https://doi.org/10.15218/ejnm.2019.07 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article Nurses Job Satisfaction in Health Care Institutions in Duhok City ABSTRACT INTRODUCTION Job satisfaction can be defined as the emo- tional responses of employees to their em- ployment status. Employees are generally focused on their job satisfaction which ex- plains why it has been defined as "a pleasant or positive emotional state re- sulting from the evaluation of employee's a job or career experience". Therefore, there is a wide variation in what people expect from their jobs and how they inter- act with one another in the workplace *1+. Background and objectives: Nurses are one of the most important human resources work- ing in health care institutions as they range in different levels and disciplines. They are the mainstay of modern health care institutions and a vital component in these institutions achieving their goals. Therefore, nurses' job satisfaction is an important aspect in providing quality health care. This study was conducted to determine nurses' job satisfaction in health care institutions in Duhok City. Methods: A descriptive study design was carried out to assess the nurses' job satisfaction in health care institutions of Duhok City. This study involved nurses who worked the morn- ing shift in both primary health care centers and public hospitals in Duhok City. A total of 137 nurses were selected from 946 nurses through utilizing a non-probability (purposive) sampling method and agreed to be subject of present study. A questionnaire designed by researchers was used for data collection through review of previous related studies and the data were gathered through self-report method. This questionnaire consisted of two aspects; the first one used for gathering nurses' socio-demographic data and the second one consisted of 30 Likert scale questions with responses ranging from strongly disagree, disagree, agree, strongly agree, and scored one to four respectively. These questions were divided into 5 categories as follow: job promotion, nature of work, work policy, communi- cation and interaction, and supervision satisfaction. Data was analyzed using descriptive and inferential statistics (frequency, percentage, mean, standard deviation, t-test, and Pearson correlation) and levels of job satisfaction were calculated through using cut off points. Results: The present study shows general dissatisfaction of nurses in regards to their job promotion, nature of work, work policy, work supervision, and communication and inter- action. Conclusions: The present study concludes that nurses working in health care institutions in Duhok City were dissatisfied in regards to the categories included in this study. Key words: Nurses, Job Satisfaction, Health Care Institution. Salim Saeed Azzez ; Department of Nursing, College of Nursing, University of Duhok , Duhok , Iraq. Alaa Noori Sarkees ; Department of Nursing, College of Nursing, University of Duhok , Duhok , Iraq. (Correspondence: alaa.sarkees@uod.ac ) 51 Erbil Journal of Nursing & Midwifery Received: 30/9/2018 Accepted: 15/1/2019 Published: 30/5/2019 mailto:alaa.sarkees@uod.ac https://doi.org/10.15218/ejnm.2019.07 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article Job satisfaction is considered an important segment of both organizational psychology and behavior. Therefore, it has been ar- gued and usually examined because it ex- amines the physical and mental well-being of individuals and work from both a psy- chological and human resources perspec- tive *2+. Due to the nature of these nurses' jobs deal with all aspects of health and ill- ness, they experience high levels of occu- pational stress. Therefore, job satisfaction is affected by this stressful nursing occupa- tion *3+. The hierarchy of needs theory was devel- oped by Abraham Maslow. In 1954, he sug- gested five basic needs that human beings need to be satisfied. These needs are phys- iological, safety, belongingness, self- esteem, and self-actualization. He ranked them into higher and lower needs. Accord- ing to his theory, the human starts to meet the unsatisfied needs that motivate behav- ior, lowest-level needs, like physiological and safety then struggles to achieve the highest-level needs such as belongingness, esteem, and self-actualization *4+. One of the top issues in health care sectors is the nursing shortage. In fact, this worldwide phenomenon continues as demand for nursing increases yet the current supply is unable to meet the needs of society. Fur- thermore, there is a high resignation rate among nurses as more than 13% of new nurses decide to leave their profession within first year *5+. Though many factors affect job satisfaction, they can be summa- rized in two domains, intrinsic and extrinsic factors. Intrinsic factors include payment, autonomy, task requirements, policies, in- teraction, and professional status. While extrinsic factors can include hygiene or care factors which if absent, can reflect job dissatisfaction *6+. Nurses are vital to mod- ern health care institutions to achieving their goals. Therefore nurses' job satisfac- tion is an important aspect in providing quality health care. This study aims to determine job satisfac- tion among nurses those working in health care institutions in Duhok City, the associa- tion of nurses' job satisfaction with their socio-demographic characteristics, and compare between job satisfactions levels according to health care institutions. A descriptive study design was carried out to assess nurses' job satisfaction in health care institutions in Duhok City. The study included all nurses working in 13 primary health care centers directed by physicians morning shift of six public hospitals. A total of 137 nurses were selected from 946 nurses through utilizing a non-probability (purposive) sampling method. The re- searchers recruited the nurses who agreed to be subject in this present study and worked during the day shift of hospitals and others were excluded from the current study. A questionnaire was used as a tool for data collection. This questionnaire was constructed through review of previous related studies and the data was gathered through self-report method. The question- naire consisted of two parts. The first part was used for gathering socio-demographic data (age, gender, level of educational, English language, marital status, monthly income, residential area, type of family) in addition to employment data (years of ser- vices, number of training courses, place of work) and the second one consisted of 30 Likert scale questions with responses rang- ing from strongly disagree, disagree, agree, strongly agree, and scored one to four re- spectively. These questions were divided into 5 main domains as job promotion, na- ture of work, work policy, communication and interaction and finally supervision satisfaction. Data was analyzed through using (frequency, percentage, mean, standard deviation, t-test, and Pearson METHODS 52 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2019.07 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article Finally, 73% of the nurses show dissatisfac- tion towards work supervision and 37.0% show discrepancy (Table 3). correlation). Levels of job satisfaction were calculated through using cut off points as follows: for the first and fifth domains, Dis- satisfied (5-9), Discrepancy (10-14) and Satisfied (15-20), for second and third do- mains, Dissatisfied (7-13), Discrepancy (14- 20) and Satisfied (21-28). Finally, for the fourth domain, Dissatisfied (6-11), Discrep- ancy (12-17) and Satisfied (18-24). Socioec- onomic status of the nurses was calculated through collecting data related to nurse's education, family crowding index, house- hold asset and monthly income. This data was scored and distributed to poor, aver- age, and high by use of the cut off point method. Results showed that the largest percentage of nurses in the study 38% were between 30-39years of age, 59.9% of them were fe- male, 40.1% attended secondary school, 44.5% of the sample has less than seven years of experience, 42.3% knew moderate amounts of the English language, most of the sample 74.5% took training courses, and 83.9% worked in a hospital setting (Table 1). Results of the present study show that two thirds of nurses are married and live within a nuclear family 65%, the majority of which, 84.7%, also receive an insufficient monthly income, and are residents of ur- ban areas, 85.4%. In addition, more than half of them, 51.1%, stated average level of socio-economic status (Table 2). Results show that 80.3% of the nurses were dissatisfied regarding job promotion, 67.9% were dissatisfied towards the nature of their work, nearly one third of the sam- ple, 31.4%, showed discrepancy and 62.8% were dissatisfied with work policy and oth- ers show discrepancy, 54.7% of them were dissatisfied with communication and inter- action, while 45.3% show discrepancy. 53 RESULTS Erbil Journal of Nursing & Midwifery Table 1: Nurses' distribution by their de- mographic characteristics Demographic Characteris- tics F (%) M (±SD) Age 20-29 30-39 40-49 50 and more Gender Male Female Level of education Intermediate school Secondary school Institute University Years of services Less 1-7 8-14 15-21 22-28 29-36 Number of training cours- es 0-2 3-5 6-8 9-11 English language Excellent Very Good Good Moderate Poor Institution Hospital Primary health care center 44 (32.1) 52 (38) 35 (25.5) 6 (4.4) 55 (40.1) 82 (59.9) 15 (10.9) 55 (40.1) 45 (32.8) 22 (16.1) 61 (44.5) 28 (20.4) 23 (16.8) 14 (10.2) 11 (8) 102 (74.5) 25 (18.2) 6 (4.4) 4 (2.9) 4 (2.9) 8 (5.8) 20 (14.6) 58 (42.3) 47 (34.3) 115 (83.9) 22 (16.1) 34.53 (7.908) 1.6 (0.492) 2.54 (0.891) 11.768 (9.612) 1.88 (2.244) 3.99 (0.996) 1.16 (0.368) https://doi.org/10.15218/ejnm.2019.07 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article Table 4 demonstrates a significant positive relationship (p= 0.023) between nature of work and health care institution at level 0.05. Moreover, there is a significant nega- tive relationship(p=0.011) between work supervision and number of training courses at level 0.05, while job promotion, work policy, and communication and interaction satisfaction-related domains did not reveal any relationship with nurses' demographic characteristics. Table 5 shows a highly sig- nificant negative relationship (p = 0.004) between nurses' monthly income with their satisfaction to work supervision do- main and at (0.01) level only. Table 6 and 7 indicate a significant difference among nurses related to their satisfaction toward nature of work domain according to their work place in health care institutions. The main purpose of this research was to determine nurses' job satisfaction in gov- ernmental hospitals and primary health 54 Erbil Journal of Nursing & Midwifery Table 2: Nurses' distribution by their Social characteristics Social Characteristics F (%) M (±SD) Marital status Single Married Divorced Widow 40 (29.2) 89 (65) 7 (5.1) 1 (0.7) 1.77 (0.569) Monthly income Sufficient Insufficient 21 (15.3) 116 (84.7) 1.85 (0.362) Residency Rural Urban 20 (14.6) 117 (85.4) 1.85 (0.354) Family type Nuclear Family Extended Family Single parent Family 89 (65) 46 (33.6) 2 (1.5) 1.36 (0.513) Socioeconomic Status Poor Average High 5 (3.6) 70 (51.1) 62 (45.3) 55.96 (9.511) Table 3: Distribution of nurses’ job satis- faction level according domains Job satisfaction level F (%) M (±SD) Job promotion Dissatisfied Discrepancy Satisfied 110 (80.3) 25 (18.2) 2 (1.5) 7.75 (2.192) Nature of work Dissatisfied Discrepancy Satisfied 93 (67.9) 43 (31.4) 1 (0.7) 12.23 (3.494) Work policy Dissatisfied Discrepancy Satisfied 86 (62.8) 51 (37.2) 0 (0) 12.64 (2.935) Communication and Interaction Dissatisfied Discrepancy Satisfied 75 (54.7) 62 (45.3) 0 (0) 10.69 (2.427) Work supervision Dissatisfied Discrepancy Satisfied 100 (73.0) 37 (27.0) 0 (0) 7.95 (2.073) DISCUSSION https://doi.org/10.15218/ejnm.2019.07 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article *Correlation is significant at the 0.05 level (2-tailed). Pearson. Co = Pearson Correlation, Sig. = Significant, N. = Number 55 Erbil Journal of Nursing & Midwifery Table 4: Relationship of nurses' job satisfaction domains with their demographic charac- teristics Age Gender Level of education Year of services Number of training courses English language Institution Job promo- tion Pearson. Co Sig.(2-tailed) N. 0.23 .787 137 -.059- .494 137 .107 .214 137 .050 .563 137 .000 .997 137 -.098- .252 137 .086 .317 137 Nature of work Pearson. Co Sig.(2-tailed) N. .147 .086 137 -.109- .204 137 -.018- .832 137 .146 .089 137 -.050- .563 137 .011 .898 137 .194* .023 137 Work policy Pearson. Co Sig.(2-tailed) N. .065 .452 137 -.046- .592 137 -.081- .344 137 .116 .177 137 -.013- .885 137 .064 .454 137 .055 .526 137 Communica- tion and in- teraction Pearson. Co Sig.(2-tailed) N. .049 .569 137 .019 .823 137 -.021- .803 137 .010 .911 137 -.045- .603 137 .008 .924 137 -.010- .905 137 Work supervision Pearson. Co Sig.(2-tailed) N. .141 .100 137 -.121- .158 137 -.084- .327 137 .154 .072 137 -.218* .011 137 .021 .806 137 .049 .567 137 care centers of Duhok city. Concerning to nurses' demographic characteristics, the present study shows most of the partici- pants are between 30-49 years of age and female. Regarding nurses level of educa- tion, most of the participants completed secondary nursing schools because college level nursing was just established at 2007. The number of nursing graduates is small compared to the number of secondary nursing school graduates. Most worked between one to seven years in the field. This was determined as most of the nurses with more experience were engaged in management duties and as a result have no time to participate in current study. In addition, due to the shortage of nursing staff in Duhok health institutions, the nurs- es do not have much opportunity to partic- ipate in many training courses. As men- tioned before, the majority of the nurses who participated in current study graduat- ed from secondary nursing schools and therefore have a moderate understanding https://doi.org/10.15218/ejnm.2019.07 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article of the English language. Finally, the majori- ty of nurses who participated in current study work in hospitals. A study conducted on nurse’s job stress in Duhok governmental hospital found that most of the participants were female, 59.3% and 53.4% received an education of less than a high school diploma. Regarding years of experience, the study showed that more than half of the nurses had less than three to six years of experience 51.6% *7+. Concerning job satisfaction and burnout among Palestinian nurses, findings show that the majority of nurses were female between 25-34 years of age. Also, they found that most nurses had certification to practice nursing and most of them have between four to six years of experience *1+. According to World Health Organization (WHO) and Ministry of Health (MOH) as of 2003-2008 in Iraq, the majority of the nurs- ing workforce, 6499 nurses out of 17743, were secondary nurses who graduated three years after intermediate school *8+. Respecting to nurses' marital status, more than half of nurses were married and life in a nuclear family. This is due to the large number of the study population being above 25 years of age. The majority of them live in a nuclear fami- ly because of Kurdistan population growth and their socio-cultural development over the last several years. Extended families tend to be independent from the immedi- ate family. Most participants have an in- sufficient monthly income, due to the last Kurdistan economic crisis and most of them have only a few years of work ser- vice. The majority of participants reside urban areas as a result of conducting this current study in health care institutions in urbanized areas of Duhok City. It was inter- esting to find out that the majority of study subjects' socioeconomic status ranged be- tween average to high because most nurs- es have private jobs rather than government jobs to compensate for the shortage in monthly payment due to com- pulsory saving measures. A research paper found that most of the nurses who participated in the study were married *9+. Musa in (2012) also found that the majority of the nurses who participat- ed in the study were married (59.6%) *7+. A study on nurses who worked in selective private hospitals in England found that (67.53%) of the participants showed dis- satisfaction toward salary and they would leave their current hospitals *10+.Regarding nurses' job satisfaction lev- els, the present study shows dissatisfaction of nurses towards job promotion, nature of work, work policy, work supervision, communication, and interaction. A recent study indicated that receiving a job promo- tion increased job satisfaction by nearly 0.12 units on average *11+. Results in a study done by Farsi indicated that nurses were less satisfied in work comfortable and neglecting aspects related to respect part of the study while also be- ing secure by having sufficient promotional opportunities and salaries *13+. A research study conducted by Lephalala et.al, related to the nature of nursing work stated that the majority of nurses show dissatisfaction toward social disruptions and working overtime *10+. A study conducted at Muhimbili National Hospital shows nearly half of the nurses who worked there displayed feelings of dissatisfaction toward hospital policy, envi- ronment, and technical supervision. On the other hand, they were satisfied with their co-worker relationships and improved working conditions *14+. Results of other studies showed low nurs- es' satisfaction regarding supervision, training issues (opportunities, time, fund- ing for courses and perceptions of ade- quate training), and moderate level of satisfaction related to contact with 56 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2019.07 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article their nature of work which lead them to feel insecure. A study conducted on job satisfaction of nurses in Ministry of Health hospitals in Riyadh, Saudi Arabia by Al- Ahmadi revealed that a combination of several aspects(recognition, technical as- pects of supervision, work conditions, ap- plying skill, job advancement, and pay- ment) have strong influence on overall job satisfaction. The combination of these as- pects clarify the difference in overall nurs- ing job satisfaction *19+. Another study was done in order to find out the factors affecting job satisfaction of registered nurses in Mashhad, Iran. This study indicated positive correlation of overall nurses' job satisfaction with sup- portive nursing management, efforts un- dertaken to improve working conditions, professional development, improved pro- fessional status, and increased salaries *20+. Finally, study findings related to their place of work found significant differences between the nurses' satisfaction towards their nature of work on the basis of their work place and no relationship between other variables. The nurses who worked in primary health care centers are partially more satisfied with their job than those in hospitals because the nature of nursing duties in primary health care centers re- quires less efforts and stress. Regarding personal job promotion, a re- cent study’s results show that 59.1% of nurses expressed dissatisfaction towards having ample opportunities for profession- al personal growth and development through the course of their education and training while 41.3% of them were satis- fied with such level of promotion. Particu- larly, out of those dissatisfied 68% work in healthcare centers while the rest of the nurses (31.7%) work in hospitals *21+. A recent study conducted to explore the job satisfaction among professional workers in primary healthcare centers in an area colleagues and feeling part of a team *15+. A recent study conducted on professional nurses who worked at public hospitals in Johannesburg City, South Africa indicated inadequate communication between pro- fessional nurses and their managers. Fur- thermore, they showed dissatisfaction to- ward the recognition of their work efforts and lack of acknowledgment that they re- ceived for their efforts *16+. Respecting the relationship between nurs- es' job satisfaction and their demographic characteristics, the present study showed a significant positive relationship between nature of work and health care institution because the nurses who worked in primary health care centers were more satisfied toward their work nature and they did not have much work stress compared to those working in hospitals. In addition, the find- ings show a significant negative relation- ship between work supervision roles and number of training courses. Because of these roles, nurses' opportunities have been limited to participating in training courses to enhance and develop their skills and knowledge. A research study by Ver- meir et al related to job satisfaction and its relation to communication among nurses concluded that a relationship exists be- tween job satisfaction and communication among nurses *17+. Furthermore, a study in Ekiti State in Nige- ria on nurses working in primary healthcare centers showed strong positive correlation between overall work environment of the- se primary healthcare centers and the gen- eral job satisfaction of the nurses *18+. Concerning the relation between nurses' job satisfaction and their social characteris- tics, the current study found a highly sig- nificant relationship between nurses' satis- faction to work supervision roles and their monthly income. This due to financial neg- ative rules and regulations of health care institutions toward nursing comparing to 57 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2019.07 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article The authors report no conflict of interests. *1+ Jayasuriya R, Whittaker M, Halim G and Matineau T. Rural health workers and their work environment: The role of inter- personal factors on job satisfaction of nurs- es in rural Papua New Guinea. British Medi- cal Center for Health Services Research. 2012; 12:156. Available from: https:// doi.org/10.1186/1472-6963-12-156 *2+ Haijuan W, YongPin N, and Bibo X. Main factors influencing nurse job satisfaction. A cross-country study. MSc. thesis. Interna- tional Business Department of Business Ad- ministration & Economics. 2006. *3+ Abushaikha L and Saca-Hazboun H. Job satisfaction and burnout among Palestinian nurses. Eastern Mediterranean Health Jour- nal.2009; 15(1):190-197. Available from: http://applications.emro.who.int/dsaf/ dsa971.pdf *4+ Younes MR. Job satisfaction and work per- formance, A case study of the American University in Cairo. MSc. thesis. American University in Cairo, School of Global Affairs and Public Policy Department of Public Poli- cy and Administration. 2012. Available form: http://dar.aucegypt.edu/ handle/10526/3129 *5+ Kalisch BJ, Lee H and Rochman M. Nursing staff teamwork and job satisfaction. Journal of Nursing Management. 2010; 18(8):938- 47. Available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ PMC2994317/ *6+ Poh LC. Nurses’ Job Satisfaction in the Ma- laysian Private Hospitals. MSc. Thesis. Busi- ness Administration Department. 2008. Available from: http:// eprints.usm.my/25387/1/NURSES%E2%80% 99_JOB_SATISFACTION.pdf *7+ Musa M. Job Stress Source among Nurses Working in Duhok Governmental Hospitals. Journal of University of Duhok (Pure and Eng. Sciences). 2012; 15(2):94-101. Availa- ble at: web.uod.ac/documents/190/ FINAL.pdf of Asturias found that the nursing staff was most satisfied with their jobs compared to other occupations who work in these cen- ters *22+. Other recent study at Rzgary teaching hospital of Erbil City shows that the nurses working in these hospitals were satisfied with their job *23+. In conclusion, this study demonstrates that nurses working in health care institutions in Duhok City were generally dissatisfied toward job promotion, nature of work, work policy, communication and interac- tion, and work supervision. Moreover, there was a significant relation- ship between the nurses' satisfaction to- ward the nature of work and their place of work and work supervision roles with the number of training courses. In addition, there was significant relationship between their satisfaction toward work supervision roles and their monthly income. Further- more, nurses working in primary health care centers were partially more satisfied with their nature of work than those work- ing in hospitals. As a result, it is recom- mended that the Director of Health of Duhok Province needs to consider the do- mains of this study to increase nurses' satisfaction towards their job as well as im- prove the quality of nursing care through increasing nursing training courses, distrib- uting them fairly, and creating a good work environment for communication. Supervisors with higher levels of education and more work experience should be able to communicate with other nurses and fa- cilitate discussions where nurses can dis- cuss their problems, needs and share in developing the policies of their healthcare institutions. 58 Erbil Journal of Nursing & Midwifery CONCLUSIONS CONFLICTS OF INTEREST REFERENCES https://doi.org/10.1186/1472-6963-12-156 https://doi.org/10.1186/1472-6963-12-156 https://doi.org/10.15218/ejnm.2019.07 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article *17+ Ayamolowo S J, Irinoye O, Oladoyin M A. Job Satisfaction and Work Environment of Primary Health Care Nurses in Ekiti State, Nigeria: an Exploratory Study. International Journal of Caring Sciences. 2013; 6(3): 531- 542. Available from: www.internationaljournalofcaringsciences.o rg *18+ Al-Ahmadi H A. Job satisfaction of nurses in Ministry of Health Hospitals in Riyadh, Saudi Arabia. Saudi Medical Journal. 2002; 23(6): 645-650. 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