Job Satisfaction and the Associated Factors Amongst Nurses In Southeastern Nigeria: Cross Sectional Study

Background: Job satisfaction is a significant indicator of the way nurses feel about their profession, the efforts to perform their professional duties, or otherwise abandons it willingly. Method: cross-sectional research design approach was used to assess the job satisfaction and the associated factors among 300 hundred nurses. Data was analyzed using descriptive statistics and kruskal wallis test for association between the socio-demographic variables and job satisfaction at significance level of 0.05 Result: About 1/3 of the respondents (31%) reported gross dissatisfaction with their job, 0% reported being well satisfaction while (68.7%) respondents reported moderate satisfaction with their job. Across items on the scale, gross dissatisfaction was noted on key managerial factors and the salary of the workers. Job satisfaction was associated with specialty (p<0.018), gender (P<0.002) and age (P<0.000) of Nurses. Conclusion: majority of the respondents were moderately satisfied with their job but grossly dissatisfied with salary and administrative roles like communication flow.


Background of the Study
Job satisfaction has been defined as the feelings and attitude of people towards their work [1]. It is a significant indicator of the way nurses feel about their profession, the efforts to perform their professional duties, or otherwise abandons it willingly [2]. It also refers to how well a work provides gratification of a need or how well it provides a means of self-gratification. Job satisfaction is an important element in keeping the work force of any organization. Lack in professional pleasure not only hinders the pace of work, but also can adversely affect the individuals as in burnout effect [3].
Optimum commitment and maximal output in any occupation depends on the level of satisfaction derived from the work or job by the employees. Job satisfaction among nurses is vital to health care delivery since they form the largest workforce and play pivotal roles in healthcare. This is because satisfied nurses are endowed with the physical and emotional dexterity and the efforts needed to perform their tasks [4]. This would enhance the quality of care provided to the patient. It has been empirically argued that organizations cannot be at their best until workers are committed to the organizational goals and objectives. Such commitment can only be achieved via job satisfaction [5]. As the largest workforce across the world, they are very vital key players if health for all and sustainable development goals must be achieved globally [6]. Nurses are mainly the only healthcare workers readily accessible to millions of people in lifetime in most countries of the world [6]. Addressing the Nurses' satisfaction with their job is a very crucial matter especially in developing countries [7]. In most developing countries, nurses are the strength of the health care delivery system. They are key players to achievement and promotion of any health program in any country [6].
As affirmed by Ahmad and Abu Raddaha [8] there are increasing number of healthcare workers such as nurses that are voluntarily leaving their countries or profession caused by numerous factors amongst which is job dissatisfaction. Job dissatisfaction and burnout has been a recurrent and serious problem among Nurses and other workers in different part of the world but more common in the third world countries leading to many nurses and other health professionals quitting their jobs for better ones in the developed countries like America [9]. Recent study has shown a direct correlation between staff satisfaction and patient satisfaction in health care organizations [10]. Job satisfaction of nurses is interrelated with the quality of health care, patient satisfaction with the services they receive, patient compliance and continuity of care [11]. Moreover, dissatisfaction leads to increased absenteeism, lower productivity and increased turnover each of which raises cost to the medical system [11]. Considering the fact that the level of job satisfaction affects not only the quality of the roles performed by the nurse, but also patient satisfaction with care, it is very important for healthcare institutions to measure these Perceptions by the nurses and do the needful to improve it [2].
Satisfaction with job can be influence by numerous factors amongst which are adequate staffing, competitive remuneration, healthy work environment, career advancement opportunities, adequate workload, mutual and friendly supervision, obvious patients' health improvement and others [12].
African as a continent is currently facing serious human resource crises in the health sector [13]. For instance South Africa has 0.818 physicians per 1000 patients and 5.229 nurses and midwives per 1000 patients. This is reportedly the second highest after Libya [14]. An estimated 1/5 African healthcare workers migrate to the western world for employment purposes. About 10,684 African physicians left the continent in 2005, 13,584 in 2015 for greener pastures in the European countries [15]. The reason for the above is poor financing of the health sector, poor remuneration, lack of career advancement and poor work environment [13]. According to WHO [16] worst health workers shortage is recorded in Asia and Africa with about 4.3million doctors, midwives and nurses shortage with in African countries and must be overcome before universal health coverage can be achieved. These severe human resource shortages have affected the ability of many countries to initiate and sustain credible health services.
Although several reform and policies have been developed to address health problems in the continent, little attention has been given to creating a desirable workplace that will lead to greater job satisfaction [10]. Healthcare system of Nigeria is one of the weakest in Africa despite being the most populous country in the continent [17] . It is a country with few doctors and nurses and poor health indicators when compared to other countries [10]. It is also a country with incessant strike action amongst health care workers thereby making access to health services by the masses very difficult. Nigeria has 15 nurses per 10,000 persons, Physicians 3.83 per 10,000 persons [18]. Nigeria is one of the countries with the poorest health indices in the world with maternal mortality rate of 1350 /100000 live birth, under-5 mortality rate of 109/1000 live birth and account for 10%of the world disease burden yet nurses and other healthcare professionals emigrate the country in good numbers to western countries in search greener pasture, healthy work environment, and positive career growth [13]. Yearly above 600 general practitioners in Nigeria migrate to other western countries especially Europe and North America, about 13% of registered nurse and midwives in Nigeria migrate to other countries leaving the healthcare of the country in shambles [14]. The major cause or reason for the mass migration of health workers from most African countries is the poor working condition, lack of security, poor financing of the healthcare sector, and need for positive progression in the workers' career [19]. For the above situation to be improved and universal health coverage for all achieved, the few health workers must be satisfied, sustained and the healthcare environment improved for better healthcare delivering. This begins with research evidence on the job satisfaction among health workers which is non-existent in Nigeria. It is in the light of the above that this study intends to assess job satisfaction and associated factors among nurses in Southeastern Nigeria

Purpose of the Study
The purpose of this study is to assess the job satisfaction amongst nurses at Federal health facility in Abakaliki.

Specific Objective of the Study
This study seeks to 1) Determine the level of job satisfaction among nurses at FETHA 2) Identify the factors associated with the job satisfaction amongst nurses at FETHA

Design
A cross sectional descriptive design was adopted for this research. An institution based survey was conducted from September to December 2019 among 300 nurses with work experience of at least six months in the Abakaliki federal health facility. The method is considered appropriate because it gives current and immediate information about the situation under study.

Study Area
The study was carried out at Federal health facility Southeastern Nigeria. Federal healthcare facility is the only hospital in Abakaliki metropolis and one of the biggest in Southeastern Nigeria. This is the only government owned hospital in the state of Ebonyi catering for the health needs over five million people and others with few nurses.

Study Population
This study assessed the job satisfaction of nurses in the federal health facility in Abakaliki Southeastern Nigeria. A total of 300 nurses with at least six months working experience in the facility were included in the study.

Sampling Method
A total population study approach using 300 nurses was done because of the small number of nurses. Job satisfaction scale for assessment of levels of job satisfaction was used this study.

Ethical Consideration
An ethical approval was got from the ethical committee of the hospital under study. The consent of the respondents was obtained before the study.

Instrument for Data Collection
The instrument for this study has two parts: part A deals with the demographic variables of the respondents while part B is the job satisfaction scale. The SOGO survey scale was used to assess the employee's job satisfaction. It is a seven likert scale with responses ranging from disagrees completely to completely agree.

Reliability of the Instrument
The reliability of the instrument was established through pilot study using 20 nurses from Ikwo general hospital, a hospital different from this study area. The reliability was established through test retest method, Cronbach alpha value of 0.78 was gotten showing that the tool is reliable.

Method of Data Collection
Data for this study were collected using Job Satisfaction Scale. The scale has two parts: part A deals with the socio-demographic variables while part B deals with job satisfaction. Following ethical approval for the study, the researcher introduced himself to the respondents, obtained their consent following explanation of the purpose of the study and administered copies of the questionnaire to the respondents on the same day on face to face basis. The researcher was assisted by two trained research assistants. All the questionnaires were retrieved on the same day giving rise to 100% return rate.

Method of Data Analysis
Data was collected and analyzed using SPSS Version 24. Descriptive statistics were used to summarize the data on the demographic variables. Data for research objective one was first computed and the mean score categorized into levels of 16-32 (dissatisfied), 33-48 (moderate satisfaction) and 49-64 (Well satisfied) [12]. Kruskal wallis test was used to test the association between the demographic factors and job dissatisfaction.

Data Quality Assurance
The quality of the collected data was assured through training of the the research assistants on the use of the scale, approaches to the respondents and other related issues. Following the training, the level of assimilation of the research assistants were assessed using 20 nurses in Ikwo healthcare Centre. After which the data were analyzed and appropriate modifications made before the main study. The researcher supervised the data collection properly and ensured responses to the tools were on individual basis not as group as was used in similar study [6]. Based on the socio-demographic characteristics of the respondents (Table 1), the study shows that majority of the respondents are females (75.3%). In terms of years of experience, a greater proportion of the participants have more than 4 years in nursing practice. The specialty of the respondents showed theatre nurse (4.7%), general nursing (36.0%), intensive care nurse (11.3%), mental health nursing (13.3%), and emergency nursing (20.3%). The current position of the participants; nursing officer I (20.0%), nursing officer II (20.0%), principal nursing officer (20.3%), assistant chief nursing officer (20.0%) and chief nursing officer (19.7%). In the study also, the educational level of the participants showed RN are the majority with quarter of the participant belonging to this category followed by RN&RM category. In terms of age, 56.7% were between 18 to 39 years of age as in table 1 above. Overall, out of the total 300 respondents, majority are moderately satisfied (68.7%) in relation to their job satisfaction while 31.3% of the respondents are dissatisfied and 0% is well satisfied with their job as shown in table 2 below. In terms of job satisfaction across the items in the scale, 53.6% agreed with "Hospital clearly conveys its mission to the staff" while 46.4% disagreed strongly with it. 72% of the participants disagree with the item on "There is good communication from manager to employees" 91.3% was dissatisfied with their monthly salary, 83.3% reported gross lack of necessary equipment to work with and others as summarized in table 3. Generally, there was variation among nurses' level of job satisfaction across socio-demographic variables (table 4). The specialty of the nurse was significantly associated with the level of job satisfaction (X 2 =13.662 [5] , p value < 0.018), age groups (X 2 =36.197 [10], p< 0.000), gender (X 2 = 16.423 [10], p<0.002) while other variables like education, rank and year of experience had no significant association with their job satisfaction.

Discussion
This study revealed that majority of the respondent nurses(68.7%) that work in the area of this study are moderately satisfied with their job in overall but a very large number remained dissatisfied(31.3%) and (0%) nurses reported being well satisfied. This finding is not really good for a healthcare system that has to cater for numerous populations in the country and the nearby states. It is also very bad for a teaching hospital that is meant to train health professionals. This finding implies poor quality of care received by the client and decreased hospital output since job satisfaction is linked to the quality of care rendered and the productivity of the hospital. This may better explain the high rate at which nurses and other healthcare workers are leaving the country health system to others in the western countries [13,14]. It therefore demands urgent attention of the, government, managing director and his team to improve the level of job satisfaction of the nurses who are the first point of call to the hospital as to better the care received by the patients. This finding is in line with that of Gyang, et al. [20] in a study of job satisfaction among healthcare workers in Nigeria in which 64.8% of the workers were satisfied with their job. However, this finding was lower than 98.1% reported of similar study in kano state Nigeria [21]. These differences may be attributed to managerial tactics, methodology of the study and cultural diversity.
Across the items on the scale, nurses were grossly dissatisfied with the way and matter the hospital administrators conveys the hospital policy, the communication flow within the hospital, the salary of the nurses, the availability level of the equipment required to perform their duties, the benefit offered by the hospital, 78% reported that there is low morale amongst the workers, lack of necessary training for their job was also reported across the respondents and the supervisors were reportedly not promoting spirit of team work. Every worker needs some form of verbal or other motivations such as praises, accolades and others to be inspired to work more [6]. This is very critical since morale of the workers is linked to their job performance and the quality of care rendered. Secondly the healthcare work is a team work that cannot be done in isolation from others, therefore for effectiveness and efficiency to be enhanced in the healthcare system, the spirit of team work must be maintained. This agrees with the findings of Gyang, et al. [20] in a similar study of job satisfaction among health workers in which the workers were grossly dissatisfied with similar items in the scale of measurement. However, the nurses showed a higher level of satisfaction with their supervisors and the level of cordiality with their co-workers.
Moreover, the level of job satisfaction among healthcare workers was revealed to have significant association with some of the demographic features such as age, gender and specialty. Across the specialties of the nurses studied, statistically significant association was noted between job satisfaction and the specialty (P<0.018). The age of the respondents was also significantly associated with their level of job satisfaction with (p< 0.000). These findings therefore imply that the level of satisfaction of the respondent is in one way or the other dependent on the specialty/department where they work and also the age of the said respondent. The hospital management should therefore in attempt to improve the working condition of the workers and their job satisfaction consider the specialty area and the age mix of the workers since this affect their job satisfaction. This finding is similar to that of Amoran, et al. [22]; Gyang, et al. [20] in which the age of the individuals were significantly associated with job satisfaction (P<0.000) with younger adults being more satisfied than workers above 40 and 44 years of age. However, the years of work experience, the educational level, position/ rank and sex of the individual workers were not significantly associated with the level of job. This does not agree with the findings of a similar study in which those workers with higher years of work experience were reported to be more satisfied than the other [20].

Conclusion
The job satisfaction amongst nurses in southeast Nigeria is moderate as reported by 68.7% of the respondents. However 31.3% dissatisfaction was also noted with 0% reporting well satisfaction with nursing job at the area. Statistical test revealed that the specialty, gender and the age of the respondents had significant association with the level of job satisfaction but the level of education, sex, rank and years of work was not correlated with the workers' level of job satisfaction.

Limitations of the Study
This is limited by the fact that it focused on nurses in the Federal healthcare facility in Abakaliki. In view of the above, the findings of this study may not be exactly applied to Nurses in other healthcare setting. The data presented in this study is based on the respondents' subjective view as such it may be over emphasized or underreported. The scale being in English language based on the assumption that nurses can understand English hence not translated to local dialects may have caused misunderstanding of the concepts under study.

Implication for Further Studies
More research studies should be carryout on the level of job satisfaction among other group of healthcare workers in the same hospital as to provide holistic evidence to support move for policy adjustment. Other nurses in other hospitals in the zone should also be assessed as to compare the findings and possibly provide more specific advice to the hospital management based on facts. Further study on the patients' satisfaction with the quality of care in this same hospital is implicated to further assess the true situation of healthcare.

Clinical Implication
The health care system of the country and other developing countries with similar finding should swing into action to improve the working condition of the nurses and other healthcare workers as to improve healthcare delivery to the citizens. The management of the hospitals should critically appraise their managerial roles especially communication flow to enhance cordiality at work and team spirit.