Nurses' Job Satisfaction and Patient Falls

83Asian Nursing Research September 2007 Vol 1 No 2

INTRODUCTION

Job satisfaction among nurses is less than satisfactorydespite well-known factors such as pay, recognition,autonomy, and organizational commitment. Aiken,Clarke, and Sloane (2002) reported that more than40% of nurses working in United States (US) hospi-tals were dissatisfied with their jobs. The low jobsatisfaction among nurses and the failure of hospitals

and other institutions to implement interventionsto improve job satisfaction contribute to the currentnursing shortage problem (Garon & Ringl, 2004).As of 2002, the Joint Commission on Accreditationof Healthcare Organizations (JCAHO) has set anexpectation that healthcare organizations collect andanalyze data on staff satisfaction and other humanresource indicators and link them to clinical outcomes(JCAHO, 2002). The purpose of this descriptive

Nurses Job Satisfaction and Patient Falls

Cecilia D. Alvarez1, DNP, RN, Joyce J. Fitzpatrick2*, PhD, RN, FAAN

1Nurse Manager, Coronary ICU, Hackensack University Medical Center, Hackensack, New Jersey, USA

2Elizabeth Brooks Ford Professor of Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio, USA

Purpose The growing concern about the low job satisfaction among nurses and the achievement of posi-tive patient outcomes are critical healthcare issues. The purpose of this descriptive correlational study was to determine the relationship between nurses job satisfaction and patient fall rate on adult medical andsurgical units.Methods Secondary data from a nurses job satisfaction survey at a large not-for-profit acute care hospi-tal on the East coast was used. The National Database of Nursing Quality IndicatorsAdapted Index ofWork Satisfaction (NDNQIAIWS) was used to measure nurses job satisfaction. The sample included 161nurses from 12 adult acute medical and surgical units. The study used retrospective data collected by theDepartment of Nursing on patient fall rate. Pearsons correlation coefficient was used to determine the relation-ship between nurse job satisfaction and patient fall rate. In addition, exploratory descriptive analysis wasconducted by type of unit (i.e., medical or surgical).Results and Conclusion No significant relationship was found between overall nurses job satisfactionand patient fall rate. MDRN interactions (r = .65) and decision-making (r = .57) were the job satisfactionsubscales that showed a significant positive correlation with patient fall rate (p < .05). Recommendationsfor future research are provided. [Asian Nursing Research 2007;1(2):8394]

Key Words job satisfaction, patient fall rate

*Correspondence to: Joyce J. Fitzpatrick, PhD, RN, FAAN, Elizabeth Brooks Ford Professor of Nursing, Frances PayneBolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA.E-mail: [email protected]

INVITED COMMENTARY

correlational study was to determine the relation-ship between nurses job satisfaction and patient fallrate in adult medical and surgical units in an acutecare setting.

The low job satisfaction among nurses and theachievement of positive outcome such as a lowpatient fall rate are issues that affect both qualityand cost of patient care (Garon & Ringl, 2004;Neisner & Raymond, 2002). Although the cost ofnurse job dissatisfaction has not been directly meas-ured, the high cost of turnover rate has been wellestablished (Garon & Ringl).

Poor patient outcome such as an increasedpatient fall rate also increases the cost of healthcare(Neisner & Raymond, 2002). Moreover, poor patientoutcomes increase the length of stay, increase resourceutilization, and increase the cost of treatment (Fleck &Forrester, 2001).

Organizations such as the American NursesAssociation (ANA) and JCAHO have establishedquality indicators for healthcare institutions to use asmonitoring standards. The ANA proposed that jobsatisfaction be measured and established as one nurse-sensitive indicator to reflect nursings contribution tothe quality of patient care (ANA, 1995). Both organ-izations recognized staff satisfaction as a humanresources quality indicator. In addition, both organiza-tions listed patient fall rate as an outcome indicator.

Only two studies explicating the relationshipbetween job satisfaction and patient outcomes(Stratton & Sovie, 2002; Tumulty, 1990) werefound in the literature. Tumulty looked at the rela-tionship between head nurse satisfaction and unitoutcomes, namely RN retention, patient satisfaction,nosocomial infection, patient falls, and skin integrity.Stratton and Sovie investigated the impact of hospi-tal nurse satisfaction on patient outcomes such asnosocomial pressure ulcer, fall rate, serious injuryrate related to falls, nosocomial urinary tract infec-tion rate, and elements of patient satisfaction. Bothstudies used aggregate data from multi-hospital set-tings. No studies were done at the unit level. Thispresent study contributes to the body of literatureby exploring the relationship between the variablesof focus at the unit level.

METHODS

This study used secondary data from a study ofnurses job satisfaction. A descriptive, correlationaldesign was used to answer the research question,What is the relationship between nurses job satis-faction and patient fall rate in adult medical andsurgical units? Secondary data from a nurse satis-faction survey conducted at a large metropolitanhospital on the East coast were used for the variableof nurse satisfaction.

Patient fall rate in the last quarter of the year wasobtained from the Department of Nursing records.Nurse satisfaction was considered an antecedent ofpatient outcomes. Therefore, patient fall rate dataobtained after the nurse satisfaction survey were used.Demographic data of the nursing staff who workedat the time of the nurse satisfaction survey and the fallrate data collection were provided by the Departmentof Nursing. These data were used to describe thenurses in terms of age, gender, race/ethnicity, num-ber of years worked in the hospital, degree in nurs-ing, hours worked, and job title. The Department ofNursing provided data that did not identify individualnurses or patients.

The setting is a 1171-bed not-for-profit acutecare hospital located in a large metropolitan city onthe East coast. The hospital provides a broad rangeof primary, secondary, and tertiary clinical services.The hospital is a member of the National Databaseof Nursing Quality Indicators (NDNQI) that con-ducted the nurse satisfaction survey; all patient careunits participated in the nurse satisfaction survey.

For the purpose of this study, only adult inpatientmedical and surgical units were included to controlfor variations related to types of patients, patientacuity, and staffing pattern. Some studies (Tumulty,1990;Whitman, Kim, Davidson,Wolf, & Wang, 2002)have recommended cohorting patients for outcomesanalysis.The average nursepatient ratio for medicaland surgical units was one nurse to 56 patients. Notincluded in the study were the critical care, step-down, maternalnewborn, pediatrics, perioperativeservices, rehabilitation, emergency services, and ambu-latory areas. The definitions of a medical unit and

C.D. Alvarez, J.J. Fitzpatrick

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a surgical unit were derived from NDNQI (2003).Medical units were defined as acute care areas thatprovided general medicine, cardiology/telemetry, neu-rology, oncology, and nephrology services. Surgicalunits were defined as acute care areas that providedgeneral surgery, cardiac surgery, gynecology, neuro-surgery, orthopedics, and transplant services. Someareas provided combined medical and surgical care topatients. Medical and surgical units that were includedin the study were those with five or more nurses whoparticipated in the nursing satisfaction survey, andthose that had submitted patient fall rate data toNDNQI. Based on the two criteria, 12 adult med-ical and surgical units were included in the study.Only one surgical unit was not included in this study.This surgical unit had only four respondents. TheNDNQI did not report any nurse job satisfaction scorefor this unit in order to maintain staff confidentiality.

A convenience sample of 161 RNs out of 375RNs working in 12 medical and surgical units wereincluded in the study. Although this study used sec-ondary data that included all adult medical and sur-gical units with available nurse job satisfaction andpatient fall data, power analysis was done to deter-mine minimum sample size.A power of .80 was usedin this study with a level of significance () = .05.When the effect size is unknown, conventional effectsize value is calculated using the test of correlationformula (Cohen & Lea, 2004). Using the formula,with a sample size of 161, an effect size of .20 wasdetermined.

Inclusion and exclusion criteria for the sample ofRNs were established by NDNQI (2003). Full-time,part-time or per diem RNs who spent at least 50%of their time on direct patient care, and who hadbeen employed a minimum of 3 months in the unitwere eligible to participate.Agency or contract nurseswere not eligible to participate.

All falls were included whether they resulted fromphysiologic reasons such as fainting or from envi-ronmental reasons such as a slippery floor. In addi-tion, all falls were included whether they resulted inpatient injury. Incidents where a patient was assistedto the floor were included. Multiple falls by the samepatient were considered separate events. The nurse

completed the Patient Falls Monthly Report form whena patient fell. The clinical nurse manager reviewedthe completed form for accuracy before it was sub-mitted to the nursing director of the PerformanceImprovement Department. A staff member in thePerformance Improvement Department determinedthe patient fall rate and submitted the data to theNDNQI. Patient fall rate is operationally defined asthe number of patient falls that occur in a designatednursing unit divided by the number of patient days inthe same unit for the same period multiplied by 1000.

NDNQIAIWS instrumentThe NDNQIAdapted Index of Work Satisfaction(AIWS) instrument was used to measure the levelof nurses job satisfaction. The NDNQIAIWS wasdeveloped by NDNQI as Part Two of a four-partRN Satisfaction Survey. The NDNQIAIWS wasbased on the Index of Work Satisfaction (IWS) orig-inally developed by Piedmonte and Stamps in 1985(Stamps, 1997). The NDNQIAIWS consists of 44items with seven subscales. The seven subscalesmeasured level of nurses job satisfaction with task(6 items), RNRN interactions (6 items), RNMDinteractions (6 items), decision-making (7 items),autonomy (7 items), professional status (6 items),and pay (6 items). Each of the 44 items was scoredusing a 6-point Likert response scale: strongly agree,agree, tend to agree, tend to disagree, disagree, andstrongly disagree. Items were both negatively andpositively worded. NDNQI had devised a scoringprocess. An average for each subscale was calculatedafter each item had been scored. Taking the averageof each subscale, the average score was then convertedinto a T-score. A modified standardized T-score trans-formation was used to facilitate interpretation andcomparison across measures. The T-score transfor-mation was based on the response continuum. Themidpoint was 3.5 and was represented by the score50 with a standard deviation of 10.T-scores 60 as high satisfaction.The responses were written in the aggregate form.

Preliminary psychometric evaluation of theNDNQIAIWS was conducted by Taunton (2001).


Asian Nursing Research September 2007 Vol 1 No 2

A factor analysis was done to assess validity. However,several items did not load on any factor. Thus, theseitems were deleted. A study by Taunton, Butcher,and Bott (2001) showed that modification of theNDNQIAIWS resulted in a stable factor structuresimilar to Stamps IWS. Miller, Boyle, and Taunton(2002) conducted a study confirming the dimension-ality of data collected and the reliability of the scale.

Taunton (2001) found that Cronbachs alpha was.71 to .87 for the five subscales: task, RNMD inter-actions, organizational policies, autonomy, and pay.RNRN interactions had a Cronbachs alpha of .66and professional status a Cronbachs alpha of .49.Some items were deleted and modified based on reli-ability and validity assessments.Taunton, Butcher, andBott (2001) conducted a second reliability assessment.For the second reliability assessment, Cronbachsalpha was .74 to .91 for all subscales except profes-sional status, which had a Cronbachs alpha of .63.

For this study, reliability assessment conductedby the investigators on the NDNQIAIWS totalsatisfaction score yielded a Cronbachs alpha of .86.Reliability assessment of subscales conducted byNDNQI in the 2003 Nurse Satisfaction surveyshowed a Cronbachs alpha of .81 for autonomyand professional status. Task, RNRN interactions,and decision-making had a Cronbachs alpha of .85,pay had a Cronbachs alpha of .88, and RNMDinteractions had a Cronbachs alpha of .91.

Patient falls monthly report formPatient fall rate was derived from reports collectedby the Department of Nursing on each acute careunit in the hospital. Each unit completed the PatientFalls Monthly Report form for every patient fall inci-dent. The Performance Improvement Departmentof the Department of Nursing counted the totalnumber of incidents and determined the patient fallrate using the formula stated in the operational def-inition.The mean patient fall rate for the last quarterof the year was derived by adding the fall rate forthe months of October, November and December,and dividing the numbers by three. This was thepatient fall rate data submitted to the NDNQI andthe data used in this study.

The nursing staff completed the Patient FallsMonthly Report form whenever a patient fell. Noreliability or validity of the Patient Falls MonthlyReport form has been established, and thus this formis subject to under-reporting, which may be commonpractice.Weingart et al. (2005) studied adverse eventreporting in a Boston teaching hospital. Medicalrecord review and patient interview either duringhospitalization or after revealed that 55% of adverseevents and 4% of near misses were documented in themedical record but not reported using the hospitalincident reporting system.

An informal survey of six nurse managers and a geriatric nurse practitioner in the study setting wasconducted.These nurse leaders stated that incidentsof patient falls were well reported. Two of the lead-ers suggested 100% reporting of patient falls. Incontrast, these leaders stated that the incidents ofpatient pressure ulcers were less frequently reported.One leader suggested 5060% reporting of patientpressure ulcers. This reporting practice percentagewas similar to the findings of Weingart et al. (2005).

In spite of the lack of reliability and validitystudies on the Patient Falls Monthly Report form andreporting practices, the authors assumed that thereporting practice within the study setting wereuniform and consistent. This assumption was basedon the orientation of newly hired RNs, the nursingreporting practice, and the informal survey of nurseleaders conducted in the study setting.All newly hiredRNs undergo centralized orientation. During central-ized orientation, newly hired RNs were instructedthat reporting of adverse events, including patientfalls, is important.After centralized orientation, newlyhired RNs undergo unit-based orientation. In the spe-cific units where newly hired RNs were assigned,the importance of adverse event reporting was reit-erated. In addition, newly hired RNs were taughthow to complete the form related to reporting ofpatient falls and how to document the incident in themedical record. Newly hired RNs were also taughtthe reporting procedures for adverse events. Thereporting procedure includes reporting patient fallsto the physician, the nurse manager, and the RN who will take care of the patient the next shift.



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A non-punitive approach to reporting was observed.Nurse managers emphasized to the staff that thefocus was patient safety.

Approval for the study was obtained from theinstitutional review board. Survey packets were deliv-ered to the RNs either through the nurse manager orthrough the nursing directors office. Survey packetscontained a letter from the director of the NDNQIRN satisfaction survey. The letter explained the pur-pose of the survey, the approximate time of surveycompletion, the protection of confidentiality, and thevoluntary nature of the survey.A letter from the VicePresident of Nursing was included in the surveypacket. The letter stated the hospitals support ofthe NDNQI RN satisfaction survey, the time linefor the survey, and the RNs eligibility to participatein a raffle drawing of $50 American Express gift cer-tificates. In addition, the letter contained instructionsto seal the envelope after completion of the surveyand to place the sealed envelope in specially markedboxes located in the nursing unit and the nursingdirectors office. Return of the completed surveyconstituted consent. Survey packets included theNDNQI questionnaire, a pencil, a list containing thehospital and unit codes, and the raffle paper.

Each nursing unit routinely collected data onpatient falls. The RN completed the Patient FallsMonthly Report form every time a patient fell. Thecompleted Patient Falls Monthly Report form was sub-mitted to the Department of Nursing. The Depart-ment of Nursing determined the patient fall rate.The hospital submitted patient fall rate data to theNDNQI.

Recruitment of subjectsThe study subjects included 161 nurses from 12 med-ical and surgical units. Only medical and surgicalunits with five or more participants were included.All nurses were recruited based on eligibility criteriaas described in the sample. There were no attritionissues in this study.

Demographic dataThe NDNQI RN Satisfaction Survey, Part IV, con-tained demographic questions regarding age, gender,

race/ethnicity, years worked as an RN, years workedin the current nursing unit, highest level of nursingeducation, highest level of education other than nurs-ing, certification, role as a nurse, and hours worked(full-time or part-time). However, data derived fromPart IV of the NDNQI RN Satisfaction Survey wasnot used for this study because only aggregate hos-pital data were provided by NDNQI. The Depart-ment of Nursing provided nurse level data thatincluded age, gender, race/ethnicity, number of yearsworked in the hospital, degree in nursing, hoursworked, and job title for all the RNs qualified toparticipate in the survey (n = 375).

Descriptive statistics were used to summarizedemographic data. Excel was used to enter, code, andanalyze data.The study used secondary data providedby a major New York City hospital. Only medical andsurgical units with NDNQIAIWS subscale scoresthat were complete were included in the study.In addition, only medical and surgical units withpatient fall rate data were included in the study.Bivariate correlation analysis using Pearsons corre-lation coefficient was used to determine the rela-tionship between variables. In addition, exploratorydescriptive analysis was conducted by unit and bytype of unit (i.e., medical or surgical).

RESULTS

The convenience sample for this study was drawnfrom all the adult medical and surgical units at a large not-for-profit acute care hospital on the Eastcoast.Thirteen adult medical and surgical units wereincluded in the study. However, one surgical unit wasnot included in the data analysis because only fourRNs from this unit participated in the study. TheNDNQI did not report nurse satisfaction data forunits with four or fewer respondents. Out of the 375medical and surgical RNs who were eligible to par-ticipate in the study, 161 RNs did so, for a responserate of 44%.

The hospital provided nurse level data on age,gender, race/ethnicity, number of years worked inthe hospital, degree in nursing, hours worked, and



job title for the 375 medical and surgical RNs whomet the inclusion criteria. These nurse level datawere analyzed to describe the personal characteris-tics of the RNs in the study. The mean age of theRNs was 41.76 years (SD = 10.18), mode was 45years, and median age was 42 years.Ages ranged from23 (n = 5) to 70 (n = 1), with 56% of the RNs above40 years of age. Twenty-nine percent of RNs werebetween 30 and 40 years of age while 15% of RNswere 30 years of age or younger. The majority of theRNs were female (90%). The racial/ethnic back-ground of RNs consisted of 39% Black, 30% Asian,22% White, and 9% Hispanic.

Over half of the RNs (64%) had worked in thehospital longer than 5 years, with 48% of themworking in the hospital more than 10 years. Twenty-five percent of the RNs had worked in the hospitalfrom 2 to 5 years, and 6% from 1 to 2 years. Only5% of the RNs had worked in the hospital for 1 yearor less. Eighty-three percent of the RNs workedfull-time and 17% worked part-time.

With regard to educational level, 88.5% of RNshad a bachelors degree, 10% had a masters degree,0.5% had a doctoral degree, and another 1% had anassociate degree. Most of the RNs (98.4%) werestaff nurses; 1.6% were nurse practitioners.

Job satisfaction dataUnit level data were used in this study. Job satis-faction scores for each subscale (i.e., task, RNRNinteractions, RNMD interactions, decision-making,

autonomy, professional status, and pay) were reportedby NDNQI. The total job satisfaction score for eachunit was derived using the average of the subscalescores. Eight (67%) of the units had moderate jobsatisfaction and four (33%) had low job satisfaction.None of the units had a high satisfaction. The meanjob satisfaction score was 42.64 (SD = 5.07), with a median of 43.7 and a range of 33.67 to 48.93. Themean, standard deviation, and range for each subscalescore are presented in Table 1.

The level of job satisfaction for each subscale wasanalyzed. The first subscale was task, which referredto activities that must be done as a regular part ofthe job (NDNQI, 2003). For the subscale task, 92%of the units had low satisfaction, 8% had moderatesatisfaction, and none had high satisfaction.

The second job satisfaction subscale, RNRNinteractions, referred to formal and informal contactamong RNs during working hours (NDNQI, 2003).Twenty-five percent of units had high satisfaction forRNRN interactions, 75% had moderate satisfaction,and no unit had low satisfaction.

The third job satisfaction subscale was RNMDinteractions, which referred to formal and informalcontact with physicians during working hours(NDNQI, 2003). Thirty-three percent of units hadlow satisfaction for RNMD interactions and 67%had moderate satisfaction. No unit had high satis-faction. It was of interest that the reverse of theRNMD interactions level of satisfaction was truefor the RNRN interactions.



Table 1

Mean, Standard Deviation (SD), and Range for NDNQIAIWS Subscales for All Units (n = 12)

Subscale Mean SD Range

Task 32.00 6.8 23.5646.57RNRN interactions 57.24 6.0 42.3566.93RNMD interactions 41.55 8.2 28.0353.48Decision-making 37.53 6.7 23.5747.90Autonomy 37.62 6.7 27.6449.41Professional status 51.40 7.3 38.4865.46Pay 40.74 6.25 31.1949.55

NDNQIAIWS = National Database of Nursing Quality IndicatorsAdapted Index of Work Satisfaction.

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The fourth job satisfaction subscale was decision-making, which referred to management policies andpractices that relate to decision-making (NDNQI,2003). Half of the units (50%) had low satisfactionand the other half (50%) had moderate satisfaction.None of the units had high satisfaction.

The fifth job satisfaction subscale was autonomy,which was defined as the amount of independence,initiative, and freedom permitted or required for dailywork activities (NDNQI, 2003).Two-thirds (67%) ofthe units had low satisfaction and one-third (33%)had moderate satisfaction. None of the units had highsatisfaction for the autonomy subscale.

The sixth job satisfaction subscale was professionalstatus, which referred to the importance or signifi-cance of the job from the perspective of the RN andof others (NDNQI, 2003). A majority of the units(75%) had moderate satisfaction, 17% had low sat-isfaction, and 8% had high satisfaction.

The last job satisfaction subscale was pay, whichreferred to the cash remuneration and fringe bene-fits received for work performed (NDNQI, 2003).None of the units had high satisfaction. Half of theunits (50%) had moderate satisfaction and the otherhalf (50%) had low satisfaction.This result was similarto that of the decision-making subscale.

Patient fall rateThe mean patient fall rate for all units (n = 12) was4.26 (SD = 2.5), the median was 4.22, and the modewas 2.48. The mean patient fall rate in each unit forthe last quarter of the year is summarized in Table 2.

Nurses job satisfaction and patient fall rate bytype of unitThis section describes the RN job satisfaction andpatient fall rate data aggregated at the type of unitlevel: medical (n = 6), surgical (n = 3), and combinedmedical and surgical (n = 3). RNs working in com-bined medical and surgical units had the highest jobsatisfaction score (45.9) followed by RNs workingin the medical units (43.8). RNs working in the sur-gical units had the lowest job satisfaction score (37.1).The medical units had the highest patient fall rate(5.9) followed by the surgical units (3.3). Combinedmedical and surgical units had the lowest patient fallrate (2.0). It is of interest that the combined medicaland surgical units had the highest RN job satisfactionscore and the lowest patient fall rate. Medical unitshad a higher RN job satisfaction score than surgicalunits. However, medical units also had a higher patientfall rate (Table 3).

Relationship between nurses job satisfaction andpatient fall rateThe previous section described RN job satisfactionand patient fall rate data aggregated at the type ofunit level.This section describes data for all the adultmedical, surgical, and combined medical and surgicalunits (n = 12). Pearsons correlation coefficient wasused to determine the relationship between nursesjob satisfaction and patient fall rate. The NDNQIAIWS nurses overall job satisfaction score showeda moderate correlation with patient fall rate (r = .46).However, this correlation was not significant at thecritical value of p < .05 (one-tailed).

Three subscales showed a weak correlation withpatient fall rate: task (r = .06), RNRN interactions(r = .11), and professional status (r = .17).Three othersubscale scores showed a moderate correlation withpatient fall rate: pay (r = .45), autonomy (r = .46),and decision-making (r = .57). RNMD interactions



Table 2

Mean Patient Fall Rate per Unit, Fourth Quarter(n = 12)

Unit code Patient fall rate

01 2.4802 5.9603 5.9804 7.3005 7.1306 6.4807 2.4808 0.7010 6.7011 1.6312 2.0213 2.28

(r = .65) was the only subscale that showed a strongcorrelation with patient fall rate, and task was theonly subscale with a negative r value. The Pearson rvalues were tested for significance and were foundto be not significant at the critical value of .05 (one-tailed), except for RNMD interactions and decision-making (Table 4).

In summary, the mean RN job satisfaction scorewas 42.64 (SD = 5.07) and the mean patient fall ratefor all units was 4.26 (SD = 2.5). RN job satisfactionscores and each subscale score for all units were atthe low and moderate satisfaction levels except forthe RNRN interactions (n=3) and professional status(n = 1) subscales. RNMD interactions (r = .65) anddecision-making (r = .57) were the two subscalesthat showed a positive correlation with patient fall

rate, significant at the critical value of .05 (one-tailed).The type of unit level data indicated that the com-bined medical and surgical units had the highest RNjob satisfaction score and the lowest patient fall rate.

DISCUSSION

Compared to the National Sample Survey of Regis-tered Nurses data which is the most extensive sourcefor RN demographic data in the United States, theRNs who participated in this study were younger, buta similar proportion of nurses were above age 40.Researchers have found mixed results on the relation-ship of age and job satisfaction. Cimeti, Gencalp,and Keskin (2003) found that older RNs were moresatisfied than younger RNs, while Cellillie (2004) andRuggiero (2005) did not support this conclusion.

The majority of the RNs were female (90%).There was a higher percentage of males in this studygroup (10%) than the national percentage.The racial/ethnic background of RN subjects consisted of 39%Black, 30% Asian, 22% White and 9% Hispanic, anddid not reflect the national racial profile of 88.4%White, 4.6% Black, 3.3% Asian, 1.8% Hispanic, 0.4%American Indian, and 1.5% other. However, the racial/ethnic background of the RNs in this study reflectedthe racial/ethnic diversity of the city where the hos-pital was located.

Over half of the RNs (64%) had worked in the hospital for longer than 5 years, with 48% ofthem working more than 10 years. Only 11% of theRNs had worked in the hospital for 2 years or less.



Table 3

NDNQIAIWS Satisfaction Score and Mean Patient Fall Rate by Type of Unit (n = 12)

Satisfaction level Type of unit Mean satisfaction score Patient fall rate

Low < 40 Surgical (n = 3) 37.1 3.3

Moderate 4060 Medical (n = 6) 43.8 5.9Combined (n = 3) 45.9 2.0

High > 60 0 0 0

NDNQIAIWS = National Database of Nursing Quality IndicatorsAdapted Index of Work Satisfaction.

Table 4

Relationship of Nurses Job Satisfaction and Patient Fall Rate

r Significance

NDNQIAIWS satisfaction score .46 .07Task .06 .42RNRN interactions .11 .36RNMD interactions .65 .01*Decision-making .57 .03*Autonomy .46 .07Professional status .17 .30Pay .45 .07

*p < .05. NDNQIAIWS = National Database of Nursing QualityIndicatorsAdapted Index of Work Satisfaction.

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Although there were no comparison data for lengthof service in the hospital, these data suggested thatthe hospital was able to retain staff. Cimeti, Gencalp,and Kreskin (2003), and McNeese-Smith and VanServellen (2000) found that RNs who had beenworking longer as a nurse had higher job satisfactionthan RNs who had fewer years of service.

A large percentage of RNs (83%) worked full-timehours. Although there were no comparison data forhours worked, these data combined with the lengthof service in the hospital suggested that the hospitalwas able to retain staff. The high percentage of full-time RNs would be an advantage to the provision ofcontinuity of care.

There was a greater number of RNs in this studywith a bachelors degree (88.5%) compared to anestimated 34.2% of RNs in the nation with a bache-lors degree as the highest level of educationalpreparation. The high number of RNs with a bache-lors degree was the result of the hospitals policy ofhiring only RNs with a bachelors degree.

In summary, the personal characteristics of theRNs in this study were similar to the national demo-graphic data only in terms of the number of RNs overthe age of 40. The mean age, gender, racial/ethnicprofile, and educational preparation of the RNs inthe study were different from the national profile.There were no comparison data for length of serviceand hours worked in this study.

Job satisfactionThe nurses mean job satisfaction score was 42.64(SD = 5.07), which is a moderate satisfaction levelbut at the lower end of the moderate category forjob satisfaction. Aiken et al. (2001) reported thatmore than 40% of nurses working in US hospitalswere dissatisfied.

While the level of job satisfaction was at thelower end of the moderate satisfaction category andwas reflective of the general dissatisfaction of RNsnationwide, this finding was unexpected. The demo-graphic data indicated that the majority of RNs hadworked in the hospital for more than 10 years andwere working full time. These indicated good nurseretention.

Medical and combined medical and surgical unitshad moderate satisfaction while surgical units hadlow satisfaction. The highest subscale score for alltypes of units were RNRN interactions. This wasimportant as relations with coworkers were cited byMcNeese-Smith (1999) as particularly relevant tojob satisfaction.

In summary, RNs in the study were moderatelysatisfied. Satisfaction levels differed by type of unitwith RNs in the surgical units being the least satis-fied, followed by RNs in the medical units. RNs inthe combined medical and surgical units had thehighest level of satisfaction. Subscale scores differedby type of unit as well.

Patient fall rateThe mean patient fall rate for this study was 4.26(SD = 2.5), which is higher than the mean patient fallrate for NDNQI hospitals (3.73) (Dunton, Gajewski,Taunton, & Moore, 2004). Although the lack of reli-ability and validity of the Patient Falls Monthly Reportform was of concern, it was possible that the highermean patient fall rate for this study was due to bet-ter reporting in the study setting. Reporting of falloccurrences was a major performance initiative ofthe hospital. The clinical nurse managers routinelychecked the Patient Falls Monthly Report form forcompleteness and accuracy.

The mean patient fall rate was lowest in thecombined medical and surgical units (2.0) and high-est in the medical units (5.9).The high mean patientfall rate in the medical units was similar to the find-ings of Dunton et al. (2004) that fall occurrenceswere most commonly observed in medical units,and least commonly observed in critical care units.On the other hand, Whitman et al. (2002) foundthat fall occurrences were highest in medical as wellas surgical units.

Yauk et al. (2005) found that patients who fellwhile in the hospital were significantly older, had hada previous fall, had problems with bowel control,had some type of cognitive impairment or balanceproblem, or had need for assistance with ambulation.These conditions were common among patients inmedical units in the study setting and may account



for the higher mean patient fall rate compared to theother types of unit. In addition, patients in medicalunits generally have a greater number of comorbidi-ties and longer hospital length of stay.

Patients in combined medical and surgical unitshad the lowest patient fall rate. In general, the moreacutely-ill patients of each service (i.e., medical orsurgical) are admitted to the specific service ratherthan to combined medical and surgical units. Thispractice may account for the combined medical andsurgical units having the lowest mean patient fallrate among types of unit.

In summary, better reporting of fall occurrencesmay account for the higher mean patient fall rate inthis study compared to the NDNQI data.The highermean patient fall rate in medical units compared tothe other types of units may be due to the patientpopulation in medical units. Unit level data wouldbe more meaningful for the nurse manager of theindividual unit rather than the hospital mean fallrate data because the latter would vary based on therange of fall rates in the combined units. The meanfall rate for the type of unit (i.e., medical or surgi-cal) would give a better picture of the patient fallrate for a particular unit. This type of unit level datawould be a better guide for nurse managers in plan-ning nursing interventions.

Job satisfaction and patient fall rateThe RNMD interactions and decision-making werethe subscales that showed a positive correlation withpatient fall rate that was significant at the criticalvalue of .05 (one-tailed). This result was surprisingas one would expect that as RN satisfaction withRNMD interactions and decision-making increased,patient fall rate would decrease. This result did notsupport Sovie and Jawads (2001) finding that fallswere reduced by increased collaboration betweenRNs and MDs. Some of the explanations providedfor the lack of relationship between nurses job sat-isfaction and patient fall rate could explain thisresult. One was how fall rate was defined. Eachpatient fall was counted as an occurrence. There-fore, multiple falls by one patient would increasethe patient fall rate. Another explanation was that

while the nurse had made the decision that thepatient was at risk for falls, interventions to preventfalls may have been implemented by the supportstaff. Lastly, RNMD interactions may not be asintense for fall interventions compared to otherpatient outcomes such as nosocomial pressure ulcersand infections.

In summary, this study did not find a relationshipbetween overall nurses job satisfaction and patientfall rate. RNMD interactions and decision-makingsubscales were significantly positively correlated withpatient fall rate (p < .05). Explanations were providedto explain the results. However, further study needsto be done to explicate the results. Tumulty (1990)did not find a relationship between job satisfactionand patient fall rate. Stratton and Sovie (2002) con-cluded in their study that nurse satisfaction affectedpatient outcomes. However, the relationship betweennurse satisfaction and patient falls in their study wasnot clear.

Study limitationsThere were several limitations to this study. First,reporting of the incidence of falls was based on thehospitals incident reporting system and was subjectto under-reporting. Second, there is no establishedreliability and validity for the Patient Falls MonthlyReport form. Third, a convenience sample was usedfor the RN Satisfaction Survey. Although the RNswere assured of anonymity, there could be responsebias and reluctance to answer honestly due to fearof reprisal. History could be a factor in the RNsresponses as well.At the time of the survey, the hos-pital was going through a period of uncertainty interms of hospital leadership and finance.The financialconstraints may have affected the delivery of care atthe unit level. Fourth, secondary data were used.Variables such as patient acuity, skill mix, length ofstay, occupancy rate, and nurse to patient ratio werenot controlled. Fifth, the demographic data weresomewhat different from the national profile asreported by the National Sample Survey of Regis-tered Nurses (2005). Therefore, generalizability ofthis study would be limited to units with similardemographic data. Finally, the data came from adult



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medical and surgical units, and are not generalizablebeyond these units.

The study examined the relationship betweennurses job satisfaction and patient fall rate using unitlevel data. The results are meaningful for the nurseleaders of units because the data are unit-specific.Study results can be shared with nurse leaders torecommend changes in practice specific to the unit.In addition, tracking the relationship between nursesjob satisfaction and patient fall rate can be used as aperformance improvement initiative as recommendedby the JCAHO. Improving nurses job satisfactionand decreasing patient fall rate would have an impacton the cost and quality of patient care.

The nurse manager of the unit has an importantrole in the accuracy of data collection. A less puni-tive approach to reporting adverse events wouldimprove reporting. The need to establish reliabilityand validity assessment of the Patient Falls MonthlyReport form is indicated.

Recommendations for future researchFuture research with a study design that controls forthe characteristics of the nurse, patient population andpatient unit might provide a better explanation ofthe relationship between nurses job satisfaction andpatient outcomes.

Controlling for confounding variables related tothe organization will minimize the effect of extra-neous factors and maximize the effect of moreinfluencing factors. Matching the nurse with patientoutcome would make the outcome attributable tothe nurse.A study of the reliability and validity of thePatient Falls Monthly Report would more accuratelyrepresent the outcome variable.

Future research on identifying nurse-sensitive out-comes is needed. A scoring system can be establishedwhere outcomes more sensitive to nursing interven-tion are identified and graded according to sensitivity.This system would help researchers prioritize whichpatient outcomes will be studied.

This is the first study measuring the relationshipbetween nurses job satisfaction and patient fall rateat the unit level. The lack of significant finding maybe due to confounding variables in the acute care

setting such as organizational, personal, and workenvironment variables that were not controlled inthe study. Efforts to control variables such as patientacuity, skill mix, and length of stay, occupancy rate,and nurse to patient ratio in future research is recommended.

The results of this study will enable nurse man-agers and others to have a better understanding ofnurse job satisfaction and patient outcome at theunit level. The organization can use the results tolook at trends between units as a tool to make globalchanges in the organization. The findings of thestudy add to the general body of knowledge relatedto nurses job satisfaction and patient outcome.

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Nurses' Job Satisfaction and Patient Falls