https://doi.org/10.15218/ejnm.2018.01 EJNM, Vol. 1, No. (1), May, 2018 Original Article Impact of Nurse’s Satisfaction on Work Performance ABSTRACT INTRODUCTION Employees are the most important re- sources of all organizations. How they feel about the work and the outcomes from it have a direct impact on the organization’s performance and stability. A job is a paid position of regular employment and em- ployment is required to be financially inde- pendent and have control over life *1+. Hu- lin and Judge (2003) noted that job satis- faction includes multidimensional psycho- logical responses to one's job and that such responses have cognitive (evaluative), affective (emotional), and behavioral com- ponents *2+. Job satisfaction is defined as, “the level of contentment a person feels regarding their job while work perfor- mance is the work related activities ex- pected from an employee and how well those activities are executed by them” *3+. To measure work performance, the quality of the job has traditionally understood as being represented by the wage level, while in some sociological or industrial relations studies, it was related to working condi- tions. Recent developments in economics and socio-economic approaches propose additional dimensions to the definition of job quality *4+. The recent framework sug- gested by Green(2006) integrates these ideas and recognizes the multidimensional character of job quality through the evolu- tion of different dimensions that including Background and objective: A high satisfaction of nurses implies an improvement in effec- tiveness and performance in doing work or health care service. This study aimed to find out the relationship between nurse’s job satisfaction and their work performance in the hospital while providing health care. Methods: A descriptive cross-sectional study was carried out at both Hawler and Rizgary Teaching Hospitals in Erbil City of the Kurdistan Region of Iraq. A randomized-clustered sampling technique was used for enrolling 89 nurses and 27 their team-leaders through a direct interview by a questionnaire to assess nurse’s job satisfaction by researcher and evaluate work performance by their team-leaders. The outcome focused on the correla- tion coefficient to find out the correlation between job satisfaction and work performance of nurses. Results: The majority of the study sample was between 20 and 32 years old, Institute grad- uated, had fewer than five years of experience, and single among nurses with 33 and 45 years old, college graduated, more than five years, and married among team-leaders, from urban areas of both groups. Most of the nurses had fairly job satisfaction and team-leaders think that the nurses need some improvement in their work performance. Conclusion: There was a strong positive correlation between nurse’s job satisfaction and their work performance in the hospital during providing health care. Keywords: Nurse; Team-leader; Job satisfaction; Health work performance; Correlation. Dara Abdulla Al-Banna; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: daraaq@nur.hmu.edu.krd) 2 Erbil Journal of Nursing & Midwifery Received: 30/8/2017 Accepted: 19/10/2017 Published: 5/5/2018 https://doi.org/10.15218/ejnm.2018.01 EJNM, Vol. 1, No. (1), May, 2018 Original Article skills; work effort and intensification’ work- ers’ discretion; wages’ risk and job insecuri- ty’ and workers’ well-being and thus takes into account the multidimensional nature of job quality in work performance *5+. A nurse with a high level of job satisfaction holds positive attitudes towards his or her job in health care, while a nurse who is dis- satisfied with his or her job may hold nega- tive attitudes about the job. Therefore, job satisfaction is a key issue for health care professionals around the world and investi- gations reveal first of all that the organiza- tional features of a structure usually a hos- pital can greatly influence the job satisfac- tion of nurses *6+. However, the total organizational perfor- mance depends on the efficient and effec- tive performance of individual employees of the organization. Therefore, every or- ganization places a considerable reliance on their individual employee performance to gain high productivity in the organiza- tion *7+. A large empirical literature exists that explores the determinants of organiza- tional performance including the determi- nants of financial performance and the de- terminants of labor productivity. Many studies are based on firm-level data. One might argue, however, that, in order to un- derstand the determinants of firm perfor- mance, it is important to analyze employee level of job satisfaction given that the be- havior of employees and the decisions they make may influence workplace perfor- mance *8+. From the above definitions, it is clear that nurse’s job satisfaction is an un- observable variable. Job satisfaction can be affected by the work performance of nurs- ing care and can directly impact the productivity of each organization or hospi- tal. In examining in outcomes of job satis- faction, it is important to breakdown the analysis into a series of specific set of varia- bles regarding nurse’s satisfaction and evaluating form of work performance. The main objective of this study was to find out the correlation between nurse’s job satis- faction and their work performance, evalu- ated by their team-leaders. A cross-sectional study design was con- ducted among nurses and their team- leaders to find out the relationship be- tween job satisfaction and their work per- formance, from April to July 2017 at two hospitals of Rizgary and Hawler Teaching Hospitals in Erbil City in the Kurdistan Re- gion of Iraq. One hundred sixteen nurses enrolled in this study. They were divided in to two groups: the first group consisted of 89 nurses in different wards and units; the second group included 27 team-leaders of the nurses. The participants are working in the two hospitals of Rizgary and Hawler Teaching Hospitals in Erbil City in the Kur- distan Region of Iraq. Non-randomized- clustered sampling technique was used to establish a representative sample of the target population, according to the study’s inclusion and exclusion criteria. Both men and women were included. Agreed to be subject in this study with good personal communication. Administrative nurses (nurses working in offices without direct contact with patients) and who was in va- cation and night shift was excluded. Nurses group were asked about their job satisfac- tion, while team-leaders group were asked to evaluate these nurses who participated in the study. The sample size estimated based on the following parameters through the G-Power software Version 3.1 in two tails: Alpha I error/ level of signifi- cance = 0.05 in 95% confidence interval Power (1-Beta II error) = 80% = 0.8, Effect size (0.257) of correlation (0.0663) of the previous study. The data were collected through a direct interview by the research- er in the Kurdish language after translating from English versions and vice versus. METHODS 3 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2018.01 EJNM, Vol. 1, No. (1), May, 2018 Original Article Ethical and Scientific Committees in the College of Nursing/ Hawler Medical Uni- versity. Informal oral consent was ob- tained from each participant, and all pa- tients’ information was kept confidential. In addition, the researcher told each par- ticipant that their participation was volun- tary work, and that they were free to leave at any time, even the interview process was not finished. After data collection, the variables and data were entered to statisti- cal application (Statistical Package for So- cial Science -SPSS Version 23). The data were analyzed through using SPSS soft- ware that included descriptive statistical analysis (Frequency, Percentage, Mean, and Standard Deviation) and inferential statistical analysis (Spearman Correlation Coefficient). The confidence interval was 95%. The P-value of each test ≤ 0.05 con- sidered as statistically significant, power 0.80, and correlation between ± 1. Table 1 shows the sociodemographic characteristics of the 89 nurses and 27 their team-leaders. Regarding age group, the highest percentage of the study sam- ple was between ages 20-32 years old among nurses (76.5%) while it was be- tween ages 33-45 years old among team- leaders (70.4%). More than half of the study sample were female among nurses; but most of the team-leaders were male (92.6%). Concerning the level of education, among the nurses the majority had gradu- ated from a medical institute (75.3%), while half of the team-leaders had gradu- ated from a medical institute and others from nursing college. Half of the nurses had fewer than five years of experience, but among team-leaders, the majority had more than five years of experience (89%). Half of the nurses were unmarried, while most of team-leaders were married (85.2%). The data collection tool was prepared by the researcher based on literature review, prior studies, and expert recommendations from the field. The questionnaire consisted of two different forms. The first question- naire designed for nurses included 17 soci- odemographic characteristics of the nurse and questions regarding job satisfaction, which that contained 17 questions distrib- uted on five main domains “general work- ing conditions, pay and promotion poten- tial, work relationships, use of skills and abilities, and work activities”. Job satisfac- tion questions allowed for three levels of satisfaction (unsatisfied, moderately satis- fied, and satisfied), scored from one to three. The second questionnaire for team- leaders who leading above described nurs- es that included 14 questions related to sociodemographic characteristics of the team-leaders and 14 questions regarding evaluation of nurse’s work performance of health care by their team-leader with re- sponds of five level of work performance (major improvement needed, some im- provement needed, meets expectations, often exceeds expectations, and consist- ently exceeds expectations) scored from one to five. The validity of the question- naire was checked initially by experts from different related of nursing and administra- tive specialties. The expert responses were based on agreement or disagreement with items of questionnaire. The results indicat- ed that all experts agreed the content of the questionnaire with some modifications. The researcher took into consideration their responses and prepared the final ver- sion of the questionnaire. A pilot study was carried out in two wards of each hospital (11 nurses and 2 team-leaders) to deter- mine the reliability of the questionnaire (internal consistency by split-half). The al- pha correlation coefficient was 0.842, which is statistically adequate. The formal permission obtained from both of the 4 RESULTS Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2018.01 EJNM, Vol. 1, No. (1), May, 2018 Original Article Finally, most of the study participants were from urban areas including 86.5% of nurses and 100% of team-leaders. Table 2 shows nurses’ job satisfaction about their work. The majority of nurses responded saying they were fairly satisfied regarding general working conditions and work relationships (46.1% and 43.8% re- spectively). However, the majority of the participants responded saying they were dissatisfied regarding pay and promotion potential, use of skills and abilities, and work activities (52.8%, 48.3%, and 46.1% respectively). The overall level of nurse’s satisfaction was fairly satisfied which pre- sent 69.7%, but 21.3% and 9% for each of dissatisfied and satisfied respectively. Re- garding overall evaluation of nurse’s work performance by their team-leaders, re- sults in Table 3 show that most the majori- ty of the team-leaders indicated that the nurses required some improvements (85.2%), while 14.8% of the team-leaders suggested the nurses required major im- provements Unfortunately, there no nurs- es met the expectations of their work per- formance of providing care. Table 4 describes the correlation between the job satisfactions of nurses with their evaluation of work performance by their team-leaders which there is a nearly matching mean scores between the above two variables (M ± SD = 1.88 ± 0.540 and 2.04 ± 0.366 respectively). There is a very highly statistical significant correlation be- tween nurse’s job satisfaction and their work performance (p-value = < 0.001). The correlation between the two described variables is strong (r = 0.712) with positive direction of the correlation. 5 Table 1: Sociodemographic characteristics of nurses and team-leaders Sociodemographic Characteristics Nurse (n=89) Team- leader (n=27) F (%) F (%) Age group (years) 20-32 68 (76.5) 4 (14.8) 33-45 19 (21.3) 19 (70.4) 46-58 2 (2.2) 4 (14.8) Gender Male 43 (48.3) 25 (92.6) Female 46 (51.7) 2 (7.4) Education level Institute graduated 67 (75.3) 13 (48.1) College graduated 22 (24.7) 14 (51.9) Years of experience ≤ 5 49 (55.1) 3 (11.1) 6-10 26 (29.2) 11 (40.7) 11-15 8 (9) 10 (37.1) > 15 6 (6.7) 3 (11.1) Marital status Single 48 (53.9) 4 (14.8) Married 39 (43.9) 23 (85.2) Divorced 2 (2.2) 0 (0) Residency area Urban 77 (86.5) 27 (100) Rural 12 (13.5) 0 (0) Total 89 (100) 27 (100) Table 2: Level of Job satisfaction among nurses Questions regarding nurse’s job satisfaction Dissatisfied Moderately satisfied Satisfied F (%) F (%) F (%) General working conditions 15 (16.9) 41 (46.1) 33 (37.1) Pay and promotion potential 47 (52.8) 39 (43.8) 3 (3.4) Work relationships 13 (14.6) 39 (43.8) 37 (41.6) Use of skills and abilities 43 (48.3) 30 (33.7) 16 (18) Work activities 41 (46.1) 39 (43.8) 9 (10.1) Overall Nurse Satisfaction 19 (21.3) 62 (69.7) 8 (9) Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2018.01 EJNM, Vol. 1, No. (1), May, 2018 Original Article The aim of the current study was to find out the relationship between nurse’s job satisfaction and their work performance which was evaluated by their team leaders. Regarding the sociodemographic charac- teristics of both nurses and team-leaders, the highest percentage of the study sample was between ages 20 to 32 years old among nurses, while it was between ages 33 to 45 years old among team-leaders. Because all of the nurses graduated from medical institute and college of nursing and these institutions are newer than pre- paratory of nursing, the majority of the nurses are in the twenties of age. More than half of the study sample was female among nurses; but most of the team- leaders were male. Traditionally most of leaders are male. Concerning the level of education, among the nurses, most had graduated from a medical institute, while half of the team-leaders were graduates from the medical institute and others from the college of nursing. Half of the nurses are single, while most of team-leaders were married. These results supported by a study done in Kingdom Saudi Arabia by Almaliki et al in 2012 they found that the highest percentage of their study sample of nurses were aged between 20 and 29 years old, female, had a diploma, and were not married *9,10+. Half the nurses had fewer than five years of experience, but most team-leaders had more than five years’ experience. This result is supported by the study which was done in Public Hos- pitals-Libya by Ali et al in 2014, which showed that nearly half of the staff has fewer than five years with regards to work- ing experience in hospitals *2+. Concerning the level of job satisfaction among nurses, the highest percentage of the nurses an- swered fairly satisfied regarding general working conditions and work relationships, while the highest percentage of the partici- pants answered that they were dissatisfied Table 4: Association between nurse’s job satisfaction and their work performance 6 DISCUSSION Association between nurse’s job satisfaction and their work performance Mean Standard Deviation P-value Correlation Coefficient Strength Direction Nurse’s job satisfaction 1.88 0.540 < 0.001 VHS 0.712 Strong Positive Nurse’s work performance 2.04 0.366 Table 3: Overall evaluation of nurse’s work performance by their team-leaders Overall evaluation of nurse’s work perfor- mance by their team-leaders F (%) Major improvement needed 4 (14.8) Some improvement needed 23 (85.2) Meets expectations 0 (0) Often exceeds expectations 0 (0) Consistently exceeds expectations 0 (0) Total 27 (100) Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2018.01 EJNM, Vol. 1, No. (1), May, 2018 Original Article regarding pay and promotion potential, use of skills and abilities, and work activities. The overall level of nurses’ satisfaction was fairly satisfied and others were dissatisfied with less satisfied nurses. The political in- stability, financial crises, lack of salary and payment, wars, food insecurity, unclarity of future and missing of basic human needs affected employees’ satisfaction particular- ly among nurses. The present findings agreed with other studied done in different areas and countries as following: In a study done in Libya in 2014 under the title of “Job Satisfaction, Organizational Behavior, and Training to Improve Employees Perfor- mance” about the relationship between hospital staff and human resource manag- ers, the relationship between hospital staff and managers is sometimes breakable. The nurses and staff may feel uncomfortable giving unfavorable opinions about manag- ers because of worries about job security, while managers and supervisors wonders if nurses and staff are working to the best of their ability. The absence of incentives and low salaries were two main reasons for reported poor job satisfaction, and accord- ing to the job satisfaction factor in medical sector had a negative effect on staff’s per- formance. They also measured the incen- tives that employees received during their past period working in public hospitals. Be- cause incentives and salary are of the main factors that increase and improve perfor- mance at any organization. The result showed that 38 out of 56 respondents were disagreed and strongly disagreed. The incentive systems to medical and staff in Libyan public hospitals was approximately the major percentage of hospital staff re- vealed no incentives and less salary have been given to them in the past, which shows the lack of real incentives and salary giving to hospital staff in order to give them higher motivation and push them to work better and give their best output to their organization. The findings of the pre- sent study regarding the nurses job satis- faction supported findings from other studies conducted in Bangalore, Iran, and Turkey by Ramesh et al, Saraji and Dargahi, and Sirin in 2013, 2006, and 2015. The findings revealed that respondents were dissatisfied with their work life and these findings are consistent with findings of a number of previous studies where nurses were not satisfied with their work life *2,11 -13+. Regarding the overall evaluation of nurse work performance by their team-leaders, most of the team-leaders suggested that nurses required some improvement, while fewer team-leaders suggested that the nurses required of needing the major im- provement by nurses. Unfortunately, there are no nurses meet the expectations in their work performance of providing health care. This is because of that most of the nurses were fairly or not satisfied with their job. The study results agreed with the study done by Becton and Matthews in the USA during the years 2011 to 2012, they found that the nursing quality has a signifi- cant impact on patient outcomes. Re- search has shown that the job perfor- mance of nurses is the single largest pre- dictor of patients’ satisfaction and signifi- cantly affects patients’ health outcomes during and after hospitalization. Therefore, the consequences of poor nurse perfor- mance are significant to improve the job performance of nurses *14+. The present study found that there is an association between nurse’s job satisfaction and their work performance which was evaluated by their team-leader. There was a very high statistically significant correlation between nurse’s job satisfaction and their work per- formance. The correlation between the two described variables is strong with the positive direction of the correlation. This association is important for health care 7 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2018.01 EJNM, Vol. 1, No. (1), May, 2018 Original Article work performance in hospital in providing health care. The implications of this study are helpful for planning and increasing the level of nurse job satisfaction. This could be done through improving working hours, flexibility in scheduling, area of work, and offering adequate amount of paid vacation time or sick leave; in security and potential promotion like pay of salary in its time and amount, assurance, and job security; also in elevating work relation- ships for increasing relationships with co- workers, team-leaders, supervisors, and head of departments; improving skills and abilities through participating nurses in training courses, opportunity to learn new skills then utilizing their skills and talents. Furthermore, it is important to increase work activities including improving the va- riety of job responsibilities, increasing the degree of independence, delegating au- thorities, and adequate opportunity for periodic changes in duties. Study limitations Although the present study described im- portant findings, no study is without limita- tions, First, this study was conducted with- in two large hospitals within the same Erbil City. While the study focused on the pre- diction of the job performance of nurses, it is possible that the present study findings may be a performance and outcome of some locally or regionally specific factors which could not be controlled. Second, this study focused on nurses who are working in these two big hospitals. It should be not- ed that nurses are working in other types of healthcare organizations in addition to hospitals, such as nursing homes, health clinics, medical practices, and other out- side places of the hospital. As a result, the study design may limit the generalizability of the results to other settings. Future studies could include nurses from a variety of healthcare organizations in a variety of locations. and hospital outcomes. This expected re- sult supported by many studies. Authors Platis et al presented a study under the ti- tle “Relation between job satisfaction and job performance in healthcare services”, they showed that self-satisfaction of quan- tity of work versus self-satisfaction of productivity has a significant, strong, and positive correlation (r=0.76). In this work investigation of the performance for the quality of job satisfaction and self-job satis- faction for nurses is taking place. For the job satisfaction, two factors have been in- troduced which are manager administra- tion and job productivity, explaining the 68.7% of the total information. Further- more, the ability of nursing managers to communicate with the employees and re- spect their opinions in considered of high importance for the nursing staff satisfac- tion *9+. In a study which was done in Paki- stan by Khan et al, in 2011 entitled “Impact of job satisfaction on employee perfor- mance: An empirical study of autonomous Medical Institutions of Pakistan” they found that the relationship between productivity (often under the form of per- sonal achievements) and satisfaction in job is also considered strong *15+. In a study about employee motivation and organiza- tional performance, employee attitude and job performance are essential to the suc- cess of the organization, regardless big or small. In the modern workplace, human resources are valued above all other val- ues, so motivated, happy personal feelings, opinions, attitudes of nurses and com- mitted employees are the productive em- ployees and play a critical role in their per- formance *16+. Creating and maintaining a healthy work life for nurses is very im- portant to improve their work satisfaction, which lead to improves nursing care out- comes *10+. The present study concluded that there was a strong positive association between nurse job satisfaction and their 8 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2018.01 EJNM, Vol. 1, No. (1), May, 2018 Original Article *14+ Becton JB, Matthews MC, Hartley DL, Whitaker LD. Using biodata as a predictor of errors, tardiness, policy violations, overall job performance, and turnover among nurses. Journal of Management & Organiza- tion. 2012 Sep;18(5):714-27. *15+ Khan AH, Ahmad I, Aleem M, Hamed W. Impact of job satisfaction on employee performance: An empiri- cal study of autonomous medical institutions of Paki- stan. International Journal of Management and Inno- vation. 2011 Jul 1;3(2):1. *16+ Dobre OI. Employee motivation and organizational performance. 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