| |

Received: 26 November 2018    Revised: 19 August 2019    Accepted: 4 September 2019

DOI: 10.1111/jan.14202

ORIGINAL RESEARCH:
E M P I R I C A L R E S E A R C H – Q U A N T I TAT I V E

Job satisfaction and associated factors among psychiatric

nurses in tertiary psychiatric hospitals: Results from a
nationwide cross‐sectional study

Huixuan Zhou MD, PhD, Lecturer1,2 | Feng Jiang MD, Doctoral candidate2 |

Jeffrey Rakofsky MD, Assistant Professor3 | Linlin Hu PhD, Associate Professor2 |
Tingfang Liu Professor4 | Shichao Wu BS, Master candidate2 | Huanzhong Liu MD,
Chief Physician5 | Yuanli Liu PhD, Professor Dean2  | Yi‐lang Tang MD, PhD,
3,6
Director, Addiction Psychiatrist

1
School of Sport Science, Beijing Sport
University, Beijing, China Abstract
2
School of Public Health, Chinese Academy Aims: To investigate the job satisfaction among psychiatric nurses in China and to
of Medical Sciences and Peking Union
explore its associated factors.
Medical College, Beijing, China
3
Department of Psychiatry and Behavioral
Design: A cross‐sectional survey among a nationwide sample from 32 tertiary psychi-
Sciences, Emory University School of atric hospitals in 29 provincial capitals in China.
Medicine, Atlanta, GA, USA
4
Methods: Nurses (N  =  9.907) were targeted for this survey in December 2017. In
Institute for Hospital Management of
Tsinghua University, Shenzhen, China all, 8,493 responded (response rate  =  85.7%) and 7,881 (79.5%) were included in
5
Department of Psychiatry, Chaohu Hospital the analysis. An online questionnaire was used to collect demographics and factors
of Anhui Medical University, Hefei, China
6
related to the work environment. The short version of the Minnesota Satisfaction
Mental Health Service Line, Atlanta VA
Medical Center, Decatur, GA, USA Questionnaire was used to assess job satisfaction. Multilevel regression was used to
examine the association between job satisfaction and these factors.
Correspondence
Yuanli Liu, School of Public Health, Chinese Results: The mean job satisfaction score was 73.7. The multiple regression analysis
Academy of Medical Sciences & Peking indicated that self‐rated health, monthly income, medical liability insurance coverage,
Union Medical College, 5 Dongdansantiao,
Dongcheng District, Beijing 100730, China. perceived respect from patients, social recognition, nurse–physician collaboration,
Email: liuyl_fpo@126.com and trust were significantly associated with higher job satisfaction scores, while age,
Yi‐lang Tang, Department of Psychiatry work hours, and directly experiencing patient‐initiated violence were negatively as-
and Behavioral Sciences, Emory University
sociated with job satisfaction (p < .05).
School of Medicine, 12 Executive Park Drive
NE, Suite 300, Atlanta, GA 30329, USA. Conclusion: Overall, Chinese psychiatric nurses are closer to satisfied than neutral
Email: ytang5@emory.edu
and some demographics and factors related to stressful work environments were
Funding information associated with nurses’ job satisfaction scores.
Beijing Medical and Health Foundation,
Impact: This study examined factors associated with the job satisfaction of Chinese
Grant/Award Number: MH180924
psychiatric nurses in a nationwide sample and indicated that to improve nurses’ job
satisfaction, the government and hospital administrators could consider ways to pro-
mote nurses’ personal health and to modify the stressful work environments, such as

Huixuan Zhou and Feng Jiang Contributed equally to this paper.

The peer review history for this article is available at https://publons.com/publon/10.1111/jan.14202.

J Adv Nurs. 2019;75:3619–3630. © 2019 John Wiley & Sons Ltd |  3619
wileyonlinelibrary.com/journal/jan  
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3620       ZHOU et al.
improving income, reducing work hours, promoting the psychiatric nursing specialty
in ways that increase the public's respect for it, increasing awareness of medical li-
ability insurance coverage, and protecting nurses from patients’ violence.
KEYWORDS
China, job satisfaction, nurse–patient relationships, nurse–physician relationships, psychiatric
nursing
1 |  I NTRO D U C TI O N
Specialty psychiatric hospitals in China provide more than 90% of
mental health services (MoH, 2017). Due to the nature of their pa-
tients’ acuity, some of their patients may need restraints, seclusion,
and continuous observation, which greatly increase the workload
for psychiatric nurses; meanwhile, some patients exhibit aggressive
and violent behaviour towards nurses, creating an unsafe workplace
(Sun et al., 2016; Zou, Lu, & Teng, 2017). High healthcare costs for
patients with severe mental disorders also cause tension in relation-
ships between nurses and patients or their family members (Han et
al., 2018). To remove medical staff from complex medical disputes,
in 2013 the Ministry of Health in China (MoH, renamed as National
Health Council since 2018) required public hospitals to participate in
medical liability insurance, and the coverage of medical liability in-
surance has been gradually promoted by the provincial governments
(Zhang, 2015).
Previous reports indicate that some commonly reported stress-
ors such as low income, heavy workload, tension in interpersonal re-
lationships, and violence from patients may affect nurses’ well‐being
and job satisfaction (Baum & Kagan, 2015; Cheung, Lee, & Yip, 2018;
Tarcan, Hikmet, Schooley, Top, & Tarcan, 2017), and nurses’ job sat-
isfaction has been shown to predict quality nursing care (Aiken et
al., 2012).
The National Mental Health Working Planning (2015–2020) is-
sued by the China State Council indicates that, until 2014 there were
4,800,000 patients diagnosed as severe mental disorders and pro-
vincial government was required to improve quality of mental health
services (The State Council, 2015). Considering the stressfulness in
psychiatric nursing and the correlation of job satisfaction with qual-
ity of nursing care, the level of job satisfaction of nurses in Chinese
psychiatric hospitals and its associated factors need to be investi-
gated and paid attention, which may give some information on the
improving of nurses’ satisfaction.
1.1 | Background
Job satisfaction can be defined as the attitudes resulting from one's
job experience (Locke, 1976). Previous studies in general settings
and in psychiatric settings have identified numerous factors associ-
ated with nurses’ job satisfaction. Demographic characteristics such
as age (or working years), gender, marital status, professional title,
educational background, and health status were assessed in several
such studies, although the significance of these associations differed
based on study characteristics, such as sample and location (Baum
& Kagan, 2015; Li & Lambert, 2008; Liu, While, Li, & Ye, 2015; Lu,
While, & Barriball, 2007; Tarcan et al., 2017). For instance, a study of
215 critical nurses from 12 general hospitals in Shanghai indicated
an inverse association between age and job satisfaction (Liu et al.,
2015), whereas a study of 52 nurses in an Israeli psychiatric hospital
indicated there was no significant relationship between job satisfac-
tion and age (Baum & Kagan, 2015).
Some factors related to stressors have also been associ-
ated with nurses’ job satisfaction. Specifically, low income
(Holmberg, Sobis, & Carlström, 2015; Tarcan et al., 2017), heavy
workload (Ball et al., 2017; Baum & Kagan, 2015; Li & Lambert,
2008; Van, Clarke, Willems, & Mondelaers, 2013), and poor col-
laboration with physicians were all associated with lower nurse
job satisfaction (Van, Clarke, Willems, et al., 2013; Van, Clarke,
Wouters, et al., 2013; Zhang, Huang, Liu, Yan, & Li, 2016).
Perceptions of respect from patients and social recognition of
the specialty were positively associated with job satisfaction (Lu
et al., 2016; Zhou et al., 2018), while patient‐initiated violence
was negatively associated with nurse’ job satisfaction (Chang &
Cho, 2016; Cheung et al., 2018; Cheung & Yip, 2017; Purpora &
Blegen, 2015).
Additionally, findings from previous studies indicated that some
organizational factors, such as organizational commitment, vision,
and leadership, were positively associated with nurses’ job satisfac-
tion (De Gieter, Hofmans, & Pepermans, 2011).
To date, only a couple of published international literatures
conducted multivariate analyses about job satisfaction and associ-
ated factors in psychiatric settings and found that the job satisfac-
tion of psychiatric nurses or mental health nurses was associated
with work hours (Baum & Kagan, 2015; Van, Clarke, Willems, et al.,
2013), income, recognition by patients, (Holmberg et al., 2015) as
well as nurse–physician collaboration and team work (Van, Clarke,
Willems, et al., 2013; Van, Clarke, Wouters, et al., 2013). Studies
among Chinese psychiatric nurses were limited by small sample sizes
and were often conducted in one local hospital (Ju, Yang, & Hou,
2004; Shao, Zhang, & Chen, 2016; Shao, Zhang, Xu, & Li, 2016; Sun
et al., 2016). Moreover, these studies mainly examined associations
between job satisfaction and demographics and/or organizational
characteristics. The possible link between job satisfaction and fac-
tors contributing to stressful work environments has rarely been
explored.
ZHOU et al.
2 | TH E S T U DY
2.1 | Aims
The aim of this study was to examine job satisfaction among psy-
chiatric nurses in China and associated factors. The associated rela-
tionships between job satisfaction and demographic characteristics,
factors related to stressors in the work environment were explored
using data from a nationwide survey.
2.2 | Design
This study was part of a nationwide, cross‐sectional survey intended
to evaluate the performance of psychiatric hospitals in 2017. This
survey focused on tertiary psychiatric hospitals in each provincial
capital city in mainland China, collecting basic hospital information
and conducting a questionnaire survey among medical staff and
patients in these hospitals. Gansu and Tibet provinces were not in-
cluded because there were no psychiatric hospitals in their capital
cities. In total, 32 tertiary psychiatric hospitals from 29 provinces in
China were included in this survey and they account for 13.9% of all
psychiatric hospitals in China (MoH, 2017). Most of these hospitals
provide all emergency care, outpatient care, acute, and long‐term
inpatient care to psychiatric patients.
2.3 | Participants
The nurses who are formally employed in Chinese hospitals are
Registered Nurses. Although they may have various educational
backgrounds ranging from technical secondary school, junior college
to medical university, all of them must pass the Registered Nurse
qualification examination before they can work independently in the
hospitals. All 9,907 Registered Nurses (15.7% of all psychiatric nurses
in China) employed in those 32 hospitals were targeted for a smart-
phone‐based online survey through WeChat from 18 December–31
December in 2017. Student nurses were not included in this survey.
To ensure a response rate no less than 80%, hospital administrators
in each hospital were contacted individually to facilitate the process.
They were asked to encourage staff participation with the survey
during their staff meetings or to promote it on their bulletin boards;
however, they did not have access to the data.
2.4 | Data collection
The online questionnaire collected demographic characteristics in-
cluding gender, age, marital status, educational level, professional
title, number of years working, and health status and involved some
items related to stressors (Paris & Hoge, 2010). These items included
monthly income, work hours, patient‐initiated violence, perception
of patients’ respect for nurses, social recognition, nurse–physician
collaboration, and trust and coverage of medical liability insur-
ance offered by their hospital employer. Moreover, the short‐form
Minnesota Satisfaction Questionnaire (MSQ) was included in the
|
      3621
questionnaire survey to measure the job satisfaction of psychiatric
nurses (Weiss, Dawis, & England, 1967), which was used as the out-
come measure in this study.
Nurses were asked to rate their health status using a 5‐point
Likert scale: very poor – 1, poor – 2, fair – 3, good – 4, and very good
– 5 (de Oliveira, Griep, Portela, & Rotenberg, 2017). Having medi-
cal liability insurance coverage offered by nurses’ hospitals could be
answered with a ‘yes’, ‘no’, or ‘uncertain’ response. Having directly
experienced patient‐initiated violence (including verbal abuse and/
or physical assault) in the past 12 months could be answered with
a ‘yes’ or ‘no’ response. Similar to previous research (Zhang et al.,
2016; Zhou et al., 2018), perceived respect from patients, social rec-
ognition of the psychiatric nursing specialty, nurse–physician collab-
oration, and nurse–physician trust were measured using a 5‐point
Likert scale: very dissatisfied – 1, dissatisfied – 2, moderate – 3, sat-
isfied – 4, and very satisfied – 5.
Job satisfaction was measured using the short‐form MSQ
(University of Minnesota, 1977). This instrument includes 20 items
with a 5‐point Likert scale response for each item: very dissatisfied
– 1, dissatisfied – 2, neither – 3, satisfied – 4, and very satisfied –
5. There are three scales of the short‐form MSQ: 12 items demon-
strate intrinsic job satisfaction, six items demonstrate extrinsic job
satisfaction, and all 20 items on the scale demonstrate general job
satisfaction (Weiss et al., 1967). The general job satisfaction score
ranged from 20–100 (Weiss et al., 1967) and was used as the pri-
mary outcome measure in this study. A score of 60 would indicate
neutral and a score of 80 would indicate satisfied (Sharp, 2008). The
intrinsic and extrinsic subscales were used as outcome measures in
sensitivity analyses.
2.5 | Ethical considerations
Approval for the study protocol was obtained from the Research
Ethics Committee of the School of Public Health, Peking Union
Medical College (SPH201711EPH207). The online survey was anon-
ymous. Participants’ consent was obtained when they accessed the
online survey.
2.6 | Data analysis
Descriptive analyses about the hospital information, job satisfac-
tion, and distribution of the sample were conducted. The mini-
mum, maximum, median, and interquartile range of the number of
beds, number of patients, length of stay, and the number of nurses
in these hospitals were calculated. The means (standard deviation)
of 20 items of MSQ, intrinsic, extrinsic, and general job satisfac-
tion scores were reported. Gender (male/female), marital status
(not married/married), educational level (below bachelor's degree/
bachelor's degree and above), average work hours per week (40 hr
and below/41 hr and above), medical liability insurance coverage
(yes/no or uncertain), and directly experienced patient‐initiated vi-
olence in the past 12 months (no/yes) were dichotomous variables.
Age, working years, and mean monthly income were also treated
 |
3622       ZHOU et al.
as categorical variables and quartile cut‐off points were chosen
to ensure balance in each stratum (Zhou et al., 2018). To simplify
the analysis, the nurses’ self‐rated health was re‐categorized into
three groups: those who scored 1 or 2 were placed into the ‘poor
health’ group, those who scored 3 were categorized into the ‘fair
health’ group, and those who scored a 4 or 5 were placed into
the ‘good health’ group (de Oliveira et al., 2017). Items related to
perceived respect from patients, social recognition, nurse–physi-
cian collaboration, and nurse–physician trust were also re‐catego-
rized into three groups: nurses scoring a 4 and 5 for these items
were categorized into the ‘satisfied’ group, nurses scoring a 3 were
placed into the ‘moderate’ group, and nurses scoring a 1 and 2
were placed into the ‘dissatisfied’ group (Shi et al., 2014). Similar
to previous research using MSQ among psychiatric nurses (Hyrkas,
2005; Priebe, Fakhoury, Hoffmann, & Powell, 2005; Sharp, 2008),
job satisfaction score was treated as a continuous variable in this
analysis. Student's t test was employed to compare job satisfac-
tion scores variables with two categories, whereas one‐way analy-
sis of variance (ANOVA) and Turkey post‐hoc analysis were used
to compare job satisfaction scores for categorical variables with
three or more categories.
Given that the respondents in this study were nested in 32 hospi-
tals, a fundamental two‐level multilevel multiple linear regression was
used to examine associations between job satisfaction and factors in-
volved in the analysis, which allowed for association across respondents
in hospitals and the associations of factors with job satisfaction were
demonstrated as the fixed one‐level slope coefficients (Wang, Xie, &
Fisher, 2009). The general organizational effect, namely the effect of
the hospital itself on the nurses’ job satisfaction can be controlled by the
two‐level model and similar to previous studies (Shi et al., 2015; Zhou
et al., 2018), the narrative of corresponding hospital‐specific random
effects were omitted in results while the fixed effects were reported.
Nurses with standardized residuals greater than or equal to 3 in
the multiple linear regression model were referred to as outliers and
excluded from the final regression model as well as the descriptive
analysis. The variable distribution of nurses excluded as outliers was
compared with those who remained in the analysis using the Chi‐
squared test, while the general job satisfaction scores of the outliers
and those who remained in the analysis were compared using the
Student's t test.
Hospital information Minimum Maximum Median
Number of beds 169 2,134 810
Number of emergency 0 31,595 2,422
patients
Number of outpatients 18,470 1,768,076 181,990
Number of discharges 859 33,472 6,094
Length of stay (days) 15.9 135 49.5
Number of Nurses 38 710 303
Nurses per 100 occupied 0.04 0.19 0.1
beds
Abbreviation: IQR, interquartile range.
To test the robustness of the results, we conducted the same de-
scriptive and regression analyses mentioned above using the intrinsic
and extrinsic subscale job satisfaction scores as outcome measures
instead of the total score.Stata 14 (StataCorpLP) which was used for
all analyses. P values in this study were two‐tailed. Alpha was set at
0.05 for statistical significance.
2.7 | Validity and reliability
Cronbach's alpha was used to assess the internal reliability of the
three job satisfaction scales. The validity of the short‐form MSQ was
tested by Weiss et al. in their monograph (Weiss, Dawis, & England,
1966). The Chinese version has been widely used in the studies re-
lated to Chinese human resources for health (Ge, Fu, Chang, & Wang,
2011; Gu, 2008; Ma, 2009; Zhao, 2011).
3 | R E S U LT S
3.1 | Descriptive analysis of hospitals and study
participants
The basic hospital information varied among the 32 tertiary psychi-
atric hospitals and can be seen in Table 1. Out of the 9,907 nurses
working in the 32 tertiary psychiatric hospitals, 8,493 nurses re-
sponded (response rate = 85.7%) to the survey. Missing data were
avoided by requiring respondents to answer questions before mov-
ing forward to subsequent questions on the survey. After eliminating
from the analysis 500 participants whose responses contained logic
errors (such as age < working years and work hours per week >100)
and 52 outliers (standardized residuals in multiple linear regres-
sion≧3), 7,881 respondents (79.5%) remained, which included nurses
who were more likely to be female than the group of 52 nurses who
were excluded as outliers (p = .002), more likely to rate better health
status (p < .001), less likely to experience patient‐initiated violence
in the past 12  months (p  <  .001), more likely to be satisfied with
perceived levels of patient respect (p < .001), social recognition of
their specialty (p  <  .001), nurse–physician collaboration (p  <  .001),
nurse–physician trust (p  <  .001), and rated higher job satisfaction
scores in all three scales ((p  <  .001). There was no significant dif-
ference between study sample and outliers among the distribution
TA B L E 1   Basic information of 32
IQR
tertiary psychiatric hospitals in 2017
546
12,648
206,772
4,368
29.7
161
0.06
ZHOU et al. |
      3623

TA B L E 2   Scores and internal reliability of job satisfaction items these scales was larger than 0.7, demonstrating good internal reli-
and scales ability (Streiner & Norman, 2003).

Items Mean (SD) Intrinsic Extrinsic Table 3 shows the characteristics of respondents. The nurses
were predominately female (82%) and their median age was
Being able to keep busy all 3.75 X  
32  years. Most of them (72%) were married, 57% of them had a
the time (0.92)
bachelor's degree (the proportion was greater than 18.7% that
The chance to work alone on 3.92 X  
the job (0.78) seen in all types of China's hospitals; MoH, 2017), and the other

The chance to do different 3.67 X   43% of nurses had an educational level of technical secondary
things from time to time (0.93) school or junior college. Two‐thirds of these nurses had a junior
The chance to be ‘somebody 3.72 X   title. Their median monthly income was 6,000 RMB (867 USD),
in the community’ (0.93) with a median time working of 9 years. About a quarter of nurses
Being able to do things 4.18 X   worked more than 40  hr per week and 28.7% of them reported
that don't go against one's (0.73) good/very good health status. Almost one‐third of the nurses
conscience
(31.4%) reported that they directly experienced patient‐initiated
The way my job provides for 3.98 X   violence in the past 12 months and 63.9% of nurses had medical
steady employment (0.79)
liability insurance coverage, with a range of 37.4%–88.9% among
The chance to do things for 3.94 (0.74) X  
the different hospitals. The proportions of nurses satisfied with
other people
the amount of respect given to them by patients, the social rec-
The chance to tell people what 3.54 X  
ognition of their specialty, the nurse–physician collaboration,
to do (0.89)
and nurse–physician trust was 47.6%, 37.5%, 70.5%, and 68.6%,
The chance to do something 3.71 X  
that makes use of my ability (0.92) respectively.

The freedom to use my own 3.65 X  

The t test and ANOVA comparing general job satisfaction
judgement (0.92) scores among variables showed that, nurses who were younger,
The chance to try my own 3.64 X   had an educational level below bachelor's degree, had a junior pro-
methods of doing the job (0.91) fessional title, had fewer working years, rated their health status
The feeling of accomplishment 3.62 X   as good, had medical liability insurance coverage, perceived satis-
from the job (0.99) fying levels of respect from patients, perceived social recognition
The way hospital policies are 3.59   X of their specialty, and experienced high levels of nurse–physician
put into practice (1.04) collaboration, and trust were more likely to have a higher job
My pay and amount of work 2.88   X satisfaction score. Nurses who earned a lower monthly income,
I do (1.24)
worked more than 40  hr per week and experienced patient‐ini-
The chances for advancement 3.37   X tiated violence in the past 12 months were more likely to have a
on this job (1.08)
lower job satisfaction score (Table 3). The Tukey post‐hoc analysis
The praise I get for doing a 3.55   X
showed that the difference of job satisfaction scores among the
good job (1.02)
age groups was statistically significant between the ‘27 years old
The way my boss handles 3.76   X
and below’ group versus the other three age groups; the differ-
workers his/her (1.01)
ence among professional titles group was statistically significant
The competence of my super- 3.73   X
visor in making decisions (1.00) between the junior versus middle groups; the difference among

The working conditions 3.44    

practice years was statistically significant between the ‘4 years or
(1.12) less’ group versus the other three practice years groups; the dif-
The way co‐workers get along 4.10     ference among self‐rated health status, monthly income, respect
with each other (0.71) from patients, social recognition of their specialty, nurse–physi-
Average score, mean (SD) 3.69 3.78 3.48 cian collaboration, and nurse–physician trust was statistically
(0.72) (0.69) (0.90) significant between any two groups describing the variable. The
Total score, mean (SD) 73.72 45.34 20.86 details of these post‐hoc analyses can be seen in Table S1. There
(14.47) (8.23) (5.38) was no significant difference of general job satisfaction based on
Cronbach's alpha 0.96 0.94 0.92 gender or marital status.
Abbreviation: SD, standard deviation.

3.2 | Regression analysis of job satisfaction and

of age, marital status, educational level, professional title, working
years, monthly income, or work hours per week. The general job
satisfaction scores of 7,881 nurses, as well as score on the intrinsic
and extrinsic subscales can be seen in Table 2. Cronbach's alpha for
associated factors
The fixed effects part of the multilevel linear analysis are shown in
Table 4. We used robust linear regression models to estimate the
3624       | ZHOU et al.

TA B L E 3   Description of hospital nurses (N = 7,881)

Variables N % General p value Intrinsic p value Extrinsic p value

Gender
Male 1,421 18.0 73.85   45.38   20.48  
Female 6,460 82.0 73.08 .102 45.03 .199 20.95 .007
a
Age
27 and below 2025 25.7 75.27   46.15   21.46  
28–32 2,175 27.6 73.71   45.28   20.93  
33–40 1832 23.3 72.85   44.84   20.55  
41 and above 1849 23.5 72.88 <.001 44.93 <.001 20.43 <.001
Marital status
Not married 2,204 28.0 74.13   45.48   21.09  
Married 5,677 72.0 73.56 .109 45.26 .272 20.77 .015
Educational level
Below bachelor's 3,386 43.0 74.25   45.62   21.03  
degree
Bachelor's degree 4,495 57.0 73.31 .005 45.07 .002 20.73 .013
and above
Professional title
Junior 5,117 64.9 74.07   45.51   21.00  
Middle 2,351 29.8 72.93   44.90   20.54  
Senior 413 5.3 73.92 .007 45.35 .012 20.98 .003
Working yearsb
4 years and below 2,105 26.7 75.21   46.06   21.51  
5–9 years 1950 24.7 73.34   45.1523   20.72  
10–20 years 1976 25.1 73.18   45.0081   20.65  
21 years and 1,850 23.5 73.01 <.001 44.9886 <.001 20.49 <.001
above
Self‐rated health
Poor 2,510 31.9 66.47   41.36   18.27  
Fair 3,106 39.4 73.53   45.1671   20.84  
Good 2,265 28.7 82.02 <.001 49.9104 <.001 23.76 <.001
Average monthly incomec
4,500 RMB and 2,173 27.6 71.32   44.09   19.89  
below
4,501–6,000 2,552 32.4 72.94   44.90   20.56  
RMB
6,001–8,000 1955 24.8 74.63   45.77   21.26  
RMB
8,001 RMB and 1,201 15.2 78.24 <.001 47.71 <.001 22.62 <.001
above
Average work hours per week
40h and below 5,941 75.4 75.25   46.16   21.42  
41h and above 1940 24.6 69.04 <.001 42.74 <.001 19.14 <.001
Medical liability insurance coverage
Yes 5,033 63.9 76.61   46.86   21.95  
No or uncertain 2,848 36.1 68.61 <.001 42.60 <.001 18.93 <.001

(Continues)
ZHOU et al. |
      3625

TA B L E 3   (Continued)

Variables N % General p value Intrinsic p value Extrinsic p value

Experienced violenced
No 5,405 68.6 75.63   46.32   21.57  
Yes 2,476 31.4 69.55 <.001 43.12 <.001 19.31 <.001
Respect from patients
Dissatisfied 2,370 30.1 63.29   39.78   17.00  
Moderate 1762 22.4 70.61   43.53   19.84  
Satisfied 3,749 47.6 81.78 <.001 49.66 <.001 23.78 <.001
Social recognition of your specialty
Dissatisfied 3,284 41.7 64.60   40.51   17.42  
Moderate 1,640 20.8 72.96   44.78   20.73  
Satisfied 2,957 37.5 84.26 <.001 50.96 <.001 24.76 <.001
Nurse–physician collaboration
Dissatisfied 1,070 13.6 57.70   36.81   14.87  
Moderate 1,256 15.9 63.92   39.89   17.46  
Satisfied 5,555 70.5 79.02 <.001 48.18 <.001 22.78 <.001
Nurse–physician trust
Dissatisfied 980 12.4 57.11   36.47   14.70  
Moderate 1,492 18.9 64.31   40.11   17.58  
Satisfied 5,409 68.6 79.33 <.001 48.36 <.001 22.88 <.001
a
The median age of the respondents is 32 years old, the interquartile range (IQR) is 13.
b
The median working years of the respondents is 9 (IQR = 16); working year was not involved in regression model for multicollinearity.
c
The median monthly income of the respondents is 6,000 RMB (IQR = 3,500 RMB);
d
Experienced violence, directly experienced patient‐initiated violence in the past 12 months.

associations separately without controls and the results showed
that, with the exception of educational level, all factors were signifi-
cantly associated with job satisfaction scores.
The results of the multivariate model showed that (Table 4) age
was negatively associated with the job satisfaction score (β‐coeffi-
cient − 0.975, p < .05 for the age group of 28–32, −1.973, p < .05 for
the age group of 33–40, −3.191, p < .05 for age 41 and above, age
27 and below as reference). Compared with nurses reporting poor
health status, nurses reporting fair health had a 2.518‐point increase
in MSQ score (2.5, p < .05) and nurses reporting good health had an
increase of 5.553 points in MSQ score (5.553, p < .05). Other demo-
graphics including gender, marital status, educational level, and pro-
fessional titles were not significantly associated with job satisfaction.
Monthly income was positively associated with job satisfaction
(0.899, p  <  .05 for monthly income level between 4,501–6,000
RMB, 1.351, p < .05 for 6,001–8,000 RMB, 3.415, p < .05 for 8,001
RMB and above, with monthly income of 4,500 RMB and below as
reference). Nurses working more than 40 hr per week had lower
job satisfaction scores compared with those working 40  hr or
below (−2.702, p < .05). An awareness of medical liability insurance
coverage offered by their hospital was associated with an increase
in job satisfaction by 2.193 points (2.193, p < .05), while directly
experiencing patient‐initiated violence in the past 12 months was
associated with a decrease in job satisfaction score by 0.5 points
(−0.5, p < .05). Satisfaction with the amount of respect shown by
patients, social recognition, nurse–physician collaboration, and
trust were all positively associated with job satisfaction score
(p < .05).
3.3 | Sensitivity analysis
When using the intrinsic and extrinsic job satisfaction subscale
scores as outcomes, the results of the t test, ANOVA (Table 3; Table
S1), and regression analyses (see Table 4) were very similar to those
of the initial analysis with a few exceptions: T test analysis indi-
cated that the extrinsic job satisfaction scores were significantly but
minimally lower among male versus female nurses (20.48 vs. 20.95,
p  <  .05) and among married versus single nurses (20.77 vs. 21.09,
p < .05) and the multivariable regression analysis revealed a negative
but small association between extrinsic job satisfaction scores and
male gender (−0.216, p < .05).
4 | D I S CU S S I O N
Using a nationwide sample of 32 tertiary psychiatric hospitals, this
study investigated the job satisfaction of psychiatric nurses in China
and explored the associated demographics and factors related to
stressors in their work environment. The general job satisfaction
score of nurses in Chinese tertiary psychiatric hospitals was 73.7,
3626      | ZHOU et al.

TA B L E 4   The fixed effects of multilevel regression examining factors associated with job satisfaction of general, intrinsic, and extrinsic
scales

General Intrinsic Extrinsic

Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted

Variables coefficient coefficient coefficient coefficient coefficient coefficient

Male (ref. female) −0.963* −0.396 −0.533* −0.250 −0.427* −0.216

Age (ref. 27 and below)
28–32 −1.923* −0.975* −1.084* −0.601* −0.664* −0.293*
33–40 −2.985* −1.973* −1.625* −1.103* −1.124* −0.761*
41 and above −3.143* −3.191* −1.668* −1.708* −1.265* −1.338*
Married (ref. not married) −0.936* 0.310 −0.446* 0.260 −0.434* 0.012
Bachelor's degree and above (ref. below −0.596 0.135 −0.382* 0.023 −0.173 0.052
bachelor's degree)
Professional titles (ref. junior)
Middle −1.474* −0.166 −0.802* −0.152 −0.543* 0.046
Senior 0.472 0.982 0.172 0.330 0.221 0.610*
Self‐rated health (ref. very poor/poor)
Fair 6.768* 2.518* 3.644* 1.406* 2.455* 0.848*
Good/very good 13.934* 5.553* 7.653* 3.199* 4.918* 1.792*
Monthly income (ref. 4,500 RMB and below)
4,501–6,000 RMB −0.62 0.899* −0.351 0.476* −0.210 0.362*
6,001–8,000 RMB −0.216 1.351* −0.085 0.769* −0.099 0.507*
8,001 RMB and above 2.437* 3.415* 1.367* 1.906* 0.864* 1.270*
Working more than 40 hr per week (ref. 40 hr −6.092* −2.702* −3.368* −1.533* −2.219* −0.997*
and below)
Awareness of insurancea (ref. no) 6.267* 2.193* 3.353* 1.145* 2.367* 0.896*
b
Experienced violence (ref. no) −4.358* −0.548* −2.275* −0.215 −1.618* −0.238*
Respect from patients (ref. dissatisfied)
Moderate 6.059* 1.534* 3.121* 0.790* 2.316* 0.525*
Satisfied 15.669* 3.872* 8.378* 2.131* 5.726* 1.260*
Social recognition (ref. dissatisfied)
Moderate 7.012* 2.302* 3.593* 1.040* 2.762* 1.106*
Satisfied 16.740* 6.516* 8.888* 3.235* 6.251* 2.738*
Collaborationc (ref. dissatisfied)
Moderate 5.171* 1.697* 2.571* 0.798* 2.134* 0.790*
Satisfied 18.320* 6.506* 9.803* 3.435* 6.740* 2.469*
Trustd (ref. dissatisfied)
Moderate 6.381* 2.960* 3.232* 1.500* 2.524* 1.146*
Satisfied 19.222* 6.823* 10.319* 3.752* 7.013* 2.367*
a
Awareness of insurance, being aware of medical liability insurance coverage;
b
Experienced violence, directly experienced patient‐initiated violence in the past 12 months;
c
Collaboration, nurse–physician collaboration;
d
Trust, nurse–physician trust.
*p < .05.

which is closer to satisfied (80 or more) than neutral (60) (Sharp,
2008). Self‐rated health, monthly income, being aware of medical
liability insurance coverage, perceived respect from patients, social
recognition, nurse–physician collaboration, and trust were signifi-
cantly associated with higher job satisfaction scores; on the other
hand, age, hours worked per week, and patient‐initiated violence
were negatively associated with job satisfaction.
One of the strengths of this study is that it includes the largest
sample of psychiatric nurses in China to date. Another strength is the
inclusion of health status and several factors related to stressors in
ZHOU et al.
the work environments of psychiatric nurses in China. These include
patient‐initiated violence, medical liability insurance coverage pro-
vided by the hospital, patients’ respect, social recognition, nurse–
physician collaboration, and nurse–physician trust, which have
rarely been explored in Chinese psychiatric settings.
The general job satisfaction score of Chinese psychiatric
nurses (73.7) is slightly lower than that of 161 psychiatric nurses
working in the New England region of USA (77.6; Sharp, 2008), but
is higher than those of 439 psychiatric nurses working in Finland
(67.4; Hyrkas, 2005), 30 community psychiatric nurses working in
London (66.8) and 31 working in Berlin (71.4; Priebe et al., 2005).
The average item score in the intrisic subscale was higher than that
in the extrinsic subscale among Chinese psychiatric nurses (3.8 vs.
3.5), which is similar to Hyrkas's sample (3.7 vs. 2.7) and Priebe
et al.’s (3.8 vs. 3.3 in Berlin, 3.6 vs. 2.8 in London; Hyrkas, 2005;
Priebe et al., 2005). These results show that Chinese psychiatric
nurses’ satisfaction with their work conditions and rewards was
lower than their attitudes towards the job itself (Hyrkas, 2005;
Priebe et al., 2005).
In our sample, less than 30% of psychiatric nurses reported good
health status and self‐rated health status was positively associ-
ated with job satisfaction. Previous studies also showed that good
health status is essential to nurses’ quality of work performance (de
Oliveira et al., 2017). To improve nurses’ job satisfaction and their
work performance, hospital administrators could put some emphasis
on nurses’ health maintenance.
Notably, we found that overall 63.9% of nurses in tertiary psy-
chiatric hospitals ascertained that they had medical liability insur-
ance coverage and among the 32 hospitals involved in this study,
the proportions of nurses ranged from 37.4%–88.9%. These findings
suggest that these psychiatric hospitals are all compliant with the
national mandates and provide their nurses with medical liability
insurance, but some psychiatric nurses have not realized that the
coverage is available. This study showed that having medical liabil-
ity insurance coverage was associated with higher job satisfaction,
which may be due to these nurses feeling financially protected in
the event of a medical error. Psychiatric hospitals in China need to
make additional efforts to ensure their nurses are aware that this
insurance is available to them (Zhang, 2015).
Similar to previous studies, patient‐initiated violence was nega-
tively associated with job satisfaction (Chang & Cho, 2016; Cheung
et al., 2018; Cheung & Yip, 2017; Purpora & Blegen, 2015), while
perceived respect from patients, social recognition (Lu et al., 2016;
Zhou et al., 2018), as well as nurse–physician collaboration and
trust were positively associated with job satisfaction (Van, Clarke,
Willems, et al., 2013; Van, Clarke, Wouters, et al., 2013; Zhang et
al., 2016). A third of the psychiatric nurses reported having a direct
experience with patient‐initiated violence in the past 12  months
which is higher than that reported among nurses working in gen-
eral hospitals in China (25.8%; Xu & Meng, 2014). About 70% of
nurses were satisfied with the levels of nurse–physician collabo-
ration and trust, while 47.6% and 37.5% of nurses reported satis-
faction with the amount of patient respect demonstrated towards
|
      3627
them and the amount of social recognition given to their specialty,
respectively. This suggests much needs to be done to improve the
work environment and social environment and to provide physical
and legal protection for nurses. The government could consider to
promote the legal system to effectively prevent patient‐initiated
violence against medical staff, improve the recognition and re-
spects from public to specialty of psychiatric nurses (Wang, Wang,
& Zheng, 2012).
Working more than 40  hr per week was negatively associated
with job satisfaction, similar to previous research (Ball et al., 2017;
Baum & Kagan, 2015; Li & Lambert, 2008; Van, Clarke, Willems, et
al., 2013), while monthly income level was positively associated with
job satisfaction, echoing the results of previous research (Holmberg
et al., 2015; Tarcan et al., 2017). Reducing required work hours and
ensuring fair compensation may help in enhancing job satisfaction
among Chinese psychiatric nurses.
Gender, marital status, educational level, and professional title
were not significantly associated with psychiatric nurses’ job satis-
faction and are somewhat consistent with findings from previous
studies (Baum & Kagan, 2015; Tarcan et al., 2017). Although gender
was not associated with general and intrinsic job satisfaction, the
sensitivity analysis indicated that male gender was negatively asso-
ciated with extrinsic job satisfaction scores. The explanation for this
could be that men have a higher expectation of reward from their
employment than women (Gasser, Flint, & Tan, 2000). Similar to the
research by Liu et al. (2015), age was negatively associated with job
satisfaction, while some other studies showed non‐significance be-
tween age (or working years) and job satisfaction of nurses (Baum &
Kagan, 2015; Li & Lambert, 2008; Lu et al., 2007). These compari-
sons reveal that the association between job satisfaction and age or
working years varied in different contexts.
4.1 | Limitations
A few limitations must be acknowledged. First, the representative-
ness of this sample is limited, as our sample was from the provincial
psychiatric hospitals in the capital of each province. Given that China
is a hierarchical society, hospitals in smaller cities and rural areas
often have more limited resources and the overall working condi-
tions and compensation are likely worse (Dong, Li, Cai, & Wang,
2016). Second, causal relationships cannot be established under the
cross‐sectional design. Time‐based data could be collected in future
studies to explore causal relationship between job satisfaction and
influential factors. Third, some of the questions asked in this study
may have generated less reliable responses. For example, income
and work hours were self‐reported. Respondents may have over-
stated or understated their responses. However, since the study was
anonymous and the local cadres had no access to the survey data,
we generally had confidence about the reliability of respondents’
answers. Health status and experienced violence were both elicited
with a single question, which might have missed some more detailed
information about psychiatric nurses. Future research could incor-
porate some additional health scales or questions probing for more
 |
3628       ZHOU et al.
details (e.g., the experience and frequency of verbal abuse, bully-
ing, physical assaults, and sexual harassment Cheung et al., 2018).
Fourth, this study did not assess psychological syndromes (such as
burnout syndrome or mental stress) of nurses (Happell, Martin, &
Pinikahana, 2003; Pinikahana & Happell, 2004) and did not consider
organizational factors (De Gieter et al., 2011). The association be-
tween these factors and job satisfaction could be explored in future
studies.
5 |  CO N C LU S I O N
This study investigated the level of job satisfaction and examined
factors associated with job satisfaction in Chinese psychiatric
nurses in a nationwide sample and revealed that factors related to
stressors in the work environment were significantly associated
with job satisfaction. As psychiatric nurses in China are essential
in providing services to psychiatric patients, the government and
hospital administrators could consider ways to promote nurses’
personal health, to modify the stressful work environment, to pro-
mote recognition and respect from the public for the psychiatric
nurse profession, to promote awareness of the availability of medi-
cal liability insurance coverage and to protect nurses from patients’
violence. Doing so may go a long way towards improving the job
satisfaction of nurses in tertiary psychiatric hospitals and retain-
ing this vital component of the psychiatric workforce. Furthermore,
time‐based data could be collected to explore causal relationships
between job satisfaction and influential factors and the relationship
between psychological syndromes, organizational factors, and job
satisfaction could be explored.
AC K N OW L E D G E M E N T S
The authors would like to thank all the participants of this survey,
and we also appreciate the efforts of the hospital administers who
facilitated the survey.
C O N FL I C T O F I N T E R E S T
No conflict of interest has been declared by the authors.
AU T H O R C O N T R I B U T I O N S
HZ, FJ, LH, TL, SW, HL, YLT, and YL: Made substantial contribu-
tions to conception and design, or acquisition of data, or analy-
sis and interpretation of data; HZ, FJ, JR, YLT, and YL: Involved in
drafting the manuscript or revising it critically for important intel-
lectual content; HZ, FJ, LH, TL, SW, HL, YLT, JR, and YL: Given
final approval of the version to be published. Each author should
have participated sufficiently in the work to take public responsi-
bility for appropriate portions of the content; HZ, FJ, LH, TL, SW,
HL, YLT, JR, and YL: Agreed to be accountable for all aspects of
the work in ensuring that questions related to the accuracy or
integrity of any part of the work are appropriately investigated
and resolved.
ORCID
Yuanli Liu  https://orcid.org/0000-0002-5559-1149
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S U P P O R T I N G I N FO R M AT I O N

Additional supporting information may be found online in the

Supporting Information section at the end of the article. 

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of evidence-based
nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance and with potential to ­advance
knowledge for practice, education, management or policy. JAN publishes research reviews, original research reports and methodological and
­theoretical papers.

For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan

Reasons to publish your work in JAN:

• High-impact forum: the world’s most cited nursing journal, with an Impact Factor of 1.998 – ranked 12/114 in the 2016 ISI Journal Citation
Reports © (Nursing (Social Science)).
• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries worldwide
(including over 3,500 in developing countries with free or low cost access).
• Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan.
• Positive publishing experience: rapid double-blind peer review with constructive feedback.
• Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication.
• Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley Online Library,
as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).