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  • 28 August 2024

Exclusive: the papers that most heavily cite retracted studies

  • Richard Van Noorden &
  • Miryam Naddaf

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Computer rendered illustration of a lone figure watching as a towering house of blank white cards collapses.

Credit: Waldemar Thaut/Zoonar via Alamy

In January, a review paper 1 about ways to detect human illnesses by examining the eye appeared in a conference proceedings published by the Institute of Electrical and Electronics Engineers (IEEE) in New York City. But neither its authors nor its editors noticed that 60% of the papers it cited had already been retracted.

The case is one of the most extreme spotted by a giant project to find papers whose results might be in question because they cite retracted or problematic research. The project’s creator, computer scientist Guillaume Cabanac at the University of Toulouse in France, shared his data with Nature ’s news team, which analysed it to find the papers that most heavily cite retracted work yet haven’t themselves been withdrawn (see ‘Retracted references’).

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Chain retraction: how to stop bad science propagating through the literature

“We are not accusing anybody of doing something wrong. We are just observing that in some bibliographies, the references have been retracted or withdrawn, meaning that the paper may be unreliable,” Cabanac says. He calls his tool a Feet of Clay Detector, referring to an analogy, originally from the Bible, about statues or edifices that collapse because of their weak clay foundations.

The IEEE paper is the second-highest on the list assembled by Nature , with 18 of the 30 studies it cites withdrawn. Its authors didn’t respond to requests for comment, but IEEE integrity director Luigi Longobardi says that the publisher didn’t know about the issue until Nature asked, and that it is investigating.

Cabanac, a research-integrity sleuth, has already created software to flag thousands of problematic papers in the literature for issues such as computer-written text or disguised plagiarism . He hopes that his latest detector, which he has been developing over the past two years and describes this week in a Comment article in Nature , will provide another way to stop bad research propagating through the scientific literature — some of it fake work created by ‘papermill’ firms .

Further scrutiny

Cabanac lists the detector’s findings on his website , but elsewhere online — on the paper-review site PubPeer and on social media — he has explicitly flagged more than 1,700 papers that caught his eye because of their reliance on retracted work. Some authors have thanked Cabanac for alerting them to problems in their references. Others argue that it’s unfair to effectively cast aspersions on their work because of retractions made after publication that, they say, don’t affect their paper.

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Retracted references don’t definitively show that a paper is problematic, notes Tamara Welschot, part of the research-integrity team at Springer Nature in Dordrecht, the Netherlands, but they are a useful sign that a paper might benefit from further scrutiny. ( Nature ’s news team is independent of its publisher, Springer Nature.)

Some researchers argue that retraction of references in a narrative review — which describes the state of research in a field — doesn’t necessarily invalidate the original paper. But when studies assessed by a systematic review or meta-analysis are withdrawn, the results of that review should always be recalculated to keep the literature up to date, says epidemiologist Isabelle Boutron at Paris City University.

Retracted references

These studies have the highest proportion of retracted papers in their reference lists, according to Nature ’s analysis of articles flagged by the Feet of Clay Detector.

Year

Title of paper

Number of retracted studies in reference list

2012

33 of 51 (65%)

2023

18 of 30 (60%)

2024

46 of 77 (60%)

2012

25 of 53 (47%)

2001

25 of 53 (47%)

2016

15 of 33 (45%)

2012

40 of 125 (32%)

2013

18 of 57 (32%)

2012

47 of 225 (21%)

2023

12 of 58 (21%)

Source: Nature analysis of data from the Feet of Clay Detector . Figures for references and retractions were hand-checked and altered where necessary; detector data sources do not always give accurate counts.

Picking up fraudsters

Some of the papers that cite high proportions of retracted work are authored by known academic fraudsters who have had many of their own papers retracted.

These include engineering researcher Ali Nazari, who was dismissed from Swinburne University of Technology in Melbourne, Australia, in 2019, after a university misconduct investigation into his activities. He previously worked at Islamic Azad University in Saveh, Iran, and his current whereabouts are unclear. After Nature told publishers about his extant papers 2 , 3 topping Cabanac’s lists — including Elsevier and Fap-Unifesp, a non-profit foundation that supports the Federal University of São Paulo in Brazil — they said that they would look into the articles. One of the relevant journals was discontinued in 2013, Elsevier noted.

Cabanac’s detector also flags papers 4 by Chen-Yuan Chen, a computer scientist who worked at the National Pingtung University of Education in Taiwan until 2014. He was behind a syndicate that faked peer review and boosted citations, which came to light in 2014 after an investigation by the publisher SAGE. Some of Chen’s papers that are still in the literature were published by Springer Nature, which says it hadn’t been aware of the issue but is now investigating. Neither Chen nor Nazari responded to Nature ’s requests for comment.

Another flagged study 5 is by Ahmad Salar Elahi, a physicist affiliated with the Islamic Azad University in Tehran who has already had dozens of his papers retracted, in many cases because of excessive self-citation and instances of faked peer review. In 2018, the website Retraction Watch (which also wrote about the Nazari and Chen cases) reported that according to Mahmoud Ghoranneviss, then-director of the Plasma Physics Research Centre where Elahi worked, Elahi was likely to be dismissed from the university. Now, Ghoranneviss — who has retired — says that Elahi was barred only from that centre and not the rest of the university. Elahi continues to publish papers, sometimes listing co-authors including Ghoranneviss, who says he wasn’t aware of this. Neither Elahi nor the university responded to Nature ’s queries. The IEEE and Springer Nature, publishers of the journals that ran the Elahi papers, say they’re investigating.

Unhappy authors

Some authors are unhappy about Cabanac’s work. In May 2024, editors of the journal Clinical and Translational Oncology placed an expression of concern on a 2019 review paper 6 about RNA and childhood cancers, warning that it might not be reliable because it cited “a number of articles that have been retracted”. The journal’s publishing editor, Ying Jia at Springer Nature in Washington DC, says the team was alerted by one of Cabanac’s posts on social media last year.

Guillaume Cabanac poses for a portrait on the Paul Sabatier University campus.

Computer scientist Guillaume Cabanac has flagged more than 1,700 papers that caught his eye because of their reliance on retracted work. Credit: Fred Scheiber/SIPA/Shutterstock

Cabanac’s analysis finds that just under 10% of the article’s 637 references have been retracted — almost all after the review was published. However, the paper’s corresponding author, María Sol Brassesco, a biologist at the University of São Paulo, says that removing these references doesn’t change the conclusions of the review, and that she has sent the journal an updated version, which it hasn’t published. Because the cited works were retracted after publication, the expression of concern “felt like we were being punished for something that we could not see ahead”, she says. Jia says that editors felt that adding the notice was the most appropriate action.

In other cases, authors disagree about what to do. Nature examined three papers 7 , 8 , 9 in which between 5 and 16% of the references have now been retracted, all co-authored by Mohammad Taheri, a genetics PhD student at Friedrich Schiller University of Jena in Germany. He says that criticisms of his work on PubPeer “lack solid scientific basis”. Yet, in May, a co-author of two of those works, Marcel Dinger, dean of science at the University of Sydney in Australia, told Retraction Watch that he was reassessing review papers that cited retracted articles. He now says that his team has submitted corrections for the works, but Frontiers, which published one paper, says it hasn’t received the correspondence and will investigate. Elsevier — which published the other two papers — also says that it is examining the issue.

Catching problems early

Examples in which papers cite already-retracted work suggest that publishers could do a better job of screening manuscripts. For instance, 20 studies cited by a 2023 review paper 10 about RNA and gynaecological cancers in Frontiers in Oncology had been retracted before the article was submitted. Review co-author Maryam Mahjoubin-Tehran, a pharmacist at Mashhad University of Medical Sciences in Iran, told Nature that her team didn’t know about the retractions, and does not plan to update or withdraw the paper. The publisher, Frontiers, says it is investigating.

Until recently, publishers have not flagged citations to retracted papers in submitted manuscripts. However, many publishers say they are aware of Cabanac’s tool and monitor issues he raises, and some are bringing in similar screening tools.

Last year, Wiley announced it was checking Retraction Watch’s database of retracted articles to flag issues in reference lists, and Elsevier says it is also rolling out a tool that assesses manuscripts for red flags such as self-citations and references to retracted work. Springer Nature is piloting an in-house tool to look for retracted papers in manuscript citations and Longobardi says the IEEE is considering including Feet of Clay or similar solutions in its workflow. A working group for the STM Integrity Hub — a collaboration between publishers — has also tested the Feet of Clay Detector and “found it useful”, says Welschot.

Medical trend

Medical reviews that cite studies in areas later shown to be affected by fraud are a recurring theme in Cabanac’s findings.

In theory, meta-analyses or systematic reviews should be withdrawn or corrected if work they have cited goes on to be retracted, according to a policy issued in 2021 by the Cochrane Collaboration, an international group known for its gold-standard reviews of medical treatments .

Boutron, who directs Cochrane France in Paris, is using Cabanac’s tool to identify systematic reviews that cite retracted work, and to assess the impact the retracted studies had on the overall results.

However, a 2022 study 11 suggests that authors are often reluctant to update reviews, even when they are told the papers cite retracted work. Researchers e-mailed the authors of 88 systematic reviews that cited now-retracted studies in bone health by a Japanese fraudster, Yoshihiro Sato . Only 11 of the reviews were updated, the authors told Nature last year.

Retraction alerts

Authors aren’t routinely alerted if work cited in their past papers is withdrawn — although in recent years, paper-management tools for researchers such as Zotero and EndNote have incorporated Retraction Watch’s open database of retracted papers and have begun to flag papers that have been taken down. Cabanac thinks publishers might use tools like his to create similar alerts.

In 2016, researchers at the University of Oxford, UK, began developing a tool called RetractoBot , which automatically notifies authors by e-mail when a study that they have previously cited has been retracted. The software currently monitors 20,000 retracted papers and about 400,000 papers, published after 2000, that cite them. The team behind it is running a randomized trial to see whether papers flagged by RetractoBot are subsequently cited less than those not flagged by the tool, and will publish its results next year, says project lead Nicholas DeVito, a integrity researcher at Oxford.

The team has alerted more than 100,000 researchers so far. DeVito says that a minority of authors are annoyed about being contacted, but that others are grateful. “We are merely trying to provide a service to the community to reduce this practice from happening,” he says.

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IBM China said to be laying off more than 1,000 employees as it closes research labs

  • IBM is the latest global tech giant to cut jobs in China this year, as an intensified Sino-US rivalry threatens their mainland businesses

Xinmei Shen

US computing giant IBM has reportedly shut down its research and development (R&D) operations in China, joining a slew of global Big Tech firms in trimming their mainland businesses amid geopolitical headwinds.

IBM is closing its China Development Lab and China Systems Lab, while laying off more than 1,000 employees in cities including Beijing, Shanghai and the northern port city Dalian, according to reports by local news outlets.

IBM’s China-based R&D employees over the weekend found themselves blocked from accessing the company’s intranet system, Chinese news website Jiemian reported on Saturday. The Armonk, New York-headquartered company announced the job cuts during an internal meeting on Monday morning, according to posts by multiple employees on Chinese social media platforms.

“IBM adapts its operations as needed to best serve our clients, and these changes will not impact our ability to support clients across the Greater China region,” an IBM representative said in an email to the Post, without providing details of the lay-offs.

IBM’s local strategy is “focused on having the right teams with the right skills” to help Chinese companies – especially privately owned firms – co-create hybrid cloud and artificial intelligence (AI) solutions by drawing on its “considerable technology and consulting expertise”, the representative said.

IBM is the latest multinational tech giant to shed jobs in China, as an intensified Sino-US rivalry forces global businesses to adjust their operations on the mainland.

IBM’s sales in China have steadily declined in recent years.

In 2023, IBM’s revenue in the country dropped 19.6 per cent compared to a 1.6 per cent rise in revenue across Asia-Pacific, according to the company’s annual report. Sales in China in the six months ended June 30 this year fell 5 per cent, while revenue in Asia-Pacific increased 4.4 per cent, IBM’s financial statement showed.

Still, IBM China credited its Development Lab for making “important contributions” to the development of the company’s enterprise-facing generative AI development platform WatsonX, in a blog post published on WeChat last November.

IBM announced WatsonX in May last year and made it available to customers in China in the following August.

The China Development Lab had “more than 24 years of outstanding development experience” and was behind hundreds of main and innovative products, IBM said in the WeChat post.

IBM reported 2 per cent growth in global revenue for the second quarter, with software sales up 7 per cent. Its shares have jumped 21 per cent since the beginning of this year.

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Plan to cut 500 jobs from CSIRO ‘threatens research’

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A plan to cut CSIRO’s annual costs by at least $100 million and reduce support staff by up to 500 will threaten the agency’s ability to collaborate with industry and prosecute the government’s Made in Australia program, science industry leaders say.

The cuts are part of a broader reduction in the agency’s 5500 headcount, with the CSIRO staff union claiming as many as 700 or 13 per cent of staff will lose their jobs from the frontline research agency .

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Rural Hawai‘i faces major health challenges, UH report finds

Submitted by UH

WAILUKU–Hawai’i residents living in rural areas face significantly more health challenges than those who live in urban areas, according to a first-of-its-kind report by the University of Hawai’i Economic Research Organization (UHERO). Released Aug. 25, the report also found that the challenges are even greater for rural residents with disabilities and for those living in poverty.

The data was gathered in June 2023 through a survey of 1,571 residents, with more than 20% identifying as living in rural areas. The assessment used data from the UHERO Rapid Survey, a twice-yearly health survey of a general population cohort in Hawai’i that has been administered since 2022.

This is the first rural health report targeted specifically for Hawai’i that measures data at the individual level.

The full report can be found at https://uhero.hawaii.edu/rural-health-disparities-in-hawaii/.

Compared with those living in urban areas, residents in rural areas reported that their overall health was lower and had more days per week where their activities were restricted by their physical or mental health.

The report was produced by UHERO and funded by UH’s Rural Health Research and Policy Center (RHRPC) through a grant from the U.S. Department of Health and Human Services, Health Resources and Services Administration.

SIGNIFICANT FINDINGS:

¯ Residents in rural areas reported having a 43% lower odds of perceiving their overall health as excellent, very good or good compared to their counterparts in non-rural areas.

¯ Nearly 22% of respondents living in rural areas rated their health as fair or poor (21.7%, n=70) and fewer than 14% of non-rural respondents (14%, n=169) rated their health at this level.

¯ Rural residents reported an average of 3.8 days/week that their life activities were restricted by their physical health compared to 2.5 days in non-rural areas, and for mental health an average of 3.1 days/week versus 2.

¯ Having a disability and living in rural areas is associated with an additional 2 days/week of life activities restricted by physical health issues compared to people with disabilities in non-rural areas.

¯ Notably for Asians, high overall health (respondents who describe their overall health as excellent, very good or good) was less than 70% for rural residents, but more than 80% for non-rural residents.

¯ For those who live in rural households below the poverty line, less than 40% reported high overall health compared with more than 50% for non-rural residents.

¯ Native Hawaiians and Pacific Islanders (NHPI) made up a higher share of the rural sample (23.1%) compared to 14.7% among the people surveyed in non-rural areas, and NHPI reported 1.1 additional days per week that were affected by physical health issues compared with people who are not NHPI.

The report examines several definitions of rural areas. The results above are based on the report’s primary definition of rural areas, which are all zip codes in the state except for East O’ahu, Kāne’ohe in the east to Kapolei in the west, Līhu’e on Kaua’i, Kahului-Wailuku on Maui, and Hilo and Kailua-Kona on Hawai’i island.

The UH researchers noted that the report’s findings suggest that policy responses aimed at improving health outcomes and preventive healthcare utilization should include efforts to reduce disparities between rural and non-rural populations. The results also indicate that rural health policy should prioritize support for marginalized groups, especially individuals with disabilities and those with low incomes in rural regions.

“This report helps to tell the story of how health outcomes differ in rural areas compared to more urban areas, providing the evidence base for potential policy solutions to address these challenges,” said Aimee Grace, Principal Investigator of the Rural Health Research and Policy Center and Director of the UH System Office of Strategic Health Initiatives.

UHERO is housed in UH Mānoa’s College of Social Sciences and RHRPC is housed in the UH System Office of Strategic Health Initiatives.

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Democratic National Convention (DNC) in Chicago

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Fact-checking warnings from Democrats about Project 2025 and Donald Trump

This fact check originally appeared on PolitiFact .

Project 2025 has a starring role in this week’s Democratic National Convention.

And it was front and center on Night 1.

WATCH: Hauling large copy of Project 2025, Michigan state Sen. McMorrow speaks at 2024 DNC

“This is Project 2025,” Michigan state Sen. Mallory McMorrow, D-Royal Oak, said as she laid a hardbound copy of the 900-page document on the lectern. “Over the next four nights, you are going to hear a lot about what is in this 900-page document. Why? Because this is the Republican blueprint for a second Trump term.”

Vice President Kamala Harris, the Democratic presidential nominee, has warned Americans about “Trump’s Project 2025” agenda — even though former President Donald Trump doesn’t claim the conservative presidential transition document.

“Donald Trump wants to take our country backward,” Harris said July 23 in Milwaukee. “He and his extreme Project 2025 agenda will weaken the middle class. Like, we know we got to take this seriously, and can you believe they put that thing in writing?”

Minnesota Gov. Tim Walz, Harris’ running mate, has joined in on the talking point.

“Don’t believe (Trump) when he’s playing dumb about this Project 2025. He knows exactly what it’ll do,” Walz said Aug. 9 in Glendale, Arizona.

Trump’s campaign has worked to build distance from the project, which the Heritage Foundation, a conservative think tank, led with contributions from dozens of conservative groups.

Much of the plan calls for extensive executive-branch overhauls and draws on both long-standing conservative principles, such as tax cuts, and more recent culture war issues. It lays out recommendations for disbanding the Commerce and Education departments, eliminating certain climate protections and consolidating more power to the president.

Project 2025 offers a sweeping vision for a Republican-led executive branch, and some of its policies mirror Trump’s 2024 agenda, But Harris and her presidential campaign have at times gone too far in describing what the project calls for and how closely the plans overlap with Trump’s campaign.

PolitiFact researched Harris’ warnings about how the plan would affect reproductive rights, federal entitlement programs and education, just as we did for President Joe Biden’s Project 2025 rhetoric. Here’s what the project does and doesn’t call for, and how it squares with Trump’s positions.

Are Trump and Project 2025 connected?

To distance himself from Project 2025 amid the Democratic attacks, Trump wrote on Truth Social that he “knows nothing” about it and has “no idea” who is in charge of it. (CNN identified at least 140 former advisers from the Trump administration who have been involved.)

The Heritage Foundation sought contributions from more than 100 conservative organizations for its policy vision for the next Republican presidency, which was published in 2023.

Project 2025 is now winding down some of its policy operations, and director Paul Dans, a former Trump administration official, is stepping down, The Washington Post reported July 30. Trump campaign managers Susie Wiles and Chris LaCivita denounced the document.

WATCH: A look at the Project 2025 plan to reshape government and Trump’s links to its authors

However, Project 2025 contributors include a number of high-ranking officials from Trump’s first administration, including former White House adviser Peter Navarro and former Housing and Urban Development Secretary Ben Carson.

A recently released recording of Russell Vought, a Project 2025 author and the former director of Trump’s Office of Management and Budget, showed Vought saying Trump’s “very supportive of what we do.” He said Trump was only distancing himself because Democrats were making a bogeyman out of the document.

Project 2025 wouldn’t ban abortion outright, but would curtail access

The Harris campaign shared a graphic on X that claimed “Trump’s Project 2025 plan for workers” would “go after birth control and ban abortion nationwide.”

The plan doesn’t call to ban abortion nationwide, though its recommendations could curtail some contraceptives and limit abortion access.

What’s known about Trump’s abortion agenda neither lines up with Harris’ description nor Project 2025’s wish list.

Project 2025 says the Department of Health and Human Services Department should “return to being known as the Department of Life by explicitly rejecting the notion that abortion is health care.”

It recommends that the Food and Drug Administration reverse its 2000 approval of mifepristone, the first pill taken in a two-drug regimen for a medication abortion. Medication is the most common form of abortion in the U.S. — accounting for around 63 percent in 2023.

If mifepristone were to remain approved, Project 2025 recommends new rules, such as cutting its use from 10 weeks into pregnancy to seven. It would have to be provided to patients in person — part of the group’s efforts to limit access to the drug by mail. In June, the U.S. Supreme Court rejected a legal challenge to mifepristone’s FDA approval over procedural grounds.

WATCH: Trump’s plans for health care and reproductive rights if he returns to White House The manual also calls for the Justice Department to enforce the 1873 Comstock Act on mifepristone, which bans the mailing of “obscene” materials. Abortion access supporters fear that a strict interpretation of the law could go further to ban mailing the materials used in procedural abortions, such as surgical instruments and equipment.

The plan proposes withholding federal money from states that don’t report to the Centers for Disease Control and Prevention how many abortions take place within their borders. The plan also would prohibit abortion providers, such as Planned Parenthood, from receiving Medicaid funds. It also calls for the Department of Health and Human Services to ensure that the training of medical professionals, including doctors and nurses, omits abortion training.

The document says some forms of emergency contraception — particularly Ella, a pill that can be taken within five days of unprotected sex to prevent pregnancy — should be excluded from no-cost coverage. The Affordable Care Act requires most private health insurers to cover recommended preventive services, which involves a range of birth control methods, including emergency contraception.

Trump has recently said states should decide abortion regulations and that he wouldn’t block access to contraceptives. Trump said during his June 27 debate with Biden that he wouldn’t ban mifepristone after the Supreme Court “approved” it. But the court rejected the lawsuit based on standing, not the case’s merits. He has not weighed in on the Comstock Act or said whether he supports it being used to block abortion medication, or other kinds of abortions.

Project 2025 doesn’t call for cutting Social Security, but proposes some changes to Medicare

“When you read (Project 2025),” Harris told a crowd July 23 in Wisconsin, “you will see, Donald Trump intends to cut Social Security and Medicare.”

The Project 2025 document does not call for Social Security cuts. None of its 10 references to Social Security addresses plans for cutting the program.

Harris also misleads about Trump’s Social Security views.

In his earlier campaigns and before he was a politician, Trump said about a half-dozen times that he’s open to major overhauls of Social Security, including cuts and privatization. More recently, in a March 2024 CNBC interview, Trump said of entitlement programs such as Social Security, “There’s a lot you can do in terms of entitlements, in terms of cutting.” However, he quickly walked that statement back, and his CNBC comment stands at odds with essentially everything else Trump has said during the 2024 presidential campaign.

Trump’s campaign website says that not “a single penny” should be cut from Social Security. We rated Harris’ claim that Trump intends to cut Social Security Mostly False.

Project 2025 does propose changes to Medicare, including making Medicare Advantage, the private insurance offering in Medicare, the “default” enrollment option. Unlike Original Medicare, Medicare Advantage plans have provider networks and can also require prior authorization, meaning that the plan can approve or deny certain services. Original Medicare plans don’t have prior authorization requirements.

The manual also calls for repealing health policies enacted under Biden, such as the Inflation Reduction Act. The law enabled Medicare to negotiate with drugmakers for the first time in history, and recently resulted in an agreement with drug companies to lower the prices of 10 expensive prescriptions for Medicare enrollees.

Trump, however, has said repeatedly during the 2024 presidential campaign that he will not cut Medicare.

Project 2025 would eliminate the Education Department, which Trump supports

The Harris campaign said Project 2025 would “eliminate the U.S. Department of Education” — and that’s accurate. Project 2025 says federal education policy “should be limited and, ultimately, the federal Department of Education should be eliminated.” The plan scales back the federal government’s role in education policy and devolves the functions that remain to other agencies.

Aside from eliminating the department, the project also proposes scrapping the Biden administration’s Title IX revision, which prohibits discrimination based on sexual orientation and gender identity. It also would let states opt out of federal education programs and calls for passing a federal parents’ bill of rights similar to ones passed in some Republican-led state legislatures.

Republicans, including Trump, have pledged to close the department, which gained its status in 1979 within Democratic President Jimmy Carter’s presidential Cabinet.

In one of his Agenda 47 policy videos, Trump promised to close the department and “to send all education work and needs back to the states.” Eliminating the department would have to go through Congress.

What Project 2025, Trump would do on overtime pay

In the graphic, the Harris campaign says Project 2025 allows “employers to stop paying workers for overtime work.”

The plan doesn’t call for banning overtime wages. It recommends changes to some Occupational Safety and Health Administration, or OSHA, regulations and to overtime rules. Some changes, if enacted, could result in some people losing overtime protections, experts told us.

The document proposes that the Labor Department maintain an overtime threshold “that does not punish businesses in lower-cost regions (e.g., the southeast United States).” This threshold is the amount of money executive, administrative or professional employees need to make for an employer to exempt them from overtime pay under the Fair Labor Standards Act.

In 2019, the Trump’s administration finalized a rule that expanded overtime pay eligibility to most salaried workers earning less than about $35,568, which it said made about 1.3 million more workers eligible for overtime pay. The Trump-era threshold is high enough to cover most line workers in lower-cost regions, Project 2025 said.

The Biden administration raised that threshold to $43,888 beginning July 1, and that will rise to $58,656 on Jan. 1, 2025. That would grant overtime eligibility to about 4 million workers, the Labor Department said.

It’s unclear how many workers Project 2025’s proposal to return to the Trump-era overtime threshold in some parts of the country would affect, but experts said some would presumably lose the right to overtime wages.

Other overtime proposals in Project 2025’s plan include allowing some workers to choose to accumulate paid time off instead of overtime pay, or to work more hours in one week and fewer in the next, rather than receive overtime.

Trump’s past with overtime pay is complicated. In 2016, the Obama administration said it would raise the overtime to salaried workers earning less than $47,476 a year, about double the exemption level set in 2004 of $23,660 a year.

But when a judge blocked the Obama rule, the Trump administration didn’t challenge the court ruling. Instead it set its own overtime threshold, which raised the amount, but by less than Obama.

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SALARY AND PERFORMANCE

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Unpad needs a new payment system as the demand in improving the performance and legality of compensation payment based on the level of responsibility and the needed demand of professionalism. By proposing the principle of pay for performance, since 2015 Unpad has conducted pay reform known as remuneration. Meanwhile, the purpose of remuneration system at Unpad is to obtain human resources with the appropriate qualification so that it makes sure that they work professionally, retains good and high achieving employees, motivates employees to work productively, gives rewards to employees based on their performance and work achievements, and controls the employee cost. This paper would explain how pay reform affects the performance of Unpad, particularly in achieving tridharma perguruan tinggi (the three obligations of universities). The research method applied was the qualitative with collection data techniques of participatory observation, interviews, and literatur review. The researc...

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Annual Review of Organizational Psychology and Organizational Behavior

Volume 9, 2022, review article, compensation, benefits, and total rewards: a bird's-eye (re)view.

  • Ingrid Smithey Fulmer 1 , and Junting Li 1
  • View Affiliations Hide Affiliations Affiliations: School of Management and Labor Relations, Rutgers University, Piscataway, New Jersey, USA; email: [email protected] [email protected]
  • Vol. 9:147-169 (Volume publication date January 2022) https://doi.org/10.1146/annurev-orgpsych-012420-055903
  • First published as a Review in Advance on November 02, 2021
  • Copyright © 2022 by Annual Reviews. All rights reserved

Research on compensation and employee benefits has enjoyed a long and rich history. Energized by a new generation of scholars, changes in the broader workplace context, and developments in adjacent areas of inquiry, many classic theoretical tensions and research questions have begun to evolve in novel directions, and exciting new areas of research are developing. In addition, there have been numerous calls for more academic research on both compensation and benefits and for greater alignment of that research with the needs and interests of practice, including the tendency of many practitioners (and employees) to view pay and benefits holistically as a package. In this review we highlight selected recent research on key components of core total rewards—compensation plus retirement, health, and work-life benefits. Extrapolating from our review, we identify evolving themes and trends and advance several recommendations for future research and suggestions for practice.

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Wage, Work Environment, and Staffing: Effects on Nurse Outcomes

Matthew d. mchugh.

1 Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA, USA

Chenjuan Ma

2 National Database for Nursing Quality Indicators, Kansas City, MO, USA

Research has shown that hospitals with better nurse staffing and work environments have better nurse outcomes—less burnout, job dissatisfaction, and intention to leave the job. Many studies, however, have not accounted for wage effects, which may confound findings. By using a secondary analysis with cross-sectional administrative data and a four-state survey of nurses, we investigated how wage, work environment, and staffing were associated with nurse outcomes. Logistic regression models, with and without wage, were used to estimate the effects of work environment and staffing on burnout, job dissatisfaction, and intent to leave. We discovered that wage was associated with job dissatisfaction and intent to leave but had little influence on burnout, while work environment and average patient-to-nurse ratio still have considerable effects on nurse outcomes. Wage is important for good nurse outcomes, but it does not diminish the significant influence of work environment and staffing on nurse outcomes.

Introduction

Burnout and job dissatisfaction are perennial problems resulting in costly employee turnover ( Larrabee et al., 2003 ) and poor patient outcomes ( McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011 ; Vahey, Aiken, Sloane, Clarke, & Vargas, 2004 ). Nurses working in hospitals with excessive patient workloads and poor work environments are more likely to be burned out and dissatisfied with their job ( Aiken, Clarke, Sloane, Lake, & Cheney, 2008 ; Aiken, Clarke, Sloane, Sochalski, & Silber, 2002 ; Maslach, Schaufeli, & Leiter, 2001 ). These conditions—the level of nurse staffng and the quality of nurses’ work environment—can be changed through good management and organizational practices that value professional nursing.

A satisfactory wage is a significant factor in job-seeking behavior and is especially important in keeping workers in their current positions. Increasing wage to solve institutional workforce recruitment and retention problems is an easy-to-implement intervention in the short run ( May, Bazzoli, & Gerland, 2006 ). Wage, however, is not the only factor; many nonwage job characteristics are important considerations for workers in selecting and staying at a workplace ( Antonazzo, Scott, Skatun, & Elliott, 2003 ; Blau, 1991 ; Chiha & Link, 2003 ; García & Molina, 1999 ; Kovner, Brewer, Wu, Cheng, & Suzuki, 2006 ; Shields, 2004 ; Woodbury, 1983 ). Work takes place within a larger context of hierarchies, relationships, management environments, ethical climates, operating rules, resources, and space distribution ( Maslach et al., 2001 ). Work environments that are more favorable to workers are associated with lower burnout, job dissatisfaction, and intent to leave across a number of sectors, including health care and nursing ( Aiken et al., 2008 ; Kovner et al., 2006 ; Kovner, Brewer, Greene, & Fairchild, 2009 ; Maslach & Jackson, 1982 ; Shields, 2004 ; Shields & Ward, 2001 ; Ulrich et al., 2007 ). To nurses, the organizational climate may be as or even more important than wages as a reason for staying in their job ( Hayes et al., 2006 ; Stone et al., 2007 ).

Wage increases may need to be combined with non-pecuniary factors, especially modifiable hospital factors such as work environment and workload, to recruit adequate numbers of nurses and prevent them from leaving the hospital setting to work in other jobs ( Buerhaus, 1991 ; Ehrenberg & Smith, 2008 ; McHugh et al., 2011 ; Spetz & Given, 2003 ). Frequently missing from nurse outcomes studies, however, is the potentially confounding effect of wage. One might expect that better staffed hospitals with the best work environments also pay higher wages to their nurses. If true, work environment and staffing might be acting as a proxy when better wages is actually the determining factor for mitigating poor nurse outcomes like burnout and job dissatisfaction. Another possibility is that hospitals with less favorable work environments or staffing levels pay higher wages to compensate for poor work conditions. In either case, failing to account for the effects of both wage and nonwage factors on nurse outcomes could confound results. Our aim was to clarify how wage, work environment, and staffing are associated with burnout, job dissatisfaction, and intent to leave.

Data and Sample

The parent study of our cross-sectional secondary analysis used a two-stage sampling design with surveys mailed to the homes of registered nurses in four states (California, Florida, New Jersey, and Pennsylvania) in 2006–2007. The response rate was 39%—more than 100,000 respondents. To address potential nonresponse bias, another random sample of 1,300 nonresponders generated a response rate of 91%. A comparison of the two samples indicated no response bias ( Aiken et al., 2011 ; Smith, 2009 ). The sampling approach has been detailed elsewhere ( Aiken et al., 2011 ). The survey collected information on individual nurses’ demographic characteristics, work status, setting, role, burnout, and job satisfaction.

The nurse survey detailed earlier was also the source of information about hospital work environment and nurse staffing levels. Hospital nurses provided their employers’ names, allowing us to aggregate nurses’ responses for work environment and staffing measures. We limited analysis to data from staff nurse respondents working in adult, nonfederal acute care hospitals with at least 10 respondents. We also used Magnet hospital status—designated through the American Nurses Credentialing Center (ANCC) Magnet Recognition program—as an alternative measure indicating the presence of a good work environment for nurses. Magnet-recognized hospitals have been demonstrated to exemplify good places for nurses to work, and outcomes for both nurses and patients are better in Magnet versus non-Magnet hospitals ( Aiken et al., 2008 ; Lake, Shang, Klaus, & Dunton, 2010 ; Lake et al., 2012 ; McHugh et al., 2013 ).

Information on nonnursing structural hospital characteristics was obtained from the 2006 American Hospital Association (AHA) Annual Survey. These characteristics included number of beds, technological status, teaching status, and geographic location.

Average hourly wage data for registered nurses working as staff nurses in each hospital came from the 2006 Centers for Medicare & Medicaid Services’ (CMS) Medicare Wage Index Occupational Mix Survey. The survey collected average hourly wage data for nurses and other workers from Medicare-participating hospitals. The survey differentiated patient care nurses from those in administrative roles. The survey did not include data for nurses in skilled-nursing, psychiatric, or rehabilitation facilities, allowing us to focus on staff nurses in adult, nonfederal acute care hospitals.

As in earlier works ( Kelly, McHugh, & Aiken, 2011 ; McHugh et al., 2011 ), burnout was measured using the Emotional Exhaustion subscale of the Maslach Burnout Inventory. The intraclass correlation coefficient ICC(1, k ) for the Emotional Exhaustion subscale was acceptable at .62 with 10 nurses per hospital ( Glick, 1985 ). Nurses were classified as burned out if their score on this subscale was higher than or equal to 27, the published average for health care workers ( Maslach & Jackson, 1982 , 1986 ).

Job dissatisfaction

Job dissatisfaction was measured using nurses’ responses to the question, “How satisfied are you with your current job?” The 4-point Likert-type scale response options ranged from very satisfied to very dissatisfied . We dichotomized the measure such that nurses who reported being either very dissatisfied or a little dissatisfied were described as dissatisfied and nurses reporting being moderately satisfied or very satisfied were described as satisfied ( Kelly et al., 2011 ).

Work environment

Work environment was measured using the Practice Environment Scale of the Nursing Work Index (PES-NWI; Lake, 2002 ). We used the four subscales of the PES-NWI, measuring nurse manager ability, leadership, and support; nursing foundations for quality care; collegial nurse–physician relations; and nurses’ participation in hospital affairs. The staffng and resource adequacy subscale was omitted due to high correlation with our staffng measure—patient-to-nurse ratio. An overall PES-NWI score for each hospital was calculated as the mean of the hospital-level subscales. The intraclass correlation coefficient ICC(1, k ) for the hospital composite was acceptable at .85 with 10 nurses per hospital ( Glick, 1985 ). For descriptive purposes, hospitals were classified into three categories based on the PES-NWI scores: hospitals in the top quartile were classified as good , hospitals in the low quartile as poor , and hospitals in between as mixed . In regression models estimating the effect of work environment on nurse outcomes, continuous standardized PES-NWI scores were used.

We also evaluated models substituting an alternative indicator of a good work environment—Magnet hospital status. Hospitals recognized as Magnet hospitals by the ANCC as of 2007 were included (53 Magnet and 481 non-Magnet hospitals in our sample).

Staffing was measured as the hospital’s average patient-to-nurse ratio from the nurse survey data by dividing the average number of patients reported by nurses on their units on their last shift by the average number of nurses on that unit ( Aiken et al., 2011 ). Hospitals were categorized into three groups for descriptive purposes: hospitals in the highest quartile as having poor staffing, hospitals in the lowest quartile as having good staffing, and hospitals in between as having mixed staffing. In regression models, a continuous standardized patient-to-nurse ratio was used.

The average hourly wage (total of paid wages and salaries/total paid hours) data for staff nurses, including charge nurses but excluding nurses in administrative or leadership positions, were obtained from the 2006 CMS Medicare Wage Index Occupational Mix Survey. Total paid wages and salaries included overtime, vacation, holiday, sick, lunch, severance, other paid time off, and bonuses, but not fringe benefits or wage-related costs. Paid hours included regular hours, overtime hours, paid holiday, vacation, sick, severance pay hours, and other paid-time-off hours.

Hospital characteristics

Our analytic models included a number of hospital structural characteristics as covariates that may affect nurse outcomes ( Aiken et al., 2002 ). These variables were drawn from the AHA Annual Survey. Teaching status was a categorical variable where hospitals without any trainees (postgraduate medical residents or fellows) were nonteaching, hospitals with a 1:4 or smaller trainee-to-bed ratio were minor teaching, and those with higher than 1:4 trainee-to-bed ratios were major teaching. The number of beds was categorized as small (<100 beds), medium (101–250 beds), or large (>251 beds). High-technology hospitals were designated with a binary variable, where high-technology hospitals were those facilities that provided services for open heart surgery, organ transplantation, or both. We used the Herfindahl–Hirschman index—the sum of squared market shares for the hospital service area—as a market competition indicator. We used dummy variables for state as well as urban–rural location (urbanized areas=50,000 or more people; urban clusters=49,999–2,500 people; and rural areas encompass any area not included within an urban area or cluster).

Nurse characteristics

We included nurse-level demographic information that may have affected our nurse outcomes. These variables included gender, type of unit the nurse worked on (medical–surgical, intensive or critical care, or other), highest level of education attained (less than a Bachelor of Science in Nursing [BSN] degree vs. a BSN degree or higher), and years of experience as a registered nurse.

Data Analysis

The data sources were merged to create a final analytic sample of 26,005 registered nurses from 534 hospitals in the four states. First, we assessed the characteristics of nurses and the hospitals in which they worked. We then described the average wages by hospital characteristics. Logistic regression models were used to estimate the effects of wage, work environment, and nurse staffng on three separate nurse outcomes—burnout, job dissatisfaction, and intent to leave—while accounting for individual nurse and hospital characteristics. Our independent variables were standardized, which allowed us to interpret our results as the expected change in the outcome, corresponding with a one standard deviation ( SD ) change in the predictors. This permitted more relevant comparisons of the effects of different predictors on outcomes. We estimated robust standard errors and significance levels that accounted for the clustering of individual nurses within hospitals ( White, 1980 ; Williams, 2000 ). The study protocol for the parent study was approved by the University of Pennsylvania institutional review board.

Table 1 shows characteristics of the 534 study hospitals. Roughly half of the hospitals were nonteaching hospitals; among the teaching hospitals, most were minor teaching hospitals with a trainee-to-bed ratio of 0.25 or less. More than 90% of the hospitals in our study had more than 100 beds. Approximately 10% of the hospitals in our sample were Magnet hospitals. About 2% of the hospitals were located in rural areas. The mean score of nurse work environment was 2.73 ( SD =0.22). On average, the patient-to-nurse ratio among these hospitals was approximately 5:1 ( SD =1.1). Nurses’ average hourly wage was $37.20 ( SD =$8.84).

Hospital Characteristics and Average Hourly Wage by Hospital Characteristics ( n =534).

(%)Mean wage ( )
Nurse work environment
 Poor134 (25)$33.82 (6.61)
 Mixed267 (50)$37.49 (9.20)
 Good133 (25)$40.49 (9.05)
Nurse staffing
 Poor134 (25)$32.23 (6.48)
 Mixed267 (50)$36.43 (7.75)
 Good133 (25)$43.67 (9.11)
Magnet hospital
 Magnet53 (10)$36.29 ($6.54)
 Non-Magnet481 (90)$37.30 ($9.05)
High technology
 High technology246 (46)$38.22 (8.86)
 Not high technology288 (54)$36.54 (8.85)
Teaching status
 No273 (51)$36.97 (9.22)
 Minor217(41)$37.67 (8.65)
 Major44 (8)$37.70 (8.00)
Bed size
 ≤10051 (10)$34.80 (9.35)
 101–250234 (44)$36.79 (9.22)
 >250249 (47)$38.33 (8.34)
Ownership
 Not for profit444 (83)$37.35 ($9.08)
 For profit90 (17)$36.47 ($7.50)
State
 California204 (38)$45.27 (7.72)
 Florida132 (25)$32.15 (3.61)
 New Jersey69 (13)$37.58 (3.69)
 Pennsylvania129 (24)$29.72 (5.03)
Urban–rural status
 Urban area482 (90)$37.91 ($8.64)
 Urban cluster40 (7)$31.03 ($8.07)
 Rural12 (2)$29.33 ($7.57)

Descriptive information on registered nurses’ average hourly wage by hospital characteristics is also presented in Table 1 . The average hourly wage was higher in hospitals with good versus mixed and mixed versus poor work environments. There was little difference, however, in the average wage between Magnet and non-Magnet hospitals. Average hourly wage was higher in hospitals with lower patient-to-nurse ratios. The average hourly wage was also higher in teaching hospitals or hospitals with high technology or more beds. Similarly, wage was higher for hospitals located in urban areas compared with hospitals in rural areas. There was variation in the average wage across the states: Hospitals in California had the highest average wage ($45/hour), whereas hospitals in Pennsylvania had the lowest ($30/hour).

Table 2 describes the nurse characteristics and outcomes in the final sample. Of the 26,005 nurse respondents, approximately 25% expressed dissatisfaction with their current job and about 34% reported high burnout. Roughly 14% of the nurses expressed intent to leave their current position within the year.

Nurse Characteristics and Outcomes ( n =26,005).

Characteristics
 Age, mean ( )44.7 (10.7)
 Work experience, mean ( )16.97 (11.2)
 Female23,704 (93.2%)
 BSN degree or above10,460 (41.0%)
Outcomes
 Job dissatisfaction6,199 (24.8%)
 Burnout8,489 (33.6%)
 Intent to leave3,455 (13.7%)

Note . BSN=Bachelor of Science in Nursing.

We examined whether the differences seen between hospitals with good work environments and the other hospitals was due to their location in urban areas. Tabulating the work environment and staffing data by urban–rural location ( Table 3 ) shows that the average wage was still generally higher in hospitals with better work environments or good staffing levels. A similar relationship was found between urban–rural locations and staffing: Average wage was higher in hospitals with lower patient-to-nurse ratios. All the Magnet hospitals were in urban areas, preventing such an evaluation.

Mean ( SD ) Hourly Wage by Work Environment, Staffing, and Urban–Rural Area Classification.

Urban areaUrban clusterRural
Work environment
 Poor$33.82 ($6.07)$30.15 ($7.21)$28.40 ($5.40)
 Mixed$38.43 ($8.86)$30.02 ($7.91)$30.77 ($9.00)
 Good$40.80 ($8.92)$35.58 ($9.41)$23.00 (–)
Nurse staffing
 Poor$33.52 ($6.01)$26.98 ($4.91)$27.63 ($7.92)
 Mixed$36.73 ($7.66)$32.86 ($8.60)$32.74 ($6.38)
 Good$43.71 ($9.24)$42.45 ($3.30)

In addition to unadjusted models, we estimated two versions of our final models, both of which jointly consider the effects of work environment (measured alternatively with the PES-NWI and Magnet status) and staffing when controlling for nurse characteristics and structural hospital factors ( Table 4 ). The difference between the models was that one was estimated without wage, while the other included wage so that we could evaluate how our estimates would change when wage was held constant.

Odds Ratios Indicating the Effect of Wage, Work Environment, and Staffing on Individual Nurse Outcomes.

Adjusted [95% CI]
Unadjusted
[95% CI]
PES-NWI Magnet Hospital
Without wageWith wageWithout wageWith wage
Job dissatisfaction
 Wage0.81 [0.77, 0.86] 0.91 [0.86, 0.96] 0.91 [0.84, 0.99]
 Work environment0.66 [0.64, 0.69] 0.70 [0.67, 0.72] 0.70 [0.67, 0.72]
 Magnet status0.82 [0.71, 0.94] 0.82 [0.72, 0.94] 0.82 [0.72, 0.94]
 Staffing 0.78 [0.75, 0.82] 0.90 [0.86, 0.95] 0.91 [0.86, 0.95] 0.84 [0.79, 0.90] 0.84 [0.79, 0.90]
Burnout
 Wage0.88 [0.84, 0.92] 0.96 [0.91, 1.02]0.97 [0.90, 1.04]
 Work environment0.77 [0.74, 0.79] 0.78 [0.75, 0.81] 0.77 [0.75, 0.81]
 Magnet status0.90 [0.80, 1.00]0.87 [0.78, 0.97] 0.87 [0.78, 0.97]
 Staffing 0.86 [0.82, 0.89] 0.92 [0.87, 0.96] 0.92 [0.88, 0.96] 0.87 [0.83, 0.92] 0.87 [0.83, 0.92]
Intent to leave
 Wage0.89 [0.84, 0.94] 0.89 [0.82, 0.97] 0.90 [0.81, 0.99]
 Work environment0.75 [0.71, 0.80] 0.72 [0.68, 0.76] 0.72 [0.68, 0.76]
 Magnet status0.81 [0.70, 0.94] 0.84 [0.73, 0.97] 0.84 [0.73, 0.97]
 Staffing 0.94 [0.89, 0.99] 0.93 [0.86, 0.99] 0.93 [0.87, 1.00]0.87 [0.80, 0.94] 0.86 [0.80, 0.94]

Note. PES-NWI=Practice Environment Scale of the Nursing Work Index; OR =odds ratio; CI=confidence interval. For interpretability, we report standardized coefficients. Unadjusted estimates are based on models evaluating the effect of a predictor variable, separately, without accounting for any other covariates. Adjusted models account for nurse gender, education level, unit type, years of experience, and hospital characteristics including market competition with the Herfindahl–Hirschman index, teaching status, number of beds, technology level, ownership, state, and urban–rural location.

Our results related to job dissatisfaction show that nurses working in hospitals with better work environments and better staffing have lower odds of job dissatisfaction. When we added wage to the models, the effect of wage was significant, but the effects of work environment and staffing remained essentially unchanged. Thus, an odds ratio ( OR ) of 0.70 (95% confidence interval [CI] [0.67, 0.72]) for work environment suggests that even when we account for wage and all other covariates, nurses working at hospitals at the 50 th versus the 16 th percentile or the 84 th versus the 50 th percentiles in terms of the work environment had 30% lower odds of job dissatisfaction. The OR for both staffing ( OR =0.91; 95% CI [0.86, 0.95]) and wage ( OR =0.91; 95% CI [0.86, 0.96]) suggests that a one standard deviation change in either average wage or average staffing was associated with 9% lower odds of nurses reporting job dissatisfaction. The same was true for our models that substituted Magnet status as an indicator of a good work environment. The odds of job dissatisfaction was 18% ( OR =0.82; 95% CI [0.72, 0.94]) lower in Magnet compared with non-Magnet hospitals, accounting for wage and all other covariates.

Our results related to burnout were similar to job dissatisfaction. The notable exception was that there was no statistically significant relationship between wage and burnout in our adjusted models with either the PES-NWI ( OR for wage=0.96; 95% CI [0.91, 1.02] in the PES-NWI model) or Magnet status ( OR for wage=0.97; 95% CI [0.90, 1.04] in the Magnet status model).

Work environment and staffing were significantly associated with intent to leave even when we accounted for average wage. The one caveat was related to models measuring the work environment with the PES-NWI—when we go from a model not including wage to one that includes wage, the relationship between staffing and intent to leave becomes statistically insignificant at the p =.05 level ( p =.058). The estimate, however, remained essentially unchanged ( OR =0.93; 95% CI [0.86, 0.99] in the PES-NWI model without wage; OR =0.93; 95% CI [0.87, 1.00] in the PES-NWI model with wage). The estimates for staffing in models using Magnet status, both with and without the inclusion of wage, were statistically significant. Interactions between the work environment and wage, Magnet status and wage, and staffing and wage were not significant.

The significant association between more favorable nurse work environments and nurse outcomes, net of wage effects, implies that wages are important, but they do not account for the better outcomes associated with the work environment and nurse staffing. This supports earlier findings that more favorable work environments are associated with lower burnout, job dissatisfaction, and intent to leave across a number of sectors, including nursing ( Aiken et al., 2008 ; Kovner et al., 2006 , 2009 ; Maslach & Jackson, 1982 ; Stone et al., 2007 ). Our findings are also consistent with the literature demonstrating that it requires more than good pay to attract nurses into hospital employment and keep them working there ( McCloskey, 1974 ; Stone et al., 2007 ).

Transforming the organizational culture to support and integrate a model of professional nursing practice can be a valuable investment for hospitals ( DeBaca, Jones, & Tornabeni, 1993 ; Mark, Lindley, & Jones, 2009 ; Needleman & Hassmiller, 2009 ; Zelauskas & Howes, 1992 ), but it requires organizational willingness and commitment. The Magnet Recognition Program is one approach offering a concrete model for creating a good work environment for nurses. When we substituted Magnet hospital status as an indicator of the work environment, our findings showed that—holding wage constant—Magnet recognition was associated with lower odds of burnout, job dissatisfaction, and intent to leave. The Magnet estimates are likely conservative given the low ratio of Magnet hospitals.

The finding that a higher patient-to-nurse ratio was associated with job dissatisfaction and burnout, regardless of average wage, supports previous research ( Aiken et al., 2002 ). An excessive workload exhausts workers’ energy and makes recovery impossible. Effective and gratifying work—the satisfaction that comes from providing good quality care to patients—becomes less attainable. Although hiring more nurses can be costly, some of these costs would be offset by increased productivity, a reduction in turnover and retraining costs, and, more importantly, better patient outcomes ( Dall, Chen, Seifert, Maddox, & Hogan, 2009 ; Jones, 2004 ; Needleman & Hassmiller, 2009 ; Rothberg, Abraham, Lindenauer, & Rose, 2005 ).

Our intent was not to discount the importance of wage; wages are an important tool for administrators to use to attract and expand their workforce ( Buerhaus, 2008 ). Our goal, however, was to evaluate whether, as we found, the effects of the work environment and staffing persisted when we accounted for wage. The wage effect, as one might expect, was still important—except in the instance of burnout. Wage may do little to compensate for the conditions leading to burnout. Reforming underlying work conditions at the root of emotional exhaustion may be key to reducing and preventing burnout.

Although nurses are paid relatively well in the United States, wages are compressed ( Greipp, 2003 ) and hospitals can set nurses’ wages below their value ( Staiger, Spetz, & Phibbs, 2010 ). This has not gone unnoticed. Nurses, particularly those in direct patient care roles in hospitals and nursing homes, have reported dissatisfaction with wages, as well as nonwage benefits such as health care, tuition reimbursement, and retirement benefits ( McHugh et al., 2011 ). Wage rates and distribution should match nurse skill level to encourage entry into the profession and retention within the institution. Competitive wages, combined with good benefits and nonpecuniary factors, may be necessary to recruit adequate numbers of nurses to meet the ongoing care demands of the upcoming decades and prevent cyclical shortages that have defined the past half century ( Spetz & Adams, 2006 ; Spetz & Given, 2003 ).

Researchers have estimated that California increased wages 12% higher than other metropolitan hospitals outside of California between 2000 and 2006 ( Mark, Harless, & Spetz, 2009 ). It has been suggested that this rise in wages was a consequence of California’s mandate that limited the number of patients that nurses could care for at a given time. We also find that California’s hospital wages were higher compared with hospitals in the other states in our analysis. However, our models estimating the effect of wage, work environment, and staffing on nurse outcomes account for differences by state.

There are limitations to our study. Foremost, the cross-sectional design limited our ability to draw causal inferences. The study, however, strengthens the basis for causal inference by accounting for an important potential confounder that had previously been omitted from most research.

Another limitation is that our survey and wage data predate the economic recession that began at the end of 2007. In an environment where any job is difficult to find, the financial downturn could have tempered perceptions of less desirable aspects of the work environment. A number of factors, however, limit our concern here. The first is that, over the many investigations examining the association between work environment and nurse outcomes, the relationships that we found have been consistently identified regardless of time ( Aiken et al., 2002 ; Aiken & Patrician, 2000 ; Hare & Skinner, 1990 ; Kelly et al., 2011 ; Kutney-Lee et al., 2009 ; Larrabee et al., 2003 ; McHugh et al., 2011 ). What is important about our findings is that we show that these relationships persist when we account for wages as a potential confounder.

Furthermore, although work environments may improve over time, evidence suggests that where changes occur, they are associated with changes in nurse outcomes, that is, if work environments and staffing improve, rates of burnout, job dissatisfaction, and intent to leave decrease ( Kutney-Lee, Wu, Sloane, & Aiken, 2013 ). Additionally, research showed that the percentage of direct care hospital nurses who were very satisfied with their present job in 2006 (prerecession) was 29% compared with 28% in 2008 (during the recession). The percentage of nurses who would rate the quality of the salary and benefits package in their current or most recent work setting as excellent or very good was not significantly different from 2006 (28%) to 2008 (30%). Researchers also suggested that the recession effects on the nursing workforce were temporary ( Staiger, Auerbach, & Buerhaus, 2012 ). We expect that if we repeated our study today, we would find the same relationships. Nevertheless, additional study is warranted.

Another consideration is that our outcomes were nurse-specific, but our wage data were not. Although nurse-level wage data might have allowed a more refined analysis of the association between individual wage and our nurse outcomes, we expect that the gains would have been marginal given wage compression. Additionally, some rural hospitals are not represented in our data because there were an insufficient number of nurses from small hospitals for reliable estimates. Many of such hospitals are Critical Access Hospitals, which are not paid under the Inpatient Prospective Payment System (IPPS) and, therefore, were not required to complete the survey that was the source of our wage data.

We also do not measure union presence or membership, although evidence varies regarding how much of a premium unions confer ( Ash & Seago, 2004 ). We do, however, include many covariates we expect would at least partially account for the variation associated with unionization, including state and urban–rural indicators, teaching status, ownership, and size.

Last, the relative impact of wage on nurse outcomes may vary in different countries. Some studies conducted outside the United States, for example, have shown that dissatisfaction with wage played the biggest role with nurse job dissatisfaction and turnover ( Fochsen, Sjogren, Josephson, & Lagerstrom, 2005 ; Klopper, Coetzee, Pretorius, & Bester, 2012 ; Palmer, 2014 ). These studies, however, also found that characteristics of the work environment were important contributing factors. Multihospital studies outside the United States and cross-national studies would be valuable.

Our findings suggest that better wages do not explain the relationship between working in well-staffed hospitals with good practice environments and nurse outcomes such as nurse burnout, job dissatisfaction, and intent to leave. Although good wages are important, interventions that improve the work environment and maintain reasonable staffing levels may be more critical to attracting and retaining satisfied nurses in the hospital workforce.

Acknowledgments

The authors thank Ms. Mikaella Hill and Ms. Myra Eckenhoff for their assistance with the preparation of this manuscript.

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Robert Wood Johnson Foundation Nurse Faculty Scholars program (to M. D. McHugh) and the National Institute of Nursing Research (R01-NR-004513 and P30-NR-005043; PI: L. Aiken).

Biographies

Matthew D. McHugh , PhD, JD, MPH, RN, FAAN is The Rosemarie Greco Term Endowed Associate Professor in Advocacy at the Center for Health Outcomes & Policy Research at the University of Pennsylvania School of Nursing.

Chenjuan Ma , PhD is a post-doctoral fellow with The National Database of Nursing Quality Indicators, University of Kansas Medical Center.

Declaration of Conflicting Interests

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

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How Knowledge of Salary History Affects Wage Offers and Hiring

​Working Paper Figure w29460

In 21 states, employers cannot ask job candidates about their salary histories, but employers can nonetheless make inferences based on whether candidates voluntarily disclose them.

I n response to claims that historical salary differences related to race, gender, or ethnicity may be perpetuated when job applicants are asked to disclose their salary histories, 21 US states have made it illegal for employers to ask prospective employees about their prior compensation. Job applicants in these states may voluntarily disclose previous earnings. Prospective employers may draw conclusions about candidates’ unobserved attributes and outside options based on whether they make such disclosures.

In Salary History and Employer Demand: Evidence from a Two-Sided Audit (NBER Working Paper 29460 ) Amanda Y. Agan , Bo Cowgill , and Laura K. Gee study how information on an applicant’s salary history shapes wage offers and hiring in the labor market for software engineers. They find that not disclosing salary history decreases salary offers for both men and women.

The researchers created 2,048 fictional job applications based on typical characteristics of software engineering candidates. All applicants were college graduates from roughly equivalent schools with four to six years of experience at well-known firms. Biographical details such as gender, employment at different firms, and whether applicants disclosed their previous salary even when prospective employers did not ask were randomized. The applicants were assigned previous salaries between the 75th and 25th percentile of their prior employer’s salary scale for software engineers, as given at Payscale.com in the headquarter cities. A gender wage gap mimicking real-world gaps was built into the applicants by setting female salaries 15 percent lower.

Using an intermediary firm to pose as an employer, the researchers hired 256 US-based recruiters to evaluate the job applications. Each recruiter was given eight applications and a detailed job description. They were asked to recommend whether to call a candidate for an interview, an amount for a take-it-or-leave-it salary offer, and the maximum amount that the firm should be willing to pay the applicant. They also estimated the number of competing offers a candidate would receive and the salary offer each candidate would accept. Recruiters were paid their standard hourly rate and received incentive bonuses.

Recruiters made negative inferences about nondisclosing candidates, especially male nondisclosing candidates. On average, recruiters inferred that candidates who did not disclose had salaries at or slightly below the 25th percentile. Applicants below this level were better off not disclosing their previous pay, in the sense that they received higher offers. The fictional applicants who disclosed received higher mean recommended salaries, $103,993 versus $96,521. Recruiters estimated their mean outside offers to be 9 percent higher than those for nondisclosers .

There are many ways to earn a higher salary; the experiment was designed to measure whether employers notice these distinctions and treat them differently. Some of the candidates came from firms with a high average wage. Some candidates came from lower-wage firms, but were well-paid within their firm’s distribution. Some candidates were simply beneficiaries of the gender wage gap.

Employers in the experiment noticed these distinctions and adjusted their beliefs and choices. An extra $1 of reported salary given to men through the gender wage gap increased recruiters’ estimated value of the applicant to the firm by only $0.42. By comparison, high salaries earned by working at a high-wage firm or being well-paid within an employer’s internal distribution increased recruiters’ value of the worker by $0.64 to $0.70 per $1 of salary. The employers in the experiment detected overpaid men and treated them less generously than others with the same salary. However, they did not completely eliminate the gender wage gap.

The researchers conclude that employers see disclosing salary as a positive signal of candidate quality. However, salary history is also a signal of strong competing offers. A disclosure could increase chances of a callback, but decrease chances of getting a high salary offer, conditional on a callback. Candidates, employers and policymakers may thus face tradeoffs using and regulating salary history information.

— Linda Gorman

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