Job Satisfaction Among Nurses Working in King Abdul Aziz Medical City Primary Health Care Centers: A Cross-Sectional Study

Background Job satisfaction in the nursing field directly impacts the quality of patient care. However, increased work demand puts nurses at a higher risk of job dissatisfaction, which can, in turn, affect their work performance. This study aimed to measure job satisfaction among nurses working in National Guard Primary Healthcare Centers (PHCs) and to determine the different sources of pressure at their workplace. Methods A cross-sectional quantitative study was conducted among nurses working in the National Guard PHCs in the Makkah region, Saudi Arabia, in 2022. A validated questionnaire from previous literature was used to evaluate nurses' job satisfaction. Results A total of 77 nurses completed the questionnaire, with an overall response rate of 89.5%. While 58% (n=45) of nurses were satisfied, 42% (n=32) were dissatisfied. Approximately half the participants were dissatisfied with the rate of payment (49%, n=38), working hours (47%, n=36), and future chances of promotion (44%, n=34). Moreover, 51% (n=39) of nurses attributed considerable pressure to staff shortage and 44% (n=34) to workload. Furthermore, lower mean satisfaction scores in nurses were significantly associated with their intention to leave their current center (p-value= 0.06). In addition, reduced satisfaction scores were frequently observed among females, singles, those who finished their first nurse training five to 10 years ago, those who had a previous experience outside the Ministry of National Guard Health Affairs (MNGHA), those who had only one to five service years, and the ones who belonged to centers that did not have clearly stated standards and policies for nursing practice. However, these associations were statistically not significant. Conclusion Results indicate that nurses' job satisfaction should be improved to decrease nurses' intention to leave their workplace and maintain their optimum performance in patient care. This can be achieved by addressing the sources of dissatisfaction and pressure at work.


Introduction
Nursing is one of the noblest professions. It requires competence, compassion, and genuine commitment to patient caregiving. Since job satisfaction in the nursing field directly impacts the quality of patient care, this topic remains widely discussed and highly valued. Job satisfaction is "a pleasant or positive emotional state resulting from the assessment of our own work or the experience associated with work" [1]. It results in positive outcomes for both the nurses and the patients; some benefits to the nurses are decreased job stress, turnover, and burnout [2]. As work demand increases, nurses have to accommodate a more significant workload while simultaneously meeting the highest standards of patient care. Working in a high-paced environment with shifting work schedules and continuous responsibilities puts them at a higher risk of job dissatisfaction. This affects the nursing staff and reflects in their duties as frontline health workers [3].
der Heijden et al. explored how social support, especially from one's co-workers or direct chief, can heavily impact nurses' satisfaction, playing a role in whether or not they will leave their health institute [5]. According to Maslach et al., burnout is another crucial factor strongly correlated to job dissatisfaction [6]. The Maslach Burnout Inventory (MBI) is the most commonly used instrument for measuring burnout [7]. A high burnout score on the MBI is directly linked with a lack of good health and feeling a sense of ineptitude, leading to lower productivity. All eventually lead to job dissatisfaction [3]. In Saudi Arabia, multiple studies have shown similar results regarding job dissatisfaction. For example, AL-Dossary et al. concluded that pay, fringe benefits, contingent rewards, and operating conditions were the main reasons behind nurses' dissatisfaction [4]. In concordance with AL-Dossary et al., Aljohani KA revealed a low-to-moderate level of job satisfaction among nurses [8]. Another study found moderate-to-high levels of burnout and low levels of job satisfaction among critical care nurses [9]. Due to the weight of this topic and the lack of in-depth analysis in Jeddah, it is crucial to investigate it. This study evaluates nurses' satisfaction in National Guard Primary Healthcare Centers (PHCs) in Jeddah, Saudi Arabia. This study aimed to measure job satisfaction among nurses working in National Guard Primary Healthcare Centers (PHCs) and to determine the different sources of pressure at their workplace through a self-administered questionnaire.

Materials And Methods
This is a cross-sectional quantitative study conducted in the National Guard Primary Healthcare Centers in the Makkah region, Saudi Arabia, in 2022. The included centers were Iskan clinic, Specialized polyclinic, Bahraa, and Shareae Primary Healthcare Center. The inclusion criteria for the study were nurses who are currently practicing at said PHCs. The sample size was calculated using the Raosoft sample size calculator, and recommended minimum sample size was 71 participants [10]. Moreover, 86 participants were enrolled in this study, and convenience sampling was the followed sampling technique. Scientific approval was obtained from King Abdullah International Medical Research Center (KAIMRC), and ethical approval was obtained from the Institutional Review Board (IRB) (approval number NRJ21J-155-06).
The data were collected through a self-administered validated English questionnaire adapted from previous literature [11]. Cronbach's alpha was used to measure the reliability and internal consistency of the questionnaire and run the questionnaire for a pilot study that included participants who would not participate in the main study. The questionnaire has been validated, and Cronbach's alpha of the paper in which it was validated was 0.89 [11]. The questions were mainly given options, with the respondent checking one option. The scales used in the questionnaire are various. Job satisfaction scale: a five-point Likert type scale (1=very dissatisfied, 5=very satisfied), Organizational Commitment Scale: a five-point Likert type scale (1=strongly disagree, 5=strongly agree), Nurses' Occupational Stress Scale: a five-point Likert type scale (1=no pressure, 5=extreme pressure), Professional Identification Scale: a five-point Likert type scale (1=never, 5=very often, and Role Conflict and Ambiguity Scale: a five-point Likert type scale (1=never, 5=very often) [11]. The questionnaire consists of a demographic section followed by sections A, B, C, and D. Section A is mainly about the nurse's perspective on their current job, from different aspects such as pay, job security, and dynamics in the work field. Section B is about the work environment and hospital regulations and policies. Section C is mainly about the sources of pressure at work and obstacles nurses may face. Section D is about how nurses feel about their chosen profession regarding feelings of belonging and support among colleagues [11] (Appendix 1).
Data were entered and analyzed using IBM SPSS Statistics Version 22 (IBM Corp., Armonk, NY). The responses for section A regarding current job satisfaction were merged into three categories (Very dissatisfied/Dissatisfied -Neither satisfied nor dissatisfied -Very satisfied/Satisfied). Similarly, section B regarding the views about their PHC center was also combined into three categories (Strongly disagree/Disagree -Neither disagree nor agree -Strongly agree/Agree). In section C the responses for sources of pressure at work were also categorized into three categories (No/Slight pressure -Moderate pressure -Considerable/Extreme pressure). Section D collecting responses regarding the respondents' feelings about their chosen profession was also combined into three categories (never/Seldom -Sometimes -Often/Very often). These and the other categorical variables are presented in the descriptive statistics as frequencies and percentages.
The satisfaction mean scores were calculated by taking the mean of the 15 statements in section A on the five-point Likert scale (1=Very dissatisfied to 5=Very satisfied). These and other numerical variables are presented as mean + standard deviation. The mean satisfaction scores were compared between the categorical variables having two categories using the Independent samples t-test and using ANOVA for variables having more than two categories. A p-value less than 0.05 was considered to show a statistically significant difference for all the statistical tests.

Nurse training
Most participants chose nursing as their first career choice (82%, n=63). Forty-five percent (n=35) of participants finished their first nurse training more than ten years ago. Additionally, 38% (n=29) of respondents had 1-5 service years, 35% (n=27) had more than 10 service years, and 86% (n= 66) were program-hired. Moreover, more than half of the participants (57%, n=44) had a previous experience outside the Ministry of National Guard Health Affairs (MNGHA). Furthermore, 43% (n=33) of nurses had worked in their current PHC for less than five years, and 38% (n=29) had spent more than ten years working in the same PHC they were attending. However, 48% (n=37) of nurses had the intention to leave their current PHC. Moreover, nearly half of the nurses (48%, n=37) were paid less than 10,000 SR (Saudi Rial) per month ( Table  2).

MNGHA: Ministry of National Guard Health Affairs
As shown in Table 3, team nursing, in which an assigned registered nurse (leader) delegates tasks to a team of medical professionals who care for multiple patients, was the most commonly used patient care delivery system in PHCs (61%, n=43). In addition, 55% (n=35) of nurses did not have/did not know if their PHC had individualized written nursing care plans for each patient. However, 76% (n=51) of nurses reported having nursing notes written at the end of each shift. Moreover, 72% (n=52) of respondents agreed that their PHCs had standardized nursing care plans for common nursing care problems/nursing diagnoses. Furthermore, most participant nurses (87%, n=67) reported that their PHCs had clearly stated standards and policies for nursing practice, and 82% (n=63) revealed that some of these standards and policies were stated by MNGHA. In addition, when asked whether the MNGHA had any regulatory power over nurses, 70% (n=54) of them answered yes.   Figure 1 illustrates the overall satisfaction level of respondents. While 58% (n=45) of nurses were satisfied, 42% (n=32) were dissatisfied. The Mean±SD of the satisfaction score was measured to be 3.07± 0.93, where 1 represented the minimum score and 5 represented the maximum. In addition, scores of 3 or less were consistent with dissatisfaction. Details are shown in Table 4.   Table 5 demonstrates nurses' views about their current job satisfaction. Approximately half the participants (49%, n=38) were dissatisfied with the payment rate. In addition, 47% (n=36) of respondents found their working hours dissatisfactory. Moreover, 44% (n=34) of nurses were not satisfied with their future chances of promotion. While 42% (n=32) of participants found how the PHC was managed to be satisfactory, a comparable percentage (39%, n=30) found it dissatisfactory. Furthermore, 45% (n=35) of nurses were satisfied with the attention paid to their suggestions and their job security, while 32% (n=25) were dissatisfied and 36% (n=28) were insecure about their jobs. While 21% (n=16) of respondents were not satisfied with both their immediate bosses and fellow workers, 68% (n=52) and 64% (n=49) were satisfied with their fellows and immediate bosses, respectively. Moreover, slightly more than half of the participants were pleased with the relations between management and staff, the amount of variety in their job, and the amount of responsibility they were given, 53% (n=41), 53% (n=41), and 51% (n=39) respectively).  Current primary health care center Table 6 displays nurses' perceptions and attitudes toward the PHCs they were working in. Seventy-four percent (n=57) of participants were willing to put in a great deal of effort beyond what is normally expected to help their center succeed. In addition, 62% (n=48) of respondents agreed that they care about the fate of their center, and 61% (n=47) felt proud to tell others that they were part of their current center. Nevertheless, 52% (n=40) of the nurses could just as well be working for a different center as long as the work was similar, and 40% (n=31) felt very little loyalty to their present center. While 58% (n=45) of nurses were happy that they chose their current center to work for over others they were considering when they joined, 21% (n=16) thought that deciding to work for their current center was a definite mistake. Moreover, 38% (n=29) of participants agreed that there was not too much to be gained by sticking with their current center indefinitely.   Table 7 shows nurses' viewpoints regarding different sources of pressure at work, ranging in severity from slight to considerable stress. Approximately half of the respondents (51%, n=39) attributed considerable pressure to staff shortage and 44% (n=34) to workload. Additionally, 36% (n=28) of participants thought that dealing with challenging patients caused moderate pressure levels. Moreover, 69% (n=53) of nurses regarded slight pressure to cope with new technologies, and 64% (n=49) to exposure to death. Furthermore, employment security, coping with new situations, and lack of specialized training for present work resulted in slight pressure on more than half of nurses (55%, n=42). In addition, uncertainty about the area of their responsibility was a contributing factor to slight pressure in 51% (n=39) of respondents. Moreover, 48% (n=37) of participants agreed that little pressure was also caused by time pressures and deadlines, tasks outside of their competence, lack of support from senior staff, and lack of participation in planning/decision-making.   Table 8 shows nurses' feelings about their chosen profession. Seventy-one percent (n=55) of participants considered the nursing profession important. In addition, 66% (n=51) of respondents were glad to belong to the nursing profession. Moreover, 48% (n=37) of nurses often felt strong ties with other members of the same profession. However, 19% (n=15) of nurses were annoyed that they were members of the nursing profession, and 18% (n=14) often tried to hide their belonging to the nursing profession. Furthermore, 43% (n=33) of participants sometimes felt held back by the nursing profession.   Table 9 displays that lower satisfaction scores were frequently observed among females and those who were single, even though this was not statistically significant. Moreover, higher satisfaction scores were often seen among those aged 30 to 44 years than in other age groups, although this was not statistically significant.     Table 11 shows that lesser satisfaction scores were frequently seen among nurses in PHCs that mainly used Primary Nursing, in which a primary registered nurse is assigned to patients to take responsibility for their care throughout the hospital stay, although it was not statistically significant. Additionally, reduced satisfaction scores were frequently observed among those who belonged to centers that did not have individualized written nursing care plans for each patient, centers that did not have standardized nursing care plans for common nursing care problems/nursing diagnoses, and centers that did not have clearly stated standards and policies for nursing practice, and centers that did not have any clearly stated standards and policies for nursing practice by the MNGHA even though these associations were statistically not significant.

Discussion
The nursing profession is considered a cornerstone in the healthcare system, and their input matters the most when it comes to patient care. Job satisfaction is an essential aspect of the nursing population's work performance [12]. This study aimed to explore the levels and factors influencing this crucial aspect. In general, it was found in this study that participants had moderate job satisfaction levels, which is similar to what has been found in studies carried out in Oman and Kuwait by Al Maqbali MA and Al-Enezi et al. respectively [12,13]. Findings of studies done in other countries with different cultures and backgrounds also had comparable job satisfaction levels to this study [14,15].
Similar to AL-Dossary et al. findings, salary and working hours were identified as sources of dissatisfaction for nurses in this study [4]. This study showed that almost half of the nurses are paid less than 10,000 Saudi Riyals\ 2,666 US Dollars per month, which could explain their dissatisfaction with the payment rate. However, Burnard et al. argued that as important as income seems to influence job satisfaction, it constitutes only a tiny part compared to other factors [16]. Moreover, increased working hours can be caused by staff shortage, which was identified as a source of pressure by the respondents. Nurses might need to take on additional working hours and duties to compensate for this shortage and complete their tasks. As Aljohani described, this pressure creates a poor working environment that exposes nurses to chronic fatigue, poor physical performance, and inefficient communication [8].
While findings of several previous studies showed a significant relationship between levels of job satisfaction and nurses' intention to leave their current centers, the association in this study was borderline significant (p-value= 0.06) [17,18]. Even though it has been found that most participants have a great sense of belonging and loyalty to their workplace and more than half of participants reported that they are satisfied with co-workers, including their bosses, nearly half of them had the intention to leave their centers. Yarbrough et al. linked career development with the nurses' decision on whether to remain or leave their jobs, which, among other factors, could explain the participant's intention to leave in this study since some dissatisfaction with the future opportunities for promotion was found [17]. In addition to job satisfaction, Lu et al. regarded burnout as a contributing factor in retaining nurses and ensuring the quality of care [11]. Future studies are needed to explore nurse turnover and determine the specific aspects related to its rate.
While demographic factors such as age, level of education, and years of experience were positively associated with job satisfaction in previous studies, these associations were not clear or statistically significant in this study [19,20]. An expansion in the sample size could better reveal such relationships since it is considered modest compared to other studies.

Strengths and limitations
The main strengths of this study are the high response rate. Also, the questionnaire used for data collection included different validated scales to measure our outcome. The limited sample size is considered the main limitation of this study. It was determined based on the available study population and may explain why none of the results were statistically significant. Additionally, the generalizability of the results may be limited since the study sample only involves nurses working at National Guard PHCs in Jeddah, Saudi Arabia. Also, working conditions, shift durations, and workload may vary for nurses working in secondary or tertiary healthcare centers compared to PHCs. Therefore, future studies involving a wider range of healthcare facilities would provide a more comprehensive view of the issue.

Conclusions
Based on the results demonstrated in this study, many nurses showed dissatisfaction in various areas like rate of payment, working hours, and future chances of promotion. Moreover, sources of nurses' pressure at work varied between the shortage of staff and the amount of workload. Furthermore, reduced job satisfaction may have stimulated nurses to intend to leave their centers. Due to nurses' vital role in the patients' lives, nurses' sources of job dissatisfaction and pressure at work must be addressed and managed.

Recommendations
Healthcare facilities and decision-makers can use the findings of this study to explore the possible changes that can be implemented to improve working conditions for nurses and increase their satisfaction rates and retention. These changes can include improving the work environment, shorter working time, and more financial benefits. Moreover, giving the nurses the opportunity for self-development and more involvement in research activities and international nursing conferences will play a significant role. Also, opening the field for fellowships for those with special interests can make the nursing job more attractive than before. In the future, we would recommend qualitative studies that can help in an in-depth analysis of the current situation and come up with solutions that can increase satisfaction among nurses working in Saudi Arabia or internationally.

Very dissatisfied Dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied
The physical conditions in which you work Freedom to chose your own working methods

Your fellow workers
The recognition you get for good work

Your immediate boss
The amount of responsibility you are given The rate of pay for nurses The opportunity to use your abilities

Relations between management and staff
Future chance of promotion The way the hospital is managed The attention paid to your suggestions The hours of work The amount of variety in your job Your job security There's not too much to be gained by sticking with this hospital indefinitely.
Often, I find it difficult to agree with this hospital's policies on important matters relating to its employees.
I really care about the fate of this hospital.
For me this is the best of all possible hospitals for which to work.
Deciding to work for this hospital was a definite mistake on my part.  I am a person who makes excuses for belonging to the nursing profession.
I am a person who feels held back by the nursing profession.
I am a person who considers the nursing profession to be important.
I am a person who criticizes the nursing profession.
I am a person who is glad to belong to the nursing profession.
I am a person who sees myself as belonging to the nursing profession.
I am a person who is annoyed to say that I am a member of the nursing profession.
I am a person who tries to hide belonging to the nursing profession.
I am a person who feels strong ties with other members of the nursing profession.  Only doctors should carry out physical assessment of patients e.g. listen to chest and heart sounds. 1 2 3 Health care assistants should only give basic nursing care designed to meet physical needs of patients like bathing, feeding, dressing and elimination. 1 2 3 Only staff nurses should give prescribed medications. 1 2 3 Doctors should be involved in drawing up standards and policies of care for nursing practice. 1 2 3 Documentation of nursing care is an important part of patient care for staff nurses. 1 2 3 When a hospitalised patient is dependant in feeding and elimination, a member of his/her family should stay with him/her and help provide this care.
Doctors should give an order about specific nursing care for their patients.
Staff nurses should supervise health care assistants.
Hospital administrators are responsible for the delivery of safe nursing care.
Doctors should supervise nursing practice and nurses should do what the doctors tell them.
Staff nurses have adequate knowledge about the action and side effects of the drugs prescribed for patients.
Senior nurses could teach valuable information to junior doctors.
Staff nurses can assess the patient's condition effectively and inform the doctor when required.
Doctors should tell patients their diagnosis (at first time).
Each nurse is herself/himself professionally responsible for how well-informed and safe her/his practice is.
Nurses can decide what nursing care is appropriate for their patients.
Health care assistants can fully cover the place of staff nurses in his/her absence.
All nursing staff should comfort and reassure patients.
Most staff nurses in your hospital are knowledgeable enough to carry out a physical examination.
The patient's family solely provides all the emotional support the patient needs.
Nurses should provide health education for patients.
Doctors should be responsible for teaching nurses.