Introduction
Hospital is one of the most important elements of the health system. Hospitals account for about half of all healthcare expenditures. They play an important role in improving public health to patients by providing quality diagnostic, therapeutic, and rehabilitation services. However, this goal cannot be achieved without good human resource management. Hospital staff must possess the necessary knowledge, skills, ability, and motivation to provide quality services. Committed and motivated employees play an important role in the success of any organization. Therefore, hospital managers should pay more attention to employees’ job satisfaction [1].
Nurses account for the majority of hospital staff. As the powerful arm of the hospital, nurses play an important role in improving hospital performance. In addition to having sufficient knowledge in caring for patients, nurses have specific clinical and personality skills and at the same time have high job satisfaction to do their job effectively. Nurses provide about 80% of direct patient care and have close contact with patients [1‐3]. Given the importance of the nursing profession and its role in public health, it is crucial to ensure job satisfaction among nurses.
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Job satisfaction can be an important factor in the quality of nursing care. In service organizations like hospitals where service delivery requires close contact between employees and customers, employee satisfaction can lead to customer satisfaction. Job dissatisfaction can decrease service quality and negatively affect patient satisfaction [4]. Job satisfaction is the extent to which an employee feels positively or negatively toward his or her job [5].
Job satisfaction is positively associated with nurses’ quality of life, care quality, and patient satisfaction [6‐8]. For example, a 2017 study in Pakistan showed that nurses with high job satisfaction provide better care, thus improving hospital performance [8]. In contrast, low job satisfaction can lead to longer hospital stays, poor service delivery, and high displacement, absenteeism, and turnover among nurses [7, 9].
Job dissatisfaction is a major and consistent predictor of turnover intention among nurses [10]. Due to job dissatisfaction, a study in the USA reported 32% and 40% displacement and turnover rates among nurses, respectively. The average turnover cost for a nurse was estimated at $2,437 in 2018 [7].
Globally, many countries face critical challenges in terms of human resources for health (HRH), including worker shortages, skill-mix imbalances, a poor work environment, a weak knowledge base, and the maldistribution of resources [11‐13]. In several low and low-middle-income countries (LMICs), the supply of health professionals is being challenged by demographic trends (e.g., an aging population), growing shortages, limited education and training capacities, poor recruitment and retention strategies, skill-mix imbalance, maldistribution, poor HRH planning, absence of a reliable database, and poorly informed policy decisions [14].
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These challenges mostly affect LMICs with poor health conditions (e.g., rising mortality rates and declining life expectancy at birth) [11]. This is critical in the context of the Eastern Mediterranean Region (EMR), where 61% of its 22 countries have been classified as LMICs by the World Bank [15]. In addition, among the six administrative regions of the WHO, EMR is second only to Africa in having the lowest HRH density (per 1000 population) [16]. Lebanon has the 8th lowest nurse density in the EMR with excessive nurse migration, low job satisfaction, poor retention, and high turnover [17, 18].
There have been several studies on job satisfaction among nurses in EMR hospitals, and different levels of job satisfaction have been reported across this region. For instance, a 2015 study reported 38% job satisfaction among Jordanian nurses [19], while it was reported to be 48% in a 2017 study of Egyptian nurses [20]. However, these studies cannot provide a comprehensive picture of job satisfaction among nurses in EMR hospitals. By synthesizing these findings, better insights can be provided to health policymakers and managers. Therefore, this study aims to determine job satisfaction among nurses in EMR hospitals.
Method
The literature search for this meta-analysis was carried out based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) [21]. Three online databases (MEDLINE (via PubMed), SCOPUS, and Web of Science) and Google Scholar search engine, were searched to identify relevant full-text studies published up to 22 September 2023. The reference lists of these studies were examined for further relevant articles.
All published cross-sectional design studies that examined nurses’ job satisfaction in the EMR were included in this review. The EMR was defined based on the WHO classification [22]. Articles that did not meet the following criteria were excluded: (1) editorials, case-control studies, randomized controlled trials, and qualitative studies; (2) grey literature, books, and dissertations; (3) articles, documents, and reports published after September 22, 2023; (4) studies that did not obtain the minimum quality score of 15; (5) studies published in any language other than English.
Before starting the process, a health sciences librarian was consulted about the search methodology. Keywords included Job Satisfaction, Work Satisfaction, Hospital, Nurse, EMR Countries, Afghanistan, Djibouti, Egypt, Bahrain, Iran (Islamic Republic of), Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, Yemen, and Palestine. These keywords were combined with Boolean operators, ‘AND’ and ‘OR’.
4304 articles were yielded in the initial search. In the first screening stage, 235 duplicates and articles without full texts available were removed. By reviewing the abstracts, 4041 unrelated studies were excluded because of the article type (i.e., qualitative studies), studying nurses from other countries, or the causes of job satisfaction. Next, after a careful review of the remaining articles, 28 articles that did not report the percentage of job satisfaction among nurses were removed. Finally, 13 articles were used to evaluate job satisfaction among nurses in EMR hospitals (Fig. 1).
Fig. 1
PRISMA flow diagram illustrating the study selection process
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The STROBE checklist was used to evaluate the quality of the articles [23]. This checklist consists of 22 items. The minimum acceptable score for each study is 15. Studies were scored independently by two researchers. Disagreements were resolved by a third reviewer. A data extraction form was used to collect data, which included the details of the first author, publication year, place of study, sample size, average age, type of hospital, income level, and job satisfaction level (Table 1). Ethical considerations related to review studies such as non-bias in the stages of selection, extraction, and analysis of evidence and documents were observed.
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Table 1
Characteristics of the reviewed articles
S/N | Author | Year | Location | Total Sample | Prevalence (%) | Age Average | Hospital Type | Income Level* | Quality Score | Reference No. |
|---|---|---|---|---|---|---|---|---|---|---|
1 | Zhyan | 2017 | Iraq | 150 | 46 | 34.5 | Training | Lower middle income | 16 | [24] |
2 | Bahnassy | 2014 | Saudi Arabia | 722 | 70.13 | 34.35 | Public | High income | 15 | [25] |
3 | AbuAlRub | 2015 | Jordan | 330 | 38 | 28.7 | Public | Lower middle income | 16 | [19] |
4 | Atefi | 2013 | Iran | 421 | 28.7 | 34.2 | Public | Lower middle income | 17 | [26] |
5 | Bahalkani | 2011 | Pakistan | 56 | 14 | 35.5 | Public | Lower middle income | 17 | [27] |
6 | Jalaluddin | 2015 | Pakistan | 154 | 54 | 27.6 | Private | Lower middle income | 15 | [28] |
7 | Mehrdad | 2013 | Iran | 424 | 47.9 | 34.1 | Training | Lower middle income | 18 | [29] |
8 | Kaddourah | 2013 | Saudi Arabia | 140 | 79.3 | 33 | Training | High income | 16 | [30] |
9 | Sajjad Dar | 2015 | Pakistan | 385 | 51.5 | 34.8 | Public | Lower middle income | 19 | [31] |
10 | Randa | 2020 | Egypt | 210 | 49 | 31.8 | Public | Lower middle income | 15 | [32] |
11 | Al Haroon Hind | 2019 | Saudi Arabia | 337 | 48 | 34.5 | Public | High income | 18 | [33] |
12 | Abushaikha | 2009 | Palestine | 255 | 84.2 | 30.9 | Public-private | Lower middle income | 20 | [34] |
13 | Umayma | 2003 | Lebanon | 421 | 19 | - | - | Lower middle income | 15 | [35] |
Comprehensive Meta-Analysis software (Version 2.2.064) was used in this research for data analysis. Considering the level of job satisfaction among nurses and the number of samples extracted in each article, binomial distribution was used to calculate the variance of each study. A weighted average was used to combine the job satisfaction levels of different studies. Each study was weighted according to its variance. Due to the difference in prevalence rates in studies (heterogeneity of studies) and the significance of the I2 heterogeneity index, the random effects model was used in the meta-analysis. The degree of heterogeneity in this study was equal to 96.40%, which is in the category of studies with high homogeneity (I2 index less than 25% of low heterogeneity, between 25% and 75% of moderate heterogeneity, and 75% and more of high heterogeneity).
Meta-regression was used to investigate the relationship between the job satisfaction level of nurses with the year of publication, sample size, and average age and to investigate the cause of heterogeneity in the results of the studies. The job satisfaction level of nurses in the EMR was calculated according to income level, country, and type of hospital using subgroup analysis.
Findings
Up to September 22, 2023, 13 articles determined job satisfaction among nurses in EMR hospitals. Most of these articles were published in 2013 and 2015 (Fig. 2). These studies were conducted in eight countries, mostly in Pakistan and Saudi Arabia (3 cases each). The studied hospitals were public hospitals (7 cases), teaching hospitals (3 cases), private hospitals (1 case), and public-private hospitals (1 case). It must be noted that hospital type was not specified in one study.
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Fig. 2
Frequency distribution of the reviewed articles by publication year
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Based on the random effects model, the overall level of job satisfaction among nurses in EMR hospitals was 17.9% (95% CI (11.9–26.0)). The lowest job satisfaction was reported in Umayma’s in 2003 [35] at 4.5% (95% CI (2.9- 7.0)), and the highest job satisfaction was reported in Kaddourah’s in 2013 [30] at 56.6% (95% CI (48.3–64.6)) (Fig. 3).
Fig. 3
Forest plot of the reviewed articles
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The results were summarized by national income level, country, and hospital type (Table 2). In this study, job satisfaction among nurses was higher in high-income countries than in others. The level of job satisfaction was also higher in private hospitals. Moreover, job satisfaction among nurses was highest in Palestine.
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Table 2
Subgroup analysis of the reviewed articles
Variable | No. Studies | Prevalence (%) | 95% CI | I2 | P-value | |
|---|---|---|---|---|---|---|
Income level | High income | 3 | 22.2 | 6.3–54.6 | 98.61 | ≤ 0.0001 |
Lower-middle income | 10 | 16.8 | 10.9–24.8 | 95.24 | ≤ 0.0001 | |
Countries | Iraq | 1 | 30.7 | 23.8–38.5 | - | - |
Saudi Arabia | 3 | 22.2 | 6.3–54.6 | 98.61 | ≤ 0.0001 | |
Jordan | 1 | 11.5 | 8.5–15.4 | - | - | |
Iran | 2 | 8.9 | 5.4–14.4 | 80.17 | ≤ 0.0001 | |
Pakistan | 3 | 23.1 | 11.2–41.9 | 93.59 | ≤ 0.0001 | |
Egypt | 1 | 23.3 | 18.1–29.5 | - | - | |
Palestine | 1 | 33 | 27.5–39 | - | - | |
Lebanon | 1 | 4.5 | 2.9-7 | - | - | |
Hospital type | Training | 3 | 29.5 | 9.7–62 | 98.07 | ≤ 0.0001 |
Public | 7 | 13.5 | 9.9–18.2 | 87.32 | ≤ 0.0001 | |
Private | 1 | 35.1 | 27.9–42.9 | - | - | |
Public-private | 1 | 33.0 | 27.5–39 | - | - | |
Table 3 shows the meta-regression of studies according to average age, year of publication, and average age. According to this table, the average age, and sample size had a significant relationship with the job satisfaction level of nurses (P < 0.05). Job satisfaction among nurses decreases by 0.003 as the sample size increases. Moreover, job satisfaction increases by 0.02 as the average age increases.
Table 3
The results of the heterogeneity test (meta-regression model)
Suspicious Variables | Coefficient | SE | P-Value |
|---|---|---|---|
Sample Size | -0.003 | 0.0002 | ≤ 0.0001 |
Average age | 0.02 | 0.006 | ≤ 0.0001 |
Discussion
The purpose of this study was to determine the level of job satisfaction among nurses in EMR hospitals. Up to September 22, 2023, 13 studies had determined job satisfaction among nurses in the EMR. The overall job satisfaction of nurses was 17.9%. There has been extensive research on job satisfaction among nurses in hospitals worldwide. For example, a recent cross-country study observed the highest to lowest nurses’ job satisfaction in Germany, the U.S., New Zealand, Canada, South Korea, the UK, China, and Japan, respectively [36]. Generally, research has shown that nurses’ job satisfaction is higher in developed countries than in less developed nations. Park et al. showed that Korean nurses’ job satisfaction was poor and lower than the median level [37]. Al Maqbali found that nurses in Oman have a medium level of satisfaction [38]. Cultural, economic, and healthcare system differences may significantly impact job satisfaction [26]. Cultural differences significantly shape perceptions of job satisfaction. For instance, in countries where collectivism prevails, job satisfaction may be more closely tied to team dynamics and workplace harmony than individual achievements. Conversely, in more individualistic cultures, personal accomplishments and career advancement might hold greater weight in determining job satisfaction levels [39].
Economic conditions, including GDP per capita and employment rates, can directly affect job satisfaction. A study indicates that higher GDP correlates with increased job satisfaction among general practitioners; countries with stronger economies often provide better working conditions and benefits, enhancing overall job satisfaction [39].
Work conditions, including workload, hours worked, and access to resources, are critical factors. In Jordan, for example, long hours and high patient loads were linked to lower job satisfaction among physicians [40].
The structure and efficiency of healthcare systems also play a crucial role. For example, studies show that job satisfaction among healthcare professionals varies significantly across countries due to differences in healthcare delivery models, resource availability, and administrative support [39, 40].
Therefore, to fully understand job satisfaction levels across different countries in the EMR, it’s essential to analyze these cultural, economic, and systemic factors comprehensively. This multi-faceted approach would provide a richer understanding of how various contexts influence job satisfaction and could inform policies aimed at improving workplace conditions across diverse settings.
In this study, job satisfaction among nurses was higher in high-income countries. A study showed that nursing job satisfaction in developed countries was higher than in less developed nations [41]. Job satisfaction among nurses varied in LMICs such as Palestine, Jordan, Pakistan, Iraq, Iran, and Lebanon. EMR has the second-lowest HRH density (per 1000 population), right after Africa, among the six administrative regions of the WHO [16]. Findings showed Palestine had the highest job satisfaction and Lebanon had the lowest. The high levels of job satisfaction among nurses in Palestine can be attributed to a combination of cultural values, supportive work environments, differences in healthcare settings, adequate staffing, recognition of efforts, and a strong sense of community contribution. These factors collectively create a more satisfying work experience for nurses despite the challenges they face [34, 42, 43]. For example, Abushaikha & Saca Hazboun, in 2009, showed that many Palestinian nurses reported a strong sense of contribution to their community’s health amidst challenging socio-political circumstances [34]. This intrinsic motivation can enhance job satisfaction as they feel they are making a meaningful difference. On the other hand, the strong emphasis on community and familial relationships in Palestinian culture may contribute positively to job satisfaction. Nurses often view their roles as integral to the well-being of their communities, which can foster a sense of purpose and fulfillment in their work [34]. Since it was a single study conducted in Lebanon and Palestine, the results should be interpreted cautiously.
According to the World Bank, most (61%) of the 22 nations within the EMR are LMICs [44]. Losing nurses is basic for these nations [45], given that they are in a destitute position to lose their rare assets due to destitute well-being results and the requirement for qualified health experts [46]. LMICs are not as severe as they were, enduring destitute health indicators and the need for reliable data [47]. They are also incapable of delivering an adequate number of nurses to meet the wants of their populace in light of the changing epidemiological profile [48].
Lebanon is one of the essential exporters of nurses to the Gulf nations such as the Kingdom of Saudi Arabia (KSA), Kuwait, and the United Arab Emirates (UAE), in addition to other countries in North America and Europe [18].
Job satisfaction among nurses was also studied in one high-middle-income country, i.e. Saudi Arabia, and a value of 22.2% was reported. Generally, hospital managers and policymakers should consider instituting non-financial incentives to retain their nurses. Combinations of financial and non-financial incentives can encourage nurse retention and decrease dissatisfaction.
The results of this study showed that nurses’ job satisfaction decreased by 0.003 per unit increase in sample size. Studies with a large sample size may inadvertently suffer from sampling error. Therefore, it is necessary to ensure that the sample size is representative of the population and that appropriate sampling methods are used to measure job satisfaction among nurses.
Job satisfaction was higher in private hospitals. This finding could be due to higher costs and lower patient admissions in private hospitals compared to public hospitals, where nurses have a much higher workload. In private hospitals, various job-related and organizational decisions, such as those concerning rules, powers, and facilities, are out of the government’s jurisdiction and in the hands of the owners and/or shareholders [49]. However, given that only one private hospital was studied, this finding should be interpreted cautiously.
The results also showed that nurses’ job satisfaction increases by about 0.02% per unit increase in average age. This finding is consistent with the results of Luddy et al. [50]. Perhaps this is because young people have less experience and greater ideals that may not be compatible with the busy environment of today’s organizations, which can cause dissatisfaction. Over time, however, these individuals develop a more realistic view of their jobs possibly get used to the existing job conditions, or acquire more skills, which allows them to enjoy their jobs more and become more satisfied.
The job satisfaction of nurses is very significant because the nature of nursing activities requires that the employees of this profession do their duties with love and passion. On the other hand, nursing deals with patients’ lives, so the lack of satisfaction among nurses can have destructive effects on patients and the health system. Therefore, several solutions have been proposed to increase the job satisfaction of nurses in hospitals. Some of these strategies include increasing the managers’ support for nurses, increasing the nurses’ independence, increasing their participation in the decision-making process, improving working conditions, and improving the communication process in the hospital [51‐53].
Supporting working environments can provide the basis for increasing nurses’ job satisfaction. Social support affects the treatment of patients, job satisfaction, and job motivation, attracting and retaining them. For example, a study of 303 hospitals in the state of Pennsylvania in 2002 showed that the number of nursing personnel and the level of organizational support for nurses had a clear effect on the lack of motivation and job satisfaction of nurses [51]; Therefore, considering that most nurses work in stressful environments, managers should provide a suitable working environment for their activities by increasing organizational support.
Like many other articles, this study also has some limitations: 1- Job satisfaction among nurses has been studied in a limited number of countries in the EMR and is not comprehensive in terms of coverage and generalizability. 2- In some countries, a study was conducted, and it is necessary to interpret the results cautiously. 3- There was a lack of valuable information (e.g., work experience, gender, work shift, and number of shifts) for a detailed survey. 4- In this study, percentages were used to evaluate the level of job satisfaction. 5- The studies used different tools to determine nurses’ job satisfaction. 6- Information was collected from nurses of different wards.
Despite the challenges this review faces in analyzing literature, the results of this study could be valuable in identifying dissatisfaction among nurses. This information could be useful for informing health system policymakers, healthcare professionals, and patients alike, leading to a raised awareness which could have many beneficial outcomes, including increasing satisfaction in nurses.
Conclusion
According to the results of this study, about 18% of nurses in EMR had job satisfaction. Health policymakers and managers can empower nurses by implementing effective policies and programs and using collaborative management, thus improving their job satisfaction and the quality of care they provide.
In general, The special nature of hospitals, long working hours, working with sick and dying patients, occupational hazards, and injuries impose a great deal of stress on nurses and can lead to their dissatisfaction. Hospital managers should reduce stressors by improving the structure, culture, and hospital work processes, creating a safe and friendly work environment, providing the required resources, training nurses, and offering timely and fair compensation. Jobs should be designed in such a way as to motivate nurses. If necessary, managers should use job simplification, job rotation, job development, and job enrichment to reduce the stress caused by the very nature of the job. Creating a suitable and pleasant working environment, besides providing the equipment and supplies needed to do the job, will reduce stress and increase nurses’ job satisfaction. Employees like to be seen and appreciated for their efforts. Managers’ encouragement and appreciation can motivate employees to work harder to achieve organizational goals.
Acknowledgements
The authors would like to extend their most sincere gratitude and appreciation to the esteemed reviewers of the article.
Declarations
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Competing interests
The authors declare no competing interests.
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