Factors Affecting Performance of Hospital Nurses in Riyadh Region, Saudi Arabia

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IJHCQA 22,1

Factors affecting performance of hospital nurses in Riyadh Region, Saudi Arabia

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Hanan Al-Ahmadi Institute of Public Administration, Riyadh, Saudi Arabia

Received 13 February 2008 Revised 17 February 2008 Accepted 17 February 2008

Abstract Purpose – The purpose of this paper is to identify factors influencing performance of hospital nurses in Riyadh Region, Saudi Arabia. Specific objectives were to estimate self-reported performance, and determine whether differences in employee demographics, job satisfaction, and organizational commitment, influenced performance. Design/methodology/approach – In total, 15 hospitals were randomly selected. The questionnaire was sent to all nurses (1,834) in these facilities and 923 nurses responded. Statistical analysis included correlation, t-test, and regression analysis. Findings – The study finds that job performance is positively correlated with organizational commitment, job satisfaction and personal and professional variables. Both job satisfaction and organizational commitment are strong predictors of nurses’ performance. Job performance is positively related to some personal factors, including years of experience, nationality, gender, and marital status. Level of education is negatively related to performance. Research limitations/implications – The findings of this study have a limited generalisability due to the fact that all measures used are based on self-reports. Future research may be directed to other objective measures of performance. Practical implications – Emphasis should be placed on effective supervision, empowerment, and a better reward system. Cultural diversity is a reality for most health organizations in Saudi Arabia; therefore, they need to adopt effective human resources strategies that aim to improve commitment and retention of qualified workers, and build a high performance organizational culture based on empowerment, open communication, and appreciation of impact of national culture on work attitudes. Originality/value – This study fulfills a research gap in the area of nursing performance, and its relationship with work attitudes in Saudi Arabia. The paper also highlights the impact of national culture on job performance and work attitude among nurses in Saudi Arabia, and other countries facing the issue of multi-national work force. Keywords Nurses, Performance management, Saudi Arabia, Job satisfaction Paper type Research paper

International Journal of Health Care Quality Assurance Vol. 22 No. 1, 2009 pp. 40-54 q Emerald Group Publishing Limited 0952-6862 DOI 10.1108/09526860910927943

Introduction For decades, researchers have been studying factors influencing performance in health organizations with emphasis on worker factors and work environment factors. Nurses constitute the largest human resource element in healthcare organizations, and therefore have a great impact on quality of care and patient outcomes. Job performance has often been examined in light of work attitudes such as job satisfaction and organizational commitment. Nurses’ attitudes towards their jobs; and commitment to their employing organizations have been compelling to researchers due to their impact on behavior at work and quality of patient care. In Saudi Arabia, interest has been growing on issues related to performance in health organizations, as a reflection of the

increasing interest in quality improvement. This study examines job performance of hospital nurses in Riyadh, Saudi Arabia, focusing on the impact of job satisfaction, organizational commitment and personal characteristics. Literature review Nursing performance Nursing care is an integral component of patient care and is an important determinant of quality of healthcare services. Several scholars have investigated performance of nurses (Parker and Kulik, 1995; Borda and Norman, 1997; Judge et al., 2001; Siu, 2002; Abualrub, 2004; Tzeng, 2004; Fort and Voltero, 2004; Yang and Huang, 2005; Mrayyan, 2006; Hall, 2007). Some studies focused on the contribution of nursing care to patient outcomes such as quality of care and patient satisfaction. In Canada, a nursing role effectiveness model linking nursing role performance to patient outcomes was examined. The study found that nurse structural variables such as level of education and hospital experience influence several aspects of performance: coordination of care and quality of communication with patients. Unit structural variables such as level of autonomy, amount of time available for care, and role tension affected nursing performance. In Taiwan, staff nurses’ morale was found to be a predictor of patient satisfaction (Yang and Huang, 2005). In Jordan, Mrayyan (2006) examined patient satisfaction, nurse job satisfaction, and quality of care, and concluded that nurses had borderline level of job satisfaction, while patients reported moderate levels of satisfaction with care, and head nurses reported satisfaction with quality of nursing care. Job performance is often examined in relation to stress and burnout associated with nursing practice. Parker and Kulik(1995) found that burnout is associated with poor self-rating as well as supervisor rating of performance, more sick leave, and more absence for mental health reasons. In Jordan, Abualrub (2004) found that perceived social support from co-workers enhanced job performance and decreased job stress. In Hong Kong, Siu (2002) found that organizational climate (both physical conditions and social aspects) to influence job satisfaction and absenteeism among hospital nurses. Supportive management practices were crucial to achieve high nursing performance (Drach-Zahavy, 2004). A recent study has also found a positive correlation between perceived supervisor support and nurse occupation-related outcomes (Hall, 2007). The relationship between job performance with personal characteristics of employees such as competence, education, and years of experience were investigated by some researchers. In a study of maternal healthcare providers in Armenia, Fort and Voltero (2004) examined a conventional performance improvement model that outlined five key factors believed to influence performance outcomes: job expectations, performance feedback, environment and tools, motivation and incentives, and knowledge and skills. The study included 285 nurses and midwives, and utilized interview and observation methods to identify factors affecting performance. Results show that performance is influenced by several factors: training in the use of clinical tools, receiving recognition from employer or patient, and receiving feedback on performance (Fort and Voltero, 2004). In Taiwan, Tzeng (2004) found that nursing performance is related to nursing competencies, and suggested that education and training are essential for improving performance of nurses.

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The effect of national culture on job attitudes and performance has been the subject of investigation by several researchers (Al-Meer, 1995; Al-Otaibi, 1993; Yousef, 2000). Yousef (2000) stressed that multiculturalism is a dominant feature of the workforce in some countries, therefore, the effect of national culture on job attitudes should be investigated. In his study, Yousef (2000) found that national culture moderates the relationship of leadership behavior with job satisfaction and performance. Other researchers have also identified differences among different nationalities with respect to organizational commitment and job performance (Al-Meer, 1995; Al-Otaibi, 1993). Performance and job satisfaction Several organizational theories are based on the notion that organizations that are able to create a positive environment and make their employees happy will have more productive employees. Over the years, scholars examined this idea that a happy worker is a productive worker; however, evidence is not yet conclusive on this regard. Empirical studies have produced several conflicting viewpoints on the relationship between job satisfaction and performance. The idea that job satisfaction leads to better performance is supported by Vrooms’ (1964) work which is based on the notion that performance is a natural product of satisfying the needs of employees. Empirical evidence from research on nurses found job satisfaction to be linked to several aspects of job performance, including: patient satisfaction (Krugman and Preheim, 1999), overall job performance (Judge et al., 2001), turnover; productivity (Butler and Parsons, 1989; Robinson et al., 1991). In Jordan, Al-Badayneh and Sonnad (1993) studied job satisfaction of a sample of (303) registered nurses in five government and five private hospitals. The study identified a strong relationship between nurses overall effectiveness and overall satisfaction, as well as a moderate relationship between nurses’ job satisfaction and performance. Knoop (1995) found that job satisfaction leads to a number of consequences among nurses, more productivity, high quality of care, and intent to remain in the organization. Job dissatisfaction on the other hand was found to lead to absenteeism, grievances (Shader et al., 2001), decreased productivity and poor performance (Butler and Parsons, 1989; Robinson et al., 1991). In a review of literature, Borda and Norman (1997) concluded that job satisfaction affects turnover intentions as well as absenteeism among nurses. In a meta-analysis of the literature, Judge et al. (2001) found a positive correlation between job satisfaction and job performance of nurses. In North Vietnam, Dieleman et al. (2003) conducted a qualitative study to identify factors for job motivation of rural health workers, and recommend strategies for performance improvement. The study showed that motivation is influenced by both financial and non-financial incentives; however, the main motivating factors were appreciation by managers, colleagues and community, a stable job and income, and training. The main discouraging factors were related to low salaries and difficult working conditions. Researchers have examined the relationship between performance and various aspects of job satisfaction. Abdel-Halim (1980) reported a correlation between performance and satisfaction with several aspects of the job: work, supervision, coworkers, pay, and promotion. Some earlier research found a significant correlation between overall effectiveness and several aspects of job satisfaction: pay, coworkers, supervisor, job security, promotion, benefits, hours, and work conditions. Correlation was identified

also between overall job satisfaction and specific aspects of job performance of nurses: technical competence; ability to organize workload; planning nursing care; attendance; amount of work performed; adaptability to emergencies; completing work on schedule; quality of work; willingness to perform duties; observation of rules; communication skills; and overall effectiveness. Some researchers supported the notion that performance causes satisfaction, and found a low but consistent relationship existed between performance and job satisfaction. Their argument is that performance leads to extrinsic and intrinsic rewards, which eventually lead to satisfaction. Extrinsic reward (pay, promotion), and intrinsic reward (recognition and self-actualization) lead to satisfaction. Some researchers found no relationship between job performance and job satisfaction. Packard and Motowidlo (1987) studied the relationship of subjective stress, job satisfaction, and job performance among hospital nurses, through self reports that were obtained from 366 nurses, and performance ratings from 165 supervisors and 139 co-workers nominated by the original respondents. The findings were that stress, primarily acting through depression, is associated with lower levels of job performance, and that job satisfaction is unrelated to job performance. The controversy regarding the satisfaction-performance relationship is not fully resolved, as each approach has been supported by a number of empirical studies. Organizational commitment and job performance Interest in organizational commitment is based on the assumption that employees who feel attached to, and identify with their organizations, work harder. Organizational commitment is characterized as a strong belief in and acceptance of the organization’s goals and values, a willingness to exert considerable effort on behalf of the organization, and a strong desire to maintain membership in an organization (Mowday et al., 1982). Mathieu and Zajac (1990) see commitment as an attitude reflecting the nature and quality of the linkage between an employee and an organization. Mowday et al. (1982) define commitment which portrays a committed individual as one who has: a string belief in and acceptance of the organization’s goals and values; a willingness to exert considerable effort on behalf of the organization; and a strong desire to maintain membership in the organization. Meyer et al. (1989) identified three types of organizational commitment: affective, continuance, and normative commitment. Several scholars identified a positive relationship between organizational commitment and job performance (Mathieu and Zajac, 1990; Al-Otaibi, 1993; Ward and Davis, 1995; Yousef, 2000; Samad, 2005). Meyer et al. (1989) found a relationship between job performance and commitment, however; they concluded that the direction of the relationship depended on the type of commitment. Affective commitment was found to have a positive relationship with job performance, while a negative relationship was found between continuance commitment and performance. Mathieu and Zajac (1990) found low positive correlation between organizational commitment and performance, which lead to the belief that there are moderating variables that moderate this relationship. Similarly, Samad (2005) found a moderate positive relationship between organizational commitment and job performance, and concluded that job satisfaction moderates the relationship between organizational commitment and job performance, indicating that employees, who are committed to

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their organizations, would have better job performance if they were satisfied in their jobs. Samad (2005) emphasized the importance of motivational factors, such as relationship with supervision and peers, the quality of supervision, policy and administration, job security, working conditions, salary and the nature of work itself, achievement, and possibility of growth. In the United Arab Emirates, Yousef (2000) examined the mediating role of organizational commitment in the relationships of leadership behavior with job satisfaction and job performance. The study concluded that employees who perceive their superiors as adopting consultative or participative leadership behavior are more committed to their organizations, more satisfied with their jobs, and their performance is high. In nursing, leadership behavior was found to have a great influence over organizational commitment and productivity. Organizational commitment was found related to leadership behavior, and that several aspects of leadership behavior influence commitment, including clear vision, empowerment of workers, motivation, recognition, and effective communication (McNeese-Smith, 1997). In Taiwan, organizational commitment and intention to leave among 2,197 hospital nurses was studied and it was concluded that organizational commitment is positively related to performance and productivity, and that it is one of the determinants of intention to leave the organization. Luchak and Gellatly (2007) found a positive relationship between affective commitment and three commonly studied work outcomes (turnover cognitions, absenteeism, and job performance). Wright and Bonett (2002) conducted a meta-analysis to investigate the relationship between attitudinal commitment and job performance for 3,630 employees obtained from 27 independent studies. The study found that tenure had a very strong moderating effect on the commitment-performance correlation. Job performance was found to be influenced positively by both professional and team commitment as well as by perceived organizational and team support (Bishop, 1998). Intention to quit the organization went down as organizational support and commitment went up, and intention to leave the profession similarly was related to team support and commitment. The majority of previous studies were carried out in Western contexts and there is a growing concern over whether Western business practices and management theories are appropriate for non-Western settings (Yousef, 2000). Thus, the purpose of this study was to identify factors influencing performance of hospital nurses in Riyadh Region, Saudi Arabia. Specific objectives were to estimate self reported performance, and determine whether differences in employee demographics, and work-related attitudes, specifically job satisfaction, and organizational commitment, influenced performance. Methods Population and sample The study was conducted in 15 randomly selected Ministry of Health hospitals in Riyadh region, Saudi Arabia. All nurses (1,834) in these facilities were asked to respond anonymously to the questionnaire. Completed surveys were received from 923 nurses (return rate ¼ 50 per cent). Measurement Performance was measured using the performance appraisal form used in the Ministry of Health for annual review of health professionals. The measure contains nine items in

which respondents rate their own performance using a Likert-type scale with five responses (1 ¼ very poor, 2 ¼ poor, 3 ¼ good, 4 ¼ very good, and 5 ¼ excellent). Self-rating to measure performance is used by several researchers (Al-Badayneh and Subhash, 1993; Yousef, 2000; Tzeng, 2004). Al-Badayneh and Subhash (1993) have emphasized the importance of self rating to provide a culture of continuous development, which places major emphasis on personal growth, self motivation, and organizational potential of the employees. The scores were averaged so as to show each participant’s performance level ranging from 0 to 5. The performance measure was found reliable, with a Cronbach’s of 0.83 in this study sample. Job satisfaction was measured using the short form of the Minnesota Satisfaction Questionnaire (MSQ) (Weiss et al., 1967). This instrument utilized a 25-dimension Likert-type scale with five responses (1 ¼ very dissatisfied, 2 ¼ dissatisfied, 3 ¼ neutral, 4 ¼ satisfied, and 5 ¼ very satisfied). The short form of the MSQ was translated and adapted into Arabic by the researcher, and was tested for validity and reliability. The MSQ was reliable, with a Cronbach’s of 0.87 in this study sample. The scores were averaged so as to show each participant’s satisfaction level ranging from 0 to 5. Organizational commitment was measured by using the Organizational Commitment Questionnaire (OCQ) developed by Mowday et al. (1979). It uses 15 items to describe “global” organizational commitment. Responses are obtained using a five-point scale, where 1 ¼ strongly disagree, 2 ¼ disagree, 3 ¼ neither disagree nor agree, 4 ¼ agree, 5 ¼ strongly agree. This measure was found reliable, with a Cronbach’s of 0.85 in this study sample. Demographic variables examined in this study included age, gender, nationality, marital status, monthly salary, educational level, and years of experience. Data analysis The Statistical Package for Social Sciences (SPSS) was used to analyze the data. The initial analysis was conducted by calculating descriptive statistics including frequencies, mean scores and standard deviations. Pearson’s Production Moment Correlation analysis was used to determine the correlation of each of the independent variables with job performance at 0.05 level of significance. After this, multiple regression analysis was performed to determine the weight of each variable in the prediction of self rated job performance of employees. Results A total of 923 (50 per cent) questionnaires were returned. Demographic and work-related characteristics of study respondents are reported in Table I. The majority of the sample (90 per cent) were women, most of the respondents (94 per cent) were not Saudi nationals, few (6 per cent) were from other Arab countries, most (64 per cent) were from Southeast Asian countries, and (12 per cent) were from Western countries. The education of the respondents was as follows: health institutes (high school equivalent) (13.2 per cent), college diploma (two years) (17 per cent), bachelor’s degree (41 per cent), and graduate degree (9.6 per cent). The majority of subjects (37.4 per cent) had five to ten years’ experience, (33 per cent) had less than five years of experience, and (29 per cent) had more than ten years experience. Monthly salary was less than 4,000 Saudi Riyals ($1,066) for the majority of respondents (96 per cent).

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Table I. Sample personal and professional characteristics

Frequency

Percent

Gender Male Female

89 834

9.6 90.4

Marital status Married Unmarried

630 293

68.3 31.7

Nationality Saudi Non-Saudi

55 868

6 94

Educational level Health institute Nursing college Bachelors Graduate Other

122 157 378 89 177

13.2 17 41 9.6 19.2

Age (years) Less than 20 20 to less than 30 30 to less than 40 40-less than 50 50 or more

38 420 319 128 18

4.1 45.5 34.6 13.9 2

Monthly salary (SR) , 2,000 2,000 to , 4,000 4,000 to , 6,000 6,000 to , 8,000 . 8,000

391 390 13 7 13

48 47.9 1.6 0.9 1.6

Years of experience ,1 1 to , 5 5 to , 10 10 to , 15 15 ,

72 236 345 142 128

7.8 25.6 37.4 15.4 13.9

Table II shows descriptive statistics of self-rated performance using single and total measures. Average scores were obtained for each item as well as an overall measure was obtained by calculating the total average for all items. Overall performance is rated at (3.52), which corresponds to good or average performance on the five-point scale used in this study. Self-rated performance was rated above average for most items, highest scores was reported for attendance and punctuality (3.92), while lowest score were reported for sick and emergency leave (2.82). Improving work methods and improving personal skills were among the weakest points of performance at (3.41) and (3.4) respectively. Job satisfaction and organizational commitment scores are also presented in Table II to provide an overall picture of these two independent variables. The data show that

Variables Overall performance Performance items

Overall satisfaction Facet satisfaction

Attendance and punctuality Sick and emergency leave Improving your personal skills Relationship with patients Quality of work Relationship with superiors Relationship with colleagues Improving work methods Your overall performance as compared to your coworkers Satisfaction with supervision Satisfaction with promotion Pay satisfaction Satisfaction with work conditions Satisfaction with the job itself Satisfaction with relationships at work Organizational commitment

Mean

Std deviation

3.52 3.92 2.82 3.40 3.69 3.60 3.54 3.77 3.41

0.48 0.61 1.16 0.74 0.66 0.66 0.72 0.64 0.71

3.61 3.35 3.3476 2.9870 2.5742 3.3603 3.6386 3.7089 3.30

0.60 0.57 0.8074 0.8974 1.1345 0.7672 0.7569 0.7021 0.64

moderate levels of job satisfaction and organizational commitment exist among nurses in this study. Highest satisfaction was reported with relationship at work at (3.7), and lowest satisfaction was reported with opportunity for pay at (2.57). To obtain an overall picture of self-rated performance according to personal characteristics of nurses, t-test was conducted as shown in Table III. Self-reported performance was significantly higher among male than female nurses, married compared to unmarried, Saudi as compared to all other nationalities. Job satisfaction was found significantly higher among males, and married nurses, however, was not significantly different between Saudi and Non Saudi. Organizational commitment was found significantly higher among Saudis, among male and among married nurses. Pearson’s Production Moment Correlation analysis was used to determine the correlation of each of the independent variables (organizational commitment, overall satisfaction, facet satisfaction, monthly salary, educational level, nationality, marital status, and years of experience) with overall job performance at 0.05 level of significance. The results of this analysis show a significant positive relationship between job performance and organizational commitment, job satisfaction, all six job satisfaction facets, marital status, monthly salary, and years of experience (Table IV). Results also indicate a negative correlation exist between level of education and job performance. Table V summarizes the results of the regression analysis. Regression analysis procedure designed to gain a better understanding of the strength of association between self-rated performance and the independent variables: supervision, promotion, pay, work conditions, the job itself, and relationships at work, organizational commitment, educational level, years of experience, and overall satisfaction. The regression coefficients (b) indicate a change in performance, measured on a five-point scale, associated with a one-unit change in the independent variable.

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Table II. Work attitudes and job performance descriptive statistics

Table III. Results of t-test for comparison of means of work attitudes according to selected personal factors 0.4032 0.4839 0.4544 0.4821 0.4715 0.4890

3.7111 3.5168

3.6692 3.5133

3.5737 3.4308

Performance Std deviation 3.2937 3.3553 3.5527 3.3302 3.3944 3.2597

3.057 * 4.180 *

Mean

2.915 *

t

Note: * Correlation is significant at the 0.01 level (two-tailed)

Nationality Saudi Non-Saudi Gender Male Female Marital status Married Single

Mean

0.562 0.5910

0.6336 0.597

0.6297 0.5669

Satisfaction Std deviation

3.285 *

3.182 *

20.708

t

630 293

3.6442 3.2709

3.5040 3.2944

Mean

3.3721 3.1665

0.7270 0.6243

0.7205 0.6372

COMMITT Std deviation

48

Variables

4.533 *

5.274 *

2.106 *

t

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Factors affecting performance of nurses

Correlation coefficient r self-rated overall performance 0.307 * * 0.310 * * 0.244 * * 0.196 * * 0.084 * 0.203 * * 0.319 * * 0.268 * * 0.152 * * 2 0.108 * * 0.147 * *

Organizational commitment Overall job satisfaction Supervision Promotion Pay Work conditions The job itself Relationship at work Monthly salary Educational level Years of experience

49

Notes: * Correlation is significant at the 0.05 level (two-tailed); * * correlation is significant at the 0.01 level (two-tailed)

(Constant) Supervision Promotion Pay Work conditions The job itself Relationships at work Educational level Years of experience Nationality Organizational commitment Overall satisfaction

Std error

Standardized coefficients beta

t

Sig.

0.163 0.050 0.043 0.031 0.064 0.058 0.044 0.019 0.003 0.068 0.033 0.261

2 0.198 2 0.230 2 0.309 2 0.311 2 0.041 2 0.073 2 0.022 0.089 2 0.130 0.255 0.948

16.654 2 2.244 2 2.789 2 4.242 2 2.943 2 0.436 2 1.092 2 0.620 2.583 2 3.508 5.567 2.980

0.000 0.025 0.005 0.000 0.003 0.663 0.275 0.535 0.010 0.000 0.000 0.003

Note: Adjusted R 2 (0.19), (R ¼ 0:45), (F ¼ 16:845), (p ¼ 0:000)

Results of the regression analysis indicate that several variables contribute to overall self-rated performance: satisfaction with: supervision, promotion, pay, work conditions. Organizational commitment, overall satisfaction, and years of experience also influence performance. Other factors examined were not shown to be predictors of job performance, including educational level, satisfaction with the job itself, and relationship at work. The model explained 19 per cent of the variance in self-rated performance as measured by the adjusted R 2. Discussion This study attempted to shed light on an important issue for health organizations today, which is nursing performance. The study examines self-rated performance levels among nurses working in Ministry of Health hospitals in Riyadh Region, Saudi Arabia. Moderate levels of job performance were identified, however, some aspects of performance are lacking, specifically, ability to improve personal skills, and the ability

Table IV. Correlations between self-rated overall performance, work attitudes, and professional characteristics

Table V. Regression analysis for the relationship between job performance, work attitudes, and selected personal characteristics

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to improve work methods. The fact that these two aspects of performance received the lowest self-rating is an indication of lack of motivation for personal development and creativity among nurses in this study. It may also be a reflection of the limited opportunity available for improving nursing skills and competencies, and lack of a professional climate that stimulates ambition among nurses. Consistent with prior research, job performance was found positively correlated with overall job satisfaction as well as facet satisfaction including: Satisfaction with the job itself, supervision, relationship at work, satisfaction with pay and promotion opportunity, and work conditions (Knoop, 1995; Borda and Norman, 1997; Shader et al., 2001; Judge et al., 2001). Performance is influenced by relationships at work, including patient appreciation of nurses, cooperation among staff, as well as physicians’ respect towards nurses and the decisions they make. This finding confirms the findings of other researchers, that perceived social support enhances job performance (Abualrub, 2004), and that patient recognition of nurses influence their performance (Fort and Voltero, 2004). The nature of the job itself was found positively correlated with performance, which indicates that satisfaction with the amount of variety and challenge in one’s job actually influence performance. The sense of job significance, feeling important in the eyes of others, realizing ones’ competence, and freedom to make decisions are positively related to performance. Job performance was also positively correlated with organizational commitment, which confirms findings by prior researchers that organizational commitment is a strong determinant of performance (Al-Meer, 1995). The positive relationship between organizational commitment and performance indicates that increased loyalty leads individuals to exert more effort at work and increases productivity and performance (Yousef, 1999). Samad (2005), found that several motivational factors moderate the positive relationship between performance and commitment, including relationship with supervisors and colleagues, organizational policies, work conditions, salary, nature of the job, achievement, job security, and possibility of growth. Results of this study show that level of education is negatively correlated with job performance, indicating that the higher the level of education, the lower job performance of nurses. This is contrary to findings by prior researchers that education has a positive influence on job performance. We may attempt to explain this negative relationship between education and performance to be a result of lower motivation among highly qualified nurses due to the low level of compensation associated with higher education, and limited opportunities for career advancement. The data presented in this study show that nurses are dissatisfied with their salaries as well as opportunity for promotion It is also possible that given that 94 per cent of the sample were non-Saudis, and building on research in other countries, migrant nurses may face unequal opportunities in career advancement and skill development (Alexis et al., 2006) This is only speculation given the limited data on this issue, however; further research is needed to investigate causes of the negative correlation between education and performance. One of the main objectives of this study was to identify determinants of nursing performance, focusing on job satisfaction, organizational commitment, and selected personal characteristics. Both job satisfaction and organizational commitment were found to be strong predictors of nurses’ performance. Results further show that some

aspects of job satisfaction are more able to predict job performance than others, specifically satisfaction with pay, supervision, promotion, and work conditions. These results confirm findings by other researchers that supportive and leadership behavior have positive effect on job performance (Hall, 2007; Drach-Zahavy, 2004; Abdel-Halim, 1980). Employees who perceive their supervisors to be adopting consulting behavior, and participating leadership style are more committed to their jobs and satisfied, and have higher levels of performance (Yousef, 2000). Dieleman et al., 2003, stressed that although financial and non-financial rewards are important motivating factors, the main motivators are appreciation by managers, colleagues and community, a stable job and income, and training. The fact that pay satisfaction is found to be an important determinant of performance of nurses in this study is also confirmed by other researchers in the region (Yousef, 1999; Al-Meer, 1995). Considering the levels of monthly salary received by nurses in this study that were less than SR4000 for more than half of respondents as shown in Table I, there is a need to re-examine salary scales for nurses in Ministry of Health hospitals. Other researchers stressed the need to improve financial reward associated with nursing practice in Saudi Arabia (Saeed, 1995; Jackson and Gary, 1991; Al-Omar, 2003). Promotion as a form of reward was found to be a predictor of job performance, which confirms the conclusion of (Dieleman et al., 2003) that motivation is influenced by both financial and non-financial incentives, and that the main discouraging factors for nurses were related to low salaries and difficult working conditions. In this study, job performance was found to be affected with satisfaction with several aspects of work conditions, including working hours, hospital policies, shifts, physical surroundings, and access to supplies and equipments as a significant predictor of job performance. Finally, consistent with earlier studies, years of experience were found to be strong predictors of job performance, indicating that work experience influences performance (Yousef, 1999; Al-Meer, 1995). Consistent with previous research, nationality was also found to be a strong predictor of job performance, indicating that national culture has a strong impact on work attitudes (Yousef, 2000). This study has several implications for health organizations seeking improvement of nursing performance. Performance improvement is not only a result of well functioning systems, but also depends on effective human resources strategies that succeed in recruiting and maintaining a committed and motivated workforce. Health organizations need to focus on factors that contribute to job satisfaction and organizational commitment of nurses as the largest group of professionals in direct contact with patients. Creating a positive organizational culture and better work environment would eventually enhance motivation and performance. Developing and implementing effective supervisory skills is essential to support, empower, and motivate professionals towards better performance. Financial and non-financial incentives should be improved taking into consideration the hardships nurses go through and the need to retain qualified nurses given the large shortage of nurses throughout the world. Work conditions in nursing, such working hours, shifts, and policies need to be re-examined to create more suitable work situation that motivate nurses into better performance. Physical environment, as well as availability of job-related materials and supplies needs to be improved to facilitate better

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performance. Human resources policies need to focus on development of nursing staff knowledge and skills. Effort should be directed towards enhancing initiative and creativity among nurses. Nurses must have access to updated information, learning resources, and continuous educational opportunities. The findings regarding the relationship between nationality and job performance indicate that health organizations need to recognize the impact of national culture on work attitudes, and direct their effort to create a high performance culture that is based on empowerment, effective open communication, and respect of cultural differences. Cultural diversity is a reality for most health organizations in Saudi Arabia, as in many countries, therefore, organizations need to adopt effective human resources strategies, that aim to improve commitment and retention of qualified workers. The findings of this study should be interpreted keeping in mind that it has its limitations due to the fact that all measures used are based on self-reports, which might have the problem of common method variance, and social desirability effects. This limitation is viewed as an opportunity for future research on work attitudes and their impact on performance in health organizations. References Abdel-Halim, A. (1980), “Effects of higher order need strength on the job performance-job satisfaction relationship”, Personnel Psychology, Vol. 33 No. 2, pp. 335-47. Abualrub, R. (2004), “Job stress, job performance, and social support among hospital nurses”, Journal of Nursing Scholarship, Vol. 36 No. 1, pp. 73-8. Al-Badayneh, D. and Subhash, S. (1993), “An analysis of performance and satisfaction relationship among nurses in Jordanian hospitals”, Abhath AL-Yarmok Journal, Vol. 9 No. 1, pp. 29-66. Alexis, O., Vydelingum, V. and Robbins, I. (2006), “Overseas nurses’ experiences of equal opportunities in the NHS in England”, Journal of Health Organization and Management, Vol. 20 Nos 2-3, pp. 130-9. Al-Meer, A.A. (1995), “The relationships of work stress to organizational commitment, job performance, job satisfaction and individual differences: a comparative study”, Public Administration, Vol. 35 No. 2, pp. 207-52 (in Arabic). Al-Omar, B.A. (2003), “Job dissatisfaction and nursing withdrawal from hospitals in Saudi Arabia”, Journal of King Saud University (Admin Sciences), Vol. 15 No. 1, pp. 1-24. Al-Otaibi, A.G. (1993), “The effect of organizational commitment on job performance for Kuwaitis and expatriates in the public sector in Kuwait”, Arab Journal of Administrative Sciences, Vol. 1 No. 1, pp. 109-34 (in Arabic). Bishop, J.W. (1998), “Performance and retention of professional employees who work in teams: the effects of commitment and support”, Clinical Laboratory Management Review, Vol. 12 No. 3, pp. 150-8. Borda, R.G. and Norman, I.J. (1997), “Factors influencing turnover and absence of nurses: a research review”, International Journal of Nursing Studies, Vol. 34 No. 6, pp. 385-94. Butler, J. and Parsons, R. (1989), “Hospital perceptions of job satisfaction”, Nursing Management, Vol. 20 No. 8, pp. 45-8. Dieleman, M., Viet Cuong, P., Anh, L. and Martineau, T. (2003), “Identifying factors for job motivation of rural health workers in North Vietnam”, Human Resources for Health, Vol. 1 No. 10, available at: www.human-resources-health.com/content/1/1/10

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