The confusing picture about the impact of time on satisfaction in the literature is confirmed here. There is no single pattern and the different experiences of the three specialities studied seem to lead to different patterns. Further, the effect of time varies across dimensions of satisfaction. Many of the trends are of little practical significance and some of the differences between branches are small. What does emerge strongly is that recently qualified nurses are not satisfied with their pay (in relation to level of responsibility) which has been reported frequently elsewhere for nurses generally [32
] while they are highly satisfied with the quality of working relationships and emotional support that they receive from colleagues. This confirms previous research that nurses are satisfied with aspects of support received in their immediate work area but often less satisfied with higher level management and development opportunities [1
First impressions are positive for the adult branch, where the trends were mostly upwards, mixed for the child branch and a tendency towards the negative for the mental health branch. It would appear that newly qualified adult branch nurses have been able to make the adjustment to work more effectively than the other two branches although their satisfaction levels early on are lower than the other two branches. The decline in satisfaction for mental health nurses suggests that these nurses have perhaps faced the bigger challenge. Satisfaction with client care and resources both start at a low level and remain stubbornly low and it would not be unreasonable to propose that there was casual relationship between the two.
The V-shaped trend reported by William's and colleagues [2
] amongst postbaccalaureate nurses undergoing a residency program was found to be consistent with Kramer's theory [21
] and a decline in job satisfaction measured using the McCloskey-Mueller Satisfaction Scale was observed between entry and 6 months. Casey and colleagues [9
] have suggested that new nurses take at least 12 months to feel comfortable and confident. In this study mean scores were lower at 6 months than either of the two later time-points on all job satisfaction components except Relationships
for adult branch nurses. Children's nurses had a greater number of lowest scores at 18 months (Client Care
, Work-Life Interface
) than at 6 months (Education
, Work-Life Interface
) and 3 years (Relationships, Pay
). Mental health nurses had three lowest scores at 6 months (Development
), one at 18 months (Staffing
) and four at 3 years (Client Care
, Work-Life Interface
) suggesting that if reality shock is operating its effects happen at different times and probably in different ways depending on the specialism. The adult branch nurses would appear to provide the best fit to the theory. The theory states that satisfaction drops as formal orientation ends and working independently begins [4
]. The findings for children's nurses and mental nurses suggest that reality shock may extend beyond the period specified by Kramer [21
] and confirmed by Williams [2
], or be replaced by another phase which is less about shock and more about realism and coping with additional responsibilities. By 3 years 63% of children's nurses and 75% of mental health nurses were employed as staff or senior nurses and almost 25% of mental health nurses were in senior staff nurse posts. The rapid ascendancy of mental health nurses could be one reason for their lack of upward job satisfaction trends.
The exposure of student nurses today to the nursing environment is different from the past when UK training was hospital based and students were employees of the organisation. Nurses then were perhaps in a better position to adapt, often working in the organisation where they trained and therefore were less likely to suffer from the type of reality shock that newly qualified nurses' encounter today. They may have been better able come to terms with any discrepancies between their own needs and that of the job and organisation prior to qualification allowing for a smoother transition.
There may be a desire for nurses to compare themselves against other graduates and professions. Pay has become a major issue above that of autonomy, flexibility and a supportive organization particularly when there are shortages of nurses, rising levels of acuity and increasing workloads [49
]. Satisfaction with Pay
was low and was the only factor to produce scores consistently below 3. There was some improvement over time for the adult and mental health branch nurses however there was a small non-significant decrease in Pay
satisfaction for children's nurses. Nurses feel poorly paid compared with other public sector workers [50
] but paradoxically the estimated impact of increased wages on nurse retention is potentially small [51
]. Children's nurses, because of their young age, may be more prone than older nurses to making comparisons with their peers who on graduating are moving into better paid jobs. The larger the differential between the NHS wage and the outside wage the more likely nurses are to leave [51
]. Around 25% of children's nurses work in the London region where higher non-nursing salaried jobs are found. There are constant reminders of city bonuses in the press and media, housing costs are high and it is very difficult for nurses, along with other key workers, to get on the housing ladder. Reasons for poor retention in London include large numbers of young mobile workers, lack of access to affordable child care, high cost of living and heavy workloads [52
]. Therefore financial considerations will be central to nurses thinking. It has been suggested that more research is required on the effect of new nurses personal and financial stressors [9
]. The effect of peer comparison may lessen as the UK higher education sector moves towards even higher levels of participation, more graduates are saddled with debts and there are not the jobs to match the degree qualifications. Grow your own approaches have been suggested as one way of retaining nurses and reflecting the diversity of local populations [53
In this study pay was measured by only one item. We advise that the excluded item Grade/position in relation to level of responsibility be included after a reasonable period of time in work. Other items could be added or alternatively a generic instrument measuring satisfaction with rewards could be used.
Previous research on registered general nurses found that younger nurses were less satisfied with their overall jobs than older nurses [35
]. Children's nurses had higher scores on six of the factors suggesting that this specialism may have a counterbalancing effect on age.
The loss of the academic schedule requires a period of adjustment and has described as something akin to a "grieving process" [4
]. Satisfaction with Work-life Interface
is comparatively high for the child and mental health nurses. For adult branch nurses Work-Life Interface
shows gradual improvement over time from a lower base level. Becoming accustomed to regular shift work and juggling the tensions between work and personal life may have taken longer for these nurses. The management of shifts and schedules during orientation [4
] so as not to disaffect newly qualified staff is important. The Work-Life Interface
factor in this study was limited. It was not possible to include items for combining work hours with life with spouse/partner and responsibilities for children since they did not apply to a sufficient number of nurses. The transitional nature of work and life satisfaction probably requires a more dynamic tool for its measurement than the one used here that goes beyond leaving work on time, notice of duty and social life.
The whole issue of resources, and that includes staffing, will have a direct impact on patient care. It is worth noting for adult branch nurses in this study that when satisfaction with Resources
increased so did satisfaction with Client Care
. Satisfaction with Staffing
dipped at 18 months for children's nurses however this did not impact on satisfaction with Client Care
whilst for mental health nurses satisfaction with resources remained consistently low as did satisfaction with Client Care
and reflects the longstanding perception that mental health services are under resourced in comparison with other services [54
]. Satisfaction with Staffing
tracks satisfaction with Client Care
and supports previous research that has shown that better staffing (e.g. patient-to-nurse ratios) is linked to improved patient outcomes [56
]. It is well established that high nurse turnover can impact considerably on the well-being of nurses who remain and patient outcomes [7
A consistent picture emerged with respect to satisfaction with Education (opportunities to go on courses an study days/workshops). There was a sharp increase in satisfaction between 6 and 18 months across all branches. The biggest increase was for mental health nurses. Between 6 and 18 months the proportion of mental health nurses in staff nurse (E grade) positions increased from 4% to 64% compared with 0% to 11% and 0% to 32% for adult and children's nurses. There is an expectation that once someone becomes a staff nurse they should start attending post-registration courses and the fact that more mental health nurses were promoted correlates with this finding. Adjustment for moderating variables reversed the trend in satisfaction with Education for children's nurses so that there was now a very small increase between 6 and 18 months and a sharp fall between 18 months and 3 years (the proportion of children's nurses in staff nurse positions increased from 32% to 57%) suggesting that opportunities to attend courses had become more difficult as other responsibilities took hold and that expectations were no longer being met.
profiles remained flat throughout the three year period although a small increase was observed between 6 and 18 months for adult branch nurses. Adjusted figures indicated a steady, but non-significant, downward trend across all three branches. Job satisfaction scores for Development
were the second lowest (above Pay
) for adult and child branch nurses. Nurses are therefore lacking opportunities to reflect on practice and are not receiving sufficient feedback and guidance on career development. Not having support and guidance has been identified as a reason for graduates leaving their first nursing post [1
]. Higher acuity levels and inadequate nurse-to-patient ratios maybe contributing to low development scores by cutting down the time nurses have to reflect on practice and receive support.
Overall, the two branches that had the most similar findings were the adult and child branches. This perhaps was not unexpected because they have more in common with each other than they do with mental health.
The mix of censuses and samples had implications for sampling error. A census with complete information on all sampling units (nurses) will have no sampling error. Other sampling approaches may reduce sampling error by design (e.g. stratification) or increase sampling error (e.g. cluster sampling). The sampling fractions for both adult and mental branch nurses are 50% or higher and this more than compensated for any loss of precision induced by the multistage design. However we wanted to generalise findings beyond the year of survey [58
] to the future and adopted a more conservative approach to sampling error by treating each population sample as a simple random sample. Additional non-sampling error may also result from non-response. This was addressed by comparing job satisfaction scores across response groups and by including variables known to predict non-response (e.g. age, gender and ethnicity) in the analysis.
Interpretation of these finding should be considered in the context of the time period in which the data were collected (1997/8 – 2000/1). Many of these findings may be as relevant as they were seven years ago although under the current climate in the NHS some of the more positive aspects that have emerged from these data may have lessened.
We end by providing some suggestions on how nurses can be supported in early career that may help improve their job satisfaction. US Research has identified a number of useful avenues that could be pursued which include providing one-year support programmes, forming new nurse support groups that meet regularly and beyond the first year and encouraging more experienced nurses to become mentors [1
]. In the UK preceptorship is not mandatory however a formal one year preceptorship or probationary year should be considered best practice [59
Generally supporting nurses during the transition from student to nurse will reap longer terms benefits of reduced turnover, better patient care and reduction in costs which in the UK can run as high as £10 K and result in lost productivity [53