Nurses in most healthcare facilities have some of the highest levels of direct patient contact of any employees. They play an essential role in achieving organizational goals and of providing high quality care to the community. Hospitals are important health care and social system where nurses are the cornerstones for their effectiveness and efficiency. Devoid of people, organizations can not reach their goals. (Drucker, 1999).
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Nursing shortage and high rates of nurses’ turnover has become a prevalent global issue (Kingma, 2001). Job satisfaction is an essential element that has strong effects on patient safety, productivity, performance, quality of care, retention and turnover (Cavanagh and Cof¬n, 1992; Blegen, 1993; Irvine and Evans, 1995).. Job satisfaction refers to overall positive feelings towards a job. It is defined as, “Pleasurable or positive emotional state resulting from the appraisal of one’s job experiences (Locke, 1976).” What in terms of job satisfaction counts is the attitude of an employee towards his job. Attitude is a point of view of an individual towards an object. The object may be anything, such as, an organization, a manager, a colleague or a job. What is important about attitude is that people make decisions based on their attitudes. When people are satisfied with their job, they tend to stay in their job. On the other hand, people who are not satisfied with their job tend to take a decision of quitting their workplace.
Nurses with positive attitude are likely to be productive and effective in the organization whereas those with negative attitude have poor performance and ultimately less productive.
Satisfied employees tend to be more productive, creative, and committed to their industry, and recent studies have shown a direct relation between staff satisfaction and patient satisfaction in health care organizations (Al-Aameri, 2000). The entire employee wants to be satisfied at their job no matter what activities they are engaged in or have the will to carry out. The significance of job satisfaction arises from the fact that the nurses of whom job satisfaction is positive are not only pleased and satisfied with themselves but also affecting the quantitative and qualitative outcomes of the health organization in a positive way. Quite the opposite, the dissatisfied nurses are not peacefully pleasured resulting in poor performance, increased absenteeism, tardiness, burnout, turnover and qualititative and quantitative negative outcomes for the health care system.
Job satisfaction should be of primary concerns to the health organization because nurses take the responsibility of many positions in the hospital and their turnover would have great impact on the employers and the patients as well. The shortage of nurses has been well recognized and extended to the long-term care services (Fletcher, 2001; Mark, 2002; Mitchell, 2003) Cited in MH 2008. In response population growth, health care organizations are facing problems in finding and keeping skillful nurses (Gohen & Van Nostrand, 1995; Kassner & Bertel, 1998). The management system must be alarmed about the factors that contribute to job satisfaction and turnover to halt the potential critical effect on nurses’ performance and eventually on the delivery of patient care. High nurse turnover and vacancy rates are affecting access to health care (Best & Thurston, 2004) Cited in MH 2008. Continuously hiring new staff is costly and recurrent turnover influence the morality of nurses and vitiates patient care (Sofie, Belzar, & Young, 2003) Cited in MH 2008. The increasing rate of turnover resulted in unfavorable physical and emotional effects on nursing home residents, leading to a greater incidence of falls, medication errors, fear and anxiety, and feelings of hopelessness (Best & Thurston, 2004; Sofie, Belza, & Young, 2003).
Background and significance:
There are five governmental schools of nursing spread overall the United Arab Emirates (UAE). Three of them are called Institutes of Nursing governed by the Ministry of Health (MOH). They offer a Diploma degree and cover the Northern Emirates. Higher College of Technology and the Institute of Applied Technology are controlled by the ministry of higher education and cover Abu-Dhabi and Al-Ain cities and graduate a Bachelors degree of nursing science students. The period of study is three years. All of the graduates are female emanates and expatriates and the number of graduates in the northern emirates is relatively higher that of Abu-Dhabi and Al-Ain cities. The five schools adopted a high standard nursing curriculum.
Despite all such number of graduates, the UAE like the other countries is in severe shortage of nurses related to high rate of turnover. The UAE is need for 30000 nurses and midwives, only 23000 are available which means that the shortage is 7000 (Hill.N / the National, March 23. 2010).According to the MOH-secretary of the Nursing and Midwifery Council , low remuneration, low status and limited career development are all factors influencing the shortage. Therefore the UAE must hire up to 25 to 30 per cent; almost around 7000 to overcome the shortage of nursing staff. Dr.Rifaa, (2010), the head of federal nursing department, referred the shortage of nurses and midwives in the UAE to the perceived low status of the profession. The Emirati nurses account only 4% of the total population (UAE-MOH, cited in the national) which does not run in parallel with the demographics population of the country.
This serious nursing shortage has prompted the UAE to start a national study to identify the factors that could lead to a better workplace at the governmental hospitals. This was in response to a previous pilot study funded by the Ministry of health called ‘Thinking Magnetism’ which revealed that low wages and Lack of autonomy to make decisions are the primary reason for nurses dissatisfaction (k.Times, 23 November 2009).This push the government to start looking carefully after this phenomena particularly when the pilot study, the magnet indicators showed very low scores for ministry hospitals as compared with USA magnet hospitals. The indicators studied were based on nursing contribution in hospital affairs, nursing foundation of quality of care, ability of nurse manager, leadership, staffing and resources as well as nurse-physician relationship.
Among the 14 urgent requirements identified, the pilot study found that nurses can be retained if offered part-time jobs, flexible recruitment and promotion policies, and offered competitive salaries. Involvement in decision-making and encouragement of a healthy nurse-physician relationship was also suggested. Expatriate nurses working in the government hospitals demanded equal treatment with UAE nationals and placements according to qualifications.
The significance of the problem and the absence of related researches and statistical data to show accurate focus on the level of nurses’ satisfaction, and the factors that contribute to turnover give me the urge to study these phenomena.
In this research I would like to answer the following questions:
What is the relation between dissatisfaction factors to turnover?
What is the relationship between demographic variables and job satisfaction?
Statement of Purpose:
The aim of this research is to explore the factors contributing to job satisfaction and turnover among registered nurses in the governmental hospitals of UAE.
Find relationship between individual/ demographic variables and job satisfaction among the registered nurses in the Governmental hospital in the UAE.
Job satisfaction is multi-faceted with many definitions and theoretical framework. According to Spector (1997) Job satisfaction is the most important variable that is frequently studied in organizational behavior research. It is also a fundamental variable in both research and theory of organizational phenomena ranging from job design to supervision. The traditional model of job satisfaction focuses on all the feelings that an individual has about his/her job. Yet, being satisfied or dissatisfied does not rely on the type of the job only but also on the expectations of the individuals from their job (Spector, 1997) Cited in MH 2008.
Job satisfaction is defined as the degree to which employees enjoy their jobs (McCloskey & McCain 1987). Job satisfaction is an enjoyable affecting state resulting from the appraisal of one’s job (Locke, 1976 cited in Brief, A. P., & Weiss, H. M. (2001) cited in Wikipedia), an affective reaction to one’s job (Cranny, Smith & Stone, 1992 cited in Weiss, H. M. (2002) cited in Wikipedia) and an attitude towards one’s job (Brief, 1998 cited in Weiss, H. M. (2002) cited in Wikipedia).
Researchers usually relate job satisfaction to motivation. Motivation can be defined as an internal process that activates, guides and maintains behaviour over time (Pintrich 2003; Schunk 2000).There are several theories of motivation .The most important theories are Maslow’s hierarchy of needs, Hertzberg’s dual factor theory, and. Vroom’s expectancy theory. Unfortunately, none of these theories have gained adequate support or shown to be valid as job satisfiers. Nevertheless, they are based on satisfying human needs that address motivation.
Maslow (1954) suggested a hierarchy of needs and links these needs to motivation. Maslow divided human needs into three categories, the deficiency needs (physical and psychological well being) , growth needs(knowing, appreciating, and understanding), and self actualization(one’s potential). Maslow pointed out that individuals will not be motivated to the second need until the demands of the first need have been satisfied. Based on Maslow’s theory, job satisfaction has been approached by some researchers from the perception of need ful¬llment (Kuhlen, 1963; Worf, 1970; Conrad et al., 1985). The fulfillment of job related needs lead to increase satisfaction as individual moves up in the hierarchy to the highest level. An individual who reaches the self-realization will continue in his job and becomes more efficient and productive, whereas unfulfilled needs will lead to poor performance; less productivity, work related stress and eventually job dissatisfaction which might result in turnover..Norwood (1999) proposed that Maslow’s hierarchy can be used to describe the kinds of information individual’s seek at different levels of development. Yet, Spector 1997 focused on cognitive process rather than on underlying needs so that the attitudinal perspective has become predominant in the study of job satisfaction
. Herzberg Motivation-Hygiene theory (1959) presented a dual – factor theory. He uses the needs satisfaction to explain job satisfaction. He believed that satisfaction and dissatisfaction were separate and unrelated. Intrinsic factors called ‘motivators’ (i.e. related to the nature and experience of performing work) were found to be job ‘satis¬ers’ and included: achievement, recognition, work itself and responsibility and similar to the growth needs of Maslow’s hierarchy. Extrinsic factors called ‘hygiene’ factors were found to be job ‘dissatis¬ers’ and included: organizational policy, administration, supervision, salary, interpersonal relations and working conditions to the deficiency needs of Maslow. However , the distinction between motivators and hygiene. Was not supported by many researches (Cronin-1977;Everly and Falcione,1976;Gangadhraiah,et al.1990;Hutto&Davis,1989;Joiner,Johnson &Crokrean,1981;Koelbel,1988;Munro,1983;Simpson,1985)
Vroom’s theory (1964) :
Predicts that effort lead to performance, and performance lead to reward. However several researches have supported the principles of the theory (Campbell&Pritchard, 1976, Hollenback, 1979, Mitchell, 1974).However, questions remain to which extent an employee can increase his/her efforts about the corresponding organizational structure and decision making processes needed to fulfill the expectations of workers..
B. Definitions of Job Satisfaction based on the theories:
Job satisfaction is the affective orientation that an employee has towards his or her work (Price, 2001). Specter (1997) summarized the following facets of job satisfaction: appreciation, communication, co-workers, fringe bene¬ts, job conditions, nature of the work itself, the nature of the organization itself, an organization’s policies and procedures, pay, personal growth, promotion opportunities, recognition, security and supervision.
Table 1- Dentitions of job satisfaction
The individual matching of personal needs to the perceived potential of the occupation for satisfying those needs (Kuhlen, 1963)
Maslow’s human needs theory (Maslow, 1954
Need ful¬llment, that is, whether or not the job met the employee’s physical and psychological needs for the things within the work situation (Worf, 1970)
A match between what individuals perceive they need and what rewards they perceive they receive from their jobs (Conrad et al., 1985)
A function of satisfaction with the various elements of the job (Herzberg 1959)
Herzberg motivation-hygiene theory (Herzberg, 1959)
All the feelings that an individual has about his job (Gruneberg, 1976
Focus on cognitive process (Spector, 1997)
The affective orientation that an employee has towards his or her work (Price, 2001)
Previous Research Review
Job satisfaction is a complex phenomenon. The current global shortage of nurses places of interest the importance of understanding the effect and interrelationships of the factors that contribute to nurses dissatisfaction and consequently turnover so that healthcare organizations can put strategies to retain nurses.
Sources of nurses’ job satisfaction:
Job satisfaction has been found to be related to performance within the work environment (Landeweerd and Boumans, 1988), so it is not amazing that the notion of job satisfaction has gained much attention. Researchers have attempted to identify the different components of job satisfaction, measure the significance of each component s and examine what effect these components have on the productivity of the employee. (Burnard et al., 1999). A variety of quantitative and qualititative studies have been done on the sources of job satisfaction among nurses and here are the most important findings:
Aiken et al. (2001) found in his global study in a sample of 43,329 nurses working in adult acute hospitals that job dissatisfaction among nurses was highest in the United States (41%) followed by Scotland (38%), England (36%), Canada (33%) and Germany (17%). One third of nurses in England and Scotland and more than one ¬fth in the United States have intent to quit their job within 12 months of data collection. More striking, however, was that 27-54% of nurses less than 30 years of age intended to quit within 12 months of data collection in all countries. Opportunities for the development were the reason behind the satisfaction of the nurses in Germany (61%) while salary was the satisfier for the nurses in USA (57%) and Canada (69%).
Similarly, Adamson et al. (1995) found that British nurses were more dissatis¬ed than Australian nurses. The poor insight of professional status, insufficient relationship with hospital management system and improper working environment, were found in British more than Australian nurses. Professional organization and work design, con¬‚ict between the newly gained work during training and the available one. Lack of communication between nurses and physicians, feeling of being not respected by other related health professionals, hospital managers and physicians were a concern to the British nurses. Nevertheless, the perception of autonomy by the Australian and British nurses was nearly the same.
Different dimensions concerning nurses’ job satisfaction show a variety of sources of satisfaction. Using the likert’s scale; the following variables were identified as a disatisfiers for nurses: physical environment of the ward, professional nursing practice, professional working relationships, ward leadership, nurses’ in¬‚uence and job satisfaction (Tovey and Adams, 1999; Adams and Bond, 2000).
Adams (2000) identified the degree of cohesion among nurses and perception of staff organization as the most contributors to nurses’ job satisfaction among 834 nurses.
Tovey and Adams (1999) come up with the main sources of nurses’ dissatisfaction: working interactions, mainly those with administration, shortage of staff, professional concerns about poor standards of care and external work pressure.
Nolan et al. (1998) found that level of job satisfaction had remained stable. Nolan et al. (1998) further found in a sample of 518 nurses that 35% of nurses’ reported reduction in their level of satisfaction and 69% drop in their morality. Lundh (1999), showed in his study that the level of stress among nurses had increased and satisfaction with pay and working conditions had dropped.
Price (2002), using the satisfaction scale of Mueller and McCloskey’s (1990a, b) in a sample of 141 nurses found that (58%) were generally satis¬ed with their job. Highest satisfaction was related to co-workers and extrinsic rewards and most dissatisfaction was with the amount of control and responsibility they had and with professional opportunities. Nurses were most satis¬ed were identi¬ed as annual leave, nursing peers and hours worked (79%, 78% and 76% of respondents) and for dissatisfaction compensation for working weekends and control over work conditions and childcare facilities (55%, 55% and 46% of respondents. Using the same scale, Wang (2002) found that Chinese nurses were mostly dissatis¬ed with pay and job promotion.
Lee’s (1998) found that nurses were dissatis¬ed more than satis¬ed and reported most satisfaction with professional status and most dissatisfaction with task requirements.Moreover, no significant relationship between satisfaction with job autonomy and individual need for autonomy were noticed.
Tzeng (2002) has also noted that factors such as indirect working environment (a hospital’s policies, bene¬ts, leisure activities, housing, parking, and vacation policy), salary and promotion as very important but strongly dissatisfying. Job satisfaction is a predictor of turnover.
Finally, nurses’ job satisfaction is very essential to organizations as levels of job satisfaction would globally impact the nursing workforce. Sources of job satisfaction are relatively similar, e.g., physical working setting, relations with fellow workers and managers, salary, promotion, job security, responsibility, the recognition from managers and working hours.
Effects of job satisfaction of nurses on absenteeism, burnout, turnover and intention to quit
Matrunola, (1996) did not find any significant relationship between job satisfaction and abscentism is a small sample of 34 nurses which makes its generalization difficult.
Siu’s (2002), Job satisfaction was an important predictor of abscentism
Lee et al.’s (2003) showed that the most common reason reasons for nurses’ turnover were work overload, rotating shifts and con¬‚ict in interpersonal relationships. A total of 24%, 15% and 35% of variance regarding depersonalization, emotional exhaustion and personal accomplishment, respectively, was explained by the individual characteristics, job stress and personal resources were explained by the predictor variables.
Regarding the effect of job satisfaction on nurse turnover, Cavanagh (1990) found that job satisfaction was the determining factor of turnover which could be predicted by kinship responsibility, promotion, pay and influential communication skills.
Gauci Borda and Norman (1997) found a signi¬cant positive relationship between job satisfaction and intent to stay and negative relationships between job satisfaction and frequency of 1 day absence and short-term absence.
Yin and Yang’s (2002) meta-analysis also found that the strongest factors for nurse turnover were job satisfaction, autonomy, advancement opportunity, job stress, pay, group cohesion, marital status and educational level.
Wu et al (2000), found a positive and significant relation between the job stress and intention to quit.
Lu et al.’s (2002) found that there is a positive relation between job satisfaction and professional commitment and negative relation with the intention to quit.
To sum up, research from various countries indicates that job satisfaction is a signi¬cant predictor of nursing absenteeism, burnout, turnover and intention to quit the organization and nursing profession.
Related factors to job satisfaction of nurses
Blegen’s (1993) meta-analysis found a strong connection between job satisfaction ,stress and organizational commitment. Seven variables had strong correlations: communication with supervisor, autonomy, recognition, routinization, communication with peers, fairness and locus of control; and four variables had very weak correlations: age, years of experience, education and professionalism
A causal model of job satisfaction has been tested in Chu et al.’s (2003) study among 308 Taiwanese nurses and Seo et al.’s (2004) study among 353 South Korean nurses, respectively. In this model 11 independent variables included: job involvement, positive affectivity, negative affectivity, autonomy, distributive justice, procedural justice, job stress (role ambiguity, role con¬‚ict, and workload and resource inadequacy), pay, promotional chances, routinization and social support
Chu et al. (2003) found that six variables had significant impact on job satisfaction: routinzation, positive affectivity, involvement, negative affectivity, role ambiguity, supervisor support which explain 45% of the variance in satisfaction.
Seo et al. (2004) found seven variables had statistically signi¬cant net effects on job satisfaction : positive affectivity, supervisory support, pay, routinization, negative affectivity, workload and job opportunity and he found reasonable fit between the casual model and data; all the variables explained 53% of the variance
Packard and Motowidlo (1987) correlated job satisfaction with depression, hostility, subjective stress, frequency of stressful events, intensity of stressful events and anxiety..
Organizational commitment refers to identi¬cation with and loyalty to the organization and its goals (Blau and Boal, 1987) which Mowday et al. (1979). Commitment is characterized by three factors: a strong belief in and an acceptance of the organization’s goals and values; a willingness to exert considerable effort on behalf of the organization; and a strong desire to maintain membership in the organization. (Blegen, 1993; Al-Aameri, 2000). Knoop (1995) found organizational commitment is positively related to job satisfaction among nurses.
Fang, (2001).found that job satisfaction was significantly and positively related to organizational commitment, professional commitment, and negatively related to job stress.
Organizational commitment has an incremental effect on a professional’s intention to leave the organization (Blau and Lunz, 1998). Enhancing professional commitment in nursing has the potential to produce bene¬ts for both the individual and their organization (Cohen, 1998; Cohen, 1999). Furthermore, professional commitment is positively related to the job satisfaction of nurses (Lu et al., 2000; Jones, 2000).
Role con¬‚ict and ambiguity are signi¬cantly related to job stress, organizational commitment, job satisfaction and intentions to leave the nursing profession (Rosse and Rosse, 1981).
Dailey (1990) found that most signi¬cant predictor of intention to quit was experienced job induced stress symptoms. However, Mitchell’s (1994) US study found that there was not a signi¬cant linear association between a nurse’s job satisfaction and the correlation between work role values and actual work roles.
In summary, Although several researches has revealed that job satisfaction of hospital nurses is closely related to job stress, role con¬‚ict and ambiguity, organizational commitment and professional commitment, the findings of research have shown inconsistency: this may be due, however, to wide variations in definitions of job satisfaction and in the validity of methods used to measure it. (Cranny, Smith & Stone, 1992), as cited
in Wilson (1996).
Most member states of the WHO have reported nurse resource difficulties (Kingma, 2001). Many challenges are facing the developing countries and the UAE is one of them. These challenges are ageing nurse workforce and increasing demand for nursing care from an ageing population (Buchan, 2001).
International migration of nurses has increased for the purpose of improving pay and opportunities. Migration was facilitated by the global needs for recruiting nurses particularly from developing countries. This movement of nurses indicates that factors contributing to turnover merit attention. The present international shortage of nurses emphasizes the importance of understanding the effect and interrelationships of the known variables if healthcare organizations are to take action to improve the retention of their nursing workforce.
The studies show the relationships of need’s satisfaction to job satisfaction. However, there is much diversity among the studies making it difficult an overall consensus on job satisfiers.
The study population includes all staff nurses in the seven main governmental hospitals in the UAE. Criteria for inclusion into the study is to be a registered nurse from the UAE, working in the same area for at least 6 months, full time employment and able to read, write, and comprehend the English language in a competent way. The exclusion criteria is to be a head nurse or supervisor, working in the same area less than 6 months, part time employment staff nurse, and nurses who are permanent on one shift (A, B or C shift). The nature of supervisors and head nurses work and activities is different from the nature of staff nurses work and activities. Also, the stabilization of the staff nurse in the same area for a long period of time (more than 6 months) will enable him/her to identify the satisfiers and dissatisfiers and it will give him/her the ability to judge his/her job satisfaction appropriately. Also, the part time employment and to be permanent on one shift (A, B or C shift) will not give an accurate picture on the job related stress and job satisfaction.
Data will be collected from nurses in different nursing wards: Intensive Care Unit (ICU), Coronary Care Unit (CCU), Medical-Surgical floors, Pediatric department, Obstetric floor, operating room and Emergency room.
Descriptive correlational method will be used to examine the relationship between the various demographic variables and to find the relation between dissatisfaction and turnover. The demographic variables are: age, gender, level of education, tenure, working unit, travel distance, marital status ,number of children.
McCloskey/Mueller Satisfaction Scale (MMSS) and researcher will develop his own tool to measure the demographic variables.
The MMSS is one instrument commonly used in nursing research and in healthcare administrative practice. The attitudes of nurses towards their work and satisfaction in a variety of clinical and geographical settings, including mental health (Brodell, 199; Flannery & Van Gaasbeek, 1998), long-term care (Robertson, Higgins, Rozmus, & Robinson, 1999), public health (Cumbey & Alexander, 1998), home healthcare (Lynch, 1994), rehabilitation (Crose, 1999), rural settings (Anderko, Robertson, & Lewis, 1999), and ambulatory care (Wilkinson & Hite, 2001) can be measured by MMSS tool. MMSS is also used by the healthcare managers to measure the level of job satisfaction among nurses and to determine the factors that help in recruiting and retaining the nurses. (Roberts, Jones, & Lynn, 2004; Tang, 2003).
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Mueller and McCloskey (1990) developed a framework of eight subscales that can be grouped into the three domains of satisfaction. Safety rewards include: extrinsic rewards, scheduling, and balance of family and work. Social rewards include: co-workers and interaction opportunities. Psychological rewards include: professional opportunities, praise and recognition, and work control and responsibility (Mueller & McCloskey, 1990)
Data collection procedures
Formal approval from the MOH-UAE will be taken to conduct the study. Permission from the author of the research tool will be gained also. Participation of the nurses in the study is voluntary. All data collected are confidential and nobody is authorized to see the information unless permitted from the participant.
The purpose of the study will be explained.
The participants will know that their participation is voluntary.
The participants have the right to refuse answering any question.
Anonymity and confidentiality are guaranteed.
The result of the study when finished will be sent to any participant upon request .
The study done on the registered nurse in the governmental hospital and may not be generalized to other health care departments.
There was no statistical data or previous researches handling this issue that is why I depended on my personal observation as a member of the health care system and some small journals articles.
The instrument used is reliable and valid based on the reaserch study “Reliability and validity of instruments-measuring job satisfaction-a systematic review’ (Saane.s,el al.,2003).
The tool is valid and reliable in the UAE
Registered nurses will fill the questionnaire honestly
Registered nurses can read and write English
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