Influences over Italian nurses’ job satisfaction and willingness to recommend their workplace

Abstract

Background

Nurses’ perception towards job satisfaction and willingness to recommend their workplace are relevant to a number of areas including the quality of nursing care delivery. Hence, an increasing number of scholars seek to understand the factors that influence these two concepts. Yet, inclusiveness and openness to innovation are under-investigated.

Purpose

The paper focuses on the relative importance that factors like propensity towards innovation, working conditions and inclusion have on nurses’ job satisfaction and their willingness to recommend their workplace.

Methods

A large sample of nurses was extracted from the organizational climate survey carried out in all healthcare authorities of nine Italian Regions through the years 2016–2018. Descriptive and multilevel regressions were carried out to investigate the factors that influence nurses’ job satisfaction and their willingness to recommend the hospital in which they work in, analysing both overall and in specific age classes.

Results

When recommending a workplace, nurses tend to recommend units showing higher propensity to innovate (OR 2.83), while the most important factor related to job satisfaction is the encouragement after a failure (OR 2.23). Inclusiveness is a key factor for both job satisfaction and willingness to recommend, whilst innovation prone organizations appear to be the most attractive for nurses. The levers mix is slightly different among the age classes. Findings identify the levers to be used in order to attract nurse workforce and increase nurses’ job satisfaction. These levers are partially different for young and senior nurses.

Keywords

inclusion innovation job satisfaction nurse willingness to recommend

Introduction

Nurses play a pivotal role in the Healthcare System. The vastness of scenarios in which they are involved qualifies them as central characters in people’s lives and in global policies deployment.¹ Indeed, the World Health Organization identifies nurses as key actors in the achievement of a global health coverage, and states the concept in the “Sustainable Development Goals” through the Global strategic directions for strengthening Nursing and Midwifery.² This last report focuses on the need to keep putting efforts into better achievements in the workforce management, enhancing both the technological and innovation side of it as well as the satisfaction and motivational one. The background in which these allegations stand is filled with existing and arising elements like heavy workforce shortage, difficulties in retention, stress and burn out that lead nurses to dissatisfaction^3,4 and eventually to a deteriorated care delivery.⁵ As Newman pointed out nurses’ satisfaction is a key factor in their retention, while dissatisfaction in general is the most important factor causing nurses leaving practice. This dissatisfaction, and resultant abandonment of nursing practice, is mainly determined by poor management.⁶ An undeniably important role in the increasing shortage is played by stress and burnout, and an unfavourable nurse-to-patient ratio is associated with a higher rate of burn out among nurses^7,8 and with a drastic drop in their reported job satisfaction.⁵ In addressing the difficult topic of nursing workforce retention, there is a well described virtuous circle that has to be activated by the management in order to succeed in retaining the workforce, that is well described by the conceptual framework by Newman et al.⁶ that aims at enhancing nurses’ job satisfaction. The Newman and colleagues framework shows that workload and staffing levels, competence and team working, which are the product of a given current contingency, influence the nursing workforce’s perception of satisfaction, which influences retention, which in turn influences the quality of care delivered to patients, and it all determines both patients and nurses’ satisfaction. The current moment is serious and the forecasts show a worrying increase in the lack of nurses.⁹ Given this situation, WHO started to stress the importance of having and implementing a Global Strategy on Healthcare’s human resources that proves itself successful in reversing the negative trend by regulating Healthcare workforce² Management is the component of the system that can build enabling mechanisms among which adequate staffing policies and enabling work environments have a prominent place. Indeed, it has been recognized that management strategies may allow satisfaction to grow with positive consequences on patients’ outcomes.^10,11 Nurses’ job satisfaction is gaining more and more interests among scholars. Despite this large interest on understanding the factors related to job satisfaction, a recent review reported equivocal findings in the analyses of the influencing factors on job satisfaction.¹² Moreover, the willingness to recommend one’s workplace, although related to job satisfaction, can be considered a self-standing concept, yet an under-investigated one.¹³ In this respect, using data collected from the organizational climate survey administrated in nine Italian Regions through the years 2016–2018, the paper explores the relationships between nurses job satisfaction, willingness to recommend and various items related to working conditions; it also explores the inclusion and organization’s openness to innovation, as they were found to be among the factors that positively relate to job satisfaction in public service workers.¹⁴ Hence, the aim of this work is to familiarize middle and top management with the specific levers that can be stressed in order to attract and retain nursing workforce. More specifically, the objective is to estimate the relative importance of some of those levers, that change in importance during the professional life of nurses, in order to customize as much as possible the organization around them.

Job satisfaction and willingness to recommend the workplace

Unsatisfactory or low job satisfaction conditions are considered determinant factors in nursing shortage.¹⁵ Moreover, job satisfaction has long been paired with increases in nurses’ performance, hence capturing much interest that is widely present in literature¹⁶ as well as its linkage with patients’ outcomes. For instance, Aiken et al.¹⁷ conducted a study in nine European countries and they found that poor work environment is associated with poor outcome both for nurses and for patients in terms of quality outcome of care. Among other factors, innovation is an increasingly relevant lever to be analysed in healthcare and it is related not only to the general advancement of technology but it is also seen as a means to cope with the personnel shortage.¹⁸ However, a recent meta-analysis on job satisfaction of public workforce, highlighted that, few studies deal with the role of organization’s openness to innovation in the public sector reporting a moderate positive influence.¹⁴ Indeed, the role of innovation on job satisfaction can be controversial: while new practices may be “competence destroying”,¹⁹ they can also bring new occupations and communities of practice²⁰ modifying power relations.²¹

The same factors that impact job satisfaction may also influence the retention and the attractiveness of nursing professionals. Certainly, nurses’ remuneration is considered an important lever to attract or retain nurses as it was highlighted by the reports on the nurses mobility across countries like the United States that has attracted many nurses from Philippines where pay is lower.¹⁸ Higher nurses remuneration was also considered a valid strategy to increase the number of applicants in nursing education in some countries.²² However, in countries where nurses work under collective labor contracts job satisfaction seems to be influenced by other factors much more than pay does.²³ Given this situation, word-of-mouth such as willingness to recommend the workplace to others could be investigated as factor affecting the nurses’ attraction or retention. Willingness to recommend has been investigated as a word-of-mouth both as “a place of work and a place to care”.²⁴ In fact, willingness to recommend can be viewed as a customer loyalty to the organization²⁵ as well as a factor linked to job satisfaction.²⁶ The willingness to recommend the place of work as a place of care has been already analysed in nursing homes.²⁷ Although job satisfaction is associated with positive word-of-mouth, willingness to recommend can be considered a more complex factor²⁸ that occurs under specific conditions. As already mentioned, deeper meaning to the concept is given by Kózka and colleagues²⁹ who state that nurse’s willingness to recommend their hospital or unit “reflects confidence in the offered care, satisfaction and identification with the working place”. According to this interpretation, management should enhance factors that nurses recognize as favourable and desirable, in order to grow in them the willingness to recommend their organizations to friends and family and in order to grow in them a sense of belonging. The concept of willingness to recommend is so interesting because it can be seen as a product of the “marketing strategy” of management that interlocks, in an interdependent system, nurse’ satisfaction, willingness to recommend and staff retention.

To capture these aspects both organizational climate and culture approaches may be applied. Both constructs are based on the notion of shared meanings or a shared understanding of aspects related to organizational context.³⁰ They each, distinctly and together, play a crucial role in understanding individual as well as collective attitudes, behavior, and performance.^31,32 However, while the one that is more practices- or procedures-based (organizational climate) may be less difficult to capture quantitatively than the other that is more values- or norms-based (organizational culture).³³ This study adopted the organizational climate survey to quantify the relevance of some factors like innovation and inclusiveness on both job satisfaction and willingness to recommend their workplace.

The changing nursing role in the Italian healthcare system

Nursing practice as a self-standing profession is a relatively new concept for Italy. The act that formally established this new state of affairs is the Decree of the Ministry of Health 739/1994, therefore only a few decades ago the ancillary to the medical profession was abandoned and the full professional autonomy, alongside with full professional responsibility, was declared. The definition of what nursing science is depends on culture, more precisely “on Country, context and setting”.³⁴ The context of this study explores a relatively young concept that is developing in a National Health Service established in 1978. Italy is a devolved system where Regional administrations have significant levels of autonomy in organizing services.³⁵ Yet, the last report of health at a glance highlights that the Italian ratio of nurses to doctors is under the OECD average, overall, we have both higher number of doctors and lower nurses per population than the OECD average.³⁶ These input indicators show the underlying assumption of how care is delivered in Italy and the nurses’ role which is recently changing with the introduction for instance of the family nurse practitioners.

Methods

Data source

Data were extracted from the organizational climate survey administered across the Italian Regions between 2016 and 2018 by the Management and Health Laboratory. The survey was addressed to all employees working in the regional healthcare systems belonging to the interregional performance evaluation network.³⁷ Employees were invited to fill in the questionnaire via C.A.W.I. technology (Computer Assisted Web Interview).

The questionnaire was formulated in 2004 by a number of experts in organizational studies and healthcare management following both the international and national review on organizational climate and then validated and changes have been made in order to assure the validity and reliability of the instrument.³⁸

The questionnaire covers the following areas: Communication and information processes; management evaluation, organizational functioning (i.e. strengths and weaknesses, support to deliver quality services, understanding and promotion, encouragement and support to changes); training opportunities, managerial tools (i.e. budget and control system), and job satisfaction. All the questions had a 5-point likert scale format, ranging from 1 (strongly disagree) to 5 (strongly agree).

This analysis includes the nine Italian regions that carried out the organizational climate survey in the timespan of 2016–2018. The selected Regions represent the different parts of Italy: the Autonomous Province of Bolzano, Lombardy, Veneto (representing the Northern part of Italy) Emilia Romagna, Tuscany, Umbria, Marche (representing the Central part of Italy) and Apulia (representing the Southern part of Italy). The hospital sample (N = 91) includes teaching hospitals and local health authorities.

Statistical analysis

Nurses responses to the organizational climate survey across the Italian regions consist in 35,156 observations as reported in Table 1. The item took into consideration to measure job satisfaction is “I am satisfied with my work in my structure/unit”, while the item considered for the willingness to recommend to other colleagues to work in the organization they are currently working in is “I would recommend working in my organization to my colleagues.” Both variables were considered as dependent variables. As independent variables, we considered: inclusion, the empowerment over quality job results, sustainable work pace, organization’s propensity towards innovation and feeling of discomfort. In particular, the inclusiveness may be considered a projection and a positive consequence of a good organizational climate, that may determine a good team climate and a psychological safety³⁹ in which interactions are safe and failures are part of the job. In this study inclusiveness was measured through the item “I feel encouraged to react after the experience of a failure” coming from the reassurance and exhortation from colleagues, which takes the form of a feeling of inclusion within the work group. The empowerment over quality job results, represented by the question “I feel empowered about the quality of the results achieved and the services related to my work”; the sustainable work pace, in the form of the question “I can do my job at a sustainable pace”; the organization’s propensity towards innovation, formulated as “my company encourages changes and innovations” and the experience of discomfort while working, formulated as “I notice situations of malaise and disorders related to my daily work”.

Table 1.

Sample characteristics.

	Number of nurses
	(n = 35,159)
Mean age^a	47 ± 8,48
Gender^b
Women	28,254 (80.36%)
Men	6,672 (19.64%)
Hospital type^b
Teaching Hospital	9,775 (27.80%)
Local Health Authority	25,384 (72.20%)
Region of employment^b
A.P. Bolzano	903 (2.57%)
Emilia-Romagna	5,396 (15.35%)
Lombardy	9,768 (27.78%)
Marche	234 (0.69%)
Apulia	2,615 (7.44%)
Tuscany	7,828 (22.26%)
Umbria	759 (2.26%)
Veneto	7,611 (21.65%)
Area of employment^b
Medicine	5,653 (15.92%)
Professional Department	4,363 (12,28%)
Administration	3,987 (11.22%)
Surgery	3,434 (9.67%)
Maternity Department	2,348 (6.61%)
Emergency Department	2,276 (6.41%)
Support Services	2,053 (5.78%)
Primary Care	2,176 (6.13%)
Mixed Department (internal medicine and surgery)	1,386 (3.90%)
Mental Health	874 (2.46%)
Intensive Care	795 (2.24%)
Others	6,668 (18.77%)

^aUnit of measure in years.

^bValues shown as n (%).

All items are expressed as a 5-point Likert scale format, ranging from 1 (strongly disagree) to 5 (strongly agree).

Additionally, the model controlled for nurses’ socio-demographic characteristics (i.e. age and gender) and hospital characteristic (Local Health Authorities vs Teaching Hospitals) and Region.

We estimated two separate models: one for job satisfaction and one for the willingness to recommend one’s hospital to colleagues, testing the same key explanatory variables. Multilevel proportional odds models were chosen in both cases, taking into account the ordinal nature of the items and the hierarchical structure of the phenomenon (nurses working within hospitals). Nurses (N = 15,156 in both models) were the first, or lower, level of the models, and the 91 hospitals were the second, or higher, level. This nested -multilevel- procedure enabled us to take into account the hospital’s role in shaping subjective characteristics such as nurses’ satisfaction. A fixed effect for the Region was also included in the models. All the analysis were performed using STATA software (Version 15, StataCorp, College Station, TX).

The same models and procedures used in the data analysis were replicated to investigate the differences the variables play in the different classes of age. To our knowledge, no study has yielded evidence on this dimension, yet analysing it can highlight patterns through which to design careful and customized personnel policies to get the best out of them throughout the entire working lifespan of human resources.

Results

Table 1 shows the composition of the sample and sums up its main characteristics. The mean age of the 35,159 nurses surveyed is 47 years. The sample is mainly composed of women (80.36%) and the main contributing Regions are Lombardy, Tuscany and Veneto.

The survey reached both Teaching hospitals (9,775 respondents) and Local health authorities (25,384 respondent) from all of the eight investigated Regions. Even if some of the areas of employment are not very populated, we can state that the sample is actually representative for all the areas in which nurses work.

Table 2 shows the model results for nurses’ overall satisfaction (Model 1) and willingness to recommend (Model 2).

Table 2.

Results for nurses’ overall job satisfaction (Model 1) and willingness to recommend (Model 2).

Variables	Job satisfaction			Willingness to recommend
	OR	95% CI	p-value	OR	95% CI	p-value
Male	1.297	1.232–1.366	**	1.125	1.068–1.183	**
Age	0.997	0.995–1.000	*	0.993	0.991–0.996	**
Teaching hospital	1.055	1.008–1.105	*	0.944	0.901–0.987
Organization’s propensity towards innovation	1.367	1.339–1.396	**	2.849	2.783–2.916	**
Empowerment over quality job results	1.688	1.653–1.724	**	1.318	1.291–1.345	**
Inclusiveness	2.234	2.186–2.283	**	1.431	1.403–1.460	**
Discomfort while working	1.052	1.036–1.069	**	1.020	1.005–1.036	*
Sustainable work pace	1.472	1.444–1.501	**	1.320	1.296–1.345	**

Note: OR, odds ratio with 95% confidence interval; **p-value <0.001; *p-value <0.05.

Factors that positively impact the area of job satisfaction in descending order with respect to the odds ratio, are summarized in Table 2.

Inclusiveness (OR 2.23) turns out to be the most influential factor, followed by empowerment over quality job results (OR 1.68), sustainable work pace (OR 1.47), organization’s propensity towards innovation (OR 1.36) and experience discomfort while working (OR 1.05).

Inclusiveness has a strong influence over job satisfaction, letting us understand that the support of colleagues after a failure is a powerful element. Nurses are more satisfied with their job if they are effectively empowered over the results they get, which are a metric of their practice and an incentive to work, avoiding dissatisfaction and loss of motivation, and not least avoiding discomforts while working. The same explanatory variables positively impact the dimension “I would recommend to a colleague to work in my organization” with different importance (all statistically significant). These factors include, in descending order with respect to the odds ratio: organization’s propensity towards innovation (OR 2.84), inclusiveness (OR 1.43), sustainable work pace (OR 1.32), empowerment over quality job results (OR 1.31) and experience discomfort while working (OR 1.02).

It is interesting to notice how organization’s propensity towards innovation of an average 47 years old nursing workforce is the element that most influences their loyalty to the hospital, a feeling that we may define as “the willingness to invest time and make sacrifices in order to strengthen a relationship”⁴⁰ which in this case is the relationship with the job place.

Men are more satisfied than women with their work (OR1.29 p-value = 0.00); working in a teaching hospital rather than being in a Local Health Authority is not significant (OR 1,03, p = 0.677) under the point of view of the willingness to recommend one’s organization, but it is significant (OR 1,08, p = 0.049) under the job satisfaction’s point of view.

Table 3 divides up our sample in three classes: under 30 years old (“young”), between 45 and 55 years old (“middle aged”) and over 58 (“seniors”). The middle-aged class is the most represented in our sample. The innovative inclination of the hospital has an impact on the job satisfaction since the beginning of the career (1.55) and has a strong impact on the willingness to recommend as well (3.07), representing the strongest influence detected. The importance given to the work pace diminishes with age increasing for both job satisfaction and willingness to recommend. The exact same trajectory can be traced for the variable “experience of discomfort while working”. A positive association among inclusion, job satisfaction and willingness to recommend shows throughout the professional lifespan, in support of what has been described so far.

Table 3.

Results for nurses’ overall job satisfaction (Model 1) and willingness to recommend (Model 2), focus on three age classes: under 30 years old (“young”), between 45 and 55 years old (“middle aged”) and over 58 (“seniors”).

	Job satisfaction						Willingness to recommend
Age class (years)	<30		44–55		>58		<30		44–55		>58
	OR	p-value	OR	p-value	OR	p-value	OR	p-value	OR	p-value	OR	p-value
Organization’s propensity towards innovation	1.502	**	1.310	**	1.327	**	3.051	**	2.712	**	2.802	**
Empowerment over quality job results	1.484	**	1.684	**	1.871	**	1.253	**	1.318	**	1.435	**
Inclusiveness	1.946	**	2.245	**	2.330	**	1.414	**	1.474	**	1.4558	**
Discomfort while working	1.138	**	1.040	*	1.055	*	1.135	*	0.987		1.045
Sustainable work pace	1.687	**	1.499	**	1.388	**	1.433	**	1.341	**	1.231	**

Note: OR, odds ratio; **p-value <0.001; *p-value <0.05.

Discussion and conclusion

This study provides some insights on under-investigated aspects in the nurses perception, such as the willingness to recommend the workplace. In addition, it deepens the results across age classes of nurses to investigate whether there are differences to be considered for human resource management purposes. In particular, it analyses factors that influence both job satisfaction and willingness to recommend. Indeed, a way to combat nursing shortage is to make the workplace more attractive and the retention of personnel easier by designing organizations according to the elements that the people that actually make them suggest. Hence, the analyses of both job satisfaction and willingness to recommend may help to better understand the levers to apply in order to attract or retain personnel. The results of our study show that the two important levers are innovation and inclusion (i.e. being supported by the rest of the organization after a failure). When organizations are prone to innovate, nurses’ willingness to recommend their workplace is almost three times higher than that of nurses in organizations that are less open to innovation (Table 2). The importance of having an organization open to innovation is even higher for young nurses (Table 3) in recommending their workplace. Hence, a workplace that promotes innovation can be seen as a source of attraction and retention if we consider willingness to recommend as an antecedent of turnover. This consideration adds empirical evidence to the impact of innovation on job satisfaction and willingness to recommend: in the nurses’ case innovation plays an important role versus the mild relevance identified instead in the meta-analysis of the public sector.

The second interesting finding we want to highlight refers to inclusiveness. Inclusiveness plays a key role in job satisfaction. The more nurses are encouraged to react after an experience of failure, the higher the level of job satisfaction. These findings are in line with other studies that show how in organizations where nurses felt free to speak about their mistakes or errors, as they were used not to blame them but as elements to learn from, there was no fear and appreciation was showed.⁴¹ In particular, our results highlight that inclusiveness seems to acquire more and more relevance with the increasing responsibility given by seniority. This evidence is in line with what we reported in the second section that highlighted the importance of work environmental factors on job satisfaction. In particular, this paper adds evidence that inclusiveness seems to play a pivotal role.

Gender seems to influence both job satisfaction and willingness to recommend showing that men usually provide more positive assessment than women do. Although with a relative small effect, it seems that nurses working in a teaching hospital are more satisfied than those working in local health authorities. This finding is interesting if paired with the results of a study comparing performance indicators between teaching and general hospitals: Nuti and colleagues found that performance indicators, calculated from administrative data, were not affected by hospital type.⁴² Indeed, while hospital type seems to have no influence in the objective performance, it does in the nurses’ perception of job satisfaction.

This study presents some limitations. First, the study context focuses on public Italian teaching hospitals and local health authorities. Although we included nine Italian regional governments, which represent different ways of organizing healthcare systems due to the fact that the Italian healthcare system has devolved many powers to regional governments, we still cannot exclude the possibility that different findings may come from different types of organizations such as nursing homes or organizations with different ownership models (i.e. private hospitals). Hence, further analyses could confirm or reject our findings in a different context.

Second, there could be other factors as valuable and informative as those included in this analysis such as the turnover intention or objective factors, such as staffing, considered antecedents of workload⁴³ and job satisfaction. Moreover, we didn’t include the pay variable, as in the public hospitals the employment contract is the same across the Italian organizations but in a cross-country analysis it may play an important role as the nurses inflow and outflow highlighted.

Practice implications

Forecasts on personnel in healthcare show that doctors and nurses shortage will be a major issue for many countries in the next decade. In this context, the ability to attract and retain nurses into hospitals is a crucial aspect. Hence, job satisfaction and willingness to recommend their workplace become interesting aspects to be analysed not only because of their positive relationship with patient outcomes but also because of their potential effect on personnel shortage at organizational level.

Findings in this paper suggest that levers to be used to satisfy nurses with their job or to attract/retain nurses (willingness to recommend) are different.

In particular, the factor most influencing the willingness to recommend is innovation. In the case of young nurses, the probability to recommend their workplace is 3 times higher if they work in organizations prone to innovate. Therefore, these findings suggest that organizations should pay attention to promoting an open environment prone to innovate and change because it may help them to retain nurses but also it could be beneficial in terms of attracting nurses through the word of mouth related to the willingness to recommend. In addition, innovation seems to have a U shape over time: it is quite relevant for young nurses then it loses its relative importance in the middle age class and then it slightly grows for senior nurses. Then, the second factor in terms of weight, that play a positive influence in the willingness to recommend is inclusiveness: the higher the support received after a failure, the higher is the probability to recommend their workplace.

The lever that organizations should use to impact nurses job satisfaction is the inclusiveness together with the empowerment over quality job results. In particular, the job satisfaction is 2.23 times higher in organizations where nurses feel encouraged after a failure (1.68 for empowerment over quality job results). It is worth noticing that inclusiveness, together with the empowerment over quality job results, are the only factors that increase their influence over time (class age), suggesting that this strategy is particularly relevant to senior nurses.

Healthcare organizations should tailor their human resource strategies in relation both to their goals (attraction/retention or satisfaction) and to their particular recipients (young or senior nurses).

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Milena Vainieri

References

Quinn

Samet

JM.

Epidemiologic approaches to global health. Epidemiol Rev 2010; 32: 1–4.

WHO. Global strategic directions for strengthening nursing and midwifery 2016–2020, 2016.

McNeese‐Smith

DK.

A content analysis of staff nurse descriptions of job satisfaction and dissatisfaction. J Adv Nurs 1999; 29: 1332–1341.

Stone

Mooney-Kane

Larson

, et al. Nurse working conditions and patient safety outcomes. Medical Care 2007; 45: 571–578.

Aiken

Clarke

Sloane

, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002; 288: 1987–1993.

Newman

Maylor

Chansarkar

The nurse retention, quality of care and patient satisfaction chain. Int J Health Care Qual Assur 2001; 14: 57–68.

Vuong

Staffing ratios and burnout. AJN 2020; 120: 13.

Dall’ora

Ball

Reinius

, et al. Burnout in nursing: a theoretical review. Hum Resour Health 2020; 18:41.

Scheffler

Arnold

DR.

Projecting shortages and surpluses of doctors and nurses in the OECD: what looms ahead. Health Econ Policy Law 2019; 14: 274–290.

10.

Cowin

The effects of nurses’ job satisfaction on retention: an Australian perspective. J Nurs Adm 2002; 32: 283–291.

11.

Newman

Maylor

The NHS Plan: nurse satisfaction, commitment and retention strategies. Health Serv Manage Res 2002; 15: 93–105.

12.

Zhao

While

AE.

Job satisfaction among hospital nurses: a literature review. Int J Nurs Stud 2019; 94: 21–31.

13.

Jorina

MM.

Determinants of satisfaction and willingness to recommend: physician and patient perspectives. Doctoral Dissertation, Ohio State University, 2013.

14.

Cantarelli

Belardinelli

Belle

A meta-analysis of job satisfaction correlates in the public administration literature. Rev Public Pers Adm 2015; 36(2): 115–144.

15.

Neisner

Raymond

Nurse staffing and care delivery models: a review of the evidence. Oakland: Kaiser Permanente, 2002.

16.

Michie

West

MA.

Managing people and performance: an evidence based framework applied to health service organizations. Int J Manag Rev 2004; 5: 91–111.

17.

Aiken

Sloane

Clarke

, et al. Importance of work environments on hospital outcomes in nine countries. Int J Qual Health Care 2011; 23: 357–364.

18.

OECD. Health workforce policies in OECD countries: right jobs, right skills, right places. Paris: OECD Health Policy Studies, 2016.

19.

Christensen

Overdorf

Meeting the challenge of disruptive change. Harv Bus Rev 2000; 78: 66–77.

20.

Swan

Scarbrough

Robertson

The construction of ‘Communities of Practice’ in the management of innovation. Manag Learn 2002; 33: 477–496.

21.

Mørk

Hoholm

Ellingsen

, et al. Challenging expertise: on power relations within and across communities of practice in medical innovation. Manag Learn 2010; 41: 575–592.

22.

Buchan

Black

The impact of pay increases on nurses’ labour market. OECD Health Working Papers, OECD Publishing, Paris, 2011.

23.

Vainieri

Smaldone

Rosa

, et al. The role of collective labor contracts and individual characteristics on job satisfaction in Tuscan nursing homes. Health Care Manage Rev 2019; 44: 224–234.

24.

Martin

Word-of-mouth in the health care sector: a literature analysis of the current state of research and future perspectives. Int Rev Public Nonprofit Mark 2017; 14: 35–56.

25.

Baumann

Burton

Elliott

, et al. Prediction of attitude and behavioural intentions in retail banking. Intl J Bank Marketing 2007; 25: 102–116.

26.

Anderson

Mittal

Strengthening the satisfaction-profit chain. J Serv Res 2000; 3: 107–120.

27.

Barsanti

Walker

Seghieri

, et al. Consistency of priorities for quality improvement for nursing homes in Italy and Canada: a comparison of optimization models of resident satisfaction. Health Policy 2017; 121: 862–869.

28.

Sweeney

Soutar

Mazzarol

Factors enhancing the effect of word of mouth on consumer outcomes. In: Factors enhancing the effect of word of mouth on consumer outcomes. France: IAE Aix en Provence. 2006, pp. 826–841.

29.

Kózka

Cisek

Brzyski

, et al. Factors affecting Polish nurses’ willingness to recommend the hospital as a place of care. Med Pr 2016; 67: 447–454.

30.

Schneider

Ostroff

West

MA.

Organizational climate and culture : reflections on the history of the constructs. J Appl Psychol 2017; 102(3), 468–482.

31.

Glisson

James

LR.

The cross‐level effects of culture and climate in human service teams. J Organiz Behav 2002; 23: 767–794.

32.

Ostroff

Kinicki

Tamkins

MM.

Organizational culture and climate. Hoboken: John Wiley & Sons, Inc., 2003.

33.

Hemmelgarn

Glisson

Dukes

Emergency room culture and the emotional support component of family-centered care. Children’s Health Care 2001; 30: 93–110.

34.

Grace

Zumstein‐Shaha

Using Ockham’s razor to redefine “nursing science. Nurs Philos 2020; 21: e12246.

35.

France

Taroni

Donatini

The Italian health‐care system. Health Econ 2005; 14: S187–S202.

36.

OECD. Health at a Glance 2019: OECD Indicators. Paris: OECD Publishing, 2019.

37.

Expert Group on Health Systems Performance Assessment. So what? Strategies across Europe to assess quality of care. Belgium: European Commission, 2016.

38.

Pizzini

Furlan

L’esercizio delle competenze manageriali e il clima interno. Il Caso del Servizio Sanitario della Toscana. Psicologia Sociale 2012; 18: 429–446.

39.

Dollard

Bakker

AB.

Psychosocial safety climate as a precursor to conducive work environments, psychological health problems, and employee engagement. J Occup Organ Psychol 2010; 83: 579–599.

40.

Reichheld

FF.

The one number you need to grow. Harv Bus Rev 2003; 81: 46–55.

41.

Nembhard

Edmondson

AC.

Making it safe: the effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. J Organiz Behav 2006; 27: 941–966.

42.

Nuti

Grillo Ruggieri

Podetti

Do university hospitals perform better than general hospitals? A comparative analysis among Italian regions. BMJ Open 2016; 6: e011426.

43.

Oppel

E-M

Mohr

DC.

Multilevel analysis exploring the relative importance of workplace resources in explaining nurses’ workload perceptions. Are we setting the right focus. Health Care Manage Rev. Epub ahead of print 6 April 2020. DOI: 10.1097/HMR.0000000000000285.