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WORKPLACE ISSUES IN NURSING Factors influencing Macao nurses’ intention to leave current employment Moon Fai Chan, Andrew Leung Luk, Sok Man Leong, Siu Ming Yeung and Iat Kio Van Aims. To investigate factors associated with nurses’ intention to leave current employment in Macao. Background. The shortage of nursing staff and nurses voluntarily leaving their jobs has continued to be a problem affecting the delivery of health care all over the world. One way to alleviate this shortfall is via recruitment, but this is not always successful. Another way is to reduce the rate at which nurses voluntarily leave their work places. Design. A descriptive survey was conducted and data were collected using a self-reported structured questionnaire. Nurses were recruited in the Health Bureau and one private hospital in Macao. The status of nurses’ intention to leave current employment (yes vs. no) was the dependent variable and nurses’ predisposing characteristics, organisational environments and five components on job satisfaction outcomes were independent variables. Results. Of 426 nurses, 166 (39Æ0%) indicated an intention to leave current employment. The results showed that age (p < 0Æ001), work experience (p < 0Æ001), workplace (p =0Æ015) and job satisfaction: pay and benefits (p < 0Æ001) were significant risk factors to predict nurses’ intention to leave current employment. Conclusions. More than one-third of the nurses in Macao indicated an intention to leave current employment. This figure may be a cause of concern for the hospital management and highlights the need to implement strategies to improve the commu- nication between nurses and the organisation, to enhance nurse job satisfaction and commitment to the organisation. Relevance to clinical practice. Our findings outline some issues contributing to this problem and provide the nurse manager with information regarding specific influences on nurses’ turnover in Macao. Given the complexity of issues outlined in this analysis, nurse managers should assist their nursing staff to deal with those influences, make efforts to address the nursing shortage that will require additional communications and recognise the needs and values of their staff and empower them to create a better work environment. As a consequence, their commitment to the organisation can be fostered. Key words: intention to leave, job satisfaction, Macao, nurses, nursing Accepted for publication: 2 January 2008 Introduction Over the past 10 years, the shortage of nursing staff and nurses voluntarily leaving their jobs has continued to be a problem affecting the delivery of health care all over the world. One way to alleviate this shortfall is via recruitment, but this is not always successful (Kunaviktikul et al. 2000, Shields & Ward 2001). Another way is to reduce the rate at which nurses voluntarily leave their workplaces (Sourdif 2004, Tourangeau & Cranley 2006). Tourangeau and Cranley (2006) developed a ‘Determinants of Nurse Intention to Remain Employed’ model that identifies a set of four predictor variables of nurses’ intention to remain employed: (1) job satisfaction, (2) nurses’ personal characteristics, (3) Authors: MF Chan, PhD, CStat, Former Associate Professor of Kiang Wu Nursing College of Macau, Macau SAR, China; AL Luk, PhD, RN, Associate Professor, Kiang Wu Nursing College of Macau, Macau SAR, China; SM Leong, MSc, Assistant Professor, Kiang Wu Nursing College of Macau, Macau SAR, China; SM Yeung, MSN, CNS, RN, Senior Lecturer, Kiang Wu Nursing College of Macau, Macau SAR, China; IK Van, RN, Head, Kiang Wu Nursing College of Macau, Macau SAR, China Correspondence: MF Chan, Assistant Professor, Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore, 117574. Telephone: 65 6516 8684. E-mail: [email protected] Ó 2008 The Authors. Journal compilation Ó 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 893–901 893 doi: 10.1111/j.1365-2702.2008.02463.x

Factors influencing Macao nurses’ intention to leave current employment

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WORKPLACE ISSUES IN NURSING

Factors influencing Macao nurses’ intention to leave current

employment

Moon Fai Chan, Andrew Leung Luk, Sok Man Leong, Siu Ming Yeung and Iat Kio Van

Aims. To investigate factors associated with nurses’ intention to leave current employment in Macao.

Background. The shortage of nursing staff and nurses voluntarily leaving their jobs has continued to be a problem affecting the

delivery of health care all over the world. One way to alleviate this shortfall is via recruitment, but this is not always successful.

Another way is to reduce the rate at which nurses voluntarily leave their work places.

Design. A descriptive survey was conducted and data were collected using a self-reported structured questionnaire. Nurses were

recruited in the Health Bureau and one private hospital in Macao. The status of nurses’ intention to leave current employment

(yes vs. no) was the dependent variable and nurses’ predisposing characteristics, organisational environments and five

components on job satisfaction outcomes were independent variables.

Results. Of 426 nurses, 166 (39Æ0%) indicated an intention to leave current employment. The results showed that age

(p < 0Æ001), work experience (p < 0Æ001), workplace (p = 0Æ015) and job satisfaction: pay and benefits (p < 0Æ001) were

significant risk factors to predict nurses’ intention to leave current employment.

Conclusions. More than one-third of the nurses in Macao indicated an intention to leave current employment. This figure may

be a cause of concern for the hospital management and highlights the need to implement strategies to improve the commu-

nication between nurses and the organisation, to enhance nurse job satisfaction and commitment to the organisation.

Relevance to clinical practice. Our findings outline some issues contributing to this problem and provide the nurse manager with

information regarding specific influences on nurses’ turnover in Macao. Given the complexity of issues outlined in this analysis,

nurse managers should assist their nursing staff to deal with those influences, make efforts to address the nursing shortage that

will require additional communications and recognise the needs and values of their staff and empower them to create a better

work environment. As a consequence, their commitment to the organisation can be fostered.

Key words: intention to leave, job satisfaction, Macao, nurses, nursing

Accepted for publication: 2 January 2008

Introduction

Over the past 10 years, the shortage of nursing staff and

nurses voluntarily leaving their jobs has continued to be a

problem affecting the delivery of health care all over the

world. One way to alleviate this shortfall is via recruitment,

but this is not always successful (Kunaviktikul et al. 2000,

Shields & Ward 2001). Another way is to reduce the rate at

which nurses voluntarily leave their workplaces (Sourdif

2004, Tourangeau & Cranley 2006). Tourangeau and

Cranley (2006) developed a ‘Determinants of Nurse Intention

to Remain Employed’ model that identifies a set of four

predictor variables of nurses’ intention to remain employed:

(1) job satisfaction, (2) nurses’ personal characteristics, (3)

Authors: MF Chan, PhD, CStat, Former Associate Professor of Kiang

Wu Nursing College of Macau, Macau SAR, China; AL Luk, PhD,

RN, Associate Professor, Kiang Wu Nursing College of Macau,

Macau SAR, China; SM Leong, MSc, Assistant Professor, Kiang Wu

Nursing College of Macau, Macau SAR, China; SM Yeung, MSN,

CNS, RN, Senior Lecturer, Kiang Wu Nursing College of Macau,

Macau SAR, China; IK Van, RN, Head, Kiang Wu Nursing College

of Macau, Macau SAR, China

Correspondence: MF Chan, Assistant Professor, Alice Lee Centre for

Nursing Studies, National University of Singapore, Singapore,

117574. Telephone: 65 6516 8684.

E-mail: [email protected]

� 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 893–901 893

doi: 10.1111/j.1365-2702.2008.02463.x

work group cohesion and collaboration and (4) nurses’

organisational commitment. They reported that control over

these four main factors had direct effects on nurse intention

to remain employed. A limited number of Macao studies have

been conducted (in Chinese) to identify factors influencing

nurses’ intention to leave or remain employed (Leong 2003,

2004, Wong et al. 2003, Van 2005, Luk et al. 2006). These

studies suggested that the current settings and conditions of

the health-care system are not optimised to retain nurses. It is

therefore essential to focus on the development and imple-

mentation of effective retention strategies. However, Morrell

(2005) look at this issue in a different way by analysing the

decision processes of nurses who have actually left, rather

than drawing inferences based on current employees; by

constructing a typology for nurse leavers, to devise retention

programmes for current employees to enhance the effective-

ness of workforce planning. Nevertheless, before any effec-

tive retention programmes can be developed, the factors

which influence nursing staff decisions to change their career

must first be identified.

Factors related to nurses’ intention to leavecurrent employment

Throughout the literature, job satisfaction was the most

consistent predictor of nurse intention to leave and has been

reported as explaining most of the variance on intention to

leave (Hsiao & Lu 1996, Borda & Norman 1997, Aiken et al.

2002, Ingersoll et al. 2002, Sourdif 2004, Morrell 2005).

Shields and Ward (2001) found that nurses who reported

overall dissatisfaction with their jobs had a 65% higher

probability of intending to leave than satisfied nurses.

Consistently, positive relationships have been found between

job satisfaction and intention to leave (Chan & Morrison

2000). Most studies have also reported positive relationships

between nurse intention to leave and specific components of

job satisfaction, including satisfaction with pay and benefits

(Santos & Cox 2000, Lacey 2003, Morrell 2005), scheduling

(Roberts et al. 2004), autonomy and responsibility (Larrabee

et al. 2003), professional opportunities (Anderson & Choi

1980, Joshua-Amadi 2002), support (Sourdif 2004) and good

work relationships (Adams & Bond 2000, Chan & Morrison

2000). Other associated factors, including individual predis-

posing characteristics such as age (Blegan 1993, Borda &

Norman 1997), years of experience (Shader et al. 2001) and

education (Roberts et al. 2004), are found to have an impact

on nurses’ intention to leave. Studies suggested that nurses

were more likely to stay in their jobs when they were older,

worked in specialised clinical areas and had more years of

experience (Chan & Morrison 2000, Shader et al. 2001, Hu

et al. 2004). By contrast, younger and more educated nurses

were more likely to be dissatisfied with their jobs and leave

(Shields & Ward 2001). However, some researchers suggest

that it is age cohort or generational affiliation issues rather

than age alone that affects nurses’ intention to leave

(Duchscher & Cowin 2004, Hu et al. 2004). To summarise,

there are mixed findings on the association of nurses’

predisposing characteristics (age, education, work experi-

ences), organisational environment factors (types of wards,

levels of grade) and nurses’ perceived job satisfaction with

nurses’ intention to leave. There is limited knowledge about

which factors contribute to Macao nurses’ intention to stay

or leave.

Aims

The aim of this quantitative study was to investigate factors

associated with nurses’ intention to leave current employment

in Macao. This is an important issue because turnover and

retention are not synonymous and understanding nurses’

intention to remain employed or to leave is important for

Macao’s health-care educators and health policy makers as

they plan the future management of health care in Macao

(Leong 2003, 2004, Van 2005). Identifying which factors

cause the retention of nurses as a distinct construct from those

causing turnover is crucial. This study considers intent rather

than actually remaining employed as the dependent variable,

because this has been supported by other studies (Cavanagh &

Coffin 1992, Chan & Morrison 2000, Sochalski 2002).

The study

Design and participants

There are only two hospitals in Macao, one is public and the

other is private and a descriptive study was conducted and

recruitment was performed via these two hospitals. This

survey was one component of a study investigating the status

of health-care services in Macao (Luk et al. 2006). Hence, we

use elements of the nurse survey to explore factors affecting

nurses’ intention to remain employed in Macao. All full-time

nurses who worked in the two organisations were included in

this study. They also had to be able to read or write Chinese

and give informed consent. The recruitment period was

between April–June in 2006.

Power calculation

The power of this study was estimated based on the logistic

model and the odds ratios (OR) between nurses’ intention to

MF Chan et al.

894 � 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 893–901

leave current employment and job satisfaction from previous

studies (Chan & Morrison 2000, Ingersoll et al. 2002,

Larrabee et al. 2003). An average OR was found (=1Æ34) and

the required sample was around 420, which could achieve

83% power at a 5% level of significance (nQuery Advisor

2001).

Data collection

Data were collected via a self-completed structured question-

naire in two hospitals and the average time for completing it

was around 30 minutes; 968 were sent out and 792 received

at the end (an 81Æ8% response rate), but due to (1) missing

responses to the question on intention to remain employed or

not and (2) the fact that 268 nurses replied ‘Not sure’ to this

question, only 426 records (53Æ8%) were ultimately used in

this study for further data analysis.

Instrument

Several tools have been developed in the West to assess

nurses’ job satisfaction, for example, the Nursing Work Index

(NWI) or NWI-R (Aiken & Patrician 2000, Aiken et al.

2002), the Index of Work Satisfaction (IWS) (Stamps &

Piedmonte 1986, Lee 1998) and the Job Satisfaction Scale

(Murrells et al. 2005) but none of them included Chinese

culture. However, Wong et al. (2003) had developed a Job

Satisfaction Questionnaire in the Macao setting (Appendix

1). The self-reported questionnaire consisted of two parts:

Part I comprised the demographic data and Part II comprised

questions on the Job Satisfaction Questionnaire developed by

Wong et al. (2003). Part I consisted of questions regarding

age, education level, ranking, employment status, years of

work experience, workplace and type of hospital. This

information provided a background about the nurses and

was used to determine factors related to the intention to

remain employed. In addition, a question was asked to each

nurse, ‘Do you intend to change your job?’, to which they

replied using one of three choices, ‘Yes’, ‘No’ and ‘Not sure’.

Those who replied ‘Not sure’ were not used for this study due

to their unconfirmed status. Part II consisted of 37 items

comprising five-point scale questions that queried nurses’ job

satisfaction levels on five components: (1) pay and benefits

(10 items), (2) support (seven items), (3) autonomy and

professional opportunities (10 items), (4) scheduling (six

items) and (5) relationships and interaction (four items). Each

item was ranked on a five-point scale, from 5 ‘very satisfied’

to 1 ‘very dissatisfied’. The average mean scores of each

component were used for comparison, with higher scores

indicating positive job satisfaction levels.

Validity and reliability of the instrument

Validity

Confirmatory factor analyses (CFA) were conducted to

establish the construct validity for this questionnaire. Unlike

traditional factor analysis, CFA enables the researcher to

construct and statistically test hypotheses about the rela-

tionship between observed variables and the constructs they

are assumed to measure (Joreskog & Sorbom 1993). CFA

were conducted using AMOS (Arbuckle 1999). A five-factor

model was assessed. A covariance matrix was used as the

starting point for the estimation process and the maximum

likelihood function was used to estimate the parameters. The

assessment of fit for the present study was based on (1) the v2

likelihood ratio; (2) the ratio of the v2 to its expected value

(v2/df), a ratio of four or less being judged as an acceptable fit

(Bentler 1990); (3) the goodness-of-fit index (GFI); (d) the

adjusted goodness-of-fit index (AGFI); (4) the comparative fit

index (CFI), a revised norm fit index corrected for sample size

dependency and (5) the root mean square residual (RMR), an

index of the average discrepancy between the observed and

hypothesised covariance matrices (Marsh & Hocevar 1985,

Bentler 1990). Table 1 presents the goodness-of-fit indices of

the factor model assessed for job satisfaction, with significant

v2 values (p < 0Æ001). The v2/df ratio was under the critical

value (3Æ16) and the CFI (0Æ79) indicated an acceptable fit to

the data. The other indices, GFI (0Æ80), AGFI (0Æ77) and

RMR (0Æ06) also indicated an acceptable fit in the model.

Reliability

Internal consistency was evaluated for the job satisfaction

scale with Cronbach’s alpha coefficients. It showed an

acceptable internal consistency. For the five components on

Table 1 Goodness-of-fit indices of the

factor model for the nurses’ satisfaction

questionnaire

Model v2 df p-value v2/df GFI AGFI CFI RMR RMSEA

Five factor 1958Æ70 619 <0Æ001 3Æ16 0Æ80 0Æ77 0Æ79 0Æ06 0Æ07

v2/df, a ratio of four or less being judged as an acceptable fit. GFI, Goodness-of-fit index, scaled

to range from zero to one, one mean 100% fit. AGFI, Adjusted goodness-of-fit index, scaled to

ranged from zero to one, one mean 100% fit. CFI, Comparative fit index, a revised norm fit

index corrected for sample size dependency. RMR, Root mean square residual, an index of the

average discrepancy between the observed and hypothesised covariance matrices.

Workplace issues in nursing Nurses’ intention to leave

� 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 893–901 895

job satisfaction, the Cronbach’s alpha on pay and benefits,

support, autonomy and professional opportunities, schedul-

ing, relationships and interaction and overall was 0Æ87, 0Æ87,

0Æ83, 0Æ77, 0Æ67 and 0Æ93, respectively.

Ethical considerations

The study was approved by the ethics committees of the

college and the study organisations. Informed consent was

obtained from participants prior to the conduct of the study.

Confidentiality was assured and participants were told that

they could withdraw from the study at any point without

adverse effects on their subsequent care.

Data analysis

A descriptive statistical analysis of the quantitative data was

conducted using SPSSSPSS 120Æ0 (SPSS 2004). Several statistical

techniques were employed to analyse the data. The data

analysis strategy was as follows. A confirmatory factor

analysis was performed initially on the items to confirm the

factorial reliability of the subscales of these measures in the

study sample. In addition, Cronbach’s alpha coefficients were

used to examine the internal reliability of each sub-scale in

each component, because a cluster analysis can be dramat-

ically affected by the inclusion of only one or two undiffer-

entiated variables. Thus, it is important to examine the factor

structure of the variables to be included in the cluster

analysis. Next, univariate analysis was used to examine any

factors (e.g. demographic and job satisfaction scores) asso-

ciated with the intention to leave. Finally, a multiple logistic

regression model (forward stepwise Wards method) was used

to identify which factors can predict intention to leave, with

the level of significance set at p < 0Æ05.

Findings

Predisposing characteristics, work environment and

intention to leave current employment

The predisposing characteristics of nurses are shown in

Table 2. Among the nurses, 73Æ3% aged 34 or below

(n = 121) reported that they had intention to leave, but

28Æ4% (n = 73) of those aged 45 or above reported that they

would remain employed (p < 0Æ001). More than 68% of

nurses (n = 112) with less than 10 years’ work experience

reported that they had intention to leave, but 62Æ5% of nurses

(n = 157) with more than 10 years’ work experience reported

that they would stay. Fifty-six percent (n = 93) who worked

in private hospitals reported that they had intention to leave,

but 60Æ8% (n = 158) who worked in public hospitals said

they would remain employed. Forty-six percent (n = 76) of

nurses working in internal/medical wards reported that they

had intention to leave, but 35Æ4% (n = 91) who worked in

OPD said they would stay. However, no statistically signif-

icant associations were found between intention to leave/stay

and nurses’ educational level (p = 0Æ052).

Job satisfaction and intention to leave current

employment

For job satisfaction, nurses scoring more than three in each

component were classified as the ‘satisfied’ group; otherwise,

they were ‘unsatisfied’. In Table 3, among nurses who had

intention to leave, 80Æ7% (n = 134), 33Æ1% (n = 55), 21Æ7%

(n = 36) and 68Æ1% (n = 113), scored as unsatisfied on pay

and benefits, support, autonomy and professional opportu-

nities and scheduling, respectively, but for those who said

they would not leave, only 50Æ0% (p < 0Æ001) on pay and

benefits, 17Æ7% (p < 0Æ001) on support, 7Æ7% (p < 0Æ001)

on autonomy and professional opportunities and 51Æ9%

(p = 0Æ001) on scheduling scored as unsatisfied. However, no

significant association was found between relationships and

interaction scores and intention to leave (p = 0Æ228).

Predictors of intention to leave current employment

Multiple logistic regression analyses were used to identify a

model to predict nurses’ intention to leave. The results

showed that age, work experience, workplace and job

satisfaction: Pay and benefits were significant risk factors

for intention to leave (Table 4). This model had a good fit

under the Hosmer–Lemeshow goodness-of-fit test (R2 = 0Æ35,

v2 = 1Æ38, p = 0Æ995), with 63Æ0% sensitivity, 77Æ2% speci-

ficity and 71Æ6% over power. Nurses with less than five years’

work experience were 4Æ62 times more likely to leave than

nurses with 10+ years’ (p < 0Æ001) work experience. Nurses

aged 24 or below were 0Æ21 times less likely to leave than

nurses aged 25–44 (p < 0Æ001). Nurses who worked in

internal/medical wards were 3Æ12 and 2Æ16 times more likely

to leave than nurses who worked in surgical wards

(p = 0Æ021) and OPD (p = 0Æ009), respectively. On job

satisfaction scores, nurses who scored as unsatisfied on pay

and benefits were 4Æ14 times more likely to leave than nurses

who scored as satisfied (p < 0Æ001).

Discussions

The findings in this study overall are consistent with those of

other studies conducted overseas. Evidence was found to

MF Chan et al.

896 � 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 893–901

support Tourangeau and Cranley’s (2006) model, with one of

the significant predictors being age: nurses aged 45 or above

were more likely to remain employed. This may be due to

their attitudinal priorities and the differences in values among

generations, as those nurses born in the 1960s or earlier are

generally called the ‘silent generation’ and are typified by

strong loyalty and seniority (Duchscher & Cowin 2004).

Today, those born in the 1980s are called ‘generation Xers’

and prefer more changes or challenges to achieve a better life

and prospects (Santos & Cox 2000). Another significant

predictor of intention to remain employed was nurses’ years

of work experience, which also reflect their commitment to

the organisation (Kunaviktikul et al. 2000, Sourdif 2004).

From our findings, nurses with less than five years’ work

experience are less likely to remain employed than those who

have worked for more than 10 years. It is therefore in the best

interest of management to develop and implement strategies

that support nurse organisational commitment (Hsiao & Lu

1996, Borda & Norman 1997, Ingersoll et al. 2002); for

example, promoting job security, abiding by humanitarian

values like fairness and courtesy, promoting more communi-

cation channels such as newsletters and encouraging staff

involvement in decision making to show the transparency of

the communication system (Ingersoll et al. 2002). The

workplace is another predictor of intention to remain

employed, as ward culture was found to have a pervasive

Table 2 Comparison of characteristics

of the study nurses by intention to leave

current employment

Characteristics n (%)

Total (n = 426)

n (%)

Intention to leave current

employment v2 test

Yes (n = 166)

n (%)

No (n = 260)

n (%) p-value

Age group (years)*

24 or below 49 (11Æ6) 18 (10Æ9) 31 (12Æ1) <0Æ001

25–34 186 (44Æ1) 103 (62Æ4) 83 (32Æ3)

35–44 101 (23Æ9) 31 (18Æ8) 70 (27Æ2)

45–54 74 (17Æ5) 10 (6Æ1) 64 (24Æ9)

55+ 12 (2Æ8) 3 (1Æ8) 9 (3Æ5)

Educational level�

Certificate or others 38 (8Æ9) 8 (4Æ8) 30 (11Æ5) 0Æ052

Higher diploma 160 (37Æ6) 62 (37Æ6) 98 (37Æ7)

Baccalaureate or equivalent 227 (53Æ4) 95 (57Æ6) 132 (50Æ8)

Work experience (years)�

Five or fewer 108 (26Æ2) 59 (36Æ4) 49 (19Æ5) <0Æ001

6–10 98 (23Æ7) 53 (32Æ7) 45 (17Æ9)

10+ 207 (50Æ1) 50 (30Æ9) 157 (62Æ5)

Ranking�

Senior staff 30 (7Æ1) 7 (4Æ2) 23 (8Æ8) <0Æ001

Nurses working in a

hospital setting

353 (83Æ1) 154 (93Æ3) 199 (76Æ5)

Nurses work outside a

hospital setting

42 (9Æ9) 4 (2Æ4) 38 (14Æ6)

Perceived current quality of care

Very satisfied/satisfied 325 (76Æ3) 108 (65Æ1) 217 (83Æ5) <0Æ001

Very dissatisfied/dissatisfied 101 (23Æ7) 58 (34Æ9) 43 (16Æ5)

Type of hospital

Public 231 (54Æ2) 73 (44) 158 (60Æ8) 0Æ001

Private 195 (45Æ8) 93 (56) 102 (39Æ2)

Workplace/ward§

Internal/medical 143 (34) 76 (46Æ3) 67 (26Æ1) <0Æ001

Obstetrics and gynaecology 75 (17Æ8) 28 (17Æ1) 47 (18Æ3)

Surgical 31 (7Æ4) 7 (4Æ3) 24 (9Æ3)

Acute and emergency 52 (12Æ4) 24 (14Æ6) 28 (10Æ9)

Outpatient department 120 (28Æ5) 29 (17Æ7) 91 (35Æ4)

*Four missing data.�One missing data.�Thirteen missing data.§Five missing data.

Workplace issues in nursing Nurses’ intention to leave

� 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 893–901 897

influence over nurses’ behaviour patterns and their views of

the work environment (Santos & Cox 2000). In addition,

wards within the same hospital have been shown to vary on

several organisational characteristics (Adams & Bond 2000).

These patterns are consistent between staff grades within

wards and are related to the way in which patient care is

provided (Anderson & Choi 1980, Ingersoll et al. 2002).

Other studies have also reported that quality of ward

facilities and of services provided to the ward can affect

nurses’ ability to do their work. This in turn affects their job

satisfaction level, which indirectly affects their intention to

leave or stay. Consistent with previous studies, our results

show that nurses who work in the internal/medical wards are

more likely to leave than nurses working in surgical and OPD

wards. In specific reference to the workplace, medical wards

are usually the busiest wards in an acute hospital. Therefore a

rotation programme should be designed for junior nurses so

that they can be rotated to other specialties after working in

such busy wards for a year or two. This would not only

release them from the heavy workload, but also enrich their

professional experience by giving them the opportunity to

work in a new specialty. Furthermore, in-services training

should also be enhanced so that they are more equipped to

meet patients’ needs even if they are young and lacking

experience in the profession.

The final significant predictor is job satisfaction: pay and

benefits, as job satisfaction has frequently been reported as

the most common predictor for someone who decided to stay

or leave. Therefore, it is not surprising that this study found

that nurses who were unsatisfied with pay and benefits were

more likely to leave and those who felt otherwise were more

likely to remain employed. Regarding the job satisfaction of

nurses in Macao, a local study conducted by Luk et al. (2006)

showed that nurses in both public and private hospitals were

Table 3 Comparison of nurses’ Job

Satisfaction Questionnaire by intention to

leave current employment

Component

Total (n = 426)

n (%)

Intention to leave current

employment v2 test

Yes (n = 166)

n (%)

No (n = 260)

n (%) p-value

Component 1 – Pay and benefits (10 items)

Unsatisfied 264 (62) 134 (80Æ7) 130 (50) <0Æ001

Satisfied 162 (38) 32 (19Æ3) 130 (50)

Component 2 – Support (seven items)

Unsatisfied 101 (23Æ7) 55 (33Æ1) 46 (17Æ7) <0Æ001

Satisfied 325 (76Æ3) 111 (66Æ9) 214 (82Æ3)

Component 3 – Autonomy and professional opportunities (10 items)

Unsatisfied 56 (13Æ1) 36 (21Æ7) 20 (7Æ7) <0Æ001

Satisfied 370 (86Æ9) 130 (78Æ3) 240 (92Æ3)

Component 4 – Scheduling (six items)

Unsatisfied 248 (58Æ2) 113 (68Æ1) 135 (51Æ9) 0Æ001

Satisfied 178 (41Æ8) 53 (31Æ9) 125 (48Æ1)

Component 5 – Relationships and interaction (four items)

Unsatisfied 17 (4) 9 (5Æ4) 8 (3Æ1) 0Æ228

Satisfied 409 (96) 157 (94Æ6) 252 (96Æ9)

In each component, scores range from (1) very dissatisfied to (5) very satisfied; nurses scoring

more than three were classified as the satisfied group, with the remainder in the unsatisfied

group.

Table 4 Logistic regression model on nurses’ intention to leave

current employment

Predictor OR 95% CI p-value

Satisfaction: pay and benefits

Unsatisfied* 1 <0Æ001

Satisfied 4Æ14 2Æ52–6Æ82 <0Æ001

Age group (years)

24 or below* 1 <0Æ001

25–44 0Æ21 0Æ11–0Æ41 <0Æ001

45+ 0Æ57 0Æ22–1Æ51 0Æ257

Work experience (years)

Five or fewer* 1 <0Æ001

6–10 1Æ96 0Æ95–4Æ02 0Æ068

10+ 4Æ62 2Æ26–9Æ47 <0Æ001

Workplace or ward

Internal/medical* 1 0Æ015

Obstetrics and gynaecology 0Æ93 0Æ49–1Æ79 0Æ828

Surgical 3Æ12 1Æ19–8Æ18 0Æ021

Acute and emergency 1Æ05 0Æ52–2Æ10 0Æ895

Outpatient department 2Æ16 1Æ21–3Æ85 0Æ009

*Reference point; sensitivity is 63%, specificity is 77Æ2% and overall

is 71Æ6%; OR, odd ratios; Hosemer and Lemeshow test, v2 = 1Æ38,

p = 0Æ995; R2 is 0Æ35.

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unsatisfied, especially in the areas of pay and benefits. With

the economic boom in Macao, the shortages in the nursing

workforce are getting worse (Luk et al. 2006). This reaffirms

the importance of job satisfaction on nurses’ employment

decisions and is consistent with other studies (Santos & Cox

2000, Larrabee et al. 2003, Tourangeau & Cranley 2006).

Limitations

In line with most studies, there were several limitations in this

study that may have affected its outcomes. One potential

limitation is that our model explained 35% of variance in

nurse intention to remain employed. Our findings were

similar to those of models tested by Shader et al. (2001) and

Tourangeau and Cranley (2006), which explained 31 and

34%, respectively, and it is important to note that 65% of

variance remained unexplained, indicating that there are

other important predictors of nurse intention to remain

employed. It is suggested that these factors be explored in a

further study. Second, a self-reported questionnaire was used

to collect data for this study, leading to possible response bias

from each responder (Polit & Beck 2004). Third, although

we received a high response rate, only 53% of the data were

used for this article, which may have biased our results.

Fourth, this study may not represent the current work force in

Macao. For example we did not include gender in the

questionnaire, although it was a factor in intention to leave.

This is because of the 1136 nurses who worked in Macao at

that time, fewer than 4Æ5% were male (Statistics and Census

Service 2006) and due to this small proportion and to avoid

privacy issues we decided not to identify participants’ gender.

Fifth, although results showed that pay and benefits was one

of the principle factors in intention to leave, other studies

suggested that reasons for leave may include work-related

(Sochalski 2002) or personal events (Morrell 2005) and a

qualitative approach which includes interviews with leavers

to explore the sources and reasons of intention to leave could

increase the knowledge about the nurses in Macao. Finally,

this study did not collect further information on whether

nurses are leaving for another nursing job within the

country’s health service or leaving nursing altogether. As

we know that the former situation means a healthy turnover

within nursing, the latter indicates loss of nurses to the health

service and we did not address this issue and further study is

suggested.

Conclusion

This article shows that more than one-third of the nurses in

Macao indicated an intention to leave. The findings may be a

cause of concern for hospital management, as a shortage of

nurses already exists at present and hospitals cannot afford to

lose any more nurses. On the other hand, this study has

highlighted the importance of the factors that may contribute

to predicting intention to leave for nurses in Macao. Our

findings may provide direction for nurse managers or health-

care management to implement strategies to improve the

communication between nurses and the organisation to

enhance their commitment to the organisation and thereby

their job satisfaction. This will help nurses to develop the

ability to recognise their own needs and values and empower

them to create a better work environment. As a result, their

commitment to the organisation will be elevated.

Acknowledgements

The authors would like to thank the Secretariat of the Social

Affairs and Culture, Macao SAR, China for funding the

research project.

Contributions

Study design: SML, ALL, SMY, IKV; data collection and

analysis: SML, ALL, SMY, IKV, MFC and manuscript

preparation: MFC, SML, ALL, SMY, IKV.

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Appendix 1

Job satisfaction questions with five-point response scales from 5 = very satisfied to 1 = very dissatisfied

Component

1 The feeling of worthwhile accomplishment I get from my work 3

2 The extent to which I can use my skills 3

3 The contribution I make to patient care 3

4 The amount of challenge in my job 3

5 The extent to which my job is varied 3

6 The extent to which my job is interesting 3

7 What I have accomplished when I go home at the end of the day 3

8 The amount of personal growth and development I get from my work 3

9 The extent of independent decision-making power I can exercise in my work 3

10 The amount of independent action I can exercise in my work 3

11 The time available to get through my work 4

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Component

12 The time available for patient care 4

13 Overall staffing levels 4

14 The way that I am able to care for patients 4

15 The amount of time spent on administration 4

16 The amount of support and guidance I receive from my supervisor 2

17 The opportunities I have to discuss my concerns with colleagues 2

18 The opportunities I have to discuss my concerns with my supervisor 2

19 The support available to me in my job 2

20 The overall quality of the supervision I receive in my work 2

21 The degree of respect and fair treatment I receive from my superior 2

22 The degree to which I feel part of a team 2

23 The relationship I have with other health-care workers 5

24 The contact I have with colleagues 5

25 The value placed on my work by my colleagues 5

26 The amount of pay I receive in comparison with people in other occupations 1

27 My rank 1

28 The degree to which I am fairly paid for what I contribute to this organization 1

29 My prospects for promotion 1

30 The opportunities I have to develop professionally 1

31 The match between my job description and what I do 1

32 The amount of job security I have 1

33 Time off to attend courses 1

34 Being sponsored to attend course 1

35 The extent to which I have adequate training for what I do 1

36 The value place on my work by my patients and/or their relatives 5

37 The amount of time spent talking with my patients 4

Component 1: pay and benefits; Component 2: support; Component 3: autonomy and professional opportunities; Component 4: scheduling;

Component 5: relationships and interaction.

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