New Publication Focuses on Nurses Returning to School
Employers in the health care industry along with national medical and nursing organizations are placing increased emphasis on nurses earning a baccalaureate degree or higher. This study examines nurse motivation and job satisfaction as mediators between potential inhibitors and intent to return to school. Nurses Returning to School can be found in its entirety at http://doe.state.wy.us/LMI/nursing.htm.
The growing number of pressures placed on the occupation of nursing and the health care industry has been significant. These pressures include nursing shortages, educational attainment, and quality of care. Two recommendations by the Institute of Medicine (IOM) deal specifically with the education level of nurses (2010). The first is increasing the number of nurses with a baccalaureate degree by 80% and the second is to double the number of nurses with doctoral degrees by 2020. The chief arguments for increasing the educational level of the nation’s nurses are to enable them to care for an increasingly diverse population and to contribute to the research and scientific community.
In order to determine the contributing factors associated with a nurse’s decision to return to school, the Research & Planning (R&P) section of the Wyoming Department of Workforce Services administered a survey to Wyoming nurses that included measures of motivation, inhibition, and job satisfaction. The survey also included a question regarding the intent to return to school. The current research adds to the existing literature by examining the relationship between motivators, inhibitors, and job satisfaction on nurses’ attitudes towards continuing their education.
Overview
Spencer (2008) suggests that increasing enrollments in nursing programs will help combat future nursing shortages; however, she cautions that these new enrollments will be mostly concentrated at the associate’s degree (ASN) level. The increased emphasis on earning a bachelor of science degree in nursing (BSN) is not new (American Nurses’ Association, 1965) and has recently gained momentum due to evidence-based practices within the field of nursing becoming dominant (IOM, 2010; Tri-Council for Nursing, 2010). Further, the level of change in technology and the complexity of medical and surgical care are common in a clinical workforce requiring a more advanced skillset (Aiken, Clarke, & Sloane, 2002). More than a quarter of the general public recognizes that nurses should have four years of education in order to fulfill their job duties (Mattson, 2002). The Affordable Care Act (ACA) of 2010 outlines the need to enhance the health care workforce through education and training to improve the delivery of health care services. The ACA also allows for the ability of the U.S. Department of Health and Human Services to award grants to entities that provide for educational advancement to the baccalaureate level. The most important outcome of improving the educational attainment of the nursing workforce is ensuring patient safety and enhancing the scope of practice.
It is not difficult to recognize that in order to meet the present and future demands in the nursing profession, those individuals who already have an ASN may need to pursue their BSN to fill the required vacancies and attain a sufficient level of education. As policy-makers and nursing programs continue to set goals for the future of the nursing profession, several issues still remain in meeting those goals, such as nursing program recruitment and increasing workforce training. With the abundance of individuals graduating with an ASN, the need for programs that allow for a seamless transition to the BSN level is evident.
Nurse Job Satisfaction
Measuring the level of satisfaction in a person’s current employment has been extensively studied by industrial/organizational psychologists. Specific to nursing, much research has focused on job turnover and job satisfaction due to the increasing concerns of nursing shortages currently and in the future. Cortese, Colombo, and Ghilieri (2010) administered a questionnaire to 351 nurses working in Northern Italy regarding their job satisfaction, work-family conflict, and support at work (from colleagues and co-workers). The authors found that as job demands increased, work-family conflict increased which led to a decrease in the overall level of job satisfaction. In a similar study, van der Heijden, van Dam, and Hasselhorn (2009) using a large European sample found that work-family conflict and overall job satisfaction played both direct and indirect roles in a nurse’s intention to leave the nursing profession.
To further advance the knowledge of job satisfaction in nurses, Zurmehly (2008) asked nurses to rate the job characteristics they were most satisfied with in descending order. Results from this study suggest that autonomy, recognition, and critical thinking abilities were variables which influenced higher levels of job satisfaction. However, ability and compensation were variables that were negatively associated with their job satisfaction. Finally, job advancement opportunities were strongly associated with satisfaction (e.g., the more opportunities for advancement, the higher the job satisfaction). The authors posit that the negative relationship between compensation and job satisfaction may be due to nurses placing a high degree of emphasis on intrinsic rewards (e.g., helping others) compared to compensation and other external rewards.
In terms of meeting the educational goals of nursing outlined by the IOM (2010), a focus on working ASN individuals and their level of job satisfaction may be an important factor in keeping them in the nursing field. For instance, an ASN nurse could leave the field of nursing to pursue other opportunities or return to school to have more flexibility and possibly more satisfaction within nursing.
Nurses Returning to School: Motivation, Benefits, and Barriers
For an individual who is employed, returning to school may be a life-changing decision. The individual often weighs the positives against the negatives. Landry, Orsolini-Hain, Renwanz-Boyle, Alameida, and Holpit (2012) distributed an educational needs assessment to ASNs and licensed vocational nurses (LVNs) currently employed in a hospital setting asking about their continuing education intentions including the perceived benefits and barriers of returning to school. The most frequently cited barriers were educational costs, current work commitments, age, and the thought of becoming a full-time student again. The most cited supports needed when thinking about continuing their education were the ability to work part-time, financial assistance, and having child care readily available. Overall, nearly 86% of respondents indicated that they had thought about going back to school to enhance their careers.
Several studies have examined the factors associated with returning to school as an adult, including credit hours transferred and institution type (Lewis & Lewis, 2000), job burnout while in school (Dick & Anderson, 1993), and the effects on work and family stress (Kirby, Biever, Martinez, & Gomez, 2004). However, few studies have been conducted which take into account the level of motivation needed to begin and finish a BSN degree program. The concept of achievement motivation in goal attainment research is wide, especially within the industrial/organizational settings (Ward, 1997). Achievement motivation is a multifaceted concept which describes a “personal striving of individuals to attain goals within their social environment” (Cassidy & Lynn, 1989, p. 301). Individuals with a high level of achievement motivation are thought to be highly competitive and adept at finding ways to improve their job performance and status (Lewin & Stephens, 1992).
As discussed above, the motivators and barriers to continuing education are often thought to be multidimensional. Using a sample of working nurses in Ireland, Murphy, Cross, and McGuire (2006) developed a questionnaire consisting of both potential motivators and inhibitors to continuing education. The authors found numerous factors among the set of questions. For the motivators, two factors were identified: job-related and personal. The job-related construct is thought to tap into how returning to school would increase a person’s professional development in the field of nursing. The personal motivators construct is the motivation necessary to feel an increased sense of competence and importance as a nurse. For the inhibitors, three factors were identified: time-related, outcome-related, and employer-related. The time-related construct is believed to tap into the inhibitors associated with the amount of time available for both work and personal obligations if one returned to school. The employer-related construct taps the perception of a lack of support from employers when deciding to return to school. In the current study, we did not examine the outcome-related construct as all items were theoretically thought to be a part of the other four constructs.
We expected that higher levels of inhibitive forces would create higher levels of personal and professional motivation and a lower level of job satisfaction. Due to past research suggesting that employees find that time commitment (Kirby, et al.. 2004) and employer support (Guffey, West, & White, 1997; Keeling, Jones, & Botterill, 1998) are significant factors when deciding to return to school, the key hypothesis was that when individuals feel they have less time to devote to school and are increasingly discouraged by their employers, personal and professional motivation would mediate the relationship between the inhibitors and intent to return to school. Job satisfaction was expected to have a negative, direct relationship with the intent of returning to school. Mediation occurs when one or more variables accounts for all or part of the relationship(s) between other variables.
Methodology
Sample
R&P collects licensure data for 98 of occupations within the state. Of the 5,212 employed nurses in fourth quarter 2012 (2012Q4) with an active license with the Wyoming State Board of Nursing, a stratified random sample based on seven separate regions1 of the state was selected for a total survey sample of 2,086. Each of the selected participants was mailed a packet of questionnaires (described in the measures section) to their home address as indicated on the Wyoming State Board of Nursing licensing file. Participants were instructed to return their completed questionnaires by mail, fax, or to call R&P staff and give their responses over the phone. A total of 796 nurses completed the questionnaire for a response rate of 38.2%. An additional 298 participants (14.2%) did not have a forwarding address and were not sent another questionnaire packet. The response waves for the 798 nurses were as follows: 50.6% of participants completed the packet during the first mailing, 35.2% completed the packet during the second mailing, and 14.3% completed the packet during the third mailing. Four participants asked to not be included in the study. The vast majority (99.5%) returned their completed packet by mail.
Due to the interest in the attitudes regarding returning to school for nurses currently employed in the health care industry, only those nurses employed full-time or part-time (35 hours or less) in health care were included in the analysis, which resulted in 142 participants being excluded. A total of 159 participants were removed from the analysis because they indicated that they did not know if they planned to return to school or did not respond to the question. Due to the low response rate of the first and second waves of mailings, a shorter questionnaire was created which excluded important questions used in the present analysis. Ninety-four participants who completed this shorter version were excluded from the analysis. Finally, missing data on the questionnaire led to the removal of 98 participants. After all exclusion criteria were imposed, the sample was comprised of 305 participants.
Measures
The motivation and inhibitor questions from Murphy, et al. (2006) were included in the questionnaire2. Participants answered the questions based on the following instructions: “Using a scale from 1 to 3 where 1 means ‘Not at all Influential’ and 3 means ‘Very Influential,’ please circle the response that best describes how you feel about the influence each of the following statements has on your thoughts of returning to school (or not). If you are unsure how to respond to a statement, please mark ‘DK’ for Don’t Know.”3
Job satisfaction was assessed using 13 items ranging from satisfaction with salary to autonomy and work environment. Individuals answered the items based on the following instructions: “Using a scale from 1 to 5 where 1 means ‘Very Dissatisfied’ and 5 means ‘Very Satisfied,’ please circle the response that best describes how you feel about each of the following statements at your primary nursing position.” The Cronbach’s Alpha was .86, indicating good internal consistency for these items as a measure of job satisfaction. The items were averaged across individuals and had a mean of 3.77, SD = .64.
One item was used to assess the individual’s intent to return to school. Respondents were asked, “Do you plan to return to school to further your education?” The responses were in the form of time intervals. Intent was measured with the following four options: “Yes, within the next 3 years”; “Yes, in 3 to 5 years”; “Yes, in more than 5 years”; and “No.” Reponses were coded from 0 (No) to 3 (Yes, within the next 3 years) with higher numbers indicating a more immediate goal of returning to school. It was thought that as nurses endorsed a shorter timespan (e.g., within 3 years) to return to school, the intent to return was greater.
Results
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Table 1 shows the demographic characteristics of the participants included in the analysis. Of the licensed nurses working in Wyoming who responded to R&P’s survey, 45.2% had less than a bachelor’s degree in nursing, 75.7% were employed full-time, and more than half had a primary position of a staff nurse. The majority of the sample (93.1%) was female and of White/Caucasian race (94.8%). A significant percentage (85.3%) indicated they had an annual household income of $50,000 or more a year. The average age of the participants was 46.4 years.
The main goal of this study was to understand the predictive relationships of motivation, inhibition, and job satisfaction on the intent to return to school. In order to test the hypotheses outlined in the introduction, a structural equation model (SEM) approach was employed. SEM uses both observed and unobserved characteristics (e.g., job satisfaction, personal motivation) to predict other characteristics (e.g., intent to return to school).
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The hypothesized model was found to adequately fit the data4, and the final model is presented in the Figure. All paths were statistically significant at the p <.05 level except for the paths from professional motivation to intent to return, and from time constraints to intent to return. A p-value of less than .05 indicates that there is less than a 5% chance that a result occurred by chance alone. All paths were in the expected direction except for the path from professional motivation to intent to return (which was negative instead of the expected positive). The path coefficients in the Figure are standardized and can range from -1.0 to 1.0. The closer the path coefficient is to 1 (either positive or negative) indicates a greater effect.
On the basis of our estimated paths, as perceived employer discouragement increases, personal (.29) and professional motivation (.33) to return to school increases. Employer discouragement had a significant negative effect on job satisfaction (-.30). The estimated paths from time constraints indicated that as perceived time constraints increases, professional (.30) and personal motivation (.37) increases.
The direct path from time constraints to intent to return was positive but was not statistically significant (.11). The direct path from employer discouragement to the intent to return was negative and statistically significant, indicating that as perceived employer discouragement on returning to school increases, the intent to return to school (-.24) decreases.
Several indirect paths should be noted. As employer discouragement increases through both types of motivation and job satisfaction, intent to return to school increases.5
It should be noted that this effect (.20) is slightly lower than the direct effect of employer discouragement on intent to return (-.24). Also, the mediated effect is positive (compared to the negative direct effect) which indicates that as motivation increases and job satisfaction decreases due to employer discouragement, the more likely an individual will return to school. Further, as time constraints increase through both types of motivation, this leads to an increase in the intent to return to school6. This effect was significant (p <.05) compared to the non-significant direct effect of time constraints on intent to return (.11).
Overall, 31.0% of the variance in professional motivation was explained by the model. This means that 69.0% of the variance was explained by other factors not included in the model. Our model explained 33.9% of the variance of personal motivation and 9.2% of the variance in job satisfaction. The low percentage of explained variance in job satisfaction was not surprising as we did not tap into concepts such as job embeddedness (Michell, Holtom, Lee, Sablynski, & Erez, 2001), work/family conflict (Kirby, et al., 2006), job burnout (Dick & Anderson, 1993), or work environment (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). Finally, 35.0% of the variance in likelihood of return was explained by the model.
Discussion
The goal of this study was to examine the structural relationships between the inhibitors (employer discouragement and time constraints) associated with the intent to return to school as mediated by motivation and job satisfaction. The hypothesis that employer discouragement has a significant negative effect on intent to return was supported. Time constraints had a slightly positive effect on returning to school but was not statistically significant. As expected, motivation and job satisfaction have a positive mediating effect between time constraints and employer discouragement on intent to return. These results suggest that as employers discourage (or do not support)their employees from returning to school (or to continue their education) and as time constraints increase, a person is more likely to return to school only if they are sufficiently motivated both personally and professionally.
The hypothesis that professional motivation had a positive relationship with intent to return was not supported. The negative effect of this relationship may indicate that professional motivation is playing a different role on returning to school. However, in our analysis, the effect was not statistically significant so no conclusions could be drawn.
In this study, the relationship between the inhibitors and intent to return was only partially mediated by motivation and job satisfaction. The direct relationship between employer discouragement and intent to return remained statistically significant. This result indicates that even though motivation and job satisfaction do play a role in overcoming perceived employer discouragement, the intent to return is still directly affected by perceived employer discouragement. However, the relationship between time constraints and intent to return was not statistically significant which indicates that time constraints were mediated by motivation.
As the pressure from national organizations, policy-makers, and employers continues to mount for nurses to gain at least a BSN, the need to understand why individuals decide to return to school or not is necessary. This study demonstrated the relationship between two types of inhibitors and their effect on the intent of returning to school. As people view themselves as having an employer who is discouraging them from pursuing education by not providing financial assistance, the required time off to study, or the recognition of staff educational needs, people may rely more on their personal and professional motivation to seek out educational advancement and opportunities. However, the direct relationship between employer discouragement and returning to school is not completely diminished even if a person is personally or professionally motivated. This finding suggests that as people look to their employers for support in returning to school and if nurses perceive a lack of support, this can still hinder continuing their education even if sufficiently motivated for other reasons. This is in contrast to perceived time constraints which had no direct effect on returning to school if a person is sufficiently motivated.
The current study found that job satisfaction is being negatively influenced by employer discouragement. Past research suggests that the more opportunities there are for career advancement, the higher the job satisfaction (Zurmehly, 2008) and that as job satisfaction increases, nurses are less likely to leave their current employment in the nursing profession (van der Heijden, et al., 2009). The findings in the current study support these conclusions. A significant factor in job advancement is often educational attainment. If employers are perceived to be discouraging returning to school (and thus potential job advancement), nurses are less likely to be satisfied on the job. This is likely due to the perceived inability to advance into higher level positions with the current employer. However, as job satisfaction increased, nurses had less intent to return to school. This finding suggests that people who are more satisfied with their jobs are in positions where no further education is necessary to obtain career goals.
Due to employers having such a significant impact on nurses deciding to continue their education, employers should take a more proactive role in promoting employee educational goals. This is consistent with prior research indicating that employees, generally, value tuition assistance highly by viewing it as part of the organizational support system and a reward for performing a job with excellence (Guffey, et al., 1997). However, nursing shortages may be interfering with an employer’s ability to allow nurses to further their education due to hospitals and other care facilities needing to meet required staffing patterns.
Several limitations of the present study should be noted. The age of the sample was relatively high (a mean of 46.4 years). Individuals who are in the middle of their careers or who are nearing retirement age may not be either inhibited or motivated to return to school due to job tenure or impending workforce exit. Replicating the findings using a younger sample should provide additional evidence of the relationships presented in the current study. There were also significantly more females than males which limits the generalizability across gender.
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The survey response rate (38.2%) was low compared to other nursing research R&P has conducted in the past. In 2008, R&P sent a survey to nurses throughout the state and received response rates ranging from 66.6% to 69.9% (Gallagher, Harris, Jones, Knapp, & Leonard, 2008). This report can be found here: http://doe.state.wy.us/LMI/nursing.htm. The large number of questions in the current study may have discouraged potential respondents and resulted in a low response rate. Also, the cover letter that accompanied the survey indicated that the purpose of the study was nursing education and due to the age of the sample may not have been pertinent to a large number of nurses. As seen in Table 2, more than half of the nurses age 55 and older (50.5%) completed the survey compared to 30.6% for those nurses age 35 and younger. Age clearly played a role in the response rate. It should be noted that those who completed the survey may have responded differently compared to those who did not. Also, the response rate differences between R&P studies may simply be due to the time period the survey was conducted (2008 versus 2013) which would indicate economic conditions as a possible contributing factor.
Finally, the amount of variance explained in intent to return was relatively small (35.0%). Current research suggests that inhibition, motivation, and job satisfaction play a significant role in likelihood of return, but other factors should be considered in future research. Labor market factors such as job stability (e.g., using unemployment insurance claims), age, work/family conflict, current wages, and job tenure may have covariate effects on motivation and inhibition and their relationship with returning to school. Further, only one question was used to assess intent to return to school. Future research should include additional questions that tap into continuing education intent.
Future research should include employer satisfaction regarding the skills of newly employed nurses in the health care industry. R&P selects a random sample of employers every quarter through the New Hires Survey and asks about the importance of certain job skills and also the overall satisfaction with an employee’s work skills. Further, the New Hires Survey also asks the employer to indicate the level of education required to perform the duties of the job. Employers may be more likely to support a nurse returning to school if the current skills are perceived to be insufficient to complete the job.
This study adds to the nursing workforce literature by differentiating the roles of motivators, inhibitors, and job satisfaction and their effects on deciding to return to school for employed nurses in the health care industry. The current study was able to use working nurses in the health care industry to advance the understanding of the causal relationships between perceived inhibitors of returning to school and how a nurse’s own motivation can help overcome those barriers. It is evident that employer support plays a significant role in the motivation of a nurse to return to school both in direct and indirect ways. As policy-makers, national organizations, and healthcare employers continue to place an increased emphasis on nurses obtaining a bachelor’s degree, a shift in continuing education support in the workplace environment may be warranted.
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1 Regions include Casper Metropolitan Statistical Area, Cheyenne Metropolitan Statistical Area, Northeast, Southwest, Northwest, Central-Southeast, and Other. These regions are based on the Occupational Employment Statistics (OES) program designation. A map of the regions is available here: http://doe.state.wy.us/LMI/oes.htm.
2 This section discusses the questions included in the current study. Please contact the author for a complete copy of the questionnaire.
3 The motivation and inhibition items were analyzed using confirmatory factor analysis and were found to have adequate goodness-of-fit. For more information on the measurement model, please contact the author.
4 Contact the author for information regarding the goodness-of-fit indices and measurement model coefficients.
5 This effect was calculated by adding -.29 x .90, -.30 x -.15, and .33 x -.33 from the three possible pathways in the estimated model for a total indirect effect of .20 for employer discouragement on intent to return to school.
6 This effect was calculated by adding .30 x -.33 and .37 x .90 from the two possible pathways in the estimated model for a total indirect effect of .23 for time inhibition on intent to return to school.