Factors influencing job satisfaction and ethical dilemmas in acute psychiatric care

INTRODUCTION

Job satisfaction among nurses has traditionally andconsistently been linked to staff turnover (Cavanagh,1990). High rates of staff turnover cause negativeeffects on productivity and effectiveness (Hinshaw &Atwood, 1984). Previous research has identified thatnursing work is stressful (McLeod, 1997) and that theincidence of occupational stress-related burnout isdouble that of other professions (Inaoka et al., 1986).Rees & Smith (1991) identified mental health nurses,community mental health nurses and speech thera-pists as the groups with the highest levels of stress.The review of stress and burnout in communitymental health nursing performed by Edwards et al.(2000) provides evidence that health professionalsworking as part of community teams experienceincreasing levels of stress and burnout as a result ofincreasing workloads, increasing duties and lack of

supportive resources. Stress can be viewed as adynamic process and a reciprocal relationship be-tween the nurse and the environment (Lazarus &Folkman, 1984). Stress is neither a static feature of the environment nor a stable personality disposition,but a transactional phenomenon that arises becauseof certain types of person–environment dynamics(Bartlett, 1998, p. 151).

Several studies focusing mainly on stress andburnout in psychiatric nurses that work in in-patientcare settings have been found in the research (Fagin et al., 1995; Sundin-Huard & Fahy, 1999). Hummelvoll& Severinsson (2001a) found that the demand for‘treatment effectiveness’ seems to promote a medicalmodel in the daily work of nurses despite the fact thata humanistic and existential approach can be found inthe nurses’ caring philosophy. This situation can thengive rise to moral distress. Robertson et al. (1995)found a very strong relationship between job satisfac-tion and quality of patient care. They used an in-depthobservational study of four psycho-geriatric hospitalsfocusing on the quality of care perceived by patientsand how this was affected by the level of job satisfac-tion among the nurses. The authors identified the fol-lowing inter-related factors of job satisfaction with

Nursing and Health Sciences (2001), 3, 81–90

Research Article

Factors influencing job satisfaction and ethical dilemmasin acute psychiatric care

Elisabeth Severinsson, rpn, rnt, mnsc, drph1,2 and Jan K. Hummelvoll, rpn, rnt, ba, drph1,3

1Department of Nursing Education, Hedmark College, 2University of Oslo, Institute of Nursing Science, Osloand 3Gjovik College, Faculty of Health Studies, Gjøvik, Norway

Abstract This study addressed the factors that nursing staff perceived as creating job satisfaction in theirworking environment in addition to addressing the ethical dilemmas that staff experiencedwithin an acute psychiatric care setting. It also addressed how clinical supervision contributed tojob satisfaction among staff as well as the differences between staff who attended and staff whodid not attend to clinical supervision. Data were analyzed using descriptive statistics. Overall, theresults of this study showed that the factors influencing nurses are related to areas of dissatisfac-tion, for example, stress and experiences with shortcomings. Factors that contribute to job satis-faction or dissatisfaction were found to be related to the nurses’ value systems. The ethicaldilemmas that were specifically addressed involved how to care for patients and handle work inrelation to patients’ autonomy, how to approach the patient, how to provide care against the willof the patient, and what action was ethically right for each particular patient.

Key words clinical supervision, ethical dilemmas, job satisfaction, psychiatric care.

Correspondence: Professor Elisabeth Severinsson, Södra Gåsekilsvägen4, SE-439 94 Onsala, Sweden.Email: [email protected] 11 April 2001; accepted 17 May 2001.

82 E. Severinsson and J. K. Hummelvoll

regard to quality of care: (i) high levels of job satisfac-tion may lead to high-quality care, possibly throughincreased staff motivation and interest in their work;and (ii) poor job satisfaction would have the oppositeeffect. This suggests some kind of mutual feedbackmechanism. Low satisfaction, for instance, can lead toa decline in the quality of care extended to patients,and this further diminishes the satisfaction that nursesgain from their work. Furthermore, these factorsmight be linked through the influence of some thirdfactor such as contextual aspects, organizational bar-riers, unsatisfactory work environments and/or diffi-culties experienced with teamwork. However, it isthese daily hassles and events that are considered tobe factors that provide meaning for nurses working inin-patient psychiatric care.

Berg & Hallberg (2000) studied psychiatric nurses’lived experiences of working with in-patient care in ateam psychiatric ward in order to reveal the meaningof being a nurse. In their study, three main themesemerged: (i) developing a working relationship withthe patient; (ii) encountering and handling the un-foreseeable in daily living; and (iii) struggling withprofessional independence and dependency. More-over, there is evidence in the literature of a correla-tion between moral distress and burnout in nurses(Sundin-Huard & Fahy, 1999). Previous research onethical distress indicates that the higher the moral dis-tress experienced by the nurse, the more likely theyare to burnout, and possibly abandon their profession(Cameron, 1997).

There is evidence in research to support the theorythat the effects of clinical supervision helps nurses to retain their integrity (De Raeve, 1997), influencesnurses’ decision-making (Berggren & Severinsson,2000) and influences nurses’ sensibility towards theirpatients as well as their personal growth (Severinsson& Hallberg, 1996).

To further examine work-related stress, job satis-faction was surveyed among a sample of staff as apart of a broader study (Hummelvoll & Severinsson,2001a,b). The present study addressed what staff per-ceived as creating job satisfaction in their workingenvironment in addition to the ethical dilemmas thatstaff experienced within an acute psychiatric caresetting. It also investigated how clinical supervisioncontributed to job satisfaction as well as the differ-ences between the staff attending and the staff notattending clinical supervision.

RESEARCH SETTING AND METHODS

This research took place in a county psychiatric hos-pital in Eastern Norway in an acute ward with 22

nursing staff positions (four psychiatric nurses, ninenurses, five assistant nurses and four unskilled assis-tants), a social worker, a chief physician, two regis-trars (80%), an assistant occupational therapist (50%)and a secretary (50%). Thirty-seven percent of thesepositions were vacant and were temporarily filled byunskilled assistants. The mandate of the ward was totake care, assess and treat patients with an immediateneed of psychiatric specialist expertise (regulated bylaw). The patients are often in a state of crisis withmainly psychotic reactions, of which affective disor-ders constitute a considerable part. Due to a highadmission threshold and only 12 beds, the patientssuffering from complex psychosocial problems haveonly a short time to get acquainted with the ward, tobe ‘seen’ as persons and to receive help. Similarly,the staff had limited times for assessing, diagnosing,establishing relationships with patients and imple-menting treatment programs. During the period ofdata collection, the turnover of patients was relativelyhigh (mean : 11 days). Up to 33% of the patients areadmitted involuntarily to the ward. The dischargethreshold towards the local communities and primarycare was low. Therefore, treatment has a tentative andsummary character in the form of crisis intervention(Hummelvoll & Severinsson, 2001a) and readmissionis a phenomenon the staff have to adjust to.

Instruments

The instrument package contained three question-naires related to job satisfaction and perceptions ofethical dilemmas. The first questionnaire, a demo-graphic data questionnaire for nursing staff, consistedof five items: age, sex, years of work in psychiatriccare and general care, attending or not attending con-tinual group supervision. The second questionnairecontained the following areas of job satisfaction andwork environment: commitment to career, influenceon duties, routines, communication, meaningful work,organizational changes, workload, job stress, job moti-vation, job expectations, and security at work. Theinstrument consists of 26 Likert-type items that arerated on an ordinal scale from 1 (not at all) to 6 (verymuch so). In the third questionnaire, a 27-item, 7-point scale was used to measure staff’s perception ofethical dilemmas (Lützén, 1993). This questionnairewas designed to express benevolence or the moralmotivation to do ‘good’; interpersonal orientation,which focuses on building a trusting relationship;finding ways of responding to patients’ individualneeds; structuring moral meaning, which refers to theways of deriving moral meaning from decision-making and actions undertaken; modifying autonomy

and experiencing moral conflicts; and confidence innursing knowledge (Lützén, 1993). The content valid-ity, construct validity and reliability of the question-naires have been established. Construct validity wasaddressed through factor loading and the overallCronbach’s alpha coefficient was 0.73 (Lützén,Nordström & Evertzon, 1995) and 0.74 (Severinsson& Kamaker, 1999). All 27 staff known to be in theward at the time of the survey were given the packageof questionnaires by the charge nurse.

Data analysis

Data were analyzed using descriptive statistics.The responses to the statements in the Job Satisfactionand Work Environment Questionnaire and the MoralSensitivity Questionnaire were analyzed by means offactor analysis with varimax rotation (Polit & Hungler,1995). This was done to condense the number of itemsand to identify related factors. These factors were usedfor the descriptive and inferential analyses. To esta-blish internal consistency, Cronbach’s alpha and Spearman’s rank correlation coefficient were used tocalculate the correlation between the instruments(Cronbach, 1990; Siegel & Castellan, 1988). The Statis-tical Package for Social Sciences (SPSS, 2000) version10.0 was used for statistical analysis.

RESULTS

Twenty-seven questionnaires were distributed and 23were returned, giving a return rate of 85.2%. Therespondents’ (N = 23) demographics show that theirmean age was 39.1 years (SD 8.7), their experience ofpsychiatric nursing was a mean of 7.8 years (SD 2.3years), their experience of supervision was 2.5 years(SD 1.8 years) and that 11 respondents had previoussupervision experience (Table 1).

Job satisfaction and work environment

The principal component analysis factor extractionafter varimax rotation revealed five factors using26.9% of the variance, each factor having an Eigen-value above 1.5. These factors were labeled ‘stress andexperiences of shortcomings’, ‘general satisfaction’,‘managerial support’, ‘communication and coopera-tion’ and ‘professional development’ (Table 2). Theoverall alpha coefficient was 0.91.

Ethical dilemmas

Based on the outcome of the factor analysis, a 6-factor solution was chosen for the items reflecting the

nurses’ experiences of ethical dilemmas in acute psy-chiatric care (17.6% of variance, each factor havingan Eigenvalue > 2.0). The interpretation was made of the underlying content of the items within eachfactor. Six factors were labeled ‘patient autonomy and collaboration’, ‘ethical conflicts’, ‘decision-makingaccording to norms and duties’, ‘primacy of a caringrelationship’, ‘following rules’ and ‘benevolence andmoral sensing’ (Table 3).

Relationships between the factors

The correlations between the two areas of job satis-faction and ethical dilemmas in acute psychiatric care are described in Table 4. Stress and experiencesof shortcomings showed a moderate correlation with‘ethical conflicts’ (P < 0.01). In addition, a mild corre-lation was revealed in the total score of the factors of‘job satisfaction’ and the factor ‘ethical conflicts’(P < 0.04) as well as between ‘job satisfaction’ and thefactor ‘following rules’ (P < 0.04).

Descriptive data and comparisons between the re-spondents who attended and those who did notattend supervision are shown in Table 5.

DISCUSSION

The aim of this study was to survey those elementsthat the staff perceived as contributing towards jobsatisfaction in addition to the ethical dilemmas faced

Job satisfaction and ethical dilemmas 83

Table 1. Description of the respondents (n = 23) workingin the acute psychiatric ward

Demographic Variable information

GenderFemale/male 11/12

AgeYears (mean ± SD) 39.1 ± 8.7

Professional backgroundRegistered nurse 10Specialist in psychiatric nursing 4Enrolled nurse 3Unskilled assistant 5Physician 1

Experience of general health careYears (mean ± SD) 7.8 ± 2.3

Experience of psychiatric health careYears (mean ± SD) 8.2 ± 1.4

Supervision (yes/no) 11/12Experience of supervision

Years (mean ± SD) 2.5 ± 1.8


within their work environments in an acute psychi-atric care setting. We also wanted to investigate howclinical supervision contributed to their job satisfac-tion and to look at the differences that existedbetween the nurses attending and those not attendingclinical supervision. Data were collected by using a package of instruments, and the questions wereanswered according to a Likert scale.

Factors influencing nurses’ job satisfaction andethical dilemmas were statistically analyzed. Overall,the results of the study showed that factors that in-fluence nurses are related to areas of dissatisfaction,i.e. stress and experiences of shortcomings. On the

other hand, factors in the work environment, forexample, general satisfaction, managerial support,communication and collaboration as well as profes-sional development and goals of nursing, were alsoreported to have an influence on job satisfaction.

Ethical dilemmas were specifically concerned with how to care for and handle work in relation to patients’ autonomy, ethical conflicts of how toapproach the patient, how to provide care against thewill of the patient, and what action is ethically rightfor a particular patient. Ethical dilemmas also in-cluded what is right and what should be done, how torecognize one’s own values and norms that have an

Table 2. Factor analysis of the items reflecting the nurses’ experiences of their work environment in acute psychiatric care

Factors and loadings Loading on primary factor

Factor 1 (Eigenvalue 7.0, Percentage of variance 26.9, Cronbach’s alpha 0.92)Stress and experiences of shortcomings

Q17 I have too much to do 0.93Q20 I am worried that I can not manage well at work 0.88Q16 I feel stressed in my job 0.88Q 21 I am concerned about my job 0.88Q15 I am feeling heavy pressure of work 0.78Q14 I have difficulty in planning my job because of a poorly written job description 0.76Q19 I am feeling time-related pressures and there is a risk of failure and misunderstandings 0.73Q18 I feel my work takes time away from ‘direct’ work with the patients 0.72Q 13 I have difficulty in doing my job because of lack of planning and unnecessary routines 0.72

on the wardFactor 2 (Eigenvalue 6.7, Percentage of variance 25.6, Cronbach’s alpha 0.92)

General satisfactionQ1 I feel my job is interesting and stimulating 0.91Q23 I have good relationships with colleagues and I cooperate well 0.90Q25 I get support from my colleagues when I need it 0.88Q2 I feel my job is varied 0.87Q24 I feel that we have good collegiate relations 0.81Q4 I can use my capabilities at work 0.75Q26 I feel free to express my (professional) opinions 0.71Q6 I feel that my colleagues are open to new ideas 0.68Q7 I agree with the charge nurse about the goals of nursing 0.59

Factor 3 (Eigenvalue 3.4, Percentage of variance 13.1, Cronbach’s alpha 0.80)Managerial support

Q12 I feel that I get feedback from my senior nurse 0.82Q5 I have possibilities to learn new things 0.79Q10 I can discuss work-related problems with my seniors 0.75Q11 I receive confirmation from my senior nurse when I do a good job 0.53

Factor 4 (Eigenvalue 2.5, Percentage of variance 9.7, Cronbach’s alpha 0.80)Communication and cooperation

Q9 I can get information about changes and restructuring at the hospital 0.77Q8 I get the information I need when my work situation changes 0.75Q 22 I feel my job has been more stressful in the last few months 0.61

Factor 5 (Eigenvalue 1.5, Percentage of variance 5.7, Cronbach’s alpha 0.65)Professional development

Q3 I have possibilities to develop my professional career 0.86


Table 3. Factor analysis of the items reflecting the nurses’ experiences of ethical dilemmas in acute psychiatric care

Factors and loadings Loading on primary factor

Factor 1 (Eigenvalue 4.7, Percentage of variance 17.6, Cronbach’s alpha 0.75)Patient autonomy and collaboration

Q17 Most of all, it is the reaction of the patients that lets me know if I have made the 0.84right decision

Q19 My own experience is more useful than theory in situations where it is difficult to 0.77know what is ethically right

Q3 It is important that I get a positive response from the patient in everything I do 0.71Q27 I find meaning in my role even if I do not succeed in helping a patient gain insight into -0.64

his or her illnessQ7 I believe that good care includes respecting the patient’s self-choice 0.52

Factor 2 (Eigenvalue 3.7, Percentage of value 13.6, Cronbach’s alpha 0.73)Ethical conflicts

Q8 I am often confronted with situations where I experience a conflict as to how to 0.82approach the patient

Q23 I find it difficult to give good care against the will of the patient 0.79Q10 I often face situations where it is difficult to know what action is ethically right for 0.75

a particular patientFactor 3 (Eigenvalue 3.1, Percentage of value 11.5, Cronbach’s alpha 0.73)

Decision-making according to norms, duties and rulesQ24 In situations where it is difficult to know what is right, I consult my colleagues about 0.73

what should be doneQ 11 If I am unacquainted with the case of a patient, I follow the rules that are available -0.67Q6 When I have to make difficult decisions for the patient, it is important to always be 0.63

honest with him or herQ1 It is my responsibility as a nurse to have knowledge of the patient’s total situation 0.59Q16 I rely mostly on other nurses’ knowledge about a patient when I am unsure about him/her -0.55Q18 I often think about my own values and norms that may influence my actions 0.50Q26 As a nurse I must always know what individual care a patient on the ward is entitled to 0.48

Factor 4 (Eigenvalue 2.6, Percentage of value 9.8, Cronbach’s alpha 0.46)The primacy of a caring relationship

Q12 What is most important in care is my relationship with my patients 0.81Q15 I think that good care often includes making decisions for the patient 0.78Q5 If I were to lose the patient’s trust, I would feel that my work would lack meaning 0.66Q21 I believe that good care includes patient participation 0.63Q2 My work would be meaningless if I never saw any improvement in my patients -0.58Q13 I often face situations where I have difficulty in letting a patient make his or her 0.42

own decisionFactor 5 (Eigenvalue 2.2, Percentage of variance 8.1, Cronbach’s alpha 0.68)

Following rulesQ20 It is important that I have rules to follow when a patient refuses treatment 0.81Q14 I always base my actions on medical knowledge of what is the best treatment, even if 0.72

a patient protestsFactor 6 (Eigenvalue 2.0, Percentage of variance 7.6, Cronbach’s alpha 0.57)

Benevolence and moral sensingQ9 I believe that it is important to have firm principles for the care of certain patients 0.73Q4 When I need to make a decision against the will of a patient, I do it according to my 0.69

opinion about what is good careQ25 I rely mostly on my own feelings when I have to make a difficult decision for the patient 0.55Q22 I am often caught in predicaments where I have to make decisions without the patient 0.55


influence on one’s actions, and how to create a goodrelationship with the patient, while at the same timefollowing the ethical principles of nursing and usingbenevolence and moral sensing.

The discussion is divided into two parts. The firstpart discusses the factors that influence job satisfac-tion and the provision of quality of care in relation toprevious research into job satisfaction in nursing. Thesecond part focuses on the nurses’ experiences ofethical dilemmas at work related to clinical supervi-sion, i.e. the differences in relation to attending versusnot attending clinical supervision as well as reportedeffects of clinical supervision.

Factors influencing the provision of quality of care

The main factor, stress and experiences of shortcom-ings, showed a significant correlation (P < 0.00)with nurses’ experiences of ethical conflicts in the

delivery of care. This finding of job-related stress con-cerns high workloads and time constraints, and theperceptions associated with these including risk offailure and misunderstandings related to the deliveryof nursing care. In addition, the nurses reported diffi-culties in planning their work because of diffuse jobdescriptions and unnecessary routines on the ward.This may partly explain the high turnover of patientsas well as the nurses’ experiences of shortcomings. Italso questions the quality of care and patient satisfac-

Table 4. Spearman’s correlation analysis between the factors

Stress and experiences of General Managerial Communication Professional Total

Job satisfaction shortcomings satisfaction support and cooperation development score

Ethical dilemmasPatient autonomy and 0.35 -0.14 -0.17 0.01 0.69 -0.02

collaborationEthical conflicts 0.71** 0.16 0.15 0.23 0.17 0.48*Decision-making according to 0.22 -0.17 -0.41 0.23 -0.06 0.21

norms and dutiesThe primacy of a caring -0.06 0.39 0.00 0.05 0.13 0.22

relationshipFollowing rules -0.45 0.15 0.12 -0.37 -0.26 -0.49*Benevolence and moral sensing 0.03 -0.08 -0.41 -0.32 -0.40 -0.41

Total score 0.32 -0.11 -0.36 -0.25 -0.24 -0.31

*P< 0.05, ** P <0.01.

Table 5. Descriptive data (mean rank) on differences inthe respondents’ supervision related to the factors of jobsatisfaction and ethical dilemmas (Mann–Whitney U-test)

No supervision Supervisionn = 9 n = 11 P-value

Job satisfactionFl° 5.7 13.3 0.00**F2^ 8.4 10.6 0.43F3ƒ 9.2 9.8 0.86F4≈ 9.9 9.11 0.79F5∆ 8.9 10.1 0.66

Total score 7.1 11.9 0.06

Ethical dilemmasF1« 10.4 10.5 1.0F2» 6.0 14.1 0.00*F3… 12.0 9.2 0.33F4� 8.9 11.8 0.29F5À 12.8 8.6 0.13F6Ã 11.0 10.0 0.77

Total score 10.1 10.8 0.82

∞Includes 9 items (range 9–63), ^includes 9 items (range9–63), ƒ includes 4 items (range 4–28), ≈ includes 3 items(range 7–21), ∆ includes 1 (range 1–7), « includes 5 items(range 5–30), » includes 3 items (range 3–18), … includes 7 items (range 7–42), �includes 6 items (range 6–36), Àincludes 2 items (range 2–12), Ã includes 4 items (range4–24). A high score means a strong relationship with clinicalsupervision. * P-value < 0.05, ** P-value < 0.01.

tion with the care provided as patient satisfaction hasbeen found to be an important aspect of quality ofcare (Johnson, 1996). These aspects are consequencesof stress and burnout and contribute to the existingknowledge about stress in nursing (Edwards et al.,2000).

One important finding in this study was a moder-ately significant correlation (P < 0.01) between stressand shortcomings as well as nurses’ experiences ofethical conflicts in providing care. These conflictsincluded difficulties about how to approach patients,giving care against the will of a patient, and decision-making. According to Demerouti et al. (2000), jobdemands, such as demanding contacts with patientsand time constraints, are predictive of exhaustion andpoor job resources. Examples of the latter are poorpersonal rewards and lack of participation in deci-sion-making, factors that are predictive of disengage-ment from the work situation. It has been found that,when nurses perceived their job as unsatisfactory,they developed a distancing attitude towards theirnursing tasks (Demerouti et al., 2000). Nurses mayalso distance themselves from patients that they aretaking care of, other staff, and possibly from them-selves (Cameron, 1997). There is also evidence thatnurses experience moral stress as a result of a highworkload, low influence over their work and in-structed assignments, limited opportunities for en-hancement of skills, and diminishing support fromtheir supervisors. This creates considerable tensionand results in the deterioration of working conditionsand decreased job satisfaction (Severinsson &Kamaker, 1999). According to Sundin-Huard & Fahy(1999), nurses who experienced moral distress andwho attempted to advocate on behalf of vulnerablepatients without success experienced intensified moraldistress, frustration and anger. As nurses’ moral dis-tress is a factor that has previously been linked toburnout (Kendrick & Cubbin, 1996), it may be neces-sary to explore the consequences of behavior that isassociated with burnout as well as the relationshipbetween such behavior and patient satisfaction withthe care provided.

Another important finding was the significant cor-relation of stress and experiences of shortcomingswith ‘following rules’. The relationship between nurseand patient is the core element in psychiatric nursing(Hummelvoll & Barbosa da Silva, 1994). The relation-ship is grounded in respect for the individual patient’strust, and participation in the care. This relationship isdependent on nurses’ abilities to be autonomous intheir profession. It is likely that different health-caredelivery systems affect job satisfaction and the qualityof care in different ways but that the impact may vary

depending on other factors in the environment. Inthis study, the heterogeneous patient group is takencare of by the primary nursing system on the ward.This system is complemented with ‘day contacts’ inorder to compensate for the absence caused by shift-work and sick leave. Ideally, primary nursing shouldaddress each patient’s needs, but patients who clearlyarticulate their needs, claims and wishes tend to begiven priority (Hummelvoll & Severinsson, 2001b).Quiet and silent patients are put on a ‘waiting list’with regard to attention and contact. This fact, whichis known to the nurses, may stimulate feelings ofshortcomings and contribute to work-related stress.The primary nursing system moves towards ‘ideologi-cal crumbling’ as primary nurses have limited time forassessing and establishing relationships with patients,and are often absent when their patients are dis-charged from the ward. Some patients do not knowwho their primary nurse is, and the arrangement withday contacts does not compensate for the lack of con-tinuity. Consequently, the essential characteristics ofprimary nursing are not fully present (i.e. continuous,holistic and person-oriented care as well as being aprimary nurse that is autonomous, responsible andhas authority). With high turnovers in staff andpatients, it can be difficult to achieve and maintaingood relationships with individual patients. If nursestake responsibility for inviting a patient into such arelationship, it is essential that they also complete therelationship when the patient is discharged from theward. If the patient is discharged without the nursebeing informed or not being aware of the decision ofdischarge, the primary contact nurse might developguilt because of not being able to fulfil the agree-ments made in the nursing-care plan for the patient.Nurses commit themselves to the patient by enteringinto the relationship.

The way that care is organized (e.g. primary care orteamwork) and the rules and routines at the institu-tion also may have an impact on the quality of care.One of the ethical dilemmas experienced by nurseswas how best to follow the rules. Another ethicaldilemma was the difficulties incurred when decision-making. To be able to make decisions, there is a needfor information and the possibility to reflect and tocommunicate with other team members. Karasek &Theorell (1990) identified the importance of highwork demands, low influence over decisions and poorfeedback on performance. In this study, the staffreported a low influence over decisions related to thepatient’s autonomy and collaboration with other staff.Further, it seems that the issue of leadership wasoften unclear in relation to who was responsible forindividual patients. It also was unclear as to what



information the individual staff members wereexpected to have in order to enable effective commu-nication with those with responsibility for thepatient’s care.

Ethical dilemmas and clinical supervision

It is not only information and knowledge that influ-ences nurses’ actions, attitudes, values and ideas ofhow to improve quality of care. Clinical supervisiongives nurses the opportunity to learn about their ownvalues through engaging in dialogue, reflecting andexploring (Severinsson, 1995; Severinsson, 2001). Itwas possible to readily differentiate between the staffattending and those not attending clinical supervisionin terms of job satisfaction and experiences of ethicaldilemmas. In light of these findings concerning clinicalsupervision, there are several aspects that may be discussed.

A significant difference (P < 0.00) was foundbetween the groups with and without systematicsupervision. Staff who attended supervision experi-enced stress and perceived shortcomings to a higherdegree (P < 0.05). This is in accordance with previousresearch by Severinsson & Kamaker (1999) and canbe interpreted as staff who attend supervision havingan increased awareness of moral issues that makesthem more susceptible to stress (Johns, 1995).However, it is possible for the nurse, who takes partin clinical supervision, to become a skilled practi-tioner and to upgrade her profession. Also, throughclinical supervision, nurses might become more awareof patient needs. This awareness is believed to be aneffect of systematic clinical supervision and has beenreported previously by Paunonen (1991) and Hallberg(1994).

Staff who attended supervision also showed ahigher mean score related to the factor of ‘primacy ofa caring relationship’ than those who did not attendsupervision. There was also a difference related to‘following rules’ and ‘ethical principles’. The staff whoattended supervision seemed to feel less bound tofollow the rules. This might be explained by thenurses having had the possibility to reflect on theiractions and to gain a deeper insight into their ownethical values. They have also had the opportunity toreflect on their moral decision-making and the impor-tance of taking time to reflect before making deci-sions (Lantz & Severinsson, 2001).

Methodological aspects of the study

A package of three questionnaires related to staff jobsatisfaction and perceptions of ethical dilemmas was

used. There are limitations in this study that have tobe recognized: (i) data was collected on one occasiononly; and (ii) there are some limitations relating tothe return rate (85.2%). However, it is possible thatthose who felt strongly about job satisfaction replied;thus, the responses might not reflect the perception ofall staff. For this reason, the results and conclusionshave to be considered with caution as they can onlybe said to be representative of the staff who partici-pated. The use of factor analysis means that ratherthan reporting all variables, factors and underlyingconcepts are identified. Even if the number of staffwas low, the factor analysis was only used to explainand find causal relations between the factors. Theinternal consistency for the factors measuring job sat-isfaction was above a = 0.91. For the factors measur-ing ethical dilemmas, the internal consistency was 0.59(Cronbach’s alpha), which indicates high item inter-correlations. This, in turn, may indicate that the instru-ment reflects several constructs rather than a singleconstruct (Burns & Grove, 1997). No follow up wasincluded in the present study. Hence, the tools need tobe assessed and monitored for the effects of changesin the organizational climate on job satisfaction andexperiences of ethical dilemmas over time. Surveyssuch as this can be repeated with several time inter-vals to provide valuable information when institu-tional changes are made.

An objective for further research might be to usefocus group interviews to explore the motives for staffwillingness to attend supervision as well as whoadvised them to take part in supervision.

CONCLUSIONS

Factors that contribute to job satisfaction or dissatis-faction can be related to the nurses’ value systems.Working in an organization, where its values coincidewith one’s own, is an important determinant of jobsatisfaction. To have the power to make decisions may enhance staff self-esteem and elicit a positiveresponse from staff. However, the level of anxietymay be increased when decisions involve a heavyresponsibility. It is therefore important for staff toknow who are responsible for tasks in the workplace.Specific information provides the staff with knowl-edge of what the patient considers to be high-qualitycare. If staff can maintain a close relationship with apatient, it gives them information about the patient’sneeds and the patient’s satisfaction with the care provided. This study provides an insight into the influ-ence that clinical supervision can have on job satisfac-tion among staff working within acute psychiatriccare. There is a need for further research aimed at

finding out how clinical supervision may help staff tomaintain a close relationship with patients and toincrease their opportunities for inter-professionalinvolvement and decision-making in patient care.

ACKNOWLEDGEMENTS

We are grateful to our colleagues for their valuableparticipation in the action research process. We alsowish to thank Vibeke Hortsman at the GerontologicalResearch Center, Lund University, for her statisticalsupport.

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Factors influencing job satisfaction and ethical dilemmas in acute psychiatric care