there is growing evidence that occupational burnout has been widely present among nurses since the end of last century . a patient - oriented nursing model requires high - quality care while at the same time may increase mental and physical stress in nurses . a survey involving 711 hospitals showed that more than 40% of usa nurses were dissatisfied with their jobs , and the percentage of nurses who were planning to leave their jobs was more than 33% in england and scotland and more than 20% in the usa . chinese nurses may be facing even higher occupational stress than counterparts from other countries because of poor doctor - patient relationship and frequent violence against medical staff in hospitals . several studies have reported that more than 40% of nurses had emotional exhaustion or high - level burnout . the quality of the nursing practice environment was considered to be a main factor associated with nurse recruitment and retention . therefore , the practice environment scale has been widely used to quantitatively evaluate the job satisfaction of nurses . the chinese version of the practice environment scale ( cppe-38 ) was translated in 2009 , and one study that included 573 participants from different hospitals showed that the satisfaction scores were very low in china . gender , clinical work duration , geographic location of the work place , and highest nursing qualification were demonstrated to be predictive factors of low satisfaction . however , this study included hospitals of different levels , and nurse satisfaction scores from a tertiary hospital were not specifically identified . in our present study , the satisfaction scores were studied in a university - affiliated tertiary hospital in shanghai , china to investigate the associated factors and the change of satisfaction from 2013 to 2015 . this study is a historical control study based on a paper questionnaire survey performed in 2013 and 2015 . all nurses from huashan hospital , fudan university were asked to complete the cppe-38 anonymously at the end of 2013 and 2015 . the questionnaire was conducted in the same general population , although the population sizes in the two years were different as a small proportion of nurses may have resigned or moved to other hospitals over the two years of the study . linear regression analysis was performed based on the survey in 2013 to identify the potential factors correlated with each item and subscale of the cppe-38 . multiple improvement measures were then established to improve the satisfaction of nurses in 2014 and 2015 . the scores of cppe-38 in 2015 were compared with those in 2013 to evaluate the effects of these improvement measures . the study was approved by the human research ethics committee of huashan hospital , fudan university . the main components of the questionnaire were the 38 items of the cppe-38 , which were divided into 5 subscales , including internal work motivation ( 10 questions ) , control over practice ( 6 questions ) , interpersonal interaction ( 7 questions ) , supportive leadership and handling conflict ( 10 questions ) , internal relationship and autonomy ( 5 questions ) . other information in the questionnaire included gender , marital status , highest educational degree , age , years of being a nurse , years at the current hospital , years in the current unit , work unit , and job title . first , a web - based communication platform was established to receive any comments or complaints from the nurses . second , a psychological forum was offered twice a year to carry out psychological intervention in some special units based on the questionnaire and the problems exposed by the communication platforms . third , continuing education was enhanced among the nurses and a certificate was established to authenticate their capacities . all statistical analyses were performed by the spss 16.0 ( chicago , il , usa ) . the continuous data was expressed as mean sd and the enumeration data was expressed as number ( percentage ) . the potential associated factors with the scores of cppe-38 were screened using the backward method of linear regression analysis . the dependent factor was the subscale score , and the total score of the cppe-38 and the independent factors included all the demographic data . the cppe-38 scores in 2013 and 2015 were compared using the student s t - test . this study is a historical control study based on a paper questionnaire survey performed in 2013 and 2015 . all nurses from huashan hospital , fudan university were asked to complete the cppe-38 anonymously at the end of 2013 and 2015 . the questionnaire was conducted in the same general population , although the population sizes in the two years were different as a small proportion of nurses may have resigned or moved to other hospitals over the two years of the study . linear regression analysis was performed based on the survey in 2013 to identify the potential factors correlated with each item and subscale of the cppe-38 . multiple improvement measures were then established to improve the satisfaction of nurses in 2014 and 2015 . the scores of cppe-38 in 2015 were compared with those in 2013 to evaluate the effects of these improvement measures . the study was approved by the human research ethics committee of huashan hospital , fudan university . the main components of the questionnaire were the 38 items of the cppe-38 , which were divided into 5 subscales , including internal work motivation ( 10 questions ) , control over practice ( 6 questions ) , interpersonal interaction ( 7 questions ) , supportive leadership and handling conflict ( 10 questions ) , internal relationship and autonomy ( 5 questions ) . other information in the questionnaire included gender , marital status , highest educational degree , age , years of being a nurse , years at the current hospital , years in the current unit , work unit , and job title . first , a web - based communication platform was established to receive any comments or complaints from the nurses . second , a psychological forum was offered twice a year to carry out psychological intervention in some special units based on the questionnaire and the problems exposed by the communication platforms . third , continuing education was enhanced among the nurses and a certificate was established to authenticate their capacities . all statistical analyses were performed by the spss 16.0 ( chicago , il , usa ) . the continuous data was expressed as mean sd and the enumeration data was expressed as number ( percentage ) . the potential associated factors with the scores of cppe-38 were screened using the backward method of linear regression analysis . the dependent factor was the subscale score , and the total score of the cppe-38 and the independent factors included all the demographic data . the cppe-38 scores in 2013 and 2015 were compared using the student s t - test . a total of 1,050 respondents were recruited out of 1,198 nurses in 2013 , with a response rate of 87.6% . the cppe-38 scores of each item and the subscale scores , as well as total satisfaction in 2013 are listed in table 2 . the total satisfaction score was 2.990.64 . among the five subscales , the lowest score was 2.400.59 in interpersonal interaction and the highest score was 3.150.40 in internal work motivation . nurses from the operating room and post - anesthesia care unit had the lowest scores in internal work motivation and total satisfaction ( table 4 ) . nurses with an educational degree higher than a masters degree had the highest score for internal relationship and autonomy ( table 5 ) . the cppe-38 survey was performed again at the end 2015 , with a total of 1,085 respondents . the results showed significantly higher scores in the subscales of internal work motivation , control over practice , interpersonal interaction , and internal relationship and autonomy . but no significant difference was observed in the scores for supportive leadership , handling conflict , or the total satisfaction score ( table 6 ) . our present study identified several significant associated factors in the cppe-38 scores . with the introduction of improvement measures , including web - based communication platform , psychological forum , continuing education , psychological rewards , and income elevation , we observed increases in the scores for internal work motivation , control over practice , interpersonal interaction , and internal relationship and autonomy . a positive practice environment is critical to improving the quality of nursing care and reducing mortality according to the american nurses credentialing center . the practice environment scale is one of the most widely used scales in evaluating job satisfaction of nurses , and prior to 2010 had been reported by more than five countries and translated into three languages . however , the practice environment scale has seldom been reported in studies from mainland china . a cross - sectional study performed by cao et al .   recruited 435 paper - based and 163 online - based questionnaires and reported a mean score ranging from 2.66 to 3.05 . the average score in our present study was 2.990.64 and only two subscales had scores lower than 3.0 , including control over practice and interpersonal interaction . organization has been reported as one of the factors associated with the scores and the respondents from a level - three hospital account for only 58.0% among all the participants in the cao et al . our multiple regression analysis found that nurses from the operating room , post - anesthesia care unit , and intensive care unit had the lowest satisfaction scores . the operating department has been considered a frequent source of adverse events and work stress . the intensive care unit is also a complicated unit with low job satisfaction among the nurses . a survey performed by lai et al .   showed that 48.9% of nurses from the intensive care unit intended to leave their jobs . several issues has been proposed as important regarding the current status of chinese nurses , including nursing shortages , inadequate salary income , little support from managers , and less professional autonomy . therefore , we paid more attention to the psychological and living status of nurses from these special units by establishing a web - based communication platform and a psychological forum . dissatisfaction on income is common in chinese hospitals and the employment status has been reported to be a critical issue influencing the job satisfaction of nurses . in our study group , the income and benefits of a relatively small proportion of nurses were provided by the government or the university while most of the nurses were contract - based employees whose benefits might be less . thus we raised both the salary income and social benefits among the contract - based employees . finally , our improvement measures were proven to be effective according to the increase in scores of the cppe-38 survey two years later . inadequate education might lead to less confidence and professional autonomy in caring for patients during practice . support from the nurse managers and doctors might increase autonomy , thus we establish an online communication platform to receive any comments or complaints from the nurses who might be facing a difficult problem . davies et al . reported a statistically significant association between autonomy and educational preparation in qualified staff undertaking continuing education and having contact with educational centers . . showed that implementation of a phased educational approach could improve communications between healthcare staff and improve job satisfaction in a developing country . first , this was a single center study recruiting nurses from a university - affiliated tertiary hospital and the results may not be representative of all hospitals in china . a multi - center investigation should be performed to evaluate the effects of the improvement measures in improving the satisfaction status of nurses . second , we did not correlate the improvement of cppe-38 scores with the quality of care . further studies should be performed to evaluate the impact of the improvement measures on patient and hospital outcomes . working location and educational degree were two factors influencing the scores of the 38-item chinese version of practice environment scale . the improvement measures , including web - based communication platform , psychological forum , continuing education , psychological rewards , and income elevation , may improve the satisfaction of nurses . a multi - center study should be performed to evaluate the effects of these measures .
backgroundthe present study was performed to quantitatively examine nurse satisfaction , to investigate the associated factors influencing satisfaction , and to evaluate the effect of improvement measures based on these factors.material/methodsa survey using the 38-item chinese version of the practice environment scale ( cppe-38 ) was performed in a university - affiliated tertiary hospital in shanghai , china in 2013 . 
 linear regression analysis was performed to screen for associated factors related to each cppe-3 score and the total satisfaction score . 
 several improvement measures were established to improve nurse satisfaction , and the cppe-38 survey was again performed in 2015 to evaluate the effect of these improvement measures.resultsa total of 1,050 respondents were recruited in 2013 , with a response rate of 87.6% . 
 the total satisfaction score of the cppe-38 was 2.990.64 . 
 the lowest score in a subscale of the cppe-38 was 2.400.59 for interpersonal interaction and the highest score was 3.150.40 for internal work motivation . 
 work location was associated with scores for work motivation and total satisfaction , while the highest education degree was associated with scores for internal relationship and autonomy . 
 the scores for internal work motivation , control over practice , interpersonal interaction , and internal relationship and autonomy were significantly improved in 2015 after two years of improvement efforts , while the total satisfaction score was not significantly different compared to the 2013 score.conclusionsworking location and education degree were two factors correlated with cppe-38 scores in our hospital . 
 humanistic concerns , continuing education , and pay raise may improve the practice satisfaction of nurses .