- Volume 13, Issue 2
Job Related Stressors and Job Satisfaction among Multicultural
Olfat A. Salem (2)
Omar Ghazi Baker (3)
(1) MSN, BSN,
RN, Head Nurse, Critical Care Department, King Saud
Medical City, Riyadh, Saudi Arabia
(2) PhD, RN, Department of Nursing Administration and
Education, College of Nursing, King Saud University,
Riyadh, Saudi Arabia. Nursing Administration Department,
Faculty of Nursing, Egypt, Menofia University
(3) Ph.D., College of Nursing, King Saud University,
Riyadh, Saudi Arabia
Huda Muhawish, MSN, BSN, RN
Critical Care Department
King Saud Medical City
Riyadh, Saudi Arabia
Received: January 2019; Accepted: March 2019; Published:
April 1, 2019
Citation: Huda Muhawish, Olfat A. Salem , Omar Ghazi
Baker. Job Related Stressors and Job Satisfaction among
Multicultural Nursing Workforce. Middle East Journal
of Nursing 2019; 13(2): 3-16. DOI: 10.5742MEJN.2019.93635
Background: Job related stressors are becoming
a huge burden on the quality of nursing care. Stress
has an impact on individuals health, wellbeing
and job satisfaction. It also has a negative impact
on the degree of absenteeism and turnover that nurses
and other medical professionals exhibit. The aim of
the study was to identify the different job-related
stressors in hospital that affect nurses job satisfaction
from a multicultural perspective
and examine how these two variables were correlated
with each other.
Design: A cross-sectional
descriptive correlational design was used.
Method: A convenience
sampling was composed of 150 nurses stationed at different
levels of education in the intensive care department.
The sample included male and female registered nurses
who had been working in their respective institution
for six months. The research instrument used to gather
the data was the Expanded Nursing Stress Scale (ENSS)
and the Job Satisfaction Scale (JSS). Statistical Package
for Social Sciences (SPSS) version 20 was used.
Results: The most stressful
factors included criticism and conflicts, which negatively
affect job satisfaction. Studies showed that the environmental
stressors, like unclear and ambiguous job roles and
unequal treatment of nurses are as important as the
internal stress factors, including the personality types.
Nurses are exposed to inadequate conditions of work
where they are not appreciated, receive low-payment
and no benefits. The job satisfaction of the participants
is relatively low (M = 3.8; SD = 0.43). As the results
showed, the respondents were particularly dissatisfied
with their pay (M = 1.46; SD = 0.63) and fringe benefits
(M = 2.14; SD = 0.95). Low job satisfaction is a result
of high stress among respondents and the character of
stressors. There is a positive correlation between disagreement
in treatment of patient and demands of work (p = 0.017;
p < 0.05); demands of work is positively correlated
with decisions under pressure (p = 0.014; < 0.05).
Conclusion: High stress
and workload is disproportionate to the payment provided
to nurses. The cumulative increase of stress among nurses
will eventually affect the quality of services and care
of patients. Work conditions need to be improved in
terms of disseminating responsibilities, not delegating
work to nurses who are overloaded with bedside nursing
care, and providing enough time for nurses to relax.
Strict protocols have to be implemented in terms of
interaction between patients and non Arabic speaking
nurses to prevent exposure to any type of conflict and
Key words: Stressors,
Job Stressors, Job Satisfaction, Multi-culture, Saudi
Nursing has been identified as one of the most stressful professions.
Stress has hazardous impact on the individual and organizational
levels. Health, wellbeing and job satisfaction are affected
by stress on the individual level, while absenteeism and turnover
are examples of negative stress influence on the organizations;
stress also impairs the quality and efficacy of healthcare
services (Sharma, Davey, Shukla, Shrivastava, & Bansal,
2014). Generally, there are four sources of anxiety among
nurses: patient care, decision making, taking responsibility,
and change. Recognizing that nurses play an important role
in hospitals and medical institutions; it becomes necessary
to study the different factors that affect their job satisfaction
and performance. One of these factors is stress. It has long
been established that nursing is one of the professions that
is most commonly associated with increased stress levels and
turnover rates. Additionally, with the changes that are expected
to come as a result of the rollout of new technologies, the
level of stress that nurses will experience can be expected
to increase (Jennings, 2008).
Chien & Yick (2016) conducted
a study about the role of work stress and strain on nurses
from an international perspective. They noted in the results
of their study that nurses are indeed some of the most stressed
and strained professionals across many industries, and on
a global scale. This applies to both private and public hospitals
and medical institutions although stress levels were particularly
higher in public institutions. Lambert & Lambert (2001)
also conducted a study on the same topic and they too arrived
at the same findings. They, however, recommended the implementation
of further studies because the majority of the studies they
reviewed in their literature review only covered nurses employed
in hospitals and medical institutions in the United States
and the United Kingdom.
That recommendation by Lambert &
Lambert (2001) makes sense because the medical and health
care industry usually differs from one country to another.
This was the same argument that Burnard et al. (2008) echoed
when they conducted a study about the factors that can be
identified as occupational stressors in the nursing profession
across different countries. Some of the stressors that were
identified include, but may not be limited to, cultural values,
education and training, and healthcare policy variations.
According to Happell et al. (2013), occupational stress can
be reduced by involving nurses in identifying initiatives
and enhancing the understanding of occupational nurses
stress. Nurses managers must be entitled to enhance
and facilitate stress reduction initiatives by understanding
the problem and engaging nurses so they too can participate
in the process of finding proper solutions.
In a study that was authored by McVicar
(2003), he identified the different causes of stress in the
nursing profession. Some of those he mentioned include workload,
inadequate staff, time pressure, poor communication and relationships
with colleagues, ineffective leadership and management style,
poor locus of control, poor group cohesion, and lack of adequate
supervisory support. Workplace stress management interventions
can be grouped into three categories according to Landy &
Conte (2010). Primary, secondary, and tertiary stress management
and prevention strategies can result in more positive nursing
stress management outcomes. The goal of primary prevention
strategies is to eliminate the sources of stress altogether.
Secondary strategies work by training nurses to react and
respond to the stressors appropriately. Lastly, tertiary strategies
focus on the actual process of addressing the impact of stress
on nurses. An effective stress management and prevention strategy
is one that incorporates varying levels of primary, secondary,
and tertiary strategies, and one that is modelled on the actual
needs of the target group of nurses based on the environment
that they work in (Landy & Conte, 2010).
Job stress among nurses could be
affected by their role in the health care facility and their
gender. According to the study conducted by Iyer (2017) among
Indian nurses; it was revealed that nurses perceive conflicting
demands of their performance and ambiguity of their roles
as the main source of job-related stress. Particularly if
nurses are appraised by their superiors in a different manner
(unequally) and their roles in the facility are unequally
distributed (concerning their gender), job satisfaction would
be particularly low and the stress level very high (Iyer,
2017). As this study confirms, nurses value their appreciation
and equal treatment on the job, which has to be considered
by their managers, superiors, and executives.
Nursing is a stressful profession,
which requires appreciation of their superiors as well as
proper training to avoid burnout. As García-Izquierdo,
de Pedro, Ríos-Risquez, & Sánchez (2018)
revealed, work overload and interpersonal conflicts, lack
of social support, and violence from patients can lead to
the development of burnout (chronic stress) in nurses, which
would be very difficult to treat. While these stressors are
difficult to avoid since they are part of the nursing profession,
it is possible to train nurses in developing resilience (García-Izquierdo,
de Pedro, Ríos-Risquez, & Sánchez, 2018).
Resilience can help nurses to overcome stress and not to develop
long-lasting emotional effects as a reaction to stressful
In addition to resilience, communication
in the team has to be productive and supporting to prevent
burnout and decrease stress. A study conducted by Fuqua (2013)
recognised that nurses, who work in a productive team where
members are eager to help each other and provide
emotional support, tend to have lower stress levels and have
higher job satisfaction compared to their counterparts working
in less positive conditions. As nurses work in the environment
where they have to interact with many stakeholders and make
emergent decisions, reliance on colleagues and effective communication
in the team are essential (Fuqua, 2013). Since higher quality
of care is correlated with job satisfaction in nurses, the
improvement of nurses teamwork and communication are
crucial in this case.
At the same time, the level of stress
is not always connected to the environmental factors, very
often it is also linked to internal factors. Particularly,
Ghasemian & Kumar (2017) managed to prove their hypotheses
claiming that there is a correlation between the personality
type and stress in nurses. As the results revealed, nurses
with type A personality, who are usually restless, tense,
impatient, and workaholic, are prone to high levels of stress,
while those with type B personality, who are more easy-going,
tolerant, and relaxed, have lower levels of stress (Ghasemian
& Kumar, 2017). These results showed that nurses have
to consider their personality type and their personal character
before entering the profession of nursing. It is also important
to make sure that the nurses with type A personality receive
proper training to help them to deal with their characteristic
traits that decrease their stress resilience.
The nurses attitudes towards,
and relationships with, their colleagues can also have a significant
impact on the levels of stress that they experience. Economic
factors such as pay levels (i.e. wages) may also contribute
to their stress levels, according to Sharma et al. (2014).
Generally, nurses expect to receive higher pay for jobs that
demand they take care of a higher volume of workload.
Studies have shown a great effect
of stress on nurses job satisfaction in general. Complexity
of critically ill patients conditions and work load
in hospital put nurses under extra stressors. A research study
that correlates role of job stressors on nurses satisfaction
rates is required to further decrease the negative outcomes
In this study, the researcher hypothesized
that there is a correlation between the two factors, namely
job related stressors and job satisfaction among nurses. To
combat this, the aim of the present study was to identify
the different job-related stressors that affect the nurses
job satisfaction, from a multicultural perspective and examine
how these two variables are correlated with each other.
Study Design and Setting
A descriptive correlational research design was used to implement
the present study. A cross-sectional approach was used. Data
was collected over a period of six months. The target hospital
was a tertiary hospital, located in Riyadh, Saudi Arabia.
It is a teaching hospital and has 800 bed capacity (Electives
Network, 2017);, the nursing population is around 5,001 to
10,000 employees, care provided includes diagnostic, primary,
secondary, tertiary medical and ancillary healthcare services
and referral-based medical service (King Khalid University
.Sample and participant:
A convenience sampling technique was used in this study to
recruit 150 nurses. They were asked to answer the ENSS and
JSS questionnaires. In addition to that, a cover letter was
attached to these scales to make sure that nurses understood
all aspects of the study before they gave their consent to
participate. The sample included male and female registered
nurses who had been working in their respective institution
for six months. The sample excluded newly hired nurses because
of their short experience in the hospital.
The administration of the selected setting was contacted and
approved the conduct of the study. Authors of the instruments
gave consent to use the questionnaire to collect data for
this research. Participants were informed that their participation
The ENSS was used to describe nurses
level of work-related stress. The ENSS is a 57-item scale
that can be answered using a five point Likert Scale. There
are essentially five choices with 1 representing never stressful
and 4 representing always stressful. The number 5 represents
the items that do not apply to the participants. The ENSS
is divided into nine sub-scales, each one by itself is basically
a work-related stressor: death and dying, inadequate emotional
preparation, conflict with physicians, peer-related problems,
supervisor-related problems, work load, treatment uncertainty,
patient and family-related problems, and workplace discrimination.
To interpret the questionnaire, one has to look at the average
score per cluster and for the entire questionnaire. Higher
scores indicate higher stress levels (French, Lenton, Walters,
& Eyles, 2000).
The second questionnaire was the Job Satisfaction Scale (JSS).
Unlike the ENSS, the JSS contains questions that can be answered
using 6 choices (numbers 1 to 6), based on the level of agreement
or disagreement with the questionnaire items. A score of 1
represents the strongest disagreement while a score of 6 represents
the strongest agreement (to a questionnaire item). There are
nine clusters under the JSS and they are: pay, supervision,
promotion, fringe benefits, contingent rewards, operating
procedures, nature of work, and communication (Spector, 1985).
Nurses demographic data were collected using a special
form that was designed for this study. Age, gender, department
practice setting, level of education were collected and used
as additional variables for comparing any significant differences
in job related stressors present in between.
Participation in the study was anonymous and no personal information
of the respondents was used. Before the survey was conducted,
the researcher obtained a permit for involving the employed
nurses in the study from the
in Riyadh, Saudi Arabia. After the respondents were recruited,
the researcher distributed a written consent form to the participants.
Data that were retrieved from the survey was protected by
the login and password available only to the researcher. Raw
data was destroyed after the data analysis. The participants
had the right to withdraw from the study at any time. In addition,
after the research was conducted, respondents had a right
to ask for the results.
SPSS version 20 was used. Specifically, the researcher calculated
the descriptive statistics and correlational analysis. It
was important to determine the characteristics of the respondents,
to determine how various factors affect stress in nurses,
and detect how these factors are correlated.
The results were generated with the help of SPSS statistical
analysis by calculating descriptive and correlational statistics.
The following table represents the demographic characteristics
Table 1 showed that all participants
(n = 150) filled in both questionnaires, including Expanded
Nursing Stress Scale (ENSS) and Job Satisfaction Scale (JSS).
The vast majority of respondents were females (93.3%); the
largest ethnic group was Indian nurses (60%); most participants
have certificates only (70%) and only some of them (30%) have
BSN. All of respondents were employed as RNs in the ICU department,
who work 12-hour shifts.
Table 1: Demographic Characteristics of Participants (n
Results of ENSS were clustered in
several blocks for a convenient analysis of data, including
criticism and conflicts on the job, harassment and discrimination,
relationship with patients, workload. The following tables
show descriptive statistics results in these clusters:
here for Table
2: Descriptive Statistics (Criticism and Conflicts)
Click here for Table
3: Descriptive Statistics (Harassment and Discrimination)
Click here for
Table 4: Descriptive Statistics (Relationship with Patients)
Click here for Table
5: Descriptive Statistics (Workload)
Tables 2-5 showed that the highest level of stress is caused
by criticism and conflicts on the job as well as discrimination.
For example, disagreement concerning the treatment of a patient
(M = 4.2; SD = 0.96), experiencing discrimination because
of race or ethnicity (M = 3.91; SD = 0.28), having to deal
with abuse from patients families (M = 3.86; SD = 0.34),
and conflicts with a supervisor (M = 3.8; SD = 0.39) were
rated the highest among the participants. Not enough time
to complete all of my nursing tasks (M = 2.38; SD = 0.55)
was rated the lowest in the clusters. The following table
presents correlational analysis:
Click here for Table
6: Correlational Analysis
As Table 6 reveals, there is a positive correlation between
the disagreement in treatment of patient and demands of work
(p = 0.017; p < 0.05); demands of work is positively correlated
with decisions under pressure (p = 0.014; < 0.05); criticism
is positively correlated with decisions under pressure (p
= 0.019; < 0.05); disagreement in treatment and the death
of a patient were also positively correlated (p = 0.02; <
0.05). It is possible to imply that the correlation between
these stressors can be explained by the nature of work and
the level of stress caused by a specific stressor. For example,
criticism and decisions under pressure are positively correlated
due to their connection. In case of exposure to criticism,
the nurses are forced to make decisions under pressure. Disagreement
in treatment and the death of the patient can be correlated
because of an inner stress in nurses like the errors in treatment
that could cause a fatality.
The following table represents the results of the Job Satisfaction
Scale (JSS) among the participants:
Table 7: Descriptive Statistics: Job Satisfaction
Table 7 determined that the job satisfaction of the participants
is relatively low (M = 3.8; SD = 0.43). As the results showed,
the respondents are particularly dissatisfied with their pay
(M = 1.46; SD = 0.63) and fringe benefits (M = 2.14; SD =
0.95). The standard deviation (SD) of fringe benefits shows
that almost all respondents agreed on their dissatisfaction
with this item. At the same time, the participants rated their
nature of work very high (M = 4.78; SD = 0.43). Operating
conditions also received high rating (M = 4.13; SD = 0.66).
Overall, as data showed, participants are not satisfied with
their benefits and financial reimbursement since these items
were rated the lowest.
As the results of current study revealed, the job satisfaction
among the respondents was quite low. The highest-rated stressors
were criticism and conflicts at work as well as discrimination.
Current results were supported by previous studies implying
that stress at the individual level affects job satisfaction
(Sharma, Davey, Shukla, Shrivastava, & Bansal, 2014);
poor interaction in the team, lack of group cohesion, ineffective
rewards, and poor payment were named as the main stressors
in the nursing job (McVicar, 2003; Sharma et al., 2014). Previous
studies recognized that stress among nurses is elevated (Jennings,
2008; Lambert & Lambert, 2001; Chien & Yick, 2016).
As current results showed, nurses were dissatisfied with payment
and benefits of their job, which have become the main contributors
to the overall satisfaction rating.
Studies showed that the environmental
stressors, such as unclear and ambiguous job roles and unequal
treatment of nurses (Iyer, 2017) were as important as the
internal stress factors, including the personality types (Ghasemian
& Kumar, 2017). Current inquiry recognized the same patterns,
emphasizing the significance of internal and external stressors
in job satisfaction and quality of care among nurses. Communication
in the team and the ability to rely on colleagues were admitted
as crucial in job satisfaction among nurses by Fuqua (2013)
as well as in the current study. As the interaction in the
team and efficacy of care are correlated, it is impossible
to ignore this aspect. Resilience was named by García-Izquierdo,
de Pedro, Ríos-Risquez, & Sánchez (2018)
as the main method to overcome job-related stress, which has
to be taken into account by management and superiors in the
healthcare facility. Some participants were dissatisfied with
their work due to exposure to cultural variations. They attributed
that some stress produced from such cultural differences could
be high because they rated exposure to violence or stressful
cultural variations as non-applicable.
The study recognized that high levels
of stress are present among respondents. Previous studies
determined the same pattern reporting that nursing is a highly
stressful occupation linked to the character of this job,
the conditions of work, and the financial benefits (Jennings,
2008; Lambert & Lambert, 2001; Chien & Yick, 2016).
These findings were supported, as the current study determined
an elevated level of stress in nurses and their dissatisfaction
with benefits and payments. It is possible to speculate that
nurses were lacking managerial support. Low payment was recognized
too by McVicar (2003) as one of the main stressors in the
nursing profession. Workload was also connected to high stress
levels among respondents, which was indicated by these results.
However, this factor was rated slightly lower compared to
other clusters. This specificity could be connected to the
initial expectations of the nurses when they enter the profession.
It is a well-known fact that a nursing is job with high workload,
which could become a stressor. Yet, this is a characteristic
of a job with which the graduates are familiar. As a result,
while workload contributes to the elevation of stress among
nurses, they are prepared for these conditions. The current
study detected that nurses are satisfied with their colleagues
and the qualifications of their supervisor. However, the criticism
and conflicts have become major stressors for all respondents.
It is clear that they encounter criticism at all levels, which
is hard to manage for newly employed nurses. Nurses have to
maintain a balance between satisfaction of their patients
and compliance to the rules developed by their supervisors,
physicians, and nursing leaders, which become problematic.
The aim of the current research was to determine the set of
job-related stressors in nurses that affect their job satisfaction.
As the results recognized, the most stressful factors include
criticism, conflicts, and discontent with benefits and payments,
which negatively affect job satisfaction. Studies showed that
the environmental stressors, like unclear and ambiguous job
roles and unequal treatment of nurses are as important as
the internal stress factors, including the personality types.
Nurses are exposed to inadequate conditions of work and receive
low-payment and no benefits. Low job satisfaction is a result
of high stress among respondents and the character of stressors.
Previous studies have drawn the same conclusions admitting
that high stress and workload is disproportionate to the payment
provided to the nurses. This situation has to change as soon
as possible, as continuous increase of stress among nurses
will eventually affect the quality of services and will affect
health of patients.
The study has several limitations. First of all, it is a descriptive
cross-sectional design which could not interpret the causal
relationships among the variables. In addition, the sample
is not homogenous in terms of gender. The vast majority of
respondents were females, which could affect the generalization
of results. The study recruited participants from one facility
and the results may reflect the conditions in this specific
hospital, which also affect generalizability of the findings.
Implication for Nursing/ Administration
Nurses need to be encouraged in their work and the work environment
needs to be re-designed to decrease
It is essential to create a transparent
system of reports and safeguard nurses from inadequate treatment
by their colleagues, managers, and patients. The reimbursement
practices have to be improved by rewarding the nurses who
demonstrate high productivity, have limited number of patient
complaints, and those who do not miss their work. Improvement
in terms of responsibilities dissemination, delegating work,
and providing enough time to relax needs to be implemented.
Strict protocols have to be applied in terms of having healthy
interaction between patients and nurses. Practice has to provide
the possibility for nurses to help patients to deal with their
physical as well as emotional wellbeing. In addition, graduates
need to be culturally competent to encourage their adaptation
to the work environment
The author is grateful to all parties who were so kind to
participate in the current research, particularly the respondents,
who found time to take part in the survey.
Current research was not affected by any conflict of interest
and it was self-funded.
(Click to view)
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