low response rate in the current study may be partially due to nonrespondents no longer working with MS patients. Nonresponse may also be due in part to incorrect contact information with no forwarding address. Self‐report data may also present some biased responses; however, bias was minimized because of anonymous identities of the respondents. The fact that more than half of the sample had additional licensure in or certification as APNs, NPs, CNSs, or in other specialized areas may be a confounding variable, but this threat is minimized by the finding that no statistically significant difference exists between respondents with additional certification to the MSCN and those with no additional certification than the MSCN on organization and MSCN job satisfaction factors. Generalizability of findings is limited, particularly to countries with very low response rates.

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Summary

Findings from this study are consistent with the theorized hypotheses and supported by published studies of job satisfaction among nurses from diverse specialty areas or general nursing. Colleague relationships, on average, were rated lower than benefits and job satisfaction factors of autonomy, professional status, professional growth, and time efficiency. Collaborative relationships are promoted by effective communication, which enhances job satisfaction among nurses and improves quality of patient care. Further development of colleague relationships among MSCNs is warranted. Although the mean ratings for MSCN job satisfaction factors of autonomy, professional status, professional growth, and time efficiency are satisfactory, none reach the very satisfactory level, suggesting that further development in these areas is warranted. The IOMSN Executive Board plans to use the study findings to focus organizational efforts over time.

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Acknowledgment

This study was funded by the International Organization of Multiple Sclerosis Nurses.

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