Seago, Jean Ann PhD, RN, FAAN; Spetz, Joanne PhD; Ash, Michael PhD; Herrera, Carolina-Nicole MA; Keane, Dennis MPH
The work of understanding hospital employee job satisfaction has been under way for decades, and RNS have been the target of many of these studies.1-4 A number of factors are associated with greater hospital nurse job satisfaction including individual nurse characteristics, such as younger age, less job tenure, an increased organizational commitment, and fewer hours worked,5-9 and hospital characteristics, such as promotional opportunities, supervisor support, recognition, a reasonable workload, higher pay, and higher status.10-16 Increased job dissatisfaction is associated with increased conflict, increased role ambiguity, factors that interfere with patient care, and feeling overloaded.9,17
Being represented by a labor union is also associated with decreased job satisfaction, as indicated by 2 important studies.18,19 Freeman and Medoff19 concluded that unionized workers more frequently or intensively express dissatisfaction with their jobs, that unionized workers have poor perceptions of supervisors, and that they are more critical of physical conditions of work and job hazards. The authors speculated that this critical attitude is due to greater awareness of problems and a willingness to speak about such concerns.19 Freeman and Medoff observed, however, the paradox that despite more dissatisfaction, unionized workers are more likely to stay in a job. They attribute greater retention both to the higher pay and benefits in unionized jobs and also, significantly, to the greater likelihood that expressed dissatisfaction is translated into improvements in actual working conditions in unionized workplaces.18,19
The second study was conducted in the state of Victoria, Australia, before that state implemented nurse-to-patient minimum staffing laws.18 Arch and Graetz18 surveyed a large public hospital in Melbourne to study work dissatisfaction and attitudinal militancy. They found that dissatisfaction with autonomy and pay and union membership are associated with attitudinal militancy.18 The concept of militancy, as presented by Arch and Graetz, is similar to the Freeman and Medoff19 notion of increased awareness of problems and a willingness to speak out. It is also clear that the militancy in Victoria continued, and ultimately the state implemented laws to define appropriate workloads, as did the state of California in the United States.20
Beyond those 2 studies, there is little empirical evidence about the relationship between unions and job satisfaction in healthcare, but unions are becoming increasingly important among RNs in the United States. Because of the link between RN retention in hospitals and job satisfaction, the purpose of this study was to examine whether unionization is associated with job satisfaction among RNs in the United States using nationally representative surveys of RNs.15,21,22
Design and Methods
We analyzed the public-use data from the 2004 and 2008 National Sample Surveys of Registered Nurses (NSSRN).15,21-23 The NSSRN has been conducted approximately every 4 years beginning in 1977 and samples roughly 30,000 RNs with impressive response rates up to 80%24-26 and has been used to examine various aspects of the nursing workforce.27,28 The 2004 NSSRN was conducted by Gallup, Inc, and the 2008 survey was conducted by Westat, under contract with the Division of Nursing in the Bureau of Health Professions of the US Department of Health and Human Services' Health Resources and Services Administration. Samples were drawn from each state's list of active licenses.29 States with smaller RN populations were oversampled to provide more valid workforce estimates at the state level. In addition, minorities were oversampled to ensure adequate representation in the survey.
The 2004 sample for the survey consisted of approximately 56,917 licensees; there were 35,724 RNs who responded, yielding a response rate of 70.5%. Respondents to the survey were asked to classify themselves, as of March 2004, as to whether they were employed and, if employed, whether they were employed in nursing, in addition to other descriptive characteristics.30 The 2008 survey sampled 55,151 RNs; 33,549 completed the survey, providing a response rate of 62.4%. Similar questions were asked in 2008 as in 2004, with March 2008 as the reference date for questions about employment. We limited our analysis to data from RNs who worked in acute-care hospitals and reported that they provided direct patient care.
The variable of interest was nurse satisfaction, based on the 2004 question: "How would you best describe your feelings about your principal nursing position?" and the 2008 question: "How satisfied are you with your principal job or most recent job if you are not now working." The 5-point Likert-scale responses were dichotomized so that 1 represents satisfied or very satisfied and 0 represents neutral, not satisfied, or very dissatisfied. The explanatory variable of interest was union status. Demographic variables included in the analyses were marital status, age, ethnicity, overall income, and sex.30-33
Measures of central tendency and bivariate correlations were calculated. We used t tests to estimate mean differences in the variables for 2004 and 2008 (Table 1), union and not union (Table 2), and satisfied or not satisfied (Table 3). Regression analyses using probit models were specified (Table 4). Probit models are useful specifications for binary responses and are estimated using standard maximum likelihood procedure. From probit coefficients, one can compute probability derivatives, which are the changes in the probability of the outcome variable in response to a 1-point change in the predictor. We also estimated models using simple linear regression (also called a linear probability model) and found no difference in the results. The sample was weighted to reflect the overall population of RNs in the United States.
The samples of hospital-employed direct-care RNs were 10,648 in 2004 and 10,291 in 2008. The shares of RNs represented by a union were 18.9% in 2004 and 19.6% in 2008. Satisfaction of hospital-employed RNs reporting satisfied or very satisfied increased between 2004 and 2008, from 74.2% to 78.1%. The improvement in satisfaction in these national data is consistent with improvements in satisfaction reported in California.15 Between 2004 and 2008, the national hospital-employed RN workforce experienced an increase in the share of men and nonwhite racial/ethnic groups, with particularly notable increases among Asians and Hispanics. Average income also rose, from $56,400 in 2004 to $60,400 in 2008.
In both 2004 and 2008, there are differences in the demographic characteristics of union and nonunion RNs (Table 2). Higher shares of union RNs are nonwhite and Asian, and unionized RNs are slightly older than nonunion nurses. In 2004, a lower percentage of married nurses was unionized, but in 2008, a higher percentage was unionized. Nurses with graduate degrees are less likely to be unionized, but unionized nurses reported higher average income from their principal nursing position in both 2004 and 2008.
There also are differences in the demographic and educational characteristics of satisfied RNs as compared with those who are not satisfied (Table 3). Nurses who were satisfied were more likely to be married and have a graduate degree. They also had higher average income than did nurses who were not satisfied.
The probit regressions provided a more complete picture of the associations among the variables. In addition to the probit regressions, we estimated models (not shown) using linear regression and other models that included interaction terms of union status/age and union status/income. The linear regressions provided the same result as the probits, and neither of the interaction terms was significant.
In the probit regressions (Table 4), being married and having a higher income were significantly, positively associated with job satisfaction in both 2004 and 2008. More experience also was positively associated with satisfaction. In 2004, female RNs were more likely to be satisfied, whereas in 2008, nurses with graduate degrees were more satisfied. In both years, union representation had a negative association with job satisfaction, although this relationship was not statistically significant in 2008.
Because some literature31,32 indicates that union status is associated with higher RN salaries, we questioned whether the higher income of the nurses was the mechanism by which union status influenced satisfaction. To test whether this was an important mediator of satisfaction, we estimated probit regressions that omitted income but included union. If having a union was the mechanism between income and satisfaction, the probability derivatives for union status would change when income was omitted; however, this did not occur. In 2004, the probability derivative was −0.038 (significant at P < .01), and in 2008, it was −0.016 (not statistically significant). Thus, we are reasonably certain that union status is not the mediator between satisfaction and higher income, so nurses in unions have more dissatisfaction and higher incomes, but the dissatisfaction is not associated with the income.
The most significant finding in these analyses was that our variable of interest, union status, predicted less nurse satisfaction with work in 2004 and 2008, although the relationship did not reach significance in 2008. There are several potential explanations for this seemingly counterintuitive finding. Because these findings indicate associations rather than causal relationships, it is possible that lower levels of job satisfaction are not the result of unionization, but rather the cause of unionization.33 Nurses who are dissatisfied may seek union representation, and thus, during some transitional period, overall job satisfaction might be lower. If a higher share of RNs had recently joined unions in 2004 as compared with 2008, the theory that low satisfaction drives unionization may explain the negative relationship in 2004 and the insignificant relationship in 2008.
It also is possible that unionized nurses are more inclined to voice dissatisfaction, as proposed by Freeman and Medoff19 and Arch and Graetz,18 but are not functionally more dissatisfied than are nonunion RNs in terms of retention. It is possible that whether they are less satisfied or not, union nurses feel freer to voice their dissatisfaction. The difference between 2004 and 2008 may reflect the overall worsening of the economy. Even union nurses may have been more insecure about voicing job dissatisfaction in the poor job climate that existed in 2008.
Implications for Practice
The finding that having an RN union was associated with lower job satisfaction in 2004 and, although not statistically significant, the association was in the same direction in 2008 may be viewed in several ways related to practice. Some managers might say that the finding is not surprising because they suspected that nurses in unions were less satisfied; others might agree because union nurses are more likely to feel free to speak about workplace dissatisfiers. Union leaders might reject this finding because it is counter to their experience.
The change in the overall economic environment between 2004 and 2008 was substantially negative, so workers, including nurses, might have been less likely to express dissatisfaction with jobs whether they had union representation or not. That does not necessarily mean that the dissatisfiers disappeared.
In both 2004 and 2008, income was a statistically significant predicator of job satisfaction, although its impact is relatively small. An increase in income of $1,000 was associated with a 0.1-percentage-point increase in reported job satisfaction in 2008; thus, an increase in satisfaction equal to the 4-percentage-point 2004 union satisfaction gap would "cost" hospitals $40,000. Some hospitals may not be willing to pay that "cost."
Another potential explanation for the findings is that unrecognized factors in the work environment associated with job dissatisfaction are also associated with having a union. Generally, union nurses know they have a specific advocate when discussing negative workplace issues; however, nurses who are not union members may be less secure about whether someone will advocate on their behalf when discussing those same issues. Because union negotiations occur regularly and may break down with disagreeable outcomes, there may be an adversarial relationship that exists between staff nurses and managers in a union environment. But with open and effective management and leadership, a good relationship between workers and managers is possible whether there is a union or not. Although having a unionized workforce might lead to more militancy, it can also lead to a greater "voice" for nurses in an organization. A savvy chief nursing officer can create an environment where it is possible to communicate effectively with union representatives to provide a more satisfying work environment for nurses and managers and better quality care for patients.
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