Job satisfaction of nurses in a Saudi Arabian university teaching hospital: a cross-sectional studyinr_

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1 Nurses Work-Life Experiences bs_bs_banner Job satisfaction of nurses in a Saudi Arabian university teaching hospital: a cross-sectional studyinr_ R. AL-Dossary 1,2 BSN, RN, MSC, PhD Candidate, J. Vail 3 RN, PhD & F. Macfarlane 4 BSC, MBA, PhD, FHEA, CFCIPD 1 Lecturer, Nursing College, Dammam University, Dammam, Saudi Arabia, 2 PhD Student, 3 Associate Professor, Assistant Dean of Doctoral Studies, College of Health and Human Services, George Mason University, Fairfax, VA, USA, 4 Senior Lecturer and Programme Leader NHS, Clinician and Manager for the MSc Health Care Management, School of Management, Surrey University, Surrey, Guildford, UK AL-DOSSARY R., VAIL J. & MACFARLANE F. (2012) Job satisfaction of nurses in a Saudi Arabian university teaching hospital: a cross-sectional study.international Nursing Review 59, Background: Saudi Arabia is developing very fast in all disciplines, especially in nursing and health. Only about five studies between 1990 and 2010 have been undertaken in Saudi Arabia concerning factors influencing job satisfaction of nurses, although a body of knowledge exists globally. Aim: The purpose of this research was to measure nurses job satisfaction in Saudi Arabia in a university teaching hospital and to determine the influencing factors. Methods: A quantitative, cross sectional method, self-administered questionnaire was used for this study. A systematic sample of N = 189 nurses was used to collect data. The SPSS version was used to analyze the data. An independent t-test and one-way analysis of variance were used to test hypotheses concerning different groups, and correlation tests (the Pearson s and Spearman s rank tests) were used to examine relationships between variables. Results: Overall, nurses were neither satisfied nor dissatisfied with their jobs. However, nurses indicated satisfaction with supervision, co-workers and nature of work. The sources of dissatisfaction were with subscales such as pay, fringe benefits, contingent rewards and operating conditions. Conclusion: These findings indicate that there is a need to increase nurses salaries and bonuses for extra duties. More training programmes and further education also should be encouraged for all nurses. Therefore, it is imperative that nursing managers and policy makers in Saudi Arabia consider these findings to improve nurses job satisfaction. Keywords: Job Satisfaction, Nurses, Saudi Arabia, University Teaching Hospital Introduction Job satisfaction is a crucial issue to any healthcare organization as it is an indicator of the physical and psychological states of its employees. Therefore, it is important for administrators to understand the Correspondence address: Mrs Reem AL-Dossary, Nursing College, Dammam University, Dammam, Saudi Arabia, 4400 University Drive, Fairfax, VA, 22030, USA; Tel: ; Fax: ; rm_aldossary@ hotmail.com, raldossa@gmu.edu. basis of job satisfaction because of the serious impact of dissatisfaction in the workplace. In nursing, job satisfaction as a topic has been studied, discussed and recognized as a key indicator of nurses performance, cost savings and quality of patient care (Seago et al. 2011). This reflects that a body of knowledge exists globally regarding the factors influencing nurses satisfaction; however, between 1990 and 2010, only about five studies have been undertaken in Saudi Arabia related to this issue (Al-Aameri 2000; Al-Ahmadi 2002, 2009; Badawy & Essawy 1992; El-Gilany & Al-Wehady 2001). 424

2 Job satisfaction of nurses in a Saudi Arabian hospital 425 Saudi Arabia is the largest country in the Middle East, covering an area of 2.25 million square kilometres. Saudi Arabia has the largest reserves of petroleum in the world and is the largest exporter (Mufti 2000; The Central Intelligence Agency World Fact Book 2011). Saudi Arabia is developing very fast in all disciplines, especially in nursing and health (Aldossary et al. 2008). However, the demand for labour in the health sector cannot be met by Saudi nationals alone because of the relatively small number of Saudi graduates from nursing schools (Abu-Zinadah 2004). Consequently, most of the healthcare providers are expatriate from different countries. For example, nurses come from over 40 different countries, including the United Kingdom, Ireland and the USA (Aboul-Enein 2002; Aldossary et al. 2008). Therefore, identifying factors influencing job satisfaction of nurses in a university hospital in Saudi Arabia was believed to be needed. Background There are numerous factors that have an impact on nurses satisfaction. One is that the role of the nurse has changed dramatically and become more complex over the past decade (Mrayyan 2005). The role change, along with other issues such as the economic downturn that currently impacts on most hospitals, may have an impact on job satisfaction among nurses. Studies have also shown that job satisfaction may be affected by demographic factors such as age; shift work and pay; and professional factors including years of experience, position and education (Al- Ahmadi 2009; Hu & Liu 2004; Larrabee et al. 2003; Yaktin et al. 2003). Some studies have shown that age and years of experience are factors that affect nurses job satisfaction. For example, Yaktin et al. (2003) showed that in Lebanon, nurses older than 30 were more satisfied than younger nurses. Al-Aameri (2000) conducted a study in public hospitals in Riyadh city, Saudi Arabia, and found that the nurses age is significantly correlated with his/her job satisfaction and commitment. Al-Ahmadi (2002) also found that job satisfaction is positively correlated with years of experience. However, the nursing literature contains conflicting evidence regarding the relationship among age, years of experience and job satisfaction. Age was not related to job satisfaction in a sample of 3472 nurses employed in a variety of patient care settings (Ma et al. 2003). Ma s study also found that nurseswhohadover2yearsworkexperiencehadlowerlevelsof job satisfaction in comparison with those who had less than 2-year work experience. A Chinese study also argued that there is no difference between different age groups and job satisfaction (Hu & Liu 2004). This study, however, found a significant difference between nurses who had worked for less than 10 years and those who had worked for more than 10 years (P < 0.01). Larrabee et al. (2003) found that age was not correlated with job satisfaction. Shift work is another factor that affects nurses job satisfaction. Havlovic et al. (2002) looked at the impact differing work shifts had on full-time and part-time nurses. The study showed that shift work and night work may affect nurses health condition and their sleeping patterns. Consequently, these nurses reported lower job satisfaction. According to the Federation of Nurses and Health Professionals (2001), the increased use of overtime is frequently cited as a key reason for job dissatisfaction among nurses. This is where there is a tendency for the working hours to be related to shift work rather than the length of the working week. Al-Ahmadi (2009) in a study conducted in Saudi Arabia tried to identify factors influencing self-reported performance of hospital nurses, and to determine whether differences in employee demographics, job satisfaction and organizational commitment influenced performance The study found that job performance is positively correlated with organizational commitment, job satisfaction and personal and professional variables. Both job satisfaction and organizational commitment are strong predictors of nurses performance. Pay and benefits are mentioned in other studies as important components of job satisfaction (Ravari et al. 2011; Sparks et al. 2005). Curtis (2007) in the Republic of Ireland also showed that pay is crucial to nurses satisfaction. Pay was identified as the second most important component, yet it made the least contribution to nurses current level of satisfaction. The study also indicated that nurses professional status and the level of interaction autonomy (being responsible for day-to-day decisions) were also factors that contributed to nurses job satisfaction. Al-Ahmadi (2002) in a study on 500 nurses in nine Ministry of Health hospitals in Riyadh, Saudi Arabia, found that the most important determinants of job satisfaction were work conditions and pay. In addition, a study in Jordan that measured nurses job satisfaction found that there was a considerable variation between the findings of head nurses and staff nurses. The study suggested that senior nurses may have had a more optimistic view of their hospital than the younger, staff nurses (Mrayyan 2006). Additionally, a study has shown that there is a strong relationship between the nurses position and his/her job satisfaction (Hu & Liu 2004). In this study, participants who held the professional title of chief nurse or higher were more satisfied with their work than those nurses who held the professional title of senior nurse or lower. Hu & Liu (2004) also demonstrated that there is a relationship between level of education and job satisfaction. Participants who had an associate degree in nursing felt a greater sense of accom-

3 426 R. AL-Dossary et al. plishment and higher job satisfaction compared with those who had a diploma in nursing. Al-Ahmadi (2002) also found differences in satisfaction according to educational level. In Kuwait, Al-Enezi et al. (2009) studied job satisfaction of nurses with multicultural backgrounds. Their aim was to identify factors related to the job satisfaction of nurses and the effect of selected background characteristics on nurses job satisfaction. They found an inverse relationship between job satisfaction and higher levels of education. In another study in Kuwait, Shah et al. (2004) stated that nurses education level is a significant predictor of job satisfaction. Purpose and objectives The purpose of this study was to measure nurses job satisfaction in a university teaching hospital in Saudi Arabia. The objectives were to (1) examine to what extent nurses in this hospital were satisfied with their jobs; (2) determine the factors, which increase or decrease the level of job satisfaction; (3) explore the relationship among the factors that affect job satisfaction; and (4) provide suggestions for policy makers and managers to improve delivery of care by increasing job satisfaction among the subject nurses. Methods Design and sample This study used a cross-sectional, quantitative research design. It took place in a university teaching hospital in the Eastern Province of Saudi Arabia. The questionnaire was piloted in January 2008 using a small group of 25 Saudi and non-saudi nurse. This pilot was to determine the level of understanding, any language or phrase difficulties, comprehension and length of time to complete the survey. The researcher talked to all the respondents after they answered the questionnaire, and they verified that the language of the survey was readable and easy to comprehend, as all the respondents did read and write in English. Thus, the researcher proceeded with the English format for both Saudi nurses and non-saudi nurses. The survey instrument was not examined for use in a different culture or environment other than the original ones, as most of the subjects (n = 167) were from Western cultures, and the Saudi nurses (n = 50) anecdotally have a Westernized exposure and were familiar with Western cultures. It took the respondents approximately 20 min to complete the questionnaire. A systematic sampling method was used. The researcher had targeted all the nurses (N = 500) in a teaching hospital in the Eastern Province of Saudi Arabia. The administration of the hospital provided the researcher with a spreadsheet including all names of the nurses, gender, age and educational status. A sample decision model by Krejcie & Morgan (1970) was used for determining the sample size, which was selected by taking the first and then every fifth (5th) nurse. The population consisted of 500 nurses, and a systematic sample of 217 nurses was drawn from this population. Instruments The job satisfaction survey (JSS; Spector 1997) was used in this research. It examines nine subscales of job satisfaction as well as overall satisfaction. The scale contains 36 items in a summated rating scale format. Each subscale has four items. The response format is a six-point Likert scale, 1 6 for each item ranging from strongly agree to strongly disagree. However, some of the items are scored in a positive and some in a negative direction. In positively worded items, agreement means job satisfaction. On the other hand, negatively worded items, agreement indicates dissatisfaction. As a result, before items were combined, the negative items were reversed as directed by Spector (1985). The procedure of recoding the negative items was by renumbering the negatively worded items responses from 6 to 1 rather than from 1 to 6. The response disagree very much becomes a 6 rather than a 1,and the response agree very much becomes a 1 rather than a 6. Similarly, the response disagree moderately becomes a 5 rather than a 2, and the response agree moderately becomes a 2 rather than a 5. In addition, the response disagree slightly becomes a 4 rather than a 3, and the response agree slightly becomesa3rather than a 4. After the items were reversed, the numbered responses for the appropriate items were summed as shown in Table S1. The total satisfaction score is the sum of the 36 items. The total score can range from 36 to 216. The JSS has been evaluated for reliability by two types of reliability estimates. First, internal consistency (Cronbach s alpha); which refers to how well items of a scale relate to one another. Second, test retest reliability shows the stability of the scale overtime. The time between test and retest was 18 months. Test retest reliability ranged from 0.37 to 0.74 (Spector 1997). According to van Saane et al. (2003), the JSS was one out of the 29 instruments that meet the quality criteria for reliability and validity as a tool to be used in a hospital environment. The Cronbach s alpha in this study was 0.70; it indicates good reliability, as the widely accepted minimum standard for internal consistency is 0.70 (Nunnally 1978). For JSS validity, evidence is provided by studies that compared different scales with one another on the same employees such as five of the JSS subscales (pay, promotion, supervision, co-workers and nature of work) correlate well with corresponding subscales of the job description index (Spector 1997), which perhaps is the most carefully validated scale of job satisfaction.

4 Job satisfaction of nurses in a Saudi Arabian hospital 427 These correlations ranged from 0.61 for co-workers to 0.80 for supervision (Spector 1997). Data collection and analysis The data were collected over a 3-month period from March to May, 2008, using a self-administered questionnaire. In this study, the data analysis was done by the assistance of a software programme, the SPSS version 16.0 (SPSS Inc., Chicago, IL, USA). The researcher carried out four steps to analyze data: first, preparing the data for analysis, and, second, by acquiring a feel for the data. This was done by measuring the central tendency and dispersion. Descriptive statistics was used to analyse demographic data. Inferential statistics (i.e. Pearson s correlation) were used to test the correlation between general job satisfaction and the nine subscales. Third, testing the goodness of data was determined through the previously calculated reliability and validity of the existing scale. Finally, the independent sample t-test and one-way analysis of variance (ANOVA) were used to test the hypotheses generated in this study. The confidence intervals (CI) were adjusted at 95%. Approval for this research was received from the Human Studies Review Board of the University Teaching Hospital where the research was conducted. All participants were informed of the purpose of the study and were given the right to refuse to participate. The questionnaire had a cover page attached that introduced the importance of this study, and stated how it could help in exposing the various factors responsible for affecting job satisfaction among the nurses in a teaching hospital. In this research, no personal identification was asked, thus ensuring anonymity. Confidentiality was maintained, and all data were treated as aggregate data. Results A total of 200 surveys were returned from the original 217 packets that were distributed, the return rate was 87.5%. Of the 200 respondents, 197 provided usable surveys and demographic information. All cases with missing data were excluded; therefore, the final sample for data analysis consisted of 189 staff nurses who worked in the teaching hospital. Of the 189 subjects, 20% were under 30 years old, 42% were between 31 and 45 years old and 38% were over 46 years old. The sample was composed of 88.36% females and 11.64% males. In addition, 88.4% of the nurses working in the teaching hospital were non-saudi, only 11.6% were Saudi. According to the Ministry of Health in 2008, the Saudi nursing workforce consists of 29.1% of the actual nursing manpower available in Saudi Arabia, and 70.9% are non-saudi, which is not exactly comparable with the population surveyed in this study (Almalki et al. 2011). Overall, most nurses in this study were neither satisfied nor dissatisfied with their jobs. General job satisfaction demonstrated a significantly, strong, positive correlation to subscales such as pay, supervision, contingent rewards, co-workers, nature of work and communication. However, job satisfaction was only moderately correlated with factors such as promotion, operating conditions and fringe benefits. A large proportion of the sample (56.9%) preferred morning shifts (from 7:00 AM to 3:00 PM) as good working hours. This preference was most prominent among all Saudi female nurses and non-saudi male nurses (68.2% compared with 55.2%). Among the 29.4% who preferred evening shifts (from 3:00 PM to 11:00 PM), most of them (92.7%) were non-saudi female nurses, and among the 9.1% who preferred the night shift (from 11:00 PM to 7 AM), all of them were non-saudi nurses. Approximately 5% of those studied had no preference for individual shifts. They felt that all shifts are the same. The relationship of personal-related factors to nurses job satisfaction was examined. A one-way ANOVA between groups was carried out to investigate the impact of age on nurses level of satisfaction. The subjects were divided into three groups according to their age (group one: under 30 years old; group two: age years; and group three: over 45 years old). The Levene s test for homogeneity of variance of (P = 0.273) indicated that the assumption of homogeneity of variance was not violated. A non-significant relationship was found between age and job satisfaction (P = 0.223). An independent-sample t-test was preformed to compare general job satisfaction scores for males and females. There was no significant difference in scores for males [M = and standard deviation (SD) = ] and females (M = , SD = ); t(186) =.564, P =.57 (two-tailed). The magnitude of the difference in the means (mean difference = 2.417, 95% CI: to ) was very small (eta squared = 0.002). Only 0.2% of the variance in general job satisfaction is explained by gender. Although non-saudi male nurses exhibited higher mean scores for most of the nine subscales of general job satisfaction compared with female nurses, except for pay, promotion, co-workers and nature of work, the results of t-tests show no overall significant relationship between gender and the nine subscales of job satisfaction. The effect of practice related to factors on nurses job satisfaction was examined. The relationship between general job satisfaction and numbers of patients per nurse, per shift was investigated using Spearman s rank correlation test. The Spearman s correlation test was not statistically significant (n = 187, Spearman s correlation rho = 0.015, P = 0.836). Each patient care unit was staffed with approximately nurses. The number of patients assigned to each nurse varied from unit to unit

5 428 R. AL-Dossary et al. according to the care each patient needed. Forty-three percent of the nurses cared for less than five patients per shift (these were usually in intensive care units), while 42% of the nurses were responsible for more than eight patients (in general care units). The data demonstrated that increased number of patients assigned per shift was not a source of job dissatisfaction. The majority of the nurses (91%) worked full-time. Eighty-six percent of the non-saudi nurses had an income less than 5000 Saudi Riyals per month (approximately US$ ). Examining the effect of professional-related factors on nurses job satisfaction, there was a statistically significant correlation (n = 182, rho = , P = 0.006) between the number of years of nursing experience and the general job satisfaction. Interestingly, in the regression model for general job satisfaction, in which the non-normal distribution of the number of years of experience was not taken into account, the number of years of nursing experience was found to be statistically significant (P = 0.029) with a parameter of 0.357, indicating that for each additional year of experience, a non-saudi nurse s general job satisfaction rises by Furthermore, in this study, the relationship between general job satisfaction and position level, for example, staff nurse, charge nurse, nurse supervisor and nurse director was not statistically significant (n = 188, rho =-0.064, P = 0.380). Forty percent had a diploma, 32% were non-saudi, 59% had a BSc, 15% were Saudi and 1% held a master s degree. There was no significant difference in general satisfaction scores (P = 0.249) for the education groups. Discussion It can be concluded that most nurses were satisfied with the leadership style of their direct supervisors. In addition, most nurses were satisfied with their relationship with their colleagues and the work they did. However, dissatisfaction was associated with subscales such as pay, fringe benefits, contingent rewards and operating conditions. Nevertheless, nurses were neither dissatisfied nor satisfied with themes such as promotion and communication. Most of the participants were females, and a nonsignificant relationship was found between gender and job satisfaction (P = 0.57), two-tailed test statistic. These results were supported from the literature (Siu 2002). Non-Saudi male nurses exhibited higher means on most of the nine subscales of general job satisfaction compared with female nurses, except for pay, promotion, co-workers and nature of work. The results of t-tests showed no significant relationship between gender and the nine subscales of job satisfaction. The relationship between general job satisfaction and number of patients assigned per shift was not statistically significant. Although some studies agree that increased number of patients assigned per shift is a common source of job dissatisfaction (Mrayyan 2005; Yaktin et al. 2003), the results of this study do not agree with those findings. In addition, a large proportion of the sample (56.9%) preferred morning shifts (7:00 AM to 3:00 PM) as good working hours in a teaching hospital; this preference was most prominent among all Saudi female nurses and non-saudi male nurses (68.2% compared with 55.2% for females). This supports the findings of other studies that indicate that nurses job satisfaction was influenced positively by the convenient job schedule that afforded the opportunity to meet the nurses personal and family needs (Brooks & Swailes 2002; Hoffman & Scott 2003). The relationship between general job satisfaction and monthly income was not statistically significant. The results of this study agrees with another study that salaries constitute only a small facet of job satisfaction compared with other factors, which may be perceived as being much more important (Burnard et al. 1999). This study also shows a significant correlation between the number of years of nursing experience and general job satisfaction. This would also support findings of other studies (Hu & Liu 2004; Yaktin et al. 2003). In this study, the relationship between general job satisfaction and position level was not statistically significant (staff nurse vs. charge nurse vs. nurse supervisor vs. nurse director). The findings of this study contradict results from other research that there is a relationship between general job satisfaction and position level (Curtis 2007; Ma et al. 2003; Mrayyan 2006). These results may have occurred because 69.3% of the sample were staff nurses and, there were not enough nurses of higher position to tell if such a relationship exists. Another reason may be that the majority of the sample (88%) was non-saudi, and most of them (87%) were in the positions of staff nurse. There was no significant difference in general satisfaction scores (P = 0.249) for the education groups. Limitations Several issues limit the generalizability of the results of this study; for example, the narrow context of the study, which is a single university hospital, and the modest sample size. In addition, in this sample, there was a disparity in the number of Saudi nurses (n = 50) and non-saudi nurses (n = 167). However, this reflects the reality of the Saudi Arabian nursing workforce, which consists of 70.9% non-saudi nurses and 29.1% Saudi nurses (Almalki et al. 2011). Also, the insufficient amount of information and resources regarding job satisfaction among nurses in teaching hospitals in Saudi Arabia was a constraining factor. This deficiency can be attributed to the fact that there has been little research in Saudi Hospitals. Recommendations The following recommendations are made to improve nurses satisfaction and, thus, the quality of care provided in Saudi teach-

6 Job satisfaction of nurses in a Saudi Arabian hospital 429 ing hospitals. (1) Most nurses in this research were dissatisfied with pay, fringe benefits, operating conditions and contingent rewards received. Therefore, nurses job satisfaction may improve if incentives are provided, such as increased pay and bonuses for extra duties. (2) Nurses who perform well should be encouraged by giving them early promotions. Suggestions for future research Further research into this subject area is needed to validate the factors influencing nurses job satisfaction in Saudi Teaching Hospitals. It would be ideal if this research was replicated concentrating on a larger sample of nurses from the other teaching hospitals, both governmental and private, in Saudi Arabia. Additionally, it would be useful to study both Saudi and non-saudi nurses and to compare the results. Moreover, it would be useful to use mixed methods research (quantitative and qualitative) to study job satisfaction in this population to gain a better understanding of the issues and to increase the knowledge about job satisfaction in both Saudi and non-saudi nurses. The study was cross-sectional. Future research should include a longitudinal study where the respondents could be followed for a period of time instead of on a one-shot basis. This will help to discover any changes in nurses satisfaction levels and factors associated with changes. In addition, the Ministry of Health should fund an ongoing survey concerning job satisfaction by identifying a large and diverse cohort of nurses and surveying them annually to substantiate the findings in this study. Conclusion This study has provided information about the factors influencing nurses job satisfaction. Job satisfaction factors may change over time; therefore, regular research is needed to discover any changes. These findings should be born in mind for healthcare managers for future decision making regarding nurses job satisfaction. Nurses satisfaction with their jobs is an important key to better work performance and staff retention. The future challenge will be to encourage nurses and managers to all work together for a better workforce, which will ultimately improve patient care of high quality. Any organizational change within university hospitals should take into consideration nurses job satisfaction. Author contributions All of the authors have contributed significantly in the development of this work. Mrs. AL-Dossary contributed to the design, collected and synthesized the data used in this paper, and wrote the main text. Dr. Vail and Dr. Macfarlane contributed to the design, editing and revisions of the manuscript, as well as provided supervision for the first author. All authors read and approved the final manuscript. References Aboul-Enein, F.H. 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