The impact of professional role and demographic characteristics on job satisfaction and retention among healthcare professionals in a military hospital

Abstract Background Job satisfaction is significantly associated with retention. Although several factors are associated with job satisfaction and retention (pay, leadership, mentorship), the association of demographic characteristics has been understudied in the literature. Purpose To explore whether professional role and demographic characteristics are associated with job satisfaction and intent to stay among nurses and physicians in a military medical center. Methods We conducted a descriptive, exploratory, cross‐sectional study, and collected data via surveys. We used multiple regression to evaluate study variables. Results Two hundred and eighty‐nine participants completed the survey. Professional role and demographic characteristics were not associated with job satisfaction. Professional role, race, and education were associated with intent to stay for military respondents. Physicians (β = 0.53, p = .0259) and Caucasians (β = −0.55, p = .0172) reported lower intent to stay; respondents with graduate degrees reported higher intent to stay (β = 2.47, p = .0045). Professional role and demographic characteristics were not associated with intent to stay for civilians. Conclusion Job satisfaction and retention of nurses and physicians are critical to the quality of care. Civilian and military healthcare leaders should focus on interventions that enhance job satisfaction and retention as a strategy to improve patient and staff outcomes alike.


| INTRODUCTION
Job satisfaction and retention among nurses and physicians are significantly associated with healthcare quality and safety. 1 Job satisfaction is the degree to which employees enjoy their job, 2 and retention is the ability of an organization to retain its employees. 3 The determinants of job satisfaction and retention are multifactorial and complex, which poses challenges to healthcare leaders who seek to develop initiatives to enhance job satisfaction and retention. The Military Health System is an important setting to explore job satisfaction and retention because of the unique roles and mission requirements of the nurses and physicians who work in these facilities. 4 Although several factors (e.g., burnout, pay, leadership support, high-quality communication, and relationships between nurses and physicians) are associated with job satisfaction among nurses and physicians, [8][9][10][11][12][13] less attention has been given to how demographic characteristics influence job satisfaction. Most researchers report the demographic characteristics of their sample; however, there is a gap in the literature regarding whether demographic characteristics are associated with job satisfaction. A few researchers have explored if demographic characteristics are related to job satisfaction. However, the results of these studies are mixed. For example, Carthon et al. 14 found that Black nurses in civilian community-based settings reported higher job dissatisfaction than Caucasian nurses. Other researchers have reported similar findings in civilian healthcare settings; in these studies, minority nurses experienced lower job satisfaction. 15,16 In other studies, however, race, 17 age, 18,19 and gender 20,21 were not associated with job satisfaction.
Researchers have also reported mixed results regarding relationships between demographic characteristics and retention. In some studies, race, 14 age, 22,23 and gender 24 were associated with retention; in other studies, these demographic characteristics were not associated with retention. 25,26 Due to the lack of consensus in the current literature, we identified two significant knowledge gaps related to demographic characteristics, job satisfaction, and retention: (1) there is limited research about job satisfaction and retention among healthcare professionals in military medical centers; (2) little is known regarding whether professional roles (e.g., nurse or physician) and demographic characteristics (e.g., race, age, sex, and rank) are associated with job satisfaction and retention among civilian and military healthcare professionals.
Exploring the relationships among professional roles, demographic characteristics, job satisfaction, and retention in civilian and military healthcare settings is important for various reasons. First, race, age, and sex diversity are increasing in the nursing and medical workforces. [27][28][29][30] The nursing workforce was once predominantly Caucasian, young, and female, while the physician workforce was predominately Caucasian and male. 27,29,30 Over the last two decades, more minorities have joined the nursing and physician workforce, there is an increase in male nurses and female physicians, and a variety of generational cohorts exist in the nursing and medical professions. [27][28][29][30] Second, the military has a formal ranking structure with clear lines of authority among military service members. [31][32][33] Thus, to provide care, nurses and physicians must navigate a complex web of rank and authority gradients predicated by military service and professional roles. Rank diversity is another unique type of diversity found in military medical centers; enlisted service members typically serve in paraprofessional roles, such as medics, corpsmen, or licensed practical nurses (LPNs), while registered nurses (RNs) and physicians are commissioned officers. There is also a ranking structure among civilian nurses and physicians who work as government service employees. General Schedule (GS) employees are professionals who work for the federal government and their ranking system consists of 15 grades, from GS-1 (the lowest level) to GS-15 (the highest level). 34 This clear ranking structure sometimes allows nurses to hold a higher GS grade than their physician counterparts, and vice versa. However, no matter the rank or grade of the employee, they are expected to work collaboratively with others to provide patient care. Examining relationships among rank, job satisfaction, and retention is critical to improving work processes among members of different ranks.
A third reason to explore relationships among professional roles, demographic characteristics, job satisfaction, and retention is that individuals create relationships with people who are similar to themselves. 35,36 Additionally, individuals who perform similar tasks within the same professional role are less likely to create relationships with professionals who perform dissimilar tasks. 37 For example, Mascia et al. 37 found that physicians were more likely to create relationships with physicians who shared similar professional backgrounds in terms of their field of specialization. Given that people create relationships with people who are similar to themselves 35 and high-quality relationships and communication are associated with higher job satisfaction and retention, [38][39][40] it is important to explore if professional role and demographic characteristics influence job satisfaction and retention. Finally, job satisfaction is positively associated with retention, [41][42][43][44] and dissatisfied nurses and physicians are more likely to resign or relocate. 41 Decreased retention ultimately affects patient outcomes and operational readiness in military hospitals. 5 To our knowledge, researchers have not extensively explored if professional role and demographic characteristics are associated with HOUSE ET AL. | 1035 job satisfaction and retention in a military hospital context. Thus, we conducted a descriptive, exploratory, cross-sectional survey study to explore job satisfaction and intent to stay among Army and civilian nurses, resident physicians, and physicians working in a military medical center. The purpose of our study was to determine if professional role and demographic characteristics are associated with job satisfaction and intent to stay. We asked the following research question: Are demographic characteristics (race, age, sex, rank) associated with job satisfaction and intent to stay for Army and civilian nurses, resident physicians, and physicians? Our study lacked a hypothesis because we desired to explore the associations among professional roles, demographic characteristics, job satisfaction, and intent to stay to develop targeted hypotheses for future research. physician assistants; and (4) nurse-midwives. We excluded these groups at the request of the hospital research council to limit the overall staff burden, given that several research studies had been previously conducted at the study site. We selected nurses (LPNs and RNs) and physicians (resident physicians and physicians) because they comprise the largest portion of the healthcare workforce. 27,30

| Recruitment activities and data collection
Recruitment activities began 1 month before data collection and included face-to-face meetings with eligible participants. We sent a detailed email to eligible participants explaining the purpose of the study. Data were collected from January 2020 to March 2020. We implemented Dillman's Total Design Method 45 to enhance response rates and sent three reminder notices to eligible participants via email. Participants had the option to complete the survey electronically or via hard copy. Completing and submitting the survey implied consent to participate in the study. Firewall protection issues at the study site prevented some participants from receiving the survey via email. Thus, we provided a second option for participants to complete the survey via hard copy. The research team placed hard copies of the survey in a folder and a locked storage box in a designated area on each unit for participants completing hard copy surveys to submit and store their data securely. We collected the surveys weekly during data collection.

| Measures
We combined three tools (relational coordination, job satisfaction, and intent to stay) into one 47-item survey. See Supporting Information: File 1 to review the participant survey. Relational coordination defined as, "a mutually reinforcing process of interaction carried out for the purpose of task integration," 46, p. 301 is a validated tool. 46 Relational coordination encompasses four communication dimensions (frequent, timely, accurate, problem-solving) and three relationship dimensions (shared goals, shared knowledge, and mutual respect). 47 We explored relational coordination because high-quality communication and relationships are associated with higher job satisfaction and retention. [10][11][12][13] However, this manuscript focuses on the data analysis concerning job satisfaction and intent to stay.

| Independent variables
Respondents self-reported the demographic variables in our study (race/ethnicity, age, sex, rank, education, and experience). (see Table 1).

Job satisfaction
Job satisfaction is the extent to which people enjoy their job. 2 We measured job satisfaction with a single-item question because singleitem measures of job satisfaction strongly correlate with multiple-item scales. 48,49 We developed a one-item job satisfaction question based on our literature review and expert opinion to satisfy the research question.
We piloted the question with a small group of personnel to test for validity and reliability and to assess question clarity and sensitivity, allowing for revisions based on feedback. We asked participants, "On the whole, how satisfied are you with your present job?" Responses ranged from "1 = very dissatisfied" to "5 = very satisfied," with higher scores indicating better job satisfaction.

Intent to stay
We conducted a thorough review of the literature to determine how to measure retention and which instrument to use for this study.
Retention was measured using a four-item intent to stay scale. Intent to stay is the extent to which employees plan to continue membership with their employer. 2  Sample items were: "I will be reluctant to leave this hospital" for the civilian intent to stay scale and "I will be reluctant to leave the Army" for the military intent to stay scale. Responses ranged from "1 = strongly agree" to "5 = strongly disagree." We used reverse scoring where appropriate so that higher scale scores indicate higher intent to stay.

| Data analysis
We used t-tests and one-way analysis of variance to explore bivariate relationships between the independent variables (demographic variables) and outcome variables (job satisfaction and intent to stay).
We organized data by professional role, employment status (military or civilian), and unit type (e.g., intensive care, labor and delivery, medical telemetry). We used multiple regression to explore whether professional role and demographic characteristics predicted job satisfaction and intent to stay, including all nonoutcome variables

| Statistical power
We conducted a power analysis before beginning data collection. We fit regression models that included all participants (estimated N = 672). Our sample size had at least 80% power to detect an effect of d = 0.22 for a dichotomous variable (e.g., sex) and a partial correlation of 0.12 for a continuous variable (e.g., age). This large sample is more than adequate for the exploration of the associations between demographic characteristics, job satisfaction, and intent to stay.

| Bivariate analysis
Job satisfaction varied across professional roles (p = .014); RNs reported the highest job satisfaction and resident physicians reported the lowest. Civilians reported the highest mean job satisfaction, followed by enlisted, and officers (p = .035). Professional role and education were associated with intent to stay for military respondents. Military resident physicians reported the lowest intent to stay (p = .007), and participants with a baccalaureate degree reported the highest intent to stay (p = .012). Intent to stay did not vary across professional role for civilian respondents (see Table 3). Job satisfaction was positively associated with intent to stay for both civilian (r = 0.48, p = .000) and military respondents (r = 0.28, p = .008). (see Table 4). Age, experience, and rank were not associated with job satisfaction or intent to stay (see Table 5).

| DISCUSSION
In this study, we explored if professional roles and demographic characteristics were associated with job satisfaction and intent to stay among nurses, resident physicians, and physicians in a military medical center. We found that demographic characteristics (race/ ethnicity, age, sex, and rank) and professional role (LPN, RN, resident physician, physician) were not associated with job satisfaction. Although findings regarding the associations between demographic characteristics and job satisfaction are mixed, our results are similar to previous researchers who reported that race, 17  Race/ethnicity was also associated with intent to stay for military respondents, with Caucasians reporting lower intent to stay.
Researchers have explored race and retention in civilian healthcare settings; however, these studies had mixed findings. For example, in one study, Black nurses were less likely to stay compared to Asian and Caucasian nurses. 15 Carthon et al. 14 reported similar results; in their study, Black nurses were more likely to report job dissatisfaction and intent to leave compared to Caucasian nurses. In another study, race was not a predictor to leave among male nurses. 54 Caucasian respondents in this study may perceive that they have better career opportunities in other healthcare facilities. For example, military physicians and resident physicians were predominately Caucasian in our sample, and they also reported lower intent to stay. Moreover, the study site was a level three trauma center, which may influence the retention of nurses and physicians seeking a more challenging level of care, expanded specialties, and higher patient acuity.
Education was also significantly associated with intent to stay.
Military respondents with graduate degrees reported the highest intent to stay scores. In previous studies, education level was associated with intent to stay. For example, previous researchers have reported that nurses' education level is associated with turnover as an antithesis to intent to stay and is often operationalized as nurses possessing a baccalaureate degree. 55 Active-duty service members achieve higher levels of education and advanced clinical licensure earlier than their civilian counterparts, and officers are required to have a bachelor's degree at entry. 4 Both military and civilian nurses and physicians are required to meet specific educational milestones for career advancement. Therefore, junior nurses and physicians may report lower intent to stay due to military and civilian education and training requirements for degree and licensure advancement.
In our study, professional role and demographic characteristics were not significant predictors of intent to stay for civilian respondents. Our findings are dissimilar to researchers who report that race, 14 age, 22,23 and gender 24 are associated with retention. For example, Blegen et al. 22 found that younger nurses reported higher intent to stay than older nurses, which is contrary to the results of Ramoo et al., 56 who found that younger nurses were more likely to leave the organization within 2 years of employment. We also found that rank was not associated with intent to stay for civilian respondents. The unique rank structure of government service civilian personnel in the Military Health System may have influenced civilian responses in our study. Unlike military service members, government service civilians are not addressed by their rank.
Therefore, civilians may not identify with their rank beyond acknowledging rank as a pay grade.

| Recommendations for hospital leaders
We recommend that hospital leaders implement evidence-based, modifiable practices and policies to enhance job satisfaction and retention, such as formal mentorship programs, 56-58 recognition and rewards, 59 professional development programs, 60 increased opportunities for advancement, 14 and increased salary and benefit packages. 14, 61 We also recommend that hospital leaders make changes at the organization level by using surveys to assess diversity, inclusion, and instances of discrimination; these surveys should be followed by measures to address identified issues and change the organizational culture. 62 Given that nurses are the largest healthcare professionals in the healthcare sector, nurse managers should focus on interventions to improve staff nurses' job satisfaction and intent to stay by enhancing nurses' autonomy and implementing strategies to improve communication. Nurse managers can enhance nurses' autonomy by including staff nurses in decision-making that affects nursing practice and allow staff nurses to have more control over their work. 63 Nurse managers can improve communication in their unit by implementing relational work practices such as relational coordination. 64 We also suggest that nurse managers use mechanisms such as one-on-one meetings, focus group discussion sessions, and suggestion boxes to enhance communication and feedback between nurse managers and staff nurses. 63 These interventions are a cost-effective way to improve nurses' job satisfaction and intent to stay.

| Limitations
We conducted this study at a single Army medical center, and the generalizability of the findings may not be applicable in all settings, including other branches of service (e.g., Air Force and Navy hospitals), larger military hospitals, or civilian hospitals. The determinants of job satisfaction and retention are complex. Although we addressed a gap in knowledge concerning the impact of demographic characteristics on job satisfaction and retention, our results are not exhaustive or comprehensive. A more comprehensive research approach would include thoroughly investigating how demographic characteristics and professional roles moderate or mediate job satisfaction and retention to better understand how demographic characteristics impact job satisfaction and retention. However, our results are essential for researchers to understand concepts clearly.
Lastly, we only collected data from LPNs, RNs, resident physicians, and physicians. Future researchers should explore job satisfaction and intent to stay from the perspective of other nursing professionals, such as nurse practitioners and clinical nurse specialists to gain a richer understanding of job satisfaction and intent to stay among nurses.

| Directions for future research
Future directions for research include exploring the demographic variables in this study as moderating variables rather than predictor variables. For example, the respondents in this study were 75% female, and females usually report higher job satisfaction than males. 65,66 Sex was not a significant predictive variable in our study; however, sex could be explored as a moderating variable in future studies. Race could also be explored as a moderating variable given that individuals create relationships with individuals who are similar to themselves, 35,36 and high-quality relationships are significantly associated with higher job satisfaction and retention. 38

| CONCLUSION
This manuscript explores the relationships among professional roles, demographic characteristics, job satisfaction, and intent to stay among nurses and physicians working in a military medical center.
We found that RNs reported the highest levels of job satisfaction, and job satisfaction was positively associated with intent to stay for both civilian and military respondents. Demographic characteristics (race/ethnicity, age, sex, and rank) and professional role (LPN, RN, resident physicians, physician) were not associated with job satisfaction, while professional role, race/ethnicity, and education significantly predicted intent to stay for military respondents.