10Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

RESEARCH PAPER

ABSTRACT

ObjectiveJob satisfaction among nurses working in five

general hospitals in Kuwait was analysed using aglobal scale based on the McClosky MuellerSatisfaction Scale (MMSS) in relation to selectedbackground characteristics (eg age gendernationality educational qualification monthly salaryand the departments in which they worked

Design The questionnaire was distributed to 500 nurses

using a stratified random sample The response ratewas 872

ResultsAge nationality and the department worked in had

a positive significant relationship with job satisfactionHowever a higher level of educational qualificationand previous work experience in other countriesshowed an inverse relationship with job satisfaction

ConclusionBased on our findings we recommend that

expatriate staff should be provided with anunderstanding of cultural differences and how to copewith them Special attention should be paid to thenorms regarding interaction among males and femalesand social interaction among professionals from theopposite gender Intensive courses in the languages tobe used in the care provision process should beprovided to impart requisite language competency

INTRODUCTIONuality of health care is a multi dimensionalphenomenon Job satisfaction among health careproviders is a crucial variable among thedeterminants of quality of health care A number

of studies have been undertaken internationally tomeasure job satisfaction among care providers and itsrelationship with quality of care

A number of studies have reported that employees whoare satisfied in their job tend to stay longer in the job(Hinshaw et al 1987 Taunton et al 1989 Tett and Meyer1993) Research also shows that employees who experiencejob satisfaction are more likely to be productive (Cohen andJosefowitz 1980 Likert and Katz 1979)

Job dissatisfaction on the other hand leads toabsenteeism tardiness grievances and increased turnoverand therefore results in higher employment costs(Hinshaw et al 1987 Tett and Meyer 1993 Lucas et al1993 Porter and Steers 1973 Seashore and Tabar 1995Weisman et al 1981 Price and Mueller 1981 Prestholdtet al 1988) Also job dissatisfaction decreases jobperformance and has a negative influence on the qualityof care (Brayfield and Crockett 1995 Petty et al 1984)

Butler and Parsons (1989) found adequate monetarycompensation and flexibility in work schedule to bepredictors of job satisfaction Cambey and Alexander(1998) in their study of public health nurses found thatparticipation in decision-making and formalisation oforganisational structure contributed to job satisfactionTonges et al (1998) found that interpersonal identity workrelated identity and autonomy were found to besignificant predictors of job satisfaction among nursesCronin and Becherer (1999) found functional verbalfeedback and meaningful recognition as satisfiers amongnurses Abu Ajmieh et al (1996) in their study ofPalestinian nurses reported timely feedback from

Makhdoom A Shah ScD is Chairman Department of HealthInformation Administration and Vice Dean (Academic Affairs)Faculty of Allied Health Sciences and Nursing KuwaitUniversity Kuwait

Naser Al-Enezi PhD is Assistant Professor Department ofHealth Information Administration and Vice Dean (StudentAffairs) Faculty of Allied Health Sciences and Nursing KuwaitUniversity Kuwait

Rafiq I Chowdhury MS is Senior Lecturer Department ofHealth Information Administration Faculty of Allied HealthSciences and Nursing Kuwait University Kuwait

Mohammed Al Otabi PhD is Assistant Professor Departmentof Nursing Faculty of Allied Health Sciences and NursingKuwait University Kuwait

Accepted for publication October 2003

ACKNOWLEDGEMENTSThe authors acknowledge the valuable contribution of Mathew Jacob FaisalHabib and Bashira Parkar in the preparation of this manuscript and thankStanley Glebocki for editorial assistance They are indebted to ProfessorNasra M Shah Department of Community Medicine and BehaviouralSciences Faculty of Medicine Kuwait University for her critique andvaluable input

DETERMINANTS OF JOB SATISFACTION AMONG NURSES IN KUWAIT

Key words job satisfaction global scale background characteristics neutral score

Q

Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

RESEARCH PAPER

11

supervisors and culturally relevant recognition assatisfiers Kangas et al (1999) reported that nurses whoperceived the organisational environment as supportivewere more satisfied Yamashita (1995) in a study of jobsatisfaction among Japanese nurses reported a positivecorrelation between age and years of experience andsatisfaction Agho (1993) found instrumentalcommunication and positive affectivity as majordeterminants of job satisfaction among nurses

The literature provides sufficient evidence to suggestthat when care givers are satisfied their patients are morelikely to be satisfied (Parrinello 1990 Shain 1990Weisman and Nathanson 1985) Research also shows thatnurses who are satisfied with their job have a higher levelof organisational commitment (Acorn et al 1997)

The role of a nurse as a member of the health careteam is of paramount importance in the preservation ofquality of care and patient satisfaction However it hasbeen reported that nurses work in an extremely stressfulenvironment (David et al 1996) Limited work has beenundertaken in Kuwait to measure nursesrsquo job satisfaction(Al-Kandari and Ogundeyin 1998 Al-Enezi 1998 Shahet al 2001) In one study from Kuwait Dalayon (1990)reported that nurses who work in a language andculturally diverse setting work under considerable stressAlso their performance can be affected adversely if theyare not satisfied with their job (Joey and Steven 1997)

BACKGROUNDKuwait is a small oil rich Arab-Muslim country of 22

million people only 35 of whom are Kuwaiti nationalsNon-Kuwaitis are comprised of persons of manynationalities from Arab as well as Asian countries Peoplefrom over 100 countries form the expatriate community(Public Authority on Civil Information 2000) About 90of all health care services are provided by the government(Vital and Health Statistics Division 2000 Naim et al1986) Kuwaiti nationals get all health care services freeof charge whereas expatriates have to pay a nominal fee

The country has a three-tier health care deliverysystem The entry point for accessing services is throughprimary health care centres (PHCs) There is one PHC forapproximately every 30000 people There are 70 generalhealth care centres 25 maternal care centres and 64 childcare centres Secondary care as well as emergency careare provided through five general hospitals Finally thereare 18 tertiary care hospitals and centres that providespecialised care (Vital and Health Statistics Division2000) Kuwaiti patients generally converse in Arabic Forhealth care provision however the Ministry of Health(MoH) relies heavily on expatriate human resources

Nursing care is provided by 8232 nurses of whom1496 (18) are males Nurses working in the MoH arefrom 35 countries Of the total nurses 997 (12) areKuwaitis Thus Kuwait has an acute shortage of nursesThe highest portion of nurses is from India (424)followed by Filipinos (156) Egyptians (139)Pakistanis (48) and Indonesians (30) A vastmajority of the Indian nurses and all of the Filipino nurses

are non-Muslims In addition to 121 Kuwaiti nurses195 are from 16 other Arabic speaking countries(Manpower Statistics 2000) Thus the nurse workforce inKuwait represents an enormous array of ethnic culturaland linguistic diversity

Conceptual framework for job satisfactionJob satisfaction is a complex phenomenon A number

of conceptual frameworks have been developed to explainits dynamics The human relations managementmovement of the 1940s focussed considerable attentionon this subject However Maslowrsquos classical work onmotivational theory has been a major influence on jobsatisfaction theory (Brunner 1989) Maslow believed thathumans are motivated and their behaviours aredetermined by unsatisfied needs In this regard heconsidered deficiency needs and growth needs Anotherlandmark contribution related to work satisfaction is thatof Herzberg et al (1959) His two-factor theorydifferentiates between motivation factors that influencejob satisfaction (achievement recognition work itselfresponsibility and growth) and hygiene factors(supervision physical working conditions interpersonalrelationships benefits management and job security)Pasternak (1988) in his work suggests that the Herzbergmodel in fact confirms Maslowrsquos theory

Abu Ajmieh et al (1996) propose that the work ofMaslow and Herzberg did not have sufficient supportfrom research and therefore their works are notconsidered as an lsquoall inclusiversquo job satisfaction theory In1990 Mueller and McCloskey tested a scale resulting in33 questions measuring McCloskeyrsquos three dimensions ofjob satisfaction A subsequent factor analysis of the 33items and a further refinement consisting of 31 itemsresulted in Mueller and McCloskeyrsquos identification ofeight sub-scales The instrument has been reported to behighly reliable with an internal consistency of 089(Mueller and McCloskey 1990) The findings from theWest Bank study from an Arab country and similar to thepresent study (Abu Ajmeih et al 1996) supported the useof the Mueller McCloskey scale in non-USA countriesand cultures However they suggested that somemodifications and refinements are needed in the MuellerMcCloskey scale to use in the different cultures

The Mueller McCloskey Satisfaction Scale (MMSS)provides a comprehensive method to study jobsatisfaction among nurses We therefore used it in Kuwaitwhich as a workplace as mentioned earlier represents anenormous array of ethnic cultural and linguisticdiversity

Research questionsThe study had three questions

i What was the level of job satisfaction using theMueller McCloskey Satisfaction Scale (MMSS)

ii What was the relationship between selectedbackground characteristics and MMSS

iii What are the predictors of job satisfaction among nurses

Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

RESEARCH PAPER

12

METHOD

SampleThe study population consisted of 3032 nurses

employed in the five general hospitals A stratifiedrandom sample of proportionate size for each hospitalwas used The initial sample size derived by using theformula for simple random sampling was 384 Afteradding the design effect for stratified random samplingthe sample size became 500 The questionnaire wasdistributed to the 500 randomly selected nurses inJanuary 1999 in the hospitals The respondents wererequested to drop the completed questionnaire in thedesignated box kept in each hospital At the end of thedata collection period a total of 436 completed self-administered questionnaires were returned yielding aresponse rate of 872 The anonymity of all respondentswas preserved In keeping with the standard researchprotocol necessary permission was obtained from theconcerned authorities of the Ministry of Health for datacollection

InstrumentFor the purpose of our study 21 items were selected

out of the 31 items of the Mueller McCloskey scale Tenitems that were not applicable to Kuwait were excludedThese pertain to benefit packages insurance part-timework child care facilities flexibility in scheduling andweekends off These privileges are not a part of theemployment benefits for nurses or for that matter forother care providers in Kuwait All health care providersin the MoH it may be noted are provided a standardsalary in keeping with academic qualifications andexperience Medical insurance is not needed because allemployees of the MoH are entitled to free medical careChild care and flexibility in scheduling weekends off arenot a part of the Kuwaiti administrative system

The eight subscales developed by Mueller McCloskyfrom 31 items were (i) extrinsic reward (ii) scheduling(iii) balance of family and work (iv) interaction with co-workers (v) interaction opportunities (vi) professionalopportunities (vii) praise and recognition and (viii)control and responsibility The range of scores for eachfactor varied according to the number of items includedand higher the score the higher the degree of jobsatisfaction Each item on the Mueller McCloskey scalewas measured on a five-point Likert scale which was alsoadopted in the present study The responses on the Likertscale ranged from 5 (very satisfied) to 1 (verydissatisfied)

The total possible minimum score for the subscale was21 and the maximum was 105 For the purpose ofanalysis a score to represent a lsquosatisfiedrsquo respondent wasneeded However Mueller McCloskey did not provide thedetermination of a lsquosatisfiedrsquo score We therefore used thefollowing procedure Considering that the neutral point onthe scale was lsquoneither satisfied nor dissatisfiedrsquo and had ascore of 3 and a score of 4 represented the lowest level of

Background Job Satisfaction Scale Characteristics

Table 1 Average and standard deviation (SD) on global scale byselected background characteristics (n=436)

Global Score Mean SD

686 135

Age (years)

Less than 30 659 131

30-39 695 137

40 and above 702 134

Gender

Male 674 134

Female 688 135

Nationality

Kuwaiti and Arabs 729 134

Indians 708 126

Filipinos 623 138

Others 676 122

Educational qualification

Diploma 716 126

Bachelor 630 134

Monthly salary

lt200 KD 708 128

200-300 KD 664 132

301+ KD 696 156

Departments

Casualty 6697 142

OR 682 99

Medical ward 707 133

Surgical ward 696 140

ICU 707 121

Paediatric ward 662 146

Maternity ward 679 125

Others 650 142

Where spouse lives

In Kuwait 709 132

Abroad 672 134

Experience in Kuwait

1-5 years 663 121

6-10 years 698 136

11-15 years 696 141

16+ years 704 148

Worked anywhere else

No 699 135

Yes 681 136

Significant at 5 level Significant at 1 level

Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

RESEARCH PAPER

13

being lsquosatisfiedrsquo a respondent who got an overall score of63 (21x3) was treated as neutral Therefore a total scoreof 64 was considered as the lowest level of satisfactionThe above conforms to the decisions of the studyundertaken by Cambey and Alexander (1998) Cronbachrsquosalpha (reliability coefficient) was used to determine theinternal consistency of the instrument The value of thealpha for the global scale in our study was 089 which isthe same as for the global scale in the Mueller andMcCloskeyrsquos 1990 study The construct validity wasassessed by factor analysis using factor loadings theseranged from 057 to 083 except one item which was 039

(compensation for work during holidays) Thequestionnaire was translated into Arabic and translatedback into English by an independent professional tocheck the validity

The background characteristics assessed in our studywere age sex nationality educational level monthlysalary place of work in terms of department within ahospital whether spouse lived in Kuwait years ofexperience in Kuwait and whether the respondent hadworked as a nurse in another country before undertakingthe job in Kuwait

Characteristics Coefficient Standarised coefficient Level of Significance

Age 4036 0212 0001

Sex

Male -0299 -0008 0869

Female 000 100

Educational qualification -5701 -0202 0002

Where spouse lives

In Kuwait 2321 0086 0112

Not in Kuwait 000 100

Monthly salary -0590 -0030 0632

Experience in Kuwait -1197 -0099 0158

Previous work experience in other country

Yes -2885 -0100 0041

No 000 100

Department working in

Casualty 0851 0017 0764

OR 0602 0010 0853

Medical ward 5314 0172 0014

Surgical ward 4839 0142 0032

ICU 5211 0118 0047

Paediatric ward 1512 0035 0559

Obs amp Gyn 3919 0082 0157

Others (endoscopy dental nephrology etc) 000 100

Nationality (Yes=1)

Kuwaiti amp other Arabs 5101 0142 0031

Indians 1492 0055 0463

Filipinos -2333 -0074 0332

Others (Europeans amp North Americans) 000 100

Constant 64785 0000

F- value 501 (plt001)

Adjusted R2 014

Significant at 5 level Significant at 1 level

Table 2 Multiple regression analysis of job satisfaction (dependent variable Overall job satisfaction) n=436

Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

RESEARCH PAPER

14

ANALYSISThe average for the global scale was 686 and the

standard deviation was 135 (see table 1) In terms of agerespondents in each of the three categories had an overallscore higher than the neutral score (ie 63) Respondentsaged above 30 were significantly more satisfied thanthose below 30 Regarding gender both male and femalenurses had an overall score slightly higher than theneutral score However there was no significantdifference between them With regard to nationalityKuwaitis and other Arabs were more satisfied followedby Indians while the Filipinos were not satisfied and thedifference was significant

Respondents who had a diploma were significantlymore satisfied than those who had a bachelors degreeThe overall score of diploma holders was much higherthan the neutral score while that of the bachelor degreeholders was equal to the neutral score

Regarding salary respondents in each of the threecategories had an overall score higher than the neutralscore However those who got a monthly salary of 200Kuwaiti Dinars or less were relatively more satisfiedcompared to the respondents in the other two categories

On place of work within a hospital the overall scorefor each setting was higher than the neutral scoreHowever the scores for respondents who worked inmedical wards surgical wards or ICU were relativelyhigher than those who worked in other wards

The respondents whose spouses lived in Kuwait weremore satisfied than those whose spouses lived abroadwith the overall score being higher than the neutral scorefor respondents in both categories The relationshipbetween the number of years of experience in Kuwait andsatisfaction showed that respondents who had worked forsix or more years were more satisfied However theoverall score for respondents in each of the four durationcategories was higher than the neutral score

Finally the overall scores of respondents who hadworked in a country other than Kuwait and those who hadnot were both higher than the neutral score

Multivariate analysisTo assess the relationship between those background

characteristics that had a significant association with thejob satisfaction we used multiple linear regression Theoverall job satisfaction score was used as the dependentvariable for which the scores ranged from 21 to 105

Dummy variables for each category were created fortwo categorical variables department where respondentworked and nationality For nationality lsquootherrsquo (includesEuropeans and North Americans) was treated as theomitted category while for department lsquoother departmentrsquo(includes endoscopy dental nephrology etc) was treatedas the omitted category

Table 2 presents the results of the multiple regressionanalysis The overall model was significant (F=501plt001) and the value of the adjusted R2 was 014 AgeKuwaiti nationality and working in a surgical departmentmedical department or ICU were found to be significantand showed a positive relationship with overall jobsatisfaction score However educational qualification andemployment in another country before taking up the jobin Kuwait showed a significant but inverse relationshipwith the overall job satisfaction The rest of theindependent variables were not significantly associatedwith job satisfaction

DISCUSSIONConsistent with previous research (Warr 1992) we

found that older nurses were more satisfied with theirjobs It appears that as professionals mature age-wise andgather more experience they tend to make a betteradjustment to the work environment when compared withyounger peers Also it is relatively more difficult forolder professionals in the Middle East to switch jobs andfind compatible positions elsewhere Further the age forretirement in most of the developing countries isrelatively low compared to that in developed countriesTherefore nurses who are aged 40 or over have extremelylimited job opportunities in their own countries shouldthey opt to return Finally the wages for the same orsimilar jobs in the countries or origin (Egypt Syria IndiaPhilippines Pakistan and Bangladesh) are much lowerthan those in the Gulf Cooperation Council (GCC)countries (Shah 1994) Besides older and experiencedpersons are accorded greater recognition by thesupervisors and administrators in the Arab culture andtherefore they tend to be more satisfied All of thesefactors result in a likely higher level of satisfaction amongolder nurses

Nurses with a diploma were found to have a higherlevel of satisfaction compared to bachelor degree holderssimilar to the results of a previous study (Cambey andAlexander 1998) An investigation into the salarystructure of nurses revealed that there is an insignificantdifference in the salary of those who have diploma asopposed to those who have a bachelor degree whichmight explain why diploma holders are comparativelymore satisfied Another possible reason for the finding isthat while bachelor degree holders receive compatiblesalaries in other countries in the region the diplomaholders get relatively higher salaries in Kuwait comparedto salaries offered elsewhere in the region

Nurses who had worked in another country beforecoming to Kuwait were less satisfied compared to thosewho had not worked elsewhere One plausibleexplanation for the finding is that nurses who had workedat some other place within the region have a point ofreference

RESEARCH PAPER

15Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

Nurses who worked on a medical ward a surgical wardor ICU were found to be more satisfied with their job withthose who worked in ICU being relatively less satisfiedThis finding is consistent with that of another study(Yamashita 1995) Our discussions with care providers inKuwait physicians and nurses alike revealed that nursestend to like those settings of work where they have agreater control over patient care and medical and surgicalwards offer such an opportunity Nurses who worked incasualty or emergency rooms (ER) for example had thelowest satisfaction score in our study Nurses reported thatthey did not like to work in those settings where there is ahigher pressure of work as is the case with emergencyroom (ER) services ER services have been found to beheavily overutilised in Kuwait (Shah and Shah 1992-93Shah et al 1994-95 Shah et al 1996 Shah et al 1997) Notriage system is followed and therefore some patients whoare not truly in need of emergency care are providedservices through ER thus resulting in a heavy burden onthe staff

Finally regarding nationality Kuwaitis and other Arabswere found to be more satisfied followed by Indians TheFilipino nurses were the least satisfied This may partly bebecause the official language in the MoH is Arabic and themajority of supervisors are either Kuwaitis or non-KuwaitiArabs Therefore the Arab employees tend to enjoy a betterrapport and working relationship with Arabic-speakingsupervisors and that results in a higher level of satisfactionamong them However this may also be due to their generalsatisfaction in life as they live in a culturally compatibleenvironment Indian nurses are relatively more satisfied thanFilipino nurses This may be because the Indian nursescome from relatively conservative cultures and have fewerproblems in adjusting to the conservative Kuwait culture(Shah 2000) Filipinos on the other hand besides havingdifficulty with the language also may have some difficultywith the culture The Philippines as a society is relativelymore open and where interaction among male and femalescontrary to the social norm in Kuwait is far morepermissible (Shah et al 2001)

CONCLUSIONIn summary the older nurses were more satisfied with

their job as were the nurses who held a diploma comparedto those who had a baccalaureate degree Experience ofworking in another country prior to Kuwait had a negativeeffect on satisfaction level Nurses were found to be moresatisfied in work settings in which they had greater controlover patient care Finally comprehension of Arabiclanguage and cultural compatibility emerged as facilitatorsof job satisfaction We therefore propose that the abovefactors be given due consideration in recruitment of nursesas members of the health care team Our findings havespecial relevance for health care services of those societieswhich recruit human resources from overseas

Specifically we recommend that societies with ashortage of nursing and other professional staff whilerecruiting expatriates should pay attention to the followingThrough a carefully planned orientation program theexpatriate staff may be provided with an understanding ofcultural differences and how to cope with them Specialattention should be paid to the norms regarding interactionamong males and females in general and social interactionamong professionals from opposite genders in particularFor instance it is customary in the western culture to shakehand with colleagues But in the Islamic culture if a persontries to shake hands with a colleague of the oppositegender it is frowned upon and in some cases it is shunnedSimilarly in conference rooms lecture theatres andcafeterias it is a common norm among conservativecultures that males and females should not intermingleWith regard to language barriers it is recommended thatstaff should be provided with intensive courses in thelanguage to be used in the care provision processLanguage cannot be learnt through short on-the-jobexperiences as has generally been the way in Kuwait andother Gulf countries

REFERENCESAbu Ajamieh AR Misener T Haddock KS and Gleaton JU 1996 Jobsatisfaction correlates among Palestinian nurses in the West Bank InternationalJournal of Nursing Studies 33422-32

Acorn S Ratner PA and Crawford M 1997 Decentralization as a determinantof autonomy job satisfaction and organizational commitment among nursemanagers Nursing Research 46(1)52-57

Agho AO 1993 The moderating effects of dispositional affectivity onrelationships between job characteristics and nursesrsquo job satisfaction Research inNursing and Health 16451-458

Al-Enezi N 1998 An analytical study of job satisfaction among healthprofessionals in Kuwaiti hospitals PhD Thesis Institute of Health Care StudiesUniversity of Wales UK

Al-Kandari FA and Ogundeyin W 1998 Patients and nursesrsquo perceptions ofthe quality of nursing care in Kuwait Journal of Advanced Nursing 27914-921

Brayfield AH and Crockett WH 1995 Employee attitudes and employeeperformance Psychological Bulletin 52396-424

Brunner KB 1989 Perceived professionalism and job satisfaction of RRA medicalrecord department directors Topics in Health Record Management 10(1)51-8

Butler J and Pearson RJ 1989 Hospital perceptions of job satisfactionNursing Management 20(8)45-48

Cambey DA and Alexander JW 1998 The relationship of job satisfaction withorganizational variables in public health nursing Journal of NursingAdministration 28(5)39-46

Cohen AR and Josefowitz N 1980 Effective behavior in organizationsHomewood IL Richard D Irwin

Cronin SN and Becherer D 1999 Recognition of staff nurse job performanceand achievements Staff and manager perceptions Journal of NursingAdministration 29(1)26-31

Dalayon A 1990 Nursing in Kuwait Problems and prospects NursingManagement 21(9)129-134

David P Sonia J Elizabeth K George S Paul B and Graham T 1996Mental health lsquoburnoutrsquo and job satisfaction among hospital and community-based mental health staff British Journal of Psychiatry 169334-337

Herzberg F Mausner B and Snyderman BB 1959 The motivation to workNew York Wiley

Hinshaw AS Smeltzer CH and Atwood JR 1987 Innovative retentionstrategies for nursing staff Journal of Nursing Administration 19(4)15-19

Joey SB and Steven BD 1997 Job satisfaction reported by AS BS degreeradiographers Radiologic Technology 69(1)62-66

Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

RESEARCH PAPER

11

supervisors and culturally relevant recognition assatisfiers Kangas et al (1999) reported that nurses whoperceived the organisational environment as supportivewere more satisfied Yamashita (1995) in a study of jobsatisfaction among Japanese nurses reported a positivecorrelation between age and years of experience andsatisfaction Agho (1993) found instrumentalcommunication and positive affectivity as majordeterminants of job satisfaction among nurses

The literature provides sufficient evidence to suggestthat when care givers are satisfied their patients are morelikely to be satisfied (Parrinello 1990 Shain 1990Weisman and Nathanson 1985) Research also shows thatnurses who are satisfied with their job have a higher levelof organisational commitment (Acorn et al 1997)

The role of a nurse as a member of the health careteam is of paramount importance in the preservation ofquality of care and patient satisfaction However it hasbeen reported that nurses work in an extremely stressfulenvironment (David et al 1996) Limited work has beenundertaken in Kuwait to measure nursesrsquo job satisfaction(Al-Kandari and Ogundeyin 1998 Al-Enezi 1998 Shahet al 2001) In one study from Kuwait Dalayon (1990)reported that nurses who work in a language andculturally diverse setting work under considerable stressAlso their performance can be affected adversely if theyare not satisfied with their job (Joey and Steven 1997)

BACKGROUNDKuwait is a small oil rich Arab-Muslim country of 22

million people only 35 of whom are Kuwaiti nationalsNon-Kuwaitis are comprised of persons of manynationalities from Arab as well as Asian countries Peoplefrom over 100 countries form the expatriate community(Public Authority on Civil Information 2000) About 90of all health care services are provided by the government(Vital and Health Statistics Division 2000 Naim et al1986) Kuwaiti nationals get all health care services freeof charge whereas expatriates have to pay a nominal fee

The country has a three-tier health care deliverysystem The entry point for accessing services is throughprimary health care centres (PHCs) There is one PHC forapproximately every 30000 people There are 70 generalhealth care centres 25 maternal care centres and 64 childcare centres Secondary care as well as emergency careare provided through five general hospitals Finally thereare 18 tertiary care hospitals and centres that providespecialised care (Vital and Health Statistics Division2000) Kuwaiti patients generally converse in Arabic Forhealth care provision however the Ministry of Health(MoH) relies heavily on expatriate human resources

Nursing care is provided by 8232 nurses of whom1496 (18) are males Nurses working in the MoH arefrom 35 countries Of the total nurses 997 (12) areKuwaitis Thus Kuwait has an acute shortage of nursesThe highest portion of nurses is from India (424)followed by Filipinos (156) Egyptians (139)Pakistanis (48) and Indonesians (30) A vastmajority of the Indian nurses and all of the Filipino nurses

are non-Muslims In addition to 121 Kuwaiti nurses195 are from 16 other Arabic speaking countries(Manpower Statistics 2000) Thus the nurse workforce inKuwait represents an enormous array of ethnic culturaland linguistic diversity

Conceptual framework for job satisfactionJob satisfaction is a complex phenomenon A number

of conceptual frameworks have been developed to explainits dynamics The human relations managementmovement of the 1940s focussed considerable attentionon this subject However Maslowrsquos classical work onmotivational theory has been a major influence on jobsatisfaction theory (Brunner 1989) Maslow believed thathumans are motivated and their behaviours aredetermined by unsatisfied needs In this regard heconsidered deficiency needs and growth needs Anotherlandmark contribution related to work satisfaction is thatof Herzberg et al (1959) His two-factor theorydifferentiates between motivation factors that influencejob satisfaction (achievement recognition work itselfresponsibility and growth) and hygiene factors(supervision physical working conditions interpersonalrelationships benefits management and job security)Pasternak (1988) in his work suggests that the Herzbergmodel in fact confirms Maslowrsquos theory

Abu Ajmieh et al (1996) propose that the work ofMaslow and Herzberg did not have sufficient supportfrom research and therefore their works are notconsidered as an lsquoall inclusiversquo job satisfaction theory In1990 Mueller and McCloskey tested a scale resulting in33 questions measuring McCloskeyrsquos three dimensions ofjob satisfaction A subsequent factor analysis of the 33items and a further refinement consisting of 31 itemsresulted in Mueller and McCloskeyrsquos identification ofeight sub-scales The instrument has been reported to behighly reliable with an internal consistency of 089(Mueller and McCloskey 1990) The findings from theWest Bank study from an Arab country and similar to thepresent study (Abu Ajmeih et al 1996) supported the useof the Mueller McCloskey scale in non-USA countriesand cultures However they suggested that somemodifications and refinements are needed in the MuellerMcCloskey scale to use in the different cultures

The Mueller McCloskey Satisfaction Scale (MMSS)provides a comprehensive method to study jobsatisfaction among nurses We therefore used it in Kuwaitwhich as a workplace as mentioned earlier represents anenormous array of ethnic cultural and linguisticdiversity

Research questionsThe study had three questions

i What was the level of job satisfaction using theMueller McCloskey Satisfaction Scale (MMSS)

ii What was the relationship between selectedbackground characteristics and MMSS

iii What are the predictors of job satisfaction among nurses

Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

RESEARCH PAPER

12

METHOD

SampleThe study population consisted of 3032 nurses

employed in the five general hospitals A stratifiedrandom sample of proportionate size for each hospitalwas used The initial sample size derived by using theformula for simple random sampling was 384 Afteradding the design effect for stratified random samplingthe sample size became 500 The questionnaire wasdistributed to the 500 randomly selected nurses inJanuary 1999 in the hospitals The respondents wererequested to drop the completed questionnaire in thedesignated box kept in each hospital At the end of thedata collection period a total of 436 completed self-administered questionnaires were returned yielding aresponse rate of 872 The anonymity of all respondentswas preserved In keeping with the standard researchprotocol necessary permission was obtained from theconcerned authorities of the Ministry of Health for datacollection

InstrumentFor the purpose of our study 21 items were selected

out of the 31 items of the Mueller McCloskey scale Tenitems that were not applicable to Kuwait were excludedThese pertain to benefit packages insurance part-timework child care facilities flexibility in scheduling andweekends off These privileges are not a part of theemployment benefits for nurses or for that matter forother care providers in Kuwait All health care providersin the MoH it may be noted are provided a standardsalary in keeping with academic qualifications andexperience Medical insurance is not needed because allemployees of the MoH are entitled to free medical careChild care and flexibility in scheduling weekends off arenot a part of the Kuwaiti administrative system

The eight subscales developed by Mueller McCloskyfrom 31 items were (i) extrinsic reward (ii) scheduling(iii) balance of family and work (iv) interaction with co-workers (v) interaction opportunities (vi) professionalopportunities (vii) praise and recognition and (viii)control and responsibility The range of scores for eachfactor varied according to the number of items includedand higher the score the higher the degree of jobsatisfaction Each item on the Mueller McCloskey scalewas measured on a five-point Likert scale which was alsoadopted in the present study The responses on the Likertscale ranged from 5 (very satisfied) to 1 (verydissatisfied)

The total possible minimum score for the subscale was21 and the maximum was 105 For the purpose ofanalysis a score to represent a lsquosatisfiedrsquo respondent wasneeded However Mueller McCloskey did not provide thedetermination of a lsquosatisfiedrsquo score We therefore used thefollowing procedure Considering that the neutral point onthe scale was lsquoneither satisfied nor dissatisfiedrsquo and had ascore of 3 and a score of 4 represented the lowest level of

Background Job Satisfaction Scale Characteristics

Table 1 Average and standard deviation (SD) on global scale byselected background characteristics (n=436)

Global Score Mean SD

686 135

Age (years)

Less than 30 659 131

30-39 695 137

40 and above 702 134

Gender

Male 674 134

Female 688 135

Nationality

Kuwaiti and Arabs 729 134

Indians 708 126

Filipinos 623 138

Others 676 122

Educational qualification

Diploma 716 126

Bachelor 630 134

Monthly salary

lt200 KD 708 128

200-300 KD 664 132

301+ KD 696 156

Departments

Casualty 6697 142

OR 682 99

Medical ward 707 133

Surgical ward 696 140

ICU 707 121

Paediatric ward 662 146

Maternity ward 679 125

Others 650 142

Where spouse lives

In Kuwait 709 132

Abroad 672 134

Experience in Kuwait

1-5 years 663 121

6-10 years 698 136

11-15 years 696 141

16+ years 704 148

Worked anywhere else

No 699 135

Yes 681 136

Significant at 5 level Significant at 1 level

Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

RESEARCH PAPER

13

being lsquosatisfiedrsquo a respondent who got an overall score of63 (21x3) was treated as neutral Therefore a total scoreof 64 was considered as the lowest level of satisfactionThe above conforms to the decisions of the studyundertaken by Cambey and Alexander (1998) Cronbachrsquosalpha (reliability coefficient) was used to determine theinternal consistency of the instrument The value of thealpha for the global scale in our study was 089 which isthe same as for the global scale in the Mueller andMcCloskeyrsquos 1990 study The construct validity wasassessed by factor analysis using factor loadings theseranged from 057 to 083 except one item which was 039

(compensation for work during holidays) Thequestionnaire was translated into Arabic and translatedback into English by an independent professional tocheck the validity

The background characteristics assessed in our studywere age sex nationality educational level monthlysalary place of work in terms of department within ahospital whether spouse lived in Kuwait years ofexperience in Kuwait and whether the respondent hadworked as a nurse in another country before undertakingthe job in Kuwait

Characteristics Coefficient Standarised coefficient Level of Significance

Age 4036 0212 0001

Sex

Male -0299 -0008 0869

Female 000 100

Educational qualification -5701 -0202 0002

Where spouse lives

In Kuwait 2321 0086 0112

Not in Kuwait 000 100

Monthly salary -0590 -0030 0632

Experience in Kuwait -1197 -0099 0158

Previous work experience in other country

Yes -2885 -0100 0041

No 000 100

Department working in

Casualty 0851 0017 0764

OR 0602 0010 0853

Medical ward 5314 0172 0014

Surgical ward 4839 0142 0032

ICU 5211 0118 0047

Paediatric ward 1512 0035 0559

Obs amp Gyn 3919 0082 0157

Others (endoscopy dental nephrology etc) 000 100

Nationality (Yes=1)

Kuwaiti amp other Arabs 5101 0142 0031

Indians 1492 0055 0463

Filipinos -2333 -0074 0332

Others (Europeans amp North Americans) 000 100

Constant 64785 0000

F- value 501 (plt001)

Adjusted R2 014

Significant at 5 level Significant at 1 level

Table 2 Multiple regression analysis of job satisfaction (dependent variable Overall job satisfaction) n=436

Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

RESEARCH PAPER

14

ANALYSISThe average for the global scale was 686 and the

standard deviation was 135 (see table 1) In terms of agerespondents in each of the three categories had an overallscore higher than the neutral score (ie 63) Respondentsaged above 30 were significantly more satisfied thanthose below 30 Regarding gender both male and femalenurses had an overall score slightly higher than theneutral score However there was no significantdifference between them With regard to nationalityKuwaitis and other Arabs were more satisfied followedby Indians while the Filipinos were not satisfied and thedifference was significant

Respondents who had a diploma were significantlymore satisfied than those who had a bachelors degreeThe overall score of diploma holders was much higherthan the neutral score while that of the bachelor degreeholders was equal to the neutral score

Regarding salary respondents in each of the threecategories had an overall score higher than the neutralscore However those who got a monthly salary of 200Kuwaiti Dinars or less were relatively more satisfiedcompared to the respondents in the other two categories

On place of work within a hospital the overall scorefor each setting was higher than the neutral scoreHowever the scores for respondents who worked inmedical wards surgical wards or ICU were relativelyhigher than those who worked in other wards

The respondents whose spouses lived in Kuwait weremore satisfied than those whose spouses lived abroadwith the overall score being higher than the neutral scorefor respondents in both categories The relationshipbetween the number of years of experience in Kuwait andsatisfaction showed that respondents who had worked forsix or more years were more satisfied However theoverall score for respondents in each of the four durationcategories was higher than the neutral score

Finally the overall scores of respondents who hadworked in a country other than Kuwait and those who hadnot were both higher than the neutral score

Multivariate analysisTo assess the relationship between those background

characteristics that had a significant association with thejob satisfaction we used multiple linear regression Theoverall job satisfaction score was used as the dependentvariable for which the scores ranged from 21 to 105

Dummy variables for each category were created fortwo categorical variables department where respondentworked and nationality For nationality lsquootherrsquo (includesEuropeans and North Americans) was treated as theomitted category while for department lsquoother departmentrsquo(includes endoscopy dental nephrology etc) was treatedas the omitted category

Table 2 presents the results of the multiple regressionanalysis The overall model was significant (F=501plt001) and the value of the adjusted R2 was 014 AgeKuwaiti nationality and working in a surgical departmentmedical department or ICU were found to be significantand showed a positive relationship with overall jobsatisfaction score However educational qualification andemployment in another country before taking up the jobin Kuwait showed a significant but inverse relationshipwith the overall job satisfaction The rest of theindependent variables were not significantly associatedwith job satisfaction

DISCUSSIONConsistent with previous research (Warr 1992) we

found that older nurses were more satisfied with theirjobs It appears that as professionals mature age-wise andgather more experience they tend to make a betteradjustment to the work environment when compared withyounger peers Also it is relatively more difficult forolder professionals in the Middle East to switch jobs andfind compatible positions elsewhere Further the age forretirement in most of the developing countries isrelatively low compared to that in developed countriesTherefore nurses who are aged 40 or over have extremelylimited job opportunities in their own countries shouldthey opt to return Finally the wages for the same orsimilar jobs in the countries or origin (Egypt Syria IndiaPhilippines Pakistan and Bangladesh) are much lowerthan those in the Gulf Cooperation Council (GCC)countries (Shah 1994) Besides older and experiencedpersons are accorded greater recognition by thesupervisors and administrators in the Arab culture andtherefore they tend to be more satisfied All of thesefactors result in a likely higher level of satisfaction amongolder nurses

Nurses with a diploma were found to have a higherlevel of satisfaction compared to bachelor degree holderssimilar to the results of a previous study (Cambey andAlexander 1998) An investigation into the salarystructure of nurses revealed that there is an insignificantdifference in the salary of those who have diploma asopposed to those who have a bachelor degree whichmight explain why diploma holders are comparativelymore satisfied Another possible reason for the finding isthat while bachelor degree holders receive compatiblesalaries in other countries in the region the diplomaholders get relatively higher salaries in Kuwait comparedto salaries offered elsewhere in the region

Nurses who had worked in another country beforecoming to Kuwait were less satisfied compared to thosewho had not worked elsewhere One plausibleexplanation for the finding is that nurses who had workedat some other place within the region have a point ofreference

RESEARCH PAPER

15Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

Nurses who worked on a medical ward a surgical wardor ICU were found to be more satisfied with their job withthose who worked in ICU being relatively less satisfiedThis finding is consistent with that of another study(Yamashita 1995) Our discussions with care providers inKuwait physicians and nurses alike revealed that nursestend to like those settings of work where they have agreater control over patient care and medical and surgicalwards offer such an opportunity Nurses who worked incasualty or emergency rooms (ER) for example had thelowest satisfaction score in our study Nurses reported thatthey did not like to work in those settings where there is ahigher pressure of work as is the case with emergencyroom (ER) services ER services have been found to beheavily overutilised in Kuwait (Shah and Shah 1992-93Shah et al 1994-95 Shah et al 1996 Shah et al 1997) Notriage system is followed and therefore some patients whoare not truly in need of emergency care are providedservices through ER thus resulting in a heavy burden onthe staff

Finally regarding nationality Kuwaitis and other Arabswere found to be more satisfied followed by Indians TheFilipino nurses were the least satisfied This may partly bebecause the official language in the MoH is Arabic and themajority of supervisors are either Kuwaitis or non-KuwaitiArabs Therefore the Arab employees tend to enjoy a betterrapport and working relationship with Arabic-speakingsupervisors and that results in a higher level of satisfactionamong them However this may also be due to their generalsatisfaction in life as they live in a culturally compatibleenvironment Indian nurses are relatively more satisfied thanFilipino nurses This may be because the Indian nursescome from relatively conservative cultures and have fewerproblems in adjusting to the conservative Kuwait culture(Shah 2000) Filipinos on the other hand besides havingdifficulty with the language also may have some difficultywith the culture The Philippines as a society is relativelymore open and where interaction among male and femalescontrary to the social norm in Kuwait is far morepermissible (Shah et al 2001)

CONCLUSIONIn summary the older nurses were more satisfied with

their job as were the nurses who held a diploma comparedto those who had a baccalaureate degree Experience ofworking in another country prior to Kuwait had a negativeeffect on satisfaction level Nurses were found to be moresatisfied in work settings in which they had greater controlover patient care Finally comprehension of Arabiclanguage and cultural compatibility emerged as facilitatorsof job satisfaction We therefore propose that the abovefactors be given due consideration in recruitment of nursesas members of the health care team Our findings havespecial relevance for health care services of those societieswhich recruit human resources from overseas

Specifically we recommend that societies with ashortage of nursing and other professional staff whilerecruiting expatriates should pay attention to the followingThrough a carefully planned orientation program theexpatriate staff may be provided with an understanding ofcultural differences and how to cope with them Specialattention should be paid to the norms regarding interactionamong males and females in general and social interactionamong professionals from opposite genders in particularFor instance it is customary in the western culture to shakehand with colleagues But in the Islamic culture if a persontries to shake hands with a colleague of the oppositegender it is frowned upon and in some cases it is shunnedSimilarly in conference rooms lecture theatres andcafeterias it is a common norm among conservativecultures that males and females should not intermingleWith regard to language barriers it is recommended thatstaff should be provided with intensive courses in thelanguage to be used in the care provision processLanguage cannot be learnt through short on-the-jobexperiences as has generally been the way in Kuwait andother Gulf countries

REFERENCESAbu Ajamieh AR Misener T Haddock KS and Gleaton JU 1996 Jobsatisfaction correlates among Palestinian nurses in the West Bank InternationalJournal of Nursing Studies 33422-32

Acorn S Ratner PA and Crawford M 1997 Decentralization as a determinantof autonomy job satisfaction and organizational commitment among nursemanagers Nursing Research 46(1)52-57

Agho AO 1993 The moderating effects of dispositional affectivity onrelationships between job characteristics and nursesrsquo job satisfaction Research inNursing and Health 16451-458

Al-Enezi N 1998 An analytical study of job satisfaction among healthprofessionals in Kuwaiti hospitals PhD Thesis Institute of Health Care StudiesUniversity of Wales UK

Al-Kandari FA and Ogundeyin W 1998 Patients and nursesrsquo perceptions ofthe quality of nursing care in Kuwait Journal of Advanced Nursing 27914-921

Brayfield AH and Crockett WH 1995 Employee attitudes and employeeperformance Psychological Bulletin 52396-424

Brunner KB 1989 Perceived professionalism and job satisfaction of RRA medicalrecord department directors Topics in Health Record Management 10(1)51-8

Butler J and Pearson RJ 1989 Hospital perceptions of job satisfactionNursing Management 20(8)45-48

Cambey DA and Alexander JW 1998 The relationship of job satisfaction withorganizational variables in public health nursing Journal of NursingAdministration 28(5)39-46

Cohen AR and Josefowitz N 1980 Effective behavior in organizationsHomewood IL Richard D Irwin

Cronin SN and Becherer D 1999 Recognition of staff nurse job performanceand achievements Staff and manager perceptions Journal of NursingAdministration 29(1)26-31

Dalayon A 1990 Nursing in Kuwait Problems and prospects NursingManagement 21(9)129-134

David P Sonia J Elizabeth K George S Paul B and Graham T 1996Mental health lsquoburnoutrsquo and job satisfaction among hospital and community-based mental health staff British Journal of Psychiatry 169334-337

Herzberg F Mausner B and Snyderman BB 1959 The motivation to workNew York Wiley

Hinshaw AS Smeltzer CH and Atwood JR 1987 Innovative retentionstrategies for nursing staff Journal of Nursing Administration 19(4)15-19

Joey SB and Steven BD 1997 Job satisfaction reported by AS BS degreeradiographers Radiologic Technology 69(1)62-66

Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

RESEARCH PAPER

12

METHOD

SampleThe study population consisted of 3032 nurses

employed in the five general hospitals A stratifiedrandom sample of proportionate size for each hospitalwas used The initial sample size derived by using theformula for simple random sampling was 384 Afteradding the design effect for stratified random samplingthe sample size became 500 The questionnaire wasdistributed to the 500 randomly selected nurses inJanuary 1999 in the hospitals The respondents wererequested to drop the completed questionnaire in thedesignated box kept in each hospital At the end of thedata collection period a total of 436 completed self-administered questionnaires were returned yielding aresponse rate of 872 The anonymity of all respondentswas preserved In keeping with the standard researchprotocol necessary permission was obtained from theconcerned authorities of the Ministry of Health for datacollection

InstrumentFor the purpose of our study 21 items were selected

out of the 31 items of the Mueller McCloskey scale Tenitems that were not applicable to Kuwait were excludedThese pertain to benefit packages insurance part-timework child care facilities flexibility in scheduling andweekends off These privileges are not a part of theemployment benefits for nurses or for that matter forother care providers in Kuwait All health care providersin the MoH it may be noted are provided a standardsalary in keeping with academic qualifications andexperience Medical insurance is not needed because allemployees of the MoH are entitled to free medical careChild care and flexibility in scheduling weekends off arenot a part of the Kuwaiti administrative system

The eight subscales developed by Mueller McCloskyfrom 31 items were (i) extrinsic reward (ii) scheduling(iii) balance of family and work (iv) interaction with co-workers (v) interaction opportunities (vi) professionalopportunities (vii) praise and recognition and (viii)control and responsibility The range of scores for eachfactor varied according to the number of items includedand higher the score the higher the degree of jobsatisfaction Each item on the Mueller McCloskey scalewas measured on a five-point Likert scale which was alsoadopted in the present study The responses on the Likertscale ranged from 5 (very satisfied) to 1 (verydissatisfied)

The total possible minimum score for the subscale was21 and the maximum was 105 For the purpose ofanalysis a score to represent a lsquosatisfiedrsquo respondent wasneeded However Mueller McCloskey did not provide thedetermination of a lsquosatisfiedrsquo score We therefore used thefollowing procedure Considering that the neutral point onthe scale was lsquoneither satisfied nor dissatisfiedrsquo and had ascore of 3 and a score of 4 represented the lowest level of

Background Job Satisfaction Scale Characteristics

Table 1 Average and standard deviation (SD) on global scale byselected background characteristics (n=436)

Global Score Mean SD

686 135

Age (years)

Less than 30 659 131

30-39 695 137

40 and above 702 134

Gender

Male 674 134

Female 688 135

Nationality

Kuwaiti and Arabs 729 134

Indians 708 126

Filipinos 623 138

Others 676 122

Educational qualification

Diploma 716 126

Bachelor 630 134

Monthly salary

lt200 KD 708 128

200-300 KD 664 132

301+ KD 696 156

Departments

Casualty 6697 142

OR 682 99

Medical ward 707 133

Surgical ward 696 140

ICU 707 121

Paediatric ward 662 146

Maternity ward 679 125

Others 650 142

Where spouse lives

In Kuwait 709 132

Abroad 672 134

Experience in Kuwait

1-5 years 663 121

6-10 years 698 136

11-15 years 696 141

16+ years 704 148

Worked anywhere else

No 699 135

Yes 681 136

Significant at 5 level Significant at 1 level

Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

RESEARCH PAPER

13

being lsquosatisfiedrsquo a respondent who got an overall score of63 (21x3) was treated as neutral Therefore a total scoreof 64 was considered as the lowest level of satisfactionThe above conforms to the decisions of the studyundertaken by Cambey and Alexander (1998) Cronbachrsquosalpha (reliability coefficient) was used to determine theinternal consistency of the instrument The value of thealpha for the global scale in our study was 089 which isthe same as for the global scale in the Mueller andMcCloskeyrsquos 1990 study The construct validity wasassessed by factor analysis using factor loadings theseranged from 057 to 083 except one item which was 039

(compensation for work during holidays) Thequestionnaire was translated into Arabic and translatedback into English by an independent professional tocheck the validity

The background characteristics assessed in our studywere age sex nationality educational level monthlysalary place of work in terms of department within ahospital whether spouse lived in Kuwait years ofexperience in Kuwait and whether the respondent hadworked as a nurse in another country before undertakingthe job in Kuwait

Characteristics Coefficient Standarised coefficient Level of Significance

Age 4036 0212 0001

Sex

Male -0299 -0008 0869

Female 000 100

Educational qualification -5701 -0202 0002

Where spouse lives

In Kuwait 2321 0086 0112

Not in Kuwait 000 100

Monthly salary -0590 -0030 0632

Experience in Kuwait -1197 -0099 0158

Previous work experience in other country

Yes -2885 -0100 0041

No 000 100

Department working in

Casualty 0851 0017 0764

OR 0602 0010 0853

Medical ward 5314 0172 0014

Surgical ward 4839 0142 0032

ICU 5211 0118 0047

Paediatric ward 1512 0035 0559

Obs amp Gyn 3919 0082 0157

Others (endoscopy dental nephrology etc) 000 100

Nationality (Yes=1)

Kuwaiti amp other Arabs 5101 0142 0031

Indians 1492 0055 0463

Filipinos -2333 -0074 0332

Others (Europeans amp North Americans) 000 100

Constant 64785 0000

F- value 501 (plt001)

Adjusted R2 014

Significant at 5 level Significant at 1 level

Table 2 Multiple regression analysis of job satisfaction (dependent variable Overall job satisfaction) n=436

Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

RESEARCH PAPER

14

ANALYSISThe average for the global scale was 686 and the

standard deviation was 135 (see table 1) In terms of agerespondents in each of the three categories had an overallscore higher than the neutral score (ie 63) Respondentsaged above 30 were significantly more satisfied thanthose below 30 Regarding gender both male and femalenurses had an overall score slightly higher than theneutral score However there was no significantdifference between them With regard to nationalityKuwaitis and other Arabs were more satisfied followedby Indians while the Filipinos were not satisfied and thedifference was significant

Respondents who had a diploma were significantlymore satisfied than those who had a bachelors degreeThe overall score of diploma holders was much higherthan the neutral score while that of the bachelor degreeholders was equal to the neutral score

Regarding salary respondents in each of the threecategories had an overall score higher than the neutralscore However those who got a monthly salary of 200Kuwaiti Dinars or less were relatively more satisfiedcompared to the respondents in the other two categories

On place of work within a hospital the overall scorefor each setting was higher than the neutral scoreHowever the scores for respondents who worked inmedical wards surgical wards or ICU were relativelyhigher than those who worked in other wards

The respondents whose spouses lived in Kuwait weremore satisfied than those whose spouses lived abroadwith the overall score being higher than the neutral scorefor respondents in both categories The relationshipbetween the number of years of experience in Kuwait andsatisfaction showed that respondents who had worked forsix or more years were more satisfied However theoverall score for respondents in each of the four durationcategories was higher than the neutral score

Finally the overall scores of respondents who hadworked in a country other than Kuwait and those who hadnot were both higher than the neutral score

Multivariate analysisTo assess the relationship between those background

characteristics that had a significant association with thejob satisfaction we used multiple linear regression Theoverall job satisfaction score was used as the dependentvariable for which the scores ranged from 21 to 105

Dummy variables for each category were created fortwo categorical variables department where respondentworked and nationality For nationality lsquootherrsquo (includesEuropeans and North Americans) was treated as theomitted category while for department lsquoother departmentrsquo(includes endoscopy dental nephrology etc) was treatedas the omitted category

Table 2 presents the results of the multiple regressionanalysis The overall model was significant (F=501plt001) and the value of the adjusted R2 was 014 AgeKuwaiti nationality and working in a surgical departmentmedical department or ICU were found to be significantand showed a positive relationship with overall jobsatisfaction score However educational qualification andemployment in another country before taking up the jobin Kuwait showed a significant but inverse relationshipwith the overall job satisfaction The rest of theindependent variables were not significantly associatedwith job satisfaction

DISCUSSIONConsistent with previous research (Warr 1992) we

found that older nurses were more satisfied with theirjobs It appears that as professionals mature age-wise andgather more experience they tend to make a betteradjustment to the work environment when compared withyounger peers Also it is relatively more difficult forolder professionals in the Middle East to switch jobs andfind compatible positions elsewhere Further the age forretirement in most of the developing countries isrelatively low compared to that in developed countriesTherefore nurses who are aged 40 or over have extremelylimited job opportunities in their own countries shouldthey opt to return Finally the wages for the same orsimilar jobs in the countries or origin (Egypt Syria IndiaPhilippines Pakistan and Bangladesh) are much lowerthan those in the Gulf Cooperation Council (GCC)countries (Shah 1994) Besides older and experiencedpersons are accorded greater recognition by thesupervisors and administrators in the Arab culture andtherefore they tend to be more satisfied All of thesefactors result in a likely higher level of satisfaction amongolder nurses

Nurses with a diploma were found to have a higherlevel of satisfaction compared to bachelor degree holderssimilar to the results of a previous study (Cambey andAlexander 1998) An investigation into the salarystructure of nurses revealed that there is an insignificantdifference in the salary of those who have diploma asopposed to those who have a bachelor degree whichmight explain why diploma holders are comparativelymore satisfied Another possible reason for the finding isthat while bachelor degree holders receive compatiblesalaries in other countries in the region the diplomaholders get relatively higher salaries in Kuwait comparedto salaries offered elsewhere in the region

Nurses who had worked in another country beforecoming to Kuwait were less satisfied compared to thosewho had not worked elsewhere One plausibleexplanation for the finding is that nurses who had workedat some other place within the region have a point ofreference

RESEARCH PAPER

15Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

Nurses who worked on a medical ward a surgical wardor ICU were found to be more satisfied with their job withthose who worked in ICU being relatively less satisfiedThis finding is consistent with that of another study(Yamashita 1995) Our discussions with care providers inKuwait physicians and nurses alike revealed that nursestend to like those settings of work where they have agreater control over patient care and medical and surgicalwards offer such an opportunity Nurses who worked incasualty or emergency rooms (ER) for example had thelowest satisfaction score in our study Nurses reported thatthey did not like to work in those settings where there is ahigher pressure of work as is the case with emergencyroom (ER) services ER services have been found to beheavily overutilised in Kuwait (Shah and Shah 1992-93Shah et al 1994-95 Shah et al 1996 Shah et al 1997) Notriage system is followed and therefore some patients whoare not truly in need of emergency care are providedservices through ER thus resulting in a heavy burden onthe staff

Finally regarding nationality Kuwaitis and other Arabswere found to be more satisfied followed by Indians TheFilipino nurses were the least satisfied This may partly bebecause the official language in the MoH is Arabic and themajority of supervisors are either Kuwaitis or non-KuwaitiArabs Therefore the Arab employees tend to enjoy a betterrapport and working relationship with Arabic-speakingsupervisors and that results in a higher level of satisfactionamong them However this may also be due to their generalsatisfaction in life as they live in a culturally compatibleenvironment Indian nurses are relatively more satisfied thanFilipino nurses This may be because the Indian nursescome from relatively conservative cultures and have fewerproblems in adjusting to the conservative Kuwait culture(Shah 2000) Filipinos on the other hand besides havingdifficulty with the language also may have some difficultywith the culture The Philippines as a society is relativelymore open and where interaction among male and femalescontrary to the social norm in Kuwait is far morepermissible (Shah et al 2001)

CONCLUSIONIn summary the older nurses were more satisfied with

their job as were the nurses who held a diploma comparedto those who had a baccalaureate degree Experience ofworking in another country prior to Kuwait had a negativeeffect on satisfaction level Nurses were found to be moresatisfied in work settings in which they had greater controlover patient care Finally comprehension of Arabiclanguage and cultural compatibility emerged as facilitatorsof job satisfaction We therefore propose that the abovefactors be given due consideration in recruitment of nursesas members of the health care team Our findings havespecial relevance for health care services of those societieswhich recruit human resources from overseas

Specifically we recommend that societies with ashortage of nursing and other professional staff whilerecruiting expatriates should pay attention to the followingThrough a carefully planned orientation program theexpatriate staff may be provided with an understanding ofcultural differences and how to cope with them Specialattention should be paid to the norms regarding interactionamong males and females in general and social interactionamong professionals from opposite genders in particularFor instance it is customary in the western culture to shakehand with colleagues But in the Islamic culture if a persontries to shake hands with a colleague of the oppositegender it is frowned upon and in some cases it is shunnedSimilarly in conference rooms lecture theatres andcafeterias it is a common norm among conservativecultures that males and females should not intermingleWith regard to language barriers it is recommended thatstaff should be provided with intensive courses in thelanguage to be used in the care provision processLanguage cannot be learnt through short on-the-jobexperiences as has generally been the way in Kuwait andother Gulf countries

REFERENCESAbu Ajamieh AR Misener T Haddock KS and Gleaton JU 1996 Jobsatisfaction correlates among Palestinian nurses in the West Bank InternationalJournal of Nursing Studies 33422-32

Acorn S Ratner PA and Crawford M 1997 Decentralization as a determinantof autonomy job satisfaction and organizational commitment among nursemanagers Nursing Research 46(1)52-57

Agho AO 1993 The moderating effects of dispositional affectivity onrelationships between job characteristics and nursesrsquo job satisfaction Research inNursing and Health 16451-458

Al-Enezi N 1998 An analytical study of job satisfaction among healthprofessionals in Kuwaiti hospitals PhD Thesis Institute of Health Care StudiesUniversity of Wales UK

Al-Kandari FA and Ogundeyin W 1998 Patients and nursesrsquo perceptions ofthe quality of nursing care in Kuwait Journal of Advanced Nursing 27914-921

Brayfield AH and Crockett WH 1995 Employee attitudes and employeeperformance Psychological Bulletin 52396-424

Brunner KB 1989 Perceived professionalism and job satisfaction of RRA medicalrecord department directors Topics in Health Record Management 10(1)51-8

Butler J and Pearson RJ 1989 Hospital perceptions of job satisfactionNursing Management 20(8)45-48

Cambey DA and Alexander JW 1998 The relationship of job satisfaction withorganizational variables in public health nursing Journal of NursingAdministration 28(5)39-46

Cohen AR and Josefowitz N 1980 Effective behavior in organizationsHomewood IL Richard D Irwin

Cronin SN and Becherer D 1999 Recognition of staff nurse job performanceand achievements Staff and manager perceptions Journal of NursingAdministration 29(1)26-31

Dalayon A 1990 Nursing in Kuwait Problems and prospects NursingManagement 21(9)129-134

David P Sonia J Elizabeth K George S Paul B and Graham T 1996Mental health lsquoburnoutrsquo and job satisfaction among hospital and community-based mental health staff British Journal of Psychiatry 169334-337

Herzberg F Mausner B and Snyderman BB 1959 The motivation to workNew York Wiley

Hinshaw AS Smeltzer CH and Atwood JR 1987 Innovative retentionstrategies for nursing staff Journal of Nursing Administration 19(4)15-19

Joey SB and Steven BD 1997 Job satisfaction reported by AS BS degreeradiographers Radiologic Technology 69(1)62-66

Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

RESEARCH PAPER

13

being lsquosatisfiedrsquo a respondent who got an overall score of63 (21x3) was treated as neutral Therefore a total scoreof 64 was considered as the lowest level of satisfactionThe above conforms to the decisions of the studyundertaken by Cambey and Alexander (1998) Cronbachrsquosalpha (reliability coefficient) was used to determine theinternal consistency of the instrument The value of thealpha for the global scale in our study was 089 which isthe same as for the global scale in the Mueller andMcCloskeyrsquos 1990 study The construct validity wasassessed by factor analysis using factor loadings theseranged from 057 to 083 except one item which was 039

(compensation for work during holidays) Thequestionnaire was translated into Arabic and translatedback into English by an independent professional tocheck the validity

The background characteristics assessed in our studywere age sex nationality educational level monthlysalary place of work in terms of department within ahospital whether spouse lived in Kuwait years ofexperience in Kuwait and whether the respondent hadworked as a nurse in another country before undertakingthe job in Kuwait

Characteristics Coefficient Standarised coefficient Level of Significance

Age 4036 0212 0001

Sex

Male -0299 -0008 0869

Female 000 100

Educational qualification -5701 -0202 0002

Where spouse lives

In Kuwait 2321 0086 0112

Not in Kuwait 000 100

Monthly salary -0590 -0030 0632

Experience in Kuwait -1197 -0099 0158

Previous work experience in other country

Yes -2885 -0100 0041

No 000 100

Department working in

Casualty 0851 0017 0764

OR 0602 0010 0853

Medical ward 5314 0172 0014

Surgical ward 4839 0142 0032

ICU 5211 0118 0047

Paediatric ward 1512 0035 0559

Obs amp Gyn 3919 0082 0157

Others (endoscopy dental nephrology etc) 000 100

Nationality (Yes=1)

Kuwaiti amp other Arabs 5101 0142 0031

Indians 1492 0055 0463

Filipinos -2333 -0074 0332

Others (Europeans amp North Americans) 000 100

Constant 64785 0000

F- value 501 (plt001)

Adjusted R2 014

Significant at 5 level Significant at 1 level

Table 2 Multiple regression analysis of job satisfaction (dependent variable Overall job satisfaction) n=436

Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

RESEARCH PAPER

14

ANALYSISThe average for the global scale was 686 and the

standard deviation was 135 (see table 1) In terms of agerespondents in each of the three categories had an overallscore higher than the neutral score (ie 63) Respondentsaged above 30 were significantly more satisfied thanthose below 30 Regarding gender both male and femalenurses had an overall score slightly higher than theneutral score However there was no significantdifference between them With regard to nationalityKuwaitis and other Arabs were more satisfied followedby Indians while the Filipinos were not satisfied and thedifference was significant

Respondents who had a diploma were significantlymore satisfied than those who had a bachelors degreeThe overall score of diploma holders was much higherthan the neutral score while that of the bachelor degreeholders was equal to the neutral score

Regarding salary respondents in each of the threecategories had an overall score higher than the neutralscore However those who got a monthly salary of 200Kuwaiti Dinars or less were relatively more satisfiedcompared to the respondents in the other two categories

On place of work within a hospital the overall scorefor each setting was higher than the neutral scoreHowever the scores for respondents who worked inmedical wards surgical wards or ICU were relativelyhigher than those who worked in other wards

The respondents whose spouses lived in Kuwait weremore satisfied than those whose spouses lived abroadwith the overall score being higher than the neutral scorefor respondents in both categories The relationshipbetween the number of years of experience in Kuwait andsatisfaction showed that respondents who had worked forsix or more years were more satisfied However theoverall score for respondents in each of the four durationcategories was higher than the neutral score

Finally the overall scores of respondents who hadworked in a country other than Kuwait and those who hadnot were both higher than the neutral score

Multivariate analysisTo assess the relationship between those background

characteristics that had a significant association with thejob satisfaction we used multiple linear regression Theoverall job satisfaction score was used as the dependentvariable for which the scores ranged from 21 to 105

Dummy variables for each category were created fortwo categorical variables department where respondentworked and nationality For nationality lsquootherrsquo (includesEuropeans and North Americans) was treated as theomitted category while for department lsquoother departmentrsquo(includes endoscopy dental nephrology etc) was treatedas the omitted category

Table 2 presents the results of the multiple regressionanalysis The overall model was significant (F=501plt001) and the value of the adjusted R2 was 014 AgeKuwaiti nationality and working in a surgical departmentmedical department or ICU were found to be significantand showed a positive relationship with overall jobsatisfaction score However educational qualification andemployment in another country before taking up the jobin Kuwait showed a significant but inverse relationshipwith the overall job satisfaction The rest of theindependent variables were not significantly associatedwith job satisfaction

DISCUSSIONConsistent with previous research (Warr 1992) we

found that older nurses were more satisfied with theirjobs It appears that as professionals mature age-wise andgather more experience they tend to make a betteradjustment to the work environment when compared withyounger peers Also it is relatively more difficult forolder professionals in the Middle East to switch jobs andfind compatible positions elsewhere Further the age forretirement in most of the developing countries isrelatively low compared to that in developed countriesTherefore nurses who are aged 40 or over have extremelylimited job opportunities in their own countries shouldthey opt to return Finally the wages for the same orsimilar jobs in the countries or origin (Egypt Syria IndiaPhilippines Pakistan and Bangladesh) are much lowerthan those in the Gulf Cooperation Council (GCC)countries (Shah 1994) Besides older and experiencedpersons are accorded greater recognition by thesupervisors and administrators in the Arab culture andtherefore they tend to be more satisfied All of thesefactors result in a likely higher level of satisfaction amongolder nurses

Nurses with a diploma were found to have a higherlevel of satisfaction compared to bachelor degree holderssimilar to the results of a previous study (Cambey andAlexander 1998) An investigation into the salarystructure of nurses revealed that there is an insignificantdifference in the salary of those who have diploma asopposed to those who have a bachelor degree whichmight explain why diploma holders are comparativelymore satisfied Another possible reason for the finding isthat while bachelor degree holders receive compatiblesalaries in other countries in the region the diplomaholders get relatively higher salaries in Kuwait comparedto salaries offered elsewhere in the region

Nurses who had worked in another country beforecoming to Kuwait were less satisfied compared to thosewho had not worked elsewhere One plausibleexplanation for the finding is that nurses who had workedat some other place within the region have a point ofreference

RESEARCH PAPER

15Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

Nurses who worked on a medical ward a surgical wardor ICU were found to be more satisfied with their job withthose who worked in ICU being relatively less satisfiedThis finding is consistent with that of another study(Yamashita 1995) Our discussions with care providers inKuwait physicians and nurses alike revealed that nursestend to like those settings of work where they have agreater control over patient care and medical and surgicalwards offer such an opportunity Nurses who worked incasualty or emergency rooms (ER) for example had thelowest satisfaction score in our study Nurses reported thatthey did not like to work in those settings where there is ahigher pressure of work as is the case with emergencyroom (ER) services ER services have been found to beheavily overutilised in Kuwait (Shah and Shah 1992-93Shah et al 1994-95 Shah et al 1996 Shah et al 1997) Notriage system is followed and therefore some patients whoare not truly in need of emergency care are providedservices through ER thus resulting in a heavy burden onthe staff

Finally regarding nationality Kuwaitis and other Arabswere found to be more satisfied followed by Indians TheFilipino nurses were the least satisfied This may partly bebecause the official language in the MoH is Arabic and themajority of supervisors are either Kuwaitis or non-KuwaitiArabs Therefore the Arab employees tend to enjoy a betterrapport and working relationship with Arabic-speakingsupervisors and that results in a higher level of satisfactionamong them However this may also be due to their generalsatisfaction in life as they live in a culturally compatibleenvironment Indian nurses are relatively more satisfied thanFilipino nurses This may be because the Indian nursescome from relatively conservative cultures and have fewerproblems in adjusting to the conservative Kuwait culture(Shah 2000) Filipinos on the other hand besides havingdifficulty with the language also may have some difficultywith the culture The Philippines as a society is relativelymore open and where interaction among male and femalescontrary to the social norm in Kuwait is far morepermissible (Shah et al 2001)

CONCLUSIONIn summary the older nurses were more satisfied with

their job as were the nurses who held a diploma comparedto those who had a baccalaureate degree Experience ofworking in another country prior to Kuwait had a negativeeffect on satisfaction level Nurses were found to be moresatisfied in work settings in which they had greater controlover patient care Finally comprehension of Arabiclanguage and cultural compatibility emerged as facilitatorsof job satisfaction We therefore propose that the abovefactors be given due consideration in recruitment of nursesas members of the health care team Our findings havespecial relevance for health care services of those societieswhich recruit human resources from overseas

Specifically we recommend that societies with ashortage of nursing and other professional staff whilerecruiting expatriates should pay attention to the followingThrough a carefully planned orientation program theexpatriate staff may be provided with an understanding ofcultural differences and how to cope with them Specialattention should be paid to the norms regarding interactionamong males and females in general and social interactionamong professionals from opposite genders in particularFor instance it is customary in the western culture to shakehand with colleagues But in the Islamic culture if a persontries to shake hands with a colleague of the oppositegender it is frowned upon and in some cases it is shunnedSimilarly in conference rooms lecture theatres andcafeterias it is a common norm among conservativecultures that males and females should not intermingleWith regard to language barriers it is recommended thatstaff should be provided with intensive courses in thelanguage to be used in the care provision processLanguage cannot be learnt through short on-the-jobexperiences as has generally been the way in Kuwait andother Gulf countries

REFERENCESAbu Ajamieh AR Misener T Haddock KS and Gleaton JU 1996 Jobsatisfaction correlates among Palestinian nurses in the West Bank InternationalJournal of Nursing Studies 33422-32

Acorn S Ratner PA and Crawford M 1997 Decentralization as a determinantof autonomy job satisfaction and organizational commitment among nursemanagers Nursing Research 46(1)52-57

Agho AO 1993 The moderating effects of dispositional affectivity onrelationships between job characteristics and nursesrsquo job satisfaction Research inNursing and Health 16451-458

Al-Enezi N 1998 An analytical study of job satisfaction among healthprofessionals in Kuwaiti hospitals PhD Thesis Institute of Health Care StudiesUniversity of Wales UK

Al-Kandari FA and Ogundeyin W 1998 Patients and nursesrsquo perceptions ofthe quality of nursing care in Kuwait Journal of Advanced Nursing 27914-921

Brayfield AH and Crockett WH 1995 Employee attitudes and employeeperformance Psychological Bulletin 52396-424

Brunner KB 1989 Perceived professionalism and job satisfaction of RRA medicalrecord department directors Topics in Health Record Management 10(1)51-8

Butler J and Pearson RJ 1989 Hospital perceptions of job satisfactionNursing Management 20(8)45-48

Cambey DA and Alexander JW 1998 The relationship of job satisfaction withorganizational variables in public health nursing Journal of NursingAdministration 28(5)39-46

Cohen AR and Josefowitz N 1980 Effective behavior in organizationsHomewood IL Richard D Irwin

Cronin SN and Becherer D 1999 Recognition of staff nurse job performanceand achievements Staff and manager perceptions Journal of NursingAdministration 29(1)26-31

Dalayon A 1990 Nursing in Kuwait Problems and prospects NursingManagement 21(9)129-134

David P Sonia J Elizabeth K George S Paul B and Graham T 1996Mental health lsquoburnoutrsquo and job satisfaction among hospital and community-based mental health staff British Journal of Psychiatry 169334-337

Herzberg F Mausner B and Snyderman BB 1959 The motivation to workNew York Wiley

Hinshaw AS Smeltzer CH and Atwood JR 1987 Innovative retentionstrategies for nursing staff Journal of Nursing Administration 19(4)15-19

Joey SB and Steven BD 1997 Job satisfaction reported by AS BS degreeradiographers Radiologic Technology 69(1)62-66

Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

RESEARCH PAPER

14

ANALYSISThe average for the global scale was 686 and the

standard deviation was 135 (see table 1) In terms of agerespondents in each of the three categories had an overallscore higher than the neutral score (ie 63) Respondentsaged above 30 were significantly more satisfied thanthose below 30 Regarding gender both male and femalenurses had an overall score slightly higher than theneutral score However there was no significantdifference between them With regard to nationalityKuwaitis and other Arabs were more satisfied followedby Indians while the Filipinos were not satisfied and thedifference was significant

Respondents who had a diploma were significantlymore satisfied than those who had a bachelors degreeThe overall score of diploma holders was much higherthan the neutral score while that of the bachelor degreeholders was equal to the neutral score

Regarding salary respondents in each of the threecategories had an overall score higher than the neutralscore However those who got a monthly salary of 200Kuwaiti Dinars or less were relatively more satisfiedcompared to the respondents in the other two categories

On place of work within a hospital the overall scorefor each setting was higher than the neutral scoreHowever the scores for respondents who worked inmedical wards surgical wards or ICU were relativelyhigher than those who worked in other wards

The respondents whose spouses lived in Kuwait weremore satisfied than those whose spouses lived abroadwith the overall score being higher than the neutral scorefor respondents in both categories The relationshipbetween the number of years of experience in Kuwait andsatisfaction showed that respondents who had worked forsix or more years were more satisfied However theoverall score for respondents in each of the four durationcategories was higher than the neutral score

Finally the overall scores of respondents who hadworked in a country other than Kuwait and those who hadnot were both higher than the neutral score

Multivariate analysisTo assess the relationship between those background

characteristics that had a significant association with thejob satisfaction we used multiple linear regression Theoverall job satisfaction score was used as the dependentvariable for which the scores ranged from 21 to 105

Dummy variables for each category were created fortwo categorical variables department where respondentworked and nationality For nationality lsquootherrsquo (includesEuropeans and North Americans) was treated as theomitted category while for department lsquoother departmentrsquo(includes endoscopy dental nephrology etc) was treatedas the omitted category

Table 2 presents the results of the multiple regressionanalysis The overall model was significant (F=501plt001) and the value of the adjusted R2 was 014 AgeKuwaiti nationality and working in a surgical departmentmedical department or ICU were found to be significantand showed a positive relationship with overall jobsatisfaction score However educational qualification andemployment in another country before taking up the jobin Kuwait showed a significant but inverse relationshipwith the overall job satisfaction The rest of theindependent variables were not significantly associatedwith job satisfaction

DISCUSSIONConsistent with previous research (Warr 1992) we

found that older nurses were more satisfied with theirjobs It appears that as professionals mature age-wise andgather more experience they tend to make a betteradjustment to the work environment when compared withyounger peers Also it is relatively more difficult forolder professionals in the Middle East to switch jobs andfind compatible positions elsewhere Further the age forretirement in most of the developing countries isrelatively low compared to that in developed countriesTherefore nurses who are aged 40 or over have extremelylimited job opportunities in their own countries shouldthey opt to return Finally the wages for the same orsimilar jobs in the countries or origin (Egypt Syria IndiaPhilippines Pakistan and Bangladesh) are much lowerthan those in the Gulf Cooperation Council (GCC)countries (Shah 1994) Besides older and experiencedpersons are accorded greater recognition by thesupervisors and administrators in the Arab culture andtherefore they tend to be more satisfied All of thesefactors result in a likely higher level of satisfaction amongolder nurses

Nurses with a diploma were found to have a higherlevel of satisfaction compared to bachelor degree holderssimilar to the results of a previous study (Cambey andAlexander 1998) An investigation into the salarystructure of nurses revealed that there is an insignificantdifference in the salary of those who have diploma asopposed to those who have a bachelor degree whichmight explain why diploma holders are comparativelymore satisfied Another possible reason for the finding isthat while bachelor degree holders receive compatiblesalaries in other countries in the region the diplomaholders get relatively higher salaries in Kuwait comparedto salaries offered elsewhere in the region

Nurses who had worked in another country beforecoming to Kuwait were less satisfied compared to thosewho had not worked elsewhere One plausibleexplanation for the finding is that nurses who had workedat some other place within the region have a point ofreference

RESEARCH PAPER

15Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

Nurses who worked on a medical ward a surgical wardor ICU were found to be more satisfied with their job withthose who worked in ICU being relatively less satisfiedThis finding is consistent with that of another study(Yamashita 1995) Our discussions with care providers inKuwait physicians and nurses alike revealed that nursestend to like those settings of work where they have agreater control over patient care and medical and surgicalwards offer such an opportunity Nurses who worked incasualty or emergency rooms (ER) for example had thelowest satisfaction score in our study Nurses reported thatthey did not like to work in those settings where there is ahigher pressure of work as is the case with emergencyroom (ER) services ER services have been found to beheavily overutilised in Kuwait (Shah and Shah 1992-93Shah et al 1994-95 Shah et al 1996 Shah et al 1997) Notriage system is followed and therefore some patients whoare not truly in need of emergency care are providedservices through ER thus resulting in a heavy burden onthe staff

Finally regarding nationality Kuwaitis and other Arabswere found to be more satisfied followed by Indians TheFilipino nurses were the least satisfied This may partly bebecause the official language in the MoH is Arabic and themajority of supervisors are either Kuwaitis or non-KuwaitiArabs Therefore the Arab employees tend to enjoy a betterrapport and working relationship with Arabic-speakingsupervisors and that results in a higher level of satisfactionamong them However this may also be due to their generalsatisfaction in life as they live in a culturally compatibleenvironment Indian nurses are relatively more satisfied thanFilipino nurses This may be because the Indian nursescome from relatively conservative cultures and have fewerproblems in adjusting to the conservative Kuwait culture(Shah 2000) Filipinos on the other hand besides havingdifficulty with the language also may have some difficultywith the culture The Philippines as a society is relativelymore open and where interaction among male and femalescontrary to the social norm in Kuwait is far morepermissible (Shah et al 2001)

CONCLUSIONIn summary the older nurses were more satisfied with

their job as were the nurses who held a diploma comparedto those who had a baccalaureate degree Experience ofworking in another country prior to Kuwait had a negativeeffect on satisfaction level Nurses were found to be moresatisfied in work settings in which they had greater controlover patient care Finally comprehension of Arabiclanguage and cultural compatibility emerged as facilitatorsof job satisfaction We therefore propose that the abovefactors be given due consideration in recruitment of nursesas members of the health care team Our findings havespecial relevance for health care services of those societieswhich recruit human resources from overseas

Specifically we recommend that societies with ashortage of nursing and other professional staff whilerecruiting expatriates should pay attention to the followingThrough a carefully planned orientation program theexpatriate staff may be provided with an understanding ofcultural differences and how to cope with them Specialattention should be paid to the norms regarding interactionamong males and females in general and social interactionamong professionals from opposite genders in particularFor instance it is customary in the western culture to shakehand with colleagues But in the Islamic culture if a persontries to shake hands with a colleague of the oppositegender it is frowned upon and in some cases it is shunnedSimilarly in conference rooms lecture theatres andcafeterias it is a common norm among conservativecultures that males and females should not intermingleWith regard to language barriers it is recommended thatstaff should be provided with intensive courses in thelanguage to be used in the care provision processLanguage cannot be learnt through short on-the-jobexperiences as has generally been the way in Kuwait andother Gulf countries

REFERENCESAbu Ajamieh AR Misener T Haddock KS and Gleaton JU 1996 Jobsatisfaction correlates among Palestinian nurses in the West Bank InternationalJournal of Nursing Studies 33422-32

Acorn S Ratner PA and Crawford M 1997 Decentralization as a determinantof autonomy job satisfaction and organizational commitment among nursemanagers Nursing Research 46(1)52-57

Agho AO 1993 The moderating effects of dispositional affectivity onrelationships between job characteristics and nursesrsquo job satisfaction Research inNursing and Health 16451-458

Al-Enezi N 1998 An analytical study of job satisfaction among healthprofessionals in Kuwaiti hospitals PhD Thesis Institute of Health Care StudiesUniversity of Wales UK

Al-Kandari FA and Ogundeyin W 1998 Patients and nursesrsquo perceptions ofthe quality of nursing care in Kuwait Journal of Advanced Nursing 27914-921

Brayfield AH and Crockett WH 1995 Employee attitudes and employeeperformance Psychological Bulletin 52396-424

Brunner KB 1989 Perceived professionalism and job satisfaction of RRA medicalrecord department directors Topics in Health Record Management 10(1)51-8

Butler J and Pearson RJ 1989 Hospital perceptions of job satisfactionNursing Management 20(8)45-48

Cambey DA and Alexander JW 1998 The relationship of job satisfaction withorganizational variables in public health nursing Journal of NursingAdministration 28(5)39-46

Cohen AR and Josefowitz N 1980 Effective behavior in organizationsHomewood IL Richard D Irwin

Cronin SN and Becherer D 1999 Recognition of staff nurse job performanceand achievements Staff and manager perceptions Journal of NursingAdministration 29(1)26-31

Dalayon A 1990 Nursing in Kuwait Problems and prospects NursingManagement 21(9)129-134

David P Sonia J Elizabeth K George S Paul B and Graham T 1996Mental health lsquoburnoutrsquo and job satisfaction among hospital and community-based mental health staff British Journal of Psychiatry 169334-337

Herzberg F Mausner B and Snyderman BB 1959 The motivation to workNew York Wiley

Hinshaw AS Smeltzer CH and Atwood JR 1987 Innovative retentionstrategies for nursing staff Journal of Nursing Administration 19(4)15-19

Joey SB and Steven BD 1997 Job satisfaction reported by AS BS degreeradiographers Radiologic Technology 69(1)62-66

RESEARCH PAPER

15Australian Journal of Advanced Nursing 2004 Volume 21 Number 4

Nurses who worked on a medical ward a surgical wardor ICU were found to be more satisfied with their job withthose who worked in ICU being relatively less satisfiedThis finding is consistent with that of another study(Yamashita 1995) Our discussions with care providers inKuwait physicians and nurses alike revealed that nursestend to like those settings of work where they have agreater control over patient care and medical and surgicalwards offer such an opportunity Nurses who worked incasualty or emergency rooms (ER) for example had thelowest satisfaction score in our study Nurses reported thatthey did not like to work in those settings where there is ahigher pressure of work as is the case with emergencyroom (ER) services ER services have been found to beheavily overutilised in Kuwait (Shah and Shah 1992-93Shah et al 1994-95 Shah et al 1996 Shah et al 1997) Notriage system is followed and therefore some patients whoare not truly in need of emergency care are providedservices through ER thus resulting in a heavy burden onthe staff

Finally regarding nationality Kuwaitis and other Arabswere found to be more satisfied followed by Indians TheFilipino nurses were the least satisfied This may partly bebecause the official language in the MoH is Arabic and themajority of supervisors are either Kuwaitis or non-KuwaitiArabs Therefore the Arab employees tend to enjoy a betterrapport and working relationship with Arabic-speakingsupervisors and that results in a higher level of satisfactionamong them However this may also be due to their generalsatisfaction in life as they live in a culturally compatibleenvironment Indian nurses are relatively more satisfied thanFilipino nurses This may be because the Indian nursescome from relatively conservative cultures and have fewerproblems in adjusting to the conservative Kuwait culture(Shah 2000) Filipinos on the other hand besides havingdifficulty with the language also may have some difficultywith the culture The Philippines as a society is relativelymore open and where interaction among male and femalescontrary to the social norm in Kuwait is far morepermissible (Shah et al 2001)

CONCLUSIONIn summary the older nurses were more satisfied with

their job as were the nurses who held a diploma comparedto those who had a baccalaureate degree Experience ofworking in another country prior to Kuwait had a negativeeffect on satisfaction level Nurses were found to be moresatisfied in work settings in which they had greater controlover patient care Finally comprehension of Arabiclanguage and cultural compatibility emerged as facilitatorsof job satisfaction We therefore propose that the abovefactors be given due consideration in recruitment of nursesas members of the health care team Our findings havespecial relevance for health care services of those societieswhich recruit human resources from overseas

Specifically we recommend that societies with ashortage of nursing and other professional staff whilerecruiting expatriates should pay attention to the followingThrough a carefully planned orientation program theexpatriate staff may be provided with an understanding ofcultural differences and how to cope with them Specialattention should be paid to the norms regarding interactionamong males and females in general and social interactionamong professionals from opposite genders in particularFor instance it is customary in the western culture to shakehand with colleagues But in the Islamic culture if a persontries to shake hands with a colleague of the oppositegender it is frowned upon and in some cases it is shunnedSimilarly in conference rooms lecture theatres andcafeterias it is a common norm among conservativecultures that males and females should not intermingleWith regard to language barriers it is recommended thatstaff should be provided with intensive courses in thelanguage to be used in the care provision processLanguage cannot be learnt through short on-the-jobexperiences as has generally been the way in Kuwait andother Gulf countries

REFERENCESAbu Ajamieh AR Misener T Haddock KS and Gleaton JU 1996 Jobsatisfaction correlates among Palestinian nurses in the West Bank InternationalJournal of Nursing Studies 33422-32

Acorn S Ratner PA and Crawford M 1997 Decentralization as a determinantof autonomy job satisfaction and organizational commitment among nursemanagers Nursing Research 46(1)52-57

Agho AO 1993 The moderating effects of dispositional affectivity onrelationships between job characteristics and nursesrsquo job satisfaction Research inNursing and Health 16451-458

Al-Enezi N 1998 An analytical study of job satisfaction among healthprofessionals in Kuwaiti hospitals PhD Thesis Institute of Health Care StudiesUniversity of Wales UK

Al-Kandari FA and Ogundeyin W 1998 Patients and nursesrsquo perceptions ofthe quality of nursing care in Kuwait Journal of Advanced Nursing 27914-921

Brayfield AH and Crockett WH 1995 Employee attitudes and employeeperformance Psychological Bulletin 52396-424

Brunner KB 1989 Perceived professionalism and job satisfaction of RRA medicalrecord department directors Topics in Health Record Management 10(1)51-8

Butler J and Pearson RJ 1989 Hospital perceptions of job satisfactionNursing Management 20(8)45-48

Cambey DA and Alexander JW 1998 The relationship of job satisfaction withorganizational variables in public health nursing Journal of NursingAdministration 28(5)39-46

Cohen AR and Josefowitz N 1980 Effective behavior in organizationsHomewood IL Richard D Irwin

Cronin SN and Becherer D 1999 Recognition of staff nurse job performanceand achievements Staff and manager perceptions Journal of NursingAdministration 29(1)26-31

Dalayon A 1990 Nursing in Kuwait Problems and prospects NursingManagement 21(9)129-134

David P Sonia J Elizabeth K George S Paul B and Graham T 1996Mental health lsquoburnoutrsquo and job satisfaction among hospital and community-based mental health staff British Journal of Psychiatry 169334-337

Herzberg F Mausner B and Snyderman BB 1959 The motivation to workNew York Wiley

Hinshaw AS Smeltzer CH and Atwood JR 1987 Innovative retentionstrategies for nursing staff Journal of Nursing Administration 19(4)15-19

Joey SB and Steven BD 1997 Job satisfaction reported by AS BS degreeradiographers Radiologic Technology 69(1)62-66

Kangas S Kee CC and McKee-Waddle R 1999 Organizational factorsnursesrsquo job satisfaction and patient satisfaction with nursing care Journal ofNursing Administration 29(1)32-42

Kuwait Manpower Statistics 2000 Manpower Planning Supervisory KuwaitMinistry of Health

Kuwait Public Authority for Civil Information 2000 Directory of CivilInformation Population and Labor Force Government of Kuwait

Kuwait Vital and Health Statistics Division 2000 Annual Report KuwaitMinistry of Health

Likert R and Katz D 1979 Supervisory practices and organizationalstructures as they affect employee productivity and morale in Robbins SP(ed) Organizational Behavior Englewood Cliffs Prentice-Hall

Lucas MD Atwood JR and Hagaman R 1993 Replication and validationof anticipated turnover model for urban registered nurses Nursing Research42(1)29-35

Mueller CW and McCloskey JC 1990 Nursesrsquo job satisfaction A proposedmeasure Nursing Research 39(2)113-117

Naim AK Shah MA Shah NM and Gomma RA 1986 Health inKuwait Kuwait Ministry of Health

Parrinello KAM 1990 Nursesrsquo satisfaction with their work and patientsatisfaction with hospital care An organizational analysis Rochester NYUniversity of Rochester Dissertation

Pasternak ID 1988 The effects of primary care nursing and feelings ofisolationdepersonalization of the critical care nurse Part I Background for thestudy Nursing Management 19(3)11-8

Petty MM McGee GW and Cavender JW 1984 A meta-analysis of therelationships between individual job satisfaction and individual performanceAcademy of Management Journal 9712-21

Porter L and Steers RM 1973 Organizational work and personal factors inemployee turnover and absenteeism Psychology Bulletin 80151-76

Prestholdt PH Lane IM and Mathews RC 1988 Predicting staff nurseturnover Nursing Outlook 36145-50

Price J and Mueller C 1981 A causal model of turnover for nurses Academyof Management Journal 24543-65

Seashore S and Tabar T 1995 Job satisfaction indicators and their correlatesThe American Behavioral Scientist 8333-68

Shah MA 2000 Care givers and recipients Islamic cultural perspectiveshttpwhisslutmbeduWHISSLcult_comISCUPERHTM

Shah MA Al-Enezi N and Chowdhury RI 2001 Cross-cultural differencesamong expatriate professionals working in Kuwait A Working PaperUnpublished

Shah MA Chowdhury RI Al-Enezi N and Shah MN 2001 Determinantsof job satisfaction among selected care providers in Kuwait Journal of AlliedHealth 30(2)68-74

Shah MA Amatayakul M and Shah NM 1997 Emergency services beingused as outpatient facilities An analysis of reasons for visit and follow-uppractices The Journal of Kuwait Medical Association 29(1)102-107

Shah MA Shah NM and Behbehani J 1994-95 Patient perception ofhealth and emergency room utilization before and after the Iraqi occupation ofKuwait Medical Principles and Practice 4135-146

Shah NM and Shah MA 1992-93 Excessive utilization of hospitalemergency services in pre-occupation Kuwait Trends and differentialsMedical Principles and Practice 3131-140

Shah NM 1994 An overview of present and future emigration dynamics inSouth Asia International Migration 32(2)

Shah NM Shah MA and Behbehani J 1996 Predictors of non-urgentutilization of hospital emergency services in Kuwait Social Sciences andMedicine 421313-1323

Shain LL 1990 A study of the relationship of quality circles to jobsatisfaction absenteeism and turnover of nurses and patientsrsquo satisfaction withnursing care in Taiwan Fairfax VA George Mason University Dissertation

Taunton RL Krampitz SD and Woods CQ 1989 Manager impact onretention of hospital staff Journal of Nursing Administration 1914-19

Tett RP and Meyer JP 1993 Job satisfaction organizational commitmentturnover intention and turnover Path analysis based on meta-analyticalfindings Personal Psychology 46259-93

Tonges MC Rothstein H and Carter HK 1998 Source of satisfaction inhospital nursing practice Journal of Nursing Administration 28(5)47-61

Warr P 1992 Age and occupational well being Psychology and Aging 737-45

Weisman CA and Nathanson CA 1985 Professional satisfaction and clientoutcomes Medical Care 19431-443

Weisman CS Alexander CS and Chase GA 1981 Evaluating reasons fornursing turnover Evaluation and the Health Professions 4107-27

Yamashita M 1995 Job satisfaction in Japanese nurses Journal of AdvancedNursing 22158-164

RESEARCH PAPER

16Australian Journal of Advanced Nursing 2004 Volume 21 Number 4