International Journal of Organization Theory & Behavior

The experience of work in hospital settings and nurse’s perceived need or desire to look for A less stressful,
more satisfying job
B.H. Rountree, Russell Porter,
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B.H. Rountree, Russell Porter, (2009) "The experience of work in hospital settings and nurse’s perceived need or desire to look
for A less stressful, more satisfying job", International Journal of Organization Theory & Behavior, Vol. 12 Issue: 1, pp.1-26,
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 INTERNATIONAL JOURNAL OF ORGANIZATION THEORY AND BEHAVIOR, 12 (1), 1-26 SPRING 2009

THE EXPERIENCE OF WORK IN HOSPITAL SETTINGS AND NURSE’S

PERCEIVED NEED OR DESIRE TO LOOK FOR A LESS STRESSFUL,
MORE SATISFYING JOB
B.H. Rountree and Russell Porter*

ABSTRACT. Work overload is an important and often singular objective for

organizational interventions targeting nurse satisfaction and turnover in
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hospital settings around the world. The centerpiece of many such

interventions involves the reassignment of nursing tasks to lesser licensed
or unlicensed staff in order to provide immediate term relief to over
extended professional nurses. These “Substitution Interventions” (SI) evolve
from the diagnostic assumptions that “lightening the load” of professional
nurses with more plentifully available “others” will provide, even in the
absence of other changes, immediate relief to over-extended staff, reducing
their growing sense of dissatisfaction and, thus, decreasing their desire or
perceived need to look for another job. The purpose of this study is to
critically examine the prevailing diagnostic assumptions that underlie
“Substitution Interventions” (SI) and, propose and test in a sample of
hospital care-givers (n=241) an alternative organization diagnostic model
that may aid in understanding their propensity to fall short of management
expectations.

INTRODUCTION
Currently, reduction in work overload is an important and often
singular objective for organizational interventions targeting nurse
satisfaction and turnover in hospital settings around the world (Cline,
Reilly & Moore, 2004; Adams & Bond, 2003; Adams & Bond 1995;
Helmlinger, 1997; Morgan & Cooper, 2004). The importance of these
------------------
* B.H. Rountree, Ph.D., was Associate Professor at Clayton State University
during the period of this research. Russell Porter, Ph.D., Ed.D. is dean of
Graduate Studies and Continuing Education, and Professor of Business
Administration at Shepherd University. His research interest includes
health organization outcomes, higher education outcomes, and ethics.

Copyright © 2009 by Pracademics Press

 2 ROUNTREE & PORTER

interventions are, in fact, intensifying with increasing vacancy rates in

budgeted positions and instability in a growing number of local
hospital labor markets (Gifford et al., 2002). The centerpiece of
many, if not most, such interventions involve the reassignment of
nursing tasks to lesser licensed or unlicensed staff in order to provide
immediate term relief to over extended professional nurses. For
present purposes, we will refer to these as “Substitution
Interventions” (SI). Senior management in hospitals are frequently
dismayed that the benefits of SI designs are short lived and/or in
some cases actually make things worse (Rountree & Golembiewski,
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2006).
Substitution intervention strategies evolve from the diagnostic
assumptions that “lightening the load” of professional nurses with
more plentifully available “others” will provide immediate relief to
over-extended staff, reducing their growing sense of dissatisfaction
and, thus, decreasing their desire or perceived need to look for
another job. Takase, Maude, and Manias (2005) suggest that this
thinking emerges from a myth perpetuated by research that nurse-
environment relationships are one-way interactions in which nurse’s
respond passively. That is, the direct effects of reducing or removing
antecedent(s) to nurse dissatisfaction will result in improvement (e.g.,
Jansen et al., 1996; Laschinger & Havens, 1996; Mills & Blaesing,
2000; Tummers et al., 2001; Tzeng, 2002).
Other researchers echo and extend Takase, Maude, and Manias’s
concerns (e.g., Adams & Bond, 2003; Salmond & Ropis, 2006). Each
emphasizes the importance that nursing staff attach to stability,
cohesion and comfortable interdependence in the primary workgroup.
Moreover, J. Clay (Personal communication, March 1, 2007), “There
is a sense of needing to be assured that the work team has your
back.” And, A. Dyer (Personal communication, March 6, 2007) , “It is
simply different to know that it is an RN who knows her way around
that you are counting on when several patients are depending on you
for their care and one is in the midst of a medical crisis and
occupying your total time and attention.” From their perspectives,
then, the impact of work overload is best understood in the context of
relationships within the work group and, according to Salmond and
Ropis (2006), the context of the toll on satisfaction that the situation
has already taken on RN members of the workgroup.
 HOSPITALS AND NURSE’S PERCEIVED DESIRE TO LOOK FOR A LESS STRESSFUL JOB 3

Existing literature provides generous guidance in regard to

“pieces and parts.” We know for example that work overload in the
current environment is important and needs be addressed. However,
neither researchers nor practitioners have yet to agree upon a
unifying theoretical model to guide intervention planning. Nor, have
intervention planners or researchers systematically mapped the
causal relationships among these critical underlying variables. The
purpose of this study is to do so; to critically examine the prevailing
diagnostic assumptions that underlie “Substitution Interventions;”
and, to explain why their narrow diagnostic prospect may lead to the
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propensity to fall short of management expectations. Therefore the

model, as theorized here, has not only the objective of deepening our
understanding of quit intentions of hospital bedside care-givers but
also improving our understanding of why the preferred category of
interventions frequently fails to deliver sustainable anticipated
(positive) results. In this study, we acknowledge the cautions of
Cavanaugh (1990; 1992) that well substantiated differences exist in
the quitting behavior of hospital nurses as opposed to other
professional pursuits. We make no suggestion that the findings in this
study can be generalized to professions other than Registered Nurses
practicing at the bedside in acute care settings. To this end, the
following section explains further why this narrowed perspective is
important in and of itself.
In order to properly set the stage for an audience of Organization
Theorists and Behaviorists, several steps seem appropriate. First,
since we insist on role and contextual differences, we begin by
describing the RN role in hospital praxis and examine the external (as
well as internal) pressures for labor productivity that give rise to the
need for intervention. Then, we provide a more detailed explanation
of the general design characteristics and assumptions underlying
“substitution interventions.” And, finally, we introduce and test the fit
of an organizational diagnostic model which differs substantially from
those frequently employed. This theory emphasizes both the direct
and interactive effects of work overload and psycho-social context on
nurse quit intentions.

CONTEXT
Productivity and quality in hospital settings are rooted in human
effort and heavily, if not extraordinarily, dependent upon the
 4 ROUNTREE & PORTER

contributions of Registered Nurses. In hospital praxis, nurses are: the

primary interface with patients and families; the principal providers of
care and treatment; consistent monitors of patient condition; and, the
linking-pin to other services provided by the organization. When
patients are in pain, discomfort or crisis, they or their significant
others call for a nurse. It, therefore, becomes a critical concern for us
all when turnover threatens adequate staffing in hospitals.
Moreover, the U. S. Department of Health and Human Services
(2002) and its counterparts around the globe forecast significant and
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increasing shortages as “baby boomer nurses” retire over the next

decade. And, shortages in several large local healthcare labor
markets are already becoming evident and as a result, vacancies in
budgeted positions are becoming increasingly difficult to fill (Wagner,
2005; Maze, 2004; Grumbach et al., 2001). In as much as
healthcare management can do little externally in the immediate term
except contribute to political pressures on government and academic
institutions to increase supply, this effort focuses on the development
of a deeper understanding of the context in which work overload
engenders quit intentions in hospital nurses in hopes of improving
internal intervention.

External Pressures for Labor Productivity

Rising turnover rates for Registered Nurses are occurring at a
time when U.S. hospitals are experiencing thinning operating margins
resulting from continual tightening in federal reimbursement and
declining revenues associated with increasing market penetration by
managed care plans (Gifford et al., 2002). Given the critical role that
professional nurse care-givers play in acute care settings, healthcare
administrator’s immediate-term responses to these externalities puts
pressure on nurses to increase productivity, e.g., work harder and
longer. Not surprisingly, then, work overload gets identified in
professional and trade publications as well as research journals as a
potent and pervasive source of job strain and dissatisfaction as well
as a prevalent cause of nurses’ decisions to leave their hospital jobs
(e.g., Geiger-Brown et al., 2004). Aiken et al. (2002) caution that
under current conditions the health care workforce faces the serious
risk of losing one in five RNs for reasons other than retirement.
 HOSPITALS AND NURSE’S PERCEIVED DESIRE TO LOOK FOR A LESS STRESSFUL JOB 5

Substitution Interventions
One category of interventions targeting nurse turnover occurs
most frequently in hospital settings. This class of design involves the
redistribution of tasks and alteration in RN mix on nursing units to
include a greater proportion of lesser licensed nurses (LPNs) and
unlicensed support staff. It is based on a simple, seemingly well
supported proposition that work overload Æ dissatisfaction Æ a need
or desire to quit. So, managers assume that introducing almost any
change that “lightens the load” will: decrease overload Æ increase
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satisfaction Æ and satisfied nurses are “stayers.” Albeit, the nursing

literature is replete with reports that such interventions may create
short-term (generally very short-term) relief for professional nurses
but not sustainable positive impacts on work overload, dissatisfaction
and quit intentions.
The redistribution of tasks through the addition of Patient Care
Assistants (PCA) or Patient Care Technicians (PCT) roles and filling RN
vacancies with LPNs/LVNs does allow for the delegation of a variety
of tasks not requiring RN knowledge, skills and abilities (Erwin,
1994). For example, it is now unusual for an RN to change a patient’s
bed because of the addition of PCAs. The logic behind such
interventions seems well substantiated by research indicating that
professional nurses spend a significant portion of their time on an
average shift performing “nonprofessional” tasks. More restrictively
licensed and unlicensed support staff can be supervised by nurse
professionals, perform a variety of tasks on behalf of the RN, freeing-
up time for professionals to spend on more complex clinical tasks
and those requiring their level of license. Those planning
interventions anticipate that divesting “simple tasks” from the RN
role will reduce workload, improve core job characteristics and,
thereby, increase job satisfaction. Moreover, implementation could be
expected to produce reductions in the cost of labor in a time of
eroding hospital operating margins.
Confronting increasing vacancies in tight local labor markets,
many intervention efforts encourage “too much of a good thing” and
the results do not produce expected positive results for RNs or the
patients they serve. The direct substitution of LPNs/LVNs to fill RN
vacancies dilutes the level of expertise brought to the care of some
patients, and support staff beyond some level intensifies work
overload. As we learned in follow-up studies of “work re-engineering”
 6 ROUNTREE & PORTER

initiatives in the late 1990s, outcomes have too often and

unintentionally been unfavorable e.g., RN opportunities to interact
with patients and families decreased; their critical function as
consistent monitors and assessors patient condition diminished;
interruptions in care-giving interfered with continuity of care; RN’s
became concerned about threats to their license; and, contrary to
expectations, experienced meaningfulness of nursing work declined
even as RN job dissatisfaction rose (Salmond & Ropis, 2005). And,
these unintended side effects are perceptible to patients. After all,
when patients are in pain, discomfort or crisis, they or their significant
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others call for a nurse and are generally disappointed, or worse, when
a PCT responds to their call.

CURRENT MODELS OF NURSING TURNOVER

Job dissatisfaction, whether general or specific to job
characteristics, occupies the central role in most, if not all, theories of
nursing turnover intentions and gets included in empirical studies as
the key predictor of voluntary turnover (e.g., Blegen, 1993; Fletcher,
2001; Shader et al., 2001; Shaver & Lacey, 2003; Foley et al., 2003;
McClure et al., 1983, Stamps & Piedmonte, 1986, Kramer & Hafner,
1989, Mueller & McCloskey 1990; McNeese-Smith, 1996, 1999).
Thus, the preponderance of the quantitative research in the nursing
literature concerns itself with assumed causes and observed
covariates of job dissatisfaction among hospital nurses. Likewise,
robust correlations or “main effects” of work overload Æ
dissatisfaction have been identified as a leading cause of nurse’s
quit intentions, or better, nurse’s perceived need or desire to look for
a less stressful, more satisfying job. Takase, Maude, and Manias
(2005) take the position that approaches employed in much of this
research perpetuates a “myth” because it identifies specific
environmental factors as the sole cause of dissatisfaction.
Cavanagh, Fichman, Jenkins, and Klesh (1979), and Cavanagh
(1990, 1992) express caution regarding the statistical interpretation
of this evidence based on the contention that most over simplify the
satisfaction Æ turnover relationship and support their findings with
bi-variate relationships, only, or regression equations explaining
relatively little variation. Moreover, citing well substantiated
differences in the quitting behavior of hospital nurses, they warn that
turnover research conducted with other professionals and in other
 HOSPITALS AND NURSE’S PERCEIVED DESIRE TO LOOK FOR A LESS STRESSFUL JOB 7

environments may be misleading when extrapolated. Thus, although

correlation between work overload, job dissatisfaction and nurse quit
intentions have regularly, though variably, display statistical
significance in nursing studies conducted in hospital settings, a
model and accompanying explanation of the interaction effects
between these variables remains a challenge.
Moreover, qualitative evidence presented in the nursing literature
emphasizes the inclusion of others factors if these relationships are
to be adequately understood. Nursing researchers report that their
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case studies and structured interviews with RNs practicing in hospital

settings accentuate the potential moderating or mediating effects of
cohesion in the primary work group as well the availability of social
and supervisor support in the work demands-turnover relationship
(e.g., Salmond & Ropis, 2005). With consistency the same
investigators advocate abandonment of simplified conceptualizations
and the inclusion of management development and team building
processes in designs targeting nursing turnover. However, with
pressure for immediate term action in hospital settings and in the
absence of compelling quantitative evidence, these “slower to
implement” design components tend to be moved to the “back
burner.”
The importance of interaction effects between these factors tends
not to receive simultaneous consideration in testable models and
quantitative tests of fit to relevant sample data. So, our aim here is to
introduce a more inclusive model theorizing variables and their
interactions and to test the fit of the hypothesis against nurses self-
reports of their experiences of work in a hospital setting.

SAMPLE
Participants in the study include 241 professional nurses working
in a large hospital located in a major metropolitan area in the
southeast. Data were collected on in-patient nursing units from
nurses scheduled to work during a two day period in forth quarter,
2006. The response rate was approximately 60 percent of bedside
care-givers scheduled for work on these days on acute care units.
The sample includes bedside care-givers only. Nurse Managers
and all other RN staff not functioning as a bedside care-giver (e.g.,
wound care and IV team members) have been excluded. Nurses in
 8 ROUNTREE & PORTER

the sample represent a broad age range (range = 22 to 66 years;

mean age = 43.6 years) and have been licensed to practice from one
to forty one years.

THEORIZED MODEL AND MEASURES

In our theory, work overload influences hospital care-giver
intentions to turnover within a psychosocial context. Two factors, we
believe, are particularly important in this regard: Satisfaction with the
work itself (e.g., current state of affection or disaffection with work)
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and the relative presence or absence of Psychological Sense of

Community in the nurse’s primary work group. In addition to exerting
their own direct affects, these factors may mediate or moderate the
work overload Æ turnover intention relationship and lead to a
different intervention design. From a practical standpoint, knowledge
of the causal ordering of these variables has important implications
for intervention planning. Identifying a model of interacting factors
which influence exit intentions provides administrators and managers
with necessary and meaningful information that can be used in
organization diagnosis to guide development of interventions
targeting turnover. Figure 1 depicts the hypothesized relationships
between these factors.

FIGURE 1
Conceptual Model

3. PSOC

4. Intent to
1. Overload
Leave

2. Satisfaction
 HOSPITALS AND NURSE’S PERCEIVED DESIRE TO LOOK FOR A LESS STRESSFUL JOB 9

The Endogenous Variable

The dependent variable in the model is intention to leave. The
intention to quit one’s job is a critical prelude to actually making the
decision to leave. Most researchers now agree that quit intentions are
a final cognitive step in the decision making process of voluntary
turnover (Steel, Ovalle & Nestor, 1984). Moreover, Dalessio,
Silverman, and Schuck (1986) argue that more attention should be
paid to the direct and indirect influences on intentions because they
are more relevant to managers than the act of turnover. In their
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reasoning, when the act of quitting actually occurs, there is little that
the employer can do but “pay the freight.” On the other hand, if
precursors are better understood, managers are more likely to be
able to anticipate unintended negative side-effects and, instead, may
choose to institute pre-emptive changes in design.
Here, Quit Intentions are measured using one of several indices
included in the Michigan Organizational Assessment Questionnaire
(Cammann, et al, 1979; Seashore, et al, 1982). In the scale, two
dimensions of employee intentions get measured across three items
on a Likert type continuum with the mean across items constituting
the scale score. Thus, items in the scale tap not only “thinking about
quitting” but also formulation of the decision to “go looking” for
another job. Scale statistics in the current study are presented in
Table 1.

TABLE 1
Statistics Summarizing Each Scale in Study (n = 241)
Scale Mean Std. Dev. Alpha
Intent to Leave 2.53 .99 .827
Satisfaction 3.61 .81 .752
Sense of Community 3.82 .75 .881
Overload 2.64 .91 .786

Work Overload
As demonstrated in earlier research, work overload seems to
exert a significantly negative effect on voluntary turnover across many
settings and professions (Mueller, Boyer, Price, & Iverson, 1994). In
hospital settings, work overload is among the more prevalent
 10 ROUNTREE & PORTER

explanations for nurse turnover intentions (e.g., Avallone & Gibbon,

1998; Chung & Corbett , 1998; Frisch, Dembeck & Shannon, 1991;
Hatcher & Laschinger, 1996; Lally & Pearce 1996; Murray, 1998;
Snape & Cavanagh, 1993). Albeit, identified causes and covariates of
nurse work overload have changed over time. Specifically, prior to
2000, increasing case complexity associated with rising patient acuity
and declining lengths of stay were common correlates. More recently,
explanations of overload acknowledge that shorter lengths of stay
and higher patient acuity are the norm and tend to focus on
inadequate staffing compounded by increasing, difficult to fill
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vacancies in budgeted positions and decreasing supply of nurses in

local healthcare markets.
Here, we employ a measure of overload specific to nurse
reactions to work in hospitals. The instrument (Rountree & McAvoy,
1991), used principally in proprietary organization development
efforts, assesses the reactions of bedside care-givers in terms of five
items tapping three dimensions: I am having difficulty these days
getting everything I need to do complete by the end of my shift; My
job requires that I do more on a single shift than I am capable of; I am
feeling increasingly frustrated by my work on the unit; The number of
patients assigned to my care is manageable for me (Reverse); and, I
feel overwhelmed by my patient assignment. Thus, by this
conceptualization, nurses are impacted by negative appraisal of their
ability to perform under current workload conditions and exhibit a
negative affective response as they exceed their capabilities and
resources for comfortable coping.
In large scale organization development initiatives targeting nurse
recruitment and retention in hospital settings (Nhealth system change
initiatives = 9; n professional nurses = 8,122) the scale has produced
consistently stable factor structures with items loadings ranging from
0.70 to 0.92 and respectable, above 0.87, alpha coefficients. Scale
statistics in the current study are presented in Table 1.

Psychological Sense of Community in the Primary Workgroup

Several definitions of psychological sense of community (PSOC)
exist in the literature. Sarason (1974) suggested that a psychological
sense of community could be achieved through perceptions of
similarity to others, acknowledged interdependence with others,
willingness to maintain interdependence by giving to, or doing for,
 HOSPITALS AND NURSE’S PERCEIVED DESIRE TO LOOK FOR A LESS STRESSFUL JOB 11

others what one expects from them, and feelings that one is part of a
larger dependable and stable structure. Klein and D'Aunno (1986)
subsequently applied Sarason’s concept of Psychological Sense of
Community to the experience of work. In their view, employee’s
experience of sense of community at work increases as employee's
develop feelings of membership, participation, and identification with
some work or their work-group.
In this study, we define the concept similarly and tap its relative
presence or absence in the experiences of nursing care givers using a
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scale developed and first applied in nursing workgroups by Deckard

and Rountree (1984). Thus, psychological sense of community exists
when members of nursing work groups acknowledge their
interdependence; experience close working relationships; feel that
members are available to and a source of support for one another
when needed; identify with and take pride in the mutual
accomplishments of the group; and, perceive their supervisor as
sensitive to the needs of members and that they treat members with
respect and fair treatment. Therefore, the conceptualization and
measure subscribe closely to the dimensions of PSOC described by
Sarason in his original work.
A distinction, however, deserves comment. As presented and
measured here, psychological sense of community in the nursing
workgroup is not about members ‘liking’ one another nor does its
operational definition require that relationships between members
extend beyond the boundaries of the work environment. In the
common vernacular, the concept relates to ‘professional
relationships’ at work as opposed to social relationships
characterized by “going out” after work, “getting together for dinner”
or exchanging phone calls to “keep up” with what is happening in life
beyond work.
The PSOC scale employed here, as with Work Overload, was
included in the several OD change efforts identified previously
(number of health system change initiatives = 9; number of
professional nurses = 8,122). The scale has produced consistently
stable factor structures with items loadings ranging from 0.68 to 0.90
and respectable, above 0.88, alpha coefficients in each of these
administrations, respectively. Still earlier the PSOC scale was
included in the HayGroup’s study of the nursing shortage that
occurred in the early 1990s (n = 185,000 professional nurses) with
 12 ROUNTREE & PORTER

similar results (Rountree & McAvoy, 1991). Scale statistics in the

current study are presented in Table 1.

Satisfaction with the Work Itself

Job satisfaction is defined as the positive emotional response to a
job resulting from attaining what the employee wants and the values
of the job (Locke, 1976). Porter and Steers (1973) assess the extent
to which the worker “likes their job” and the job “meets their
expectations.” When the unmet wants, needs and expectations of
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the employee build up over time, they result in dissatisfaction or

disaffection with the job and withdrawal. It is apparent in this
definition that leaving and “checking out” (e.g., disengagement) may
be attending outcomes.
Albeit, satisfaction gets operationally defined in several contexts,
with affective and/or cognitive components. Thus, Quinn and Staines
(1979) developed the Facet-specific Job Satisfaction Questionnaire
(i.e., with each item tapping a “facet” of job satisfaction) for use in a
national quality of employment survey. Likewise, Smith’s (1977)
Index of Organization Reactions, widely used in organization
development initiatives at Sears, Roebuck and Company, assesses
Satisfaction with Co-workers as one in a list of facet satisfactions
such as Satisfaction with Pay, Physical Working Conditions, Amount of
Work and Kind of Work. In the Michigan Organizational Assessment
Questionnaire, Cammann and colleagues (1979) incorporate Social
Reward Satisfactions separately from measures of Overall Job
Satisfaction, Intrinsic Rewards Satisfaction and Extrinsic Rewards
Satisfaction. In contrast and positioned within a somewhat more
specific theoretical framework (i.e., job characteristics theory),
Hackman and Oldham (1975) include Satisfaction with Co-workers as
a contextual satisfaction moderating or mediating the affects of job
design characteristics on the creation of critical psychological states
requisite to workers developing internalized work motivation and
general job satisfaction.
Millar and Tesser (1986) have shown that affective and cognitive
measures of job satisfaction differentially predict the same criterion.
On this basis, Brief & Weiss (2002) conclude that job satisfaction can
be approached productively from either. Thus, it is not surprising that
satisfaction (though variously conceived and measured) is regularly
identified as a significant covariate of (dis)satisfaction.
 HOSPITALS AND NURSE’S PERCEIVED DESIRE TO LOOK FOR A LESS STRESSFUL JOB 13

Mobley (1977) argued that job dissatisfaction gets translated into

thoughts of quitting on the expectation that leaving will lead to a more
satisfying job. The research interest in employee turnover has
persisted for more than four decades, with one group of investigators
concerned with “leavers” and another with “stayers.” Many of the
earliest works focused primarily on demographic and situational
variables Æ job satisfaction as predictors of employee intentions.
More recently, Trevor (2001) argues that quit decisions are
influenced by perceived opportunity to replace the current job. In the
current sample and in a great many large local healthcare markets
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around the country, we would argue that such considerations are

minimized by plentiful and expanding opportunity. To wit, one nurse
responding to the current survey responded to a question about the
local job market by saying, “If I really took my time, it might take me a
week to find another job …that didn’t increase my commute.”
Many argue that those who find satisfaction in their work stay
longer and are less often absent. On the basis of their interpretation
of the nursing satisfaction-turnover literature, Irvine and Evans
(1995) and others (Lake, 1998) observe that research has
consistently discovered negative correlation between the two
variables. In fact, the relationship between job satisfaction and
turnover is among the most comprehensively discussed and
researched topics in the turnover literature.
Care-giver Job Satisfaction is assessed here using a two item
scale by the same name developed by Hackman and Oldham (1975).
Specifically, “most people on this job feel very satisfied with this job;”
and, “I am generally satisfied with the kind of work I do.” This
particular scale was selected because of frequency with which it has
been used in earlier research in hospital settings (Simmons et al.,
2001). Scale statistics in the current study are presented in Table 1.

ANALYSES
Early in this research, we employed path analysis as our means of
model testing. Our initial results provided strong support for the
model identified above. Albeit, while path analysis provided a valid
and reliable assessment of the path coefficients, the method did not
possess the potential to explore correlated error terms (Dillon &
Goldstein, 1984). Given this constraint, it was decided that a full
parameter assessment with potential correlated error terms might
 14 ROUNTREE & PORTER

indicate more robust coefficients. Therefore, linear structural

relations (LISREL) modeling (Joreskog & Sorbom, 1989) was used to
determine if the simultaneous full parameter assessment of causal
models with correlated error terms indicated different coefficients
than the path analysis. LISREL was chosen since it is still the SEM of
choice (Kline, 1998). The specific LISREL version used in this study
was 8.72.
Using confirmatory factor analysis (CFA) initially for each of the
four concepts in the model, a structural equation model (SEM) with
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Maximum Likelihood Estimation was created based on the CFA

outcomes. This strategy is recommended to increase the efficiency of
the SEM modeling (Bollen, 1989; Kline, 1998) and allows for
exogenous constructs and the possible causal associations with
endogenous constructs identified by observable variables that
represent each construct (Hayduck, 1987).
The CFA and SEM were both assessed using the original variable
question items, rather than the scaled scores in the path analysis.
Our reasoning was simple and direct. Each of the several constructs
introduced in the model get measured by items representing
underlying dimensions. Consider, for example, that psychological
sense of community exists when members of nursing work groups
acknowledge their interdependence; experience close working
relationships; feel that members are available to and a source of
support for one another when needed; identify with and take pride in
the mutual accomplishments of the group; and, perceive their
supervisor as sensitive to the needs of members and that they treat
members with respect and fair treatment. Thus, the SEM was based
on the original intent of the questions, rather than a combination of
the questions via the scaled scores. Path analysis would not allow for
the strategy used in the SEM. This strategy of assessing the actual
questions (i.e., underlying dimensions) proved to be a more valid
representation of the path coefficients as discussed below.
Each of the four concepts was assessed in the SEM along with
the path coefficients found in the path analysis to compare and
contrast between SEM and path analysis. The SEM conceptual factor
loadings were constrained to the respective concepts and appropriate
correlated error terms were found among the variables representing
the concepts. Table 2 provides the respective conceptual factor
 HOSPITALS AND NURSE’S PERCEIVED DESIRE TO LOOK FOR A LESS STRESSFUL JOB 15

loadings to illustrate the SEM outcomes and Table 3 indicates the

final SEM concept relationships. Figure 2 presents the LISREL results.

FIGURE 2
LISREL Results
E1
0.64

E2 0.70

0.86
E3
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PSOC
0.51
E4
0.63 - 0.27
E5

- 0.61
0.99 510
0.39 0.74
76 0.65
511

77
0.78
0.27 Quit 0.83
512
0.97 Work 0.93
78 Overload 513
- 0.60
79
0.61

710
- 0.64
- 0.50

0.94
58
Satisfaction
59 0.63

Chi-Square = 14.08 df = 35
P value = 0.99937 RMSEA = 0.000
[Correlated error terms not shown from final structural relations analysis]

TABLE 2
Concept Factor Loadings
Types of Concepts Factor
Loading
Panel A. Endogenous Concept (Quit)
510. I frequently think of quitting this job 0.990
511. People on this job often think of quitting 0.653
512. I will probably look for a new job in the next year 0.825
513. I often think about quitting 0.931
 16 ROUNTREE & PORTER

TABLE 2 (Continued)
Types of Concepts Factor
Loading
Panel B. Exogenous Concept (PSOC)
E1. Members of my immediate work group are available when I 0.639
need them
E2. I have close working relationships with members of my 0.704
immediate work group
E3. Members of my immediate work group provide support for 0.861
me when I need it
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E4. Members of my work group depend a great deal on one 0.510

another
E5. I am proud of the quality of care delivered by my work group 0.631
Panel C. Exogenous Concept (Work Overload)
E76. I am having difficulty these days getting everything I need to 0.391
do complete by the end of my shift
E77. My job requires that I do more on a single shift than I am 0.783
capable of
E78. I am feeling increasingly frustrated by my work on the unit 0.967
E79. The number of patients assigned to my care is manageable -0.601
for me
E710. I feel overwhelmed by my patient assignment 0.609
Panel D. Exogenous Concept (Satisfaction)
E58. Generally speaking, I am very satisfied with this job 0.939
E59. I am generally satisfied with the kind of work I do 0.634

TABLE 3
Path Coefficients
Concept Path
Exogenous Relationships PSOC-Satisfaction .742
PSOC-Work Overload -0.611
Work Overload-Satisfaction -0.642
Exogenous-Endogenous PSOC-Quit -0.270
Relationships Work Overload-Quit 0.266
Satisfaction-Quit -0.496

Finally, Table 4 provides the SEM statistical outcomes that were

found to be highly statistically significant.
 HOSPITALS AND NURSE’S PERCEIVED DESIRE TO LOOK FOR A LESS STRESSFUL JOB 17

TABLE 4
SEM Statistical Outcomes
Statistic Result
Minimum Fit Function Chi Square 0.99937
Normed Fit Index 0.99700
Relative Fit Index 0.98900
Root Mean Square Residual (RMR) 0.02260
Standardized RMR 0.02070
Goodness of Fit Index 0.99100
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Adjusted Goodness of Fit Index 0.96600

LISREL VERSUS PATH ANALYSES

The SEM model outcome is highly statistically significant and
indicates that the data are well defined and fit the model in a robust
means. Alternative models were chosen to determine if there were
reciprocal effects inherent in the exogenous-endogenous
relationships (Bollen, 1989), but those models did not fit well (i.e.,
below 0.800 Adjusted Goodness of Fit) and therefore were
abandoned.
The initial confirmatory factor analysis (CFA) models for each of
the exogenous and endogenous concepts were conducted with highly
statistically significant outcomes. Each exogenous and endogenous
concept as indicated in the SEM outcomes had an Adjusted
Goodness of Fit Index of 0.950 or higher (ranging from 0.955 to
0.999) indicating a highly statistically significant outcome (Bollen,
1989). Based on the robust outcomes from each of the CFA
outcomes, the structural equations model (SEM) was tested.
Alternative CFA models were assessed with individual concept
analysis including each potential variable identified in the final SEM
outcome, as well as additional variables that did not have a factor
loading of at least 0.900. Only variables that had a CFA factor loading
of 0.900 were included in the final SEM.
Additionally, each exogenous and endogenous concept was
initially assessed with one other exogenous or endogenous concept
prior to the SEM assessment. Each dual CFA analysis provided
direction for the final SEM assessment. By using the dual CFA
outcomes, the SEM assessment was more reliable in terms of the
factor loadings for the SEM from the individual CFA. As indicated in
 18 ROUNTREE & PORTER

Table 4, the final SEM is highly statistically significantly valid (i.e., GFI
= 0.991 and AGFI = .966). Few SEM assessments are beyond 0.900
and therefore this SEM may be a benchmark begging replication and
extension.
Path coefficients were significantly different among the
exogenous concepts when comparing LISREL outcomes to the path
analysis outcomes. All three relations (i.e., PSOC and Satisfaction,
PSOC and Overload and Overload and Satisfaction) had higher path
coefficients in the SEM model versus the path analysis model. The
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reason for this is the full parameter assessment of correlated error

terms among the variables representing the three exogenous
concepts. With the correlated error terms we have a “full” comparison
of the concepts and thus a more valid representation than path
analysis, as long as the data are fitting well to the SEM. As Table 4
indicates, the SEM is a very tight fit to the data and, thus, the
coefficients identified in Tables 2 and 3 are more representative of
the relations among the concepts.
There are similarities between the SEM and path analysis when
comparing the exogenous Overload concept upon the endogenous
Quit concept (i.e., LISREL at .266 and Path at .233) and the
exogenous Satisfaction concept upon the endogenous Quit concept
(i.e., LISREL at -.496 and Path at -.523). The similarities are due to
the fact that there were few correlated error terms in the variables
representing the respective concepts; meaning that the path analysis
was similar in content to the LISREL analyses.
There were differences in the exogenous PSOC concept upon the
endogenous Quit concept when comparing the LISREL and path
analyses. The PSOC upon Quit relationship increased by over 157%
when using the SEM compared to the path analysis (i.e., LISREL at -
.270 and Path at -.105). The reason here was due to a moderate
number of correlated error terms among the respective variables
representing both PSOC and Quit.
With the increase in the robustness of using full parameter SEM
over path analysis, the path coefficients in the LISREL outcomes
represent a more valid “picture” of the actual situation in the field.
Additionally, by using the actual questions, the intent of the SEM
assessment is more comprehensive than that found with a scaled
score. Although the scaled scores are useful for increasing efficiency
 HOSPITALS AND NURSE’S PERCEIVED DESIRE TO LOOK FOR A LESS STRESSFUL JOB 19

of the concepts at the path analysis level, they lose their robustness
when using SEM analyses.

IMPLICATIONS FOR INTERVENTION DESIGN

Staffing patterns on hospital nursing units have undergone
significant changes, especially since prospective payments. Changes
have followed pressures to relieve strain brought on by RN shortages,
threats to organizational capacity to meet patient demand and/or as
a means of managing the increasing cost of labor. With consistency,
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these changes have involved the modification of the mix of skills

available on direct care units as RN’s work gets reassigned to lesser
licensed and unlicensed personnel. Today, the mix of skills available
on hospital nursing units are simply “lighter” than they were a decade
or so earlier, even with increases in patient acuity and shorter lengths
of stay. As Aiken (2002), Aiken, Smith and Lake (1994), and Aiken,
Sochalski and Lake (1997) point out, they are also variable hospital
to hospital. Nonetheless, a direct effects model has and continues to
influence the design of interventions targeting reductions in turnover
among professional nurses practicing in hospital settings on the
theory that work overload Æ dissatisfaction Æ nurse quit intentions.
This model, appealing in its simplicity, assumptions and speed of
intervention design Æ implementation, suggests that “lightening the
load” of professional nurses increases job satisfaction and improves
the likelihood that nurses will “stick around.” And, with intense and
immediate needs to relieve demands of bedside caregivers, it may
seem prudent to act, even with neglect for the evolution of past
changes. As Yogi Berra said, least it be “déjà vu all over again,”
results here indicate that assessments leading to intervention
designs targeting hospital nurse overload Æ quit intentions will
benefit significantly from simultaneous consideration of the psycho-
social context in which nurse’s experience overload.
The present study endeavors to amplify the assumptions on
which interventions targeting work overload Æ quit intentions arise by
proposing that the popular conception (model) of direct effects is
underspecified, then introduced and tested an alternative model
emphasizing the importance of the psychosocial context in which
bedside care-giver’s experience overload and decide to leave
employment in hospitals. Our theory emphasizes the strength of
interactions between psychological sense of community in the
 20 ROUNTREE & PORTER

primary workgroup, job satisfaction and work overload in the

formulation of nurse quit intentions. Indeed, the unusually strong fit
of hospital nursing data to the proposed model supports the
contention that attention to interaction effects enhances the
explanation of quit intentions.
The model evolved from our personal observations and missteps
in OD practice; the continuing assertions of nursing researchers in
qualitative studies that workload must be evaluated in psychosocial
context in order to be meaningful; and, a growing quantitative
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literature suggesting that staffing levels (skill mix) impact both quality
of care and patient safety. Thus, we believe that the propensity of
planners to construct intervention designs that concentrate
exclusively on “lightening the load” of RNs (to the neglect of other
factors) are likely to continue to fall short in producing sustainable
positive effects on the quit intentions of hospital RNs.

ACKNOWLEDGEMENTS
The authors would like to express their appreciation to Dipen
Patel of the healthcare management program at Clayton State
University for his valuable contributions in the collection of data and
preparation of this manuscript.

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