SUBMITTED 25 DEC 22 1 REVISIONS REQ. 7 FEB & 23 MAR 23; REVISIONS RECD. 2 MAR & 4 APR 23 2 ACCEPTED 11 APR 23 3 ONLINE-FIRST: MAY 2023 4 DOI: https://doi.org/10.18295/squmj.5.2023.031 5 6 Direct and Moderating Effects of Work Environment and Structural 7 Empowerment on Job Stress and Job Satisfaction Among Nurses in the 8 Sultanate of Oman 9 Raeda AbuAlRub,1 *Sulaiman D. Al Sabei,2 Omar Al-Rawajfah,3,4 10 Leodoro J. Labrague,5 Ikram A. Burney6 11 12 1Community and Mental Health Nursing Department, Faculty of Nursing, Jordan University of 13 Science and Technology, Irbid, Jordan; 2Fundamentals and Administration Department, College 14 of Nursing, Sultan Qaboos University, Muscat, Oman; 3Adult and Critical Care Department, 15 College of Nursing, Sultan Qaboos University, Muscat, Oman; 4College of Nursing, Al al-Bayt 16 University, Jordan; 5Health Systems & Adult Health Nursing Department, Loyola University 17 Chicago, USA; 6Sultan Qaboos Comprehensive Cancer Center, Muscat, Oman. 18 *Corresponding Author’s e-mail: alsabei@squ.edu.om 19 20 Abstract 21 Objective: This paper seeks to explore the relationships between nurses’ work environment, job 22 stress, and job satisfaction, as well as the moderating effects of work environment and 23 empowerment on the job stress–job satisfaction relationship. Methods: A descriptive 24 correlational design was utilized. The study encompassed a convenience sample of 1,796 25 hospital nurses from the 11 governorates in Oman. A self-report questionnaire that included a set 26 of instruments was used to collect data. Results: The results showed that nurses who perceived 27 higher levels of job stress reported lower levels of satisfaction and empowerment, and perceived 28 their work environment as less favorable and supportive. The findings only confirmed the direct 29 effects of work environment and empowerment on satisfaction; there was no support for indirect 30 or moderating effects. The hierarchical regression model showed that 46.5% of the variation in 31 the level of job satisfaction was explained by the study variables. Conclusion: The results of this 32 study demonstrate the importance of implementing strategies that empower staff, provide a 33 supportive and positive work environment, and tackle job stress to enhance levels of job 34 satisfaction. 35 Keywords: Work Environment; Empowerment; Job Stress; Job Satisfaction; Nurses; Oman. 36 37 Advances in Knowledge: 38 • The findings of the study supported the negative correlations between job stress and job 39 satisfaction, job stress and work environment, and job stress and empowerment. 40 • The findings support the positive direct effects of work environment as well as 41 empowerment on job stress and job satisfaction; while the indirect or moderating effects 42 of work environment and empowerment on job stress-job satisfaction relationship were 43 not supported among nurses working in Oman. 44 • Background variables, job stress, work environment, and empowerment explained 46.5% 45 of the variation in the level of job satisfaction among nurses working in Oman. 46 • The results support the existing evidence on the importance of adopting and 47 implementing strategies that tackle job stress and promote a supportive work 48 environment as well. 49 50 Application to Patient Care: 51 • Auditing healthcare services, implementing programs to lean process of tests and 52 procedures execution, and investing in subacute health services and home-based care 53 programs are essential steps to improve early discharges and minimize inappropriate 54 hospital stay. 55 • Identifying modifiable factors that can enhance satisfaction among nurses working in 56 Oman can help improve the quality of care provided to patients as well. 57 58 59 60 61 Introduction 62 Working in healthcare is stressful and can be physically and emotionally demanding.1 The work 63 environment can either support or hinder workers’ health and performance. Therefore, promoting 64 a healthy work environment has become a focus of healthcare organizations worldwide. 65 66 Research evidence has shown a strong association between supportive work environment and 67 nurse outcomes: including enhanced quality of patient care, lower levels of job stress, fewer 68 adverse events, higher levels of job satisfaction, reduced levels of intention to leave, and higher 69 levels of willingness to engage in leadership roles.2–7 70 71 In contrast, unhealthy work environments can lead to negative staff outcomes, such as higher levels 72 of job stress and lower levels of job satisfaction. Evidence has shown that unhealthy work 73 environments lead to decreased productivity, increased turnover rates, and increased healthcare 74 costs by billions of dollars annually.8 Working in unhealthy work environment can negatively 75 impact patient safety and quality outcomes.6 Exploring the work environment and its underpinning 76 variables is therefore paramount in healthcare institutions. 77 78 One such variable is the concept of empowerment, which is well researched among nurses. The 79 structural empowerment model 9 based on Kanter’s theory10 stands out among the various 80 models in the nursing context. According to Kanter,10 the characteristics of the work 81 environment determine work behaviors and attitudes, regardless of personal characteristics. 82 Thus, when the workplace is characterized by a supportive work environment that provides the 83 "necessary power" to meet job demands, nurses feel empowered. Mounting evidence has 84 demonstrated a strong positive relationship between structural empowerment and job 85 satisfaction.11,12 A meta-analysis of 59 studies showed that higher levels of job satisfaction 86 among hospital nurses are associated with a positive work environment, an increased level of 87 structural empowerment, and a decreased level of job stress.13 88 89 Nursing is regarded as a stressful profession.14 Psychological risks at work, such as job stress, 90 conflicts, and excessive workloads, have become one of the challenges of the 21st century due to 91 their negative impact on staff and organizational outcomes.15 Job stress and strain have been 92 associated with the physical and mental health and well-being of employees.1 Increased levels of 93 job stressors are significantly correlated with burnout and decreased levels of empowerment.16 94 95 Exploring job satisfaction and its associated variables has been of great interest to nurse 96 researchers around the globe. To date, several variables that have mediating or moderating 97 effects on job satisfaction have been identified by researchers.13 Despite the abundance of 98 research on job stress and satisfaction, there has been a relative lack of studies that focus on the 99 association between empowerment and job stress and their impact on job satisfaction among 100 nurses. To the author’s knowledge, no study worldwide has investigated specifically the 101 moderating effects of work environment and empowerment on the job stress–job satisfaction 102 relationship. However, studies in Western countries have investigated these concepts with 103 different aims. Evidence of the impact of the nurse work environment on nurses’ outcomes in the 104 Sultanate of Oman is scant. Thus, this study was conducted to explore the direct and moderating 105 effects of work environment and structured empowerment on job stress and job satisfaction 106 among nurses in the Sultanate of Oman. 107 108 Methods 109 Study Design 110 A descriptive correlational design was used to answer research objectives. 111 112 Setting and Sampling Procedure 113 A convenience sampling method was used to recruit nurses who had at least one year of 114 experience and at least a diploma degree. The required participants were recruited conveniently 115 from a proportional stratified clustered sample of hospitals from the 11 governorates of Oman. 116 Hospitals were stratified based on two dimensions: type (private vs. public hospitals) and 117 location (based on the 11 governorates in the country). Public hospitals included both those 118 under the Ministry of Health and those not under the Ministry of Health. The population of 119 governorates in the Sultanate is geographically diverse. For that reason, some governorates have 120 only one public hospital. For governorates that have more than one public and/or more than one 121 private hospitals, hospitals were selected using convenience approach. For example, in Muscat, 122 where there are several public and private hospitals, hospitals were selected based on their 123 convenient accessibility. 124 125 Population and Sample Size 126 The sample size in the present study was 1,796 registered nurses. The sample size was based on 127 the calculated total accessible population size of nurses working in Oman which was 11,096 at 128 the time of the survey.17According to Yamane’s standardized formula for calculating sample size 129 from the defined population,18 the estimated sample size was 386 nurses. However, 130 given that the sample was drawn from 11 governorates in the Sultanate, applying these 131 calculations will mostly result in unrepresentative sample. Therefore, the researchers decided to 132 sample at least 10% of the accessible population to produce representative results. A total of 133 2000 nurses were recruited from across the 11 governorates. The use of this method is supported 134 in the literature.6,19 135 136 Data Collection Procedure and Ethical Considerations 137 Approvals from the institutional review boards of the affiliated university, the ministry of health, 138 and the targeted private hospitals were granted before the study commenced. The purpose and 139 significance of the study were explained to the nurse administrators and participants. Nurses 140 were invited to participate by research assistants during different shifts. Participants were 141 provided with a package that contained information about the purpose and significance of the 142 study, as well the study instruments [the Nursing Work Index (PES–NWI), the Conditions of 143 Work Effectiveness Questionnaire–II (CWQ–II), one question to assess job satisfaction: “How 144 satisfied are you with your current job?”, and the Perceived Stress Scale], and a return envelope. 145 The English version of all instruments was used as there were expatriate nurses among the 146 sample. Participants were asked to drop the completed surveys in a locked box in their manager’s 147 office. Participants were assured that their responses would remain confidential and would be 148 reported in aggregate form. 149 150 Instruments 151 Nursing practice environment was measured using the 31-item Practice Environment Scale of the 152 Nursing Work Index (PES–NWI).20 The PES–NWI consists of 31 items and 5 subscales: nurse 153 participation in hospital affairs; nursing foundation for quality care; nurse manager ability, 154 leadership, and support of nurses; staffing and resource adequacy; and collegial nurse–physician 155 relations. Items are rated on a four-point Likert scale ranging from 1 (strongly disagree) to 4 for 156 (strongly agree). A score below an average of 2.5 for the scale or its subscales represents 157 disagreement, while a score of an average higher than 2.5 represents agreement that the scale or 158 the subscale items are present in the current practice environment. The scale was reported to be 159 reliable and valid in previous studies.6,20 In the present study, the alpha coefficient was 0.94. 160 161 Structural empowerment was evaluated using the Conditions of Work Effectiveness 162 Questionnaire–II (CWQ–II).21 The CWQ–II is a 12-item Likert scale ranging from 1 for none to 163 5 for a lot. It measures four dimensions of empowerment: information, access to opportunity, 164 support, and resources. The reliability and validity of the scale have been well established 165 (Cronbach’s alpha = 0.82 for the composite score).21 166 167 Job satisfaction was assessed using a single question: “How satisfied are you with your current 168 job?”. Responses range from 1 for very dissatisfied to 4 for very satisfied. This measure has been 169 widely used in international health services studies.22,23 It has also been selected over other 170 measures of job satisfaction to overcome the overlap with the satisfaction components of the 171 PES–NWI. 172 173 Job stress was measured using the four-item Perceived Stress Scale.24 Respondents are asked to 174 indicate their agreement with each item on a 5-point Likert scale from 0 for never to 4 for very 175 often. 176 177 A demographic form was used to collect information on participants’ age, gender, level of 178 education, nationality, years of work experience, marital status, place of work, and position. 179 180 Data Analysis 181 SPSS version 22 was used for analysis. Descriptive statistics were utilized to analyze 182 participants’ characteristics. Pearson's correlation coefficient was used to examine the 183 relationships between the study variables. Hierarchical regression analysis was used to examine 184 the moderating effects of work environment and empowerment on the job stress–job satisfaction 185 relationship and the variance in job satisfaction explained by the study variables. Variables with 186 more than 10% missing data were excluded from the final analysis. A P value of 0.05 was set as 187 the cutoff for significance; however, the exact p values whether higher or lower than 0.05 were 188 reported for all statistical tests. 189 190 Results 191 Characteristics of the Sample 192 A total of 1,796 registered nurses working in Omani hospitals participated in the study. The 193 mean age of the participants was 34 years (SD = 6.9); with a range from 20 to 61 years. The 194 majority of them were females (n = 1,546; 87.2%), married (n = 1,388; 79.4%), and worked as 195 staff nurses (n = 912; 76.8%). More than 50% of the participants were expatriates (n = 1,030; 196 58.5%) who worked full-time (n = 1,560; 91.9%) in governmental (n = 1,750; 97.4%) and non-197 teaching hospitals (n = 983; 54.7%). The mean value for nurses’ experience in their current unit 198 was 7.3 years (SD = 5.1). Around 42% of the participants had a bachelor’s degree (n = 731; 199 41.9%). More than a third of the participants (n = 253; 37.6%) worked day shifts in different 200 units, such as medical–surgical (n = 601; 35.2%) and critical care (n = 509; 29.9%). Background 201 variables were analyzed and reported separately for Omani and expatriate nurses. Table 1 202 presents the data regarding participants’ background variables. 203 204 Variables of the Study 205 The results showed that the participants of the present study perceived a low level of job stress 206 (M = 1.7; SD = .59 on a scale from 0 to 4); and above a moderate level of Job satisfaction (M = 207 2.9; SD = .76 on a scale from 1 to 4). The results also showed that participants perceived their 208 work environment as positive (M = 2.8; SD = .90 on a scale from1 to 4). All five subscales of the 209 work environment scale were perceived positively. The subscale that received the highest rating 210 was “Foundations for quality care (M = 3, SD = 0.47). On the other hand, “Staffing and 211 resources adequacy” was perceived as the lowest among the subscales (M = 2.7, SD = 0.62). 212 Further, the participants perceived above moderate level of empowerment (M = 3.5; SD =.71 on 213 a scale from 1 to 5). The subscale “Access to opportunity” was rated by participants as the 214 highest (M = 3.7, SD = .90), followed by “Access to information” (M = 3.5, SD = .92) and 215 “Access to support” (M = 3.5; SD = .92). “Access to resources” was rated as the lowest (M = 216 3.2, SD =.86). Table 2 presents data about means and standard deviations of the study variables. 217 218 Further analysis showed that expatriate nurses perceived (1) lower levels of job stress in 219 comparison with their counterparts (Expatriate nurses: M = 1.7; Omani nurses: 1.9; p =.001); (2) 220 their work environment more positively than Omani nurses (Expatriate nurses: M=2.9; Omani 221 nurses: 2.7; p = .001); (3) and higher levels of structural empowerment than Omani nurses 222 (Expatriate nurses: M = 3.6; Omani Nurses: 3.2; p = .001); and higher levels of Job satisfaction 223 in comparison with their counterparts (Omani nurses) (Expatriate nurses: M = 3.1; Omani 224 Nurses: M = 2.6; p = .001). Table 3 presents data about difference between Omani and expatriate 225 nurses concerning study variables. 226 227 Moreover, analysis was done to examine if the levels of job stress, work environment, 228 empowerment and job satisfaction vary according to the education degree of participants and the 229 type of hospital. The results showed that a significant difference was only found for the stress 230 level; wherein nurses who had diploma degree perceived higher levels of stress than nurses with 231 bachelor degree (t = 2.5, p = .01). For the type of hospital, the results showed that significant 232 differences were only found for the work environment and empowerment; wherein nurses who 233 worked in private hospitals perceived higher levels of empowerment (t= -3.4, p<.001) and 234 perceived their work environment more positive (t = -5.1, p < .001 than nurse who work in 235 governmental hospitals. 236 237 Relationships Between Study Variables 238 The results showed that there was a significant negative correlation between job stress and job 239 satisfaction (r = -.32, p < 0.001); that is, nurses who perceived having more job stress had lower 240 perceptions of job satisfaction. Job stress was also negatively correlated with work environment 241 (r = -.19, p < 0.001) and empowerment (r = -.19, p < 0.001); that is, nurses with higher levels of 242 job stress perceived lower levels of empowerment and a less supportive work environment. 243 Regarding the relationships between work environment, job satisfaction, and empowerment, the 244 results showed significant positive correlations between work environment and job satisfaction (r 245 = .31, p < 0.001), and between work environment and empowerment (r = .47, p < 0.001). That is, 246 nurses who perceived their work environment as supportive reported higher levels of job 247 satisfaction and empowerment. Furthermore, empowerment was positively correlated with job 248 satisfaction (r = .18, p < 0.001). That is, nurses who felt more empowered were more satisfied at 249 work. Table 4 presents data about correlations for work environment, empowerment, job stress, 250 and job satisfaction. 251 252 Hierarchical regression analysis was utilized to investigate the moderating effects of work 253 environment and empowerment on the job stress–job satisfaction relationship. Table 5 presents a 254 summary of the hierarchical regression analysis. In the first step, the demographic and work-255 related variables (age, experience in the current unit, nationality, gender, marital status, level of 256 education, work unit, type of hospital, work status, shift worked) were entered to control for their 257 effects on the dependent variable (job satisfaction). These variables explained 31% of the 258 variation (R2) in job satisfaction (cumulative R2 = 31%). 259 260 In the second step, job stress was entered in the regression model. It showed that job stress 261 explained an additional 13% of the variation in job satisfaction (R2 change = 13%, cumulative R2 262 = 44%, p < 0.01). This step showed that the relationship between job stress and job satisfaction 263 was negative (r = -.39, p < 0.001). 264 265 In the third step, work environment was added to the regression model. Work environment 266 explained another 2% of the variation in job satisfaction (R2 change = 2%, cumulative R2 = 46%, 267 p < 0.01). This increase in R2 was statistically significant, which demonstrated that the 268 perception of a positive work environment enhanced the level of job satisfaction (r = 0.16, p < 269 0.001). 270 271 In the fourth step, the empowerment variable was added to the model. It showed only a 0.003 272 addition to the cumulative R2 (46.3%), which did not reach the level of significance. 273 274 In the fifth step, the product or multiplicative term of work environment and job stress was added 275 to the model to explore the moderating effect of work environment on the job stress–job 276 satisfaction relationship. This step showed only a 0.002 addition to the cumulative R2 (46.5%), 277 which was insignificant. This indicated that the interaction between job stress and work 278 environment had no moderating effect on the job stress–job satisfaction relationship. 279 280 In the sixth step, the product of empowerment and job stress was added to the model to explore the 281 moderating effect of empowerment on the job stress–job satisfaction relationship. This step showed 282 no addition to the cumulative R2 (46.5%). This indicated that the interaction between job stress and 283 empowerment had no moderating effect on the job stress–job satisfaction relationship. 284 285 Discussion 286 The findings of the study indicated that participants of the study reported a low level of stress. 287 However, Omani nurses reported higher levels of job stress in comparison to their counterparts 288 (expatriate nurses). This might be related to the fact that expatriate nurses are older and had more 289 years of experience than Omani nurses. This is an indication that Omani nurses are more junior, 290 with less experience at work, which might have implication on their management of stressful 291 situations. 292 293 Research evidence had showed that as age and years of experience of staff increased, their job stress 294 levels decreased as well.22,23 The results also showed that a higher percentage of Omani nurses 295 (62.5%) had diploma degrees in comparison to expatriate nurses (51.8%); this might also have 296 contributed to the higher levels of stress among Omani nurses as the results of the present study 297 revealed that participants with diploma degrees reported higher levels of stress comparing to those 298 with bachelor degrees. The results also showed that participants of the study reported above average 299 level of job satisfaction and empowerment and perceived their work environment as positive. 300 However, the results showed that Omani nurses reported lower levels of job satisfaction and 301 empowerment and perceived their work environment as less positive in comparison with expatriate 302 nurses. This could be related to the fact that Omani nurses reported higher stress levels than their 303 counterparts, which in turn lead to dissatisfactions and poor perceptions of their work environment as 304 was showed in the present study and in previous literature.1,13,16,22 305 306 Further, the results also showed that a higher percentage of Omani nurses (99.9%) worked in 307 governmental hospitals in comparison to expatriate nurses (95.9%); this might also have contributed 308 to the lower levels of empowerment and the less positive perceptions of work environment among 309 Omani nurses as the results of the present study revealed that participants who worked in private 310 hospitals reported higher levels of empowerment and perceived their work environment more 311 positive comparing to those working in governmental hospitals. 312 313 The findings of the study supported the negative correlation between job stress and job satisfaction 314 and added to the research evidence on this issue.13 Increased stress levels affect the mental well-being 315 of nurses and lead to Job dissatisfaction. There is a vicious circle between job stress and job 316 satisfaction where higher stress levels enhance job dissatisfaction which in turn increase stress 317 levels.22 The results also indicated significant negative relationships between job stress and work 318 environment and empowerment. That is, nurses who perceived higher levels of job stress perceived 319 their work environment as less positive. Stressed nurses usually do not participate in hospital 320 affairs, do not focus on their collegial relationships and perceived resources in their organizations 321 to be inadequate; thus they perceived their work environment as less supportive. This result is 322 congruent with the findings of previous studies. 1,16,24 Furthermore, nurses who perceived higher 323 levels of job stress reported lower levels of empowerment. This result confirms the findings reported 324 by other researchers11,13,16 and adds an Omani cultural perspective to the international evidence in the 325 literature. 326 327 Nurses in the present study rated the characteristics of their work environment concerning the 328 participation in hospital affairs, staffing and resources adequacy, adequate access to support form 329 colleagues and perceptions of manager leadership abilities above the moderate level. However, it 330 is worth noting they rated staffing and resources adequacy as a dimension of their work 331 environment as well as access to resources as a dimension of structural empowerment as the 332 lowest among other dimensions. Evidence from research showed that better perceptions of work 333 environment characteristics can lead to reduced stress levels and enhanced empowering levels of 334 staff.25,26 335 336 Moreover, the results showed that nurses who perceived their work environment as supportive 337 reported higher levels of job satisfaction. This result is consistent with the results of other 338 previous studies.1,25,27 Staff experiences at work and how they perceive their work environment 339 affects their personal well-being as well as their levels of job satisfaction. A positive work 340 environment was also associated with higher levels of empowerment. This result is congruent 341 with the findings of a previous study.26 Such results highlight the important role of nurse 342 administrators in creating a work environment that values and promotes the empowerment of 343 nurses. 344 345 Concerning the moderating effects of empowerment and work environment on the job stress–job 346 satisfaction relationship, the results showed that there was no moderating or indirect effect of 347 either work environment or empowerment on the relationship between job stress and job 348 satisfaction. The results of the present study provided evidence only for the direct effect of work 349 environment and empowerment on the level of job satisfaction. Nonetheless, the results highlight 350 the importance of providing a supportive work environment and empowering all employees, not 351 only highly stressed ones. The regression model that included background variables (31%), job 352 stress (13%), work environment (2%), empowerment (0.04%), the product of stress and work 353 environment (0.02%), and the product of stress and empowerment (0%) explained 46.5% of the 354 total variation in job satisfaction. This percentage signifies the importance of the variables of job 355 stress, work environment and empowerment in the prediction of the level of job satisfaction. 356 357 Concerning the limitations of the study, the subjective measurement of the study variables might 358 have created reporting bias. Furthermore, the convenience sampling method might have limited 359 the generalizability of the results. However, the latter was enhanced by the fact that the study 360 utilized a national sample from different governorates of Oman. 361 362 Implications and Recommendations 363 The findings of the study emphasize the importance of implementing strategies to create a 364 positive work environment. The perceptions of Omani nurses about their work environment need 365 to be checked frequently. It is recommended to take suggestions from nurses themselves to 366 improve the work environment. The explanatory regression model points to the significance of 367 managing stress and providing a supportive work environment to enhance nurses' job 368 satisfaction. Experienced nurses’ opinions need to be considered when developing strategies 369 regarding their job satisfaction and work environment. Nurse managers should also help their 370 staff manage their stress by implementing stress management programs. Another area of specific 371 concern for nurses working in Oman was that the adequacy of staffing and resources. The issue 372 of nurse staffing is a global concern in health care organizations. It is imperative for nurse 373 managers to advocate for adequate staffing and resources in their units since these factors impact 374 both nurses' and their patients' outcomes. They need to create an organizational culture that 375 embraces a supportive work environment and empowers nurses through providing adequate 376 resources, support, teamwork, and cooperation. 377 378 Conclusion 379 The findings of the present study provided evidence only for the direct effects of work 380 environment and empowerment on job satisfaction with no support for the indirect or moderating 381 effects. The results also showed that nurses, working in Oman, who had higher levels of job 382 stress perceived lower levels of job satisfaction and empowerment and a less supportive work 383 environment. Further, nurses who perceived their work environment as supportive reported 384 higher levels of job satisfaction and empowerment. Therefore, nurse administrators need to adopt 385 and implement strategies that tackle job stress, empower staff, and promote a supportive work 386 environment for nurses working in Oman. 387 388 Acknowledgment 389 The authors would like to acknowledge and thank all nurses who contributed to this study. 390 391 Conflicts of Interest 392 The authors declare no conflict of interests. 393 394 Funding 395 This work was supported by Sultan Qaboos University (RF/CON/FACN/19/01); and The 396 Research Council, Sultanate of Oman (RC/RG-CON/FACN/18/01). 397 398 Author Contributions 399 RAA, SDS and OA-R conceptualized the study. OA-R designed the methodology and supervised 400 the work. RAA performed the formal analysis and provided the visualization. RAA, SDS, LJL 401 and IAB drafted, reviewed and edited the manuscript. All authors approved the final version of 402 the manuscript. 403 404 References 405 1. Donley J. 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J Nurs Res. 2019;27(1). doi:10.1097/jnr.0000000000000273 486 487 Table 1: Background variables of participants (n = 1796) 488 Characteristic Total (n= 855) Age (years)-Median (IQR) 64 (44-75) Female-no (%) 401(46.9%) Male -no (%) 454 (53.1%) The average length of hospital stays (days)-median (IQR) 5 (3-9) Total hospitalisation days (n) 6785.4 Admissions with appropriate date of discharge no (%) 583 (68.2%) Admissions included inappropriate hospitalization days -no (%) 272 (31.9%) Total number of inappropriate hospitalization days (days) 674 Mortality- no (%) 29 (3.4%) Note. The sample of some variables do not add to the total sample due to missing data 489 490 Table 2: Means and standard deviation (SD) of Study variables (n = 1796) 491 Variable (Scale and Subscales) Mean (SD) Job Stress Job Satisfaction Work Environment Participation in hospital affairs Foundations for quality of care Manager ability, leadership and support Staffing and resource adequacy Collegial nurse–physician relations Structural Empowerment Access to opportunity Access to resources Access to information Access to support 1.7 (.59) 2.9 (.76) 2.8 (.40) 2.8 (.55) 3 (.47) 2.9 (.54) 2.7 (.62) 2.9 (.54) 3.5 (.71) 3.7 (.90) 3.2 (.86) 3.5 (.92) 3.5 (.90) 492 493 Table 3: The differences between Omani and expatriate nurses concerning study variables (n = 494 1796) 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 Variable Mean (SD) t-test P value Job Stress Omani Nurses 1.9(.54) 10.4 .001 Expatriate Nurses 1.7(.59) Work Environment Omani Nurses 2.7(.41) -11.2 .001 Expatriate Nurses 2.9(.40) Structural Empowerment Omani Nurses 3.2(.72) -11.8 .001 Expatriate Nurses 3.6(.65) Job Satisfaction Omani Nurses 2.6(.84) -12.2 .001 Expatriate Nurses 3.1(.65) Table 4: Pearson correlations for work environment, empowerment, job stress, and job 512 satisfaction (n = 1796) 513 Work environment Empowerment Job Stress Job Satisfaction Work Environment 1 Empowerment 0.47** 1 Job Stress -0.19** -0.19** 1 Job Satisfaction 0.31** 0.18** -0.32** 1 Note. ** Correlation is signifcant at p < 0.01 514 515 Table 5: Hierarchical regression for job satisfaction as a dependent variable (n=1796) 516 Step Variables R2 Cum. R2 change Std ß t value P 1 Background Variables 0.31 0.31 - - - 2 Job Stress 0.44 0.13 -0.39 -9.5 <0.001 3 Work Environment 0.46 0.02 0.16 3.9 <0.001 4 Empowerment 0.463 0.003 -0.002 -.05 0.96 5 Stress * Work Environment 0.465 0.002 0.31 1.1 0.26 6 Stress * Empowerment 0.465 0.00 0.14 .67 0.50 517 518 Final model = R2 = 0.465 (adjusted R2 = 0.44), F(16,392) = 21.31, p < 0.001. 519 Std b, the standardized b coefficient; R2 Cum. = R2 Cumulative. 520