JONA Volume 45, Number 5, pp 276-283 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
THE JOURNAL
OF N U R S I N G
ADMINISTRATION
Linking Nurses’ Perceptions of Patient Care Quality to Job Satisfaction The Rote o f A uthentic Leadership and Empowering Professional Practice Environments
H e a th e r K. S p e n c e L a s c h in g e r, P h D , RN , FA A N , FCAHS R o b e rta F id a , BA , M A , PhD
OBJECTIVES: A model linking authentic leadership, structural em pow erm ent, and supportive professional practice environments to nurses’ perceptions of patient care quality and job satisfaction was tested. B A C K G R O U N D : Positive w ork environm ent char acteristics are im portant for nurses’ perceptions of pa tient care quality and job satisfaction (significant factors for retention). Few studies have exam ined the m echa nism by which these characteristics operate to influence perceptions of patient care quality or job satisfaction. M E T H O D S : A cross-sectional provincial survey of 723 Canadian nurses w as used to test the hypothesized m odels using structural equation modeling. RESULTS: The m odel w as an acceptable fit and all paths were significant. Authentic leadership had a posi tive effect on stru ctu ral em pow erm ent, w hich had a positive effect on perceived support for professional practice and a negative effect on nurses’ perceptions that inadequate unit staffing prevented them from provid ing high-quality patient care. These w orkplace condi tions predicted job satisfaction.
Author Affiliations: Distinguished Professor and Arthur Labatt Family Nursing Research Chair in Health Human Resource Optimi zation (Dr Spence Laschinger), Arthur Labatt Family School of Nurs ing, The University of Western Ontario, London, Ontario, Canada; Assistant Professor (Dr Fida), Departm ent of Psychology, Sapienza University of Rome, Rome, Italy. This study was funded by a research grant from the Canadian Institutes of Health Research. The authors declare no conflicts of interest. Correspondence: Dr Spence Laschinger; Faculty of Health Sciences, School of Nursing, Health Sciences Addition H41, The University of Western Ontario, 1151 Richmond Street, London, Ontario, Canada N6A 5C1 ([email protected]). DOI: 10.1097/NNA. 0000000000000198
276
C O N C L U SIO N : Authentic leaders play an im portant role in creating empowering professional practice environ ments that foster high-quality care and job satisfaction. Retention of nurses to ensure high-quality patient care (HQPC) is a w orldw ide priority in current healthcare settings.1,2 W ith many nurses approaching retirement, every effort must be made to ensure that nurses’ w ork environments foster optimal professional practice, thereby prom oting job satisfaction and discouraging thoughts of leaving the profession. An important aspect of nurses’ satisfaction with their job and career has been linked to their ability to provide high-quality care to their clients.J’4 Few studies, however, have investigated the m echa nisms through which work environment characteristics, such as em pow ering leadership and supportive p ro fessional practice environments, influence perceptions of patient care quality and, ultimately, nurses’ job satis faction.^ Leaders play an im portant role in shaping the professional practice environm ent to em pow er nurses to provide safe, effective patient care,6 which theoret ically should result in higher perceptions of patient care quality and job satisfaction. The purpose of this study is to test a m odel linking au th en tic leadership (AL), structural em powerm ent, and supportive professional practice environm ents to nurse-assessed patient care quality and, ultimately, nurse job satisfaction. T heoretical Fram ew ork T his study integrates concepts from Avolio and G ardner’s7 theory of AL, R an ter’s theory of struc tu ral em p o w erm en t,8’9 and the Magnet® H o spital M odel (M H M ), originally described by M cClure and colleagues,10’11 to examine how these factors influence
JO N A • Vol. 45, No. 5 • M ay 2015
nurse-assessed patient care quality (NAPCQ) and job satisfaction. The theoretical underpinnings of the con cepts in our proposed model are described in the up coming paragraphs. Authentic Leadership According to Avolio and Gardner,7 AL is a positive relational leadership style whereby leaders behave in an authentic manner with their followers and focus on furthering their development. Authentic leaders con sistently use 4 key behaviors in the work setting: rela tional transparency (presenting themselves as they truly are), balanced processing (considering differing points of view before making decisions), moral/ethical behavior (acting in accordance with internal moral and ethical values), and self-awareness (having insight about self and influence on others).7,12 Empirical support for this model has been shown in both general management settings and in nursing. Wong and Laschinger13 found th at AL positively influenced nurses’ perform ance through structural empowerment in their workplace. M ore recently, Laschinger and Fida14 found that AL played a protective role against early career burnout of nurses. These findings highlight the importance of AL in creating healthy, effective nursing work environments. Structural Empowerment According to Kanter’s model of organizational em powerm ent,8,9 4 organizational empowerment struc tures play an important role in employee effectiveness: access to information, access to support, access to re sources needed to do the job, and opportunities to learn and grow. Access to information refers to having knowl edge of organizational goals and policies, as well as having job-related technical knowledge and expertise. Access to support entails feedback and guidance re ceived from superiors, peers, and subordinates, as well as the emotional support from others in the workplace. Access to resources refers to access of the materials, money, supplies, time, and equipment required to ac complish organizational goals. Finally, access to oppor tunity for mobility and growth entails access to challenges and professional development opportunities to expand knowledge and skills. There is considerable support for structural em powerment theory in the nursing population. Struc tural em powerm ent (SE) has been linked to nurses’ job satisfaction, commitment, trust, productivity, and burnout.Lv 17 Empowerment has also been associated with nurses’ perceptions of support for professional practice in nursing work environments.18,19 M agnet Hospital Model The M H M was developed by the American Nurses’ Association based on a body of research identifying
JONA • Vol. 45, No. 5 • May 2015
factors in nursing w ork environments that support professional nursing practices and therefore attracted and retained nurses.10 In the original model, 3 core factors were posited to result in positive nurse and pa tient outcomes: (1) autonomy, (2) control over practice environment, and (3) effective nurse-physician relation ships.20 Laschinger and colleagues19 reported signifi cant relationships between these M agnet hospital characteristics and structural empowerment in Canadian nursing settings, and numerous studies have linked these worklife factors to a variety of nurse outcomes such as job satisfaction,21'23 burnout,24,25 and NAPCQ and adverse events occurrence.26,27 Scott et al28 re ported support for the positive effects of Magnet hospital characteristics on care quality. These findings were corroborated in a large study of European hospital nurses. Nurse-Assessed Patient Care Quality High-quality patient care is the ultimate goal of any healthcare delivery system and is arguably the essence of nursing. Often, HQPC is defined as care that results in optimal patient functioning. Nurses, given their 24-7 contact with patients, play an integrative role in the patient care process and are well qualified to pro vide accurate assessments of the quality of patient care in their units. In fact, M cHugh and Stimpfel30 found that nurse-assessed quality of patient care was signifi cantly associated with objective hospital quality indica tors, such as patient satisfaction, failure to rescue, and mortality odds. They suggest that it is therefore impor tant to consider nurses’ reports of patient care quality in addition to objective measures when monitoring pa tient care quality in hospitals. Adequate staffing is important for accomplishing satisfactory patient care.31,32 Inadequate nurse staff ing levels interfere with nurses’ ability to appropriately manage patient care needs and are a source of nurse frustration, heavier w orkload, and job dissatisfac tion.2'’^ 1,3'5 Laschinger27 found that structural em powerment and staffing adequacy were significant predictors of nurse-assessed quality of care, and Aiken and colleagues34 linked poor staffing levels to patient mortality. Poor nurse staffing levels have also been as sociated with increased risk of in-hospital complica tions, patient mortality, and patient morbidity.22,35,36 Nurse Job Satisfaction and Perceptions of Patient Care Quality Job satisfaction has been shown to be a key retention factor among nurses. N urses’ autonom y to provide patient care in line with their knowledge and experience has been consistently found to be a strong predictor of nurses’ job satisfaction,37,38 and job satisfaction has been consistently associated with nurse turnover
277
intentions.j9 N um erous studies have dem onstrated strong relationships between supportive professional practice environm ents and nurse job satisfaction and perceived quality of care.27,28’40 Research has also shown that nurses’ job satisfaction is related to the quality of care on their units.3,41’42 M ore recently, Kalisch and colleagues5 found th at process factors, such as inade quate staffing and nurses’ reports of missed care, were significant predictors of job dissatisfaction. Although these studies dem onstrate the im portance of nurses’ perceptions of patient care quality for their job satis faction, they do not provide a m ore nuanced descrip tion of how various w ork environm ent factors interact to influence nurses’ satisfaction. We draw from theory and research to propose a theoretical model linking AL to supportive practice environments and, subsequently, to N A PC Q and job satisfaction. The overall hypothesized m odel is illustrated in Figure 1. We predict that AL will lead to greater struc tural em pow erm ent (hypothesis 1). Structural em pow erment, in turn, will lead to a m ore supportive practice environm ent (hypothesis 2) and m ore adequate staff ing (hypothesis 3). W hen adequate staffing and a sup portive practice environm ent are in place, nurses will perceive greater quality of patient care (hypotheses 4 and 5), w hich will lead to greater job satisfaction (hypothesis 6).
M e th o d s
Study Design T his study used cross-sectional d ata of a provincial study of nurses w orking in direct care roles in O ntario, C anada (n = 723). Ethics approval was obtained from the university ethics board before com m encing the study. Registered nurses were random ly selected from the provincial professional registry database. Partic ipants received a mail survey package th a t included a letter of inform ation, the study questionnaire, and a $2 coffee voucher. Using the p rocedure of D illm an et al43 to optim ize response rates, nonresponders re
278
ceived a rem inder letter 4 weeks after the initial m ail ing, followed by a 2nd survey package 4 weeks later.
Participants A total of 723 nurses w ere eligible for the analysis in this study. Eligible participants were nurses w orking in direct patient care settings.
Instruments
Authentic Leadership The A uthentic Leadership Q uestionnaire12 measures 4 dimensions of AL behavior: self-awareness (4 items), m oral-ethical perspective (4 items), balanced process ing (3 item s), and tran sparency (5 item s). Item s are rated on a 5-point Likert scale from 0 = strongly dis agree to 4 = strongly agree. Previous studies have sup ported the reliability and validity of this instrum ent am ong nurses (C ronbach’s a = .91).44 In the current study, C ronbach’s a was .97.
Structural Empowerment Structural empowerment was measured using the Con ditions of W ork Effectiveness-II (CWEQ-II), a 12-item instrum ent th at measures nurses’ perceptions of access to em pow erm ent structures originally described by K anter.9 Item s are rated on a 5 -p o in t L ikert scale, which are summed and averaged to create 4 subscales (access to inform ation, support, resources, and oppor tunity), which are then summed to create an overall score ranging from 4 to 20.45 The construct validity of the CWEQ-II was established by Laschinger et al,17 with C ronbach’s a reliabilities ranging from .79 to .82.46
Magnet Hospital Characteristics We used 6 items from Aiken and Patrician’s47 Nursing W ork Index-R evised (NW I-R) to measure 3 aspects of supportive professional practice environments: auto nom y (2 item s), co ntrol over practice environm ents (2 items), and nurse-physician collaboration (2 items). We reverse-scored the item s such th a t a high score signified a high level of M agnet hospital characteristics in the w ork setting. Items were summed and averaged
JONA • Vol. 45, No. 5 • May 2015
to create a total score. In this study, the a reliability was acceptable (Cronbach’s a = .80).
Measures o f Nurse-Assessed Patient Care Quality Nurse-assessed patient care quality was measured using a single item “How would you describe the quality of nursing care delivered to patients in your unit?” rated on a 4-point Likert scale ranging from excellent, good, fair, or poor. This measure has good predictive validity and corresponds well with hospital quality indicators such as mortality, failure to rescue, and patient satis faction.l0 To create a positive measure of patient care quality, the item was reverse scored. As an additional measure of NAPCQ, nurses re sponded to the question “In the last month, how often has short-staffing affected your ability to meet your patient/clients’ needs?”3'’ The item is rated on a 5-point scale, ranging from 1 = never, 2 = monthly, 3 = weekly, 4 = several times a week, and 5 = daily.
Job Satisfaction We used 3 items from the measure of Cammann et al4S of health professionals’ job satisfaction (“All in all, I am satisfied with my job,” “In general, I don’t like my job,” and “In general, I like working here”). Items were rated on a 5-point Likert scale (1 = strongly dis agree, 5 = strongly agree). In the present study, the reliability for the job satisfaction scale was good (C ronbach’s a = .77). D ata Analysis Descriptive statistics and scale reliabilities were ana lyzed using the Statistical Package for the Social Sciences (SPSS), version 21.0.43 We tested our hypothesized model using structural equation modeling (SEM) ana lysis with MPlus version 6.1.50 To test the fit between the data and the hypo thesized model, SEM with maximum likelihood esti mation was used. Structural equation modeling provides estimates of model fit by comparing the covariance structure of the observed data to that of the theorized model. ’1 The maximum likelihood estimation method approximates model parameters that are most likely to result in the observed data.51 A perfect fit means that there is no discrepancy between the model and the observed data. Fit statistics recommended by Kline’2 and Hu and Bender’3 were used to assess the fit between the covariance structure of the data and the hypothesized model: %2, j 2 (^2/df), com parative fit index (CFI; values >0.95 indicate a good fit), incremental fit in dex (IFI), root-mean-square error of approximation (RMSEA; values
THE JOURNAL
OF N U R S I N G
ADMINISTRATION
Linking Nurses’ Perceptions of Patient Care Quality to Job Satisfaction The Rote o f A uthentic Leadership and Empowering Professional Practice Environments
H e a th e r K. S p e n c e L a s c h in g e r, P h D , RN , FA A N , FCAHS R o b e rta F id a , BA , M A , PhD
OBJECTIVES: A model linking authentic leadership, structural em pow erm ent, and supportive professional practice environments to nurses’ perceptions of patient care quality and job satisfaction was tested. B A C K G R O U N D : Positive w ork environm ent char acteristics are im portant for nurses’ perceptions of pa tient care quality and job satisfaction (significant factors for retention). Few studies have exam ined the m echa nism by which these characteristics operate to influence perceptions of patient care quality or job satisfaction. M E T H O D S : A cross-sectional provincial survey of 723 Canadian nurses w as used to test the hypothesized m odels using structural equation modeling. RESULTS: The m odel w as an acceptable fit and all paths were significant. Authentic leadership had a posi tive effect on stru ctu ral em pow erm ent, w hich had a positive effect on perceived support for professional practice and a negative effect on nurses’ perceptions that inadequate unit staffing prevented them from provid ing high-quality patient care. These w orkplace condi tions predicted job satisfaction.
Author Affiliations: Distinguished Professor and Arthur Labatt Family Nursing Research Chair in Health Human Resource Optimi zation (Dr Spence Laschinger), Arthur Labatt Family School of Nurs ing, The University of Western Ontario, London, Ontario, Canada; Assistant Professor (Dr Fida), Departm ent of Psychology, Sapienza University of Rome, Rome, Italy. This study was funded by a research grant from the Canadian Institutes of Health Research. The authors declare no conflicts of interest. Correspondence: Dr Spence Laschinger; Faculty of Health Sciences, School of Nursing, Health Sciences Addition H41, The University of Western Ontario, 1151 Richmond Street, London, Ontario, Canada N6A 5C1 ([email protected]). DOI: 10.1097/NNA. 0000000000000198
276
C O N C L U SIO N : Authentic leaders play an im portant role in creating empowering professional practice environ ments that foster high-quality care and job satisfaction. Retention of nurses to ensure high-quality patient care (HQPC) is a w orldw ide priority in current healthcare settings.1,2 W ith many nurses approaching retirement, every effort must be made to ensure that nurses’ w ork environments foster optimal professional practice, thereby prom oting job satisfaction and discouraging thoughts of leaving the profession. An important aspect of nurses’ satisfaction with their job and career has been linked to their ability to provide high-quality care to their clients.J’4 Few studies, however, have investigated the m echa nisms through which work environment characteristics, such as em pow ering leadership and supportive p ro fessional practice environments, influence perceptions of patient care quality and, ultimately, nurses’ job satis faction.^ Leaders play an im portant role in shaping the professional practice environm ent to em pow er nurses to provide safe, effective patient care,6 which theoret ically should result in higher perceptions of patient care quality and job satisfaction. The purpose of this study is to test a m odel linking au th en tic leadership (AL), structural em powerm ent, and supportive professional practice environm ents to nurse-assessed patient care quality and, ultimately, nurse job satisfaction. T heoretical Fram ew ork T his study integrates concepts from Avolio and G ardner’s7 theory of AL, R an ter’s theory of struc tu ral em p o w erm en t,8’9 and the Magnet® H o spital M odel (M H M ), originally described by M cClure and colleagues,10’11 to examine how these factors influence
JO N A • Vol. 45, No. 5 • M ay 2015
nurse-assessed patient care quality (NAPCQ) and job satisfaction. The theoretical underpinnings of the con cepts in our proposed model are described in the up coming paragraphs. Authentic Leadership According to Avolio and Gardner,7 AL is a positive relational leadership style whereby leaders behave in an authentic manner with their followers and focus on furthering their development. Authentic leaders con sistently use 4 key behaviors in the work setting: rela tional transparency (presenting themselves as they truly are), balanced processing (considering differing points of view before making decisions), moral/ethical behavior (acting in accordance with internal moral and ethical values), and self-awareness (having insight about self and influence on others).7,12 Empirical support for this model has been shown in both general management settings and in nursing. Wong and Laschinger13 found th at AL positively influenced nurses’ perform ance through structural empowerment in their workplace. M ore recently, Laschinger and Fida14 found that AL played a protective role against early career burnout of nurses. These findings highlight the importance of AL in creating healthy, effective nursing work environments. Structural Empowerment According to Kanter’s model of organizational em powerm ent,8,9 4 organizational empowerment struc tures play an important role in employee effectiveness: access to information, access to support, access to re sources needed to do the job, and opportunities to learn and grow. Access to information refers to having knowl edge of organizational goals and policies, as well as having job-related technical knowledge and expertise. Access to support entails feedback and guidance re ceived from superiors, peers, and subordinates, as well as the emotional support from others in the workplace. Access to resources refers to access of the materials, money, supplies, time, and equipment required to ac complish organizational goals. Finally, access to oppor tunity for mobility and growth entails access to challenges and professional development opportunities to expand knowledge and skills. There is considerable support for structural em powerment theory in the nursing population. Struc tural em powerm ent (SE) has been linked to nurses’ job satisfaction, commitment, trust, productivity, and burnout.Lv 17 Empowerment has also been associated with nurses’ perceptions of support for professional practice in nursing work environments.18,19 M agnet Hospital Model The M H M was developed by the American Nurses’ Association based on a body of research identifying
JONA • Vol. 45, No. 5 • May 2015
factors in nursing w ork environments that support professional nursing practices and therefore attracted and retained nurses.10 In the original model, 3 core factors were posited to result in positive nurse and pa tient outcomes: (1) autonomy, (2) control over practice environment, and (3) effective nurse-physician relation ships.20 Laschinger and colleagues19 reported signifi cant relationships between these M agnet hospital characteristics and structural empowerment in Canadian nursing settings, and numerous studies have linked these worklife factors to a variety of nurse outcomes such as job satisfaction,21'23 burnout,24,25 and NAPCQ and adverse events occurrence.26,27 Scott et al28 re ported support for the positive effects of Magnet hospital characteristics on care quality. These findings were corroborated in a large study of European hospital nurses. Nurse-Assessed Patient Care Quality High-quality patient care is the ultimate goal of any healthcare delivery system and is arguably the essence of nursing. Often, HQPC is defined as care that results in optimal patient functioning. Nurses, given their 24-7 contact with patients, play an integrative role in the patient care process and are well qualified to pro vide accurate assessments of the quality of patient care in their units. In fact, M cHugh and Stimpfel30 found that nurse-assessed quality of patient care was signifi cantly associated with objective hospital quality indica tors, such as patient satisfaction, failure to rescue, and mortality odds. They suggest that it is therefore impor tant to consider nurses’ reports of patient care quality in addition to objective measures when monitoring pa tient care quality in hospitals. Adequate staffing is important for accomplishing satisfactory patient care.31,32 Inadequate nurse staff ing levels interfere with nurses’ ability to appropriately manage patient care needs and are a source of nurse frustration, heavier w orkload, and job dissatisfac tion.2'’^ 1,3'5 Laschinger27 found that structural em powerment and staffing adequacy were significant predictors of nurse-assessed quality of care, and Aiken and colleagues34 linked poor staffing levels to patient mortality. Poor nurse staffing levels have also been as sociated with increased risk of in-hospital complica tions, patient mortality, and patient morbidity.22,35,36 Nurse Job Satisfaction and Perceptions of Patient Care Quality Job satisfaction has been shown to be a key retention factor among nurses. N urses’ autonom y to provide patient care in line with their knowledge and experience has been consistently found to be a strong predictor of nurses’ job satisfaction,37,38 and job satisfaction has been consistently associated with nurse turnover
277
intentions.j9 N um erous studies have dem onstrated strong relationships between supportive professional practice environm ents and nurse job satisfaction and perceived quality of care.27,28’40 Research has also shown that nurses’ job satisfaction is related to the quality of care on their units.3,41’42 M ore recently, Kalisch and colleagues5 found th at process factors, such as inade quate staffing and nurses’ reports of missed care, were significant predictors of job dissatisfaction. Although these studies dem onstrate the im portance of nurses’ perceptions of patient care quality for their job satis faction, they do not provide a m ore nuanced descrip tion of how various w ork environm ent factors interact to influence nurses’ satisfaction. We draw from theory and research to propose a theoretical model linking AL to supportive practice environments and, subsequently, to N A PC Q and job satisfaction. The overall hypothesized m odel is illustrated in Figure 1. We predict that AL will lead to greater struc tural em pow erm ent (hypothesis 1). Structural em pow erment, in turn, will lead to a m ore supportive practice environm ent (hypothesis 2) and m ore adequate staff ing (hypothesis 3). W hen adequate staffing and a sup portive practice environm ent are in place, nurses will perceive greater quality of patient care (hypotheses 4 and 5), w hich will lead to greater job satisfaction (hypothesis 6).
M e th o d s
Study Design T his study used cross-sectional d ata of a provincial study of nurses w orking in direct care roles in O ntario, C anada (n = 723). Ethics approval was obtained from the university ethics board before com m encing the study. Registered nurses were random ly selected from the provincial professional registry database. Partic ipants received a mail survey package th a t included a letter of inform ation, the study questionnaire, and a $2 coffee voucher. Using the p rocedure of D illm an et al43 to optim ize response rates, nonresponders re
278
ceived a rem inder letter 4 weeks after the initial m ail ing, followed by a 2nd survey package 4 weeks later.
Participants A total of 723 nurses w ere eligible for the analysis in this study. Eligible participants were nurses w orking in direct patient care settings.
Instruments
Authentic Leadership The A uthentic Leadership Q uestionnaire12 measures 4 dimensions of AL behavior: self-awareness (4 items), m oral-ethical perspective (4 items), balanced process ing (3 item s), and tran sparency (5 item s). Item s are rated on a 5-point Likert scale from 0 = strongly dis agree to 4 = strongly agree. Previous studies have sup ported the reliability and validity of this instrum ent am ong nurses (C ronbach’s a = .91).44 In the current study, C ronbach’s a was .97.
Structural Empowerment Structural empowerment was measured using the Con ditions of W ork Effectiveness-II (CWEQ-II), a 12-item instrum ent th at measures nurses’ perceptions of access to em pow erm ent structures originally described by K anter.9 Item s are rated on a 5 -p o in t L ikert scale, which are summed and averaged to create 4 subscales (access to inform ation, support, resources, and oppor tunity), which are then summed to create an overall score ranging from 4 to 20.45 The construct validity of the CWEQ-II was established by Laschinger et al,17 with C ronbach’s a reliabilities ranging from .79 to .82.46
Magnet Hospital Characteristics We used 6 items from Aiken and Patrician’s47 Nursing W ork Index-R evised (NW I-R) to measure 3 aspects of supportive professional practice environments: auto nom y (2 item s), co ntrol over practice environm ents (2 items), and nurse-physician collaboration (2 items). We reverse-scored the item s such th a t a high score signified a high level of M agnet hospital characteristics in the w ork setting. Items were summed and averaged
JONA • Vol. 45, No. 5 • May 2015
to create a total score. In this study, the a reliability was acceptable (Cronbach’s a = .80).
Measures o f Nurse-Assessed Patient Care Quality Nurse-assessed patient care quality was measured using a single item “How would you describe the quality of nursing care delivered to patients in your unit?” rated on a 4-point Likert scale ranging from excellent, good, fair, or poor. This measure has good predictive validity and corresponds well with hospital quality indicators such as mortality, failure to rescue, and patient satis faction.l0 To create a positive measure of patient care quality, the item was reverse scored. As an additional measure of NAPCQ, nurses re sponded to the question “In the last month, how often has short-staffing affected your ability to meet your patient/clients’ needs?”3'’ The item is rated on a 5-point scale, ranging from 1 = never, 2 = monthly, 3 = weekly, 4 = several times a week, and 5 = daily.
Job Satisfaction We used 3 items from the measure of Cammann et al4S of health professionals’ job satisfaction (“All in all, I am satisfied with my job,” “In general, I don’t like my job,” and “In general, I like working here”). Items were rated on a 5-point Likert scale (1 = strongly dis agree, 5 = strongly agree). In the present study, the reliability for the job satisfaction scale was good (C ronbach’s a = .77). D ata Analysis Descriptive statistics and scale reliabilities were ana lyzed using the Statistical Package for the Social Sciences (SPSS), version 21.0.43 We tested our hypothesized model using structural equation modeling (SEM) ana lysis with MPlus version 6.1.50 To test the fit between the data and the hypo thesized model, SEM with maximum likelihood esti mation was used. Structural equation modeling provides estimates of model fit by comparing the covariance structure of the observed data to that of the theorized model. ’1 The maximum likelihood estimation method approximates model parameters that are most likely to result in the observed data.51 A perfect fit means that there is no discrepancy between the model and the observed data. Fit statistics recommended by Kline’2 and Hu and Bender’3 were used to assess the fit between the covariance structure of the data and the hypothesized model: %2, j 2 (^2/df), com parative fit index (CFI; values >0.95 indicate a good fit), incremental fit in dex (IFI), root-mean-square error of approximation (RMSEA; values
