organization

Develop a Motivation Plan

First read Case Study 5-6, Develop a Motivation Plan, on page 133 in Organizational Behavior in Health Care.

Within the principles of the content theories of Maslow, Herzberg, and Alderfer, address the following in a paper:

Explain why Susan has been behaving the way she has over the past three months.
Offer three specific recommendations to address the problem.

Your well-written paper should meet the following requirements:

Be 3-4 pages in length, not including the required cover and reference pages
Formatted according to Saudi Electronic University and APA writing guidelines
Provide support for your statements with in-text citations from a minimum of three scholarly articles from peer-reviewed journal articles.

please please include citation within the paragraph

the case study attached

Classics in the History
of Psychology

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Christopher D. Green

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A Theory of Human Motivation

A. H. Maslow (

43)

Originally Published in Psychological Review,

0, 370-39

Posted August 2000

[

p. 370] I. INTRODUCTION

In a previous paper (13) various propositions were
presented which would have to be included in any theory of human motivation
that could lay claim to being definitive. These conclusions may be briefly
summarized as follows:

1. The integrated wholeness of the organism must be one of
the foundation stones of motivation theory.
2. The hunger drive (or any other physiological drive) was rejected
as a centering point or model for a definitive theory of motivation. Any
drive that is somatically based and localizable was shown to be atypical
rather than typical in human motivation.
3. Such a theory should stress and center itself upon ultimate or basic
goals rather than partial or superficial ones, upon ends rather than means
to these ends. Such a stress would imply a more central place for unconscious
than for conscious motivations.
4. There are usually available various cultural paths to the same goal.
Therefore conscious, specific, local-cultural desires are not as fundamental
in motivation theory as the more basic, unconscious goals.
5. Any motivated behavior, either preparatory or consummatory, must
be understood to be a channel through which many basic needs may be simultaneously
expressed or satisfied. Typically an act has more than one motivation.
6. Practically all organismic states are to be understood as motivated
and as motivating.
7. Human needs arrange themselves in hierarchies of pre-potency. That
is to say, the appearance of one need usually rests on the prior satisfaction
of another, more pre-potent need. Man is a perpetually wanting animal.
Also no need or drive can be treated as if it were isolated or discrete;
every drive is related to the state of satisfaction or dissatisfaction
of other drives.

. Lists of drives will get us nowhere for various theoretical
and practical reasons. Furthermore any classification of motivations [p.
371] must deal with the problem of levels of specificity or generalization
the motives to be classified.
9. Classifications of motivations must be based upon goals rather than
upon instigating drives or motivated behavior.

. Motivation theory should be human-centered rather than animal-centered.

. The situation or the field in which the organism reacts must be
taken into account but the field alone can rarely serve as an exclusive
explanation for behavior. Furthermore the field itself must be interpreted
in terms of the organism. Field theory cannot be a substitute for motivation
theory.

. Not only the integration of the organism must be taken into account,
but also the possibility of isolated, specific, partial or segmental reactions.
It has since become necessary to add to these another affirmation.
13. Motivation theory is not synonymous with behavior theory. The motivations
are only one class of determinants of behavior. While behavior is almost
always motivated, it is also almost always biologically, culturally and
situationally determined as well.

The present paper is an attempt to formulate a positive theory of motivation
which will satisfy these theoretical demands and at the same time conform
to the known facts, clinical and observational as well as experimental.
It derives most directly, however, from clinical experience. This theory
is, I think, in the functionalist tradition of James and Dewey, and is
fused with the holism of Wertheimer (19), Goldstein
(6), and Gestalt Psychology, and with the dynamicism
of Freud (4) and Adler (1). This fusion
or synthesis may arbitrarily be called a ‘general-dynamic’ theory.

It is far easier to perceive and to criticize the aspects in motivation
theory than to remedy them. Mostly this is because of the very serious
lack of sound data in this area. I conceive this lack of sound facts to
be due primarily to the absence of a valid theory of motivation. The present
theory then must be considered to be a suggested program or framework for
future research and must stand or fall, not so much on facts available
or evidence presented, as upon researches to be done, researches suggested
perhaps, by the questions raised in this paper.[p. 372]

II. THE BASIC NEEDS

The ‘physiological’ needs. — The needs that are usually taken
as the starting point for motivation theory are the so-called physiological
drives. Two recent lines of research make it necessary to revise our customary
notions about these needs, first, the development of the concept of homeostasis,
and second, the finding that appetites (preferential choices among foods)
are a fairly efficient indication of actual needs or lacks in the body.

Homeostasis refers to the body’s automatic efforts to maintain a constant,
normal state of the blood stream. Cannon (2) has described this process
for (1) the water content of the blood, (2) salt content, (3) sugar content,
(4) protein content, (5) fat content, (6) calcium content, (7) oxygen content,
(8) constant hydrogen-ion level (acid-base balance) and (9) constant temperature
of the blood. Obviously this list can be extended to include other minerals,
the hormones, vitamins, etc.

Young in a recent article (

) has summarized the
work on appetite in its relation to body needs. If the body lacks some
chemical, the individual will tend to develop a specific appetite or partial
hunger for that food element.

Thus it seems impossible as well as useless to make any list of fundamental
physiological needs for they can come to almost any number one might wish,
depending on the degree of specificity of description. We can not identify
all physiological needs as homeostatic. That sexual desire, sleepiness,
sheer activity and maternal behavior in animals, are homeostatic, has not
yet been demonstrated. Furthermore, this list would not include the various
sensory pleasures (tastes, smells, tickling, stroking) which are probably
physiological and which may become the goals of motivated behavior.

In a previous paper (13) it has been pointed out
that these physiological drives or needs are to be considered unusual rather
than typical because they are isolable, and because they are localizable
somatically. That is to say, they are relatively independent of each other,
of other motivations [p. 373] and of the organism as a whole, and secondly,
in many cases, it is possible to demonstrate a localized, underlying somatic
base for the drive. This is true less generally than has been thought (exceptions
are fatigue, sleepiness, maternal responses) but it is still true in the
classic instances of hunger, sex, and thirst.

It should be pointed out again that any of the physiological needs and
the consummatory behavior involved with them serve as channels for all
sorts of other needs as well. That is to say, the person who thinks he
is hungry may actually be seeking more for comfort, or dependence, than
for vitamins or proteins. Conversely, it is possible to satisfy the hunger
need in part by other activities such as drinking water or smoking cigarettes.
In other words, relatively isolable as these physiological needs are, they
are not completely so.

Undoubtedly these physiological needs are the most pre-potent of all
needs. What this means specifically is, that in the human being who is
missing everything in life in an extreme fashion, it is most likely that
the major motivation would be the physiological needs rather than any others.
A person who is lacking food, safety, love, and esteem would most probably
hunger for food more strongly than for anything else.

If all the needs are unsatisfied, and the organism is then dominated
by the physiological needs, all other needs may become simply non-existent
or be pushed into the background. It is then fair to characterize the whole
organism by saying simply that it is hungry, for consciousness is almost
completely preempted by hunger. All capacities are put into the service
of hunger-satisfaction, and the organization of these capacities is almost
entirely determined by the one purpose of satisfying hunger. The receptors
and effectors, the intelligence, memory, habits, all may now be defined
simply as hunger-gratifying tools. Capacities that are not useful for this
purpose lie dormant, or are pushed into the background. The urge to write
poetry, the desire to acquire an automobile, the interest in American history,
the desire for a new pair of shoes are, in the extreme case, forgotten
or become of sec-[p.374]ondary importance. For the man who is extremely
and dangerously hungry, no other interests exist but food. He dreams food,
he remembers food, he thinks about food, he emotes only about food, he
perceives only food and he wants only food. The more subtle determinants
that ordinarily fuse with the physiological drives in organizing even feeding,
drinking or sexual behavior, may now be so completely overwhelmed as to
allow us to speak at this time (but only at this time) of pure hunger drive
and behavior, with the one unqualified aim of relief.

Another peculiar characteristic of the human organism when it is dominated
by a certain need is that the whole philosophy of the future tends also
to change. For our chronically and extremely hungry man, Utopia can be
defined very simply as a place where there is plenty of food. He tends
to think that, if only he is guaranteed food for the rest of his life,
he will be perfectly happy and will never want anything more. Life itself
tends to be defined in terms of eating. Anything else will be defined as
unimportant. Freedom, love, community feeling, respect, philosophy, may
all be waved aside as fripperies which are useless since they fail to fill
the stomach. Such a man may fairly be said to live by bread alone.

It cannot possibly be denied that such things are true but their generality
can be denied. Emergency conditions are, almost by definition, rare in
the normally functioning peaceful society. That this truism can be forgotten
is due mainly to two reasons. First, rats have few motivations other than
physiological ones, and since so much of the research upon motivation has
been made with these animals, it is easy to carry the rat-picture over
to the human being. Secondly, it is too often not realized that culture
itself is an adaptive tool, one of whose main functions is to make the
physiological emergencies come less and less often. In most of the known
societies, chronic extreme hunger of the emergency type is rare, rather
than common. In any case, this is still true in the United States. The
average American citizen is experiencing appetite rather than hunger when
he says “I am [p. 375] hungry.” He is apt to experience sheer life-and-death
hunger only by accident and then only a few times through his entire life.

Obviously a good way to obscure the ‘higher’ motivations, and to get
a lopsided view of human capacities and human nature, is to make the organism
extremely and chronically hungry or thirsty. Anyone who attempts to make
an emergency picture into a typical one, and who will measure all of man’s
goals and desires by his behavior during extreme physiological deprivation
is certainly being blind to many things. It is quite true that man lives
by bread alone — when there is no bread. But what happens to man’s desires
when there is plenty of bread and when his belly is chronically filled?

At once other (and ‘higher’) needs emerge and these, rather than
physiological hungers, dominate the organism. And when these in turn are
satisfied, again new (and still ‘higher’) needs emerge and so on. This
is what we mean by saying that the basic human needs are organized into
a hierarchy of relative prepotency.

One main implication of this phrasing is that gratification becomes
as important a concept as deprivation in motivation theory, for it releases
the organism from the domination of a relatively more physiological need,
permitting thereby the emergence of other more social goals. The physiological
needs, along with their partial goals, when chronically gratified cease
to exist as active determinants or organizers of behavior. They now exist
only in a potential fashion in the sense that they may emerge again to
dominate the organism if they are thwarted. But a want that is satisfied
is no longer a want. The organism is dominated and its behavior organized
only by unsatisfied needs. If hunger is satisfied, it becomes unimportant
in the current dynamics of the individual.

This statement is somewhat qualified by a hypothesis to be discussed
more fully later, namely that it is precisely those individuals in whom
a certain need has always been satisfied who are best equipped to tolerate
deprivation of that need in the future, and that furthermore, those who
have been de-[p. 376]prived in the past will react differently to current
satisfactions than the one who has never been deprived.

The safety needs. — If the physiological needs are relatively
well gratified, there then emerges a new set of needs, which we may categorize
roughly as the safety needs. All that has been said of the physiological
needs is equally true, although in lesser degree, of these desires. The
organism may equally well be wholly dominated by them. They may serve as
the almost exclusive organizers of behavior, recruiting all the capacities
of the organism in their service, and we may then fairly describe the whole
organism as a safety-seeking mechanism. Again we may say of the receptors,
the effectors, of the intellect and the other capacities that they are
primarily safety-seeking tools. Again, as in the hungry man, we find that
the dominating goal is a strong determinant not only of his current world-outlook
and philosophy but also of his philosophy of the future. Practically everything
looks less important than safety, (even sometimes the physiological needs
which being satisfied, are now underestimated). A man, in this state, if
it is extreme enough and chronic enough, may be characterized as living
almost for safety alone.

Although in this paper we are interested primarily in the needs of the
adult, we can approach an understanding of his safety needs perhaps more
efficiently by observation of infants and children, in whom these needs
are much more simple and obvious. One reason for the clearer appearance
of the threat or danger reaction in infants, is that they do not inhibit
this reaction at all, whereas adults in our society have been taught to
inhibit it at all costs. Thus even when adults do feel their safety to
be threatened we may not be able to see this on the surface. Infants will
react in a total fashion and as if they were endangered, if they are disturbed
or dropped suddenly, startled by loud noises, flashing light, or other
unusual sensory stimulation, by rough handling, by general loss of support
in the mother’s arms, or by inadequate support.[1][p.
377]

In infants we can also see a much more direct reaction to bodily illnesses
of various kinds. Sometimes these illnesses seem to be immediately and
per
se threatening and seem to make the child feel unsafe. For instance,
vomiting, colic or other sharp pains seem to make the child look at the
whole world in a different way. At such a moment of pain, it may be postulated
that, for the child, the appearance of the whole world suddenly changes
from sunniness to darkness, so to speak, and becomes a place in which anything
at all might happen, in which previously stable things have suddenly become
unstable. Thus a child who because of some bad food is taken ill may, for
a day or two, develop fear, nightmares, and a need for protection and reassurance
never seen in him before his illness.

Another indication of the child’s need for safety is his preference
for some kind of undisrupted routine or rhythm. He seems to want a predictable,
orderly world. For instance, injustice, unfairness, or inconsistency in
the parents seems to make a child feel anxious and unsafe. This attitude
may be not so much because of the injustice per se or any particular
pains involved, but rather because this treatment threatens to make the
world look unreliable, or unsafe, or unpredictable. Young children seem
to thrive better under a system which has at least a skeletal outline of
rigidity, In which there is a schedule of a kind, some sort of routine,
something that can be counted upon, not only for the present but also far
into the future. Perhaps one could express this more accurately by saying
that the child needs an organized world rather than an unorganized or unstructured
one.

The central role of the parents and the normal family setup are indisputable.
Quarreling, physical assault, separation, divorce or death within the family
may be particularly terrifying. Also parental outbursts of rage or threats
of punishment directed to the child, calling him names, speaking to him
harshly, shaking him, handling him roughly, or actual [p. 378] physical
punishment sometimes elicit such total panic and terror in the child that
we must assume more is involved than the physical pain alone. While it
is true that in some children this terror may represent also a fear of
loss of parental love, it can also occur in completely rejected children,
who seem to cling to the hating parents more for sheer safety and protection
than because of hope of love.

Confronting the average child with new, unfamiliar, strange, unmanageable
stimuli or situations will too frequently elicit the danger or terror reaction,
as for example, getting lost or even being separated from the parents for
a short time, being confronted with new faces, new situations or new tasks,
the sight of strange, unfamiliar or uncontrollable objects, illness or
death. Particularly at such times, the child’s frantic clinging to his
parents is eloquent testimony to their role as protectors (quite apart
from their roles as food-givers and love-givers).

From these and similar observations, we may generalize and say that
the average child in our society generally prefers a safe, orderly, predictable,
organized world, which he can count, on, and in which unexpected, unmanageable
or other dangerous things do not happen, and in which, in any case, he
has all-powerful parents who protect and shield him from harm.

That these reactions may so easily be observed in children is in a way
a proof of the fact that children in our society, feel too unsafe (or,
in a word, are badly brought up). Children who are reared in an unthreatening,
loving family do not ordinarily react as we have described above (

).
In such children the danger reactions are apt to come mostly to objects
or situations that adults too would consider dangerous.[2]

The healthy, normal, fortunate adult in our culture is largely satisfied
in his safety needs. The peaceful, smoothly [p. 379] running, ‘good’ society
ordinarily makes its members feel safe enough from wild animals, extremes
of temperature, criminals, assault and murder, tyranny, etc. Therefore,
in a very real sense, he no longer has any safety needs as active motivators.
Just as a sated man no longer feels hungry, a safe man no longer feels
endangered. If we wish to see these needs directly and clearly we must
turn to neurotic or near-neurotic individuals, and to the economic and
social underdogs. In between these extremes, we can perceive the expressions
of safety needs only in such phenomena as, for instance, the common preference
for a job with tenure and protection, the desire for a savings account,
and for insurance of various kinds (medical, dental, unemployment, disability,
old age).

Other broader aspects of the attempt to seek safety and stability in
the world are seen in the very common preference for familiar rather than
unfamiliar things, or for the known rather than the unknown. The tendency
to have some religion or world-philosophy that organizes the universe and
the men in it into some sort of satisfactorily coherent, meaningful whole
is also in part motivated by safety-seeking. Here too we may list science
and philosophy in general as partially motivated by the safety needs (we
shall see later that there are also other motivations to scientific, philosophical
or religious endeavor).

Otherwise the need for safety is seen as an active and dominant mobilizer
of the organism’s resources only in emergencies, e. g., war, disease,
natural catastrophes, crime waves, societal disorganization, neurosis,
brain injury, chronically bad situation.

Some neurotic adults in our society are, in many ways, like the unsafe
child in their desire for safety, although in the former it takes on a
somewhat special appearance. Their reaction is often to unknown, psychological
dangers in a world that is perceived to be hostile, overwhelming and threatening.
Such a person behaves as if a great catastrophe were almost always impending,
i.e., he is usually responding as if to an emergency. His safety needs
often find specific [p. 380] expression in a search for a protector, or
a stronger person on whom he may depend, or perhaps, a Fuehrer.

The neurotic individual may be described in a slightly different way
with some usefulness as a grown-up person who retains his childish attitudes
toward the world. That is to say, a neurotic adult may be said to behave
‘as if’ he were actually afraid of a spanking, or of his mother’s disapproval,
or of being abandoned by his parents, or having his food taken away from
him. It is as if his childish attitudes of fear and threat reaction to
a dangerous world had gone underground, and untouched by the growing up
and learning processes, were now ready to be called out by any stimulus
that would make a child feel endangered and threatened.[3]

The neurosis in which the search for safety takes its dearest form is
in the compulsive-obsessive neurosis. Compulsive-obsessives try frantically
to order and stabilize the world so that no unmanageable, unexpected or
unfamiliar dangers will ever appear (

); They hedge
themselves about with all sorts of ceremonials, rules and formulas so that
every possible contingency may be provided for and so that no new contingencies
may appear. They are much like the brain injured cases, described by Goldstein
(6), who manage to maintain their equilibrium by avoiding
everything unfamiliar and strange and by ordering their restricted world
in such a neat, disciplined, orderly fashion that everything in the world
can be counted upon. They try to arrange the world so that anything unexpected
(dangers) cannot possibly occur. If, through no fault of their own, something
unexpected does occur, they go into a panic reaction as if this unexpected
occurrence constituted a grave danger. What we can see only as a none-too-strong
preference in the healthy person, e. g., preference for the familiar,
becomes a life-and-death. necessity in abnormal cases.

The love needs. — If both the physiological and the safety needs
are fairly well gratified, then there will emerge the love and affection
and belongingness needs, and the whole cycle [p. 381] already described
will repeat itself with this new center. Now the person will feel keenly,
as never before, the absence of friends, or a sweetheart, or a wife, or
children. He will hunger for affectionate relations with people in general,
namely, for a place in his group, and he will strive with great intensity
to achieve this goal. He will want to attain such a place more than anything
else in the world and may even forget that once, when he was hungry, he
sneered at love.

In our society the thwarting of these needs is the most commonly found
core in cases of maladjustment and more severe psychopathology. Love and
affection, as well as their possible expression in sexuality, are generally
looked upon with ambivalence and are customarily hedged about with many
restrictions and inhibitions. Practically all theorists of psychopathology
have stressed thwarting of the love needs as basic in the picture of maladjustment.
Many clinical studies have therefore been made of this need and we know
more about it perhaps than any of the other needs except the physiological
ones (14).

One thing that must be stressed at this point is that love is not synonymous
with sex. Sex may be studied as a purely physiological need. Ordinarily
sexual behavior is multi-determined, that is to say, determined not only
by sexual but also by other needs, chief among which are the love and affection
needs. Also not to be overlooked is the fact that the love needs involve
both giving and receiving love.[4]

The esteem needs. — All people in our society (with a few pathological
exceptions) have a need or desire for a stable, firmly based, (usually)
high evaluation of themselves, for self-respect, or self-esteem, and for
the esteem of others. By firmly based self-esteem, we mean that which is
soundly based upon real capacity, achievement and respect from others.
These needs may be classified into two subsidiary sets. These are, first,
the desire for strength, for achievement, for adequacy, for confidence
in the face of the world, and for independence and freedom.[5]
Secondly, we have what [p. 382] we may call the desire for reputation or
prestige (defining it as respect or esteem from other people), recognition,
attention, importance or appreciation.[6] These needs
have been relatively stressed by Alfred Adler and his followers, and have
been relatively neglected by Freud and the psychoanalysts. More and more
today however there is appearing widespread appreciation of their central
importance.

Satisfaction of the self-esteem need leads to feelings of self-confidence,
worth, strength, capability and adequacy of being useful and necessary
in the world. But thwarting of these needs produces feelings of inferiority,
of weakness and of helplessness. These feelings in turn give rise to either
basic discouragement or else compensatory or neurotic trends. An appreciation
of the necessity of basic self-confidence and an understanding of how helpless
people are without it, can be easily gained from a study of severe traumatic
neurosis (8).[7]

The need for self-actualization. — Even if all these needs are
satisfied, we may still often (if not always) expect that a new discontent
and restlessness will soon develop, unless the individual is doing what
he is fitted for. A musician must make music, an artist must paint, a poet
must write, if he is to be ultimately happy. What a man can be,
he must be. This need we may call self-actualization.

This term, first coined by Kurt Goldstein, is being used in this paper
in a much more specific and limited fashion. It refers to the desire for
self-fulfillment, namely, to the tendency for him to become actualized
in what he is potentially. This tendency might be phrased as the desire
to become more and more what one is, to become everything that one is capable
of becoming.[p. 383]

The specific form that these needs will take will of course vary greatly
from person to person. In one individual it may take the form of the desire
to be an ideal mother, in another it may be expressed athletically, and
in still another it may be expressed in painting pictures or in inventions.
It is not necessarily a creative urge although in people who have any capacities
for creation it will take this form.

The clear emergence of these needs rests upon prior satisfaction of
the physiological, safety, love and esteem needs. We shall call people
who are satisfied in these needs, basically satisfied people, and it is
from these that we may expect the fullest (and healthiest) creativeness.[8]
Since, in our society, basically satisfied people are the exception, we
do not know much about self-actualization, either experimentally or clinically.
It remains a challenging problem for research.

The preconditions for the basic need satisfactions. — There
are certain conditions which are immediate prerequisites for the basic
need satisfactions. Danger to these is reacted to almost as if it were
a direct danger to the basic needs themselves. Such conditions as freedom
to speak, freedom to do what one wishes so long as no harm is done to others,
freedom to express one’s self, freedom to investigate and seek for information,
freedom to defend one’s self, justice, fairness, honesty, orderliness in
the group are examples of such preconditions for basic need satisfactions.
Thwarting in these freedoms will be reacted to with a threat or emergency
response. These conditions are not ends in themselves but they are almost
so since they are so closely related to the basic needs, which are apparently
the only ends in themselves. These conditions are defended because without
them the basic satisfactions are quite impossible, or at least, very severely
endangered.[p. 384]

If we remember that the cognitive capacities (perceptual, intellectual,
learning) are a set of adjustive tools, which have, among other functions,
that of satisfaction of our basic needs, then it is clear that any danger
to them, any deprivation or blocking of their free use, must also be indirectly
threatening to the basic needs themselves. Such a statement is a partial
solution of the general problems of curiosity, the search for knowledge,
truth and wisdom, and the ever-persistent urge to solve the cosmic mysteries.

We must therefore introduce another hypothesis and speak of degrees
of closeness to the basic needs, for we have already pointed out that any
conscious desires (partial goals) are more or less important as they are
more or less close to the basic needs. The same statement may be made for
various behavior acts. An act is psychologically important if it contributes
directly to satisfaction of basic needs. The less directly it so contributes,
or the weaker this contribution is, the less important this act must be
conceived to be from the point of view of dynamic psychology. A similar
statement may be made for the various defense or coping mechanisms. Some
are very directly related to the protection or attainment of the basic
needs, others are only weakly and distantly related. Indeed if we wished,
we could speak of more basic and less basic defense mechanisms, and then
affirm that danger to the more basic defenses is more threatening than
danger to less basic defenses (always remembering that this is so only
because of their relationship to the basic needs).

The desires to know and to understand. — So far, we have mentioned
the cognitive needs only in passing. Acquiring knowledge and systematizing
the universe have been considered as, in part, techniques for the achievement
of basic safety in the world, or, for the intelligent man, expressions
of self-actualization. Also freedom of inquiry and expression have been
discussed as preconditions of satisfactions of the basic needs. True though
these formulations may be, they do not constitute definitive answers to
the question as to the motivation role of curiosity, learning, philosophizing,
experimenting, etc. They are, at best, no more than partial answers.[p.
385]

This question is especially difficult because we know so little about
the facts. Curiosity, exploration, desire for the facts, desire to know
may certainly be observed easily enough. The fact that they often are pursued
even at great cost to the individual’s safety is an earnest of the partial
character of our previous discussion. In addition, the writer must admit
that, though he has sufficient clinical evidence to postulate the desire
to know as a very strong drive in intelligent people, no data are available
for unintelligent people. It may then be largely a function of relatively
high intelligence. Rather tentatively, then, and largely in the hope of
stimulating discussion and research, we shall postulate a basic desire
to know, to be aware of reality, to get the facts, to satisfy curiosity,
or as Wertheimer phrases it, to see rather than to be blind.

This postulation, however, is not enough. Even after we know, we are
impelled to know more and more minutely and microscopically on the one
hand, and on the other, more and more extensively in the direction of a
world philosophy, religion, etc. The facts that we acquire, if they are
isolated or atomistic, inevitably get theorized about, and either analyzed
or organized or both. This process has been phrased by some as the search
for ‘meaning.’ We shall then postulate a desire to understand, to systematize,
to organize, to analyze, to look for relations and meanings.

Once these desires are accepted for discussion, we see that they too
form themselves into a small hierarchy in which the desire to know is prepotent
over the desire to understand. All the characteristics of a hierarchy of
prepotency that we have described above, seem to hold for this one as well.

We must guard ourselves against the too easy tendency to separate these
desires from the basic needs we have discussed above, i.e., to make
a sharp dichotomy between ‘cognitive’ and ‘conative’ needs. The desire
to know and to understand are themselves conative, i.e., have a striving
character, and are as much personality needs as the ‘basic needs’ we have
already discussed (19).[p. 386]

III. FURTHER CHARACTERISTICS OF THE BASIC NEEDS

The degree of fixity of the hierarchy of basic needs. — We have
spoken so far as if this hierarchy were a fixed order but actually it is
not nearly as rigid as we may have implied. It is true that most of the
people with whom we have worked have seemed to have these basic needs in
about the order that has been indicated. However, there have been a number
of exceptions.

(1) There are some people in whom, for instance, self-esteem seems to
be more important than love. This most common reversal in the hierarchy
is usually due to the development of the notion that the person who is
most likely to be loved is a strong or powerful person, one who inspires
respect or fear, and who is self confident or aggressive. Therefore such
people who lack love and seek it, may try hard to put on a front of aggressive,
confident behavior. But essentially they seek high self-esteem and its
behavior expressions more as a means-to-an-end than for its own sake; they
seek self-assertion for the sake of love rather than for self-esteem itself.

(2) There are other, apparently innately creative people in whom the
drive to creativeness seems to be more important than any other counter-determinant.
Their creativeness might appear not as self-actualization released by basic
satisfaction, but in spite of lack of basic satisfaction.

(3) In certain people the level of aspiration may be permanently deadened
or lowered. That is to say, the less pre-potent goals may simply be lost,
and may disappear forever, so that the person who has experienced life
at a very low level, i. e., chronic unemployment, may continue to
be satisfied for the rest of his life if only he can get enough food.

(4) The so-called ‘psychopathic personality’ is another example of permanent
loss of the love needs. These are people who, according to the best data
available (9), have been starved for love in the earliest
months of their lives and have simply lost forever the desire and the ability
to give and to receive affection (as animals lose sucking or pecking reflexes
that are not exercised soon enough after birth).[p. 387]

(5) Another cause of reversal of the hierarchy is that when a need has
been satisfied for a long time, this need may be underevaluated. People
who have never experienced chronic hunger are apt to underestimate its
effects and to look upon food as a rather unimportant thing. If they are
dominated by a higher need, this higher need will seem to be the most important
of all. It then becomes possible, and indeed does actually happen, that
they may, for the sake of this higher need, put themselves into the position
of being deprived in a more basic need. We may expect that after a long-time
deprivation of the more basic need there will be a tendency to reevaluate
both needs so that the more pre-potent need will actually become consciously
prepotent for the individual who may have given it up very lightly. Thus,
a man who has given up his job rather than lose his self-respect, and who
then starves for six months or so, may be willing to take his job back
even at the price of losing his a self-respect.

(6) Another partial explanation of apparent reversals is seen
in the fact that we have been talking about the hierarchy of prepotency
in terms of consciously felt wants or desires rather than of behavior.
Looking at behavior itself may give us the wrong impression. What we have
claimed is that the person will want the more basic of two needs when deprived
in both. There is no necessary implication here that he will act upon his
desires. Let us say again that there are many determinants of behavior
other than the needs and desires.

(7) Perhaps more important than all these exceptions are the ones that
involve ideals, high social standards, high values and the like. With such
values people become martyrs; they give up everything for the sake of a
particular ideal, or value. These people may be understood, at least in
part, by reference to one basic concept (or hypothesis) which may be called
‘increased frustration-tolerance through early gratification’. People who
have been satisfied in their basic needs throughout their lives, particularly
in their earlier years, seem to develop exceptional power to withstand
present or future thwarting of these needs simply because they have strong,[p.
388] healthy character structure as a result of basic satisfaction. They
are the ‘strong’ people who can easily weather disagreement or opposition,
who can swim against the stream of public opinion and who can stand up
for the truth at great personal cost. It is just the ones who have loved
and been well loved, and who have had many deep friendships who can hold
out against hatred, rejection or persecution.

I say all this in spite of the fact that there is a certain amount of
sheer habituation which is also involved in any full discussion of frustration
tolerance. For instance, it is likely that those persons who have been
accustomed to relative starvation for a long time, are partially enabled
thereby to withstand food deprivation. What sort of balance must be made
between these two tendencies, of habituation on the one hand, and of past
satisfaction breeding present frustration tolerance on the other hand,
remains to be worked out by further research. Meanwhile we may assume that
they are both operative, side by side, since they do not contradict each
other, In respect to this phenomenon of increased frustration tolerance,
it seems probable that the most important gratifications come in the first
two years of life. That is to say, people who have been made secure and
strong in the earliest years, tend to remain secure and strong thereafter
in the face of whatever threatens.

Degree of relative satisfaction. — So far, our theoretical discussion
may have given the impression that these five sets of needs are somehow
in a step-wise, all-or-none relationships to each other. We have spoken
in such terms as the following: “If one need is satisfied, then another
emerges.” This statement might give the false impression that a need must
be satisfied 100 per cent before the next need emerges. In actual fact,
most members of our society who are normal, are partially satisfied in
all their basic needs and partially unsatisfied in all their basic needs
at the same time. A more realistic description of the hierarchy would be
in terms of decreasing percentages of satisfaction as we go up the hierarchy
of prepotency, For instance, if I may assign arbitrary figures for the
sake of illustration, it is as if the average citizen [p. 389] is satisfied
perhaps 85 per cent in his physiological needs, 70 per cent in his safety
needs, 50 per cent in his love needs, 40 per cent in his self-esteem needs,
and 10 per cent in his self-actualization needs.

As for the concept of emergence of a new need after satisfaction of
the prepotent need, this emergence is not a sudden, saltatory phenomenon
but rather a gradual emergence by slow degrees from nothingness. For instance,
if prepotent need A is satisfied only 10 per cent: then need B may not
be visible at all. However, as this need A becomes satisfied 25 per cent,
need B may emerge 5 per cent, as need A becomes satisfied 75 per cent need
B may emerge go per cent, and so on.

Unconscious character of needs. — These needs are neither necessarily
conscious nor unconscious. On the whole, however, in the average person,
they are more often unconscious rather than conscious. It is not necessary
at this point to overhaul the tremendous mass of evidence which indicates
the crucial importance of unconscious motivation. It would by now be expected,
on a priori grounds alone, that unconscious motivations would on the whole
be rather more important than the conscious motivations. What we have called
the basic needs are very often largely unconscious although they may, with
suitable techniques, and with sophisticated people become conscious.

Cultural specificity and generality of needs. — This classification
of basic needs makes some attempt to take account of the relative unity
behind the superficial differences in specific desires from one culture
to another. Certainly in any particular culture an individual’s conscious
motivational content will usually be extremely different from the conscious
motivational content of an individual in another society. However, it is
the common experience of anthropologists that people, even in different
societies, are much more alike than we would think from our first contact
with them, and that as we know them better we seem to find more and more
of this commonness, We then recognize the most startling differences to
be superficial rather than basic, e. g., differences in style of
hair-dress, clothes, tastes in food, etc. Our classification of basic [p.
390] needs is in part an attempt to account for this unity behind the apparent
diversity from culture to culture. No claim is made that it is ultimate
or universal for all cultures. The claim is made only that it is relatively
more
ultimate, more universal, more basic, than the superficial conscious desires
from culture to culture, and makes a somewhat closer approach to common-human
characteristics, Basic needs are more common-human than superficial
desires or behaviors.

Multiple motivations of behavior. — These needs must be understood
not to be exclusive or single determiners of certain kinds of behavior.
An example may be found in any behavior that seems to be physiologically
motivated, such as eating, or sexual play or the like. The clinical psychologists
have long since found that any behavior may be a channel through which
flow various determinants. Or to say it in another way, most behavior is
multi-motivated. Within the sphere of motivational determinants any behavior
tends to be determined by several or all of the basic needs simultaneously
rather than by only one of them. The latter would be more an exception
than the former. Eating may be partially for the sake of filling the stomach,
and partially for the sake of comfort and amelioration of other needs.
One may make love not only for pure sexual release, but also to convince
one’s self of one’s masculinity, or to make a conquest, to feel powerful,
or to win more basic affection. As an illustration, I may point out that
it would be possible (theoretically if not practically) to analyze a single
act of an individual and see in it the expression of his physiological
needs, his safety needs, his love needs, his esteem needs and self-actualization.
This contrasts sharply with the more naive brand of trait psychology in
which one trait or one motive accounts for a certain kind of act, i.
e., an aggressive act is traced solely to a trait of aggressiveness.

Multiple determinants of behavior. — Not all behavior is determined
by the basic needs. We might even say that not all behavior is motivated.
There are many determinants of behavior other than motives.[9]
For instance, one other im-[p. 391]portant class of determinants is the
so-called ‘field’ determinants. Theoretically, at least, behavior may be
determined completely by the field, or even by specific isolated external
stimuli, as in association of ideas, or certain conditioned reflexes. If
in response to the stimulus word ‘table’ I immediately perceive a memory
image of a table, this response certainly has nothing to do with my basic
needs.

Secondly, we may call attention again to the concept of ‘degree of closeness
to the basic needs’ or ‘degree of motivation.’ Some behavior is highly
motivated, other behavior is only weakly motivated. Some is not motivated
at all (but all behavior is determined).

Another important point [10] is that there is a basic
difference between expressive behavior and coping behavior (functional
striving, purposive goal seeking). An expressive behavior does not try
to do anything; it is simply a reflection of the personality. A stupid
man behaves stupidly, not because he wants to, or tries to, or is motivated
to, but simply because he is what he is. The same is true when I speak
in a bass voice rather than tenor or soprano. The random movements of a
healthy child, the smile on the face of a happy man even when he is alone,
the springiness of the healthy man’s walk, and the erectness of his carriage
are other examples of expressive, non-functional behavior. Also the style
in which a man carries out almost all his behavior, motivated as well as
unmotivated, is often expressive.

We may then ask, is all behavior expressive or reflective of
the character structure? The answer is ‘No.’ Rote, habitual, automatized,
or conventional behavior may or may not be expressive. The same is true
for most ‘stimulus-bound’ behaviors. It is finally necessary to stress
that expressiveness of behavior, and goal-directedness of behavior are
not mutually exclusive categories. Average behavior is usually both.

Goals as centering principle in motivation theory. — It will
be observed that the basic principle in our classification has [p. 392]
been neither the instigation nor the motivated behavior but rather the
functions, effects, purposes, or goals of the behavior. It has been proven
sufficiently by various people that this is the most suitable point for
centering in any motivation theory.[11]

Animal- and human-centering. — This theory starts with the human
being rather than any lower and presumably ‘simpler’ animal. Too many of
the findings that have been made in animals have been proven to be true
for animals but not for the human being. There is no reason whatsoever
why we should start with animals in order to study human motivation. The
logic or rather illogic behind this general fallacy of ‘pseudo-simplicity’
has been exposed often enough by philosophers and logicians as well as
by scientists in each of the various fields. It is no more necessary to
study animals before one can study man than it is to study mathematics
before one can study geology or psychology or biology.

We may also reject the old, naive, behaviorism which assumed that it
was somehow necessary, or at least more ‘scientific’ to judge human beings
by animal standards. One consequence of this belief was that the whole
notion of purpose and goal was excluded from motivational psychology simply
because one could not ask a white rat about his purposes. Tolman (

)
has long since proven in animal studies themselves that this exclusion
was not necessary.

Motivation and the theory of psychopathogenesis. — The conscious
motivational content of everyday life has, according to the foregoing,
been conceived to be relatively important or unimportant accordingly as
it is more or less closely related to the basic goals. A desire for an
ice cream cone might actually be an indirect expression of a desire for
love. If it is, then this desire for the ice cream cone becomes extremely
important motivation. If however the ice cream is simply something to cool
the mouth with, or a casual appetitive reaction, then the desire is relatively
unimportant. Everyday conscious desires are to be regarded as symptoms,
as [p. 393] surface indicators of more basic needs. If we were to
take these superficial desires at their face value me would find ourselves
in a state of complete confusion which could never be resolved, since we
would be dealing seriously with symptoms rather than with what lay behind
the symptoms.

Thwarting of unimportant desires produces no psychopathological results;
thwarting of a basically important need does produce such results. Any
theory of psychopathogenesis must then be based on a sound theory of motivation.
A conflict or a frustration is not necessarily pathogenic. It becomes so
only when it threatens or thwarts the basic needs, or partial needs that
are closely related to the basic needs (10).

The role of gratified needs. — It has been pointed out above
several times that our needs usually emerge only when more prepotent needs
have been gratified. Thus gratification has an important role in motivation
theory. Apart from this, however, needs cease to play an active determining
or organizing role as soon as they are gratified.

What this means is that, e. g., a basically satisfied person
no longer has the needs for esteem, love, safety, etc. The only sense in
which he might be said to have them is in the almost metaphysical sense
that a sated man has hunger, or a filled bottle has emptiness. If we are
interested in what actually motivates us, and not in what has, will,
or might motivate us, then a satisfied need is not a motivator. It must
be considered for all practical purposes simply not to exist, to have disappeared.
This point should be emphasized because it has been either overlooked or
contradicted in every theory of motivation I know.[12]
The perfectly healthy, normal, fortunate man has no sex needs or hunger
needs, or needs for safety, or for love, or for prestige, or self-esteem,
except in stray moments of quickly passing threat. If we were to say otherwise,
we should also have to aver that every man had all the pathological reflexes,
e.
g., Babinski, etc., because if his nervous system were damaged, these
would appear.

It is such considerations as these that suggest the bold [p. 394] postulation
that a man who is thwarted in any of his basic needs may fairly be envisaged
simply as a sick man. This is a fair parallel to our designation as ‘sick’
of the man who lacks vitamins or minerals. Who is to say that a lack of
love is less important than a lack of vitamins? Since we know the pathogenic
effects of love starvation, who is to say that we are invoking value-questions
in an unscientific or illegitimate way, any more than the physician does
who diagnoses and treats pellagra or scurvy? If I were permitted this usage,
I should then say simply that a healthy man is primarily motivated by his
needs to develop and actualize his fullest potentialities and capacities.
If a man has any other basic needs in any active, chronic sense, then he
is simply an unhealthy man. He is as surely sick as if he had suddenly
developed a strong salt-hunger or calcium hunger.[13]

If this statement seems unusual or paradoxical the reader may be assured
that this is only one among many such paradoxes that will appear as we
revise our ways of looking at man’s deeper motivations. When we ask what
man wants of life, we deal with his very essence.

IV. SUMMARY

(1) There are at least five sets of goals, which we may call basic needs.
These are briefly physiological, safety, love, ‘esteem, and self-actualization.
In addition, we are motivated by the desire to achieve or maintain the
various conditions upon which these basic satisfactions rest and by certain
more intellectual desires.

(2) These basic goals are related to each other, being arranged in a
hierarchy of prepotency. This means that the most prepotent goal will monopolize
consciousness and will tend of itself to organize the recruitment of the
various capacities of the organism. The less prepotent needs are [p. 395]
minimized, even forgotten or denied. But when a need is fairly well satisfied,
the next prepotent (‘higher’) need emerges, in turn to dominate the conscious
life and to serve as the center of organization of behavior, since gratified
needs are not active motivators.

Thus man is a perpetually wanting animal. Ordinarily the satisfaction
of these wants is not altogether mutually exclusive, but only tends to
be. The average member of our society is most often partially satisfied
and partially unsatisfied in all of his wants. The hierarchy principle
is usually empirically observed in terms of increasing percentages of non-satisfaction
as we go up the hierarchy. Reversals of the average order of the hierarchy
are sometimes observed. Also it has been observed that an individual may
permanently lose the higher wants in the hierarchy under special conditions.
There are not only ordinarily multiple motivations for usual behavior,
but in addition many determinants other than motives.

(3) Any thwarting or possibility of thwarting of these basic human goals,
or danger to the defenses which protect them, or to the conditions upon
which they rest, is considered to be a psychological threat. With a few
exceptions, all psychopathology may be partially traced to such threats.
A basically thwarted man may actually be defined as a ‘sick’ man, if we
wish.

(4) It is such basic threats which bring about the general emergency
reactions.

(5) Certain other basic problems have not been dealt with because of
limitations of space. Among these are (a) the problem of values
in any definitive motivation theory, (b) the relation between appetites,
desires, needs and what is ‘good’ for the organism, (c) the etiology
of the basic needs and their possible derivation in early childhood, (d)
redefinition of motivational concepts, i. e., drive, desire, wish,
need, goal, (e) implication of our theory for hedonistic theory,
(f) the nature of the uncompleted act, of success and failure, and
of aspiration-level, (g) the role of association, habit and conditioning,
(h) relation to the [p. 396] theory of inter-personal relations,
(i) implications for psychotherapy, (j) implication for theory
of society, (k) the theory of selfishness, (l) the relation between
needs and cultural patterns, (m) the relation between this theory
and Alport’s theory of functional autonomy. These as well as certain other
less important questions must be considered as motivation theory attempts
to become definitive.

Notes

[

1] As the child grows up, sheer knowledge and familiarity
as well as better motor development make these ‘dangers’ less and less
dangerous and more and more manageable. Throughout life it may be said
that one of the main conative functions of education is this neutralizing
of apparent dangers through knowledge, e. g., I am not afraid of
thunder because I know something about it.

[

2] A ‘test battery’ for safety might be confronting
the child with a small exploding firecracker, or with a bewhiskered face;
having the mother leave the room, putting him upon a high ladder, a hypodermic
injection, having a mouse crawl up to him, etc. Of course I cannot seriously
recommend the deliberate use of such ‘tests’ for they might very well harm
the child being tested. But these and similar situations come up by the
score in the child’s ordinary day-to-day living and may be observed. There
is no reason why those stimuli should not be used with, far example, young
chimpanzees.

[

3] Not all neurotic individuals feel unsafe. Neurosis
may have at its core a thwarting of the affection and esteem needs in a
person who is generally safe.

[

4] For further details see (

12)
and (

, Chap. 5).

[

5] Whether or not this particular desire is universal
we do not know. The crucial question, especially important today, is “Will
men who are enslaved and dominated inevitably feel dissatisfied and rebellious?”
We may assume on the basis of commonly known clinical data that a man who
has known true freedom (not paid for by giving up safety and security but
rather built on the basis of adequate safety and security) will not willingly
or easily allow his freedom to be taken away from him. But we do not know
that this is true for the person born into slavery. The events of the next
decade should give us our answer. See discussion of this problem in (

5).

[

6] Perhaps the desire for prestige and respect from
others is subsidiary to the desire for self-esteem or confidence in oneself.
Observation of children seems to indicate that this is so, but clinical
data give no clear support for such a conclusion.

[

7] For more extensive discussion of normal self-esteem,
as well as for reports of various researches, see (

11).

[

8] Clearly creative behavior, like painting, is like
any other behavior in having multiple, determinants. It may be seen in
‘innately creative’ people whether they are satisfied or not, happy or
unhappy, hungry or sated. Also it is clear that creative activity may be
compensatory, ameliorative or purely economic. It is my impression (as
yet unconfirmed) that it is possible to distinguish the artistic and intellectual
products of basically satisfied people from those of basically unsatisfied
people by inspection alone. In any case, here too we must distinguish,
in a dynamic fashion, the overt behavior itself from its various motivations
or purposes.

[

9] I am aware that many psychologists md psychoanalysts
use the term ‘motivated’ and ‘determined’ synonymously, e. g., Freud.
But I consider this an obfuscating usage. Sharp distinctions are necessary
for clarity of thought, and precision in experimentation.

[

10] To be discussed fully in a subsequent publication.

[

11] The interested reader is referred to the very
excellent discussion of this point in Murray’s Explorations in Personality
(

[

12] Note that acceptance of this theory necessitates
basic revision of the Freudian theory.

[

13] If we were to use the word ‘sick’ in this way,
we should then also have to face squarely the relations of man to his society.
One clear implication of our definition would be that (1) since a man is
to be called sick who is basically thwarted, and (2) since such basic thwarting
is made possible ultimately only by forces outside the individual, then
(3) sickness in the individual must come ultimately from sickness in the
society. The ‘good’ or healthy society would then be defined as one that
permitted man’s highest purposes to emerge by satisfying all his prepotent
basic needs.

References

1. ADLER, A. Social interest. London: Faber
& Faber, 1938.

2. CANNON, W. B. Wisdom of the body. New York:
Norton, 1932.

3. FREUD, A. The ego and the mechanisms of defense.
London: Hogarth, 1937.

4. FREUD, S. New introductory lectures on psychoanalysis.
New York: Norton, 1933.

5. FROMM, E. Escape from freedom. New York:
Farrar and Rinehart, 1941.

6. GOLDSTEIN, K. The organism. New York: American
Book Co., 1939.

7. HORNEY, K. The neurotic personality of our time.
New York: Norton, 1937.

8. KARDINER, A. The traumatic neuroses of war.
New York: Hoeber, 1941.

9. LEVY, D. M. Primary affect hunger. Amer.
J. Psychiat., 1937, 94, 643-652.

10. MASLOW, A. H. Conflict, frustration, and the theory
of threat. J. abnorm. (soc.) Psychol., 1943, 38, 81-86.

11. ———-. Dominance, personality and social
behavior in women. J. soc. Psychol., 1939, 10, 3-39.

12. ———-. The dynamics of psychological security-insecurity.
Character
& Pers., 1942, 10, 331-344.

13. ———-. A preface to motivation theory. Psychosomatic
Med., 1943, 5, 85-92.

14. ———-. & MITTLEMANN, B. Principles
of abnormal psychology. New York: Harper & Bros., 1941.

15. MURRAY, H. A., et al. Explorations in Personality.
New York: Oxford University Press, 1938.

16. PLANT, J. Personality and the cultural pattern.
New York: Commonwealth Fund, 1937.

17. SHIRLEY, M. Children’s adjustments to a strange
situation. J. abrnorm. (soc.) Psychol., 1942, 37, 201-217.

18. TOLMAN, E. C. Purposive behavior in animals
and men. New York: Century, 1932.

19. WERTHEIMER, M. Unpublished lectures at the New
School for Social Research.

20. YOUNG, P. T. Motivation of behavior. New
York: John Wiley & Sons, 1936.

21. ———-. The experimental analysis of appetite.
Psychol.
Bull., 1941, 38, 129-164.

Work stress, work motivation and their
effects on job satisfaction in community
health workers: a cross-sectional survey
in China

Li Li,

Hongyan Hu,

2
Hao Zhou,

3
Changzhi He,

1
Lihua Fan,

1
Xinyan Liu,

Zhong Zhang,
1
Heng Li,

1
Tao Sun

To cite: Li L, Hu H, Zhou H,
et al. Work stress, work
motivation and their effects
on job satisfaction in
community health workers: a
cross-sectional survey in
China. BMJ Open 2014;4:
e004897. doi:10.1136/
bmjopen-2014-004897

▸ Prepublication history for
this paper is available online.
To view these files please
visit the journal online
(http://dx.doi.org/10.1136/
bmjopen-2014-004897).

LL, HH and CH contributed
equally.

Received 21 January 2014
Revised 13 May 2014
Accepted 19 May 2014

1Department of Health
Management, School of
Public Health, Harbin Medical
University, Harbin, China
2Research Service Office,
The Second Affiliated
Hospital, Harbin Medical
University, Harbin, China
3Department of Emergency,
Harbin Center for Disease
Control and Prevention,
Harbin, China

Correspondence to
Dr Li Li;
lilihmu@gmail.com

ABSTRACT
Objective: It is well documented that both work
stress and work motivation are key determinants of
job satisfaction. The aim of this study was to
examine levels of work stress and motivation

and

their contribution to job satisfaction among
community health workers in Heilongjiang Province,
China.
Design: Cross-sectional survey.
Setting: Heilongjiang Province, China.
Participants: The participants were 930 community
health workers from six cities in Heilongjiang
Province.
Primary and secondary outcome measures:
Multistage sampling procedures were used to measure
socioeconomic and demographic status, work stress,
work motivation and job satisfaction. Logistic
regression analysis was performed to assess key
determinants of job satisfaction.
Results: There were significant differences in some
subscales of work stress and work motivation by some
of the socioeconomic characteristics. Levels of overall
stress perception and scores on all five work stress
subscales were higher in dissatisfied workers relative
to satisfied workers. However, levels of overall
motivation perception and scores on the career
development, responsibility and recognition motivation
subscales were higher in satisfied respondents relative
to dissatisfied respondents. The main determinants of
job satisfaction were occupation; age; title; income; the
career development, and wages and

benefits

subscales of work stress; and the recognition,
responsibility and financial subscales of work
motivation.
Conclusions: The findings indicated considerable
room for improvement in job satisfaction among
community health workers in Heilongjiang Province
in China. Healthcare managers and policymakers
should take both work stress and motivation into
consideration, as two subscales of work stress and
one subscale of work motivation negatively
influenced job satisfaction and two subscales of
work motivation positively influenced job
satisfaction.

INTRODUCTION
As the basis of the three-tier health system in
China, community health service institutions
have played a very important role in improv-
ing access to healthcare, enhancing equity
and improving health.1 2 In 2009, the
Chinese central government promulgated a
new set of health system reforms and called
for the development of community health
services. The state established basic public
health service goals, which focused on pro-
viding health education, chronic disease
management, and disease prevention ser-
vices for urban and rural residents. From
2009 to 2012, the number of community
health service institutions increased by 6254
and the number of visits increased by
193 949 million. Therefore, community
health centres (CHCs) and those who work
in them, are very important to the process of
health system reform.
Heilongjiang Province is located in north-

eastern China and has a population of about
38.1 million people. There were 410 urban
CHCs and 366 community health stations
with 13 100 health workers as of 31
December 2012.3 On average, there were 23
and 10 medical personnel in each CHC and

Strengths and limitations of this study

▪ This study is one of the first to examine the
combined effects of work stress and work motiv-
ation on job satisfaction among urban commu-
nity health workers in China since the
implementation of health system reform.

▪ However, the instrument used in this study is
not a commonly used international scale, there
may be an inherent bias in self-report measures,
and the small sample may limit the generalisabil-
ity of the research findings.

Li L, Hu H, Zhou H, et al. BMJ Open 2014;4:e004897. doi:10.1136/bmjopen-2014-004897 1

Open Access

Research

http://dx.doi.org/10.1136/bmjopen-2014-004897

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community health station, respectively. Since the intro-
duction of CHCs, there have been difficulties with
limited resources and insufficient and poorly trained
staff. There were 5416 practitioners (including assistant
practitioners) in community health institutions in
Heilongjiang Province.3 However, based on the popula-
tion of the province and human resource planning
ratios, there was an approximate shortfall of 30% in the
number of general practitioners (5416 vs 7620) in 2012.4

In addition, recent reforms have expanded the scope of
public health services and increased workload without
equivalent increases in staffing levels.5 6

In some CHCs, general practitioners, public health
physicians and nurses have been working in teams, pro-
viding medical and basic public health services to com-
munity residents, both in the centres and during home
visits. Many of these practitioners were initially hospital-
based specialists, and the majority of public health physi-
cians did not have a public health background.
Therefore, to improve skills and knowledge, continuing
medical education was compulsory and no fewer than 25
credit points were required per year for the title
promotion. Other problems with the CHCs were lower
wages and fewer title promotion opportunities relative to
general hospitals. Limited resources and a shortage of
skilled health workers created very tight bottlenecks in
the provision of services, which led to many community
health workers experiencing work-related stress and low
work motivation, in addition to receiving low salaries
and having restricted opportunities for promotion.7 8

Many studies have shown that work stress and work
motivation can greatly affect job satisfaction and, in
turn, the quality and delivery of healthcare. However,
few studies have focused on work stress and motivation
and their effects on job satisfaction among Chinese com-
munity health workers since the implementation of the
new health system reform policy.
Work stress is of great concern to managers, employ-

ees and other stakeholders in organisations. It is a
complex phenomenon and has a multitude of defini-
tions in a variety of theoretical models.9 According to
Lazarus and Folkman’s10 cognitive theory of stress and
coping, work stress was defined as the interaction
between the individual and the environment. This
theory suggested that when demands from the environ-
ment exceed the available resources, the result was
either stress or coping, depending on the individual’s
appraisal of the stressors. Karasek’s11 demand–control
model assumed that psychological strain resulted from
the joint effects of work demands and the degree of
decision-making freedom available to workers facing the
demands. The effort–reward imbalance model proposed
that work stress resulted from a mismatch between high
commitment and effort at work and low rewards, includ-
ing salary, recognition and career promotion.12 Nakasis
and Ouzouni13 defined work stress as the harmful phys-
ical and emotional responses that occur when job
requirements do not match workers’ capabilities,

resources and needs. In general, a greater imbalance
between demands and individual abilities will result in
greater stress.14 Riggio15 classified work stress into work
task stress and work role stress. Cooper and Marshall’s16

model of job stress proposed that the intrinsic require-
ments of the job, role within the organisation, career
development, organisational structure and climate, and
relationships at work all contributed to work-related
stress within an organisation. In our study, five subscales
of work stress were identified based on this model.
Existing research has recognized heavy workload, insuffi-
cient resources, work relationships, lack of professional
respect, and lack of promotion opportunities as possibly
the most salient work stressors for community health
workers.17–19 Long-term stress may be harmful to the
health of workers themselves and may also affect com-
munity health service centres through employee dissatis-
faction, burnout, poor performance or turnover
intention.20–24 Therefore, it is important to reduce work
stress.
Work motivation can be defined as the degree of an

individual’s willingness to exert and maintain an effort
towards attaining organisational goals.25 It reflects the
interactions between workers and their work environ-
ments. Nahavandi and Malekzadeh believed that motiv-
ation depends on a stable mind, aspiration or interest by
the individual and can translate into action.26 Motivation
theory examined the process of motivation and
explained why people at work behave the way they do in
terms of efforts. Building on Vroom’s27 expectancy–
valence theory of motivation, Porter and Lawler28

proposed a model of intrinsic and extrinsic work motiv-
ation. This model suggested that intrinsic and extrinsic
rewards were additive, and accounted for total job satis-
faction. Intrinsic motivation refers to doing something
for the inherent satisfaction involved and is highly
autonomous (ie, self-regulated). In contrast, extrinsic
motivation means doing something in order to obtain a
separable outcome (ie, tangible or verbal rewards).29 30

Peters identified job content and work environment,
extrinsic benefits, autonomy and security, and transpar-
ency as factors in work motivation for health workers
using factor analysis.31 Patrick et al32 and Wilbroad et al33

developed a tool to measure health worker motivation
and revealed that organisational commitment, conscien-
tiousness, intrinsic job satisfaction, timeliness and attend-
ance were the major determinants of higher motivation.
Tribolet34 explored the relationship between intrinsic
and extrinsic motivation. Hoonakker et al35 found that
nurses appreciated challenges and opportunities for new
learning and teamwork. Pool36 explored the significant
positive association between work motivation and job sat-
isfaction, while Stringer et al37 found that intrinsic motiv-
ation was positively associated, and extrinsic motivation
negatively associated with job satisfaction.
In China, previous studies have reported that poor

competency and excessive workload were key work stres-
sors among community health workers.7 19 Shi et al38

2 Li L, Hu H, Zhou H, et al. BMJ Open 2014;4:e004897. doi:10.1136/bmjopen-2014-004897

Open Access

suggested that policymakers should focus on training
and educational opportunities for primary care workers
and consider ways to reduce workload stress and
improve salaries. Hung et al39 identified professional
development, training opportunities, living environ-
ment, benefits and working conditions as the most
important motivating factors for primary care providers
in China. Ge analysed the relationship between work
stress and job satisfaction among Chinese community
health workers and reported that a degree of freedom
in decision making and good workplace

relationships

were positive predictors of job satisfaction.40 Chen et al41

investigated relationships between work motivation, work
stress and job satisfaction in cross-strait employees in
Taiwan and mainland China.
The present study focuses on the major factors affect-

ing work stress and motivation identified in previous
research and provides an overview of community health
workers’ perspectives of work stress and motivation
factors.16 42–44 The purpose of this study was to assess
the predictors of job satisfaction among community
health workers in one Chinese province. A cross-
sectional survey was conducted to measure levels of work
stress, work motivation and job satisfaction. The key pre-
dictors of job satisfaction for community health workers
were assessed with special attention given to work stress
and motivation.

METHODS
Sample
A cross-sectional survey of community health workers
was conducted from 1 March to 31 October 2013 in
Heilongjiang Province, China. Based on the literature
on community health services in China, a multistage,
stratified sampling design was employed to ensure that
study data were representative of the province.7 40 First,
six cities (Harbin, Qiqihar, Suihua, Jiamusi, Qitaihe and
Heihe) were selected based on gross domestic product
and the cities selected were matched according to the
community health services they provided. Second, 15
CHCs were randomly selected from each city. On
average, 22 medical personnel worked in each of the
selected CHCs. Third, 60% of general practitioners,
public health physicians, nurses and other health tech-
nical staff in each centre were chosen randomly, exclud-
ing those who were absent. The research team invited
all selected staff members to participate in the study.
The questionnaire included a cover page explaining the
purposes and procedures of the study. The data were
collected anonymously and the respondents completed
the survey questionnaires privately to ensure confidenti-
ality. Respondents were assured that participation in the
survey was voluntary, and the return of questionnaires
represented informed consent. The research staff stayed
at the CHC and answered respondents’ questions during
the survey. Respondents were able to choose the best
time to complete the questionnaire, such as when they

were not busy or their offices were quiet. Most com-
pleted questionnaires were collected on site by the inves-
tigator on the day of the visit. If some respondents did
not finish that day, investigators set a date for retrieving
the questionnaires. Respondents were asked to seal the
completed questionnaires in individual envelopes pro-
vided by the research team. The questionnaire was rela-
tively brief and no private personal information was
collected. A total of 980 questionnaires were delivered to
community health workers, all of which were returned.
However, 50 (5.1%) were incomplete or blank, which
left 930 valid questionnaires.

Assessment tools
In the present study, Porter and Lawler’s intrinsic and
extrinsic motivation model, and Voom’s expectancy–
valence motivation theory were used to analyse the rela-
tionship between work motivation and job satisfaction.
Lazarus and Folkman’s10 cognitive theory of stress and
coping, and Karasek’s11 demand–control model were
used to analyse the relationship between work stress and
job satisfaction. The study instrument consisted of a self-
administered questionnaire composed of four sections.
Section 1 focused on respondents’ socioeconomic and

demographic status.
Section 2 assessed work stress. Thirty items related to

work stress were developed through intensive qualitative
interviews with policymakers, healthcare managers and
community health workers, a review of the literature,
and an initial pilot study.16 42 Then factor analysis, which
is not discussed in this paper, yielded five subscales that
comprised 26 items. The five-subscale solution
accounted for 69.43% of the overall variance, and was
found to be internally consistent (overall Cronbach’s
α=0.87). Based on Cooper and Marshall’s16 model of job
stress, these five subscales of work stress were named
work task and role, career development, wages and ben-
efits, workplace relationships, and organisational struc-
ture and climate stress. They individually accounted for
16.05%, 25.10%, 12.00%, 9.08% and 7.20% of the
overall variance, respectively, and the Cronbach’s α
within individual subscales ranged from 0.85 to 0.90.
Respondents were asked to rate their perception of work
stress on each item based on a five-point Likert scale:
not at all stressful (1), slightly stressful (2), average (3),
stressful (4) and very stressful (5). The Cronbach’s α
value for this study was 0.87.
Section 3 assessed work motivation. Twenty-one items

were developed based on previous research, panel dis-
cussions and an initial pilot study.43–45 Then three items
were deleted and the 18 retained items were divided
into four subscales by factor analysis, which is not dis-
cussed in this paper. The four-subscale solution
accounted for 65.10% of the overall variance, and was
found to be internally consistent (overall Cronbach’s
α=0.75). The subscales were renamed based on the con-
ceptual meaning of the items and comprised: career
development, recognition, responsibility and financial

Li L, Hu H, Zhou H, et al. BMJ Open 2014;4:e004897. doi:10.1136/bmjopen-2014-004897 3

Open Access

motivation. They individually accounted for 21.20%,
19.40%, 14.60% and 9.90% of the overall variance, and
the Cronbach’s α within individual subscales ranged
from 0.82 to 0.89. According to Porter and Lawler’s28

intrinsic and extrinsic motivation model, we defined
career development and financial motivation as extrinsic
motivation, and recognition and responsibility motiv-
ation as intrinsic motivation.44 Respondents were asked
to rate their motivation intensity on each item based on
a five-point Likert scale: very weak (1), weak (2), average
(3), strong (4) and very strong (5).
Section 4 assessed job satisfaction. In this study, a single-

item measure was used to measure overall job satisfac-
tion.46 Respondents were asked to indicate their level of
job satisfaction on a four-point Likert scale: strongly dis-
satisfied (1), dissatisfied (2), satisfied (3) and strongly sat-
isfied (4). During the process of data analysis, strongly
satisfied and satisfied were coded as 1, while strongly dis-
satisfied and dissatisfied were coded as 0.

Data analysis
Survey results were analysed using SPSS V.17.0.
Descriptive analyses included frequencies and percen-
tages for categorical variables and means and SDs for
continuous variables. Mean differences were examined
using t tests and ANOVAs for relevant subgroups. We
used logistic regression to measure the key predictors of
job satisfaction because the dependent variable ( job sat-
isfaction) was a binary variable, which made linear
regression unsuitable.

RESULTS
Socioeconomic and demographic status of respondents
The socioeconomic and demographic characteristics of
the respondents are shown in table 1. A majority of par-
ticipants were female (74.6%). General practitioners
accounted for 36% of community health workers sur-
veyed, followed by nurses (28.8%) and public health
physicians (19.1%). In this survey, only 18.6% of the
respondents had senior professional titles and less than
half (40.2%) of them had a bachelor degree or higher.
Only 19.6% of them had monthly incomes above 3000
CNY (approximately US$480$ in 2012). Nearly 90% of
respondents worked more than 40 h/week.

Work stress and motivation according to socioeconomic
and demographic factors
The results of variance analysis and further multiple
comparison t tests are shown in table 1. There were sig-
nificant differences in scores for all five subscales of
work stress according to occupation (p<0.01) and gender (p<0.05), with general practitioners and men showing higher levels of work stress. Scores for the wages and benefits subscale of work

stress differed significantly according to educational
background (p<0.05) and income (p<0.05). Mid-level professionals reported significantly higher levels of stress

on the work task and role subscale (p<0.01) and in workplace relationships (p<0.05). Participants aged 35– 44 and 45–54 years reported significantly higher levels of stress on the work task and role subscale (p<0.01). Men had significantly higher levels of recognition and

financial motivation (p<0.05). Younger workers (<25) had significantly higher levels of recognition motivation (p<0.05) and responsibility motivation (p<0.05). General practitioners had a higher level of recognition motivation (p<0.05). There were no significant differences in any of the

four work motivation subscale scores according to edu-
cational background, professional title or income.

Levels of work stress, work motivation and

job satisfaction

The mean score for overall perception of work stress was
3.11, which is slightly higher than the mid-point of 3
(table 2). The wages and benefits (3.60) subscale of
work stress ranked highest, followed by work task and
role (3.31), career development (2.96), organisational
structure and climate (2.90), and relationships (2.75)
(F=154.9, p<0.001). Statistically significant differences were noted in overall perception of stress and scores on all five work stress subscales between satisfied and dissat- isfied respondents; those who were dissatisfied reported higher levels of work stress (p<0.001). Career development motivation was rated highest, fol-

lowed by financial, recognition and responsibility motiv-
ation (F=202.6, p<0.001). Levels of overall perception of work motivation and all subscales with the exception of financial motivation were significantly different between the satisfied and dissatisfied groups of respondents, and the satisfied workers had higher levels of work motiv- ation (p<0.01). Regarding motivation, career development was rated

highest, followed by financial, recognition and responsi-
bility motivation (F=202.6, p<0.001). Levels of overall perception of motivation and scores on all work motiv- ation subscales, with the exception of financial motiv- ation, differed significantly between the satisfied and dissatisfied respondents, and the satisfied workers reported higher levels of work motivation (p<0.01).

Predictors of job satisfaction
In this study, 61.3% of respondents were satisfied with
their jobs. Table 3 presents the results of a logistic
regression model that examined the key predictors of
job satisfaction, with special attention given to work
stress and work motivation.
Only a few demographic characteristics were predic-

tors of job satisfaction. We found that when scores on
the career development and wages and benefits sub-
scales of work stress increased by one grade, job satisfac-
tion decreased by 32% (OR 0.68, p<0.05) and 37% (OR 0.63, p<0.01), respectively. When financial motivation increased by one grade, job satisfaction decreased by

4 Li L, Hu H, Zhou H, et al. BMJ Open 2014;4:e004897. doi:10.1136/bmjopen-2014-004897

Open Access

Table 1 Analysis of work stress and work motivation by socioeconomic and demographic status for respondents

N Per cent

Work stress

Work motivation

Work

task

and role

Career

development

Wages

and
benefits

Workplace

relationships

Organisational

structure and

climate Recognition

Career

development Responsibility Financial

Occupation

General practitioner 335 36.0 3.53 3.17 3.78 2.90 3.14 3.61 4.20 3.44 4.15

Public health physician 178 19.1 3.20 2.89 3.70 2.63 2.96 3.57 4.11 3.67 4.06

Nurse 267 28.8 3.24 2.95 3.54 2.76 2.78 3.53 4.05 3.39 4.01

Other 150 16.1 3.09 2.79 3.45 2.65 2.84 3.59 4.11 3.40 4.03

F 6.91** 4.97** 3.45** 3.05** 6.25** 0.66 2.31* 1.96 0.99

Sex

Male 236 25.4 3.44 3.10 3.77 2.88 3.12 3.71 4.18 3.50 4.19

Female 694 74.6 3.27 2.93 3.56 2.72 2.85 3.56 4.12 3.43 4.03

F 2.50* 2.27* 2.60* 2.51* 4.09* 2.36* 1.23 1.04 2.39*

Educational background

High school or below 110 11.8 3.18 2.90 3.36 2.81 2.72 3.57 4.13 3.42 4.05

Junior college 446 48.0 3.28 2.94 3.61 2.74 2.86 3.57 4.14 3.49 4.02

College and above 374 40.2 3.36 3.00 3.65 2.73 3.16 3.60 4.11 3.39 4.11

F 2.30 0.66 4.21* 0.45 4.02* 0.13 0.24 1.53 1.33

Age in years

<25 78 8.4 3.08 2.81 3.45 2.60 2.77 3.80 4.23 3.60 3.92

25–34 258 27.7 3.21 2.94 3.63 2.72 2.91 3.65 4.11 3.48 4.17

35–44 329 35.4 3.36 2.98 3.55 2.78 2.88 3.52 4.13 3.35 4.03

45–54 234 25.2 3.43 3.02 3.69 2.79 2.94 3.53 4.13 3.51 4.04

≥55 31 3.3 3.12 2.88 3.54 2.71 2.93 3.48 3.98 3.28 3.91
F 4.71** 1.01 1.36 1.12 0.83 2.89* 1.83 2.86* 2.39

Title

Senior title 42 4.5 3.12 3.11 3.38 2.69 2.73 3.37 3.97 3.55 3.96

Vice-senior title 131 14.1 3.32 2.92 3.65 2.63 2.93 3.46 4.05 3.25 4.03

Middle title 399 42.9 3.43 3.03 3.69 2.85 2.94 3.56 4.16 3.44 4.06

Primary title 299 32.2 3.20 2.93 3.54 2.72 2.87 3.62 4.12 3.49 4.08

No title 59 6.3 3.23 2.86 3.48 2.58 2.89 3.73 4.16 3.49 4.04

F 3.96** 1.07 1.71 3.04* 0.59 1.73 0.98 2.13 0.16

Monthly income (CNY)

<2000 361 38.9 3.24 2.95 3.69 2.76 2.90 3.61 4.15 3.49 4.09

2000–2999 386 41.5 3.32 2.96 3.61 2.75 2.88 3.59 4.13 3.40 4.06

3000–3999 139 14.9 3.43 2.97 3.44 2.68 2.96 3.52 4.02 3.43 3.97

≥4000 44 4.7 3.39 3.03 3.21 2.93 2.78 3.44 4.27 3.53 4.28
F 2.11 0.99 3.14* 2.11 0.99 0.54 1.87 0.86 1.36

Working hours (per week)

<40 110 11.8 3.27 2.82 3.52 2.82 2.94 2.96 4.14 3.56 3.91

40–47 509 54.7 3.26 2.73 3.59 2.73 2.95 2.87 4.10 3.42 4.06

48–55 250 26.9 3.36 2.71 3.62 2.71 2.93 2.89 4.19 3.46 4.12

≥56 61 6.6 3.52 2.93 3.75 2.93 3.36 3.13 4.16 3.43 4.14
F 0.06 0.20 0.48 0.20 0.01* 0.11 0.39 0.44 0.13

*p<0.05, **p<0.01.

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28% (OR 0.72, p<0.01), and when recognition motiv- ation and responsibility motivation increased by one grade, job satisfaction increased 1.86-fold (OR 2.86, p<0.01) and 0.36-fold (OR 1.36, p<0.05), respectively. Compared with nurses, general practitioners (OR 0.56, p<0.01) and public health physicians (OR 0.42, p<0.05) reported lower job satisfaction, while other technical staff (OR 1.89) reported higher job satisfaction. Workers with no title (OR 7.02, p<0.05) were more satisfied than workers with a senior title.

DISCUSSION
Job satisfaction in community health workers is import-
ant for the sustainable development of basic healthcare
in China, but health policymakers and managers have
neglected it for a long time.47 This study is one of the
first to examine the level of work stress and work motiv-
ation and their combined effects on job satisfaction
among urban community health workers in China since
the implementation of health system reform.
Results indicated that the wages and benefits subscale

of stress ranked highest, followed by the work task and
role subscale. Similarly, previous research related to
work stress found that low salary, heavy workload and
few promotion opportunities were the most frequently
cited workplace stressors.48 49 Several factors may have
contributed to these findings. In Heilongjiang Province,
the average annual income of health service personnel
in urban hospitals was 52 564 CNY (approximately US
$8437) in 2012. In this study, 80.4% of the respondents’

annual incomes were below 36 000 CNY (approximately
US$5778). These low salaries for community health
workers increased their wages and benefits stress.50 In
addition, based on the population of the province and
human resource planning ratios, there was an approxi-
mate shortfall of 30% in the number of general practi-
tioners in 2012.4 The recent reforms have also expanded
the scope of public health services and increased work-
load without equivalent increases in staffing levels.5 6

Unfortunately, the present study found that scores on
the career development, and wages and benefits sub-
scales of work stress were negatively associated with job
satisfaction. These findings were consistent with previous
studies in which workers were likely to report low job sat-
isfaction if they did not receive promotion and advance-
ment opportunities or adequate salaries.22 33 51

With regard to work motivation, results showed the
career development and financial subscales of work
motivation ranked first and second, respectively, consist-
ent with Hung and Hou’s study, which found income,
benefits and professional development were the most
important motivating factors among community health
workers in China.39 52

In this study, we defined career development and
financial motivation as extrinsic motivation and recogni-
tion and responsibility motivation as intrinsic motivation
based on the literature.37 53 Results showed that the rec-
ognition and responsibility subscales of work motivation
were positive predictors of job satisfaction, and financial
motivation was a negative predictor. This was consistent
with the ‘crowding-in’ effect, which proposes that intrin-
sic motivation increases job satisfaction, whereas

Table 2 Mean scores of the overall perception and subscales of work stress and work motivation with respect to the level of

job satisfaction

Mean±SD Level of job satisfaction

Total (n=930) Satisfied (n=570, 61.3%) Dissatisfied (n=360, 38.7%) p Value

Work stress

Overall perception* 3.11±0.68 2.95±0.68 3.37±0.60 0.000

Work task and role† 3.31±0.81 3.18±0.82 3.52±0.76 0.000

Career development† 2.96±0.87 2.79±0.85 3.22±0.83 0.000

Wages and benefits† 3.60±0.95 3.38±0.94 3.95±0.85 0.000

Workplace relationships† 2.75±0.79 2.61±0.79 2.96±0.74 0.000

Organisational structure and climate† 2.90±0.79 2.74±0.79 3.15±0.71 0.000

Work motivation

Overall perception‡ 3.80±0.55 3.86±0.55 3.70±0.55 0.000

Career development§ 4.13±0.57 4.24±0.51 3.95±0.62 0.000

Recognition§ 3.58±0.77 3.66±0.77 3.45±0.77 0.000

Responsibility§ 3.45±0.77 3.53±0.77 3.32±3.52 0.000

Financial§ 4.06±0.79 4.02±0.79 4.12±0.80 0.295

*Mean score of overall perception of work stress was calculated for each respondent by adding the value of each item of work stress and then
dividing by the total number of items.
†Mean score of each subscale of work stress was calculated for each respondent by adding the value of each item of the subscale of work
stress and then dividing by the total number of items.
‡Mean score of overall perception of work motivation was calculated for each respondent by adding the value of each item of work motivation
and then dividing by the total number of items.
§Mean score of each subscale of work motivation was calculated for each respondent by adding the value of each item of the subscale of
work motivation and then dividing by the total number of items.

6 Li L, Hu H, Zhou H, et al. BMJ Open 2014;4:e004897. doi:10.1136/bmjopen-2014-004897

Open Access

extrinsic motivation decreases job satisfaction.54 It
should be noted that in this study, the level of extrinsic
motivation was higher than that of intrinsic motivation.
These findings have significant implications for man-

agers of CHCs and policymakers in their efforts to
improve workers’ job satisfaction. First, policymakers
should take measures to improve community health
workers’ salaries. In China, basic public health services
are funded by the government and provided free by
community health workers. If health workers are dissatis-
fied with their salaries, they may prefer to work for
profit-making medical organisations instead of non-
profit public health services. In the meantime, managers
should pay staff based on their performance to increase
staff enthusiasm and reduce their financial stress.

Second, policymakers should focus on appropriate pro-
motion policies for community health workers. At
present, it is difficult for community health workers to
get title promotion for there are limited annual promo-
tion quotas for CHCs in Heilongjiang Province and our
study found only 18.6% of respondents had a senior pro-
fessional title. Third, managers should provide and
support their workers to attend training or continuing
education. Fourth, managers and policymakers should
take measures to inspire intrinsic motivation in workers.
Becchetti et al53 proposed that when workers do not
work for financial incentives, they may find satisfaction
irrespective of their salaries, even if the financial incen-
tive is kept to a minimum. Therefore, managers and pol-
icymakers should introduce more incentives to
encourage community health workers to work in order
to gain responsibility or recognition.
As some subscales of work stress and work motivation

can influence job satisfaction either positively or nega-
tively, we examined levels of work stress and motivation
according to demographic characteristics and found that
policymakers and managers should pay more attention
to three types of workers. The first group of workers are
those aged between 35 and 54 years (35–44 and 45–54
age groups), who reported higher levels of stress on the
work task and role subscale and lower levels of intrinsic
motivation. Similar results have been reported else-
where; in Qu’s55 study, community health workers in
mid-level age groups were significantly more stressed
than those in the youngest age group in one province of
China. This could be related to workload or the diffi-
culty and complexity of the work task, which is usually
greater for 35–54-year-old workers, as they are the back-
bone of community health services. Men are the second
group that requires attention. In our study, men’s scores
on all of the work stress subscales tended to be higher
than women’s, and men reported higher levels of finan-
cial motivation.56 However, another Chinese study of
primary health workers found no differences in financial
motivation.52 David and Srinika57 found that women
reported more stress in the financial rewards and role
ambiguity subscales. The final group of workers identi-
fied as requiring attention consists of general practi-
tioners, who experienced the highest stress according to
all five work stress subscales and reported the highest
career development motivation. General practitioners in
CHCs face more difficult and complicated tasks and
greater medical risk than other healthcare workers, and
receive lower salaries and fewer promotion opportunities
than their counterparts in general hospitals.

Limitations of this study
The findings in this study should be viewed in light of
four key limitations. First, this study was based on a small
sample of community health workers, which may limit
the generalisability of the research findings. Based on
the literature on community health services in China, a
multistage, stratified sampling design was employed to

Table 3 Logistic regression analysis for job satisfaction†

OR 95% CI

Occupation (reference: nurse)

General practitioner 0.56** 0.38 to 0.81

Public health physician 0.42* 0.20 to 0.87

Other technical staff 1.89* 1.04 to 3.44

Sex (reference: male)

Female 1.27 0.83 to 1.95

Educational background (reference: high school or below)

Junior college 0.76 0.43 to 1.34

College and above 0.75 0.41 to 1.40

Age in years (reference: <25)

25–34 0.60 0.30 to 1.21

35–44 1.10 0.51 to 2.42

45–54 1.04 0.45 to 2.35

≥55 8.53** 1.86 to 39.01
Title (reference: senior title)

Vice-senior title 1.86 0.476 to 7.29

Middle title 2.57 0.67 to 9.78

Primary title 3.84 0.96 to 15.39

No title 7.02* 1.53 to 32.12

Monthly income in CNY (reference: <2000)

2000–2999 0.50 0.26 to 0.98

3000–3999 0.99 0.64 to 1.52

≥4000 1.30 0.86 to 1.97
Weekly hours worked (reference: <40)

40–47 0.90 0.59 to 1.37

48–55 1.07 0.67 to 1.70

≥56 1.20 0.62 to 2.33
Work stress

Work task and role 0.98 0.74 to 1.300

Career development 0.68* 0.49 to 0.94

Wages and benefits 0.63** 0.50 to 0.79

Workplace relationships 0.80 0.59 to 1.09

Organisational structure and

climate

0.97 0.71 to 1.33

Work motivation

Career development 1.13 0.85 to 1.505

Recognition 2.86** 2.02 to 4.04

Responsibility 1.36* 1.02 to 1.81

Finance 0.72** 0.56 to 0.92

*p<0.05, **p<0.01. †Strongly satisfied and satisfied coded as 1 versus strongly dissatisfied and dissatisfied coded as 0.

Li L, Hu H, Zhou H, et al. BMJ Open 2014;4:e004897. doi:10.1136/bmjopen-2014-004897 7

Open Access

ensure that study data were representative of the prov-
ince.7 40 Six sample cities were selected to account for
the variability in regional per capita gross domestic
product and the levels of healthcare development. Then
15 CHCs in each city were selected randomly. On
average, there are 23 medical technical personnel in a
CHC in Heilongjiang Province and there were approxi-
mately 22 health workers in each of the CHCs in our
study. In addition, the proportions of general practi-
tioners, public health physicians, nurses and other
medical technical personnel in this study were close to
the proportions found in the province as a whole.3

Consequently, this sample was representative of
Heilongjiang community health service providers,
thereby enhancing the potential for generalisation of
the study findings. Second, the instrument for assessing
work stress and work motivation was developed from
earlier study and discussed with experts, although not
an international commonly used scale. Third, we used a
cross-sectional survey, which may limit our ability to iden-
tify causal relationships between work stress and motiv-
ation and job satisfaction. Fourth, the questionnaires
were self-administered and thus could have been
affected by respondents’ prevailing emotions. Therefore,
the common method bias and the self-administration
bias might have affected the results.

CONCLUSION
It is important for healthcare managers to improve the
job satisfaction of health workers in low-resource set-
tings. In this study, we examined levels of work stress and
motivation according to demographic characteristics
and levels of job satisfaction; additionally, the key predic-
tors of job satisfaction were identified using logistic
regression analysis. The results indicated that community
health workers rated wages and benefits highest among
five subscales of work stress, and workers’ extrinsic
motivation was higher than their intrinsic motivation.
The career development, and wages and benefits sub-
scales of work stress and financial motivation were sig-
nificant negative predictors of job satisfaction, while the
recognition and responsibility subscales of work motiv-
ation were significant positive determinants.
Our findings suggest that there is considerable room for

improvement in the job satisfaction of community health
workers in Heilongjiang Province, and healthcare man-
agers and policymakers should take both work stress and
work motivation into consideration. First, they should pay
more attention to three types of workers, who were aged
between 35 and 54 years, male and general practitioners,
as these particular groups reported higher work stress and
extrinsic motivation. Second, they should take a variety of
measures to reduce career development, and wage and
benefits stress, as they were negative determinants of job
satisfaction. Third, it is important for managers and policy-
makers to inspire workers’ intrinsic motivation, as it can
have a positive influence on job satisfaction.

Acknowledgements We are thankful to all the community health workers
who participated in the study. We are also grateful to Yin Li, Xingsan Li,
Zhuang Wang and Hongjuan Wei, who worked closely with the team to
ensure the field survey was successfully implemented.

Contributors LL was responsible for study design, data analysis, and drafting
and revising the manuscript. HH and CH were responsible for study design, data
collection and data analysis. HZ and ZZ provided statistical expertise. XL, TS and
HL carried out data collection and provided technical support. LF provided
administrative support. All authors read and approved the final manuscript.

Funding This study was funded by the National Science Foundation of China
(NSFC), Contract No. 71203050/G0308, Contract No. 71073034 and was
supported by the Young Seed Foundation of the Public Health College of
Harbin Medical University.

Competing interests None.

Ethics approval This study was approved by the Medical Ethics Committee of
Harbin Medical University.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement Factor analyses of work stress and work motivation
are available from Li Li at lilihmu@gmail.com

Open Access This is an Open Access article distributed in accordance with
the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license,
which permits others to distribute, remix, adapt, build upon this work non-
commercially, and license their derivative works on different terms, provided
the original work is properly cited and the use is non-commercial. See: http://
creativecommons.org/licenses/by-nc/3.0/

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Li L, Hu H, Zhou H, et al. BMJ Open 2014;4:e004897. doi:10.1136/bmjopen-2014-004897 9

Open Access

Work stress, work motivation and their effects on job satisfaction in community health workers: a cross-sectional survey in China

Abstract
Introduction
Methods
Sample
Assessment tools
Data analysis
Results
Socioeconomic and demographic status of respondents
Work stress and motivation according to socioeconomic and demographic factors
Levels of work stress, work motivation and job satisfaction
Predictors of job satisfaction
Discussion
Limitations of this study
Conclusion
References

This Week’s Citation Classic CC/NUMBER 19
IHerzberg F, MausnerB & SnydermanB B

The motivation to work.

New York: Wiley, 1959. 157 p.
(Dept. Psychology,WesternReserveUniv., Cleveland.OH andDept. Psychology.
BeaverCollege, Glenside,PAJ

The book describes the original re-
search leading to the development of
motivation-hygiene theory. It suggests
that there are no antonyms for affec-
tive states. In this instance, job satisfac-
tion and job dissatisfaction are
separate continua produced by dif-
ferent sets of job factors. [The Social
Sciences Citation Index® (SSCI®) in-
dicates that this book has been cited in
over 795 publications since 1966.]

Frederick I. Herzberg
Graduate School of Business

University of Utah
Salt Lake City, UT 84112

March 13, 1984
“In 1950, I received my PhD in

psychology. I was offered a fellow-
ship to attend the Graduate School
of Public Health at the University
of Pittsburgh. My major was to be
in industrial mental health under
the direction of an industrial psy-
chiatrist from McGill University in
Canada by the name of Graham
Taylor. Unfortunately, I soon dis-
covered that the concepts of indus-
trial mental health were really a re-
statement of the concepts of men-
tal illness that I had previously
studied in clinical and abnormal
psychology. Reflecting this disap-
pointment, I entitled my Public
Health Practice thesis Mental
Health Is Not the Opposite of Men-
tal Illness. After receiving my mas-
ter’s degree in public health, I took
a job as research director for Psy-
chological Services of Pittsburgh.
A local industrialist came to see
me after a nasty labor relations

disturbance and asked me plain-
tively, ‘What do people want from
their jobs?’ I answered him in typi-
cal academic fashion, ‘Sir, I don’t
know but if you give me enough
money I will find out.’.

“I followed up on my School of
Public Health thesis by designing a
study to test the hypothesis that
job satisfaction and job dissatisfac-
tion were separate concepts. The
result was the book, The Motiva-
tion to Work, which led to a funda-
mentally different approach to the
study of people’s affective states.
This is the twenty-fifth anniversary
of the publication of The Motiva-
tion to Work. The original study
has produced perhaps more repli-
cations than any other research in
the history of industrial and orga-
nizational psychology. The new ap-
proach to viewing job attitudes
was the beginning of many present-
day concepts and applications of
industrial and organizational psy-
chology (e.g., job enrichment, qual-
ity control circles, quality of work
life, cafeteria-style benefits, guar-
anteed annual wage, flextime, etc.).

“Bernard Mausner and Barbara
Snyderman were two senior mem-
bers of my research staff. Both of
them contributed significantly to
the carrying out of the research
and to the publication of The Moti-
vation to Work.

“I have since published three
major amplifications of motiva-
tion-hygiene theory: Work and the
Nature of Man,l The Managerial
Choice,2 and Herzberg on Motiva-
tion.”3

I. HerzbergFI. Work andthe nature of man. New York: Crowell, 1966. 203 p.
2. (The managerialchoice. Salt Lake City. UT: Olympus, 1982.360 p.
3. . Herzbe,~on motivation. Cleveland, OH: Penton/IPC,1983. 52 p.

14 s&8s ©l984bylS1® CURI~ENTCONTENTS®

A peer-reviewed electronic journal.

Copyright is retained by the first or sole author, who grants right of first publication to Practical Assessment, Research & Evaluation. Permission is granted to distribute this article for
nonprofit, educational purposes if it is copied in its entirety and the journal is credited. PARE has the right to authorize third party reproduction of this article in print, electronic and
database forms.

Volume 5, Number 11, November, 1997 ISSN=1531-7714

Herzberg’s theory of motivation and

Maslow’s hierarchy of needs

Joseph E. Gawel,
The Catholic University of America

Among various behavioral theories long generally believed and embraced by American business are those of Frederick
Herzberg and Abraham Maslow. Herzberg, a psychologist, proposed a theory about job factors that motivate employees.
Maslow, a behavioral scientist and contemporary of Herzberg’s, developed a theory about the rank and satisfaction of
various human needs and how people pursue these needs. These theories are widely cited in the business literature.

In the education profession, however, researchers in the ’80s raised questions about the applicability of Maslow’s and
Herzberg’s theories to elementary and secondary school teachers: Do educators, in fact, fit the profiles of the average
business employee? That is, do teachers (1) respond to the same motivators that Herzberg associated with employees in
profit-making businesses and (2) have the same needs patterns as those uncovered by Maslow in his studies of business
employees?

This digest first provides brief outlines of the Herzberg and Maslow theories. It then summarizes a study by members of
the Tennessee Career Ladder Program (TCLP). This study found evidence that the teachers in the program do not
match the behavior of people employed in business. Specifically, the findings disagree with Herzberg in relation the
importance of money as a motivator and, with Maslow in regard to the position of esteem in a person’s hierarchy of
needs.

Herzberg’s theory of motivators and hygiene factors

Herzberg (1959) constructed a two-dimensional paradigm of factors affecting people’s attitudes about work. He concluded
that such factors as company policy, supervision, interpersonal relations, working conditions, and salary are hygiene
factors rather than motivators. According to the theory, the absence of hygiene factors can create job dissatisfaction, but
their presence does not motivate or create satisfaction.

In contrast, he determined from the data that the motivators were elements that enriched a person’s job; he found five
factors in particular that were strong determiners of job satisfaction: achievement, recognition, the work itself,
responsibility, and advancement. These motivators (satisfiers) were associated with long-term positive effects in job
performance while the hygiene factors (dissatisfiers) consistently produced only short-term changes in job attitudes and
performance, which quickly fell back to its previous level.

In summary, satisfiers describe a person’s relationship with what she or he does, many related to the tasks being
performed. Dissatisfiers, on the other hand, have to do with a person’s relationship to the context or environment in which
she or he performs the job. The satisfiers relate to what a person does while the dissatisfiers relate to the situation in
which the person does what he or she does.

Maslow’s hierarchy of needs

In 1954, Maslow first published Motivation and Personality, which introduced his theory about how people satisfy
various personal needs in the context of their work. He postulated, based on his observations as a humanistic
psychologist, that there is a general pattern of needs recognition and satisfaction that people follow in generally the
same sequence. He also theorized that a person could not recognize or pursue the next higher need in the hierarchy
until her or his currently recognized need was substantially or completely satisfied, a concept called prepotency.
Maslow’s hierarchy of needs is shown in Table 1. It is often illustrated as a pyramid with the survival need at the broad-
based bottom and the self-actualization need at the narrow top.

Table 1
Maslow’s hierarchy of needs

Level Type of Need Examples

1 Physiological Thirst, sex, hunger

2 Safety Security, stability, protection
Page 1 of 3

3 Love and
Belongingness

To escape loneliness, love and be loved,
and gain a sense of belonging

4 Esteem Self-respect, the respect others

5 Self-actualization To fulfill one’s potentialities

According to various literature on motivation, individuals often have problems consistently articulating what they want
from a job. Therefore, employers have ignored what individuals say that they want, instead telling employees what they
want, based on what managers believe most people want under the circumstances. Frequently, these decisions have
been based on Maslow’s needs hierarchy, including the factor of prepotency. As a person advances through an
organization, his employer supplies or provides opportunities to satisfy needs higher on Maslow’s pyramid.

TCLP study in relation to Herzberg’s theory

According to Bellott and Tutor (1990), the problems with Herzberg’s work are that it occurred in 1959–too long ago to be
pertinent–and did not cover teachers. They cite earlier research by Tutor (1986) with Tennessee Career Ladder
Program as a means of overcoming both those problems. TCLP has three levels, the largest and beginning one of which
(Level I) has 30,000 members. Bellott and Tutor believe that the data from the study clearly indicate that the Level I
participants were as influenced by motivation factors as by hygiene factors (Table 2), contrary to Herzberg’s position
that hygiene factors do not motivate.

Table 2
Distribution of motivation and hygiene tendencies

among teachers at the various
Career Ladder levels (from Bellott and Tutor)

Tendency Level I Level II Level III Total

Motivation 71 101 149 321

Hygiene 70 11 24 105

Total 141 112 173 426

The survey asked classroom teachers, “To what extent did salary influence your decision to participate in the (TCLP)
program?” Teachers responded using a scale of from 1 (little influence on deciding to participate in the program) to 7
(large influence). The results for the four highest-average items, shown in Table 3, indicate that at all three levels
teachers viewed salary as a strong motivating factor, easily the most important of 11 of Herzberg’s hygiene factors on the
survey.

Table 3
The importance of various of Herzberg’s

hygiene factors in teachers’ decisions to participate
in TCLP (from Bellott and Tutor)

Factor Level I Level II Level III

Personal life 3.658 4.794 4.984

Possibility for growth 4.013 5.528 5.394

Salary 5.980 6.500 6.468

Status 2.960 4.373 4.261

Items ranked lower than those shown were Interpersonal
relations with peers, with students, and with superiors; job
security; school policy and administration; supervisor; and
working conditions.

On Herzberg’s five motivation factors, achievement ranked as the most important one. However, the overall conclusion
drawn from the research is that salary was the single most important influence on the teachers’ decisions to participate

Page 2 of 3

in TCLP, regardless of level in the organization. Further, actual salary increases ranged from $1000 to 7000 per year.
The teachers perceived the amount of salary increase to be tied to achievement and the other motivation factors.

The study and Maslow’s theory

According to data from the TCLP survey, the teachers at all three experience levels are less satisfied with their personal
achievement of esteem (a middle level need according to Maslow) than with their achievement of self-actualization.
These results are summarized in Table 4. Therefore, it can be concluded that self-actualization is a prepotent need for
esteem. Two reasons seem to account for this. First, self-actualization provides the basis for self-esteem. Second, this self-
actualized performance is also the basis for reputation, the esteem of others.

Table 4
Arithmetic means of perceived need

deficiency areas by Career Ladder levels
(from Bellott and Tutor)

Teacher Level in TCLP

Need Deficiency I II III

Security 1.4266 1.0563 0.7906

Social 1.0312 1.1537 0.8747

Esteem 2.1173 2.3278 1.9016

Autonomy 1.8640 2.1188 1.5052

Self-actualization 1.8265 2.2883 1.3792

Conclusion

Although Herzberg’s paradigm of hygiene and motivating factors and Maslow’s hierarchy of needs may still have broad
applicability in the business world, at least one aspect of each, salary as a hygiene factor (Herzberg) and esteem as a
lower order need than self-actualization (Maslow), does not seem to hold in the case of elementary and secondary school
teachers. These findings may begin to explain why good teachers are being lost to other, higher paying positions and to
help administrators focus more closely on the esteem needs of teachers, individually and collectively.

References

Bellott, F. K., & Tutor, F. D. (1990). “A Challenge to the Conventional Wisdom of Herzberg and Maslow Theories.” Paper
presented at the Nineteenth Annual Meeting of the Mid-South Educational Research Association. New Orleans, LA.

Herzberg, F., Mausner, B., & Snyderman, B. B. (1959). The Motivation to Work (2nd ed.). New York: John Wiley & Sons.

Maslow, A. H. (1970). Motivation and Personality (2nd ed.). New York: Harper and Row.

Tutor, F. D. (1986). The Relationship between Perceived Need Deficiencies and Factors Influencing Teacher Participation
in the Tennessee Career Ladder. Doctoral dissertation, Memphis State University, Memphis, TN.

Descriptors: Career Ladders; Elementary Secondary Education; Industrial Psychology; *Job Satisfaction; *Motivation; *Needs; *State
Programs; *Teachers

Citation: Gawel, Joseph E. (1997). Herzberg’s theory of motivation and maslow’s hierarchy of needs. Practical Assessment, Research &
Evaluation, 5(11). Available online: http://PAREonline.net/getvn.asp?v=5&n=11.

Page 3 of 3

http://pareonline.net/getvn.asp?v=5&n=11

Do I Just Look Stressed or am I Stressed? Work-
related Stress in a Sample of Italian Employees

Gabriele GIORGI1*, Jose M. LEON-PEREZ2, Vincenzo CUPELLI3,
Nicola MUCCI3 and Giulio ARCANGELI3

1 Department of Psychology, Università Europea di Roma, Italy
2 Business Research Unit, Instituto Universitário de Lisboa (ISCTE-IUL), Portugal
3 Chair of Occupational Medicine, Health Services Research Unit, Department of Clinical and Experimental

Medicine, University of Florence, Italy

Received September 26, 2012 and accepted November 21, 2013
Published online in J-STAGE November 29, 2013

Abstract: Work-related stress is becoming a significant problem in Italy and it is therefore essential
to advance the theory and methodology required to detect this phenomenon at work. Thus, the aim
of this paper is to propose a new method for evaluating stress at work by measuring the discrepan-
cies between employees’ perceptions of stress and their leaders’ evaluation of the stress of their sub-
ordinates. In addition, a positive impression scale was added to determine whether workers might
give socially desirable responses in organizational diagnosis. Over 1,100 employees and 200 leaders
within several Italian organizations were involved in this study. Structural equation modeling was
used to test such new method for evaluating stress in a model of stress at work that incorporates
relationships among individual (positive impression), interpersonal (workplace bullying) and orga-
nizational factors (working conditions, welfare culture, training). Results showed that the leaders’
capacity to understand subordinates’ stress is associated with subordinates’ psychological well-
being since higher disagreement between self and leaders’ ratings was related to lower well-being.
We discuss the implications of healthy leadership for the development of healthy organizations.

Key words: Work-related stress, Workplace bullying, psychological well-being, Healthy organizations,
Healthy leadership

Introduction

In the past several years, workplace stress has attracted
the attention of researchers, organizations and public
opinion alike. A considerable amount of data has been ac-
cumulated which confirms that stress is a serious problem
of organizational life1, 2). Empirical investigations in many
different countries have provided data that point to the
negative consequences of stress for employees’ health

and well-being (e.g., anxiety, depression or compulsive
behavior)2–5) as well as for the organization and its working
environment (e.g., absenteeism, turnover, loss of creativity
and decreased productivity)5–7). Furthermore, meta-analytic
techniques and longitudinal studies have shown that orga-
nizational environmental factors are associated with stress
and its subsequent negative consequences2, 3, 6, 7).

Similarly, there has been a marked increase in the
interest in issues involving work-related stress in Italy
in the last 5 yr. This is due primarily to the promulgation
of the new law for the protection of health and safety
in the workplace (Legislative Decree no. 81/2008 and
subsequent amendments) which enshrined the obligation

*To whom correspondence should be addressed.
E-mail: gabriele.giorgi@unier.it

Industrial Health 2014, 52, 43–53 Original Article

G GIORGI et al.44

Industrial Health 2014, 52, 43–53

of all employers in every area of employment to assess
the risks associated to work-related stress. Moreover,
given the decline in traditional occupational diseases (i.e.,
noise-induced hearing loss, silicosis, lead poisoning), oc-
cupational physicians have examined work-related stress
more carefully and it has become one of the new frontiers
of occupational health8).

Despite the abundance of data and coherent theories
that have been developed on work stress, there is a grow-
ing consensus that the accumulative empirical evidence
on work stress comes mainly from studies that rely on
self-reported measures (i.e., questionnaires)9, 10), which
is considered one of the most common limitations in the
field11–13). Accordingly, some authors have proposed us-
ing alternative measures to assess employees’ experience
of stress at work (e.g., observational check-lists, focus
groups), underlining the importance of stress evaluations
by key people of the organization, such as leaders12, 13).

In response, this study tries to overcome these previous
limitations by suggesting a model to better evaluate and
explore stress at work based on multiple sources of data
(i.e., self and supervisors’ ratings). This innovative per-
spective not only highlights the problem of stress across
a sample of Italian employees but also provides useful
insights for the development of suitable organizational
strategies to detect and counteract job stress.

Measuring job stress: the use of multiple sources
As mentioned above, there is an over reliance on self-

report data in the stress literature. Using only self-report
data might affect results through the introduction of self-
bias errors (i.e., social desirability bias or impression
management: employees tendency to report in a way that
makes them or their organizations look more favorable)14).
Indeed, when research relies only on one source of data,
it is possible that the strength of the correlations between
variables is inflated as a result of common method vari-
ance. Thus, variance that is attributed to the measurement
method rather than the constructs of interest may cause
systematic measurement error and bias15).

In light of these possible methodological drawbacks
of using solely self-report measures, in this section we
emphasize the benefits of combining the perceptions of
employees and their leaders when assessing job stress.
First, multiple measures have been examined in studies of
competencies, performance appraisal and leader-member
exchange relationships16). Moreover, as noted by Offer-
mann and Hellmann17), the use of multiple perspectives
enables the mapping of similarities and differences in per-

ceptions, which can provide powerful tools for individual
and organizational application, particularly in the case of
work stress.

Second, the use of diverse perspectives when assessing
job stress may help to reduce self-bias, from both employ-
ees and their leaders. On one hand, employees may intro-
duce some bias if they give socially desirable responses to
questions on stress so that they transmit a more favorable
impression to their employers. On the other hand, leaders
might make fundamental errors18) as observers of subordi-
nates by attributing stress responses to their subordinates’
personal characteristics rather than to their working
environment19, 20). Thus, the leaders’ perception of stress
experienced by their subordinates might overestimate the
gaps in subordinates’ competencies or the weakness of
their personalities rather than organizational factors such
as the level of conflicts, poor team atmosphere or the bad
design of the tasks21). As a result of these incorrect evalua-
tions, subordinates may feel unable to cope effectively and
constructively with stress and managers may take ineffec-
tive organizational measures against job stress. Moreover,
research has shown that leaders might have the tendency
to report higher levels of stress tolerance than the general
work population22). For this reason, it is possible that man-
agers are not only less likely than their less stress-tolerant
employees to recognize work stress accurately, but are
also unaware of many of their subordinates’ stress-related
problems.

In addition, the tendency not to acknowledge their
subordinates’ stress may increase in difficult financial
circumstances when leaders tend to focus on short-term
productivity and the company’s viability and sometimes
ignore employees’ welfare23). On the other hand, employ-
ees may feel it is in their best economic interest to hide
their experiences of stress from their managers in situa-
tions of financial crisis, especially when competition is
high and organizational resources are limited24). However,
the suppression and avoidance of the stress problem can
be particularly dangerous from a medium to long-term
perspective25). Thus, measuring job stress by comparing
the evaluation of both employees and their leaders on
work-related stressors is of particular interest in the cur-
rent context of financial crisis in many countries.

Finally, research has shown that high supervisor support
in the workplace has a positive impact on several indica-
tors of employee well-being17, 21). However, given that
non-supportive leaders can negatively affect their follow-
ers’ health and well-being26), we argue that discrepancies
between leaders’ and followers’ stress ratings may have

WORK STRESS IN A SAMPLE OF ITALIAN WORKERS 45

a negative impact for the followers’ health. Leaders who
do not recognize their subordinates’ stress will not be able
to determine the causes or provide supportive feedback,
which would lead to lower levels of well-being among
subordinates27). Therefore, work stress assessment needs
to consider different sources of information in order to
capture this phenomenon better so that organizational mea-
sures can be introduced to prevent possible detrimental
consequences on employee well-being and organizational
performance.

Hypotheses and proposed model
According to the above mentioned recent trends in the

work stress literature, and assuming that leaders play a key
role in their followers’ health and well-being, we propose
a model in which the analysis of work-related stress and
its impact on employees’ psychological well-being is
based on the discrepancy between how employees per-
ceive their stress and how this is perceived by their leaders
-rather than relying exclusively on employees’ perception
of stress-. Furthermore, we expect that the proposed model
will predict employee health and well-being better than
a model than only considers employee self-assessment.
Thus, we evaluate the fit to data of these two competing
models (leader-employee discrepancies vs. employee
self-assessment) by using structural equation modeling
techniques to empirically support our model.

Moreover, the proposed model tries to integrate previ-
ous experimental and theoretical research in stress at work.

Thus, we test the possible mediating role of several work-
related stress factors − at individual (positive impression),
interpersonal (workplace bullying), and organizational
(welfare culture, training opportunities, and ergonomic
conditions) levels − on the relationship between leader-
subordinate divergence in stress perceptions and employ-
ees’ health (Fig. 1).

Regarding individual factors, it is assumed that some
employees tend to report stress in a way that makes them
look more favorable to their colleagues and superiors14).
Employees may believe it to be in their best economic
interest to hide their experiences of stress from their man-
agers, thereby avoiding potential negative repercussions of
showing vulnerability to stressful environments in which
leaders’ views of stress are different and organizational
resources (such as welfare and training) are limited20–24).
Thus, employees might modify or adapt answers to stress
questionnaires to fit their leaders’ perceptions of their
stress and give their leaders a positive impression28).

Likewise, discrepancies on stress perceptions among
employees and their leaders might stimulate the percep-
tion of a negative work-environment and experiences of
bullying. Workplace bullying is considered an acute orga-
nizational stressor derived from being exposed to repeated
health-harming mistreatment exerted mainly by leaders
but also by other colleagues29–31). Leaders that are not
aware about the stress their subordinates are experiencing
from exposure to bullying behaviors at work will not offer
them enough feedback and will fail to provide the neces-

Fig. 1. The proposed theoretical model.

G GIORGI et al.46

Industrial Health 2014, 52, 43–53

sary support to deal with such a situation32). Moreover,
workplace bullying has been strongly linked to subsequent
psychological disorders and poor mental health29–32). Thus,
it seems plausible to think that bullying will be positively
associated with divergence in stress perception and less
psychological well-being.

Finally, the non-recognition of subordinates’ stress by
leaders might also be associated with the organizational
culture and the policies adopted to counteract organi-
zational factors considered to be precursors of stress at
work. Thus, if organizational policies and culture neglect
employee welfare, they might suppress and even fake the
perception of stress during organizational diagnosis. Stress
might be to some extent tolerated and considered part of
the job by employees if stress is largely widespread, and
therefore attributed to broader aspects of the environment
such as the culture of the work group, the entire organiza-
tion or external causes30–33). As a consequence, lack of
welfare and training opportunities as well as exposure to
bad ergonomic conditions might be viewed as more nega-
tive when leaders do not recognize subordinates’ stress.
In this regard, the lack of organizational policies will be
positively associated with divergence in stress perception
and less psychological well-being.

In conclusion, this study aims to propose a model that
better evaluates stress at work and its association with
employee psychological well-being. In particular, we
propose that (1) divergence in stress perception (leaders-
subordinate) will be negatively associated with employee
psychological well-being. This relationship will be medi-

ated by diverse processes and factors at different levels: (2)
at an individual level, a positive impression will be nega-
tively associated with divergence in stress perception and
less psychological well-being; (3) at an interpersonal level,
bullying will be positively associated with divergence in
stress perception and less psychological well-being; and (4)
at an organizational level, the lack of organizational poli-
cies on welfare, training and ergonomic conditions will be
positively associated with divergence in stress perception
and less psychological well-being.

Subjects and Methods

Participants
We contacted human resource and occupational health

and safety managers of several medium/large size Italian
companies and invited them to participate in a stress as-
sessment not only for research purposes but also to help
them fulfill work-related stress obligations imposed by
Italian regulations on occupational health and safety (Leg-
islative Decree no. 81/2008 and subsequent amendments).
Thus, 14 out 52 companies (26.9%) agreed to participate
in the research and gave their employees some time during
working hours to complete the questionnaires. In return,
each organization received a report to be included in their
“Risk Assessment Document” (Documento di Valutazione
dei Rischi). The participating companies represented a
convenient sample that also reflected a multitude of work
environments, thus conferring the results with greater
validity (Table 1). The protocol of the research project

Table 1. General description of the sample across participating organizations (n=1,113)

Type of companya Participants Response rate No. of leaders

1. Insurance company 31 71% 6
2. Engineering company 10 100% 1
3. Manufacturing company (luxury and leather) 100 71% 25
4. Manufacturing company (luxury and leather) 161 72% 34
5. Shop (luxury and leather) 10 90% 1
6. Manufacturing company (furniture) 78 78% 5
7. Textile company 76 85% 7
8. Public administration 152 88% 36
9. Private company (fashion) 15 100% 1
10. Private company (gas and energy) 208 73% 28
11. Private company (gas and energy) 111 76% 26
12. Private company (gas and energy) 37 82% 6
13. Manufacturing company (leather) 29 70% 5
14. Manufacturing company (construction) 95 75% 19

Total/Mean 1,113 80% 200

a Numbers indicate the order in which the organization collected data.

WORK STRESS IN A SAMPLE OF ITALIAN WORKERS 47

was approved by the “Ethics Committee on Psychological
Research” established at the Department of Psychology of
the European University of Rome.

Moreover, to ensure anonymity and confidentiality in
the responses, the questionnaires were administered to
the employees in rooms provided by the organizations by
experienced research assistants with knowledge of and re-
spect for the privacy law. The participants were informed
that the survey was intended to fulfill legal obligations
regarding the assessment of work-related stress, with the
opportunity to use the findings to make improvements in
the work organization in the companies where they were
employed. In this context, the compilation of the survey
was very thorough and nearly all of the questionnaires
were collected with complete data or a few missing ele-
ments that were replaced with the scales’ means. Conse-
quently, the response rate in the 14 organizations was very
high, ranging from 72% to more than 90%.

In total, 1,113 Italian workers took part in the study:
59.3% were males (40.7% females) and 39.9% had
worked up to 7 yr in their current company (60.1% had
worked 8 yr or longer). Jobs in the administrative (40.5%)
and technical area (43.9%) were more heavily weighted
in our sample than those in sales and services (7.9%) or in
general areas (7.7%). In addition, there were 200 leaders
who rated the subordinates’ stress in this study (Table 1):
35.4% of them were coordinating fewer than 5 employees,
32.5% 5–10 employees, and 32.1% more than 10 employ-
ees.

We defined “leaders” as those workers who managed
and/or coordinated a team within each organization.

Measures
Work-related stress was measured with the Stress

Questionnaire (SQ)34), that assess five stress-related fac-
tors on a Likert scale ranging from 1 (absolutely agree)
to 5 (absolutely disagree): a) role conflict, which appears
when employees have no awareness of their roles and
responsibilities (5 items; e.g., “I have a clear idea about
what is expected of me at work”); b) colleagues’support or
collaboration and support among employees (5 items; e.g.,
“I get the support I need from colleagues”); c) supervisors’
support or the extent to which employees experience sup-
port and understanding from their supervisors/leaders (5
items; e.g., “My supervisor energizes me at work”); d) job
demands, which refers to quantitative, demanding aspects
of the job (6 items; e.g., “I have unrealistic deadlines”);
and e) job control or job resources that pertain to the task (5
items; e.g., “I can plan my work”). After recoding respons-

es to positively worded items, the questionnaire gives a to-
tal score in which a higher score indicates a greater degree
of work-related stress. It is important to note that leaders
responded to a different version of this questionnaire, in
which “I” was changed to “My subordinates” in all the
items.

Positive impression was measured with a 4-item specific
scale for stress which is included in the above mentioned
SQ (e.g., “I never had a stressful day in my working life”).

Organizational policies were measured with a specific
scale focusing on facilitating stress factors that is included
in the above mentioned SQ. Three scales of organizational
policies were used for this study: 1) welfare (4 items), the
extent to which the organization values and cares for em-
ployees, 2) training (3 items), the concern for developing
employee skills, and 3) ergonomics (5 items), the organi-
zation designs equipment and devices that fit the human
body, its movements and its cognitive abilities.

Workplace bullying was assessed by the shortened Ital-
ian version of the Negative Acts Questionnaire Revised
(NAQ-R)35). This questionnaire measures the frequency of
exposition to 17 specific negative acts (bullying behaviors)
at work (response categories were 1: Never, 2: Now and
then, 3: Monthly, 4: Weekly, and 5: Daily) within the last
six months. Items are divided into personal bullying (12
items described as exposure to behaviors such as gossip,
insulting remarks, excessive teasing, and persistent criti-
cism) and work-related bullying (5 items, such as unrea-
sonable deadlines, unmanageable workloads, excessive
monitoring, and experiencing that crucial information is
being withheld). The questionnaire provides a total score
(ranging from 17 to 85) in which a higher score means
greater exposure to negative acts (bullying behaviors).

Psychological well-being was assessed with the General
Health Questionnaire (GHQ-12) in its 12-item Italian ver-
sion36). This scale measures subjective mental health by
asking whether the respondent has recently experienced a
symptom or behavior of psychiatric disturbance. As physi-
cal health is not investigated in the scale, it is also consid-
ered a measure of psychological well-being or subjective
mental health. After recoding responses to positively
worded items, each item is rated on a 4-point Likert-type
scale (0–1–2–3) for scoring the responses (less than usual
= 0, no more than usual = 1, rather more than usual = 2, or
much more than usual = 3). Thus, the questionnaire gives
a total score ranging from 0 to 36, in which a higher score
indicates a greater degree of psychological distress (less
psychological well-being).

G GIORGI et al.48

Industrial Health 2014, 52, 43–53

Statistical analysis
We used the methodology proposed by Assor, Tzelgov,

Thein, Ilardi and Connell37) to examine potential effects
of over-rating, agreement, and under-rating when ratings
from different informants are compared (i.e., ratings of
students and their teachers about students’ academic com-
petence). The same methodology was used to assess work
stress by Offermann and Hellmann17), who considered
“subordinate stress perceptions as “actual” ratings and
leader stress perceptions as “perceived” ratings (p. 387)”.
Similarly, we did not consider the dyadic leader-follower
agreement in this study, but rather the discrepancies
between the subordinate (“actual ratings”) and the lead-
ers of his/her specific unit/department in the organization
(“perceived ratings”) about work stress. Consequently,
we subtracted the subordinate’s rating from the mean
of the leaders’ ratings. Thus, we examined whether the
data collected through the self-report stress questionnaire
were discrepant with the rating data collected through the
leaders because both recent studies12, 13) and the Italian
regulation (Legislative Decree no 81/2008) suggest the
integration of measures from different informants in stress
diagnosis. On the other hand, the other constructs were
considered at the self-report level (only subordinates) in
line with previous literature.

We then performed structural equation modeling (SEM)
analyses to empirically examine the validity of our pro-
posed model (leader-subordinate work stress ratings) in re-
lation to more traditional models (in our case, a model that
considers only subordinates’ work stress ratings). SEM
is a statistical technique for testing and estimating causal
relations among constructs in which a theoretical model is
tested against the obtained measurement data to determine
how well the model fits the data. Thus, χ2 difference tests

for nested models38) and multiple indices were used to
evaluate the fit of the competing models: the goodness of
fit index (GFI), the adjusted goodness of fit index (AGFI),
the comparative fit index (CFI), the root-mean-square er-
ror of approximation (RMSEA), the incremental fit index
(IFI). According to several authors39–41), a model needs
to meet the following criteria to fit the data: GFI ≥ 0.90,
AGFI ≥ 0.90, CFI ≥ 0.90, RMSEA<0.08, IFI ≥ 0.90.

Results

Table 2 presents the descriptive statistics and inter-
correlations of the research variables. All variables were
correlated. In addition, the reliability of each variable is
shown in the diagonal between parentheses by means of
their Cronbach’s alpha value.

The variables were then tested for normality. Although
all variables had skewness and kurtosis values below 1, the
Kolmogorov-Smirnov normality test for samples higher
than 200 cases revealed that variables did not follow a nor-
mal distribution (p values<0.05). Therefore, we used a non parametric rank test (Mann-Whitney test) to examine dif- ferences the between leaders’ and subordinates’ responses on job stressor variables. Results indicated that leaders perceived higher supervisor support (Mdn=2.50; U=80.46, p=0.01, r=0.08), job control (Mdn=2.40; U=71.47, p=0.01, r=0.14), colleagues’ support (Mdn=2.40; U=80.93, p=0.01, r=0.07), role conflict (Mdn=2.00; U=73.56, p=0.01, r=0.13), welfare policies (Mdn=3.00; U=63.01, p=0.01, r=0.21), training policies (Mdn=3.00; U=67.11, p=0.01, r=0.17), and ergonomic policies (Mdn=2.75; U=74.67, p=0.01, r=0.12) than their subordinates (Mdn=2.25, Mdn=2.20, Mdn=2.20, Mdn=2.00, Mdn=2.50, Mdn=2.67, and Mdn=2.50, respectively); on the other hand, non-

Table 2. Means, Standard Deviations, Alpha and correlations among variables (n=913)

Variable M SD 1 2 3 4 5 6 7 8 9 10 11

1 Job demands 2.7 .72 (.73)a .35** .35** .35** .20** .40** .44** –.27** .33** .26** .30**
2 Job control 2.4 .71 (.75) .41** .38** .50** .35** .40** –.21** .42** .34** .35**
3 Supervisors’ support 2.5 .94 (.80) .44** .46** .34** .41** –.20** .55** .35** .44**
4 Colleagues’ support 2.4 .74 (.76) .32** .33** .50** –.20** .44** .32** .34**
5 Role conflict 2.0 .68 (.75) .35** .37** –.18** .45** .32** .43**
6 Psychological well-being 10.6 5.23 (.85) .51** –.35** .36** .26** .28**
7 Workplace Bullying 25.0 7.60 (.87) –.24** .45** .29** .32**
8 Positive impression 2.3 .72 (.62) –.30** –.21** –.21**
9 Welfare 3.0 .92 (.84) .46** .66**
10 Ergonomics 2.7 .85 (.70) .40**
11 Training 2.8 .91 (.75)

aCronbach’s alpha is reported in the diagonal between parentheses. **Correlation is significant at the 0.01 level (2-tailed).

WORK STRESS IN A SAMPLE OF ITALIAN WORKERS 49

significant differences were found for neither job demands
nor for positive impression.

Considering the expected discrepancies in stress percep-
tions, we tested our theoretical model and an alternative
model that includes only self-report measures (without
including discrepancies between workers and leaders).
The results from structural equation modeling supported
the proposed theoretical model. Chi-square difference
tests for nested models indicated that the model combin-
ing self-report and leader-report measures fitted the data
significantly better than the alternative model including
only self-report measures (χ2=41.6, p<0.001). Moreover, an inspection of the fit indices considered in the present study showed that they met the recommended criteria: GFI=0.945, AGFI=0.921, CFI=0.928, RMSEA=0.064, IFI=0.929. In combination, these fit indices indicated a sufficient fit to the data.

Finally, the path coefficients, representing the latent
indicator for the structural equation model, indicated that
the values were significant, with standardized estimates
ranging from 0.87 to 0.23 (Fig. 2). Thus, the SEM model
shows that disagreements in leader-employee stress
perception are significantly and indirectly associated with
subordinates’ psychological well-being, supporting our
hypotheses. As can be seen in Fig. 2, differences in stress
perception are associated with negative acts (β=0.84) and,
in turn, negative acts are associated with psychological
well-being (β=0.87). Positive impression mediated the
relationship between differences in stress perception and

psychological well-being (β=−0.28). Finally, differences
in stress perception is associated with the organizational
polices (β=0.72) and, in turn, organizational polices are
associated with both negative acts (β=0.56) and positive
impression (β=−0.23).

Discussion

Over the last decade, researchers have become more
aware of occupational aetiology for work related stress8, 42).
This has led to the need for innovative research methods
for the assessment of work-related stress, particularly mul-
tiple sources for evaluating stress at work that overcome
bias from using solely self-report measures11–13). The aim
of this study was therefore to measure stress among a
sample of Italian employees with an innovative approach
that combines the stress ratings of both workers and their
leaders. Recent Italian studies have also highlighted the
importance of work-related stress8, 12, 13), which is the
subject of mandatory control under the Legislative Decree
no. 81/2008 and subsequent amendments.

In this regard, our results indicated that disagreements
in stress ratings appeared to be highly associated with
employee psychological well-being, suggesting that the
leader’s inability to understand subordinates’ stress is
negatively associated with the follower’s health. Specifi-
cally, stronger disagreement between self and leader
ratings was related to lower levels of subordinates’ health.
Furthermore, this research finds leaders’ accuracy in

Fig. 2. Structural equation model results (n=1,113)

G GIORGI et al.50

Industrial Health 2014, 52, 43–53

perceiving stress to be low. These data imply that leaders’
evaluations of aspects related to subordinate stress may
not always coincide with the factors that subordinates
themselves perceive as enhancing or reducing stress. In
particular, we find that leaders reported less stress than
subordinates and this might be associated to the under-
estimation of subordinates stress. Leaders may underrate
their subordinates’ stress either they have an inflated self-
view or a self-enhancement bias. For example, leaders
may not perceive greater subordinate stress because they
enjoy resources and a high level of control, which, in turn,
makes leaders perceive the organization more positively
and their employee as more healthy.

Thus, the organizational level influences rating dis-
crepancies because groups on different hierarchical levels
might have different ideas of what stress actually is43).
Following this line of thinking, it would appear that con-
sensus and agreement on stress perceptions is something
organizations should value and support. Consequently, our
results reveal that using leader-follower discrepancies on
stress fits better with data and explains the consequences
of stress more fully than solely the subordinates’ self-
reports. In other words, our results confirm that the con-
sequences of stress do not depend on the employees’ own
perception but are associated with leaders’ understanding
of their subordinates’ stress. It seems that some followers
may need their leaders to be able to fully understand their
stress; their incapacity to do so leads to a higher risk of
followers developing mental health problems.

In addition, our results also reveal that the relationship
of disagreement between self and leaders’ stress ratings
and employee psychological well-being seems to be
mediated by different factors. Two divergent pathways are
of particular interest due to their practical implications.
First, subordinates might avoid stress by suppressing it.
A positive impression scale was added in the survey to
determine whether workers might give fake responses in
organizational diagnosis. However, workers who tolerate
too much stress and hide their emotions might not cope ef-
fectively with health problems, triggering a negative cycle
of deteriorating long term effects. For example, research-
ers have suggested that the suppression of emotions may
cause anxiety or depression8, 25). This might be especially
applicable in emotional cultures like Italy and other South
European countries44–47), which encourage the expression
of emotions in social interactions. The European Agency
for Safety and Health at Work (EU-OSHA) observed −
among other aspects − that not only is there a high level
of work-related emotional demands rated as an emerging

risk, but also that workers may try to hide their difficul-
ties in coping with this high level of emotional demands,
which is seen by the respondents as a reaction to the fear
of losing their job44–46). The strong link between emotions
and work-related stress among Italians has also been noted
by the European Foundation for the Improvements and
Working Living Condition (EUROFOUND) in the Euro-
pean Quality of Life Survey (EQLS) 2012, particularly in
terms of lower optimism and happiness and their negative
effects on work performance47). Nevertheless, cultural is-
sues should be investigated further since cultural variables
are not measured in this study.

In addition, employees might even feel particularly
discriminated by the leaders that are not acknowledging
their difficulties and consequently develop perceptions of
being bullied. Similarly, a nationwide study on psycho-
social risks at work conducted in Great Britain revealed
that the absence of adequate leadership emerged as the
strongest predictor of perceiving exposure to bullying
behaviors32). Indeed, “the absence of adequate leadership
may be experienced by subordinates as an intended and
systematic neglect and ignorance, even to the extent that
they feel socially excluded and ostracized”, which are key
aspects of bullying situations (p. 457). Moreover, negative
emotions and low psychological well-being are associated
with subordinates’ perceptions of leaders’ insensitivity and
a poor leader–subordinate relationship48).

Finally, positive impressions and bullying as mediators
of the relationship between stress and health both seem
to be affected by the existing organizational policies on
welfare, training and ergonomics within the company.
Therefore, organizational cultures that offer little welfare,
a low level of training and poor ergonomics might disap-
prove of, or strongly discourage, individual reporting of
stress as well as stimulate bullying perceptions29–32).

Limitations and further research
This study is not free from limitations that should be

addressed in future studies. First, although our sample
involved a large number of companies and employees,
it cannot be considered representative of the entire Ital-
ian workforce and the generalizability of the results are
consequently limited. Indeed, sampling bias due to a non-
random sample might be present (e.g., results can be
erroneously attributed to the phenomenon under study
rather than to the method of sampling). Thus, it is possible
that participating companies are more sensitive to work-
related stress than the average medium and large Italian
companies, and therefore are also more careful to provide

WORK STRESS IN A SAMPLE OF ITALIAN WORKERS 51

workers with practical answers to their questions about
occupational safety and health49).

Second, it would be useful to evaluate the impact of
our variables at the group level by using a multilevel ap-
proach; this was not possible in our study because data
collection did not allow us to establish correspondence
between leaders and workers at a group level.

Finally, the cross-sectional nature of our data limits
causal interpretations and further longitudinal studies
are required to fully understand the relationship between
divergence in stress ratings and psychological well-
being. Furthermore, future research should make an in-
depth study of how discrepancies between leaders and
their subordinates develop over time. The possible spill-
over hypothesis between stress and bullying should also
be explored since subordinates who do not see their stress
recognized might easily develop conflicts or act negatively
at work as a way of dealing with their frustration (in the
case of perpetrators of bullying), while recipients of such
negative acts will also experience stress as they perceive
bullying behaviors as a job stressor (in the case of bullying
victims).

Conclusion
Despite the above mentioned limitations, our results

suggest that a stress assessment method that includes rat-
ings from different informants (i.e., leader-subordinate
discrepancies) attenuates the effects of self-report bias
and other potential distortions common to stress. Thus,
measures of stress should incorporate various information
sources in order to have a more accurate organizational
diagnosis of this widespread and severe problem. Indeed,
by extending the body of previous research that focused
predominantly on the individual, we found that discrepan-
cies between employees and their leaders provide impor-
tant additional information when looking at organizational
health. Moreover, the use of a specific positive impression
scale is recommended in the diagnosis of organizations
and stress, notably in countries (like Italy) where the leg-
islation provides a mandatory assessment of work-related
stress.

In conclusion, the supervisors’ reports can make an
important contribution to the constructs under study both
for organizational diagnosis and intervention purposes.
Healthy leadership, which is an important predictor of
employee well-being50, 51), should be developed by train-
ing the leaders to better understand their employees’ stress
and provide appropriate feedback. Similarly, organizations
can reduce stress by creating healthy environments that

encourage cooperation between leaders and followers.

Acknowledgement

The authors would like to thank the anonymous re-
viewers for their valuable comments and suggestions to
improve the quality of the paper.

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J UOEH.

2001 Mar 1;23(1):13-22.

Occupational factors contributing to low self-esteem in registered nurses and licensed practical nurses: a multivariate analysis.

Imai K

Author information

1
Department of Public Health Nursing, School of Health Sciences, University of Occupational and Environmental Health, Japan, Yahatanishi-ku, Kitakyushu 807-8555, Japan.

Abstract

The present study examines job-related factors leading to low self-esteem in nurses. The lowering of self-esteem suggests that such nurses had difficulty in fully accepting themselves and their circumstances. Subjects were registered nurses (RN) and licensed practical nurses (LPN) at hospitals, and unemployed registered nurses (UEN) seeking employment. Questionnaires were provided at 53 hospitals and a Nurse Bank in Kanagawa Prefecture. The responses of 552 RN, 146 LPN and 433 UEN were analyzed. Questions were asked about personal life, past or present nursing experience, working conditions, nursing skills, satisfaction with work performance and self-esteem. Factors giving rise to low self-esteem were determined using logistic regression analysis and logistic discriminant analysis. Employment status and qualifications were determined to be the most important factors determining the self-esteem of nurses. The next most important factors were ‘a limited number of years of experience (less than five years)’ and ‘dissatisfaction with discretion and responsibility as a nurse’ (P < 0.01). Adjusted odds ratio for a reduction in self-esteem for LPN was 4.07 times higher than for UEN, and 2.2 times higher than for RN by logistic regression analysis. LPN are treated as unskilled workers, and thus significant differences were apparent in their performance of certain job tasks. These differences were analyzed using discriminant analysis, and were referred to as follows, 1: Advanced assessment skills, 2: Advanced technical skills, 3: Advanced communication skills, and 4: Nursing plan and documentation (positive discrimination rate was 70.8%). Job dissatisfaction is closely associated with the level of professional training. Continuous education and a feedback system for various levels of nurses are needed.

PMID:
11279837

[Indexed for MEDLINE]

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MeSH terms

Adult
Clinical Competence
Female
Humans
Job Satisfaction
Middle Aged
Multivariate Analysis
Nurses/psychology*
Occupational Health Nursing
Self Concept*

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J Nurs Manag.

2014 Sep;22(6):792-802. doi: 10.1111/jonm.12033. Epub 2013 Mar 7.

Supporting ethical competence of nurses during recruitment and performance reviews – the role of the nurse leader.

Poikkeus T

Leino-Kilpi H

Katajisto J

Author information

1
Department of Nursing Science, University of Turku, Turku, Finland.

Abstract

AIM:

The aim of this study was to analyse how nurse leaders support the ethical competence of nurses during recruitment and performance reviews.

BACKGROUND:

Ethical competence of nurses refers to ethical behaviour and action requiring ethical knowledge and reflection. Nurse leaders have a key role in supporting the ethical competence of nurses, but little is known about just how this should be done.

METHOD:

The data were collected using a structured questionnaire and analysed statistically. The target sample consisted of nurse leaders (n = 198) from two university hospitals in two healthcare districts in Finland.

RESULTS:

Nurse leaders support the ethical competence of nurses more often during performance reviews than during recruitment. During recruitment, nurse leaders ensure the ethical behaviour and knowledge of nurses to varying degrees. During performance reviews, nurse leaders ensure that nurses meet the requirements for collegiality and comply with ethical guidelines and that they do so according to nursing values and principles.

CONCLUSIONS:

There seems to be a need to examine and improve support for the ethical competence of nurses, both during recruitment and performance reviews. Future priorities should include a focus on supporting the ethical knowledge, reflection and behaviour of nurses.

IMPLICATIONS FOR NURSING MANAGEMENT:

An important aspect in terms of supporting the ethical competence of nurses has to do with the ethical knowledge and education of nurse leaders and organisational policies or recommendations for ethical support.

KEYWORDS:

ethical competence; nurse; nurse leader; performance reviews; recruitment

PMID:
23465074
DOI:

10.1111/jonm.12033

[Indexed for MEDLINE]

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MeSH terms

Adult
Clinical Competence/standards
Decision Making/ethics
Employee Performance Appraisal/methods*
Ethics, Nursing*
Female
Finland
Humans
Male
Middle Aged
Nurse Administrators*
Nurses/psychology
Nurses/standards*
Personnel Selection/methods
Personnel Selection/standards*
Surveys and Questionnaires

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OPEN ACCESS

EURASIA Journal of Mathematics Science and Technology Education
ISSN: 1305-8223 (online) 1305-8215 (print)

2017 13(7):4009-

4020

DOI 10.12973/eurasia.2017.00769a

Correspondence: You-Te Lu, Southern Taiwan University of Science and Technology, Taiwan.

yowder@stust.edu.tw

The Relationship between Motivation, the use of

Mobile Devices and Satisfaction with life for Older

Farmers

You-Te Lu
Southern Taiwan University of Science and Technology, TAIWAN

Yi-Hsing Chang
Southern Taiwan University of Science and Technology, TAIWAN

Tien-Wen Sung
Fujian University of Technology, CHINA

Received 30 May 2016 ▪ Revised 30 November 2016 ▪ Accepted 11 March 2017

ABSTRACT

In terms of functionality, today’s mobile devices allow users to surf the Internet, monitor e-mail, watch and share

videos and pictures, interact on social-networks and utilize a large array of software-driven applications. Much

research concerns motivation and satisfaction in the school system, but there is little empirical evidence of how

these factors affect older farmers. While mobile technologies and social media have changed the value and

importance of human connections, it is necessary to understand the interaction between motivation and

satisfaction with life for older famers. This study determines the relationships between motivation, the use of

mobile devices and satisfaction with life for older farmers. Key factors are operationalized using scales that are

widely used and tested. A survey is distributed to participators and a multiple regression is used to determine

whether positive motivation for the use of the Internet and mobile devices predicts the scale for the satisfaction

with life. This study contributes to related subjects by determining factors that could be optimized with a view to

enhancing learning and satisfaction with life for old farmers.

Keywords: motivation, mobile technology, satisfaction with life, old farmers

INTRODUCTION

Overview

Agriculture is the backbone of most Chinese economies, especially in Taiwan, where it

accounts for 1.88 percent of the nation’s gross domestic product. However, Taiwan’s

agriculture sector is facing problems such as an aging farmer population, shortage of business

managers and the gap between education and employment. As the aging problem inhibits the

adoption of new technologies and the use of new knowledge, mobile learning could open the

door for a new type of learning for seniors.

Lifelong learning is broadly defined as learning that is pursued throughout life at any

time and in any place. In other words, an adult’s learning activities play a notable role in the

mailto:yowder@stust.edu.tw

Y. T. Lue et al.

4010

pursuit of knowledge. Horrigan (2016) pointed out that the majority of Americans feel that

they are lifelong learners and that they participate in activities that include the use of

technology to learn more about a personal interest. Although those with more education and

higher incomes are more likely to engage in lifelong learning, technology assets are strongly

tied to the possibility that adults engage in learning activities. With a rapidly aging farming

population, any attempt to improve the welfare of older farmers is

vital.

Adults with technology access tools, such as mobile devices, are also more likely to be

lifelong learners and to use the Internet to pursue knowledge. There is a strong sense that

people feel more comfortable when they continue to learn, in order to stay relevant in a

changing environment. In terms of learning and technology, new means of communications

could translate learning into a happier life. Therefore, with the Internet and mobile

technologies providing possible access to information and the general mobility of knowledge,

mobile devices allow farmers to gain instant access to useful information. There is much

research about motivation and satisfaction in the school system, but there is little empirical

evidence of how these factors affect older farmers. While mobile technologies and social media

have changed the value and importance of human connection, it is necessary to understand

the interaction between motivation and satisfaction with life for

older famers.

THEORETICAL BACKGROUND

Older Farmers

Agriculture is one of the most hazardous occupations in many regions and older farmers

are often considered to be a “special needs population that needs recognition and attention”

(Hernadez-Peck, 2001). Although agriculture is a major industry in the majority of countries,

the share of the population that works in agriculture is declining as countries develop. In

State of the literature

 As the aging problem inhibits the adoption of new technologies, mobile learning could open the

door for a new type of learning for seniors.

 With a rapidly aging farming population, any attempt to improve the welfare of older farmers is

vital.

 It is necessary to understand the interaction between motivation and satisfaction with life for

older famers.

Contribution of this paper to the literature

 The intention to adopt new technology is positively related to users’ needs and the proliferation

of mobile learning has created a wealth of learning opportunities for seniors.

 Motivation and the use of mobile devices are understandably correlated with satisfaction with

life levels for older farmers.

 Older farmers who are confident in using information communication technologies to interact

with others have good quality of life.

EURASIA J Math Sci and Tech Ed

4011

particular, the proportion of older farmers is significant and is growing. According to O’Neill

(2014), 12.1 per cent of Asian farmers are over 55. An agricultural holder is defined as the

person who exercises management control over the agricultural holding and makes major

decisions concerning the use of resources. The average proportion of Asian agricultural

holders who are over the age of 55 is 28.5 percent. Therefore, older farmers over the age of 55

are the subjects for this study.

Motivation and the use of Mobile Devices

Motivation refers to factors that engage goal-directed behavior for the needs that drive

individuals and explain what people do (Pezzulo, Van Der Meer, Lansink & Pennartz, 2014;

Redman, 2016). Mobile devices are any devices that are carried on the person the majority of

the time, such as a smartphone, a tablet, or a hand-held device. A mobile device is also capable

of communication via the Internet Hoffmann, 2015). The key factors that define mobile

learning are mobility and the ability of users to access the Internet for learning purposes,

without being tied to a location (Wu et al., 2012; Hoffmann, 2015).

Six aspects of learning with mobile devices that might be motivating were proposed at

the IADIS International Conference on Mobile Learning in 2007: control over learners’ goals,

ownership, fun, communication, learning-in-context and continuity between contexts. The

authors suggested that using mobiles for learning is likely to be highly motivating. (Jones &

Issroff, 2007). With respect to the definition of the terminology of motivation (Chang &

Villegas, 2008; Stafford, Stafford, & Schade, 2001), mobile devices have several functions that

lead consumers to use them, such as (1) short text mail, (2) communication with friends, (3)

taking photos and uploading them, (4) playing games, (5) listening to music and (6) mobile

nets. Chang & Villegas (2008) listed six motivation factors for the use of mobile phones, as

Figure 1. The Motivation Factors for the use of Mobile Phones （Chang & Villegas, 2008）

Y. T. Lue et al.

4012

shown in Figure 1. It is seen that mobile devices are a new multidimensional communication

technology that are used to enrich learners’ knowledge, from the user standpoint. Indeed, the

fact that this technology supports learners in defining their own interests and ways of

accessing further learning opportunities is crucial.

The use of Mobile Devices and Satisfaction with life

According to Saeednia & Nor (2013), Maslow’s hierarchy gives the most accurate

description of human motivation. Specific factors, such as safety and esteem, have been proved

to have the greatest correlation with satisfaction with life. Leung & Matanda (2013) showed

that self-determined motivation mediates the relationships between the use of technology and

satisfaction with life.

However, the use of mobile devices could be a significant predictor of negative influence

on the users (Salehan & Negahban, 2013).Mobile learning might not give sufficient importance

to what it is that makes a learning activity valuable, in that it does offer a way to extend the

support of interactions in everyday life and personal satisfaction with life. Sharples et al.,

(2007) also proposed a theory of learning for the mobile age that emphasizes lifelong learning

activity. “A theory of mobile learning must take account of the ubiquitous use of personal and

shared technology.” (p. 224). In other words, mobile technologies and the new conceptions of

learning are a personally managed lifelong activity.

Four elements must be incorporated into the design of a mobile framework (Liu et al,

2008). As shown in Figure 2, these four elements are (1) an analysis of requirements and

constraints, (2) mobile learning scenario, (3) the design of the technology environment and (4)

Figure 2. The Design Framework for Mobile Learning (Liu et al., 2008)

EURASIA J Math Sci and Tech Ed

4013

the design of learner support services. It is emphasized that an understanding of user needs

and the factors that influence learning is essential to the design of mobile learning activity.

This is an activity-oriented design framework that places emphasis on supporting the learners

in their goal to acquire knowledge and skills that could enhance their satisfaction

with life.

Many studies have explored the relationship between the use of mobile devices and

measures of satisfaction with life. A relationship has been suggested whereby cell phone use

increases subjective well-being or happiness. However, if the use of mobile devices is

negatively related to the adoption of technology and positively related to anxiety, then it may

have an indirect, negative influence on satisfaction with life （Lepp, Barkley, & Karpinski,

2014). Satisfaction with life was defined by Shin and Johnson (1978) as referring to “a

judgmental process in which individuals assess the quality of their lives on the basis of their

own unique set of criteria” (Pavot & Diener, 1993, p.164).

Adult Learners and Technology

Studies have indicated that the perceived usefulness of technology affects the user’s

intention to adopt mobile learning that might be perceived as valuable to adult learners, such

as learning opportunities (Tan et al, 2014). The technology provides a shared learning space

for single learners and for groups. Most importantly, for learners who use an interactive

technology with online help systems, there is a shared understanding. However, learning

approaches that use mobile technology with knowledge resources have become important

tools for the delivery of educational resource (Sharples, 2007; Paulins, balina, & Arhipova,

2014).

Tang et al (2012) identified several factors that impact older adults’ learning using mobile

technology. Firstly, if a task list is provided for the learning process using mobile devices, older

adults are very motivated (Goal setting). Secondly, older adults’ motivation to learn to use a

mobile device is positively related to their perceived need to use a mobile phone (Perceived

needs). Thirdly, older adults’ motivation for learning to use a mobile device is influenced by

their understanding of technology (Exposure to technology). Finally, older adults who are

highly motivated to learn are generally found to experience more successes and greater

satisfaction with their learning outcomes (Tang et al, 2012).

METHODOLOGY

Research Design

This study determines the motivational factors that contribute to participation in mobile

learning by older farmers. Previous and current research and unpublished interview data that

is presented in this paper shows that there is reason to suspect that the use of mobile devices

and Satisfaction with life are related. Because the capabilities of mobile devices are expanding,

there is a need to study older farmers’ adoption of mobile devices. The two main research

questions (RQs) are: (1) What is the relationship between motivation (Goal setting, Perceived

Y. T. Lue et al.

4014

needs, Exposure to technology) and the use of mobile devices? and (2) What is the relationship

between the use of mobile devices and Satisfaction with Life. The following hypotheses (H1 =

RQ1; H1 = RQ2; see below) are proposed:

(RQ1 – H1). Mobile Device Use (MDUse) has a positive relationship with Goal Setting

and a positive relationship with Perceived Need. Exposure to Technology is negatively related

to the use of Mobile Devices.

(RQ2 – H1). The use of mobile devices is positively related to Satisfaction with Life.

Population and Sample

The target population for this paper is limited to the members of the Tainan City Anna

District Farmer’s Association. A total of 107 of the 130 surveys were returned. Two of the 107

surveys were not completed, so were not useable. A total of 105 surveys were used for the

analysis.

Instrumentation

A survey was completed during class in a school of continuing education by all adults

who consented to participate. The survey composed several sections: (1) demographic

information, (2) the Satisfaction with Life Scale (SWLS; Diener et al., 1985), (3) questions about

the use of mobile devices (Lepp et al., 2013) and (4) Positive attitude

towards the Internet

(Shillair et al., 2015).

Data Collection

Demographic information included questions about sex, age and educational level. Less

than elementary school was 1, high school graduate is 2 and college graduate is 3. The SWLS

contains five statements about general satisfaction with life (i.e., subjective well-being) using

a 5-point Likert scale from ‘‘Strongly Disagree’’ to ‘‘Strongly Agree’’. Higher scores on this

measure indicate greater satisfaction with life, with a score of 20 representing the neutral point

on the scale (i.e., equally satisfied and dissatisfied).

Questions about the use of mobile devices stated the following: “As accurately as

possible, please estimate the total amount of time you spend using your mobile phone each

day. Please consider all uses, except listening to music” (Lepp et al., 2013). For instance, the

total amount of time that older adults spend with mobile devices includes calling, texting,

using Facebook, e-mailing, sending photos, gaming, surfing the Internet, watching videos and

all other activities that use mobile devices.

Key factors were operationalized using scales that are widely use and tested. Full

variables and Cronbach’s alpha levels are given in Table 1. Satisfaction with life indicators

include questions developed by Diener, Emmons, Larsen & Griffin (1985), and the perceptions

of positive attitude towards the Internet from Hiltz and Johnson (1990) and modified by

Shillair et al (2015) are also listed in Table 1.

EURASIA J Math Sci and Tech Ed

4015

Data Analysis

Descriptive statistics are used to examine the demographic data. Pearson correlations

between the main variables of interest were examined prior to the path analysis and two

Multivariate Analysis of Variances (MANOVAs) were conducted to determine the influence

of sex and the interaction between sex and the use of mobile devices and the SWLS.

Based on the review of previous research, the hypothesis was that motivation works as

a mediated moderator between the use of mobile devices and the level of satisfaction with life.

RESULTS

Sample Demographics

The sample in this study includes 105 randomly selected farm household members

from the Tainan City Anna District Farmer’s Association in Taiwan. The overall response rate

for this research was 82.3% (n = 107). The total useable response rate was 80.7% (n = 105).

Descriptive statistics for all the major variables are presented in Table 2. On average,

participants reported spending 150.15 (SD = 112.00) minutes per day using their mobile

devices. The mean GS score was just above 3.05 (SD = .42) and the mean PN score was just

above 3.05 (SD = .3). The mean ET score was 2.1 (SD = .2). The hypothesized correlations

Table 1. Questions and Variables

Variables Questions Source and alpha levels

Satisfaction with Life

Scale

Five point scale (1=strongly disagree to 5=strongly

agree)

Diener, Emmons, Larsen &

Griffin, 1985

Alpha = .889

In most ways my life is close to ideal

The conditions for my life are excellent

So far, I have gotten the important things I want in life

I am satisfied with my life as a whole

If I could live my life over, I would change almost nothing

Positive Attitude

towards the Internet

Five point scale (1= strongly disagree to 5=strongly

agree) “Please tell me how much you agree or disagree

with the following statements: Using the Internet has:

Hiltz and Johnson, 1990

Shillair, et al., 2015

alpha= .97

Made it easier for me to reach people

Contributed to my ability to stay in touch with people I

know

Made it easier to meet new people

Made it easier to get information that I

need

Increased the quantity of my communication with others

Made me feel less isolated

Helped me connect with my friends and family

Increased the quality of my communication with others

Is useful to me

Y. T. Lue et al.

4016

between the major variables are in the expected direction and statistically significant (p < .05)

and the correlations between MDUse and SWL are statistically significant (p < .05).

Regression Analysis

Table 3 shows the relationships between positive motivation, the use of mobile devices

and the satisfaction with life scale. The table shows that the correlation between positive

motivation and mobile device use is a medium .217 and that here is a negative correlation

between satisfaction with life and other variables.

A multiple regression was conducted to determine whether a positive motivation

towards the Internet and the use of mobile devices predicts satisfaction with life scale. Using

the enter method, a positive motivation towards the Internet and the use of mobile devices

explain a significant amount of the satisfaction with life scale (F(2, 102))=13.138, p < .000), with

an R2 adjusted value of .189.

Figure 3 shows the mediation moderation regression analysis. If the use of mobile

devices is viewed as an independent variable and satisfaction with life as a dependent variable,

the positive motivation towards the Internet on satisfaction with life levels has an effect that

changes through the satisfaction with life scale.

Table 2. Descriptive statistics for the major variables in the mobile devices data set (N = 105)

Variable Mobile Devices

M SD Min Max

MDUse 131.4 64..40 60.00 240.00

GS 3.05 .42 2.0 4.5

PN 3.05 .3 2.1 3.8

ET 2.1 .2 0.0 3.0

SWLs 14.08 3.45 5 25

Age 70.5 9.09 55 85

Education 1.86 .790 1 3

Note. MDUse = minutes per day, GS = goal setting score, PN = perceived needs score, ET = exposure to

technology score. SWLs = Total Satisfaction with Life Scale score.

Table 3. Correlations between Positive Motivation, MDUse and SWLs

Measure Positive Motivation Satisfaction with life

Positive Motivation –

.217* –

Satisfaction with life -.336** -.369** –

** Correlation is significant at the 0.01 level (2-tailed).

* Correlation is significant at the 0.05 level (2-tailed).

EURASIA J Math Sci and Tech Ed

4017

Discussion

Aside from factors such as the aging of the agricultural labor force and the transfer of

the agricultural labor force to nonagricultural sectors, one of the issues that Taiwanese farmers

face is a lack of information and technical knowledge regarding learning approaches and

improved methods of farming that can significantly affect yields. This study uses a

quantitative research survey: a questionnaire was distributed to 130 older farmers in a Tainan

Farmer Organization in Taiwan. Motivation factors were identified using principal

components analysis. The conceptual framework was tested using correlation analysis and

Multivariate Analysis of Variances (MANOVAs). Statistically significant relationships are

observed between motivation and the use of mobile devices. The findings enable the

implementation of strategies to enhance older farmers’ learning opportunities and satisfaction

with life.

Motivation and the use of mobile devices are understandably correlated with

satisfaction with life levels for older farmers. Although this model explains only 19% of the

variance, it does show that Internet adaptation is an important factor for older people, who

would gain benefits from mobile technologies with networking. This research suggests that

older farmers who are confident in using information communication technologies to interact

with others have good quality of life. This supports the theory that “mobile learning must take

account of the ubiquitous use of personal and shared technology” (Sharples et al., 2007). It also

supports the conclusion that the intention to adopt new technology is positively related to

users’ needs, which implies that the nature of an innovation is the most powerful predictor for

the use of technology and satisfaction with life (Li, 2014).

In terms of functionality, today’s mobile devices allow users to surf the Internet, e-mail,

watch and share videos and pictures, interact on social-networks and utilize a large array of

software driven applications. The proliferation of mobile technology and online learning has

created a wealth of learning opportunities for learners. According to Negahban & Chung

Figure 3. Mediation Moderation Analysis

Y. T. Lue et al.

4018

(2015), mobile devices create a social image in the society for the users. The use of mobile

devices increases users’ perception of the fit between functionalities of their needs, which leads

to greater satisfaction with life.

Limitations and Suggestion for Future Research

It is not easy to accurately measure the levels of satisfaction with life and the positive

motivation towards the Internet, especially for older adults. Most of the participants only use

their own mobile devices for basic functionality, such as making calls. The main reason for not

exploring beyond basic features, such as apps, is the lack of knowledge about the services that

are provided via the Internet. As a result, participants are reluctant to use their mobile devices

freely. They also stated that they needed to acquire a better understanding of modern

technologies and the accompanying learning resources. Therefore, older farmers are

motivated to achieve a successful and enjoyable learning experience, which leads to

satisfaction through lifelong learning.

However, further research is necessary, using a greater number of participants, in order

to further clarify the relationship between motivation and learning experience and to

determine how the motivational factors can be manipulated to increase older farmers’ desire

to learn to use mobile devices more generally.

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RESEARCH ARTICLE

Core Self-Evaluation and Burnout among
Nurses: The Mediating Role of Coping
Styles
Xiaofei Li1, Lili Guan2, Hui Chang3, Bo Zhang4*

1. Emergency Department, The First Affiliated Hospital of China Medical University, Shenyang, China, 2.
Faculty of Nursing, Huaiyin Advanced Vocational and Technical School of Health, Huaian, China, 3. Social
Education Department, Center for Health Education of Liaoning Province, Shenyang, China, 4. Nursing
Department, The First Affiliated Hospital of China Medical University, Shenyang, China

*1345596429@qq.com

Abstract

Objectives: This study aimed to determine the potential association between core

self-evaluation and the burnout syndrome among Chinese nurses, and the

mediating role of coping styles in this relationship.

Methods: A cross-sectional survey was conducted in Shenyang, China, from May

to July, 2013. A questionnaire which consisted of the Maslach Burnout Inventory-

General Survey (MBI-GS), the Core Self-Evaluation Scale (CSE), and the

Simplified Coping Style Questionnaire (CSQ), was completed by a total of 1,559

nurses. Hierarchical linear regression analyses and the Sobel test were performed

to determine the mediating role of coping styles on the relationship between CSE

and burnout.

Results: Nurses who had higher self-evaluation characteristics, reported less

emotional exhaustion and cynicism, and higher professional efficacy. Coping style

had a partial mediating effect on the relationship between CSE and the burnout

syndrome among nurses.

Conclusions: Core self-evaluation had effects on burnout and coping style was a

mediating factor in this relationship among Chinese nurses. Therefore, the

improvement of coping strategies may be helpful in the prevention of burnout

among nurses, thus enhancing professional performance.

Background

Burnout is the result of continuous work pressures that are not effectively handled

[1] and is defined by three dimensions: emotional exhaustion (EE), cynicism (CY)

OPEN ACCESS

Citation: Li X, Guan L, Chang H, Zhang
B (2014) Core Self-Evaluation and Burnout among
Nurses: The Mediating Role of Coping
Styles. PLoS ONE 9(12): e115799. doi:10.1371/
journal.pone.0115799

Editor: Delphine Sophie Courvoisier, University of
Geneva, Switzerland

Received: September 12, 2014

Accepted: November 27, 2014

Published: December 26, 2014

Copyright: � 2014 Li et al. This is an open-
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and repro-
duction in any medium, provided the original author
and source are credited.

Data Availability: The authors confirm that all data
underlying the findings are fully available without
restriction. All relevant data are within the paper
and its Supporting Information files.

Funding: The authors have no support or funding
to report.

Competing Interests: The authors have declared
that no competing interests exist.

PLOS ONE | DOI:10.1371/journal.pone.0115799 December 26, 2014 1 / 12

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and reduced professional efficacy (PE). Emotional exhaustion refers to an

individual being overextended emotionally, which leads to the depletion of an

individual’s resources. Cynicism refers to a negative, callous or excessively

detached response to various aspects of the job. Reduced professional efficacy

represents a general sense of one’s inefficacy at work and to a feeling of lack of

professional success and competency [2]. Burnout has been recognized as an

occupational hazard in various people-oriented professions [3]. In the area of

healthcare, nursing staff face high demands in terms of quality services, and are

subjected to numerous stressful situations. Therefore, nurses are at risk of burnout

[4]. A severe nursing shortage and an increase in demanding workload in terms of

physical, emotional and moral stress, combined with comparatively low wages

and devaluation of the profession have caused nurses to experience burnout in

China. Burnout among nurses can result in mental fatigue, anxiety, lack of

motivation, and absence from work [5], which undoubtedly threatens not only

their own health, but also that of their patients. Therefore, the prevention of

burnout among nurses is essential for improving the quality of patient care.

With regard to personal resources, traditional research on personality and

burnout has focused on the Big Five personality dimensions and emotional

affectivity [6, 7]. However, recently, Core self-evaluation (CSE) has received a

great deal of attention in personality research. CSE, a broad personality concept,

which describes an individual’s evaluation about themselves, their ability, and

their control, consists of four traits: self-esteem, general self-efficacy, locus of

control, and neuroticism [8]. Numerous studies have reported that CSE

significantly influenced salary [9], goal setting [10], job satisfaction [11], job

performance [10, 12], career commitment [13], and job burnout [13, 14]. In

addition, Spence Laschinger et al. identified the important role of CSE on nurse

managers’ burnout [15]. However, previous studies did not determine how CSE

influences burnout.

Stress is accompanied by the process of coping [16]. Coping styles are defined

as stable psychological and behavioral strategies to overcome or tolerate external

and internal challenges or stressors [17]. Some people cope with stress actively,

while others cope passively. Active coping strategies are either behavioral or

psychological responses designed to change the nature of the stressor itself or how

one thinks about it, whereas passive coping strategies lead people into activities

(such as alcohol use) or mental states (such as withdrawal) which prevent them

from directly addressing stressful events [18]. Coping behaviors of individuals

contribute to the explanation of why exposure to the same stressors may cause

burnout in some subjects, but not in others [19]. A study conducted in Hong

Kong by Wang et al. indicated that making use of effective coping strategies plays

a pivotal role in reducing stress among nurses [20]. The coping strategies used by

nurses may vary with respect to their personal, psychological, and cultural factors

[21]. A previous study reported that Chinese nurses tended to cope actively with

stress associated with decreased personal achievement, but passively when the

stress originated from resource and environment problems, patient care and

interaction issues, and from interpersonal relationships and management issues

Core Self-Evaluation and Burnout

PLOS ONE | DOI:10.1371/journal.pone.0115799 December 26, 2014 2 / 12

[22], suggesting regional differences in the coping styles of nurses. According to

previous studies, burnout can be alleviated by coping strategies. Active coping

may protect against the negative impact of stressors on adaptive outcomes by

strengthening the person’s coping efficacy in a specific situation [4]. However,

Payne et al. [23] concluded that the investigation of problem-focused and

emotion-focused coping in relation to burnout, oversimplied the coping-burnout

relationship in a sample of hospice nurses. The association between CSE and

burnout and the association between coping styles and burnout have been

investigated in previous studies [5, 13, 14, 15, 23]. In addition, Kammeyer-Mueller

et al. [24] investigated the role of CSE in the coping process, and demonstrated

that individuals with high CSE practice less avoidance coping. However, to our

knowledge, there has been no integrative effort to examine coping styles as a

mediator in the relationship between CSE and burnout.

Nurses need to care for themselves before they can provide care for their clients.

Given the high stress, difference in coping styles, as well as high workload in

Chinese nurses, there is a need to develop an educational program and strategies

for the prevention of burnout among nurses. For this purpose, it is important to

clarify the relationships between burnout, CSE, and coping styles among Chinese

nurses. In the present study, we examined the relationship between CSE and

burnout and determined the mediating role of coping styles on the relationship

between CSE and burnout using a cross-sectional survey of 1,559 Chinese nurses

from Shenyang, China.

Methods

Participants and procedure

A cross-sectional survey was conducted in Shenyang, China from May to July,

2013. Respondents in this study were selected from five hospitals which included

three university-affiliated hospitals, one provincial tertiary hospital, and one

municipal tertiary hospital. The inclusion criteria required that an individual held

the RN licensure granted by the Ministry of Health, PR China and was currently

working in one of the hospitals as a registered nurse. Head nurses and

administrators were excluded. Anonymous questionnaires were distributed and

collected during staff meetings in all hospital units by the researcher (the third

author) over a 4-week period. A sample of 1995 clinical nurses was recruited and

1,662 questionnaires were returned (return rate: 83.3%). 103 questionnaires were

discarded due to incomplete data, resulting in 1,559 analyzed questionnaires.

Ethical approval of the study was given by the medical ethics committee of

China Medical University. All participants signed an informed consent form.

Core Self-Evaluation and Burnout

PLOS ONE | DOI:10.1371/journal.pone.0115799 December 26, 2014 3 / 12

Instruments

Core Self-Evaluation Scale (CSE)

This scale was developed by Judge et al. [8] and is a 12-item self-report measure of

CSE. Items are rated from 1 (strongly disagree) to 5 (strongly agree). The scale

scores are the sum of the ratings of the items. Relevant items were reverse-coded.

The Chinese version of the CSE has previously been used in the Chinese

population and demonstrated good reliability and validity [25]. In this study, the

Cronbach’s alpha coefficient for CSE was 0.745.

Maslach Burnout Inventory–General Survey (MBI-GS)

The MBI-GS was developed by Maslach et al. [26, 27] and is a 15-item self-report

measure of job burnout which includes three dimensions, emotional exhaustion,

cynicism, and professional efficacy. The items are scored on a Likert scale from 0

(never) to 6 (every day). Higher scores on emotional exhaustion and cynicism

dimensions and lower scores on professional efficacy dimension indicated higher

levels of burnout. The Chinese version of the MBI has been widely used in Chinese

studies and has demonstrated satisfactory reliability and validity [28, 29]. In the

present study, Cronbach’s alpha coefficients for the three dimensions of MBI-GS

were 0.896, 0.747, and 0.825, respectively.

The Simplified Coping Style Questionnaire (CSQ)

This questionnaire developed by Xie YN [30] was based on the Ways of Coping

questionnaire by Folkman and Lazarus [31] and is a 20-item self-report that

includes two dimensions, active coping (12-item) and passive coping (8-item).

The items were measured using four-point Likert scales (05 never; 35 very

often). The instrument has been commonly used in China and the internal

consistency measured by Cronbach’s alpha was reported to be 0.78 [30]. In this

study, the Cronbach’s alpha coefficients for the two dimensions of SCSQ were

0.796 and 0.728, respectively.

Demographic data sheet

Demographic data including gender, age, educational level, work experience, and

job rank were obtained from a structured questionnaire.‘‘Educational level’’was

categorized as ‘‘high school or under’’, ‘‘junior college’’ and ‘‘undergraduate or

above’’. ‘‘job rank’’ was categorized as ‘‘junior nurse’’, ‘‘senior nurse’’ and ‘‘nurse-

in-charge’’.

Statistics

Data were imported to the Epidata 3.1 database. All analyses were conducted

using SPSS 17.0 for Windows and all statistical tests were two-sided (a50.05).
The distributions of dimensions of burnout in categorical demographic

characteristics were tested by one-way ANOVA. Pearson correlation was

performed to test the relationship between core self-evaluation, coping styles, and

burnout. Baron and Kenny’s [32] technique was used to test the mediating effect

of coping styles on the relationship between core self-evaluation and burnout.

Core Self-Evaluation and Burnout

PLOS ONE | DOI:10.1371/journal.pone.0115799 December 26, 2014 4 / 12

According to Baron and Kenny [32], the following conditions should be satisfied

to establish mediation: (1) The independent variable (CSE) is significantly

associated with the dependent variable (Emotional exhaustion/Cynicism/

Professional efficacy), (2) the independent variable (CSE) is significantly

associated with the mediator (Active coping/Passive coping), and (3) the mediator

(Active coping/Passive coping) is significantly associated with the dependent

variable (Emotional exhaustion/Cynicism/Professional efficacy), and the effect of

the independent variable (CSE) on the dependent variable (Emotional exhaus-

tion/Cynicism/Professional efficacy) reduces when the mediator (Active coping/

Passive coping) is added to the model (partial mediator). If the independent

variable does not affect the dependent variable when the mediator is added to the

model, then full mediation is established.

Before performing the regression analyses, all the continuous variables were

centered in order to avoid multicollinearity [33]. In addition, tolerance and the

variance inflation factor were used to check for multicollinearity. We performed

Pearson correlation and one hierarchical linear regression analysis for each of the

three burnout dimensions to test the mediating effect. In step one of the

hierarchical linear regression analyses, the control variables and positive results of

variance analysis were added to the model. In the present study, we included

gender, age, educational level, work experience and job rank in the model as

potential confounders. Because educational level and job rank are categorical

variables without a linear trend, dummy variables for these two variables were set.

For educational level, ‘‘High school or under’’ was set as the reference group. For

job rank, ‘‘junior nurse’’ was set as the reference group. In step 2, core self-

evaluation was added. In step 3, active coping and passive coping were added.

In addition, the statistical significance of the mediation effect was confirmed

using the Sobel test.

Results

The demographic and working characteristics of the subjects and the distribution

of each dimension of burnout in the categorical items are shown in Table 1. Mean

emotional exhaustion, cynicism, and professional efficacy differed across the age

and work experience groups. Nurses aged 30–40 years had the highest scores in

emotional exhaustion and cynicism and nurses aged over 40 years had the highest

scores in professional efficacy. The group with 10–15 years work experience had

the highest scores in the three dimensions of burnout. Mean emotional

exhaustion and cynicism differed between male and female nurses. Female nurses

were more easily affected by emotional exhaustion and cynicism. Mean emotional

exhaustion and professional efficacy differed among the job rank groups. Senior

nurses had the highest scores in emotional exhaustion, whereas nurse-in-charge

had the highest scores in professional efficacy. In addition, mean professional

efficacy differed across the education level groups. Nurses with an undergraduate

degree or above had the highest scores in professional efficacy.

Core Self-Evaluation and Burnout

PLOS ONE | DOI:10.1371/journal.pone.0115799 December 26, 2014 5 / 12

Pearson correlations

The results of Pearson correlation analysis among core self-evaluation, coping

styles, and burnout are shown in Table 2. The CSE scale was significantly

correlated with the dimensions of burnout (r520.343, 20.345, 0.282, P,0.01),

where nurses with a higher score on the CSE scale had better professional efficacy,

whereas nurses with a lower score on the CSE tended to be more susceptible to

emotional exhaustion and cynicism. In addition, CSE was significantly associated

with the dimensions of coping styles (r50.314, 20.254, P,0.01), where nurses

with active coping styles were found to have a higher score on the CSE scale and

passive coping styles had a negative impact on the CSE score.

The mediating role of coping styles on the relationship between

CSE and emotional exhaustion

As shown in Table 3, both CSE score and active coping style were negatively

associated with emotional exhaustion (b520.500 and 20.148, respectively,

P,0.01), the higher the score on the CSE scale and the more active coping style a

nursing professional had, the lower the chance of emotional exhaustion.

Conversely, a positive correlation between emotional exhaustion and passive

coping style was observed in our subjects (b50.308, P,0.01). Importantly, coping

Table 1. Demographics and working variables of the subjects and distribution of the MBI-GS.

Variable N(%) Mean(SD)

Emotional exhaustion Cynicism Professional efficacy

Gender P50.011 P50.010 P50.161

Male 60(3.8%) 11.58(7.19) 7.57(5.06) 24.42(9.58)

Female 1499(96.2%) 14.28(8.05) 9.67(6.20) 25.90(7.95)

Age (yr) P50.011 P50.037 P50.004

,30 1027(65.9%) 14.41(7.81) 9.46(6.00) 25.39(8.02)

30–40 334(21.4%) 14.42(8.27) 10.31(6.60) 26.42(7.37)

.40 198(12.7%) 12.58(8.60) 9.03(6.27) 27.21(8.87)

Education level P50.210 P50.099 P50.007

High school or under 213(13.7%) 13.29(7.67) 9.08(5.94) 24.93(8.68)

Junior college 840(53.9%) 14.37(7.83) 9.44(6.00) 25.54(7.87)

Undergraduate or above 506(32.5%) 14.23(8.49) 10.04(6.54) 26.71(7.91)

Work experience(years) P50.000 P50.026 P50.003

,5 862 (55.2%) 14.10(7.64) 9.35(5.85) 25.18(8.06)

5–10 326 (20.9%) 15.14(8.41) 9.99(6.55) 26.30(7.22)

10–15 88 (5.6%) 15.92(7.54) 11.22(6.59) 27.05(6.26)

.15 283 (18.2%) 12.75(8.67) 9.34(6.48) 26.94(8.65)

Job rank P50.029 P50.209 P50.000

Junior nurse 756 (48.5%) 13.98(7.57) 9.31(5.78) 24.83(8.26)

Senior nurse 533 (34.2%) 14.86(8.17) 9.81(6.43) 26.72(7.15)

Nurse-in-charge 270 (17.3%) 13.36(8.91) 9.94(6.71) 26.93(8.62)

doi:10.1371/journal.pone.0115799.t001

Core Self-Evaluation and Burnout

PLOS ONE | DOI:10.1371/journal.pone.0115799 December 26, 2014 6 / 12

styles (Active coping/Passive coping) had a partial mediating effect on the

relationship between CSE and emotional exhaustion, in that the regression

coefficient for CSE was reduced when coping styles were added to the model

(from b50.500 to b50.396). The result of the Sobel test confirmed the

significance of the mediating effect of active coping (z525.66, P,0.001) and

passive coping (z526.44, P,0.001). In addition, gender, age, and job rank

affected emotional exhaustion.

The mediating role of coping styles on the relationship between

CSE and cynicism

As shown in Table 4, both CSE and active coping style were negatively associated

with cynicism (b520.390 and 20.107, respectively, P,0.01). However, negative

coping style was positively associated with cynicism (b50.288, P,0.01). Coping

style not only directly impacted the cynicism score, but also affected it indirectly

by partially mediating the relationship between CSE and cynicism. The regression

Table 2. Means, standard deviations (SD) and correlations of all variables.

Variables Mean SD 1 2 3 4 5 6

1 Emotional exhaustion 14.18 8.03 1

2 Cynicism 9.59 6.18 0.704** 1

3 Professional efficacy 25.84 8.02 0.027 0.001 1

4 Core self-evaluation 40.47 5.34 20.343** 20.345** 0.282** 1

5 Active coping 24.11 5.38 20.156** 20.144** 0.271** 0.314** 1

6 Passive coping 9.96 4.13 0.206** 0.239** 20.095** 20.254** 0.171** 1

*P,0.05, **P,0.01 (two-tailed).

doi:10.1371/journal.pone.0115799.t002

Table 3. Results of hierarchical linear regression analyses, with emotional exhaustion as the criterion variable.

Variables Emotional Exhaustion

Step 1(b) Step 2(b) Step 3(b)

Gender 2.745** 2.628** 2.812**

Age 20.316** 20.265** 20.273**

Work experience(years) 0.116 0.096 0.103

Job rank-1 1.623** 1.675** 1.847**

Job rank-2 2.454* 2.384* 2.718**

Core self-evaluation 20.500** 20.396**

Active coping 20.148**

Passive coping 0.308**

R2 0.020 0.134 0.158

D R2 0.020 0.114 0.024

Note: Job rank-1 indicates ‘‘senior nurse’’ vs. ‘‘junior nurse’’, Job rank-2 indicates ‘‘nurse-in-charge’’ vs. ‘‘junior nurse’’.
*P,0.05, **P,0.01 (two-tailed).

doi:10.1371/journal.pone.0115799.t003

Core Self-Evaluation and Burnout

PLOS ONE | DOI:10.1371/journal.pone.0115799 December 26, 2014 7 / 12

coefficient for CSE in relation to cynicism score was reduced from 0.39 to 0.303

(P,0.01) when coping styles were added to the regression analysis. The result of

the Sobel test supported the significance of the mediating effect of active coping

(z525.26, P,0.001) and passive coping (z527.00, P,0.001). In addition,

gender, age, and work experience also affected cynicism.

The mediating role of coping styles on the relationship between

CSE and professional efficacy

The impact of coping styles on professional efficacy is shown in Table 5. Both CSE

and active coping style were positively associated with professional efficacy (b5

0.413 and 0.329, respectively, P ,0.01). However, passive coping style was

negatively associated with professional efficacy (b5 20.148, P ,0.01). More

importantly, coping styles (active coping/passive coping) indirectly affected

professional efficacy by partially mediating the relationship between CSE and

professional efficacy, in that the regression coefficient for CSE decreased when

active coping/passive coping was added to the regression analysis (from b50.413

to b50.283, P,0.01). The result of the Sobel test supported the significance of the

mediating effect of active coping (z58.47, P,0.001) and passive coping (z53.54,

P,0.001).

Discussion

This study investigated the relationship between CSE, coping styles, and burnout

dimensions among Chinese nurses, and demonstrated that CSE was an integrated

personality variable that may affect job burnout, and coping styles might have

both a direct and indirect effect on burnout. Our data suggest that strategies

which promote active coping styles among nursing professionals may help to

reduce job burnout, and thus enhance nursing efficacy. With regard to the

relationship between CSE and burnout, CSE was shown by our study and others

Table 4. Results of hierarchical linear regression analyses, with cynicism as the criterion variable.

Variables Cynicism

Step 1(b) Step 2(b) Step 3(b)

Gender 2.082* 1.998** 2.194**

Age 20.195* 20.155* 20.159*

Work experience(years) 0.167* 0.149* 0.164*

Core self-evaluation 20.390** 20.303**

Active coping 20.107**

Passive coping 0.288**

R2 0.008 0.126 0.159

D R2 0.008 0.117 0.033

*P,0.05, **P,0.01 (two-tailed).

doi:10.1371/journal.pone.0115799.t004

Core Self-Evaluation and Burnout

PLOS ONE | DOI:10.1371/journal.pone.0115799 December 26, 2014 8 / 12

[13, 14] to be a possible predictor of job burnout. This was supported by our data

which showed that nurses with higher CSE scores had less emotional exhaustion

and cynicism and higher professional efficacy. CSE is a deep personality trait.

Those with higher CSE scores will always have higher self-confidence and esteem,

and a more positive attributive style [13], which may result in lower levels of

emotional exhaustion and cynicism. CSE reflects the long-term faith of

individuals in their ability to maintain a stable self and a sense of control, which

are important in the evaluation of individual ability [34, 35]. Thus, those with a

higher CSE score might have a higher level of professional efficacy.

Positive factors relating to the prevention of nursing burnout such as hardiness,

active coping, and social support were found to be the most important buffering

factors [4]. In the present study, active coping was negatively associated with

emotional exhaustion and cynicism, and was positively associated with

professional efficacy. These findings contribute to the understanding that coping

styles have a significant effect on burnout, and active coping may be a positive

resource for combating burnout.

As shown in Table 3, as passive coping increased, emotional exhaustion scores

increased accordingly. This is consistent with Gibbons’ study [36], where active

coping and older age played a clear role in decreasing vulnerability to emotional

exhaustion and cynicism. It appears that younger nurses experience more burnout

than their older colleagues. This may indicate that with increased life experience,

individuals might have a lower tendency to use passive coping styles and more

confidence, thus have less burnout. Active coping is helpful in preventing

cynicism, and this is in agreement with a previous study which found that active

coping style can decrease the negative impact of stressors by strengthening one’s

Table 5. Results of hierarchical linear regression analyses, with professional efficacy as the criterion variable.

Variables Professional efficacy

Step 1(b) Step 2(b) Step 3(b)

Age 20.153 20.189 20.180

Work experience(years) 0.126 0.131 20.131

Education-1 0.537 0.664 0.767

Education-2 0.935 1.161 1.272

Job rank-1 1.882** 1.856** 1.673**

Job rank-2 1.984 2.061 1.533

Core self-evaluation 0.413** 0.283**

Active coping 0.329**

Passive coping 20.148**

R2 0.018 0.096 0.136

D R2 0.018 0.078 0.041

Note: Job rank-1 indicates ‘‘senior nurse’’ vs. ‘‘junior nurse’’, Job rank-2 indicates ‘‘nurse-in-charge’’ vs. ‘‘senior nurse’’. Education-1 indicates ‘‘Junior
college’’ vs. ‘‘High school or under’’, Education-2 indicates ‘‘Undergraduate or above’’ vs. ‘‘High school or under’’.
*P,0.05,
**P,0.01 (two-tailed).

doi:10.1371/journal.pone.0115799.t005

Core Self-Evaluation and Burnout

PLOS ONE | DOI:10.1371/journal.pone.0115799 December 26, 2014 9 / 12

coping efficacy and dynamics in a specific situation [4]. Dysfunctional coping

strategies in nurses results in the deterioration of nurse-patient relationships, and

failures are increasingly experienced leading to a gradual sense of lack of personal

accomplishment [4]. Nurses who usually face disease, death and other situations

tend to develop emotionally-negative characteristics, and feelings of emotional

exhaustion. If no effective resources are adopted to cope with exhaustion, this will

lead to cynicism and reduced professional efficacy. Conversely, when a successful

coping style is adopted (e.g., active coping), nurses can achieve their goals and

professional efficacy improves. Moreover, Folkman and Lazarus [31] stated that

the problem-solving coping style can result in an improvement in the person-

environment relationship, thus achieving a better cognitive appraisal and a more

positive emotional response. An optimistic coping strategy can result in nurses

using problem solving to deal with their difficulties to effectively reduce their

stress levels [37].

Our study revealed that coping styles (Active coping/Passive coping) partially

mediated the effects of CSE on emotional exhaustion, cynicism and professional

efficacy. Nurses with lower CSE might be more likely to use passive coping which

in turn leads to higher levels of emotional exhaustion and cynicism, and lower

levels of professional efficacy. Compared to changing the CSE score in nurses, it

might be more positive and feasible for hospitals to conduct nurse training on

problem-solving skills with the goal of helping nurses develop and employ active

coping styles to deal with the stress they face at work. This type of training would

be expected to improve nurses’ health and well-being and to reduce professional

burnout, and thus improve the quality of healthcare.

Although the present study demonstrates the important role of self-evaluation

and coping styles on job burnout among Chinese nursing professionals, there are

limitations regarding the design of the study. Firstly, we conducted this study in

large general hospitals, which may not necessarily reflect the burnout experienced

by nurses in different hospitals and community health centers. Secondly, the study

relied only on self-report measures which may have introduced bias. Therefore,

future studies in different hospitals and consisting of more objective parameters,

such as behavioral and physiological indicators, as well as broader influencing

factors, will provide more insightful knowledge regarding the inter-relationships

between self-evaluation, coping styles, and nursing burnout. In addition, this was

a cross-sectional study, thus the causality could not been established in

this study.

Prospective studies should be conducted in the future to confirm the findings

obtained in this study.

Conclusions

The present study demonstrated that CSE may be a possible predictor of job

burnout among nursing professionals, indicating that nurses with a high CSE

score display less burnout. More importantly, coping style might be an important

factor which can affect burnout directly or indirectly by partially mediating the

Core Self-Evaluation and Burnout

PLOS ONE | DOI:10.1371/journal.pone.0115799 December 26, 2014 10 / 12

relationship between CSE and job burnout. Our results suggest that when active

coping strategies are adopted, burnout is likely to be reduced. Therefore,

interventions focused on the improvement of coping strategies may be helpful in

the prevention of job burnout in nurses, thus enhancing nursing care efficacy.

Supporting Information

S1 Table. The clinical data of 1559 nurses, which were analyzed in this study.

doi:10.1371/journal.pone.0115799.s001 (XLS)

Acknowledgments

We would like to give our heartfelt thanks to all the nurses who participated in

this study.

Author Contributions
Conceived and designed the experiments: XFL BZ. Performed the experiments:

HC LG. Analyzed the data: HC. Contributed reagents/materials/analysis tools:

XFL LG. Wrote the paper: XFL BZ.

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International Journal of Academic Research in Accounting, Finance and Management Sciences
Vol. 4, No.1, January 2014, pp. 293–298

E-ISSN: 2225-8329, P-ISSN: 2308-0337
© 2014 HRMARS

www.hrmars.com

The Impact of the Motivation on the Employee’s Performance in
Beverage Industry of Pakistan

Hashim ZAMEER
1

Shehzad ALI
2

Waqar NISAR
3

Muhammad AMIR
4

1,2,3,4
BZU-Bahadur Sub Campus Layyah, Pakistan,

1
E-mail: hashimzameer@hotmail.com (Corresponding author)

Abstract Motivation plays an important role in all public and private organizations. Without motivating thei

employees organizations can’t run and can’t achieve their goals. Purpose of present study is to explore
the impact of motivation on employee’s performance of beverage industry in Pakistan. The data for
present study has been collected from five major cities of Pakistan using structured questionnaire. Results
from present study explores that motivation plays a vital role toward the performance of employees in
beverage industry of Pakistan.

Key words Motivation, employee’s performance, motivational theories

DOI: 10.6007/IJARAFMS/v4-i1/630 URL: http://dx.doi.org/10.6007/IJARAFMS/v4-i1/630

1. Introduction

Motivation is the most important matter for every organization public or a private sector. For the
success of any organization motivation play an important role. All organization encounters the matter of
motivation whether they are in the public or private sector (Chintallo & Mahadeo, 2013). According to
Chaudhary & Sharma (2012) basically motivation word is derived from “Motive”. The meaning of “motive”
is needs, wants, and the desire of the persons. So that “employees motivation mean the process in which
organization inspiring our employee with the shape of rewards, bonus etc. for achieving the organizational
goals.

Today organization can easily change their material, needs, goods and services to other organization,
or to other countries. But the only one resource which is not easily exchangeable is human resources. So
we can say that human resources is the very important or most competitive assets of any organization that
cannot be exchangeable. Human resources or human assets mean the workers or the employee of any
organization. So the motivation is main factor that affect the human resources of the organization. The
organization should be motivating their employees for the best performance or for achieving the
organizational goals. In fact motivation is the best tool for best performance. Today there are many
discussions about motivation and the relationship of employee’s efficiency and the organizational
efficiencies. Motivation will lead to the fact that workers or employees of the organization will seriously do
his duties and responsibilities (Azar and Shafighi, 2013). Attractive Salaries or pays also a Valuable tool and
play an important role to increase employee’s performance and also increase the productivity of an
organization (MUOGBO U.S, 2013).

According to Iqbal et al. (2012), Employee’s motivation and their ability collectively participate into
employee’s performance and in their difficult tasks given by the manger are to purpose get maximum
productivity. Now a day’s researcher have more concerned with increase productivity, perfection and
working ability. Employee’s needs and wants having more important in research history.

Motivation is the one of the most important term of psychology and most of mangers who want
maximum output and productivity. They tackle this is with a good way and motivate their employee in
batter way. And also increase the cooperation between employee and mangers, it also encourage their

mailto:hashimzameer@hotmail.com

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responsibilities. And also encourage participation their sub ordinates, to take their responsibilities in batter
way and also help to overseas other employee and monitor their performance. And motivate get their
maximum interaction toward work and knowing employee’s working capacity and assign work according to
their capacity to get maximum productivity (Ali, Abrar and Haider, 2012).

Another way used to monitor employee performance is Performance Appraisal.by performance
appraisal we can monitor quality of performance of an employee. We monitor performance by using these
broader performance management system that links: 1. Organization objective; 2. Day by day performance;
3. Professional development; 4. Rewards and incentives. In simple words we said that appraisal is the
assessment in individual performance in an systematic way, performance can be measured in such

factors

e.g. job knowledge, quality and quantity of output, leadership abilities, supervision, dependency,
cooperation, judgment, versatility and versatility. Performance cannot depend on past performance of
employee.

Employees play important role in the customer perception about the company. Company spend huge
amount of money to gain customer loyalty but they forget the Employees motivation. Customer interact
with the employees and also carry out company image in their mind through the behavior and attitude. So
company should be move their attention toward the employee motivation. Now the era of globalization
companies face competition in the market, if company could not successfully motivate their employee.
Company didn’t exist in competitive environment of business (Ahmad, 2012).

2. Literature Review

There are number of views of literary personalities relating to motivation and motivational theories.
Content theories give us a lead to know about people’s needs and the things which are necessary for
motivation work:

 Maslow’s Needs Hierarchy;

 Herzberg’s theory of Two Factor;

 Alderfer’s Hierarchy of Needs That Contains Three Part;

 McClelland’s Motivational Achievement theory.

Maslow’s-Hierarchy of Needs Theory

Maslow’s full Name Abraham Maslow. He says that five universal needs motivate a person. He
arrange them as:

Physiological or Basic needs
According to Anyim (2012) physiological or basic needs are the basic need of a person. It includes as

driving force. This is also called felt need. This need causes physiological tension which is shown by any
body’s behavior. This can be reduced by eating something.

Chintalloo and Mahadeo (2013) also explain physiological needs. According to them physiological
needs basically is satisfied the basic need of human. Physiological needs or basic needs also called biological
needs. Maslow said when a person fulfills the basic, physiological or biological needs him move up the next
level. For example: Food, shelter, clothes, sleeping and breathing etc.

Safety needs
Safety needs is the needs for shelter and protection. In this need a person needs security, stability

and dependency. In this a humans needs freedom from anxiety law and order and structure. This need is
also called security needs. For examples the employee’s or the worker’s in a private organization demand
that the organization or company must be provide their job security, health security and promoting safety.
And nowadays private organizations also provide the promoting safety and health plan, and emergency fun
and accident cover’s benefits.

Belongings needs
These needs are also known as social needs. It includes love and belongings. Usually man’s needs

love and care. These needs can be fulfill by interaction with coworker and colleagues. For examples the
feelings of friendship, feelings of love, caring of family or relative etc.

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At work, having a good relation with group fellow or colleagues. For promoting the team work and
achieving the organizational goal the managers could force the workers that they must be works in groups
or in a team.

Esteem needs
Esteem needs are also known as egoistic needs. In this a man needs self-respect and the esteem of

other. Man needs or reputation, prestige, status, fame, glory, dominance and recognition etc.
Esteem needs are difficult to satisfy in some industries. In an organization a manager should be

respectively treat their employees. And the workers should also respect the policies or the law of the
organization. The worker’s also respect each other. Example of these needs is the achievement and
confidence.

Self-actualization needs
This is the highest need. A man wants self-realization and self-development and desire to be able to

do something. Morality, acceptance of facts, lack of prejudice, creativity, spontaneity and problem solving
are all examples of self – actualization needs.

Herzberg’s Two-Factor Theory

This is called motivation hygiene theory. He says people that having two sets of needs.

 Their these needs to avoid pain as animal

 Their needs to grow psyche of human
He derived this theory from interviewing a person

 When a person thinks well about job

 When a person thinks negative about a job
There are two factors which is result of this investigation.

Satisfiers
Five steps are strong favors as job gratification acquirement, appreciation, restraint and

improvement. Last three issues were found to be most significant for changes in approach.

Dissatisfies
Company policy, supervision, salary, administrative policies, and working conditions are cause

dissatisfaction. Satisfying factors are also called intrinsic factors and dissatisfying factors are called extrinsic
factors. These are two different things. Elimination of these dissatisfactory factors brings peace not
motivation.

Alderfer’s Three -Party Hierarchy of Needs:

According to Alderfer theory is closely related to Marlow’s theory. His theory name is ERG. Which
includes need for existence, growth?

E means existence needs.
R means relatedness needs
G means growth needs

Maslow’s vs. Alderfer’s Philosophy:

 Substances: Maslow’s philosophy was created on five needs whereas Alderfer’s theory was based
on three needs.

 Course terms: Maslow spoke about the contentment advancement, Alderfer talked about both
fulfillment and prevention relapse.

 Maslow needs can be fulfilled one by one but Alderfer says these can be fulfilled simultaneously.
Alderfer says that a person fulfills lower order need and then his longer needs. He also says that if

higher order need is not satisfied lower level become more desirable.

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McClelland’s Achievement Inspiration Philosophy:

He established the concept of inspiration on human need for accomplishment. This need to attain
has been abridged as n-ach. He says this need is fulfilled by people to avoid failure and compelling desire
for success such person must have following qualities.

He sets judiciously tough but attainable goal:

 He takes ‘premeditated perils’;

 He likes response on his performance;

 He likes precise and swift response on how he is doing;

 He needs talented co-workers in spite of personal feelings. He says that this can be taught to under-
developed persons.

According to him there are three needs of human that are very important and necessary. (a)
necessity for attainment; an erudite need to outrival and show in life, (b) necessity for power, an erudite
need to lead and change the conducts and dogmas of others, (c) need for connection, a speculative need
for social interaction with others.

Motivational factors

There are number of motivational factors that increase the presentation of employee’s in an
association.

Salaries and wages
If the association administration paid the reason able remunerations in time and fixing the salaries

then enactment of the employees habitually increase. Otherwise not well. Because salaries and wages is
the main and very important motivational aspect that affect the employees performance in the
organization (Agwu, 2012).

Bonus
Association administration can easily increase the work performance of the workforces with the help

of additional benefit. We can say that additional benefit is the above salary gives the employee’s according
to their performance. Bonus is an important tool for increasing the productivity (Agwu, 2013).

Encouragements
Encouragements mean additional allowances like medical allowance, travel allowance and house

allowances etc. company can increase the employee’s performance by providing this encouragement.

Job Security
Organization increases the employee’s performance or productivity by providing job security.

Promotion
Organization increases the employee productivity by promoting them.

3. Theoretical Framework

Motivation

This study involves monetary and non-monetary motivational factors as independent variables. In
independent variables monetary motivational factors include main three dimensions salaries and wages,
bonus, and special individual incentives. And non-monetary motivational factors include main four
dimensions working conditions, job status, job security, job enrichment.

Employees’ performance

According to literature review employee’s performance as dependent variable. And in dependent
variable employee’s performance include three major dimensions job productivity, job quality, and job
accomplishment.

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Figure 1. Research frame work on the relationship of motivation towards employee’s performance

Hypothesis development

Ho: Motivation not affects the employee’s performance in beverage industry

H1: Motivation affects the employee’s performance in beverage industry.

4. Material and Methods

4.1. Research instrument and sample

To examine the impact of motivation on employee’s performance in beverage industry survey
method is applied. Questionnaire we have designed comprises of two sections. First section is related to
the personal profile of the respondents including their age, gender, marital status, education level etc.
which is measured by nominal scale. Second section is related to the questions relevant to variables namely
motivation and employee’s performance measured by 5-point Likert scale. We selected the 5 cities Lahore,
Islamabad, Faisalabad, Multan and Layyah. 150 questionnaires were distributed randomly to the beverage
industry (Pepsi, Coke and Gorment).

4.2. Analysis, Findings and Interpretation of Results

To observe the impact of motivation on employee’s performance in beverage industry we used the
regression analysis and correlation analysis to examine the connection between dependent and
independent variables. Table 1.1 indicates that motivation is positively correlated with employee’s
performance in beverage industry with p value of 0.000 which is significant at 1%.

Table 1.1. Correlations

Motivation Performance
Motivation Pearson Correlation 1 .537

Sig. (2-tailed) .000

N 150 150

Performance Pearson Correlation .537
**

Sig. (2-tailed) .000
N 150 150

Table 1.2 shows beta values which mean individual independent motivation variables influence on
dependent performance variable. Result indicates that motivation has the strong influence on employee’s
performance in beverage industry with beta value.0.537.

Table 1.2. Coefficients

Model
Unstandardized Coefficients

Standardized
Coefficients

T Sig. B Std. Error Beta

1 (Constant) 1.799 .248 7.260 .000

Motivation .520 .067 .537 7.740 .000

a. Dependent Variable: Performance

Independent variables:

Monetary motivational

factors

Non-monetary motivational

factors

Dependent variable:

Employee’s performance

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The results further suggested that the motivation in beverage industry of Pakistan can significantly
influence performance of employees. We can say that if top management put their focus upon motivation
of employees then it will leaders toward a positive increase in employee’s performance.

5. Discussion & Conclusion

In this study having motivational theories such as Maslow’s hierarchy of need, Herzberg’s Two-Factor
Theory and Alderfer’s three party hierarchies of needs. We follow two theories of needs Maslow’s
hierarchy of need and Alderfer’s three party hierarchies of needs. These researchers gave their point of
view related to human needs and human needs play an important role to motivate the employees of any
organization. Anyim (2012) and Chintalloo & Mahadeo (2013) also follow these theories of need. These
theories helps us how to motivate the employee. According to Maslow hierarchy of need if organization
fulfills basic need, safety need, belonging need, self-esteem need and self-actualization of their employees
then the performance of employee easily increase. And according to Alderfer’s three party hierarchy of
needs if organization fulfill the existence need, relatedness needs and growth needs the performance of
employees are also increase.

Present study is used to examine the relationship between motivation and employees performance
in beverage industry. Results from present study suggest that if beverage industry (Coke, Pepsi and
Gorment etc.) motivate their employee’s by using these tools such as job enrichment, job security,
reasonable salary and other additional incentives then the employee’s performance automatically
increased and industry achieve their goals easily.

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Comparison between Body Image and Self-Esteem Among Female
Nursing Students in Three Different Arab Countries

NABILA TAHA, D.N.Sc.*; ESSMAT MANSOUR, D.N.Sc.**;
AMAL SOBHY, D.N.Sc.*** and ENTISAR M. YOUNESS, D.N.Sc.*

The Departments of Obstetrics & Gynecological Nursing*, Faculty of Nursing, Assiut University; Medical Surgical Nursing**,
Tanta University and Psychiatric & Mental Health Nursing***, Port-Said University.

Abstract

Current western culture promotes standards of beauty and
success which focus on physical attractiveness. These standards
can create feeling of inadequacy and body dissatisfaction.
Traditionally, women have responded most strongly to cultural
messages of bodily attractiveness, there by experiencing
greater body dissatisfaction than men. Failure to achieve the
ideal has been shown to lead to decreased self-esteem which
compounds body dissatisfaction and body image disturbance.
Therefore; this study aimed at assessing and comparing the
level of body image and self-esteem among three communities
based sample from Riyadh- Kindom of Saudia Arabia (KSA),
Hadhramout-Yemen, and Assiut-Egypt, 300 female students
were recruited, 100 female students from each country. The
study was carried out in three different settings; Riyadh Female
Health Science Collage-KSA, and Faculty of Nursing,
Hadhramout University of Science and Technology-Yamen,
Faculty of Nursing, Assiut University-Egypt. Tools for data
collection included; body image scale, which developed by
El-Desouki. This scale consisted of 20 statements about
positive and negative sensation of body image, Rosenberg
self-esteem scale, this scale consisted of 10 statements about
the positive and negative sensation of self-esteem and interview
Questionnaire which developed by the investigators, it includes
information about student’s age, residence, marital condition,
economic condition, parent’s educational level, number of
brothers and sisters and their orders among them. Results of
this study revealed that positive body image constitutes 86

in KSA, 84% from Egypt while 73% from Yemen. The majority
of the students in the three countries had high self esteem
(78% in KSA, 96% in Egypt and 84% in Yemen). The study
also found that positive perception of body image is associated
with high self esteem (85.9%, 84.8% and 69.0%) among the
studied students’ in KSA, Egypt and Yemen respectively),
fortunately; negative perception of body image is associated
with low self esteem in (13.6%, 15.2% and 6.2%) among
students’ of KSA, Egypt and Yemen respectively. In conclusion
high level of self esteem positively correlated with body
image. Age, parent’s education, marital status, numbers of
brothers and sisters are significantly correlated to body image
and self esteem. This study recommended another informative

Correspondence to: Dr. Entisar Mohammad Youness
Lecturer Obstetrics and Gynecological Nursing, Faculty of
Nursing, Assuit University,
E. mail: entisarmohamedyones@yahoo.com

study to investigate other dimensions of body image and self
esteem in multi dimensional settings and studying the healthy
lifestyle choices which are

also a key to improve body image.

Key Words: Body image – Self esteem – Body image scale –
Self esteem scale – Female nursing students.

Introduction

IN the light of the sudden and rapid changes in
physical growth and psychological development
among adolescents it was reported that body image
related problems have become a critical determinant
of nutritional status that place adolescents, partic-
ularly girls, as one of the nutritionally vulnerable
groups. Evidences have shown that negative body
image is significantly linked to various health
issues, including a spectrum of disordered eating,
low self esteem, depression and unhealthy weight-
loss practices [1,2] .

Body image is the person’s perception of his
or her physical self. This perception includes con-
scious and unconscious perceptions of physical
attributes and functioning, emotions, and sensation,
it extends beyond the body to include objects such
as clothing or items used in work [3] . A person’s
body image forms and changes as he or she devel-
ops, and is closely tied to self esteem and identity,
both of which are threatened by a change in body
image. Body image also is influenced by cultural
beliefs and values and massages one receives from
others [4] .

Body image is changed as one progress through
the different developmental stages of life. Persistent
preoccupation with one’s body image can impair
emotional and cognitive development, interfere
with interpersonal relationships, and place an
individual at risk for the development of an eating
disorder [5] . Any change in body image has de-
stroyed all of his or her strengths. The client may

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510 Comparison between Body Image & Self-Esteem Among Female Nursing Students

feel incapable of succeeding at anything and may
need encouragement to attempt activities. Activities
within the client’s abilities provide opportunities
for success. Positive feedback can enhance self
esteem. Clients with low self esteem don’t benefit
from flattery or undue praise [3] .

Negative body image is a serious issue during
adolescence and should be duly addressed. Al-
though body image has been increasingly studied
over the last half century, no consensus was found
in the definition of the body image concept. How-
ever, body image scholars [6] had agreed that body
image comprises a multi-dimensional construct
with various dimensions. One of the most common
dimensions that have been described is body dis-
satisfaction, which is used interchangeably with
negative body image or body image disturbance.
Overlooking in the body image concept and failure
to distinguish the various dimension of body image
may hinder the important role of body image in
population health and well-being. So, a thorough
understanding of the body image concept is crucial
in determining the etiology, prevention and treat-
ment of body image and its related problems,
particularly eating disorders and obesity [7] .

As body image encompasses a complex and
multi-dimensional construct, [8] recommended that
multi scales should be used to assess body image.
However, this may raise the issue of whether the
items of the scales are overlapping to the point of
redundancy.

With a positive or healthy body image, a woman
has a real perception of her size and shape. She
also feels comfortable with her body. With a neg-
ative body image, a woman has a distorted percep-
tion of her shape and size, compares her body to
others, and feels shame and anxiety about her body.
Being unhappy with your body can affect how you
think and feel about yourself as a person. A poor
body image can lead to emotional distress, low
self-esteem, unhealthy dieting habits, anxiety,
depression, and eating disorders. Developing a
positive body image and a healthy mental attitude
is crucial to a woman’s happiness and wellness [3] .

Aim of the study:
The aim of this study was to assess and compare

the level of body image and self esteem of the
female nursing students in three different Arabic
countries (Saudi Arabia, Egypt and Yemen).

Research question:
What are the differences between the level of

body image and self-esteem among female nursing
students in the three different Arab Countries?

Subjects and Methods

Research design:

Comparative research design was utilized in
this study.

Settings:

The study was carried out in three different
setting; Faculty of Nursing, Assiut University,
Egypt, Riyadh Female Health Science Collage,
Kingdom of Saudia Arabia, and Faculty of Nursing,
Hadhramout University of Science and Technology,
Yemen. These faculties are governmental faculties
(Ministry of Higher Education), and encompass
multi-residential studies.

Subjects:

Subjects consisted of 300 female nursing stu-
dents from three different Arab Countries, 100
students from each one. Their age ranges between
18 and 30 years. As the study involved only ado-
lescent girls, the sample is limited by sampling
location whereby these girls had became physically
and psychologically mature, so all subjects were
from the second year students in the three faculties
which involved on the average of 100 female
students.

Tools of data collection:

Data were collected using a self-administered
questionnaire which has been translated into Arabic
language.

Three tools were utilized in this study:
1- Interview questionnaire:

It includes information about socio–demograph-
ic characteristics such as student’s age, residence,
marital status, economic status, parents’ educational
level, number and orders of brothers & sisters.

2- Body image scale:

Body image scale which was developed by El-
Desouki [9] were used to assess students’ body
image. This is a factorial derived measure of male
and female body esteem. This scale consisted of
20 statements about positive and negative sensation
of body image. For example “I accept my shape
as it is”. Items were rated on a five-point Likert
scale, from strongly negative feelings to strongly
positive feelings. Each scoring response is classified
to 1-5 degrees: 1 for never, 2 for rare, 3 for some-
times, 4 for mostly, 5 for always. In total score for
each student the high score indicates positive body
image and the low score indicates negative body
image.

Nabila Taha, et al. 511

3- Self-esteem scale:
Self-esteem was assessed through using a

Rosenberg self-esteem scale (1965) [10] ; this scale
consisted of 10 statements about the positive and
negative sensation of self-worth, an example of
which is “I feel that I have a number of good
qualities. There were five positive statements and
five negative statements, with four-point Likert
scale ranging from ‘strongly agree’ to strongly
disagree” Each scoring response is classified to 1-
4 degrees. 1 degree is assigned for strongly agree,
2 degrees for agree, 3 degrees for disagree, and 4
degrees for strongly disagree. In total score for
each student the high score indicates high self-
esteem and the low score indicates low self-esteem.

study. No health hazards were present. Participants
were assured that all their data are highly confi-
dential, anonymity was also assured through as-
signing a number for each student instead of names
to protect their privacy. Data was only available
to the researchers and the participants.

Statistical analysis:
Collected data were coded and analyzed. De-

scriptive statistics for the variables were calculated.
Variables were compared using chi-square test.
The variables were significant at p-value <0.05. All the statistical analysis was performed using SPSS package version 11.

Results
Content validity:

It was established by panel of 5 experts who
reviewed the instruments for clarity, relevance,
comprehensiveness, understanding, applicability
and easiness.

Pilot study:
A pilot study was conducted on 10 students

from each country, to test feasibility of tools and
time required to be applied. Simple modification
was done of some items of the interview question-
naire sheet that they were not consistent with this
study.

Administrative design:
Before the conduction of the pilot study as well

as the actual study, an official permission was
obtained from the dean of each collage in each
country.

Procedure:
The official permission was obtained from the

research ethical committee in the three nursing
faculties in the three countries to approve this
study. The students were gathered in the faculty
class for each session of data collection. An infor-
mation sheet explaining the study purpose and its
protocol was disseminated and explained before
informed consent was obtained from the students.
Data were collected using a self-administered
questionnaire and the tools utilized to collect the
desired data were explained sufficiently. The stu-
dents were interviewed in groups, 25 students in
each session in their classes for about 20 minutes.
The duration for data collection lasts for 3 months
precisely from April to June, 2010.

Ethical consideration:
The study protocol was approved by pertinent

research and ethical committees. Informed consent
was taken from every girl before inclusion in the

Table (1) Describes the socio-demographic
characteristics of the students. It shows that 91%,
68% and 88% of the students were in the age group
from 20 to less than 25 years in KSA, Egypt and
Yemen respectively. Most of mothers and fathers
education in three countries had basic education.
There is a highly statistical significant difference
between the three countries regarding age (X 2=
41.774, p=0.000) and mother’s education (X 2=
18.78, p=0.005) while there are no statistically
significant differences between them as regards
father’s education (X 2=9.006, p=.170).

Regarding mother’s job, the majority of mothers
in the three countries were housewives (73%, 77%
and 89%) in KSA, Egypt and Yemen respectively.
In relation to place of residency, it was found that
93% of students in KSA, 35% of students in Egypt
and 87% of students in Yemen are coming from
urban areas and the majority of students had inter-
mediate family income in the three countries (79%
from KSA, 92% from Egypt and 61 % from Yemen).
There is a statistical significant difference between
the three countries regarding mother’s job (X 2=
8.560, p=0.014), place of residency (X 2=100.202,
p=0.000) and family income/month (X 2=56.434,
p=.000).

Also Table (1) represented that about half of
the females had from 1-3 brothers and sisters (51%,
52% and 46%) and more than half of them in the
medium of birth order (57%, 55% and 56%) in
KSA, Egypt and Yemen respectively. Regarding
marital status, about one quarter of the students in
KSA (24%), only 3% of students of Egypt, while
86% of Yemen were married. There is a highly
statistical significant differences between the three
countries regarding number of brothers and sisters
(X

2
=26.775, p=0.000), marital status (X 2=161.041,

p=0.000) while there is no statistically significant

512 Comparison between Body Image & Self-Esteem Among Female Nursing Students

differences between them regarding birth order
(X2=.648, p=.958).

Distribution of the study sample according to
their self esteem represented in Table (3), the
subjects were grouped according to their scores of
the level of self esteem into two groups (low and

high self esteem). The majority of the students in
the three countries had high self esteem (78% in
KSA, 96% in Egypt and 84% in Yemen) while the
rest of subjects had low self esteem (22% of KSA
students, 4% of Egypt students and 16% of Yemen
students) with a highly statistically significant
difference (X

2
=13.953, p=.001).

Table (1): Distribution of the subjects according to their socio demographic characteristics.

Country

Socio-demographic

characteristics KSA (100) Egypt (100) Yemen (100) Total (300)
Chi-Square

Test
p-value

N % N % N % N %

Age (years):
<20 4 4 32 32 7 7 43 14.3 20- 91 91 68 68 88 88 247 82.4 41.774 .000 25-30 5 5 0 0 5 5 10 3.3

Mother’s education:

Illiterate 20 20 28 28 21 21 69 23.0
Basic 36 36 32 32 53 53 121 40.4 18.787 .005
Secondary 20 20 28 28 13 13 61 20.3 S
University 24 24 12 12 13 13 49 16.3

Father’s education:

Illiterate 11 11 13 13 6 6 30 10.0 9.006 .170
Basic 34 34 31 31 38 38 103 34.3 N.S
Secondary 28 28 30 30 40 40 98 32.7

University 27 27 26 26 16 16 69 23.0

Mother’s job:

Housewife 73 73 77 77 89 89 239 79.7 .014

Employed 27 27 23 23 11 11 61 20.3 8.560 S

Place of Residency:

Urban 93 93 35 35 87 87 215 71.7 100.202 .000
Rural 7 7 65 65 13 13 85 28.3 S

Family income/month:
High 5 5 0 0 31 31 36 12.0
Intermediate 79 79 92 92 61 61 232 77.3 56.434 .000
Low 16 16 8 8 8 8 32 10.7 S

Number of brothers & sisters:

Null 3 3 0 0 2 2 5 1.7
1-3 3 3 23 23 25 25 51 17.0 26.775 .000
4-6 51 51 52 52 46 46 149 49.6 S
More than 7 43 43 25 25 27 27 95 31.7

Birth Order:

First 24 24 23 23 21 21 68 22.7
Medium 57 57 55 55 56 56 168 56.0 .648 .958
The last 19 19 22 22 23 23 64 21.3 N.S

Marital status:
Single 73 73 96 96 14 14 183 61.0
Married 24 24 3 3 86 86 113 37.7 161.041 .000
Divorced and widow (ed) 3 3 1 1 0 0 4 1.3 S

Nabila Taha, et al. 513

Table (2): Distribution of the students according to their body image perception.

Country

Body image KSA Egypt
(100) (100)

Yemen
(100)

Total
(300)

Chi-Square
Test

Positive perception 86 (86%) 84 (84%)

Negative perception 14 (14%) 16 (16%)

73 (73%)

27 (27%)

243 (81%)

57 (19%)

6.368

p .041 S

Table (3): Distribution of the subjects according to self esteem.

Country
Total
(300)

Chi-Square
Test

Self esteem
KSA (100) Egypt (100) Yemen (100)

Low self esteem 22 4
22% 4%

High self esteem 78 96
78% 96%

16
16%

84
84%

42
14%

258
86%

13.953
p .001

The relation between self esteem and body
image among the studied students is clarified in
Table (4), it was found that 85.9%, 84.4% and
69.0% of the subjects with a high self esteem had
positive body image among the studied students
in KSA, Egypt and Yemen respectively, with a
statistically significant difference (X 2=13.58,
p=.001) between groups, while 75.0%, 84.8% and
93.8% of the subjects with a low self esteem had
positive body image among the studied students
in Saudi, Egypt and Yemen respectively, with no
statistically significant differences.

Comparison between sociodemographic char-
acteristics in relation to body image in the three
countries was presented in Table (5). It was found
that students’ age from 20-25 years is correlated
positively with positive perception of the body
image among students of KSA, Egypt and Yemen
(94.2%, 65.5% and 86.3%) respectively with a
highly statistical significant differences between
groups (X2=34.75, p=.000). Fortunately mother’s

education, urban areas, mediated family income,
birth order among sisters and brothers and marital
status all are associated with positive perception
of body image with a highly statistical significant
differences between groups owing this to the
communities differences.

Concerning the comparison between socio-
demographic characteristics in relation to self-
esteem in the three countries Table (6) presented
that, students’ age from 20-25 years is correlated
positively with high selfesteem among students
of the thre countries KSA, Egypt and Yemen
(89.7%, 69.8% and 85.7%) respectively with a
highly statistical significant differences between
groups (X 2=31.98, p=.000). Fortunately moth-
er’s job, urban areas, mediated family income,
number of sisters and brothers and marital status
all are associated with high self esteem with a
highly statistical significant differences between
groups.

Table (4): Relation between self esteem and body image.

Student self esteem

High self esteem

Low self esteem

Student body image

Saudia (78)

Test
Egypt (96) Yemen (84)

χ
2 Saudia (22) Egypt (4) Yemen (16)

% N

Positive perception 67 85.9 81 84.4 58 69.0 13.58 19 75.0 3 84.8 15 93.8

Negative perception 11 14.1 15 15.6 26 31.0

p=.001 S

3 25.0 1 51.6 1 6.2

514 Comparison between Body Image & Self-Esteem Among Female Nursing Students

Table (5): Comparison between students’ sociodemographic characteristics in relation to the three Arab Countries.

Student body image

Socio-demographic
Characteristics

Positive perception

Test
x 2

Negative perception

Al-Riyadh
(86)

Assiut
(84)

Yemen
(73)

Al-Riyadh
(14)

Assiut
(16)

Yemen
(17)

N % N % N % N % N % N %

Age (years):
<20 4 4.7 29 34.5 7 9.6 34.75 0 0 3 18.8 0 0 20- 81 94.2 55 65.5 63 86.3 p=.000 10 71.4 13 81.3 25 92.6 25-30 1 1.2 0 0 3 4.1 S 4 28.6 0 0 2 7.4

Mothers education:
Illiterate 15 17.4 23 27.4 15 20.5 19.23 5 35.7 5 31.3 6 22.2
Basic 30 34.9 28 33.3 41 56.2 p=.004 6 42.9 4 25.0 12 44.4
Secondary 19 22.1 23 27.4 10 13.7 S 1 7.1 5 31.3 3 11.1
University 22 25.6 10 11.9 7 9.6 2 14.3 2 12.4 6 22.2

Fathers education:
Illiterate 7 8.1 11 13.0 4 5.5 11.65 4 28.6 2 12.4 2 7.5
Basic 32 37.2 26 31.0 32 43.8 p=.070 2 14.3 5 31.3 6 22.2
Secondary 22 25.6 26 31.0 28 38.4 N.S 6 42.9 4 25.0 12 44.4
University 25 29.1 21 25.0 9 12.3 2 14.3 5 31.3 7 25.9

Mothers job:
Housewife 61 70.9 65 77.4 65 89.0 7.81 12 85.7 12 75.0 24 88.9
Employed 25 29.1 19 22.6 8 11.0 p=.020S 2 14.3 4 25.0. 3 11.1

Place of Residency:
Urban 84 97.7 30 35.7 61 83.6 87.85 9 64.3 5 31.3 26 96.3
Rural 2 2.3 54 64.3 12 16.4 p=.000S 5 35.7 11 68.7 1 3.7

Family income/month:
Sufficient 2 2.3 0 0 24 32.9 58.03 3 21.4 0 0 7 25.9
Mediate 68 79.1 76 90.5 44 60.3 p=.000 11 78.6 16 100 17 63.0
Insufficient 16 18.6 8 9.5 5 6.8 S 0 0 0 0 3 11.1

Number of daughters
and sons:

Null 3 3.5 0 0 2 2.7 27.22 0 0 0 0 0 0
1-3 2 2.3 21 25.0 22 30.1 p=.000 1 7.1 2 12.5 3 11.1
4-6 44 51.2 39 46.4 30 41.1 S 7 50.0 13 81.3 16 59.3
More than 7 37 43.0 24 28.6 19 26.0 6 42.9 1 6.3 8 29.6

Birth order:
First 19 22.1 20 23.8 17 23.3 1.12 5 35.7 3 18.8 4 14.8
Medium 51 59.3 46 54.8 38 52.1 p=.891 6 42.9 9 56.2 18 66.7
The last 16 18.6 18 21.4 18 24.7 N.S 3 21.4 4 25.0 5 18.5

Marital status:
Single 65 75.6 81 96.4 12 16.4 124.08 8 57.1 15 93.7 2 7.4
Married 19 22.1 2 2.4 61 83.6 p=.000 5 35.7 1 6.3 25 92.6
Divorced and

widow (ed)
2 2.3 1 1.2 0 0 S 1 7.1 0 0 0 0

Nabila Taha, et al. 515

Table (6): Comparison between students’ sociodemographic characteristics in relation to selfesteem in the three different Arab
Countries.

Student self esteem
Socio-demographic
Characteristics
Low self esteem
Test
x 2

High self esteem

Al-Riyadh
(22)

Assiut
(4)

Yemen
(16)

Al-Riyadh
(78)

Assiut
(96)

Yemen
(84)

N % N % N % N % N % N %

Age (years):
<20 1 4.5 3 75.0 0 0 22.22 3 3.8 29 30.2 7 8.3 20- 21 95.5 1 25.0 16 100 p=.000 70 89.7 67 69.8 52 85.7 25-30 0 0 0 0 0 0 S 5 6.5 0 0 5 6.0

Mothers education:
Illiterate 2 9.1 0 0 0 0 14.71 18 23.1 28 29.2 21 25.0
Basic 11 50.0 1 25.0 15 93.7 p=.023 25 32.1 31 32.3 38 45.2
Secondary 3 13.6 2 75.0 0 0 S 17 21.8 26 27.1 13 15.5
University 6 27.3 1 25.0 1 6.3 18 23.1 11 11.5 12 14.3

Fathers education:
Illiterate 1 4.5 1 25.0 0 0 13.39 10 12.7 12 12.5 6 7.1
Basic 9 40.9 0 0 13 81.3 p=.037 25 32.1 31 32.3 25 29.8
Secondary 9 40.9 2 50.0 2 12.5 S 19 24.4 28 29.2 38 45.2
University 3 13.7 1 25.0 1 6.3 24 30.8 25 26.0 15 17.9

Mothers job:
Housewife 14 63.6 2 50.0 14 87.5 3.58 59 75.6 75 78.1 75 89.3
Employed 8 36.4 2 50.0 2 12.5 p=.167 N. S 19 24.4 21 21.9 9 10.7

Place of Residency:
Urban 20 90.9 1 25.0 10 62.5 9.32 73 93.6 34 35.4 77 91.7
Rural 2 9.1 3 75.0 6 37.5 p=.009 S 5 6.4 62 64.6 7 8.3

Family income/month:
Sufficient 2 9.1 0 0 0 0 4.02 3 3.8 0 0 31 36.9
Mediate 18 81.8 4 100 16 100 p=.403 61 78.2 88 91.7 45 53.6
Insufficient 2 9.1 0 0 0 0 N.S 14 17.9 8 8.3 8 9.5

Number of sisters
and brothers:

Null 3 13.6 0 0 0 0 22.69 0 0 0 0 2 2.4
1-3 0 0 0 0 10 62.4 p=.001 3 3.8 23 24.0 15 17.8
4-6 11 50.0 2 50.0 3 18.8 S 40 51.3 50 52.0 43 51.2
More than 7 8 36.4 2 50.0 3 18.8 35 44.9 23 24.0 24 28.6

Birth order:
First 3 13.6 1 25.0 1 6.3 2.85 21 26.9 22 22.9 20 23.8
Medium 13 59.1 3 75.0 9 56.2 p=.583 44 56.4 52 54.2 47 56.0
The last 6 27.3 0 0 6 37.5 N.S 13 16.7 22 22.9 17 20.0

Marital status:
Single 17 77.3 4 100 0 0 11.04 56 71.8 92 95.8 0 0
Married 5 22.7 0 0 5 31.3 p=.004 19 24.4 3 3.1 9 10.7
Divorced and

widow (ed)
0 0 0 0 11 68.7 S 3 3.8 1 1.0 75 89.3

Discussion

Over the past ten to twelve years, there has
been an increase of study in the area of self esteem;
self-esteem is the judgment of worth an individual
assigns to his or her self [11] . In the areas of self
concept and self esteem there has been a particular
emphasis on college students in their second years

of studies. In this population self esteem appears
to correlate with body image, the overall perception
on individual has about their physical body [12] .

The aim of this study was to assess and compare
the level of body image and self esteem of the
females nursing students in three different Arabic
countries (KSA, Egypt and Yemen).

516 Comparison between Body Image & Self-Esteem Among Female Nursing Students

The study results have shown that 79.8% of
the female with positive body image had high self
esteem; this finding expresses a strong relationship
between body image and self esteem. This is in
agreement with Friedman and Haaga [13] who
found in their research that, the participants who
endorsed more depressive symptoms and reported
lower levels of self esteem used proportionately
more negative terms when describing themselves.
Moreover, Dimitra [14] says that, for many women
self esteem is based executively on their body
image. On the other hand Trampe [15] , supported
the negative effects “these perfect images have
ones’ self esteem.”She found in her study that, the
more body dissatisfied women were the more they
indicated that they compare their body with that
of other women. It follows that if in fact these
images can change the way women feel about
themselves over time, they can be even more dam-
aging to anyone who is already dissatisfied with
his/her body. Mean while Killi [16] found a weaker
relation between body image dissatisfaction and
self esteem.

The current study revealed that, the majority
of the subjects were with positive body image,
there is a contribution to this finding, in which
most of Arabic females usually tend to reject ex-
ternal standards of beauty, essentially in an effort
to protect their self esteem, by the virtue of satis-
faction which is acquired from the religion, the
Arabic females have been described as “working
with they have” instead of trying to obtain the ideal
beauty presented by the media, So they tend to
positively accept their body as it is.

In relation to the level of self esteem, high level
of self esteem 96% was observed in the study
sample of Egypt followed by Yemen 84% then
KSA 78%, It may contributed to the nature of
society in both Riyadh (KSA) and Yemen which
is a male dominant society, and the female consid-
ered as dependant and follower to the male and in
most occasions she losses her identity which will
negatively affect her self esteem. This comes in
line with Lightstone [17] , who said that self esteem
can be ever change and is not created based on
fact but influenced by environmental, physical and
physiological experiences; it is not inborn but
learnt. The learning comes from family and peers
but only reinforces what is learnt and experience
culturally.

Concerning the socio-demographic character-
istics of the study sample, the findings illustrated
that the percentage of the students with a positive
body image is more higher than the percentage of

the students with a negative body image and were
found between 20 to less than 25 years old. This
result isn’t in accordance with Yuerk et al. [18] who
found no effect of age on the level of body image,
but it is contradictory with other studies where
they find a relation between age and body image
[19] , and Arnet [20] , suggested that individuals
experience some identity confusion during the
middle adulthood (20-30 years), during this time
females between the ages of 20-24 years old may
feel negative body image about themselves.

As regards to the father’s and mother’s educa-
tion, the study showed that, the percentage of
fathers and mothers who had basic education were
higher between subjects with a low self esteem, it
may be due to the lack of satisfactory level of
education which may affect the personality of the
parents and the way of communications they used
to relate with their daughters as a consequence it
will affect the subject’s way of thinking about the
self concept and self esteem.

Regarding the marital status in relation to body
image, the present study found that, the single
students constituted (65%,96.4% and 16.4%) of
students who have positive body image of KSA,
Egypt and Yemen students respectively with a
highly statistical significant difference between
them, (X2 =124.08, p=.000) compared to (57. 1,
93.7% and 7.4% of the married females who had
negative body image. This finding is contradicting
with the Dimitra [14] , findings which indicated
that, marital status was related significantly with
body image, married women having a more positive
body image than women that were single, divorced
or widowed. On the same line Spencer [21] found
that married women accept more and view their
bodies better than the women who are not married.

Concerning the number of brothers and sisters
in the family, the findings of the present revealed
that most of the students who had 4-6 brothers and
sisters were with a high self esteem. This comes
in line with Dimitra [14] , who stressed that the
different sources of social support (family members,
parents, and friends) they all seemed important in
developing healthy body image and self esteem.

Conclusion:
In conclusion high level of self esteem posi-

tively correlated with body image.

Hence, female students with lower self-esteem
were more likely to be at risk of negative body
image. Age, parent’s education, marital status,
numbers of brothers and sisters, all are significantly
correlated to body image and self esteem.

Nabila Taha, et al. 517

Recommendations:
This study recommended:
• Another informative study is advised to investigate
other dimensions of body image and self esteem
in multi-dimensional setting.
• Studying the healthy lifestyle choices which are

also a key to improve body image.

Acknowledgement:
We would like to acknowledge the help of our

nursing students of the three Arab countries for their
valuable participation.

References
1- World Health Organization: Physical status. The use and

interpretation of anthropometry, WHO Technical Series
Report No. 854, Geneva, Switzerland, pp. 263-311, 1995.

2- NEUMARK-SZTAINE D., PAXTON S.J., HANNAN
P.J., HAINES J. and STORY M.: Does body dissatisfaction
matter? Five year longitudinal associations between body
satisfaction and health behaviors in adolescent females
and males. J. Adolesec Health, 39: 244-251, 2006.

3- JUDITH M., SCHULTZ I. and SHEILA L. VIDE BECK:
Disturbed Body Image: Lippincot’s Manual of Psychiatric
Nursing Care plans. Eighth ed. Lippincott Williams &
Wilkins, pp. 359-360, 2009.

4- MELAND E., HAUUGLAND S. and BRIIDABLIK H.J.:
Body image and perceived health in adolescence. Health
Education Research, 223 (3): 342-350, 2007.

5- BENSING K.: Unveiling the mystery of body image.
Advance for Nurses, 4 (7): 13-17, 2003.

6- CASH T.F.: Body image: Past, present and future. Body
Image, 1: 1-5, 2004.

7- CHIN Y.S., TAIB M.N., SHARIFF Z.M. and LINKHOR
G.: Development of multi-dimensional body image scale
for Malaysian female adolescents Nutr. Res. Pract., 2
(22): 85-92, 2008.

8- THOMPSON J.K.: The (mis) measurements of body
image: Ten strategies to improve assessment for applied
and research purposes. Body Image, 1: 7-14, 2004.

9- EL-DESOUKI M.M.: Body Image Questionnaire, El-
Anglo Egyptian Library, 2002.

10- ROSENBERG M.: Society and the adolescent self-image.
Princeton University Press, Princeton, New York. USA,
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11- LAURA S., and STORMER C.: Socio cultural variation
the body image perceptions of urban adolescent females:
Journal of Youth and Adolescent, 31 (6): 443-450, 2002.

12- Vallerand R.: On obsessive and harmonious Passion:
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767, 2003.

13- FRIEDMAN E. and HAAGA D.: Using hierarchical
classes to analyze organization of the self concept. Euro-
pean Journal of Psychological Assessment, 23: 9-14,
2007.

14- DIMITRA M.: Body image in relation to self-esteem in
a sample of Spanish women with early stage breast cancer.
Psicooncologia, 2 (1): 103-116, 2005.

15- TRAMPE D., STAPEL D. and SIERO F.: On models and
vases: Body dissatisfaction and proneness to social psy-
chology, 92: 106-118, 2007.

16- KILLI E.: Body image partially mediates the relationship
between obesity and psychological distress. Obesity
Research, 10: 33-41, 2002.

17- LIGHTSTONE J.: Improving body image, 2005. ht-
tp://www.edreferral.com /body image. htm.

18- YUREK D., FARRAR W. and ANDERSEN B.: Breast
cancer surgery: Ring surgical groups and determining
individual differences in postoperative sexuality and
body change stress. J. Consult Clin. Psycho., 68: 697–70,
2000.

19- MAYER A.: Psychosocial outcomes of breast-conserving
surgery versus mastectomy; a meta- analytic review health
Psycho., 16: 284-98, 1997.

20- ARNET J.: Emerging adulthood the winding road from
teens through the twenties, 2004. http//www.joffereyamett.
com/winding road.htm.

21- SPENCER S.: Concerns about breast cancer and relations
to psychosocial well-being in a multiethnic sample. Health
Psycho, 18: 159-68, 1999.

http://www.joffereyamett.com/winding

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Review Article
Job Satisfaction among Care Aides in Residential
Long-Term Care: A Systematic Review of Contributing Factors,
Both Individual and Organizational

Janet E. Squires,1,2 Matthias Hoben,3 Stefanie Linklater,2 Heather L. Carleton,3

Nicole Graham,1 and Carole A. Estabrooks3

1School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, ON, Canada K1H 8M5
2Ottawa Hospital Research Institute, Centre for Practice-Changing Research (CPCR), 501 Smyth Road, Room 1282, Box 711,
Ottawa, ON, Canada K1H 8L6
3Faculty of Nursing, University of Alberta, Level 3, Edmonton Clinic Health Academy, 11405 87 Avenue NW Edmonton,
AB, Canada T6G 1C9

Correspondence should be addressed to Janet E. Squires; jasquires@ohri.ca

Received 25 March 2015; Accepted 25 June 2015

Academic Editor: Maria H. F. Grypdonck

Copyright © 2015 Janet E. Squires et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Despite an increasing literature on professional nurses’ job satisfaction, job satisfaction by nonprofessional nursing care provider

and, in particular, in residential long-term care facilities, is sparsely described. The purpose of this study was to systematically review
the evidence on which factors (individual and organizational) are associated with job satisfaction among care aides, nurse aides, and
nursing assistants, who provide the majority of direct resident care, in residential long-term care facilities. Nine online databas

were searched. Two authors independently screened, and extracted data and assessed the included publications for methodological
quality. Decision rules were developed a priori to draw conclusions on which factors are important to care aide job satisfaction.
Forty-two publications were included. Individual factors found to be important were empowerment and autonomy. Six additional
individual factors were found to be not important: age, ethnicity, gender, education level, attending specialized training, and years of
experience. Organizational factors found to be important were facility resources and workload. Two additional factors were found
to be not important: satisfaction with salary/benefits and job performance. Factors important to care aide job satisfaction differ
from those reported among hospital nurses, supporting the need for different strategies to improve care aide job satisfaction i

residential long-term care.

1. Background

1.1. Aging and Residential Long-Term Care. In the first half
of the 21st century, the global population 60 years or over
is projected to expand threefold to nearly 2 billion, with
33 countries having more than 10 million people 60 years
of age or over [1]. With this dramatic demographic shift
come sharp increases in numbers of older adults with age-
related dementias (ARDs) [2–4]. ARDs are a world-wide
public health concern, with nearly 7.7 million new cases
globally each year [5]. ARDs are the main factor escalating
the need for residential long-term care (LTC) [6–8]. Without
dramatic breakthroughs in ARD prevention, treatment, or

management, the need for residential LTC facilities will
increase as the population ages.

Residential LTC facilities offer 24-hour on-site housing
and health care services to the elderly, defined as persons of
age 65 and older. The individuals cared for at these facilities
are frail, vulnerable, functionally dependent older adults
who frequently suffer from a range of chronic diseases or
disabilities [9, 10]. There are varying terms to describe resi-
dential LTC facilities, for example, residential care, assisted
living facilities, nursing homes, long-term care homes, and
residential aged care. These facilities offer different levels of
care and may be individual structures or associated within or
with community care centres or hospitals.

Hindawi Publishing Corporation
Nursing Research and Practice
Volume 2015, Article ID 157924, 24 pages
http://dx.doi.org/10.1155/2015/157924

2 Nursing Research and Practice

Nonprofessional workers (care aides, also commonl

referred to as personal care workers, nursing assistants, and
nurse aides) provide most direct nursing care in these facil-
ities. In Canada and the USA, these individuals provide 70–
80% of direct care to residents in residential LTC facilities [11–
15]. These workers often lack adequate formal qualificatio

[16], continuing education, and monitoring [16], which poses
a serious concern in meeting minimum standards of care in
LTC [17]. Care aide duties may include apparently simple
tasks related to personal hygiene, toileting, feeding, and
housekeeping, but aides are also vital to the quality of life of
our growing vulnerable older adult population.

Across all care settings, we currently see widespread
shortages of all levels of nursing care providers and high
turnover rates. This global issue is increasingly important
to both developed and developing countries [18–21] and
of increasing concern in many countries [17, 18] and the
LTC sector. Staff turnover in residential long-term ca

facilities ranges from 40% to 500% [22, 23]. Numerous factors
have been linked to turnover of nursing care providers; job
satisfaction however is by far the most frequently cited [24–
26].

1.2. Job Satisfaction. Multiple definitions of job satisfaction
abound in the literature. For this review, we defined job
satisfaction using the traditional model frequently cited in
empirical studies of job satisfaction of nursing care providers.
This model focuses on job satisfaction as the affective orien-
tation of an employee towards his or her work (i.e., on the
feelings an individual has about his or her job [20, 27]). This
“affective” focus can be seen in frequently cited definitions of
job satisfaction scholars such as Locke [28, 29] who describes
job satisfaction as a “pleasurable or positive emotional state
resulting from the appraisal of one’s job or job experiences”
and Brooke and colleagues who describe job satisfaction as
“an affective response to the job situation” [30].

Not all dissatisfied staff will leave their job, but dissat-
isfaction may impact their work, their coworkers, and the
quality of resident care delivered. Dissatisfied staff often
show signs of an unreliable work ethic, such as tardiness
and taking unscheduled days off [31]. Some dissatisfied staff
show greater aggression towards other workers [32] and
residents [33]. Job dissatisfaction is associated with reduced
quality of resident care [34] and resident quality of life
[35], as well as reduced ability of organizations to change
[36]. Conversely, caregivers (including care aides) who report
perceiving high quality of care in their facilities also report
higher satisfaction with their job [31]. For the last several
decades, quality of care in some residential LTC facilities has
been consistently reported as substandard [37–39]. This fact,
coupled with evidence of residential LTC facilities’ limited
ability to change in a meaningful way [31], highlights the
importance of understanding job satisfaction of care aides in
these facilities.

While multiple individual studies examine factors related
to care aide’s job satisfaction and/or job satisfaction in
residential LTC facilities, this evidence has not yet been
synthesized. However, a synthesis of factors associated with
job satisfaction among hospital registered nurses was recently

published. In that review, Lu and colleagues [20] found
that job satisfaction is closely related to working conditions
and the organizational environment, job stress, role conflict
and ambiguity, role perception and role content, and orga-
nizational and professional commitment [20]. The purpose
of this systematic review is to synthesize the evidence on
factors (both individual and organizational) associated with
job satisfaction among care aides in residential LTC facilities.

2. Methods

2.1. Selection Criteria for Types of Studies. Primary studies
that used experimental (randomized controlled trials, clinical
trials, and quasi-experimental, e.g., pre/posttest [40]) and
nonexperimental (observational and qualitative [40]) designs
examining factors associated with job satisfaction for care
aides in residential LTC facilities were eligible for inclusion.
Studies were limited to those published in English, with no
restrictions on country of origin or publication date.

2.2. Selection Criteria for Types of Participants, Factors, and
Outcomes. Participants included care aides, nurse aides,
and/or nursing assistants. Care aide was defined as a non-
professional worker providing direct resident care, under
the supervision of a registered nurse (RN) or licensed
practical nurse (LPN) or registered practical nurse (RPN).
Nursing assistant/aide (NA) was defined as a person who
has completed a brief health care training program and who
provides support services for RNs and LPNs/RPNs. An NA
is termed a certified nurse aide (CNA) when certified by
a state agency (USA) or province (Canada) [41]. Factors
(independent variables) of interest were any individual or
organizational variable associated with job satisfaction, the
outcome of interest. We defined job satisfaction as the
affective orientation of an employee towards his or her work
(i.e., on the feelings an individual has about his or her job
[20, 27]). We included studies of job satisfaction that met this
definition. We included studies of job satisfaction in other
care providers only if a separate analysis of care aide/NA job
satisfaction was provided or could be extracted. Only studies
published in English were eligible for inclusion.

2.3. Search Strategy for Identification of Studies. The search
strategy (Table 1) was developed in consultation with a health
sciences librarian. We searched nine online databases: the
Cochrane Database of Systematic Reviews, CINAHL, Busi-
ness Source Complete, Medline, EMBASE, AARP AgeLine,
Web of Science, SCOPUS, and ABI Inform. Key words
included long-term care, care aide, and job satisfaction (and
their synonyms).

2.4. Study Identification. Two team members independently
screened all abstracts identified by the search strategy (𝑛 =
967 after removal of duplicates). Full text copies were
retrieved for all citations identified as potentially relevant to
our review aim or with insufficient information to make a
decision on relevance (𝑛 = 164). Any article not meeting
all inclusion criteria outlined above was excluded from the
review.

Nursing Research and Practice 3

Table 1: Search strategy (all searches performed through to May 1, 2013).

Database Search terms

CINAHL

(MH “Nursing Assistants”) OR (MH “Nursing Home Personnel”

)

“health care aide∗” or “nursing assistant∗” or “nurs∗ aide∗” or “personal care aide∗” or “resident companion∗” or
“geriatric aide∗” or hca
(MH “Job Satisfaction”)
(“Job satisfaction”) or career N2 satisf∗ or work N2 satisf∗∗ or employ∗ N2 satisf

∗

Business Source
Complete

(“health care aide∗” or “nursing assistant∗” or aide∗ or “nurs∗ aide∗” or “personal care aide∗” or “resident
companion∗” or “geriatric aide∗”) and (“job satisfaction” or satisf∗ N2 work∗ or satisf∗ N2 employ∗ satisf∗ N2
career∗)

Medline

Nurses’ Aides/(health care aide∗ or health care attendant∗ or HCA or personal care or personal care attendant or
nursing assistant∗ or resident companion or geriatric aide∗).tw. ((auxiliary adj 1 nurs∗) or (nurs∗ adj 1 aide∗)).tw.
Job Satisfaction/job satisfaction.tw.
(satisf∗ adj 2 (work∗ or employ∗ or career∗)).tw.

EMBASE

nursing assistant/(health care aide∗ or health care attendant∗ or HCA or personal care or personal care attendant or
nursing assistant∗ or resident companion or geriatric aide∗).tw.
((auxiliary adj 1 nurs∗) or (nurs∗ adj 1 aide∗)).tw.
job satisfaction/job satisfaction.tw.
(satisf∗ adj 2 (work∗ or employ∗ or career∗)).tw.

AARP Ageline

“Nurses-Aides”.de.
(health care aide∗ or health care attendant∗ or HCA or personal care or personal care attendant or nursing assistant∗
or resident companion or geriatric aide∗).tw.
((auxiliary adj 1 nurs∗) or (nurs∗ adj 1 aide∗)).tw.
“Job-Satisfaction”.de.
job satisfaction.tw.
(satisf∗ adj 2 (work∗ or employ∗ or career∗)).tw.

Web of Science
TS = (“health care aide∗” or “health care attendant∗” or HCA or “personal care attendant∗” or “nursing assistant∗” or
“resident companion∗” or “geriatric aide∗”) AND TS = (“job satisfaction”)
Databases = SCI-EXPANDED, SSCI, CPCI-S

SCOPUS (TITLE-ABS-KEY(“health care aide
∗” OR “health care attendant∗” OR hca OR “personal care attendant∗” OR

“nursing assistant∗” OR ”resident companion∗” OR “geriatric aide∗”) AND TITLE-ABS-KEY(“job satisfaction”))

ABI Inform (“health care aide
∗” OR “nursing assistant∗” OR “nurs∗ aide∗” OR “personal care aide∗” OR “resident companion∗”

OR “geriatric aide∗”) AND (“job satisfaction”)
Cochrane job satisfaction

Two reviewers independently assessed all retrieved arti-
cles; 42 articles were retained (see PRISMA flow diagram
in Figure 1). Screening discrepancies were resolved through
consensus.

2.5. Quality Assessment. Methodological quality of the final
set of included articles was independently assessed by two
reviewers with disagreements resolved through consensus.
Four previously validated assessment tools were used. Quan-
titative studies were assessed using 1 of 3 tools: (1) the Qual

ity

Assessment and Validity Tool for Cross-Sectional Studies, (2)
the Quality Assessment and Validity Tool for Pre/Posttest
Studies, and (3) the Quality Assessment Tool for Quanti-
tative Studies (used for randomized controlled trials). The
original tools are described in detail in previously published
systematic reviews (e.g., [42–45]). Quality assessment consid-
ered appropriateness of study design based on the research
objectives, sample, measurement of key variables (individual
and organizational factors) and the outcome of interest (job
satisfaction), and appropriateness of the statistical analysis.

The first two tools, the Quality Assessment and Validity
Tool for Cross-Sectional Studies and the Quality Assessment
and Validity Tool for Pre/Posttest Studies, were originally

developed by members of our team based on Cochrane
guidelines (in existence since 2001) and the medical literature
[86, 87] and have been used in other published systematic
reviews by our group [42–45]. The cross-sectional tool
contains a maximum of 16 points and assesses studies in three
core areas: sampling, measurement, and statistical analysis.
The pre/posttest tool contains a maximum of 18 points and
assesses studies in 6 core areas: sampling, design, control
of confounders, data collection and outcome measurement,
statistical analysis, and dropout. To derive a final quality score
for each article, we divided the total points scored by the
total points possible (16 or 18 minus the number of points
not applicable for the article). Each study was then classified
as weak (≤0.50), moderate-weak (0.51 to 0.65), moderate-
strong (0.66 to 0.79), or strong (≥0.80). This rating system
has been used in several recent reviews [43–45] and is based
on a scoring system developed by De Vet et al. [88]. These
two tools were used to assess the methodological quality of all
cross-sectional (𝑛 = 29) and pre/post (𝑛 = 7) studies included
in our review.

The third quality assessment tool used in this review
was the Quality Assessment Tool for Quantitative Studies,
developed by the Effective Public Health Practice Project,

4 Nursing Research and Practice

Records identified through database
searching (after removal of

duplicates)

Sc
re

en
in

g
In

cl
ud

ed
El

ig
ib

ili
ty

Id
en

tifi
ca

tio
n

Records screened Records excluded

Full-text articles assessed for Full-text articles excluded, with

Studies included (data extraction
and quality assessment completed)

(n = 967)

(n = 42)

(n = 803)

eligibility (n = 164) reasons (n = 122)

Figure 1: PRISMA flow diagram.

Canada. This tool has been judged suitable to be used in
systematic reviews of effectiveness (measuring interventions)
[89] and been shown to have content and construct validity
[90]. The tool assesses studies on the basis of six areas:
selection bias, study design, confounders, blinding, data
collection methods, and withdrawals/dropouts. Each article
is scored as weak, moderate, or strong in each of these
areas according to preset criteria within the tool. The tool
developers do not provide a means for calculating an overall
quality score. However, in order to compare the quality scores
for the included articles assessed with this tool to those that
used cross-sectional and pre/posttest tools, we derived an
overall quality score. We applied the scoring system of this
tool used in a previously published review [44]. This score was
derived by assigning values of 1, 2, and 3 to the categorizations
of weak, moderate, and strong respectively. A final quality
score was then obtained by dividing the summative score
obtained by the total amount of points possible. Each study
was classified as weak (1 to 1.5), moderate-weak (1.6 to 2.0),
moderate-strong (2.1 to 2.5), or strong (>2.5) by applying the
same categorization system used (and published) in the cross-
sectional and pre/posttest tools. The Quality Assessment Tool
for Quantitative Studies Tool was used to assess RCT studies
included in this review (𝑛 = 1).

Qualitative studies were assessed using the Critical
Appraisal Skills Programme (CASP) Quality Assessment Tool
[91]. This tool assesses qualitative studies through 10 ques-
tions on research aims, appropriateness of research design,
appropriateness of recruitment strategy, data collection, rela-
tionship between researcher and participants, ethical issues,

data analysis, statement of findings, and value of the research
[91]. A final quality score for each article was then obtained by
dividing the summative score obtained by the total amount
of points possible. Each study was classified using the same
rating scale as for the cross-sectional and pre/posttest studies:
weak (≤0.50), moderate-weak (0.51 to 0.65), moderate-strong
(0.66 to 0.79), or strong (≥0.80).

2.6. Data Extraction and Synthesis. One team member
extracted data from all included articles, double-checked
by a second team member for accuracy. Discrepancies in
data extraction were resolved through consensus. Data were
extracted on year of publication, title, journal, country of
origin, purpose/objectives, data collection methods, study
design, sample size and setting, job satisfaction measure
(including number of items, reliability, and validity), inde-
pendent variables investigated (individual and organizational
factors), analyses, and main outcome(s).

Data on individual factors were grouped into five broad
categories (each having subgroups). The five broad categories
were (1) sociodemographic, (2) education, (3) healthcare
provider characteristics, (4) personal life, and (5) other.
Data on organizational factors were also grouped into five
categories, again with subgroups. The five broad organi-
zational categories were (1) facility, (2) work environment,
(3) supervision, (4) staffing, and (5) other. Categories (and
their subgroups) were not predetermined; after reviewing
and extracting data, we found that factors relevant to our
aim centered on these themes. We used the primary studies
authors’ conceptualizations in this grouping. For example, if
an author reported investigating autonomy, it was classified as
autonomy in our synthesis; we did not reclassify any variables
based on the definitions provided in the primary studies.
Grouping the factors facilitated comparing and interpreting
their importance to care aide job satisfaction in residential
LTC facilities.

We used a vote-counting approach to synthesize the
quantitative evidence. The overall assessment of a relation-
ship between a factor and job satisfaction was based on the
percentage of studies demonstrating, or failing to demon-
strate, statistically significant associations. As recommended
by Grimshaw et al. [92], we supplemented this by extracting
direction and magnitude of effect for all factors displaying
statistically significant effects (𝑝< 0.05), where provided. If a study included multiple analyses (e.g., univariate, bivariate, and/or multivariate), we relied on the highest level model (e.g., multivariate where available).

Qualitative findings were assessed for themes and sum-
marized narratively. We applied the following previously pub-
lished a priori rules [45] to guide our quantitative synthesis.

(1) To conclude whether or not a factor (individual or
organizational) was associated with job satisfaction,
it had to be assessed four or more times (this
could reflect two assessments of different variables
comprising the same factor from one study). If a
factor was assessed fewer than 4 times it was coded
as inconsistent (i.e., insufficient evidence to reach a
conclusion).

Nursing Research and Practice 5

(2) Factors assessed four or more times were coded as

(a) significant with (important to) job satisfaction
if 60% or more of the quantitative tests showed
a significant association between the factor and
job satisfaction;

(b) nonsignificant with (not important to) job sat-
isfaction if 60% or more of the quantitative tests
showed a nonsignificant association between
the factor and job satisfaction;

(c) equivocal with (undetermined importance to)
job satisfaction if<60% of the quantitative tests showed significant/nonsignificant associations between the factor and job satisfaction.

3. Results

3.1. Description of Studies. Forty-two studies were included
in the review. The majority (𝑛 = 29) of studies used a
cross-sectional survey design [9, 10, 33, 46–48, 52–54, 56–
58, 60–62, 64, 66–71, 73–75, 77–79, 93]. Of these, 1 study
used mixed methods (survey plus qualitative data) [78], 1
study used a randomized controlled trial [59], and 7 stud-
ies used observational before-and-after quasi-experimental
(pre/posttest) design [49, 51, 55, 65, 72, 76, 80]. One of the
quasi-experimental studies also used mixed methods and
included qualitative data [55]. Five additional studies used a
qualitative design [81–85]. Overall, our sample included 37
studies with quantitative statistical data and 7 studies with
qualitative data.

Studies were conducted with CNAs (𝑛 = 24), NAs (𝑛 = 7),
and care aides (𝑛 = 5); 6 studies included multiple groups.
Studies were set in residential LTC facilities (𝑛 = 22), other
LTC facilities (𝑛 = 7), assisted living facilities (𝑛 = 1), skilled
nursing facilities (𝑛 = 2), and combined assisted living/skilled
nursing facilities (𝑛 = 1). Countries of origin were the USA
(𝑛 = 37), Taiwan (𝑛 = 2), Sweden (𝑛 = 1), Canada (𝑛 = 1),
and Australia (𝑛 = 1). Studies were published between 1976
and 2012 with the majority being published after 2000 (𝑛 =
28). Different measures of job satisfaction were used across
the studies. Only 4 job satisfaction tools were used in greater
than one study: Minnesota Satisfaction Questionnaire (𝑛 = 4
studies), Job Descriptive Index (𝑛 = 3 studies), Benjamin
Rose Institute Job Satisfaction Scale (𝑛 = 3 studies), Job
Diagnostic Survey (𝑛 = 3studies), and Job Attitude Scale (𝑛 =
2 studies). Details on included studies are given in Table 2;
a list of studies was excluded and the reason(s) for their
exclusion are in Additional File 1 (in Supplementary Material
available online at http://dx.doi.org/10.1155/2015/157924).

3.2. Methodological Quality of Included Studies. We com-
pleted 44 quality assessments on the 42 included studies; the
2 studies [55, 78] with mixed methods designs both had 2
quality assessments done. Details of methodological quality
assessments of all 42 studies are in Additional File 2.

From the 44 quality assessments, 5 (11%) studies were
rated strong [9, 78, 81, 84, 85], 6 (14%) high moderate [53, 56,
66–68, 73], 15 (34%) low moderate [10, 52, 57, 58, 61, 64, 65,

69, 71, 72, 75, 76, 78, 83, 93], and 18 (41%) weak [33, 46–49, 51,
54, 55, 59, 60, 62, 70, 74, 77, 79, 80, 82]. Differences in quality
assessment arose mainly from sample representativeness,
treatment of missing data, and appropriateness of statistical
test(s) used.

We conducted a sensitivity analysis, comparing findings
from all studies with those rated moderate and strong. No
significant differences were noted; thus, we report findings
from all studies.

3.3. Individual/Organizational Factors and Job Satisfaction

3.3.1. Quantitative Findings. A total of 33 and 25 studies
investigated the statistical association of care aide job satisfac-
tion with individual and organizational factors, respectively.
Details of the statistical effects including direction of effect
and significance of the studies meeting our criteria to be
able to draw a conclusion (i.e., assessed four or more times)
are presented in Table 3 (individual factors) and Table 4
(organizational factors). Additionally, an overall picture of
the findings and the resulting conclusions drawn are depicted
in Table 5 (individual factor conclusions) and Table 6 (orga-
nizational factor conclusions). A summary of findings with
respect to the relationship between job satisfaction and
individual and organizational factors that were assessed less
than four times can be found in Additional File 3.

As illustrated in Tables 3 and 5, 11 individual (care aide)
factors spanning 4 of the 5 main categories were assessed 4 or
more times. Two of these factors, both under the category of
healthcare provider characteristics, had a significant positive
relationship with care aide job satisfaction: empowerment
and autonomy. Six additional individual factors (spanning
3 categories; categories are identified in brackets) showed
no relationship to job satisfaction: age (sociodemographics),
ethnicity (sociodemographics), gender (sociodemographics),
level of education/years of education (education), special
training (education), and years of experience as a care
aide (healthcare provider characteristics). The remaining 3
individual factors assessed 4 or more times showed equivocal
findings in relation to care aide job satisfaction: current posi-
tion (personal characteristics), employment status (personal
characteristics), and stress (personal life).

Tables 4 and 6 depict the five organizational factors that
were assessed 4 or more times; these 5 factors spanned 3 orga-
nizational categories. Two of these factors had a significant
positive relationship overall with care aide job satisfaction
(the categories are identified in brackets): resources (facilit

and workload (workload). Two factors showed no relation-
ship to job satisfaction: satisfaction with salary/benefits (work
environment) and job performance (work environment). The
remaining organizational factor assessed 4 or more times was
support from coworkers (work environment) which had an
equivocal relationship with care aide job satisfaction.

3.3.2. Qualitative Findings. Most factors identified in the
qualitative data were organizational in nature and were
reported in a single study (Table 7). Overall, qualitative
findings support the conclusions drawn from the synthesis
of the quantitative data. Factors related to work environment

6 Nursing Research and Practice
Ta

bl
e
2:
C
ha
ra
ct
er
is
tic

so
fi
nc
lu
de
d

st
ud

ie
s.

Fi
rs
ta
ut
ho

r,
jo
ur
na

ye
ar

)

St
ud

si
gn

ca
tio

n/
sa
m
pl
e/
su
bj
ec
ts

D
at
a
co
lle
ct
io
n

m
et
ho

d
Ex

pl
an
at
or
y

va
ri
ab
le
s

st
ud

ie
d
(i
nd

iv
id
ua
l

va
ri
ab
le
s)

Jo
b

sa
tis
fa
ct
io
n

in
st
ru
m

en
t

Q
ua

lit
y

Jo
b
sa
tis
fa
ct
io
n

ea
su
re

(s
)

R
el
ia
bi
lit
y

Va
lid

ity
Q
ua

nt
ita

tiv
e
st
ud

ie
s(
n
=
37
)

A
lb
an
es
e
[4
6]
,

Th
es
is

(1
99
5)

ro
ss
-s
ec
tio

na
l

(s
in
gl
e

gr
ou

ou
nt

ry
:U

Sa
m
pl
e
siz

e:
n
=
25
5

Su
bj
ec
ts
:C

N
A

m
pl
oy
ed

in
14

re
si
de
nt
ia

lc
ar
e

fa
ci
lit

ie
s

ue
st
io
nn

ai
re

So
ci
al

or
ga
ni
za
tio

na
l

va
ri
ab
le
s:

m
be
ro

fb
ed
s,

oc
cu
pa
nc
y
ra
te
,i
m
m
ed
ia
te

su
pe
rv
is
or

st
at
us
,N

A
em

pl
oy
m
en
ts
ta
tu
s,
C
N
A

ov
er
tim

e
ho

ur
s,
N
A
ni
gh
t

sh
ift
,n

ur
si
ng

di
re
ct
or

le
ng

th
of

em
pl
oy
m
en
t,

nu
rs
in
g

di
re
ct
or

pr
of
es
si
on

m
em

be
rs
hi
p,

ad
m
in
is
tr
at
or

ed
uc
at
io
n,

pr
op

or
tio

n
of

M
ed
ic
ai
d

re
si
de
nt
s,
pr
op

or
tio
n
of

M
ed
ic
ar

e
re
si
de
nt

nu
m
be
ro

fc
hi
ld
re
n
liv
in
g

w
ith

N
A
,C

A
sa

tis
fa
ct
io
n

w
ith

re
lig
io
us

lif
e

W
or
k
ro
le

re
la
tio

ns
va
ri
ab
le
s:

si
tiv

an
d

ne
ga
tiv

e
re
si
de
nt
re
la
tio

ns
,p
os

iti
ve

an
d
ne
ga
tiv

e
su
pe
rv
is
or

re
la
tio
ns
,p
os
iti
ve
an
d
ne
ga
tiv

e
vi
si
to
rr
el
at
io
ns

C
N
A

jo
b

st
re
ss

Q
ui
nn

an
d
St
ai
ne
sJ
ob

Sa
tis
fa
ct
io
n
Sc
al
e

𝛼
=
0.
76

N
ot

re
po

rt
ed

W
ea
k

A
lle
ns
w
or
th
–

D
av
ie
s[
47
],

ea
lth

C
ar
e

an
ag
em

en
t

e
vi
ew

(2
00

C
ro
ss
-s
ec
tio

na
l

su
rv
ey

(s
in
gl

e
gr
ou

C
ou
nt
ry
:U

SA
.

Sa
m
pl
e
siz

e:
n
=
13

Su
bj
ec
ts
:N

A
sa

t4
ne
w

En
gl
an
d’
sr
es
id
en
tia

lc
ar
e

fa
ci
lit
ie
s

Q
ue
st
io
nn

ai
re

(i
)W

or
kp
la
ce

cu
ltu

ra
l

co
m
pe
te
nc
y

(i
i)

A
ge

(i
ii)

R
ac
io

et
hn

ic
ity

(iv
)A

ut
on

m
y

G
en
er
al
sa
tis
fa
ct
io
n
sc
al
e

fr
om

th
e

Jo
b

D
ia
gn

os
tic

Su
rv
ey

ite
m
s)

N
ot
re
po
rt
ed
N
ot
re
po
rt
ed

W
ea
k

B
er
g
[4
8]
,

Sc
an

di
na
vi
an

Jo
ur
na

lo
f

Re
ha
bi
lit
at
io
n

M
ed
ic
in
e
(1
97

C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)

C
ou
nt
ry
:S
w
ed
en

Sa
m
pl
e
siz

e:
n
=
23
3

Su
bj
ec
ts
:C

N
A
si
n
on

e
ge
ri
at
ri
c
LT

C
ho

sp
ita

l(
20

w
ar
ds
)

Q
ue
st
io
nn
ai
re

(i
)D

et
er
m
in
an
ts
fo
rt
he

m
ea
n

sc
or
es

of
th
e

se
ve
n

sc
al
es

(o
ne

of
th
em

“s
at
is
fa
ct
io
n
w
ith

th
e

w
or
k

its
el
f”
):
ag
e,
le
ng

th
of

em
pl
oy
m
en
t,
an
d

tr
ai
ni
ng

co
ur
se

pa
ss
ed

ye
s/
no

(i
i)
D
et
er
m
in
an
ts
fo
rt
he

ov
er
al
lJ
S
qu

es
tio

n
(t
he

se
ve
n
qu

es
tio

nn
ai
re

sc
al
es
):
(1
)s
at
is
fa
ct
io
n
w
ith

th
e
w
or
k

its
el
f,
(2
)

pe
rc
ei
ve
d
st
ra
in
,(
3)

ad
ju
st
m
en
tt
o
ge
ri
at
ri
c

w
or
k,
(4
)r
el
at
io
n
w
ith

co
lle
ag
ue
sa

nd
su
pe
rv
is
or
s,

(5
)p

er
ce
iv
ed

ne
ed

fo
r

in
fo
.,
(6
)p

er
ce
iv
ed

de
m
an
d
fo
rp

hy
si
ca
la
nd

ps
yc
hi
c
st
re
ng

th
,a
nd

(7
)

pe
rc
ei
ve
d
ne
ed

fo
r

ed
uc
at
io
n

53
ite
m
s(
7
sc
al
es
)i
n
th
e

en
tir
e
qu

es
tio

nn
ai
re
;4

ite
m
si
n
on

e
sc
al
e
w

er
e

re
la
te
d
to

N
ot

re
po
rt
ed
N
ot
re
po
rt
ed
W
ea
k

Nursing Research and Practice 7

bl
e
2:

C
on

tin
ue
d.

Fi
rs
ta
ut
ho
r,
jo
ur
na

l(
ye
ar
)

St
ud

de
si
gn

Lo
ca
tio

n/
sa
m
pl
e/
su
bj
ec
ts

D
at
a
co
lle
ct
io
n
m
et
ho

d
Ex

pl
an
at
or
y
va
ri
ab
le
s

st
ud
ie
d
(i
nd
iv
id
ua
l
va
ri
ab
le
s)

Jo
b
sa
tis
fa
ct
io
n
in
st
ru

m
en
t

Q
ua
lit
y

Jo
b
sa
tis
fa
ct
io
n

m
ea
su
re

(s
)

R
el
ia
bi
lit
y
Va
lid
ity

Bl
ac
km

on
[4
9]
,

Th
es
is

(1
99
3)

B
ef
or
e-
an
d-
aft

er
∗
∗

C
ou
nt
ry
:U
SA
.
Sa
m
pl
e
siz

e:
n
=
18
8

(s
am

pl
e

si
ze

re
du

ce
d
to

88
in

re
gr
es
si
on

du
e
to

ap
pl
ic
at
io
n
of

th
e
lis
tw
is
e

pr
oc
ed
ur
e)

Su
bj
ec
ts
:C

N
A
s(
nu

m
be
r

re
si
de
nt
ia
lc
ar
e

fa
ci
lit
ie
s

tr
ep
or
te
d)

Q
ue
st
io
nn
ai
re

(i
)I
nt
er
ve
nt
io
n:

tr
ai
ni
ng

(i
i)
R
eg
re
ss
io
n:

te
st
ed

kn
ow

le
dg

e
of

ho
w

pe
rf
or
m

ca
re

ta
sk

pe
rc
ei
ve
d
kn

ow
le
dg
e
of

ho
w
to
pe
rf
or
m
ca
re
ta
sk
s,

se
x,
ag
e,
ed
uc
at
io
n,

le
ng
th
of

em
pl
oy
m
en
t,
ra
ce
,a
nd

de
gr
ee

of
re
lig
io
si
ty

Ea
ch

of
th
e
3
ite
m
sw

er
e

bo
rr
ow

ed
fr
om

th
e
JS

sc
al
e

de
ve
lo
pe
d

K
ah
n

(1
96

[5
0]

N
ot
re
po
rt
ed
N
ot
re
po
rt
ed
W
ea
k

Br
au
n
[5
1]
,

Jo
ur
na

lo
fE

ld
er

A
bu

se
an
d
N
eg
le
ct

(1
99
7)

B
ef
or
e-
an
d-
aft
er
∗
∗
C
ou
nt
ry
:U

SA
Sa
m
pl
e
siz

e:
n
=
10
5

Su
bj
ec
ts
:C
N
A
s(
nu
m
be
r

of
N
H
sn

t
re
po

rt
ed
)

Q
ue
st
io
nn
ai
re

El
de
ra

bu
se

an
d
ne
gl
ec
t

pr
ev
en
tio

n
tr
ai
ni
ng

(lo
ca
lly

de
ve
lo
pe
d

pr
og
ra
m

co
ns
is
tin

g
of

vi
de
os
,b
oo

kl
et
,a
nd

in
te
ra
ct
iv
e
w
or
ks
ho

sk
ed

to
ra
te
th
ei
rl
ev
el
of

JS
on

a
sc
al
e
fr
om

1t
o
10

N
ot
re
po
rt
ed
N
ot
re
po
rt
ed
W
ea
k

Bu
rg
io

[5
2]
,

Th
e

G
er
o

n
to

lo
gi
st

(2
00
4)

C
ro
ss
se
ct
io
na
l

(b
et
w
ee
n
gr
ou

ps
qu

as
i-
co
m
pa
ri
so
n

de
si
gn
)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
17
8

Su
bj
ec
ts
:C

sf
ro
m

N
H
s

(i
)D

ir
ec
ts
tr
uc
tu
re
d

ob
se
rv
at
io
n

(i
i)

St
ru
ct
ur
ed

qu
es
tio

nn
ai
re
s

(i
ii)
A
na
ly
si
so

fr
es
id
en
t

re
co
rd
s

(i
)P

er
m
an
en
tv
er
su
s

ro
ta
tin

g
sh
ift

as
si
gn

m
en
t

(i
i)
Is
ol
at
ed

an
d
co
m
bi
ne
d

eff
ec
ts
of

w
or
k
sh
ift

Jo
b
Sa
tis
fa
ct
io
n

In
de
x

(J
SI
)

𝛼
=
0.
69
–0

.8
9
in

pr
ev
io
us

st
ud

y
N
ot

re
po
rt
ed

Lo
w

m
od

er
at
e

C
ho

i[
53
],

Re
se
ar
ch

N
ur
sin

g
an
d

H
ea
lth

(2
01
2)

co
nd

ar
y
an
al
ys
is

cr
os
s-
se
ct
io
na
l

su
rv
ey

da
ta

C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
2,
25
4

Su
bj
ec
ts
:C

N
A
sw

ith
in

51
6

N
H
s

C
om

pu
te
r-
as
si
st
ed

te
le
ph

on
e

in
te
rv
ie

w
in
g

(C
A
T
I)
sy
st
em

w
he
re

in
te
rv
ie
w

er
sa

sk
ed
qu
es
tio

ns
ov
er

th
e
te
le
ph
on
e

(D
at
a
fr
om

th
e
ex
is
tin

N
at
io
na
lN

ur
si
ng

A
ss
is
ta
nt

Su
rv
ey
an
d
N
at
io
na
lN
ur
si
ng

H
om

e
Su
rv
ey
)

Fi
xe
d
eff
ec
ts
w
or
k-
re
la
te
d

ct
or
s

Le
ve
l1

(

in
di
vi
du

al
C
N
A
)

Su
pp

or
tiv

su
pe
rv
is
io
n,

pe
rc
ep
tio

n
of

be
in
g
va
lu
ed
,

w
or
k-
re
la
te
d
in
ju
ry
,h
ou

rl
y

w
ag
e,
em

pl
oy
ee

be
ne
fit
s,

he
al
th

in
su
ra
nc
e

Le
ve
l2

(r
es
id
en
tia

lc
ar
e

fa
ci
lit
ie
s)

B
ed

si
ze
s,

fo
r-
pr
ofi

t/
no

ro
fit

lo
ca
tio

n
(m

et
ro
po

lit
an
,

m
ic
ro
po

lit
an
,r
ur
al
),

pe
rc
en
to

fM
ed
ic
ar
e

re
si
de
nt
s,
pe
rc
en
to

f
M
ed
ic
ai
d
re
si
de
nt
s,
R
N

H
PP

D
,L
PN

H
PP

D
,C

N
A
H
PP

D
Pe
rs
on
al
fa
ct
or
s

A
ge

(y
ea
rs
),

w
hi
te
/n
on

w
hi
te
,e
du

ca
tio

n
le
ve
l(
hi
gh

sc
ho

ol
or

le
ss
),

nu
m
be
ro

fj
ob

si
n
th
e
pa
st

5
ye
ar
s(
0–

5+
)

A
si
ng

le
-i
te
m

m
ea
su
re
fo
r

an
ov
er
al
lm

ea
su
re

of
JS
.

Th
e
ite
m

w
as

sc
or
ed

us
in
g

a
4-
po

in
tL

ik
er
t-
ty
pe

sc
al
e,
ra
ng

in
g
fr
om

1
(e
xt
re
m

el
y

di
ss
at
is
fie
d)

to
4
(e
xt
re
m
el
y
sa
tis
fie
d)

N
ot
re
po
rt
ed
N
ot
re
po
rt
ed

H
ig
h
m
od

er
at
e

8 Nursing Research and Practice
Ta

bl
e
2:
C
on
tin
ue
d.
Fi
rs
ta
ut
ho
r,
jo
ur
na
l(
ye
ar
)
St
ud

y
de
si
gn

Lo
ca
tio
n/
sa
m
pl
e/
su
bj
ec
ts
D
at
a
co
lle
ct
io
n
m
et
ho
d
Ex
pl
an
at
or
y
va
ri
ab
le
s
st
ud
ie
d
(i
nd
iv
id
ua
l
va
ri
ab
le
s)

Jo
b
sa
tis
fa
ct
io
n
in
st
ru
m
en
t

Q
ua
lit
y
Jo
b
sa
tis
fa
ct
io
n

m
ea
su
re
(s
)

R
el
ia
bi
lit
y
Va
lid
ity

C
re
ad
y
[5
4]
,

Jo
ur
na
lo
f

G
er
on
to

lo
gi
ca
l

N
ur
sin

g
(2
00

C
ro
ss
-s
ec
tio
na
l
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
43

Su
bj
ec
ts
:H

C
A
sa

nd
nu

rs
es

fr
om

10
N
H
s

Q
ue
st
io
nn
ai
re

Em
po

w
er
m
en
t(
lo
w
,

m
ed
iu
m
,o
rh

ig
h)

N
ot
re
po

rt
ed
—

au
th
or

st
at
ed

th
at
“w

he
n

av
ai
la
bl
e,
ite
m
sw

er
e
ta
ke
n

fr
om
pr
ev
io
us
st
ud
ie
s

[5
5]
”

N
ot
re
po
rt
ed
N
ot
re
po
rt
ed
W
ea
k

Fr
ie
dm

an
[5
6]
,

e
G
er
on
to
lo
gi
st

(1
99

C
ro
ss
-s
ec
tio
na
l

(t
w
o-
gr
ou

p
co
m
pa
ri
so
n;

qu
as
i-
ex
pe
ri
m
en
ta
l)

su
rv
ey
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
34

Su
bj
ec
ts
:C

N
A
si
n
10

N
H
s

(5
PA

C
E,

5
no

n-
PA

C
E)

Q
ue
st
io
nn
ai
re
(i
)D

og
ra
ph

ic
s(
ag
e,

ed
uc
at
io
n,

ex
pe
ri
en
ce

w
ith

el
de
rl
y
in

ch
ild

ho
od

)
(i
i)
Jo
b
de
sc
ri
pt
io
n

(i
ii)

or
ki
ng

in
PA

C
E

ve
rs
us

re
gu
la
rr
es
id
en
tia

l
ca
re

fa
ci
lit
ie
s

(i
)M

in
ne
so
ta
Sa
tis
fa
ct
io
n

Q
ue
st
io
nn
ai
re

(i
i)
Tw

o
qu

es
tio

ns
ra
te
d

on
a
sc
al
e
fr
om

1–
5
on

:
(i
ii)

“h
ow

sa
tis
fie
d

th
ey

w
er
e

w
ith

th
ei
rc

ur
re
nt

jo
b”

(iv
)“
ho

w
lik

el
y
th
ey

w
er
e

to
le
av
e
th
ei
rj
ob

in
th
e

ne
xt

ye
ar
”

𝛼
=

0.
90

St
at
ed

va
lid

ity
in

pr
ev
io
us
st
ud
ie
s
H
ig
h
m
od
er
at
e

G
ar
la
nd

[5
7]
,

Jo
ur
na

lo
fA

gi
ng

St
ud

ie
s
(1
98
9)

C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
13
8

Su
bj
ec
ts
:N

A
sf
ro
m

45
N
H
s

Q
ue
st
io
nn
ai
re

Fi
fte

en
ite
m
sb

ro
ke
n
do

w
n

in
to

fo
ur

gr
ou

ps
:

(i
)S

vi
si
on

(h
av
in
g

ne
ce
ss
ar
y

su
pp

lie
s;
en
ou

gh
tim

e;
am

ou
nt

of
w
or
k

m
an
ag
ea
bl
e;
ac
ce
ss
to

ne
ce
ss
ar
y
in
fo
;k
no

w
in
g

ho
w
su
pe
rv
is
or

is
ev
al
ua
tin

g
yo
u;
no

t
kn

ow
in
g
w
ha
ts
up

er
vi
so
r

ex
pe
ct
s;
be
in
g
su
re

w
ha
t

su
pe
rv
is
or

w
an
ts
;

co
nfl

ic
tin

g
or
de
rs
fr
om

pe
op

le
in

au
th
or
ity

)
(i
i)
Pe
rs
on

al
re
co
gn

iti
on

(s
up

er
vi
so
ra

sk
sf
or

yo
ur

op
in
io
n;

ot
he
rs
ca
re

ho
w

w
el
ly
ou

do
yo
ur

jo
b)

(i
ii)

Fa
m
ily
/w

or
k
co
nfl

ic
t

(jo
b
in
te
rf
er
es

w
ith

fa
m
ily

lif
e;
fa
m
ily

lif
e
in
te
rf
er
es

w
ith
jo
b)

(iv
)Q

ua
lifi

ca
tio

ns
(w

is
h

fo
rm

or
e
tr
ai
ni
ng

;f
ee
l

qu
al

ifi
ed

)

M
od

ifi
ca
tio

n
of

K
ah
n
et

al
.(
19
64

)[
50
]J
ob

Sa
tis
fa
ct
io
n
Sc
al
e

𝛼
=
0.
74

N
ot
re
po
rt
ed

Lo
w
m
od

er
at
e

G
itt
el
l[
58
],

H
um

an
Re
so
ur
ce

M
an
ag
em

en
t
Jo
ur
na

l(
20
08
)

C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
25
2

Su
bj
ec
ts
:C

N
A
sf
ro
m

2
sp
ec
ifi
c
un

its
at
15

di
ffe
re
nt

LT
C

fa
ci
lit
ie
s(
10

no
np

ro
fit

an
d
5
fo
r-
pr
ofi

Q
ue
st
io
nn
ai
re
(i
)D

em
og
ra
ph

ic
s

(i
i)
Fa
ci
lit
y

ch
ar
ac
te
ri
st
ic
s

(s
iz
e
an
d
ow

ne
rs
hi
p)

(i
ii)

R
el
at
io
na
l

co
or
di

na
tio

n
(c
om

m
un

ic
at
io
n
an
d

re
la
tio

ns
hi

ps
)

O
ne

JS
ite
m

“o
ve
ra
ll,
ho

w
sa
tis
fie
d
ar
e
yo
u
w
ith

yo
ur

jo
b?
”

N
ot
re
po
rt
ed
N
ot
re
po
rt
ed
Lo
w
m
od
er
at
e

G
ol
dw

as
se
r[
59
],

Jo
ur
na

lo
fM

en
ta
l

H
ea
lth

an
d
A
gi
ng

(1
99
6)

R
C
T

(w
ith

fo
ur
gr
ou
ps
)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
27

Su
bj
ec
ts
:C
N
A
si
n
on

e
LT

C
fa
ci
lit
y

Q
ue
st
io
nn
ai
re
(i
)M

od
el
of

ca
re

(r
em

in
is
ce
nc

e
ve
rs
us

pr
es
en
tf
oc
us
ed
)

(i
i)
Pr
es
en
td

ur
in
g
re
si
de
nt

in
te
rv
ie
w
sv

er
su
sn

ot
pr
es
en
td

ur
in
g

in
te
rv
ie
w
s

Sh
or
tf
or
m

of
th
e

M
in
ne
so
ta

Sa
tis
fa
ct
io
n

Q
ue
st
io
nn
ai
re

(2
0
ite
m
s)

In
te
rn
al

co
ns
is
te
nc
y

co
effi

ci
en
ts
of

th
e

su
bs
ca
le
sr
an
ge

fr
om

0.
80

st
o

0.
90
s
N
ot
re
po
rt
ed
W
ea
k

Nursing Research and Practice 9

Ta
bl
e
2:
C
on

tin
ue
d.
Fi
rs
ta
ut
ho
r,
jo
ur
na
l(
ye
ar
)
St
ud
y
de
si
gn
Lo
ca
tio
n/
sa
m
pl
e/
su
bj
ec
ts
D
at
a
co
lle
ct
io
n
m
et
ho
d
Ex
pl
an
at
or
y
va
ri
ab
le
s
st
ud
ie
d
(i
nd
iv
id
ua
l
va
ri
ab
le
s)
Jo
b
sa
tis
fa
ct
io
n
in
st
ru
m
en
t
Q
ua
lit
y
Jo
b
sa
tis
fa
ct
io
n
m
ea
su
re
(s
)
R
el
ia
bi
lit
y
Va
lid
ity

G
ri
es
ha
be
r[
60
],

Th
e
H
ea
lth

C
ar
e

Su
pe
rv
is
or

(1
99
5)
C
ro
ss
-s
ec
tio
na
l
su
rv
ey
de
si
gn

(2
gr
ou

ps
)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
79

Su
bj
ec
ts
:C

N
A
s

Q
ue
st
io
nn
ai
re

(i
)F

ac
ili
ty
ty
pe

(u
rb
an

ve
rs
us

su
bu

rb
an
)

(i
i)
A
ge

(i
ii)

Ed
uc
at
io
n

(iv
)J
ob

te
nu

re
(v
)O

cc
up

at
io
n
te
nu

re
Sh
or
tf
or
m
of
th
e
M
in
ne
so
ta
Sa
tis
fa
ct
io
n
Q
ue
st
io
nn
ai
re

R
el
ia
bl
e
in

ot
he
r

st
ud

ie
s,
bu

tn
o

nu
m
be
rs

w
er
e

re
po
rt
ed
St
at
ed
va
lid

in
ot
he
rs
tu
di
es

W
ea
k

G
ru
ss
[6
1]
,

Th
es
is

(2
00
7)

C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
42

Su
bj
ec
ts
:C
N
A
sf
ro
m

3
de
m
en
tia

ca
re

un
its

in
3

C
fa
ci
lit
ie
s

Q
ue
st
io
nn
ai
re

IV
=
em

po
w
er
m
en
t:

(i
)S

tr
uc
tu
ra
l

em
po

w
er
m
en
t(
su
m
m
ar
y

sc
or
e
of

4
su
bs
ca
le
s:

op
po

rt
un

ity
,i
nf
or
m
at
io
n,

su
pp

or
t,
re
so
ur
ce
s)

(i
i)

Ps
yc
ho

lo
gi
ca
l
em
po

w
er
m
en
t

A
br
id
ge
d
Jo
b
D
es
cr
ip
tio

n
In
de
x
(2
5
ite
m
s)

N
ot

in
di
ca
te
d
fo
r

th
is
sa
m
pl
e,

re
fe
rr
ed

to
ot
he
r

st
ud

ie
sw

ith
ou

t
re
po

rt
in
g

nu
m
be
rs
N
ot
in
di
ca
te
d
fo
r
th
is
sa
m
pl
e,
re
fe
rr
ed
to
ot
he
r
st
ud
ie
s
Lo
w
m
od
er
at
e

H
ol
tz
[6
2]
,

Jo
ur
na
lo
f

G
er
on
to
lo
gi
ca
l

N
ur
sin

g
(1
98
2)

C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
31

Su
bj
ec
ts
:H

C
A
sf
ro
m

3
le
ve
lI
Ia
nd

II
Ir
es
id
en
tia

l
ca
re
fa
ci
lit
ie
s
Q
ue
st
io
nn
ai
re

(i
)A

dm
in
is
tr
at
iv
e
po

lic
ie
s

(i
i)
Su
pe
rv
is
io
n

(i
ii)

Sa
la
ry

(iv
)I
nt
er

pe
rs
on

al
re
la
tio

ns
hi
ps

(v
)W

or
ki
ng
co
nd
iti
on

s
(v
i)
A
ch
ie
ve
m
en
t

(v
ii)

R
ec
og
ni
tio

n
(v
iii
)Th

e
w
or
k
its
el
f

(i
x)

R
es
po

ns
ib
ili
ty

(x
)A

dv
an
ce
m
en
t

Q
ue
st
io
nn
ai
re

ba
se
d
on

H
er
zb
er
g’s

m
ot
iv
at
io
n-
hy
gi
en
e

fa
ct
or
s2

0
ite
m
s:
2
fo
re

ac
h

of
th
e
10

H
er
zb
er
g
ite
m
s

Pi
lo
tw

ith
10

su
bj
ec
ts
(s
pl
it-
ha
lf

re
lia
bi
lit
y
w
as

0.
80
)

N
ot
re
po
rt
ed
W
ea
k

H
ou

se
[6
3]
,

Th
es
is

(1
99
0)

C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
14

Su
bj
ec
ts
:C
N
A
sf
ro
m
10
N
H
s
Q
ue
st
io
nn
ai
re
(i
)M

ot
iv
at
io
n
fa
ct
or
s:

ac
hi
ev
em

en
t,
re
co
gn

iti
on

,
w
or
k
its
el
f,

re
sp
on

si
bi
lit
y,

po
ss
ib
ili
ty
of

gr
ow

th
,a
nd

ad
va
nc
em

en
t

(i
i)
H
yg
ie
ne

fa
ct
or
s:
sa
la
ry
,

te
ch
ni
ca
ls
up

er
vi
si
on

,
co
m
pa
ny

po
lic
y,

in
te
rp
er
so
na
lr
el
at
io
ns
hi
ps

w
ith

pe
er
s,
in
te
rp

er
so
na
l

re
la
tio
ns
hi
ps
w
ith

su
pe
rv
is
or
s,

w
or
ki
ng

co
nd
iti
on

s,
se
cu
ri
ty
,s
ta
tu
s,

pe
rs
on

al
lif
e,
an
d

in
te
rp
er
so
na
lr
el
at
io
ns
hi
p

w
ith

nu
rs
e

M
od
ifi
ed

ve
rs
io
n
of

th
e
JS

in
st
ru
m
en
td

ev
el
op

d
by

K
ro
en

w
hi
ch

in
co
rp
or
at
es

m
ot
iv
at
io
n/
hy
gi
en
e

th
eo
ry

S
sc
al
e

ha
sa

re
lia
bi
lit
y
of

0.
84

an
d
th
e

S
sc
al
e
ha
sa
re
lia
bi
lit
y
of

0.
79

(a
st
es
te
d
by

K
ro
en
)

R
ep
or
te
d
va
lid

in
pr
ev
io
us

st
ud
ie
s
Lo
w
m
od
er
at
e

K
os
tiw

a
[6
4]
,

C
lin

ic
al

G
er
on
to
lo
gi
st
(2
00
9)
C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
60

Su
bj
ec
ts
:C
N
A
sf
ro
m

re
si
de
nt
ia
lc
ar
e
fa
ci
lit
ie
s

Q
ue
st
io
nn
ai
re
(i
)S

er
vi
ce

al
ity

(i
i)
Ps
yc
ho
lo
gi
ca
l
em
po
w
er
m
en
t

Th
e

B
en
ja
m
in

R
os
e
Jo
b

Sa
tis
fa
ct
io
n
Su
rv
ey

(J
SS
;

18
ite
m
s)

𝛼
=
0.
93

(o
ve
ra
ll

sc
or
e)

N
ot
re
po
rt
ed
Lo
w
m
od
er
at
e

10 Nursing Research and Practice

Ta
bl
e
2:
C
on
tin
ue
d.
Fi
rs
ta
ut
ho
r,
jo
ur
na
l(
ye
ar
)
St
ud
y
de
si
gn
Lo
ca
tio
n/
sa
m
pl
e/
su
bj
ec
ts
D
at
a
co
lle
ct
io
n
m
et
ho
d
Ex
pl
an
at
or
y
va
ri
ab
le
s
st
ud
ie
d
(i
nd
iv
id
ua
l
va
ri
ab
le
s)
Jo
b
sa
tis
fa
ct
io
n
in
st
ru
m
en
t
Q
ua
lit
y
Jo
b
sa
tis
fa
ct
io
n
m
ea
su
re
(s
)
R
el
ia
bi
lit
y
Va
lid
ity

K
ov
ac
h
[9
],

Re
se
ar
ch

in
G
er
on
to
lo
gi
ca
l

N
ur
sin

(2
01
0)

C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
17
7

Su
bj
ec
ts
:C

N
A
si
n
3

re
si
de
nt
ia
lc
ar
e
fa
ci
lit
ie
s
Q
ue
st
io
nn
ai
re
(i
)P

er
so
na
lit
y
tr
ai
ts
,f
or

ex
am

pl
e,
ad
ju
st
m
en
t,

pr
ud

en
ce
,l
ik
ea
bi
lit
y,
be
in
g

ex
ci
ta
bl
e,
be
in
g
du

tif
ul

(i
i)
Jo
b

pe
rf
or
m
an
ce

Th
e
G
en
er
al
Jo
b

Sa
tis
fa
ct
io
n

Sc
al
e
(5

ite
m
s)

Th
e
in
te
rn
al

co
ns
is
te
nc
y
of

th
e

G
JS

fo
rt
hi
s

sa
m
pl
e
w
as

0.
57

Pr
io
re

vi
de
nc
e
of

co
ns
tr
uc
tv
al
id
ity

:
ne
ga
tiv

e
re
la
tio

ns
to

or
ga
ni
za
tio
na
l
si
ze

an
d
po

si
tiv
e
re
la
tio

ns
w
ith

jo
b

le
ve
l,
te
nu

re
,

pe
rf
or
m
an
ce
,a
nd

m
ot
iv
at
io
na
lfi

t
w
ith

w
or
k

St
ro
ng

K
uo

[1
0]
,

Jo
ur
na

lo
fC

lin
ic
al

N
ur
sin
g
(2
00
8)
C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)

C
ou
nt
ry
:T
ai
w
an

Sa
m
pl
e
siz

e:
n
=
11
4

Su
bj
ec
ts
:N
A
sf
ro
m

28
re
si
de
nt
ia
lc
ar
e
fa
ci
lit
ie
s

Q
ue
st
io
nn
ai
re

(i
)O

rg
an
iz
at
io
na
l

em
po
w
er
m
en
t

(i
i)
D
em

og
ra
ph

ic
va
ri
ab
le
s,
fo
re

xa
m
pl
e,

na
tio

na
lit
y,
ag
e,
m

ar
ita

l
st
at
us
,e
du

ca
tio

na
ll
ev
el
,

w
or
k
du

ra
tio

n
at
a
fa
ci
lit
y

Sh
or
tf
or
m
of
th
e
M
in
ne
so
ta
Sa
tis
fa
ct
io
n
Q
ue
st
io
nn
ai
re

(M
SQ

;2
0

ite
m
s)

𝛼
=
0.
87

(o
ve
ra
ll
sc
or
e)
N
ot
re
po
rt
ed
Lo
w
m
od
er
at
e

Le
rn
er

[6
5]
,

Jo
ur
na
lo
f
N
ur
sin

g
A
dm

in
ist
ra
tio

n
(2
01
1)

C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:U
SA
.
Sa
m
pl
e
siz

e:
n
=
55
6

Su
bj
ec
ts
:N
A
sf
ro
m

12
sk
ill
ed

nu
rs
in
g
fa
ci
lit
ie
s

Su
rv
ey

pr
e-

an
d

po
st

in
te
rv
en
tio

n
(i
)S

ki
lle
d
nu

rs
in
g
fa
ci
lit
y

si
te

(i
i)
A
ge
(i
ii)

G
en
de
r

(i
v)

Ed
uc
at
io
n

(v
)Y

ea
rs
of

ex
pe
ri
en
ce

(v
i)
Se
lf-
es
te
em

(v
ii)

Se
lf-
effi

ca
cy

(v
iii
)O

ut
co
m
e

ex
pe
ct
at
io
ns

fo
r
pe
rf
or
m
an
ce

re
st
or
at
iv
e

ca
re

ac
tiv

iti
es

(i
x)

O
bs
er
ve
d
pe
rf
or
m
an
ce

of
re
st
or
at
iv
e

ac
tiv

iti
es

Jo
b
at
tit
ud

e
sc
al
e

(1
7

ite
m
s)
m
ea
su
ri
ng

co
m
po

ne
nt
s;
pa
y
fa
ct
or
s,

or
ga
ni
za
tio

na
lf
ac
to
rs
,

ta
sk

re
qu

ir
em

en
ts
,j
ob

st
at
us
,a
nd

au
to
no

m
y
R
es
po

ns
e
op

tio
ns

ra
ng
e

fr
om

1(
st
ro
ng

ly
di
sa
gr
ee
)

to
5
(s
tr
on

gl
y
ag
re
e)

N
ot
re
po
rt
ed
Va
lid
ity
in
pr
ev
io
us
st
ud
ie
s

by
si
gn

ifi
ca
nt

re
la
tio

n
be
tw
ee
n

its
sc
or
es

an
d
sc
or
es
of
th
e
M
in
ne
so
ta
Sa
tis
fa
ct
io
n
Sc
al
e
Lo
w
m
od
er
at
e

Li
u
[6
6]
,

G
er
ia
tr
ic
N
ur
sin

g
(2
00
7)

C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:T
ai
w
an
Sa
m
pl
e
siz

e:
n
=
24
4

Su
bj
ec
t:
C
N
A
sf
ro
m

17
re
si
de
nt
ia
lc
ar
e
fa
ci
lit
ie
s

Q
ue
st
io
nn
ai
re
(i
)M
ar
ita

ls
ta
tu
s

(i
i)
Fu

ll
tim

e
ve
rs
us

pa
rt

tim
e

(i
ii)

Le
ng

th
of
te
nu

re
(iv

)F
ee
lin

gs
to
w
ar
d
th
e

jo
b

(v
)I
nt
en
tio

n
to

qu
it

(v
i)
JS

Fa
ce
t2

(w
or
k

pe
rf
or
m
an
ce

an
d
re
w
ar
ds
)

D
es
ig
ne
d
by

au
th
or

ac
co
rd
in
g
to

re
le
va
nt

th
eo
re
tic

al
lit
er
at
ur
es

an
d

ad
dr
es
se
d
5
m
ai
n

di
m
en
si
on

so
fj
ob

sa
tis
fa
ct
io
n

𝛼
=
0.
81

N
ot
re
po
rt
ed
H
ig
h
m
od
er
at
e

M
cG

ilt
on

[6
7]
,

Jo
ur
na
lo
f
N
ur
sin
g
A
dm
in
ist
ra
tio

n
(2
00

C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)

C
ou
nt
ry
:C

an
ad
a

Sa
m
pl
e
siz

e:
n
=
22
2

Su
bj
ec
ts
:C
N
A
si
n
10
LT
C
fa
ci
lit
ie
s
Q
ue
st
io
nn
ai
re

(i
)C

N
A
ch
ar
ac
te
ri
st
ic
s

(a
ge
,g
en
de
r,
ed
uc
at
io
n,

ex
pe
ri
en
ce
w
or
ki
ng

in
LT

C
,e
th
ni
ci
ty
[o
ri
gi
n
of

bi
rt
hp

la
ce
,C

an
ad
ia
n

ve
rs
us

no
n-
C
an
ad
ia
n
an
d

fir
st
la
ng

ua
ge
,E

ng
lis
h

ve
rs
us

no
n-
En

gl
is
h]
)

(i
i)

Jo
b
st
re
ss

(i
ii)

Su
pe
rv
is
or
y
su
pp

or
t

N
ur
si
ng

Jo
b
Sa
tis
fa
ct
io
n

Sc
al
e
(4
2
ite
m
s)

𝛼
=
0.
89

(t
ot
al

sc
al
e)
𝛼
=

0.
88
–0

.9
5

(s
ub

sc
al
es
)

N
ot
re
po
rt
ed
H
ig
h
m
od
er
at
e

Nursing Research and Practice 11

Pa
rm

el
ee

[6
8]
,

Jo
ur
na
lo
f

A
m
er
ic
an

M
ed
ic
al
D
ire

ct
or
s

ss
oc
ia
tio

n
(2
00
9)
C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz
e:
n
=
18
8
Su
bj
ec
ts
:N

A
sr
eg
is
te
re
d
at

th
e
20
06

co
nf
er
en
ce

of
th
e

N
at
io
na
lA

ss
oc
ia
tio
n
of
H
ea
lth

C
ar
e
A
ss
is
ta
nt
s

Q
ue
st
io
nn
ai
re
(i
)P
er
ce
iv
ed

ba
rr
ie
rs
to

jo
b
pe
rf
or
m
an
ce

(i
i)
Te
am

w
or
k
(i
ii)
Jo
b
st
re
ss

(iv
)R

es
pe
ct

(v
)W

or
kl
oa
d

(v
i)
Ex

cl
us
io
n

(v
ii)

N
ew

N
A
s
B
en
ja
m
in

R
os
e
In
st
itu

e
N
ur
se

A
ss
is
ta
nt
Jo
b

Sa
tis
fa
ct
io
n
Sc
al
e
(1
8

ite
m
s)

𝛼
=
0.
95

N
ot
re
po
rt
ed
H
ig
h
m
od
er
at
e

Pa
rs
on

s[
33
],

Jo
ur
na
lo
f
G
er
on
to
lo
gi
ca
l
N
ur
sin

g
(2
00
3)

C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
55
0

Su
bj
ec
ts
:H
C
A
sf
ro
m

70
LT

C
fa
ci
lit
ie
s
Q
ue
st
io
nn
ai
re
(i
)D
em
og
ra
ph

ic
s:
ag
e,

ra
ce
,s
ex
,m

ar
ita

ls
ta
tu
s,

ed
uc
at
io
n
an
d
ed
uc
at
io
n

go
al
s,
fa
m
ily

re
sp
on

si
bi
lit
ie
s,
w
or
k

ch
ar
ac
te
ri
st
ic
s(
do

es
no

t
sp
ec
ify

w
ha
t)

(i
i)
Se
ve
n
fa
ct
or
s:
(1
)t
as
k

re
w
ar
ds
,(
2)

so
ci
al
re
w
ar
ds
,

(3
)s
up

er
vi
si
on

,(
4)

be
ne
fit
s,
(5
)p

er
so
na
l
op
po
rt
un

ity
,(
6)

co
w
or
ke
r

su
pp

or
t,
(7
)s
al
ar
y
an
d

m
an
ag
em

en
tk

ee
pi
ng

em
pl
oy
ee
si
nf
or
m
ed

(i
ii)

Tu
rn
ov
er

D
ev
el
op

ed
th
ei
ro

w
n:

ov
er
al
ls
at
is
fa
ct
io
n
(3

ite
m
s)
N
ot
re
po
rt
ed
N
ot
re
po
rt
ed
W
ea
k

Pr
oe
nc
a
[6
9]
,

A
ca
de
m
y
of

M
an
ag
em
en
t

A
nn

ua
lM

ee
tin

g
Pr
oc
ee
di
ng
s(
20
08
)C

ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
12
9

Su
bj
ec
ts
:C
N
A
sf
ro
m

6
re
si
de
nt
ia
lc
ar
e
fa
ci
lit
ie
s

Q
ue
st
io
nn
ai
re
(i
)W

or
k-
fa
m
ily

co
nfl

ic
t,

rn
ou

t
(i
i)
Bu

rn
ou

t
(i
ii)

Su
pp
or
tiv

e
su
pe
rv
is
io
n

(iv
)S

up
po

rt
iv
e
co
w
or
ke
rs

Su
bs
ca
le
sf
ro
m

th
e
Jo
b

D
ia
gn
os
tic
Su
rv
ey
an
d
th
e

M
ic
hi
ga
n
O
rg
.

A
ss
es
sm

en
tQ

ue
st
io
nn
ai
re

w
er
e
us
ed

to
m
ea
su
re

jo
b

sa
tis
fa
ct
io
n
an
d

tu
rn
ov
er

te
nt

io
ns

𝛼
’s
>
0.
80

N
ot
re
po
rt
ed
Lo
w
m
od
er
at
e

Pu
rk

[7
0]
,

Jo
ur
na
lo
f

H
ou
sin

g
fo
rt
he

El
de
rly

(2
00
6)
C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz
e:
n
=
34
Su
bj
ec
ts
:C
N
A
sf
ro
m

5
fa
ci
lit
ie
s

Q
ue
st
io
nn
ai
re
(i
)P

ay
,p
ro
m
ot
io
n,

su
pe
rv
is
io
n,

w
or
k
on

pr
es
en
tj
ob
,p
eo
pl
e
at
w
or
k

(i
i)
Pe
rc
ei
ve
d
em

ot
io
na
l

an
d
ph

ys
ic
al
st
re
ss

(i
ii)

In
te
nt

to
qu

it
w
ith

in
th
e
ne
xt

3
m
on

th
s

(iv
)I
nt
en
tt
o
qu

it
w
ith
in
th
e
ne
xt
ye
ar

Th
e
Jo
b
D
es
cr
ip
tiv

e
In
de
x

(J
D
I)
an
d
th
e
Jo
b
in

G
en
er
al
Sc
al
e
(J
IG

)
N
ot

re
po
rt
ed
N
ot
re
po
rt
ed
W
ea
k

R
am

ir
ez

[7
1]
,

Jo
ur
na
lo
fM
en
ta
l
H
ea
lth
an
d
A
gi
ng

(1
99
8)

C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
33
7

Su
bj
ec
ts
:H
C
A
sf
ro
m

20
re
si
de
nt
ia
lc
ar
e
fa
ci
lit
ie
s

St
ru
ct
ur
ed

(f
ac
e-
to
-f
ac
e

in
te
rv
ie
w
s)

W
or
k
re
la
te
d
de
m
an
ds

an
d

st
re
ss
or
s

(i
)N

A
w
or
kl
oa
d

(i
i)
N
A
pe
rc
ei
ve
d
bi
as

(i
ii)

W
or
k

en
vi
ro
nm

en
t

ev
al
ua
tio

n
W
or
k
re
so
ur
ce
s

(i
)N

A
tr
ai
ni
ng

(i
i)
W
or
k-
re
la
te
d
su
pp

or
t

In
di
vi
du

al
re
so
ur
ce
s

Ye
ar
sw

or
ki
ng

as
a
N
A

SC
U
A
ss
ig
nm

en
t

A
da
pt
io
n
of

C
an
to
ra

nd
C
hi
ch
in

Jo
b
Sa
tis
fa
ct
io
n
Sc
al
e
(5
ite
m
s)
In
te
rn
al
co
ns
is
te
nc
y
co
effi

ci
en
tf
or

th
e

5-
ite
m

se
tw

as
0.
41

in
th
is
st
ud

y
N
ot
re
po
rt
ed
Lo
w
m
od
er
at
e

12 Nursing Research and Practice

R
es
ni
ck

[7
2]
,

G
er
ia
tr
ic
N
ur
sin
g
(2
00
4)

Q
ua
si
–

ex
pe
ri
m
en
ta
l∗
∗

(s
in
gl
e-
gr
ou

p
re
pe
at
ed

m
ea
su
re
de
si
gn
)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz
e:
n
=
13
Su
bj
ec
ts
:H
C
A
sf
ro
m

1
fa
ci
lit
y

Q
ue
st
io
nn
ai
re

pl
em

en
ta
tio

n
of
th
e

R
es
-C

ar
e
pi
lo
t

in
te
rv
en
tio

n
(r
es
to
ra
tiv

e
ca
re

ph
ilo

so
ph

Jo
b

A
tti
tu
de

Sc
al
e
(1
7

ite
m
s)
N
ot
re
po
rt
ed

R
ef
er
re
d
to

a
pr
ev
io
us

st
ud

ite
m
so

n
th
e
JA
S

re
la
te
d
to
ite
m
so

n
M
in
ne
so
ta

Sa
tis
fa
ct
io
n
Sc
al
e
Lo
w
m
od
er
at
e

Si
m

ps
on

[7
3]
,

Th
es
is
(2
01
0)
C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou

p)
(s
ec
on

d
an
al
ys
is
of

R
es
ni
ck

20
07
)

C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
50
4

Su
bj
ec
ts
:C

N
A
se

m
pl
oy
ed

in
12

re
si
de
nt
ia
lc
ar
e
fa
ci
lit
ie
s
N
A
In
di
vi
du

al
fa
ct
or
s:
ag
e,

ex
pe
ri
en
ce
Ps
yc
ho

so
ci
al
fa
ct
or
s:

se
lf-
es
te
em

,s
el
f-
effi

ca
cy
,

ou
tc
om

e
ex
pe
ct
at
io
ns
,

kn
ow
le
dg
e
of
re
st
or
at
iv
e
ca
re

C
N
A
jo
b
pe
rf
or
m
an
ce

(i
.e
.,

pe
rf
or
m
an
ce
of
re
st
or
at
iv
e

ca
re
)

Th
e
N
ur
sin

g
A
ss
ist
an
tJ
ob

A
tti
tu
de

Sc
al
e
(N

A
JA
S)

(1
7

ite
m
s)
:5

co
m
po

ne
nt
s:
pa
y

fa
ct
or
s,
or
ga
ni
za
tio

na
l

fa
ct
or
s,
ta
sk

re
qu
ir
em

en
ts
,

jo
b
st
at
us
,a
nd

au
to
no
m
y

𝛼
=
0.
94

C
on

ve
rg
en
ce

va
lid

ity
:“
pr
io
ru

se
of

th
e
N
A
JA
S
in

a
sa
m
pl
e
of

28
6

ce
rt
ifi
ed

nu
rs
e

ai
de
sr
es
ul
te
d
in

fin
di
ng

ss
im

ila
rt
o

th
os
e
fo
un

d
by

ot
he
rm

ea
su
re
so

f
jo
b
sa
tis
fa
ct
io
n”

H
ig
h
m
od
er
at
e

Sn
ow

[7
4]
,

N
ur
sin

g
H
om

es
/L
on
g

Te
rm

C
ar
e
M
an
ag
em
en
t
(2
00
7)
C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
12
1

Su
bj
ec
ts
:H
C
A
sa

ta
ss
is
te
d

liv
in
g
an
d
sk
ill
ed

nu
rs
in
g
fa
ci
lit
ie
s
Q
ue
st
io
nn
ai
re
(i
)P

ur
su
in
g
ed
uc
at
io
n

(i
i)
Ex

pa
ns
io
n
of

sc
op

e
of

pr
ac
tic

e
N
ot

re
po
rt
ed
N
ot
re
po
rt
ed
N
ot
re
po
rt
ed
W
ea
k

So
lo
m
on

[7
5]
,

Th
es
is
(2
00

9)
C
ro
ss
-s
ec
tio

na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
66

Su
bj
ec
ts
:C

N
A
s,
5
R
N
s,

an
d
1a

dm
in
is
tr
at
or

in
on

re
si
de
nt
ia
lc
ar
e
fa
ci
lit
y

Q
ue
st
io
nn
ai
re

Le
ad
er
sh
ip

ch
ar
ac
te
ri
st
ic
s

of
ad
m
in
is
tr
at
or
sa

nd
re
gi
st
er
ed

nu
rs
es

(i
)M

od
el

in
g
th
e

w
ay

(i
i)
In
sp
ir
in
g
a
sh
ar
ed

vi
si
on
(i
ii)

C
ha
lle
ng

in
g
th
e

pr
oc
es
s

(iv
)E

na
bl
in
g
ot
he
rs
to

ac
t

(v
)E

nc
ou

ra
gi
ng

th
e
he
ar
t

Th
e
B
en
ja
m
in

R
os
e
N
ur
se

A
ss
is
ta
nt
Jo
b
Sa
tis
fa
ct
io
n
Su
rv
ey
N
ot
re
po
rt
ed
N
ot
re
po
rt
ed
Lo
w
m
od
er
at
e

Ta
nn

az
zo

[7
6]
,

A
lz
he
im

er
’s

C
ar
e

To
da
y
(2
00
8)

pr
e/
po

st
-t
es
t

in
te
rv
en
tio

n∗
∗

C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
30

Su
bj
ec
ts
:C
N
A
sf
ro
m

4
re
si
de
nt
ia
lc
ar
e
fa
ci
lit
ie
s

Q
ue
st
io
nn
ai
re

Ed
uc
at
io
n
in
te
rv
en
tio

n,
kn

ow
le
dg
e
of
A
lz
he
im
er
’s

G
en
er
al
Jo
b
Sa
tis
fa
ct
io
n

(G
JS
)(
5
ite
m
s)
an
d
a
G
ra
u

Sa
tis
fa
ct
io
n
Sc
al
e
(G

SS
;2

ite
m
s)
m
ea
su
ri
ng

in
tr
in
si
c

sa
tis
fa
ct
io
n
an
d

sa
tis
fa
ct
io
n
w
ith

be
ne
fit
s

G
JS
:𝛼

=
0.
45
–0

.5
8

G
SS
:𝛼

=
0.
81
–0

.8
4

N
ot
re
po
rt
ed
Lo
w
m
od
er
at
e

Th
om

ps
on

[7
7]
,

Jo
ur
na
lo
f
G
er
on
to
lo
gi
ca
l
N
ur
sin

g
(2
01
1)

C
ro
ss
-s
ec
tio
na
l
su
rv
ey
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
40

Su
bj
ec
ts
:N

A
si
n
1s
ki
lle
d

nu
rs
in
g
fa
ci
lit
y

M
ai
le
d
qu

es
tio
nn
ai
re

W
or
k
co
nt
en
t,
qu

al
ity

of
ca
re
,t
ra
in
in
g,
co
w
or
ke
rs
,

su
pe
rv
is
or
s,
w
or
k

de
m
an
ds
,w

or
kl
oa
d,

re
w
ar
ds
,g
lo
ba
lr
at
in
g

A
da
pt
ed

N
ur
si
ng
H
om
e
N
ur
se

A
id
e
Jo
b

Sa
tis
fa
ct
io
n
Q
ue
st
io
nn

ai
re

[3
1]

N
ot
re
po

rt
ed
.

C
on
te
nt
va
lid

ity
—

in
st
ru
m
en
tb

as
ed

on
th
e
lit
er
at
ur
e;
a

pa
ne
lo
fe
xp

er
ts

an
d
co
gn

iti
ve

te
st
in
g
w
er
e

al
so

co
nd

uc
te
d

W
ea
k

Nursing Research and Practice 13

Ty
le
r[
78
]∗
,

H
ea
lth
C
ar
e
M
an
ag
em
en
t

Re
vi
ew

(2
00
6)

M
ix
ed

m
et
ho

ds
(q
ua
lit
at
iv
e
gr
ou

nd
th
eo
ry

an
d

qu
an
tit
at
iv
e

cr
os
s-
se
ct
io
na
l

su
rv
ey
)

C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
11
46

(s
ur
ve
ys
)

n
=
14
4
(i
nt
er
vi
ew

s)
n
=
37

ar
tic

ip
an
t

ob
se
rv
at
io
ns

)

Su
bj
ec
ts
:C

N
A
s,
R
N
s,

m
an
ag
em

en
ta
t2

0
fa
ci
lit
ie
s

Q
ua
lit
at
iv
e:

et
hn
og
ra
ph

ic
in
te
rv
ie
w
s

an
d
pa
rt
ic
ip
an
t

ob
se
rv
at
io
ns

Q
ua
nt
ita
tiv

e:
qu

es
tio
nn
ai
re
(i
)S

ki
ll
va
ri
et
y

(i
i)

Ta
sk

id
en
tit
y

(i
ii)
Ta
sk
si
gn

ifi
ca
nc
e

(iv
)A
ut
on

om
y

(v
)I
nt
ri
ns
ic
fe
ed
ba
ck

M
od
ifi
ed
ve
rs
io
n
of
th
e

Jo
b
D
ia
gn

os
tic
Su
rv
ey

(J
D
S)

𝛼
=
0.
35
–0

.7
1

N
ot
re
po
rt
ed
Lo
w
m
od

er
at
e/
st
ro
ng

W
al
bo

rn
[7
9]
,

Th
es
is
(1
99
6)
C
ro
ss
-s
ec
tio
na
l
su
rv
ey
(s
in
gl
e
gr
ou
p)
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
n
=
18
5

Su
bj
ec
ts
:H
C
A
sa

nd
ch
ar
ge

nu
rs
es
fr
om
on
e
re
si
de
nt
ia
lc
ar
e
fa
ci
lit
y
Q
ue
st
io
nn
ai
re
(i
)D
em
og
ra
ph

ic
va
ri
ab
le
s

(a
ge
,e
du

ca
tio

n,
nu

m
be
ro

f
ye
ar
ss
in
ce

tr
ai
ni
ng

,y
ea
rs

of
ex
pe
ri
en
ce
)

(i
i)
Jo
b
pe
rf
or
m
an
ce

va
ri
ab
le
s
(i
ii)

A
bs
en
te
ei
sm

va
ri
ab
le
s

(iv
)V

ar
ia
bl
es

of
pe
rc
ep
tio

ns
of

th
e
w
or
k
en
vi
ro
nm
en
t
Th
e
Jo
b
D
es
cr
ip
tiv
e
In
de
x
(J
D
I)
an
d
th
e
Jo
b
in

G
en
er
al
Sc
al
e
(J
G
S)

an
d
2

ite
m
sf
ro
m

th
e
Q
ua
lit
y
of

Em
pl
oy
m
en
ts
ur
ve
y

(Q
ES

)m
ea
su
ri
ng

ov
er
al
l

JD
I:
𝛼
=
0.
74

(o
ve
ra
ll)

𝛼
=
0.
67
–0

.9
2
(f
or

5
su
bs
ca
le
s)

JG
S:
𝛼
=
0.
86

(o
ve
ra
ll)

R
ep
or
te
d
as

va
lid
in
pr
ev
io
us
st
ud

ie
s
W
ea
k

W
eb
b
[8
0]
,

Th
es
is
(2
00
3)

Q
ua
si
-e
xp

er
im

en
ta
l

(n
on

eq
ui
va
le
nt

co
nt
ro
lg

ro
up

de
si
gn
w
ith
pr
e-
an
d

po
st
te
st
)∗
∗

C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz
e:
n
=
17
8
Su
bj
ec
ts
:C
N
A
sf
ro
m
2
re
si
de
nt
ia
lc
ar
e
fa
ci
lit
ie
s
Q
ue
st
io
nn
ai
re
R
ec
og
ni
tio

n
an
d
re
w
ar
ds

tr
ai
ni
ng
pr
og
ra
m

Th
e
N
ur
se

A
ss
is
ta
nt
A
ss
es
sm

en
tS
ur
ve
y

In
st
ru
m
en
t:
Jo
b

Sa
tis
fa
ct
io
n
w
hi
ch

w
as

de
ve
lo
pe
d
by

Io
w
a

C
ar
eG

iv
er
sA

ss
oc
ia
tio

n
an
d
H
ill

Si
m
on

to
n
B
el
l

(1
99
8)

(4
8
ite
m
s)

𝛼
=
0.
87

(p
re
te

st
)

𝛼
=
0.
88

(p
os
tte

st
)
C
on
te
nt
va
lid

ity
by

3
ex
pe
rt
s

W
ea
k

Ye
at
ts
[5
5]
∗

,
Th

e
G
er
on
to
lo
gi
st
(2
00
7)
M
ix
ed
m
et
ho

ds
(b
ef
or
e-
an
d-
aft

er
∗
∗
w
ith

sm
al
la
m
ou

nt
of

al
ita
tiv

e
da
ta

)

C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz

e:
no

tr
ep
or
te
d

Su
bj
ec
ts
:w

or
k

te
am

so
f5

re
si
de
nt
ia
lc
ar
e
fa
ci
lit
ie
s
w
ith
in
te
rv
en
tio

n
im

pl
em

en
te
d
an
d
5
w
or
k

te
am
sf
ro
m

5
ot
he
r

re
si
de
nt
ia
lc
ar
e
fa
ci
lit

ie
sa

s
co
nt
ro
l

Q
ua
nt
ita
tiv
e:
qu
es
tio
nn
ai
re
s
Q
ua
lit
at
iv
e:
(i
)P
ar
tic

ip
at
in
g

ob
se
rv
at
io
ns
,o
fo

ve
r2

70
C
N
A
te
am

m
ee
tin

gs
(i
i)
Ex

am
in
at
io
n
of

w
ee
kl
y
te
am

-m
ee
tin

g
su
m
m
ar
ie
sf
or

m
an
ag
em

en
ta
nd

m
an
ag
em

en
t’s

re
sp
on

se
s

Em
po
w
er
m
en
t

In
de
x
in

C
N
A
su
rv
ey

(d
et
ai
ls
of

ite
m
sn

ot
re
po

rt
ed
)
C
N
A
su
rv
ey

in
di
ce
sr
an
ge
d

fr
om

0.
60

to
0.
85

(s
pe
ci
fic

in
de
x
fo
r

JS
no

tr
ep
or
te
d)

Fa
ct
or

an
al
ys
is
to

de
te
rm

in
e
ite
m
si
n

al
ls
ur
ve
y
in
di
ce
s

W
ea
k
Q
ua

lit
at
iv
e
st
ud

ie
s
(n

=
7)

Ba
ll
[8
1]
,

Jo
ur
na
lo
fA
gi
ng
St
ud

ie
s(
20
09
)

Lo
ng

qu
al
ita
tiv

e
gr
ou
nd
th
eo
ry
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz
e:
n
=
43

Su
bj
ec
ts
:m

an
ag
em
en
t

st
aff

m
em

be
rs
an
d
D
C
W
s

in
2

A
LF

s
(i
)P
ar
tic
ip
an
t
ob
se
rv
at
io
n

(i
i)
In
-d
ep
th

an
d

in
fo
rm

al
in
te
rv
ie
w
s

(i
)N

o
pr
ed
efi
ne
d

in
di
vi
du

al
va
ri
ab
le
s

(i
i)
O
pe
n-
en
de
d
in
te
rv
ie
w
s

w
er
e
us
ed

to
fin

d
ou

tw
ha
t

in
di
vi
du

va
ri
ab
le
sa

re
im

po
rt
an
tf
ro
m

th
e

pa
rt
ic
ip
an
ts
’p
er
sp
ec
tiv

Pa
rt
ic
ip
an
to

bs
er
va
tio

ns
an
d
qu

al
ita
tiv

e
in
te
rv
ie
w
s

N
/A

N
/A
St
ro
ng

By
e
[8
2]
,

N
ur
sin
g
H
om

es
an
d
Se
ni
or

C
iti
ze
n
C
ar
e

(1
98
7)

Q
ua
lit
at
iv
e

cr
os
s-
se
ct
io
na
l
in
te
rv
ie
w
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz
e:
n
=
30
Su
bj
ec
ts
:N
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sf
ro
m

3
re
si
de
nt
ia
lc
ar
e
fa
ci
lit
ie
s

Se
m
is
tr
uc
tu
re
d

cr
os
s-
se
ct
io
na
li
nt
er
vi
ew

st
ud
y
(i
)N
o
pr
ed
efi
ne
d
in
di
vi
du
al
va
ri
ab
le
s
(i
i)
O
pe
n-
en
de
d
in
te
rv
ie
w
s
w
er
e
us
ed
to
fin
d
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tw
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rt
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m
th
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pa
rt
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sp
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tiv
es

A
sk
ed

pa
rt
ic
ip
an
ts
fo
r

th
ei
rs
ub

je
ct
iv
e

pe
rc
ep
tio
ns
of
w
ha
t

sa
tis
fie
d
th
em

in
th
ei
rj
ob

s
N
/A

N
/A
W
ea
k

14 Nursing Research and Practice

K
ar
ne
r[
83
],

Jo
ur
na
lo
f
G
er
on
to
lo
gi
ca
l
N
ur
sin

g
(1
99
8)

Q
ua
lit
at
iv
e
cr
os
s-
se
ct
io
na
l
gr
ou
nd
th
eo
ry
C
ou
nt
ry
:U
SA
Sa
m
pl
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siz

e:
17

Su
bj
ec
ts
:C
N
A
s(
ar
tic
le

fo
cu
se
d
on

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N
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sb

ut
re
sp
on

de
nt
si
nc
lu
de
d

ot
he
rs
ta
ff
m
em

be
rs
)

Se
m
is
tr
uc
tu
re
d
gu

id
ed

in
te
ns
iv
e
in
te
rv
ie
w
s

(i
)N
o
pr
ed
efi
ne
d
in
di
vi
du
al
va
ri
ab
le
s
(i
i)
O
pe
n-
en
de
d
in
te
rv
ie
w
s
w
er
e
us
ed
to
fin
d
ou
tw
ha
t
in
di
vi
du
al
va
ri
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sa
re
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po
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ro
m
th
e
pa
rt
ic
ip
an
ts
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er
sp
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tiv
es
A
sk
ed
pa
rt
ic
ip
an
ts
fo
r
th
ei
rs
ub
je
ct
iv
e
pe
rc
ep
tio
ns
of
w
ha
t

im
pa
ct
st
he
ir
sa
tis
fa
ct
io
n

N
/A
N
/A
Lo
w
m
od
er
at
e

M
oy
le
[8
4]
,

Jo
ur
na
lo
fC
lin
ic
al
N
ur
sin
g
(2
00
3)
Q
ua
lit
at
iv
e
cr
os
s-
se
ct
io
na
l

in
te
rv
ie
w
st
ud

C
ou
nt
ry
:A

us
tr
al
ia

Sa
m
pl
e
siz
e:
n
=
13
Su
bj
ec
ts
:C

N
A
s(
pl
us

9
R
N
sa

nd
5
EN

s)
Fo

cu
sg

ro
up
in
te
rv
ie
w
s
(i
)N
o
pr
ed
efi
ne
d
in
di
vi
du
al
va
ri
ab
le
s

(i
i)
O
pe
n-
en
de
d
fo
cu
s

gr
ou

ps
w
er
e
us
ed

to
fin
d
ou

tw
ha
ti
nd

iv
id
ua
l
va
ri
ab
le
sa
re
im

po
rt
an
t

fr
om

th
e
pa
rt
ic
ip
an
ts
’

pe
rs
pe
ct
iv
es

Fo
cu
sg

ro
up

s:
su
bj
ec
tiv

e
vi
ew

sa
nd

op
in
io
ns

of
th
e

in
te
rv
ie
w
ed

in
di
vi
du
al
so

r
gr
ou

p
m
ea
ni
ng

s,
re
sp
ec
tiv

el
y
N
/A
N
/A
St
ro
ng
Q
ui
nn

[8
5]
,

Th
es
is

(2
00
2)

M
ix
ed
m
et
ho

ds
:

qu
al
ita
tiv

e
lo
ng

in
te
rv
ie
w
st
ud

y
w
ith

su
rv
ey
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz
e:
n
=
14
Su
bj
ec
ts
:C

N
A
so

fo
ne

re
si
de
nt
ia
lc
ar
e
fa
ci
lit
y

Se
m
is
tr
uc
tu
re
d,

en
-e
nd

ed
in
te
rv
ie
w
s

in
th
ei
r

jo
bs
.S
ta
rt
ed

w
ith

2
op

en
-e
nd

ed
jo
b

sa
tis
fa
ct
io
n
qu

es
tio
ns
N
/A
N
/A
St
ro
ng
Ty
le
r[
78
]∗
,
H
ea
lth
C
ar
e
M
an
ag
em
en
t
Re
vi
ew
(2
00
6)
M
ix
ed
m
et
ho
ds
:
gr
ou

nd
ed

th
eo
ry
an
d
cr
os
s-
se
ct
io
na
l
su
rv
ey
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz
e:
n
=
11
46
(s
ur
ve
ys
)
n
=
14
4
(i
nt
er
vi
ew
s)
n
=
37

(p
ar
tic

ip
an
t

ob
se
rv
at
io
ns
)

Su
bj
ec
ts
:C
N
A
s,
R
N
s,
m
an
ag
em
en
ta
t2
0
fa
ci
lit
ie
s
Q
ua
lit
at
iv
e:
et
hn
og
ra
ph
ic
in
te
rv
ie
w
s
an
d
pa
rt
ic
ip
an
t
ob
se
rv
at
io
ns
Q
ua
nt
ita
tiv
e:
qu
es
tio
nn
ai
re
(i
)S
ki
ll
va
ri
et
y

(i
i)
Ta
sk

id
en
tit
y
(i
ii)
Ta
sk
si
gn
ifi
ca
nc
e
(iv
)A
ut
on
om
y
(v
)I
nt
ri
ns
ic
fe
ed
ba
ck
M
od
ifi
ed
ve
rs
io
n
of
th
e
Jo
b
D
ia
gn
os
tic
Su
rv
ey
(J
D
S)
𝛼
=
0.
35
–0
.7
1
N
ot
re
po
rt
ed
Lo
w
m
od
er
at
e/
st
ro
ng
Ye
at
ts
[5
5]
∗
,
Th
e
G
er
on
to
lo
gi
st
(2
00
7)
M
ix
ed
m
et
ho
ds
:

be
fo
re
-a
nd

-a
fte

r
w
ith

sm
al
la
m
ou
nt
of
qu
al
ita
tiv
e
da
ta
C
ou
nt
ry
:U
SA
Sa
m
pl
e
siz
e:
no
tr
ep
or
te
d
Su
bj
ec
ts
:C
N
A
s
Q
ua
nt
ita
tiv
e:
qu
es
tio
nn
ai
re
s
Q
ua
lit
at
iv
e:
(i
)P
ar
tic
ip
at
in
g
ob
se
rv
at
io
ns
,o
fo
ve
r2
70
C
N
A
te
am
m
ee
tin
gs
(i
i)
Ex
am
in
at
io
n
of
w
ee
kl
y
te
am
-m
ee
tin
g
su
m
m
ar
ie
sf
or
m
an
ag
em
en
ta
nd
m
an
ag
em
en
t’s
re
sp
on
se
s
Em
po
w
er
m
en
t
In
de
x
in
C
N
A
su
rv
ey
(d
et
ai
ls
of
ite
m
sn
ot
re
po
rt
ed
)
C
N
A
su
rv
ey
in
di
ce
sr
an
ge
d
fr
om
0.
60
to
0.
85
(s
pe
ci
fic
in
de
x
fo
r
JS
no
tr
ep
or
te
d)
Fa
ct
or
an
al
ys
is
to
de
te
rm
in
e
ite
m
si
n
al
ls
ur
ve
y
in
di
ce
s
W
ea
k
∗

Th
es
e
st
ud

ie
sa

re
lis
te
d
as

bo
th

qu
an
tit
at
iv
e
an
d
qu

al
ita
tiv

e
as

th
ey

em
pl
oy
ed

a
m
ix
ed

m
et
ho

ds
st
ud

y
de
si
gn

.
∗
∗

Th
e
ov
er
al
ls
tu
dy

de
si
gn

is
qu

as
i-
ex
pe
ri
m
en
ta
l.
Th

e
ex
pl
an
at
or
y
va
ri
ab
le
sf
ro
m

th
es
e
st
ud

ie
su

se
d
in

ou
ra

na
ly
si
sa

re
th
e
in
de
pe
nd

en
tv
ar
ia
bl
es
,n

ot
th
e
ex
pe
ri
m
en
ta
lv
ar
ia
bl
e(
s)
.

A
LF

:a
ss
is
te
d
liv
in
g
fa
ci
lit
y,
C
N
A
:c
er
tifi

ed
nu

rs
in
g
as
si
st
an
t,
D
C
W
:d

ir
ec
tc

ar
e
w
or
ke
r,
EN

:e
nr
ol
le
d
nu

rs
es
,H

C
A
:h

ea
lth
ca
re

ai
de
s,
H
PP

D
:h

ou
rs

pe
r
pa
tie

nt
da
y,
JS
:j
ob

sa
tis
fa
ct
io
n,

LT
C
:l
on

g-
te
rm

ca
re
,N

A
:

nu
rs
in
g
as
si
st
an
t,
PA

C
E:

Pr
og
ra
m

of
A
ll-
In
cl
us
iv
e
C
ar
e
fo
rt
he

El
de
rl
y,
R
N
:r
eg
is
te
re
d
nu

rs
e,
an
d
SC

U
:s
pe
ci
al
ca
re

un
it.

Nursing Research and Practice 15

Table 3: Individual factors (reported four or more times).

Category First author Significance (S=𝑝< .05) Direction

(magnitude)
Methodological

quality Sample size

(1) Sociodemographics (n = 13 studies)

Age (𝑛 = 12
studies)

Allensworth-Davies [47] NS Weak 135
Blackmon [49] NS Weak 188
Choi [53] NS High moderate 2,254
Friedman [56] S + (𝛽= 0.15) High moderate 349
Gittell [58] NS Low moderate 252
Grieshaber [60] NS Weak 79
Kuo [10] NS Low moderate 114
Lerner [65] NS Low moderate 556
McGilton [67] NS High moderate 222
Parsons [33] NS Weak 550
Simpson [73] S + (𝛽= 0.14) High moderate 504
Walborn [79] S + (𝑟= 0.218) Weak 185

Ethnicity (𝑛 = 7
studies)

Allensworth-Davies [47] NS Weak 135
Blackmon [49] NS Weak 188
Choi [53] NS High moderate 2,254
Kuo [10] S + (𝛽= 0.32) Low moderate 114
McGilton [67] S − (𝛽=−0.28) High moderate 222
Parsons [33] NS Weak 550

Ramirez [71] S (for 2/3races)
− (𝛽=−0.14
to−0.20) Low moderate 337

Gender (n = 6
studies)

Blackmon [49] NS Weak 188
Gittell [58] NS Low moderate 252
Kuo [10] NS Low moderate 114
Lerner [65] NS Low moderate 556
McGilton [67] NS High moderate 222
Parsons [33] NS Weak 550

(2) Education (n = 17 studies)

Level of
education/years
Education (n = 10
studies)

Blackmon [49] NS Weak 188
Choi [53] NS High moderate 2,254
Friedman [56] NS High moderate 349
Gittell [58] NS Low moderate 252
Goldwasser [59] S −∗ Weak 27
Grieshaber [60] NS (urban) Weak 79
Grieshaber [60] S (suburban) − (𝑟=−0.51) Weak 79
Kuo [10] NS Low moderate 114
Lerner [65] NS Low moderate 556
Parsons [33] NS Weak 550

Walborn [79] S − (𝑟=
−0.274) Weak 185

Special training (n
= 8 studies)

Blackmon [49] NS Weak 188
Braun [51] S +∗ Weak 105
Ramirez [71] S − (𝑟=−0.13) Low moderate 337
Resnick [72] NS Low moderate 13
Simpson [73] NS High moderate 504
Tannazzo [76] NS Low moderate 301
Thompson [77] NS Weak 40
Webb [80] NS Weak 178

16 Nursing Research and Practice

Table 3: Continued.

Category First author Significance (S=𝑝< .05) Direction (magnitude) Methodological quality Sample size

(3) Healthcare provider characteristics (n = 18 studies)

Empowerment
(n = 5 studies)

Cready [54]
(autonomy in decision making and
perceived meaningful work with a
feeling of competence to do it)

S +∗ Weak 434

Gruss [61]
(perceived control and access to power
within the organization)

S + (𝑟= 0.46) Low moderate 42

Kostiwa [64]
(transfer of power to nonmanagement
employees)

S + (𝛽= 0.294) Low moderate 60

Kuo [10]
(perceived support, access to
information and resources,
opportunity to learn and grow, good
relationships with staff)

S + (𝑟= 0.366) Low moderate 114

Yeatts [55]
(autonomy in decision making and
perceived meaningful work with
competence to do it)

NS Weak Not reported

Years of experience
(n = 5 studies)

McGilton [67] NS High moderate 222
Lerner [65] S + (𝛽= 0.230) Low moderate 114
Ramirez [71] NS Low moderate 337
Simpson [73] NS High moderate 504
Walborn [79] S + (𝑟= 0.204) Weak 185

Current position
tenure (n = 3
studies)

Gittell [58] NS Low moderate 252
Grieshaber [60] NS (urban) Weak 79
Grieshaber [60] S (suburban) + (𝑟= 0.38) Weak 79
Liu [66] S − (𝛽=−0.14) High moderate 244

Employment status
(rotating, part
time, full time) (n
= 4 studies)

Albanese [46] NS Weak 255

Burgio [52] S 𝐹(1,173)=6.38 Low moderate 178

Liu [66] S − (𝛽=−0.15) High moderate 244
McGilton [67] NS High moderate 222

Autonomy (n = 3
studies)

Allensworth-Davies [47]
(definition not reported) S + (𝛽= 0.23) Weak 135

Friedman [56] (opportunity to use
their own judgment) NS High moderate 349

Friedman [56] (opportunity to
organize workload) S + (𝛽= 0.17) High moderate 349

Tyler [78]
(degree to which a job provides
independence and discretion in
scheduling work and determining
ways to carry it out)

S ∗ Lowmoderate/strong 1146

(4) Personal life (n = 4 studies)

Stress (n = 4
studies)

Albanese [46] S − (𝑟=−0.37) Weak 255
McGilton [67] S − (𝛽=−0.19) High moderate 222
Parmelee [68] NS High moderate 188
Purk [70] NS Weak 34

∗: test statistic value not reported; 𝑟: estimate of the Pearson product-moment correlation coefficient; 𝛽: in multiple regression, a standardized coefficient
indicating the relative weight of a predictor variable.

Nursing Research and Practice 17

Table 4: Organizational factors (reported four or more times).

Category First author Significance(S =𝑝< .05) Direction

(magnitude)
Methodological
quality Sample size

(1) Facility (n = 3 studies)

Resources
(𝑛= 3 studies)

Garland [57] S + (𝑟= 0.43) Low moderate 138
Kuo [10],

information NS Low moderate 114

Kuo [10], resources S + (𝛽= 0.32) Low moderate 114
Ramirez [71] S + (𝛽= 0.24) Low moderate 337

(2) Work environment (n = 13 studies)

Satisfaction with
salary/benefit
(𝑛= 4 studies)

Choi [53], salary NS High moderate 2,254
Choi [53], benefits S OR = 1.14∗∗ High moderate 2,254

House [63] NS Low moderate 148
Parsons [33], salary NS Weak 550

Parsons [33],
benefits NS Weak 550

Purk [70] S ∗ Weak 34

Job performance
(𝑛 = 4 studies)

Kovach [9] NS Strong 177
Liu [66] S + (𝛽= 0.40) High moderate 244

Simpson [73] NS High moderate 504
Walborn [79] NS Weak 185

Support from
coworkers

(𝑛 = 6 studies)

Friedman [56] NS High moderate 349
Kuo [10] NS Low moderate 114

Parmelee [68] S − (𝛽=−0.145) High moderate 188
Parsons [33] S + (𝛽= 0.138) Weak 550
Proenca [69] NS Low moderate 129

Thompson [77] S ∗ Weak 40
(3) Workload (n = 5 studies)

Workload
(𝑛 = 5 studies)

Berg [48]
(perceived strain) S − (𝑟=−0.38) Weak 233

Garland [57] S + (𝑟= 0.3) Low moderate 138
Parmelee [68] S − (𝛽=−0.283) High moderate 188
Ramirez [71] S − (𝛽=−0.21) Low moderate 337

Thompson [77] S ∗ Weak 40
∗: test statistic value not reported; ∗∗: 𝜒2 not reported; 𝑟: estimate of the Pearson product-moment correlation coefficient; 𝛽: in multiple regression, a
standardized coefficient indicating the relative weight of a predictor variable.

were most frequently mentioned in both quantitative and
qualitative studies; respondents in all 7 qualitative studies
discussed 1 or more work environment factors. Of partic-
ular significance is that 3 factors not studied quantitatively
emerged in the qualitative studies as important to care aide
job satisfaction: contact/relationships with residents [82–85],
nature of the job (care aide work) [62, 84, 85], and opportunity
for learning and advancement [62, 74, 82].

4. Discussion

4.1. Summary of Findings. This systematic review examined
the evidence on associations between individual and orga-
nizational factors and care aide job satisfaction. The body
of evidence provides significant empirical support for the
relationship of several factors to an increase in care aides’

job satisfaction. Important individual factors identified were
empowerment and autonomy. Six individual factors were
shown to be not important: age, ethnicity, gender, education
level, attending specialized training, and years of experience.
Important organizational factors were facility resources and
workload. Two organizational factors were found to be not
important: care aide satisfaction with salary/benefits and job
performance.

4.2. Comparison with the Review on Job Satisfaction among
Hospital Registered Nurses. No previous syntheses exist on
job satisfaction in care aides or with nursing care providers
in residential LTC, but job satisfaction among registered
nurses in hospitals was subject to a recent systematic review
[20]. Both studies found the individual factors autonomy and
empowerment to be important to job satisfaction. However,

18 Nursing Research and Practice

Table 5: Individual factor conclusions.

Sociodemographic

Age 3/12 (25%) reports significant No relationship with jobsatisfaction

Ethnicity 3/7 (43%) reports significant No relationship with jobsatisfaction

Gender 0/6 (0%) reports significant No relationship with jobsatisfaction
Education

Level of education/years
Education 3/11 (27%) reports significant

No relationship with job
satisfaction

Special training 2/8 (25%) reports significant No relationship with jobsatisfaction
Professional characteristics

Empowerment 4/5 (80%) reports significant Positive relationship with jobsatisfaction

Years of experience 2/5 (40%) reports significant No relationship with jobsatisfaction

Current position 2/4 (50%) reports significant Equivocal relationship with jobsatisfaction

Employment status 2/4 (50%) reports significant Equivocal relationship with jobsatisfaction

Autonomy 3/4 (75%) reports significant Positive relationship with jobsatisfaction
Personal life

Stress 2/4 (50%) reports significant Equivocal relationship with jobsatisfaction

Table 6: Organizational factor conclusions.

Facility
Resources 3/4 (75%) reports significant Positive relationship with job satisfaction

Work environment
Satisfaction with salary/benefits 2/6 (33%) reports significant No relationship with job satisfaction
Job performance 1/4 (25%) reports significant No relationship with job satisfaction
Support from coworkers 3/6 (50%) reports significant Equivocal relationship with job satisfaction

Workload
Workload 5/5 (100%) reports significant Positive relationship with job satisfaction

several important differences between our review and the
hospital registered nurse review are evident. First, in the
hospital registered nurse group, job satisfaction was closely
related to working conditions and organizational and envi-
ronmental factors, namely, job stress, role conflict/ambiguity,
role perception/content, organizational commitment, and
professional commitment. While we found similar overall
categories, we found different factors within these categories
to be important to care aide job satisfaction in residential
LTC. For example, both nurse job satisfaction and care aide
job satisfaction were closely related to working conditions,
but care aides noted workloads and availability of facility level
resources as important (Table 4) while registered hospital
nurses noted team cohesiveness and physical conditions of
the unit to be important [20]. Coworker support had a
high moderate relationship to hospital registered nurse job
satisfaction [20] but was only equivocally related to care

aide job satisfaction (Table 4). Second, while age, years of
experience, and education level all had significant relation-
ships with job satisfaction in hospital registered nurses [20],
these individual factors were not consistently significant to
care aide job satisfaction (Table 3). Third, stress had a strong
relationship with registered nurse job satisfaction [20] but
only an equivocal relationship for care aides (Table 3). Each
of these discrepancies may reflect true differences between
groups (i.e., between registered nurses and care aides) and/or
settings (i.e., between hospitals and residential LTC) or may
reflect differences in synthesis methods. Lu and colleagues
[20] reported all factors displaying statistically significant
findings in any study as important to registered nurse job
satisfaction. In this synthesis, we applied stringent decision
rules. To classify a factor as important to job satisfaction,
we required it to be tested 4 or more times and have
significant findings in at least 60% of those studies. Regardless

Nursing Research and Practice 19

Table 7: Summary of qualitative findings.

Factor First author Details

Individual factors

Education
Pursuing education Snow [74] CNAs reported they would have greater job satisfaction with more education/expanded skills

Pursuing nursing
career Snow [74]

(i) CNAs pursuing a nursing career reported the highest level of job satisfaction, followed by
CNAs with no plans for further education
(ii) CNAs pursuing education outside of health care reported the lowest levels of job
satisfaction

Other
Feeling needed/useful Bye [82] 93% stated feeling needed/useful was the most satisfying aspect of their work

Organizational factors
Facility: resources
Equipment and
supplies Quinn [85] Mainly positive responses, more resources linking to higher job satisfaction

Facility: other
Workplace flexibility Moyle [84] Related to job satisfaction
Working on skilled
units Bye [82] Some enjoyed challenge of working on skilled units

Facility Bye [82] Some were happy in their current facility and would not like to go to another facility
Pay satisfaction Quinn [85] Typical responses positive in relation to job satisfaction
Benefits satisfaction Quinn [85] Many variant responses positive/negative re job satisfaction
Facility’s response to
needs and concerns Quinn [85] Many variant responses positive/negative re job satisfaction

People in
management Quinn [85] Many variant responses positive/negative re job satisfaction

Admin support Karner [83] Contributing to increased job satisfaction—appropriate and kind administrative support;respectful of aides’ knowledge
Work environment
Working with
unskilled or
inappropriately
trained staff

Moyle [84] Related to job dissatisfaction

Working conditions Holtz [62] 68% of aides said that they were extremely or very important to their job satisfaction
Organizational
structure Karner [83]

Contributing to increased job satisfaction—fair and consistent organizational structures;
hands-on training and adequate staff

Recognition/respect

Holtz [62] 77% of aides said that it was extremely or very important

Quinn [85] Many variant responses—some say recognition for work is important to job satisfaction andothers lead to job dissatisfaction
Quinn [85] Typical response negative for quantity of recognition leading to job satisfaction
Walborn [79] Nurse aides would like more respect, for example, from family members

Residents

Bye [82] Most identified their interaction with residents as the most satisfying aspect of their job
Quinn [85] Many variant responses, typical response positive in relation to job satisfaction

Moyle [84]
(i) Related to job satisfaction
(ii) Contact with residents promotes enjoyment and job satisfaction
(iii) Job satisfaction comes from resident: interactions and appreciation

Walborn [79] Interacting with residents was a satisfying aspect of the job
Karner [83] Relation with residents was a satisfying aspect of the job

Family member
participation in
resident care

Karner [83] Contributing to increased job satisfaction

Interpersonal
relationships

Quinn [85] Typical response positive in relation to job satisfaction
Holtz [62] 100% of aides said that interpersonal relationships were important or extremely important
Bye [82] 53% said these were 2nd and 3rd greatest satisfiers

20 Nursing Research and Practice

Table 7: Continued.

Factor First author Details
Support from
coworkers

Moyle [84] (i) Good teamwork increases job satisfaction(ii) Job dissatisfaction occurs when staff members are intolerant/upset
Karner [83] Contributing to increased job satisfaction
Quinn [85] Typical response positive in relation to job satisfaction

Tensions within role
expectations Moyle [84] Related to job dissatisfaction

Absenteeism Quinn [85] Typical responses negative in relation to job satisfaction
Environment
(homelike) Karner [83] Contributing to increased job satisfaction

Building design Quinn [85] Many variant responses positive in relation to job satisfaction

Positive feedback Tyler [78] Positive feedback often comes from residents and this type of feedback is more important thanfeedback received from supervisors
Communication—
valued
input

Quinn [85] Many variant responses negative in relation to job satisfaction

Respect Walborn [79] Nurse aides would like more respect, for example, from family members
Supervision

Supervision Holtz [62] 90% of aides said that it was extremely or very important
Walborn [79] Nursing assistants would like to be listened to by charge nurses/managers

Staffing
Number of staff and
workloads Quinn [85] Mainly positive responses with respect to more staff linking to higher job satisfaction

Staffing levels Moyle [84]
(i) Job satisfaction decreases when tasks and time constraints prevent the opportunity to relate
to residents and increases likelihood of error
(ii) Dissatisfied with anything that took them away from resident care

Increasing need to be
available for overtime Moyle [84]

(i) Related to job dissatisfaction
(ii) Overtime created both job satisfaction and dissatisfaction

Other: opportunity for
learning and
advancement
Learning and growing
on the job Bye [82] 17% said this was 2nd and 3rd greatest satisfiers

Expansion of scope of
practice Snow [74]

Overall 92% of the certified nursing assistants believed that expansion of their scope of practice
would increase their job satisfaction

Advancement Holtz [62] 48% of aides said that it was extremely or very important
Other: nature of the
job

Work itself
Holtz [62] 84% of aides said that it was extremely or very important
Quinn [85] Many variant responses in relation to job satisfaction

Moyle [84]
(i) Laborious tasks (such as documentation) related to job dissatisfaction
(ii) Job dissatisfaction occurs when tensions are not recognized in the workplace: managerial
staff not listening to concerns

of the reason(s) for differences between the two reviews,
these differences highlight the importance of conducting
systematic reviews in LTC and with nursing care provider
groups other than registered nurses. These findings also
importantly suggest that different strategies may be needed to
improve care aide job satisfaction in residential LTC facilities
compared to hospital nurses.

4.3. Methodological Implications for Future Research. Sys-
tematic reviews typically identify problems with internal
validity of research under investigation. Future studies on
factors related to care aide job satisfaction need to empha-
size methodological quality, to reduce bias and increase

confidence in this growing body of knowledge. Researchers
will then be able to design better-informed interventions to
improve care aide job satisfaction, recruitment, and retention
of this vital staffing group.

Two important methodological limitations of the studies
conducted to date included in this review are methodological
quality and statistical rigor. Few studies included in this
review were of high moderate or strong methodological
quality, illustrating a clear need for well-designed, robust
studies in the area. Studies also varied in statistical rigor,
although we observed a promising trend in recent studies to
more robust analyses (multivariate regression over bivariate
and univariate statistics). Given the heterogeneity among

Nursing Research and Practice 21

studies, however, we could only draw conclusions on which
factors are associated with job satisfaction and not on which
factors predict job satisfaction. Future research should look
more closely at prediction; only 14 (38%) of our 37 included
quantitative studies reported prediction (multivariate regres-
sion).

4.4. Limitations of This Review. While we used rigorous
methods in this review, there are limitations. First, we did
not search all grey literature databases; therefore, this review
may not include all relevant work. Second, we did not
attempt to clarify unclear study details by contacting the
study authors; nonreported aspects of methods may have
lowered scores in our quality assessment. Third, we used
vote counting to synthesize quantitative data. Vote counting
does not account for effect sizes (it gives equal weight to
all associations irrespective of magnitude) or precision of
estimates (it gives equal weight to comparisons irrespective of
sample size). To lessen these problems we reported the num-
ber of comparisons showing statistically significant effects
(regardless of direction) and the magnitude of effect for
significant findings [92]. Fourth, there is a small possibility
of a culture effect given the fact that different countries may
experience job satisfaction differently and also have different
determinants to job satisfaction. This effect should however
be minimal given the fact that the vast majority of studies
identified are from the USA (𝑛 = 37 of 42). Finally, our
criteria for reaching a conclusion on the factors important
to job satisfaction were stringent and while we considered
overall methodological quality of the included studies in
determining these conclusions, we did not take into account
specific individual methodological strengths and weaknesses
of each study in determining which factors were important
overall to care aide job satisfaction.

5. Conclusions

We identified several factors as important to care aide
job satisfaction. Individual factors were empowerment and
autonomy; organizational factors were facility resources and
workload. Equally important, several factors were shown to be
not important: age, ethnicity, gender, education level, attend-
ing specialized training, years of experience, satisfaction with
salary/benefits, and job performance. Factors identified as
important hold promise as targets of care aide job satisfaction
interventions. However, methodological problems inherent
in many studies suggest that additional research using more
robust study designs and multivariate assessment methods
is required. Future research might also usefully test the
association between care aide job satisfaction and the factors
identified in qualitative studies included in this review:
contact/relationships with residents, nature of the job (care aide
work), and opportunity for learning and advancement.

List of Abbreviations

ARD: Age-related dementia
LTC: Long-term care
RN: Registered nurse

LPN: Licensed practical nurse
RPN: Registered practical nurse
NA: Nursing assistant/aide
CNA: Certified nurse aide.

Disclosure

Janet E. Squires holds a University Research Chair in Health
Evidence Implementation and a Canadian Institutes for
Health Research (CIHR) New Investigator Award. Carole
A. Estabrooks holds a CIHR Canada Research Chair in
Knowledge Translation. Matthias Hoben holds an Alberta
Innovates-Health Solutions (AIHS) Postdoctoral Fellowship.

Conflict of Interests

The authors declare that they have no competing interests.

Authors’ Contribution

Janet E. Squires and Carole A. Estabrooks conceptualized the
study. Janet E. Squires and Heather L. Carleton undertook the
articles selection. Janet E. Squires, Matthias Hoben, Stefanie
Linklater, Heather L. Carleton, and Nicole Graham under-
took data extraction and quality assessment. Janet E. Squires,
Stefanie Linklater, and Heather L. Carleton undertook data
synthesis. Janet E. Squires drafted the paper. All authors
provided critical commentary on the paper and approved the
final version.

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