Quality of work life among primary health care nurses in the Jazan region, Saudi Arabia: a cross-sectional study – Human Resources for Health
The purpose of this study was to assess the QWL among PHC nurses in the Jazan region, Saudi Arabia. The findings of this study indicated a number of factors of concern regarding the QWL among PHC nurses.
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Perception of the quality of work life among primary health care nurses
The PHC nurses were asked to rate their QWL. The aim was to gain an understanding of the QWL of PHC nurses by assessing their work life experience. Contrary to the Brooks and Anderson study [8], where respondents were pleased overall with their work life situations, the findings of the present study indicated that the respondents were dissatisfied with their work life. However, these findings are consistent with findings of a number of previous studies where nurses were not satisfied with their work life [9–11, 20]. Efficient QWL programs can improve the morale of employees and organizational effectiveness [37]. QWL can also improve the quality of nursing care and retention of nurses [33, 38]. Improving QWL may be a more practical and long-term approach to attracting and retaining the workforce that should be considered by health care managers [4].
The majority of nurses in this study perceived dissatisfaction with the work life/home life factors including family needs, working hours and energy left after work. Nurses reported that they spent a long time at work so they had little energy left after work. As a result, the nurses were unable to balance their work with their family life. This is consistent with findings from previous studies [8, 10]. According to Ashy [39] “many working Saudi women have to work hard to balance the demands of their careers and their families.” The standard working hours for PHC professionals, including nurses, are 47.5 hours per week raised to 49 hours in PHC centres that work two periods per day, compared to 35 hours for other workers in all other public sector occupations [40]. However, nurses only receive 20% extra in their salary, compared to 45% for pharmacists and 70% for physicians, in recognition of these additional hours [41]. When nurses found the demands of work incompatible with a fulfilling home life, their turnover intention become more pronounced [42, 43]. Lack of support for the family members of nurses (that is, children and adult dependents) and inadequacy of vacations were other sources of unsatisfactory nursing work life. These findings are in-line with previous literature [8–10].
In keeping with global trends, a shortage in the nursing workforce in PHC was identified as a main problem in the current study. This shortage puts a high load on the nurses who remain in PHC settings. Issues of poor staffing and demanding workloads among nurses were found to be ‘push’ factors for nurses considering leaving their organizations [44, 45]. Lack of support for the family members of nurses (that is, children and adult dependents) and inadequacy of vacations were other sources of unsatisfactory nursing work life. These findings are in-line with previous literature [8–10]
Despite the shortage of PHC nurses, the nurses in this study were given additional non-nursing tasks. This malutilization of the nursing workforce may increase the shortage of nurses and affect their nursing skills and experience. Such challenges may put significant pressure on nurses, affecting their perceptions towards their work lives [46]. Approximately one third of respondents reported that they do not have the required autonomy to make client/patient care decisions. Autonomy of practice in nursing was found to be associated with quality of care and job satisfaction [47–49].
Management practices were identified as one of the problematic areas in the ‘work context’ dimension. There is a lack of supervision, feedback, participation in decision making and respect shown by upper-level management. Additionally, working policies and procedural guidelines are inadequate. Of concern, nurses were not recognized for their efforts and accomplishments. In previous studies, nursing management practices were found to be associated with the quality of care, employee productivity, employee satisfaction and the intent to stay or leave [44, 50–52]. Bodek [53] argued that employees want to feel respected at work for what they do and who they are. Above all, they need to feel valued for their skills, knowledge, performance and participation in the development process. According to AbuAlRub and Al-Zaru [54], recognition of the performance of nurses has a direct effect on the level of intention to stay at work. Working hard without appreciation can intensify the turnover intention among registered nurses.
Opportunities for professional development (that is career advancement, opportunity to further nursing education, and access to continuing education) were reported by the respondents as unsatisfactory. This finding was supported by prior nursing research [22, 55]. According to Cabigao [22] insufficient opportunities for professional development often diminish nurses efforts to provide quality care and is a major reason for their job dissatisfaction. Hart [56] found that nurses who were enrolled in an educational program were less likely to leave their positions than those who were not enrolled in any program. In terms of continuing education, 72% of nurse respondents stated that they did not receive support to attend continuing and in-service education programs. Similarly, Alhusaini [13] found that 30.3% of nurses in Riyadh were not offered any training courses or continuing education programs and 65.9% were offered very short courses (1 to 5 days per year). Nurses, as health care professionals, seek to continually refresh their knowledge and skills to provide quality patient and community care and to satisfy their QWL. A lack of training programs for nurses will impact on their competence and performance [13]. Dissatisfaction with career advancement was also reported in other nursing studies [8, 10, 57, 58]. Alhusaini [13] found that the lack of role clarity is one of the noticeable work obstacles for Saudi nurses. Hence, there is a need to establish an appropriate career ladder or rank system for PHC nurses.
The working environment was also of concern among PHC nurses. More than half of the respondents reported that the security department does not provide a secure working environment. A number of previous nursing studies highlighted concerns about the safety of the working environment as a major factor in nurses’ dissatisfaction with their workplaces [8, 10, 13]. El-Gilany and colleagues [15] conducted a survey study in Al-Hassa, Saudi Arabia, to highlight the incidence of workplace violence against 1,091 PHC workers. About 28% were exposed to at least one violent event during the past year. Emotional and physical violence accounted for 92.1% and 7.9% of violent events, respectively. Feeling safe at work is essential for nurses to perform their work appropriately. In accordance with prior nursing research [13, 57], the majority of nurses in this study were not happy with their break area (recreation room). They do not have a particular place to rest, eat or pray. Private and furnished break areas for PHC nurses are essential for their comfort in the workplace. More important to the working environment experience, nurses reported a lack of client/patient care supplies and equipment. Availability of supplies and equipment is essential for providing quality health care. A number of PHC studies in Saudi Arabia revealed that many essential resources for health care were not adequately available [16, 18, 19]. Lack of essential patient care supplies may impact on the level of QWL of nurses and their performance and productivity. Nurses need more efficient and effective working environments, which ensure that patients become the priority and patient needs are met [59].
Many nurses in this study felt that people do not have an accurate image of the nursing profession. In Saudi Arabia, nursing is not ranked as highly as other medical jobs, such as medicine and pharmacy [60, 61]. According to Al Thagafi [61], the public does not appreciate the role of nurses in providing health care, believing that nurses are no more than the assistants to physicians. Alamri and colleagues [62], however, found that people in Saudi Arabia understand the importance of nursing and they believe jobs must be occupied by locals; however, for their young, they prefer high prestige occupations such as medicine [62, 63]. This view of nursing in Saudi Arabia is in-line with other countries such as Iran, Japan, Jordan and Kuwait [10, 23, 24, 64]. Public stereotypes are found to negatively affect nursing practice and retention [65, 66].
Payment including salary and financial incentives was found to be a major factor in the dissatisfaction of nurses with their QWL (61.4%). Although several research studies found that payment is not the prime motivator for employees [67], behavioural theorists such as Herzberg [68] and Maslow [69] suggest that satisfying basic needs is essential because people cannot concentrate on their higher needs until basic needs are met [1]. In support of this, several recent nursing studies have found that salary, financial benefits and equity in pay were very important to nurses [1, 20, 46, 70–72], and the lack of such benefits may impact on the satisfaction, commitment and performance of affected employees [11, 73–75].
The majority of respondents in this study (76.6%) reported that their jobs are secure and they do not expect to lose them unexpectedly. This result appears at odds with research conducted overseas [10, 74]. Additionally, the majority of respondent nurses had a high belief in the value of the nursing profession. In contrast, a study of 346 hospital nurses in Saudi Arabia found that only about one third of the sample had a high perception of nursing [76]. A high perception of the profession and the personal interest in PHC nursing as well as the sense of belonging in the workplace among respondents of the current study are noteworthy for the nursing directors, PHC managers and health care policy makers to maintain their nursing workforce through improving QWL.
Demographic variables and quality of work life
Significant differences in the QWL were found according to gender, age, marital status, dependent children, dependent adults, nationality, nursing tenure, organizational tenure, positional tenure, and payment per month. Male nurses had significantly lower mean scores of job satisfaction than female respondents, which is similar to other studies [77, 78]. As 99% of male respondents in this study were Saudi nurses, this result could be attributed to the poor image of the nursing profession in Saudi Arabia [61]. Older nurses had significantly higher mean scores of QWL than younger nurses. Likewise, nurses with more years of nursing experience and time spent at their current PHC organization and position were more satisfied with their QWL than those with less experience. Many studies have shown that older and more experienced nurses are more satisfied than younger and less experienced nurses [77, 79–83]. This may be attributed to the ability of older nurses (as mature age-wise) to make a better adjustment to the work environment when compared with younger nurses [80]. The years of experience may increase the familiarity and competence of nurses as well as their understanding of the work-related expectations [77, 82]. Moreover, in the Arab culture, older and experienced employees are accorded greater recognition by managers, and therefore they tend to be more satisfied [80]. When marital status was considered, never-married nurses were found to have significantly lower mean scores of QWL than other peers, a finding both consistent [84] and inconsistent [81, 85, 86] with previous research studies. One possible explanation for the finding may be that the never-married nurses were younger compared to other groups so they may not have the required skills to cope with challenges at work when they differ from expectations. Another explanation is that the majority of married nurses may have been living with their families, which contributed significantly to their work satisfaction [84]. Although majority of nurses were asking for childcare services by their employees, respondents with children were more satisfied with their QWL than those who had no children. Presence of children in the life of PHC nurses may increase their responsibilities and in turn encourage their stabilization and job satisfaction. Nurses with dependent adults were less satisfied with their QWL compared to those without dependent adults. A number of previous nursing studies reported on the impact of dependent adults on the satisfaction of employees regarding their QWL [8–10]. In Saudi Arabia, according to the Islamic context and the local culture, offspring have clear obligations towards their parents and relatives. However, employers in Saudi Arabia do not provide any support services for employees with dependent adults. In respect to nationality, non-Saudi nurses were found to have significantly higher mean scores of QWL when compared with Saudi nurses. However, previous research has been controversial in this regard. While a number of studies found a significant relationship between employee satisfaction and nationality [77, 84, 87], others revealed no association [81, 86]. Why the Saudi nurses were less satisfied than their counterparties is not clear. However, this could be attributed to their general perception towards their work life, including family needs, professional development, work environment, work conditions, public image of nursing and financial benefits. An investigation into the monthly salary level as a demographic variable revealed a significant difference in scores of nurse satisfaction with the QWL. While this result is inconsistent with findings of a previous nursing study in Saudi Arabia [86], it is in-line with study findings elsewhere [88]. Finally, although many previous studies support the notion that highly educated individuals develop higher satisfaction with their work [89–91], this study did not reveal any significant differences in the QWL scores of nurses related to educational level. However, based on the mean scores, it was observed that nurses with a Bachelor Degree or postgraduate qualification had higher QWL scores.
Recommendations
Based on the findings of the present study, key suggestions are proposed to improve QWL of PHC nurses and consequently the quality of care provided in PHC facilities.
Nursing executives and PHC managers need to consider the family aspect of their registered nurses. Childcare facilities, support for nurses who have elderly parents, convenient working hours, and sufficient vacations should be made available for nurses. These advantages will help nurses to balance work with their family requirements.
More qualified registered nurses and sufficient and trained support personnel (that is, nursing assistants and service workers) as well as an equitable distribution of the current nursing workforce are needed to reduce workload, and to ensure adequate nursing services for patients, families and the community, particularly in an era of a transition into family medicine and PHC services. The PHC department could attract unemployed graduate nurses from private health institutes, subject to appropriate preparation for the field of PHC. However, to achieve this, PHC organizations should be financially independent. Currently, the funding policy is governed by the Ministry of Health.
PHC managers and nursing leaders should consider partnerships with relevant departments and educational organizations to offer part-time and distance-learning opportunities to enable nurses to further their education and develop their nursing knowledge and skills while working in PHC centres, especially those in rural areas. Additionally, PHC organizations should run free-of-charge continuing nursing programs and various training workshops at PHC centres and assist staff to attend training provided by other organizations.
PHC managers and policy makers should encourage the professional growth of PHC nurses through the provision of a systematic career ladder. Currently, there is no significant difference in roles and positions of PHC nurses, irrespective of their qualifications or experience.
For the comfort of nurses, they should be provided with a furnished break area where they can rest and be able to place their private belongings securely. Additionally, the security of the PHC working environment must be improved such as through the introduction of security departments as in other health care organizations. Finally, to provide quality nursing care, PHC centres must be supported with the required materials and equipment for health care services. Nurses need working environments that meet the needs of patients, employees and providers.
PHC managers should work with the media to demonstrate the vital role of PHC nurses in the care of the community, in the provision of health care services and in the advancement of the health of the population.
The current salary system is problematic for PHC nurses. The salary of nurses should be increased commensurate with the tasks performed. Nurses also should be provided with fair financial benefits such as allowances for housing, working in remote areas, dealing with infectious diseases, or working in open public areas. Other health professionals in Saudi Arabia receive several of these benefits.
Most nurses in this study were not satisfied with management practices. Nurse managers/supervisors should be provided with short training programs on the art of management, leadership and communication skills. Approaches should be developed to allow nurses to participate in decision making regarding practices that influence their work life, receive meaningful feedback on their performance and recognition for their accomplishments. Finally, adequate job descriptions, working policies and standard procedures for PHC nursing practice are urgently required.
More social, managerial, professional and organizational support should be directed to young and novice nurses who were found in this study to be less satisfied than experienced nurses. Older nurses may require more sense of appreciation, valuation and respect.
Suggestions for future research
The current study used a cross-sectional survey design which limits the observation of change over time. There is a need to conduct longitudinal research using a few selected PHC organizations to gain an in-depth understanding of the determinants of and changes in QWL of PHC nurses at various points in time. An intervention study to improve QWL of PHC nurses using the findings of the current study is required. A comparative study between PHC centres and hospitals as well as public sector and private sector organizations in terms of QWL of nursing personnel is required. Such a study may assist in identifying the determinants of QWL in each sector that may be different from sector to sector according to differences in the working system and environment. A further comparative study regarding QWL between nurses and other health professionals in PHC services is required.
Limitations
A number of limitations in the current study have been identified. The sample was drawn from nurses who were willing to participate in the study. Although all of the PHC centres (n = 134) in the Jazan region were included in this research, the voluntary sampling methodology may limit the generalizability of the findings. However, the high response rate (effective response rate = 87%) suggests that response bias is minimal. The information was gathered through a self-reporting survey leaving the interpretation to the participant. The use of self-reporting instruments may have decreased the reliability of responses due to misinterpretation of some of the items. The questionnaires were distributed to the PHC nurses through their managers – this strategy could have allowed the managers to pressure (intentional or unintentional) registered nurses to complete the survey in a particular way [74]. However, there were no reports of pressure placed on respondents from managers. Despite these limitations, the findings of the study provide important contribution to the existing research on the QWL, particularly for PHC nurses.