bs_bs_banner
Nursing Work and Life
Job satisfaction of overseas-qualified nurses working in Australian hospitals K.K. Timilsina Bhandari1* CN, RN, MN, MA (English), Bachelor of Health Education, L.D. Xiao2 RN, MNg, PhD, FACN & I. Belan3 PhD, Grad Dip (AppSci), BSC 1 Clinical Nurse, 3 Senior Lecturer, School of Nursing and Midwifery, 2 Associate Professor, School of Nursing and Midwifery, Faculty of Health Sciences, Flinders University, Adelaide, SA, Australia
TIMILSINA BHANDARI K.K., XIAO L.D. & BELAN I. (2015) Job satisfaction of overseas-qualified nurses working in Australian hospitals. International Nursing Review 62, 64–74 Aims: The aims of this study were to explore factors associated with the job satisfaction of overseas-qualified nurses working in public hospitals in South Australia and to compare whether factors associated with job satisfaction of overseas nurses from English-speaking backgrounds differed from those from non-English-speaking backgrounds. Background: Overseas-qualified nurses have become an essential part of the nursing workforce in Australia. Although this nurse population has different expectations and values in relation to their jobs when compared with local nurses, studies on job satisfaction among overseas nurses are scarce. Methods: A cross-sectional survey using the Job Satisfaction of Overseas-Qualified Nurses questionnaire was conducted in five major public hospitals in South Australia. Results: One hundred and fifty-one overseas-qualified nurses completed the questionnaire. Four factors were found to influence job satisfaction: Supportive work environment, interpersonal relationships, communication in English, and salary and salary-related benefits. Communication in English was the predominant factor that was associated with job satisfaction in nurses from non-English-speaking backgrounds. This group of nurses also showed a negative correlation between length of stay in Australia and satisfaction with their work environment. Participants’ responses to open-ended questions revealed issues relating to discrimination and racism. Conclusion: Supportive work environment, interpersonal relationships, communication in English, and salary and salary-related benefits were major factors associated with job satisfaction in overseas-qualified nurses in this study. Nurses from non-English-speaking backgrounds faced additional challenges in communication in the workplace and in dealing with issues of discrimination and racism.
Correspondence address: Dr Lily Dongxia Xiao, School of Nursing and Midwifery, Faculty of Health Sciences, Flinders University, PO Box 2100, Adelaide, SA 5001, Australia; Tel: +61 8 8201 3419; Fax: +61 8 8276 1602; E-mail: [email protected].
*Current address: Modbury Hospital, Adelaide, SA 5092 Funding statement This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Conflicts of interest No conflict of interest has been declared by the authors.
© 2014 International Council of Nurses
64
Job satisfaction of overseas-qualified nurses
65
Implications for Nursing and/or Health Policy: Nurses from non-English-speaking backgrounds need to be supported early in their employment, especially with their communication skills. Consideration also needs to be given to the education of local staff regarding cultural differences of overseas workers. Keywords: Human Resource Management, Immigrant Nurses, Job Satisfaction, Multicultural Issues, Recruitment and Retention, Workforce Organization
Background Many developed countries, including Australia, have depended on international recruitment of registered nurses (RNs) to mitigate a labour shortage of nurses (Australian Bureau of Statistics (ABS) 2013; Smith et al. 2011). According to a 2009 report from the Australian Institute of Health and Welfare (AIHW), 15.5% of RNs have been trained overseas (AIHW 2009). The demand for highly skilled RNs has been growing in Australia and other developed countries due to a number of pull factors such as an ageing population, an increase in the population living with chronic conditions and the ageing nursing workforce (ABS 2013; AIHW 2009). The immigration policy in Australia has supported the international recruitment of overseas-qualified nurses through the skilled migration process and through employer-sponsored visas (Australian Department of Immigration and Citizenship 2011). In addition, factors that push overseas-qualified nurses to migrate to developed countries have played a key role. These push factors have included better career opportunities, better working environment, better lifestyle, political stability and earning income to support family in the home country (Hayne et al. 2009; Jose 2011; Zhou et al. 2011). Both pull and push factors have impacted on job expectations and job satisfaction (Castaneda & Scanlan 2014; Jose 2011). In a global context of increasing trends of nurse migration, studies on job satisfaction of overseas-qualified nurses have become more important both in improving nursing human resource management and facilitating the equitable treatment of migrating nurses (International Council of Nurses 2014). Previous studies have highlighted that overseas-qualified nurses have different expectations and values in relation to their job as a result of the unique challenges they face during integration and subsequent career development, such as language barriers, workplace diversity, and differences in nursing and social culture (Jose 2011; Zhou et al. 2011). An understanding of factors influencing job satisfaction of overseasqualified nurses has been considered important in developing strategies that will help retain and integrate these nurses in the workforce.
© 2014 International Council of Nurses
Job satisfaction has been defined as the fulfilment of expectations and values that the employee has for that work and has been widely used as an important aspect of human resource management by organizations (Hayne et al. 2009). In healthcare settings, a high level of job satisfaction among nurses has been associated with a high level of staff retention, decrease in staff absenteeism, and has contributed to better patient care (Bae 2013; McHugh et al. 2011). In the context of nurse migration, job satisfaction has been viewed as an indicator of a hospital’s performance on managing the diverse nursing workforce in a multicultural workplace (Hayne et al. 2009; Xiao et al. 2014). The Nursing and Midwifery Board of Australia (NMBA) has classified overseas-qualified nurses into two subgroups, RNs from English-speaking background (ESB) and RNs from nonEnglish-speaking background (NESB) in the Registration Standards for Internationally Educated Nurses (NMBA 2011). RNs from six recognized English-speaking countries are exempted from the English proficiency test (NMBA 2011). These countries are Canada, New Zealand, Republic of Ireland, South Africa, UK and USA. RNs from NESB have been expected to be proficient in English (NMBA 2011). The English language proficiency of overseas-qualified nurses has played an important role in communication and has been identified as a significant factor that either hinders or facilitates communication with patients, physicians and host nurses (Cummins 2009; Xiao et al. 2014). However, language use and communication have been found to be culturally bound, suggesting overseas-qualified nurses from both ESB and NESB have faced challenges to learn words and slang in order to fit into the workplace culture and conduct effective communication with patients and colleagues in the workplace (Xiao et al. 2014; Zhou et al. 2011). Numerous studies have identified that passing an English proficiency test by NESB nurses does not guarantee communication success in the workplace (Xiao et al. 2014; Zhou et al. 2011). Misunderstandings and errors in communication with patients and colleagues have contributed to fear, anxiety, and rejection and bullying by patients or colleagues, interpersonal
66
K. K. Timilsina Bhandari et al.
conflict and low states of self-esteem (Jose 2011; Xu et al. 2008). In addition, language barriers also have prevented Asian nurses from using their skills and knowledge in the clinical setting, being assertive and demonstrating leadership (Xiao et al. 2014; Xu et al. 2008). These negative experiences relating to communication may have contributed to low levels of job satisfaction. The country of origin has been shown to have a strong influence on overseas-qualified nurses’ experiences in adapting their nursing practice and thereby their satisfaction with their job. Nurses emigrated from English-speaking countries share similarities in nursing practice and have encountered fewer challenges in adjusting their practice to the host country (Alexis & Vydelingum 2009; Allan et al. 2009). However, NESB nurses have emigrated mainly from less developed countries with different healthcare systems and scope of practice compared with developed countries (Alexis & Vydelingum 2009; Xiao et al. 2014). NESB nurses may not have had formal nursing education or experience in demonstrating autonomy, critical thinking, holistic patient care, and maintaining activities of daily living (Xiao et al. 2014; Zhou et al. 2011). However, they may have knowledge and skills such as inserting vein cannulation, vein puncture, nasal-gastric tube insertion and collecting arterial blood that have been usually performed by medical doctors or allied health professionals in developed countries (Xiao et al. 2014; Zhou et al. 2011). Cultural background has been demonstrated to have a significant impact on job satisfaction among immigrant nurses (Ea et al. 2008; Itzhaki et al. 2013). Cultural background also may have an impact on interactions with local nurses in the workplace. For example, nurses from NESB may have originated from collectivist cultures that value public face and prefer feedback from supervisors in private (Xu et al. 2008). In contrast, nurses from ESB may have come from largely individualistic cultures and prefer competitive and confrontational conflict management styles (Jose 2011; Xu et al. 2008). These differences in interactions may have contributed to interpersonal conflict and may have impacted upon interpersonal relationships in the workplace. Similarly, several studies have reported that nurses from NESB face challenges in patient–nurse intercultural interactions due to inadequate knowledge about intercultural communication with patients and the provision of appropriate care that met patients’ cultural needs (Smith et al. 2011; Zhou et al. 2011). Discrimination towards overseas-qualified nurses due to differences in their accent and culture also has been reported (Cheng & Liou 2011; Jose 2011), and has been evidenced by the under-representation of overseas-qualified nurses in senior positions in hospitals (Mapedzahama et al. 2012; Xiao et al.
© 2014 International Council of Nurses
2014). Most overseas-qualified nurses have many years of experience and bring rich knowledge, experience and skills to the Australian nursing workforce (Xiao et al. 2014; Zhou et al. 2011). Despite these qualifications, many overseas-qualified nurses have not been given positions reflecting their skills, and this may have impacted on their ability to adapt to their new environment and job satisfaction. Although overseas-qualified nurses have been shown to comprise an important portion of the nursing workforce in Australia, no previous studies have examined the levels of job satisfaction of overseas-qualified nurses in Australia. This lack of studies may have an impact on workforce planning aimed at integrating and retaining overseas-qualified nurses in order to meet the healthcare needs of South Australians. It is important to understand whether factors associated with job satisfaction of overseas-qualified NESB nurses differ from ESB nurses, so that supporting mechanisms for adaptation and integration will be more responsive to the needs of these groups.
Aims The aims of this study were to explore factors associated with the job satisfaction of overseas-qualified nurses working in public hospitals in South Australia and to compare whether factors associated with job satisfaction of overseas nurses from ESB differed from those from NESB.
Methods The aims of this study were examined using a cross-sectional survey design.
Ethical considerations
Ethics approval was received from the Southern Adelaide Flinders Clinical Human Research Ethics Committee and the human resource ethics committees of all participating hospitals. Participants were provided with information sheets that outlined their rights and responsibilities. Completion and return of the questionnaire was regarded as providing consent to participate in the study. The survey was anonymous, and the data were stored according to the guidelines of the National Health and Medical Research Council of Australia.
Setting and samples
Participants were overseas-qualified nurses working in one of five major public hospitals in South Australia. The sample size was based on a factor analysis to identify factors underlying
Job satisfaction of overseas-qualified nurses
multiple items. It was estimated that at least 150 participants were required for conducting the factor analysis (Tabachnick & Fidell 2007). Data collection
Data were collected in 2011 using an investigator-designed questionnaire named Job Satisfaction of Overseas-Qualified Nurses (JSOQN) which included demographic information, 36 items on job satisfaction and three open-ended questions relating to overseas nurses’ perception of job satisfaction (Appendix 1). Participants were invited to participate in the survey if they had completed their initial nursing education leading to registration in their home country and had worked as a nurse for more than 1 year in a South Australian hospital. A contact person in each hospital assisted the researcher in distributing the questionnaires to the pigeonholes of potential participants. In addition, flyers about the study were posted in the staff rooms of each hospital. Instrument development
The researchers in the present study developed the JSOQN instrument based on questionnaires commonly used to examine job satisfaction of nurses. These instruments included Index of Work Satisfaction (Stamp 1997), Nursing Work Index-R (Aiken & Patrician 2000), and Mueller and McCloskey Satisfaction Scale (Mueller & McCloskey 1990). As ‘Communication in English’ was identified as an important component in job satisfaction of migrant nurses in many qualitative studies (Alexis & Vydelingum 2009; Xiao et al. 2014; Xu et al. 2008), but was not examined in the existing job satisfaction scales, this component was developed by the researchers. In addition, three open-ended questions were included. The first openended question was adapted from Hayne et al. (2009) whereas the second and third questions were devised by the researchers based on the current literature. Therefore, a new instrument was developed that comprised a compilation of the three most commonly used job satisfaction instruments indicated above and the newly created items (Appendix 1). The items were rated on a 7-point Likert scale, ranging from 1 (strongly disagree) to 7 (strongly agree). Validity and reliability
Validity of the JSOQN instrument was achieved via a number of strategies. Content validity of the instrument was achieved through the application of a content validity index (CVI) rated by an expert panel (Polit & Beck 2012a). Exploratory factor analysis, employing principal component analysis, was performed to determine factors in the JSOQN instrument and test structural validity (internal consistency reliability) of these
© 2014 International Council of Nurses
67
factors. Known-group validity was used to generate evidence of contrast validity (Kline 2013). Of the new factor, ‘Communication in English’, we hypothesized that nurses from ESB would demonstrate a significantly higher score than those from NESB. Test and retest reliability was examined in a pilot study involving 20 overseas-qualified nurses, who did not participate in the main study. The JSOQN was administered twice to this group with a 2-week gap between administrations. Data analyses
Raw data from the questionnaire were entered into the Statistical Package for Social Science (SPSS) version 20. In order to minimize errors, the data were rechecked by another researcher and missing values were imputed by using case mean substitution. All interval data were assessed for normal distribution using the Kolmogorov–Smirnov test. The level of significance chosen for all analysis was P < 0.05 and all tests were two tailed. A Mann–Whitney U-test was used to examine differences in job satisfaction between the ESB and NESB groups for each of the four factors and to determine if there were any differences in age, length of stay and years worked in hospitals between the ESB and NESB groups. Chi-square test was used to compare categorical variables across groups. Spearman’s correlation was used to examine the relationship between the level of job satisfaction and factors that may influence job satisfaction. The three open-ended questions were analysed using content analysis to identify major categories as well as subcategories (Polit & Beck 2012b).
Results Of the 255 questionnaires distributed, a total of 151 questionnaires were returned yielding a response rate of 60%. Participants had migrated from 24 countries, with the top four donor countries being India, China, Philippines and the UK. A greater proportion (82.8%) of overseas-qualified nurses was from NESB than from ESB (17.2%). Participants’ ages ranged from 23 to 58 years with 70% of the participants aged between 23 and 40 years. The majority of participants (88.7%) were working as a RN 1 level, but significantly more ESB nurses (46.2%) were employed at a RN 2 level than NESB nurses (4.0%) (P < 0.001). No other significant differences were found in demographic characteristics between NESB and ESB nurses (Table 1). Reliability and validity indices of the JSOQN instrument Content validity index
Eight experts in the subject area were requested to evaluate the content of each of the 37 items in the initial survey instrument
68
K. K. Timilsina Bhandari et al.
Table 1 Demographic characteristics of participants (N = 151) Categories Gender: n (%) Male Female Age: years mean (SD) Marital status: n (%) Married Single Widow/Widower Level of employment: n (%) RN 1 RN 2 and higher Education in Australia: n (%) Education leading to RN registration Post-registration education Work experience in the present hospital mean years (SD) Length of stay in Australia mean years (SD)
ESBN
NESBN
Total
P-value
2 (7.7) 24 (92.3) 40 (10.0)
30 (24.0) 95 (76.0) 35.46 (7.3)
32 (21.2) 119 (92.3) 36.4 (8.0)
0.112†
18 (69.2) 6 (23.0) 2 (7.7)
91 (72.8) 33 (26.4) 1 (0.8)
109 (72.2) 39 (25.8) 3 (2)
0.071†
14 (53.8) 12 (46.2)
120 (96.0) 5 (4.0)
134 (88.7) 17 (11.3)
0.0005*†
5 (45.5) 6 (45.4) 5.12 (2.7) 5.77 (3.1)
40 (74.1) 14 (25.9) 3.84 (3.6) 5.27 (4.2)
45 (69.2) 20 (30.8) 4.06 (3.5) 5.4 (4.1)
0.068§
0.014*‡
0.002*‡ 0.133‡
*P-value < 0.05. †Chi-square test. ‡Mann–Whitney U-test. §Fisher’s exact test. ESBN, English-speaking background nurses from Canada, New Zealand, South Africa, UK and USA; NESBN = non-English-speaking background nurses mainly from India, China, Philippines, Nepal, Malaysia and Japan; RN, registered nurse.
developed by the researchers. The CVI of 36 items was between 0.80 and 1.00, and one item had a CVI score of less than 0.80. This item was removed from the questionnaire, and therefore only 36 items were used for the pilot study. Test and retest reliability
Prior to the main study, 20 overseas-qualified nurses completed the initial version of the JSOQN. After a 2-week interval only 17 nurses completed the questionnaire. Scores from the two tests were compared using a Spearman’s rank correlation. The correlation coefficient value was 0.979, which exceeded the required value of 0.70 (Polit 2010). Structural validity (internal consistency reliability)
Prior to performing factor analysis to examine factors underlying the multiple items and structural validity of these factors, the suitability of the data for factor analysis was assessed. The Kaiser–Meyer–Oklin value was 0.86 and the Bartlett test was significant (χ2 = 2761.0, P = 0.0005), indicators that the sample size was adequate for a factor analysis (Polit 2010). Factors were extracted based on examination of interpretability of meanings of items loaded on a factor, and a loading value of 0.40 or over was regarded as acceptable for an item to be included in the
© 2014 International Council of Nurses
factor (Polit 2010). Three rounds of analysis were performed that identified four factors. High loadings were found for 15 items on factor 1 – supportive work environment, 6 on factor 2 – interpersonal relationships, 8 on factor 3 – communication in English, and 3 on factor 4 – salary and salary-related benefits (Appendix 2). The internal consistency reliability of the JSOQN was 0.922 (Cronbach’s alpha). The internal consistency reliability tests of each factor in the JSOQN scale were between 0.36 and 0.47, indicating an acceptable internal consistency (Polit 2010; Worthington & Whittaker 2006). Known-group validity
As hypothesized, the communication in English score of the participants from ESB was significantly higher than participants from NESB (P < 0.0005, Table 2). Therefore, the newly developed items under the factor of communication in English showed good contrast validity among different groups. Job satisfaction levels between the ESB group and the NESB group
A comparison of job satisfaction levels between the ESB group and the NESB group was made by computing the total score for each of the four factors and the total score of the JSOQN. Overall, overseas-qualified nurses were satisfied with their job as
Job satisfaction of overseas-qualified nurses
69
Table 2 Comparisons of job satisfaction scores between RNs from ESB and NESB Factors
ESB group Med (Q1–Q3)
NESB group Med (Q1–Q3)
P-value
F1: Supportive work environment (15I) F2: Interpersonal relationship (6I) F3: Communication in English (8I) F4: Salary and salary-related benefits (3I) Total score of JSOQN (0–224 points)
81 (75–90) 47 (43–48) 36 (36–37) 18 (15–18) 180 (170–191)
80 (70–89) 46 (43–48) 35 (31–36) 18 (16–19) 174 (163–189)
0.359 0.398 0.0005* 0.542 0.116
The items were rated on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). *P < 0.05 using Mann–Whitney U-test. ESB, English-speaking background; F, factor; I, item; Med, median; NESB, non-English-speaking background; Q1–Q3, interquartile range.
evidenced by the relatively high total score in both groups. While not significant, nurses from NESB showed a lower level of satisfaction than those from ESB, and this appeared to be influenced primarily by the factor of communication in English (Table 2). Factors associated with job satisfaction
The association between demographic variables such as age, length of stay in Australia and the number of years worked in the present hospital for each group was examined using Spearman’s correlation. Only length of stay was significantly correlated with job satisfaction (r = −0.196, P < 0.05) (Appendix 3). The longer overseas-qualified nurses stayed employed in Australia, the less satisfied they were. Overseas-qualified nurses’ responses to open-ended questions
There were 238 statements made by participants in response to the open-ended questions. Content analyses were used to group these statements into categories based on meanings. Four categories were identified: (1) positive experience, (2) feeling of discrimination, racism and isolation, (3) communication in English, and (4) education about diversity and equal opportunity. Participants reported that no education programs on cultural diversity in the nursing workforce were available in these hospitals. Examples of comments under each category from the ESB nurses and the NESB nurses were given in Table 3.
Discussion This study was one of a few studies that investigated factors associated with the job satisfaction of overseas-qualified nurses and that compared these factors between overseas-qualified nurses from ESB and from NESB. The present study revealed
© 2014 International Council of Nurses
that communication in English was a major factor contributing to a lower level of job satisfaction for NESB nurses although overall job satisfaction did not differ between the two groups. Indeed, ESB and NESB nurses showed similar levels of satisfaction with regard to a supportive work environment, interpersonal relationships, and salary and salary-related benefits. The contribution of communication in English as a factor associated with job satisfaction was an important finding. While numerous qualitative studies reported that NESB nurses encountered language barriers in the workplace that produced a negative impact on their interactions with patients and colleagues, no study had been previously undertaken to quantify its impact on job satisfaction. The lack of a suitable instrument to measure job satisfaction for overseas-qualified nurses that takes into account their language background may have contributed to the scarcity of benchmarks and best practice in policies and practices used to manage the diverse nursing workforce among healthcare organizations in the global context of nurse migration (Alexis & Vydelingum 2009; Xiao et al. 2014; Zhou et al. 2011). The JSOQN developed in this study has been useful for comparing the magnitude of job satisfaction for overseasqualified nurses across or within populations in human resource management. However, as communication also has been shown to be influenced by culture (Xiao et al. 2014; Xu et al. 2008), how cultural dissonance has contributed to job satisfaction remains unknown in the present study, suggesting the need for further studies. The finding that the longer overseas-qualified nurses remained in the host country, the less satisfied NESB nurses were with the work environment, was completely contrary to other studies that showed a positive correlation between length of stay and job satisfaction (Ea et al. 2008; Xu et al. 2008).
70
K. K. Timilsina Bhandari et al.
Table 3 Participants’ responses to open-ended questions Categories
Examples from NESB nurses
Examples from ESB nurses
1. Positive experience
a. I enjoy it due to flexibility of shift, good income autonomy of self-development and good welfare b. It is a rewarding experience. We get the right nurse-patient ratio and are well paid. Here we got 1:4 nurse-patient ratio. a. Migrant nurses are not getting equal opportunity for career development b. There is no clinical nurse from NESB group of nurses in this hospital c. We have experienced racial discrimination sometimes d. Although it is a free nation some people are very racist and have wrong perception about overseas-qualified nurse e. Most managers still prefer local nurse rather than overseas nurse even though we do qualify for it f. Sometimes we felt a little bit homesick as they ignore us g. They (local nurses) don’t help you when you need them for patient’s care, rather they chat with their colleagues a. Initially it was frustrating that I could not express myself as good in English as how I could have done in my own language. Especially I had to get used to the Australian slang and accent and not every colleague or patient was patient. b. Language is a barrier for me . . . but I believe things are getting better gradually a. The awareness of equality and peer support needs to be advocated continuously b. More education towards anti-racism c. Discrimination on the base of colour should be stopped d. Promote equal rights between local and overseas-qualified nurses e. Need understanding and supportive supervisors
a. I enjoy my work in Australia, nursing is not really any different here as in the UK. We are well paid. a. I do get ‘Hack’ for being a Kiwi. Little friendly banter between cultures. But sometimes its pushed too far you get sick of it.
2. Feeling of discrimination, racism and isolation
3. Communication in English
4. Education about diversity and equal opportunity
Nil
Welcome them (NESB) to the ward, respect and acknowledge their experiences
ESB, English-speaking background; NESB, non-English-speaking background.
However, this finding was similar to the results of a study on job satisfaction of Filipino RNs in the USA that reported a negative association between length of stay and lower levels of satisfaction with professional status, task requirements and organizational policies (Itzhaki et al. 2013). Possible reasons underlying this observation may be related to the lack of opportunities for career advancement and lack of recognition of overseas-qualified nurses’ previous nursing skills and knowledge. The present study found that the proportion of nurses employed at RN level 2 was higher in the ESB group than in nurses from the NESB group. This result was consistent with other studies that reported the lack of opportunity for career advancement among NESB nurses (Alexis & Vydelingum 2009; Xiao et al. 2014). In addition, the absence of family, the loss of usual social networks and homesickness may also have contributed to the result. These reasons were reported in previous studies (Alexis & Vydelingum 2009; Hayne et al. 2009; Zhou et al. 2011), and the homesickness was also mentioned by participants in the present study (see Table 3).
© 2014 International Council of Nurses
The lack of career advancement also may have reflected discrimination and racism against overseas-qualified nurses experienced by nurses from NESB in this study. The prevalence of these issues may be attributed to the lack of education and resources to tackle these issues as reported in previous studies (Alexis & Vydelingum 2009; Xiao et al. 2014). Previous studies reported that discrimination and racism were covert in many forms. For example, studies found that overseas-qualified nurses were classified at a junior level despite their previous experiences in nursing, denied requests to practice in the area of their expertise, imitated verbally, threatened by local colleagues or patients and given few opportunities for promotion (Allan et al. 2009; Mapedzahama et al. 2012; Xiao et al. 2014). Although these forms of racism were not examined in this study, the results suggest a need for additional studies. It was evident that anti-discrimination and anti-racism policies alone without leadership and resources to support the implementation of the policies may not be able to amend the undesirable situations in the nursing workforce.
Job satisfaction of overseas-qualified nurses
The participants made a number of recommendations that they felt would enable them to better integrate with the host country workforce. They emphasized that they required time to improve communication in English, and that positive interactions and tolerance to cultural differences by local colleagues were important in assisting NESB nurses to integrate (Xiao et al. 2014; Zhou et al. 2011). Programs to improve knowledge, skills and attitudes necessary for positive intercultural communication for both overseas-qualified nurses and local nurses were strongly suggested by participants in the present study and in previous studies (Xiao et al. 2014; Zhou et al. 2011). Therefore, preparing local and overseas-qualified nurses with knowledge, skills and leadership in raising awareness of these issues, promoting equity, cultural diversity and tolerance at ward level may be a long-term solution for facilitating nursing workforce integration in a multicultural society.
Limitations There were a number of limitations in this study. Firstly, the study used a cross-sectional research design that provided information about job satisfaction levels of overseasqualified RNs working in five public hospitals in South Australia at a particular point in time only. Secondly, this study used convenience sampling, therefore findings cannot be generalized. The third major limitation related to the selfdeveloped scale with no previously established psychometric property records. Further tests of the JSOQN questionnaire are needed to establish psychometric properties in a wider population.
Conclusions This study identified four factors that influenced job satisfaction in overseas-qualified nurses working in five major hospitals in South Australia. These factors along with findings from the open-ended questions provide evidence for nursing human resource planning and management when developing strategies to assist and retain nurses from NESB. Communication in English has been identified as a major challenge for nurses from the NESB group that was associated with job satisfaction. Unlike previous studies, this study identified a negative correlation between job satisfaction and length of stay among overseas-qualified nurses from the NESB group. This finding may be related to the lack of opportunities for career advancement and lack of recognition of their previous nursing skills and knowledge. Discrimination and racism described by NESB nurses need to be further examined in future studies.
© 2014 International Council of Nurses
71
Implications for nursing and/or health policy Nurses from NESB need to be supported early in their employment, especially with their communication skills. Consideration also needs to be given to the education of local staff regarding cultural differences of overseas nurses to support their adaptation to the workplace.
Acknowledgements This manuscript is from the first author’s master thesis which was completed in School of Nursing & Midwifery, Flinders University of Australia in 2013. The authors wish to thank all the participants from five public hospitals in Adelaide, South Australia.
Author contributions KTB designed the research, developed study conception, collected, analysed and interpreted data, and developed the draft manuscript. LDX supervised this study and contributed to the design of the study, statistical expertise, data analyses and interpretation, and made significant revision for the manuscript. IB supervised this study and contributed to the design of the study, statistical expertise and made significant revision for the manuscript.
References AIHW (2009) Nursing and midwifery labour force 2007. Canberra, Australian Institute of Health and Welfare. Aiken, L.H. & Patrician, P.A. (2000) Measuring organizational traits of hospitals: the revised nursing work index. Nursing Research, 49 (3), 146–153. Alexis, O. & Vydelingum, V. (2009) Experiences in the UK National Health Service: the overseas nurses’ workforce. Health Policy, 90 (2–3), 320–328. Allan, H.T., Cowie, H. & Smith, P. (2009) Overseas nurses’ experiences of discrimination: a case of racist bullying? Journal of Nursing Management, 17 (7), 898–906. Australian Bureau of Statistics (ABS) (2013) Australian Social Trends. Canberra, Australian Bureau of Statistics. Australian Department of Immigration and Citizenship (2011) Visa options for nurses. Australian Department of Immigration and Citizenship, Caberra. Available at: http://www.australia-migration.com/page/ Options_for_Nurses/39 (accessed 5 November 2014). Bae, S.H. (2013) Organizational socialization of international nurses in the New York metropolitan area. (vol 59, pg 81, 2012). International Nursing Review, 60 (2), 275. Castaneda, G.A. & Scanlan, J.M. (2014) Job satisfaction in nursing: a concept analysis. Nursing Forum, 49 (2), 130–138. doi: 10.1111/ nuf.12056. Cheng, C.-Y. & Liou, S.-R. (2011) Intention to leave of Asian nurses in US hospitals: does cultural orientation matter? Journal of Clinical Nursing, 20 (13–14), 2033–2042.
72
K. K. Timilsina Bhandari et al.
Cummins, T. (2009) Migrant nurses’ perceptions and attitudes of integration into the perioperative setting. Journal of Advanced Nursing, 65 (8), 1611–1616. Ea, E.E., Griffin, M.Q., L’Eplattenier, N. & Fitzpatrick, J.J. (2008) Job satisfaction and acculturation among Filipino registered nurses. Journal of Nursing Scholarship, 40 (1), 46–51. Hayne, A.N., Gerhardt, C. & Davis, J. (2009) Filipino nurses in the United States recruitment, retention, occupational stress, and job satisfaction. Journal of Transcultural Nursing, 20 (3), 313–322. International Council of Nurses (2014) International Centre on Nurse Migration. International Council of Nurses. Available at: http:// www.intlnursemigration.org/sections/about/aboutus.shtml (accessed 2 September 2014). Itzhaki, M., Ea, E., Ehrenfeld, M. & Fitzpatrick, J.J. (2013) Job satisfaction among immigrant nurses in Israel and the United States of America. International Nursing Review, 60 (1), 122–128. Jose, M.M. (2011) Lived experiences of internationally educated nurses in hospitals in the United States of America. International Nursing Review, 58 (1), 123–129. Kline, P. (2013) Handbook of Psychological Testing. Routledge, New York. Mapedzahama, V., Rudge, T., West, S. & Perron, A. (2012) Black nurse in white space? Rethinking the in/visibility of race within the Australian nursing workplace. Nursing Inquiry, 19 (2), 153–164. McHugh, M.D., et al. (2011) Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs, 30 (2), 202–210. Mueller, C.W. & McCloskey, J.C. (1990) Nurses job-satisfaction – a proposed measure. Nursing Research, 39 (2), 113–117. NMBA (2011) Nursing and Midwifery English Language Skills Registration Standard. Nursing and Midwifery Board Australia, Canberra. Available at: http://www.nursingmidwiferyboard.gov.au/RegistrationStandards.aspx (accessed 20 October 2011).
© 2014 International Council of Nurses
Polit, D.F. (2010) Statistics and Data Analysis for Nursing Research. Person Education, Boston. Polit, D.F. & Beck, C.T. (2012a) Measurement and data quality. In Nursing Research: Generating and Assessing Evidence for Nursing Practice, 9th edn (Polit, DF, Beck, CT, ed.). Lippincott Williams & Wilkins, Philadelphia, pp. 328–350. Polit, D.F. & Beck, C.T. (2012b) Qualitative research design and approaches. In Nursing Research: Generating and Assessing Evidence for Nursing Practice, 9th edn (Polit, DF, Beck, CT, ed.). Lippincott Williams & Wilkins, Philadelphia, pp. 487–514. Smith, C.D.A., Fisher, C. & Mercer, A. (2011) Rediscovering nursing: a study of overseas nurses working in Western Australia. Nursing & Health Sciences, 13 (3), 289–295. Stamp, P. (1997) Nurses and Work Satisfaction: An Index for Measurement. Health Administration Press, Chicago. Tabachnick, B.G. & Fidell, L.S. (2007) Using Multivariate Statistics, 6th edn. Pearson, Sydney. Worthington, R.L. & Whittaker, T.A. (2006) Scale development research – a content analysis and recommendations for best practices. Counseling Psychologist, 34 (6), 806–838. Xiao, L.D., Willis, E. & Jeffers, L. (2014) Factors affecting the integration of immigrant nurses into the nursing workforce: a double hermeneutic study. International Journal of Nursing Studies, 51 (4), 640–653. Xu, Y., Gutierrez, A. & Kim, S.H. (2008) Adaptation and transformation through (un)learning: lived experiences of immigrant Chinese nurses in US healthcare environment. ANS. Advances in Nursing Science, 31 (2), E33–E47. Zhou, Y., Windsor, C., Theobald, K. & Coyer, F. (2011) The concept of difference and the experience of China-educated nurses working in Australia: a symbolic interactionist exploration. International Journal of Nursing Studies, 48 (11), 1420–1428.
Job satisfaction of overseas-qualified nurses
73
Appendix 1 Items newly developed or adapted in the Job Satisfaction of Overseas-Qualified Nurses instrument development Items under each factor Supportive work environment I have an opportunity to work in my specialty area that I developed in my home country I have an opportunity to select my annual leave I feel included in staff meetings and/or any discussion within my ward/unit The team leader is always fair in allocating patient load to nursing staff I am always assigned the shift that I requested My supervisor is fair in selecting staff for education and training programs regardless of their background My supervisor encourages me to undertake a higher degree study My performance in my current workplace is acknowledged by my supervisors My current work environment is pleasant and comfortable to me The organization recognizes my previous skills and experiences in nursing and appointed me at an appropriate level My nurse manager is very supportive of me My supervisor encourages me to organize in-services in the ward I feel that I am treated fairly in my current workplace of employment I can negotiate my workload with the team leader or nurse manager I have the same opportunity to attend seminars, training and workshops as Australian nurses Interpersonal relationships My colleagues always communicate and explain what they mean if I don’t understand them I can share my ideas with other interdisciplinary members in my hospital My work is valued by my colleagues at work I have colleagues to discuss work-related issues within my current workplace My colleagues always show their tolerance to my accent I received fair treatment and respect from my colleagues I feel comfortable in communicating with my colleagues in my current workplace I have opportunities to socialize with my colleagues during breaks Communication in English Language is not a barrier for me in communicating with patients The use of Australian slang words by patients does not frustrate me I feel confident to talk to the family members on the phone I can understand the different accents and Australian words used by family members of patients I interact well with my patients Patients show their tolerance to my accent and communication difference Salary and salary-related benefits I am satisfied with the benefits (remunerations) offered to me through this job I am paid fairly in this hospital as Australian-educated nurse I am satisfied with the salary scale offered to me in this job Open-ended questions What are your feelings and experiences about working and living in Australia? In your opinion, what are the areas that needed to be addressed in order to create a sound working environment for overseas-qualified nurses? Does your hospital provide special program for the overseas-qualified nurses? If yes, please specify what sort of program your hospital provides for overseas-qualified nurses.
New
Adapted
New New New New MMS, 5 New NWRI, 30 NWRI, 18 New New NWRI, 4 NWRI, 30 MMS, 23 New New New NWRI, 11 MMSS, 25 MMSS, 19 New New New MMSS, 17 New New New New New New MMSS, 3 New MMSS, 1 Hayne et al. 2009 New New
IWS, Index of Work Satisfaction (Stamp 1997); NWI-R, Nursing Work Index-R (Aiken & Patrician 2000); MMSS, Mueller & McCloskey Satisfaction Scale (Mueller & McCloskey 1990).
© 2014 International Council of Nurses
74
K. K. Timilsina Bhandari et al.
Appendix 2 Factor loadings on 32 items
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Items
F1
My supervisor is fair in selecting staff for education and training programs regardless of their background I have an opportunity to select my annual leave I am always assigned the shift that I requested The team leader is always fair in allocating patient load to nursing staff My supervisor encourages me to undertake a higher degree study My performance in my current workplace is acknowledged by my supervisors My supervisor encourages me to organize in-services in the ward I feel included in staff meetings and/or in any discussion within my ward/unit The organization recognizes my previous skills and experiences in nursing and appointed me at an appropriate level My nurse manager is very supportive of me I have an opportunity to work in my specialty area that I developed in my home country My current work environment is pleasant and comfortable for me I feel that I am treated fairly in my current workplace of employment I can negotiate my workload with the team leader or nurse manager I have the same opportunity to attend seminars, training and workshops as Australian nurses Language is not a barrier for me in communicating with patients The use of Australian slang words by patients does not frustrate me I feel confident to talk to the family members on the phone I can understand the different accents and Australian words used by family members of patients I interact well with my patients Patients show their tolerance to my accent and communication difference My colleagues always communicate and explain what they mean if I don’t understand them. I can share my ideas with other interdisciplinary members in my hospital My work is valued by my colleagues at work I have colleagues to discuss work-related issues within my current workplace My colleagues always show their tolerance to my accent I received fair treatment and respect from my colleagues I feel comfortable in communicating with my colleagues in my current workplace I have opportunities to socialize with my colleagues during breaks I am satisfied with the benefits (remunerations) offered to me through this job I am paid fairly in this hospital as Australian-educated nurse I am satisfied with the salary scale offered to me in this job
0.857 0.791 0.685 0.678 0.670 0.653 0.631 0.562 0.546 0.527 0.511 0.468 0.440 0.422 0.419
F2
F3
F4
0.845 0.779 0.731 0.716 0.500 0.463 −0.721 −0.695 −0.685 −0.658 −0.633 −0.565 −0.562 −0.547 0.778 0.621 0.563
F1, factor 1 – supportive work environment; F2, factor 2 – interpersonal relationship; F3, factor 3 – communication in English; F4, factor 4 – salary and salary-related benefits.
Appendix 3 Correlation between demographic variables and job satisfaction Categories
Work environment
Communication in English
Interpersonal relationship
Financial rewards
Demographics Age Length of stay in Australia Years worked in the hospital
ESB 0.13 0.27 0.58
ESB 0.25 0.17 0.30
ESB −0.35 −0.16 −0.10
ESB −0.35 −0.36 −0.25
NESB −0.06 −0.20* −0.08
NESB −0.04 −0.15
*Correlation significant at the 0.05 level (two tailed) using Spearman’s correlation.
© 2014 International Council of Nurses
NESB −0.11 −0.14 0.03
NESB −0.05 −0.07 −0.05
Copyright of International Nursing Review is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Nursing Work and Life
Job satisfaction of overseas-qualified nurses working in Australian hospitals K.K. Timilsina Bhandari1* CN, RN, MN, MA (English), Bachelor of Health Education, L.D. Xiao2 RN, MNg, PhD, FACN & I. Belan3 PhD, Grad Dip (AppSci), BSC 1 Clinical Nurse, 3 Senior Lecturer, School of Nursing and Midwifery, 2 Associate Professor, School of Nursing and Midwifery, Faculty of Health Sciences, Flinders University, Adelaide, SA, Australia
TIMILSINA BHANDARI K.K., XIAO L.D. & BELAN I. (2015) Job satisfaction of overseas-qualified nurses working in Australian hospitals. International Nursing Review 62, 64–74 Aims: The aims of this study were to explore factors associated with the job satisfaction of overseas-qualified nurses working in public hospitals in South Australia and to compare whether factors associated with job satisfaction of overseas nurses from English-speaking backgrounds differed from those from non-English-speaking backgrounds. Background: Overseas-qualified nurses have become an essential part of the nursing workforce in Australia. Although this nurse population has different expectations and values in relation to their jobs when compared with local nurses, studies on job satisfaction among overseas nurses are scarce. Methods: A cross-sectional survey using the Job Satisfaction of Overseas-Qualified Nurses questionnaire was conducted in five major public hospitals in South Australia. Results: One hundred and fifty-one overseas-qualified nurses completed the questionnaire. Four factors were found to influence job satisfaction: Supportive work environment, interpersonal relationships, communication in English, and salary and salary-related benefits. Communication in English was the predominant factor that was associated with job satisfaction in nurses from non-English-speaking backgrounds. This group of nurses also showed a negative correlation between length of stay in Australia and satisfaction with their work environment. Participants’ responses to open-ended questions revealed issues relating to discrimination and racism. Conclusion: Supportive work environment, interpersonal relationships, communication in English, and salary and salary-related benefits were major factors associated with job satisfaction in overseas-qualified nurses in this study. Nurses from non-English-speaking backgrounds faced additional challenges in communication in the workplace and in dealing with issues of discrimination and racism.
Correspondence address: Dr Lily Dongxia Xiao, School of Nursing and Midwifery, Faculty of Health Sciences, Flinders University, PO Box 2100, Adelaide, SA 5001, Australia; Tel: +61 8 8201 3419; Fax: +61 8 8276 1602; E-mail: [email protected].
*Current address: Modbury Hospital, Adelaide, SA 5092 Funding statement This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Conflicts of interest No conflict of interest has been declared by the authors.
© 2014 International Council of Nurses
64
Job satisfaction of overseas-qualified nurses
65
Implications for Nursing and/or Health Policy: Nurses from non-English-speaking backgrounds need to be supported early in their employment, especially with their communication skills. Consideration also needs to be given to the education of local staff regarding cultural differences of overseas workers. Keywords: Human Resource Management, Immigrant Nurses, Job Satisfaction, Multicultural Issues, Recruitment and Retention, Workforce Organization
Background Many developed countries, including Australia, have depended on international recruitment of registered nurses (RNs) to mitigate a labour shortage of nurses (Australian Bureau of Statistics (ABS) 2013; Smith et al. 2011). According to a 2009 report from the Australian Institute of Health and Welfare (AIHW), 15.5% of RNs have been trained overseas (AIHW 2009). The demand for highly skilled RNs has been growing in Australia and other developed countries due to a number of pull factors such as an ageing population, an increase in the population living with chronic conditions and the ageing nursing workforce (ABS 2013; AIHW 2009). The immigration policy in Australia has supported the international recruitment of overseas-qualified nurses through the skilled migration process and through employer-sponsored visas (Australian Department of Immigration and Citizenship 2011). In addition, factors that push overseas-qualified nurses to migrate to developed countries have played a key role. These push factors have included better career opportunities, better working environment, better lifestyle, political stability and earning income to support family in the home country (Hayne et al. 2009; Jose 2011; Zhou et al. 2011). Both pull and push factors have impacted on job expectations and job satisfaction (Castaneda & Scanlan 2014; Jose 2011). In a global context of increasing trends of nurse migration, studies on job satisfaction of overseas-qualified nurses have become more important both in improving nursing human resource management and facilitating the equitable treatment of migrating nurses (International Council of Nurses 2014). Previous studies have highlighted that overseas-qualified nurses have different expectations and values in relation to their job as a result of the unique challenges they face during integration and subsequent career development, such as language barriers, workplace diversity, and differences in nursing and social culture (Jose 2011; Zhou et al. 2011). An understanding of factors influencing job satisfaction of overseasqualified nurses has been considered important in developing strategies that will help retain and integrate these nurses in the workforce.
© 2014 International Council of Nurses
Job satisfaction has been defined as the fulfilment of expectations and values that the employee has for that work and has been widely used as an important aspect of human resource management by organizations (Hayne et al. 2009). In healthcare settings, a high level of job satisfaction among nurses has been associated with a high level of staff retention, decrease in staff absenteeism, and has contributed to better patient care (Bae 2013; McHugh et al. 2011). In the context of nurse migration, job satisfaction has been viewed as an indicator of a hospital’s performance on managing the diverse nursing workforce in a multicultural workplace (Hayne et al. 2009; Xiao et al. 2014). The Nursing and Midwifery Board of Australia (NMBA) has classified overseas-qualified nurses into two subgroups, RNs from English-speaking background (ESB) and RNs from nonEnglish-speaking background (NESB) in the Registration Standards for Internationally Educated Nurses (NMBA 2011). RNs from six recognized English-speaking countries are exempted from the English proficiency test (NMBA 2011). These countries are Canada, New Zealand, Republic of Ireland, South Africa, UK and USA. RNs from NESB have been expected to be proficient in English (NMBA 2011). The English language proficiency of overseas-qualified nurses has played an important role in communication and has been identified as a significant factor that either hinders or facilitates communication with patients, physicians and host nurses (Cummins 2009; Xiao et al. 2014). However, language use and communication have been found to be culturally bound, suggesting overseas-qualified nurses from both ESB and NESB have faced challenges to learn words and slang in order to fit into the workplace culture and conduct effective communication with patients and colleagues in the workplace (Xiao et al. 2014; Zhou et al. 2011). Numerous studies have identified that passing an English proficiency test by NESB nurses does not guarantee communication success in the workplace (Xiao et al. 2014; Zhou et al. 2011). Misunderstandings and errors in communication with patients and colleagues have contributed to fear, anxiety, and rejection and bullying by patients or colleagues, interpersonal
66
K. K. Timilsina Bhandari et al.
conflict and low states of self-esteem (Jose 2011; Xu et al. 2008). In addition, language barriers also have prevented Asian nurses from using their skills and knowledge in the clinical setting, being assertive and demonstrating leadership (Xiao et al. 2014; Xu et al. 2008). These negative experiences relating to communication may have contributed to low levels of job satisfaction. The country of origin has been shown to have a strong influence on overseas-qualified nurses’ experiences in adapting their nursing practice and thereby their satisfaction with their job. Nurses emigrated from English-speaking countries share similarities in nursing practice and have encountered fewer challenges in adjusting their practice to the host country (Alexis & Vydelingum 2009; Allan et al. 2009). However, NESB nurses have emigrated mainly from less developed countries with different healthcare systems and scope of practice compared with developed countries (Alexis & Vydelingum 2009; Xiao et al. 2014). NESB nurses may not have had formal nursing education or experience in demonstrating autonomy, critical thinking, holistic patient care, and maintaining activities of daily living (Xiao et al. 2014; Zhou et al. 2011). However, they may have knowledge and skills such as inserting vein cannulation, vein puncture, nasal-gastric tube insertion and collecting arterial blood that have been usually performed by medical doctors or allied health professionals in developed countries (Xiao et al. 2014; Zhou et al. 2011). Cultural background has been demonstrated to have a significant impact on job satisfaction among immigrant nurses (Ea et al. 2008; Itzhaki et al. 2013). Cultural background also may have an impact on interactions with local nurses in the workplace. For example, nurses from NESB may have originated from collectivist cultures that value public face and prefer feedback from supervisors in private (Xu et al. 2008). In contrast, nurses from ESB may have come from largely individualistic cultures and prefer competitive and confrontational conflict management styles (Jose 2011; Xu et al. 2008). These differences in interactions may have contributed to interpersonal conflict and may have impacted upon interpersonal relationships in the workplace. Similarly, several studies have reported that nurses from NESB face challenges in patient–nurse intercultural interactions due to inadequate knowledge about intercultural communication with patients and the provision of appropriate care that met patients’ cultural needs (Smith et al. 2011; Zhou et al. 2011). Discrimination towards overseas-qualified nurses due to differences in their accent and culture also has been reported (Cheng & Liou 2011; Jose 2011), and has been evidenced by the under-representation of overseas-qualified nurses in senior positions in hospitals (Mapedzahama et al. 2012; Xiao et al.
© 2014 International Council of Nurses
2014). Most overseas-qualified nurses have many years of experience and bring rich knowledge, experience and skills to the Australian nursing workforce (Xiao et al. 2014; Zhou et al. 2011). Despite these qualifications, many overseas-qualified nurses have not been given positions reflecting their skills, and this may have impacted on their ability to adapt to their new environment and job satisfaction. Although overseas-qualified nurses have been shown to comprise an important portion of the nursing workforce in Australia, no previous studies have examined the levels of job satisfaction of overseas-qualified nurses in Australia. This lack of studies may have an impact on workforce planning aimed at integrating and retaining overseas-qualified nurses in order to meet the healthcare needs of South Australians. It is important to understand whether factors associated with job satisfaction of overseas-qualified NESB nurses differ from ESB nurses, so that supporting mechanisms for adaptation and integration will be more responsive to the needs of these groups.
Aims The aims of this study were to explore factors associated with the job satisfaction of overseas-qualified nurses working in public hospitals in South Australia and to compare whether factors associated with job satisfaction of overseas nurses from ESB differed from those from NESB.
Methods The aims of this study were examined using a cross-sectional survey design.
Ethical considerations
Ethics approval was received from the Southern Adelaide Flinders Clinical Human Research Ethics Committee and the human resource ethics committees of all participating hospitals. Participants were provided with information sheets that outlined their rights and responsibilities. Completion and return of the questionnaire was regarded as providing consent to participate in the study. The survey was anonymous, and the data were stored according to the guidelines of the National Health and Medical Research Council of Australia.
Setting and samples
Participants were overseas-qualified nurses working in one of five major public hospitals in South Australia. The sample size was based on a factor analysis to identify factors underlying
Job satisfaction of overseas-qualified nurses
multiple items. It was estimated that at least 150 participants were required for conducting the factor analysis (Tabachnick & Fidell 2007). Data collection
Data were collected in 2011 using an investigator-designed questionnaire named Job Satisfaction of Overseas-Qualified Nurses (JSOQN) which included demographic information, 36 items on job satisfaction and three open-ended questions relating to overseas nurses’ perception of job satisfaction (Appendix 1). Participants were invited to participate in the survey if they had completed their initial nursing education leading to registration in their home country and had worked as a nurse for more than 1 year in a South Australian hospital. A contact person in each hospital assisted the researcher in distributing the questionnaires to the pigeonholes of potential participants. In addition, flyers about the study were posted in the staff rooms of each hospital. Instrument development
The researchers in the present study developed the JSOQN instrument based on questionnaires commonly used to examine job satisfaction of nurses. These instruments included Index of Work Satisfaction (Stamp 1997), Nursing Work Index-R (Aiken & Patrician 2000), and Mueller and McCloskey Satisfaction Scale (Mueller & McCloskey 1990). As ‘Communication in English’ was identified as an important component in job satisfaction of migrant nurses in many qualitative studies (Alexis & Vydelingum 2009; Xiao et al. 2014; Xu et al. 2008), but was not examined in the existing job satisfaction scales, this component was developed by the researchers. In addition, three open-ended questions were included. The first openended question was adapted from Hayne et al. (2009) whereas the second and third questions were devised by the researchers based on the current literature. Therefore, a new instrument was developed that comprised a compilation of the three most commonly used job satisfaction instruments indicated above and the newly created items (Appendix 1). The items were rated on a 7-point Likert scale, ranging from 1 (strongly disagree) to 7 (strongly agree). Validity and reliability
Validity of the JSOQN instrument was achieved via a number of strategies. Content validity of the instrument was achieved through the application of a content validity index (CVI) rated by an expert panel (Polit & Beck 2012a). Exploratory factor analysis, employing principal component analysis, was performed to determine factors in the JSOQN instrument and test structural validity (internal consistency reliability) of these
© 2014 International Council of Nurses
67
factors. Known-group validity was used to generate evidence of contrast validity (Kline 2013). Of the new factor, ‘Communication in English’, we hypothesized that nurses from ESB would demonstrate a significantly higher score than those from NESB. Test and retest reliability was examined in a pilot study involving 20 overseas-qualified nurses, who did not participate in the main study. The JSOQN was administered twice to this group with a 2-week gap between administrations. Data analyses
Raw data from the questionnaire were entered into the Statistical Package for Social Science (SPSS) version 20. In order to minimize errors, the data were rechecked by another researcher and missing values were imputed by using case mean substitution. All interval data were assessed for normal distribution using the Kolmogorov–Smirnov test. The level of significance chosen for all analysis was P < 0.05 and all tests were two tailed. A Mann–Whitney U-test was used to examine differences in job satisfaction between the ESB and NESB groups for each of the four factors and to determine if there were any differences in age, length of stay and years worked in hospitals between the ESB and NESB groups. Chi-square test was used to compare categorical variables across groups. Spearman’s correlation was used to examine the relationship between the level of job satisfaction and factors that may influence job satisfaction. The three open-ended questions were analysed using content analysis to identify major categories as well as subcategories (Polit & Beck 2012b).
Results Of the 255 questionnaires distributed, a total of 151 questionnaires were returned yielding a response rate of 60%. Participants had migrated from 24 countries, with the top four donor countries being India, China, Philippines and the UK. A greater proportion (82.8%) of overseas-qualified nurses was from NESB than from ESB (17.2%). Participants’ ages ranged from 23 to 58 years with 70% of the participants aged between 23 and 40 years. The majority of participants (88.7%) were working as a RN 1 level, but significantly more ESB nurses (46.2%) were employed at a RN 2 level than NESB nurses (4.0%) (P < 0.001). No other significant differences were found in demographic characteristics between NESB and ESB nurses (Table 1). Reliability and validity indices of the JSOQN instrument Content validity index
Eight experts in the subject area were requested to evaluate the content of each of the 37 items in the initial survey instrument
68
K. K. Timilsina Bhandari et al.
Table 1 Demographic characteristics of participants (N = 151) Categories Gender: n (%) Male Female Age: years mean (SD) Marital status: n (%) Married Single Widow/Widower Level of employment: n (%) RN 1 RN 2 and higher Education in Australia: n (%) Education leading to RN registration Post-registration education Work experience in the present hospital mean years (SD) Length of stay in Australia mean years (SD)
ESBN
NESBN
Total
P-value
2 (7.7) 24 (92.3) 40 (10.0)
30 (24.0) 95 (76.0) 35.46 (7.3)
32 (21.2) 119 (92.3) 36.4 (8.0)
0.112†
18 (69.2) 6 (23.0) 2 (7.7)
91 (72.8) 33 (26.4) 1 (0.8)
109 (72.2) 39 (25.8) 3 (2)
0.071†
14 (53.8) 12 (46.2)
120 (96.0) 5 (4.0)
134 (88.7) 17 (11.3)
0.0005*†
5 (45.5) 6 (45.4) 5.12 (2.7) 5.77 (3.1)
40 (74.1) 14 (25.9) 3.84 (3.6) 5.27 (4.2)
45 (69.2) 20 (30.8) 4.06 (3.5) 5.4 (4.1)
0.068§
0.014*‡
0.002*‡ 0.133‡
*P-value < 0.05. †Chi-square test. ‡Mann–Whitney U-test. §Fisher’s exact test. ESBN, English-speaking background nurses from Canada, New Zealand, South Africa, UK and USA; NESBN = non-English-speaking background nurses mainly from India, China, Philippines, Nepal, Malaysia and Japan; RN, registered nurse.
developed by the researchers. The CVI of 36 items was between 0.80 and 1.00, and one item had a CVI score of less than 0.80. This item was removed from the questionnaire, and therefore only 36 items were used for the pilot study. Test and retest reliability
Prior to the main study, 20 overseas-qualified nurses completed the initial version of the JSOQN. After a 2-week interval only 17 nurses completed the questionnaire. Scores from the two tests were compared using a Spearman’s rank correlation. The correlation coefficient value was 0.979, which exceeded the required value of 0.70 (Polit 2010). Structural validity (internal consistency reliability)
Prior to performing factor analysis to examine factors underlying the multiple items and structural validity of these factors, the suitability of the data for factor analysis was assessed. The Kaiser–Meyer–Oklin value was 0.86 and the Bartlett test was significant (χ2 = 2761.0, P = 0.0005), indicators that the sample size was adequate for a factor analysis (Polit 2010). Factors were extracted based on examination of interpretability of meanings of items loaded on a factor, and a loading value of 0.40 or over was regarded as acceptable for an item to be included in the
© 2014 International Council of Nurses
factor (Polit 2010). Three rounds of analysis were performed that identified four factors. High loadings were found for 15 items on factor 1 – supportive work environment, 6 on factor 2 – interpersonal relationships, 8 on factor 3 – communication in English, and 3 on factor 4 – salary and salary-related benefits (Appendix 2). The internal consistency reliability of the JSOQN was 0.922 (Cronbach’s alpha). The internal consistency reliability tests of each factor in the JSOQN scale were between 0.36 and 0.47, indicating an acceptable internal consistency (Polit 2010; Worthington & Whittaker 2006). Known-group validity
As hypothesized, the communication in English score of the participants from ESB was significantly higher than participants from NESB (P < 0.0005, Table 2). Therefore, the newly developed items under the factor of communication in English showed good contrast validity among different groups. Job satisfaction levels between the ESB group and the NESB group
A comparison of job satisfaction levels between the ESB group and the NESB group was made by computing the total score for each of the four factors and the total score of the JSOQN. Overall, overseas-qualified nurses were satisfied with their job as
Job satisfaction of overseas-qualified nurses
69
Table 2 Comparisons of job satisfaction scores between RNs from ESB and NESB Factors
ESB group Med (Q1–Q3)
NESB group Med (Q1–Q3)
P-value
F1: Supportive work environment (15I) F2: Interpersonal relationship (6I) F3: Communication in English (8I) F4: Salary and salary-related benefits (3I) Total score of JSOQN (0–224 points)
81 (75–90) 47 (43–48) 36 (36–37) 18 (15–18) 180 (170–191)
80 (70–89) 46 (43–48) 35 (31–36) 18 (16–19) 174 (163–189)
0.359 0.398 0.0005* 0.542 0.116
The items were rated on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). *P < 0.05 using Mann–Whitney U-test. ESB, English-speaking background; F, factor; I, item; Med, median; NESB, non-English-speaking background; Q1–Q3, interquartile range.
evidenced by the relatively high total score in both groups. While not significant, nurses from NESB showed a lower level of satisfaction than those from ESB, and this appeared to be influenced primarily by the factor of communication in English (Table 2). Factors associated with job satisfaction
The association between demographic variables such as age, length of stay in Australia and the number of years worked in the present hospital for each group was examined using Spearman’s correlation. Only length of stay was significantly correlated with job satisfaction (r = −0.196, P < 0.05) (Appendix 3). The longer overseas-qualified nurses stayed employed in Australia, the less satisfied they were. Overseas-qualified nurses’ responses to open-ended questions
There were 238 statements made by participants in response to the open-ended questions. Content analyses were used to group these statements into categories based on meanings. Four categories were identified: (1) positive experience, (2) feeling of discrimination, racism and isolation, (3) communication in English, and (4) education about diversity and equal opportunity. Participants reported that no education programs on cultural diversity in the nursing workforce were available in these hospitals. Examples of comments under each category from the ESB nurses and the NESB nurses were given in Table 3.
Discussion This study was one of a few studies that investigated factors associated with the job satisfaction of overseas-qualified nurses and that compared these factors between overseas-qualified nurses from ESB and from NESB. The present study revealed
© 2014 International Council of Nurses
that communication in English was a major factor contributing to a lower level of job satisfaction for NESB nurses although overall job satisfaction did not differ between the two groups. Indeed, ESB and NESB nurses showed similar levels of satisfaction with regard to a supportive work environment, interpersonal relationships, and salary and salary-related benefits. The contribution of communication in English as a factor associated with job satisfaction was an important finding. While numerous qualitative studies reported that NESB nurses encountered language barriers in the workplace that produced a negative impact on their interactions with patients and colleagues, no study had been previously undertaken to quantify its impact on job satisfaction. The lack of a suitable instrument to measure job satisfaction for overseas-qualified nurses that takes into account their language background may have contributed to the scarcity of benchmarks and best practice in policies and practices used to manage the diverse nursing workforce among healthcare organizations in the global context of nurse migration (Alexis & Vydelingum 2009; Xiao et al. 2014; Zhou et al. 2011). The JSOQN developed in this study has been useful for comparing the magnitude of job satisfaction for overseasqualified nurses across or within populations in human resource management. However, as communication also has been shown to be influenced by culture (Xiao et al. 2014; Xu et al. 2008), how cultural dissonance has contributed to job satisfaction remains unknown in the present study, suggesting the need for further studies. The finding that the longer overseas-qualified nurses remained in the host country, the less satisfied NESB nurses were with the work environment, was completely contrary to other studies that showed a positive correlation between length of stay and job satisfaction (Ea et al. 2008; Xu et al. 2008).
70
K. K. Timilsina Bhandari et al.
Table 3 Participants’ responses to open-ended questions Categories
Examples from NESB nurses
Examples from ESB nurses
1. Positive experience
a. I enjoy it due to flexibility of shift, good income autonomy of self-development and good welfare b. It is a rewarding experience. We get the right nurse-patient ratio and are well paid. Here we got 1:4 nurse-patient ratio. a. Migrant nurses are not getting equal opportunity for career development b. There is no clinical nurse from NESB group of nurses in this hospital c. We have experienced racial discrimination sometimes d. Although it is a free nation some people are very racist and have wrong perception about overseas-qualified nurse e. Most managers still prefer local nurse rather than overseas nurse even though we do qualify for it f. Sometimes we felt a little bit homesick as they ignore us g. They (local nurses) don’t help you when you need them for patient’s care, rather they chat with their colleagues a. Initially it was frustrating that I could not express myself as good in English as how I could have done in my own language. Especially I had to get used to the Australian slang and accent and not every colleague or patient was patient. b. Language is a barrier for me . . . but I believe things are getting better gradually a. The awareness of equality and peer support needs to be advocated continuously b. More education towards anti-racism c. Discrimination on the base of colour should be stopped d. Promote equal rights between local and overseas-qualified nurses e. Need understanding and supportive supervisors
a. I enjoy my work in Australia, nursing is not really any different here as in the UK. We are well paid. a. I do get ‘Hack’ for being a Kiwi. Little friendly banter between cultures. But sometimes its pushed too far you get sick of it.
2. Feeling of discrimination, racism and isolation
3. Communication in English
4. Education about diversity and equal opportunity
Nil
Welcome them (NESB) to the ward, respect and acknowledge their experiences
ESB, English-speaking background; NESB, non-English-speaking background.
However, this finding was similar to the results of a study on job satisfaction of Filipino RNs in the USA that reported a negative association between length of stay and lower levels of satisfaction with professional status, task requirements and organizational policies (Itzhaki et al. 2013). Possible reasons underlying this observation may be related to the lack of opportunities for career advancement and lack of recognition of overseas-qualified nurses’ previous nursing skills and knowledge. The present study found that the proportion of nurses employed at RN level 2 was higher in the ESB group than in nurses from the NESB group. This result was consistent with other studies that reported the lack of opportunity for career advancement among NESB nurses (Alexis & Vydelingum 2009; Xiao et al. 2014). In addition, the absence of family, the loss of usual social networks and homesickness may also have contributed to the result. These reasons were reported in previous studies (Alexis & Vydelingum 2009; Hayne et al. 2009; Zhou et al. 2011), and the homesickness was also mentioned by participants in the present study (see Table 3).
© 2014 International Council of Nurses
The lack of career advancement also may have reflected discrimination and racism against overseas-qualified nurses experienced by nurses from NESB in this study. The prevalence of these issues may be attributed to the lack of education and resources to tackle these issues as reported in previous studies (Alexis & Vydelingum 2009; Xiao et al. 2014). Previous studies reported that discrimination and racism were covert in many forms. For example, studies found that overseas-qualified nurses were classified at a junior level despite their previous experiences in nursing, denied requests to practice in the area of their expertise, imitated verbally, threatened by local colleagues or patients and given few opportunities for promotion (Allan et al. 2009; Mapedzahama et al. 2012; Xiao et al. 2014). Although these forms of racism were not examined in this study, the results suggest a need for additional studies. It was evident that anti-discrimination and anti-racism policies alone without leadership and resources to support the implementation of the policies may not be able to amend the undesirable situations in the nursing workforce.
Job satisfaction of overseas-qualified nurses
The participants made a number of recommendations that they felt would enable them to better integrate with the host country workforce. They emphasized that they required time to improve communication in English, and that positive interactions and tolerance to cultural differences by local colleagues were important in assisting NESB nurses to integrate (Xiao et al. 2014; Zhou et al. 2011). Programs to improve knowledge, skills and attitudes necessary for positive intercultural communication for both overseas-qualified nurses and local nurses were strongly suggested by participants in the present study and in previous studies (Xiao et al. 2014; Zhou et al. 2011). Therefore, preparing local and overseas-qualified nurses with knowledge, skills and leadership in raising awareness of these issues, promoting equity, cultural diversity and tolerance at ward level may be a long-term solution for facilitating nursing workforce integration in a multicultural society.
Limitations There were a number of limitations in this study. Firstly, the study used a cross-sectional research design that provided information about job satisfaction levels of overseasqualified RNs working in five public hospitals in South Australia at a particular point in time only. Secondly, this study used convenience sampling, therefore findings cannot be generalized. The third major limitation related to the selfdeveloped scale with no previously established psychometric property records. Further tests of the JSOQN questionnaire are needed to establish psychometric properties in a wider population.
Conclusions This study identified four factors that influenced job satisfaction in overseas-qualified nurses working in five major hospitals in South Australia. These factors along with findings from the open-ended questions provide evidence for nursing human resource planning and management when developing strategies to assist and retain nurses from NESB. Communication in English has been identified as a major challenge for nurses from the NESB group that was associated with job satisfaction. Unlike previous studies, this study identified a negative correlation between job satisfaction and length of stay among overseas-qualified nurses from the NESB group. This finding may be related to the lack of opportunities for career advancement and lack of recognition of their previous nursing skills and knowledge. Discrimination and racism described by NESB nurses need to be further examined in future studies.
© 2014 International Council of Nurses
71
Implications for nursing and/or health policy Nurses from NESB need to be supported early in their employment, especially with their communication skills. Consideration also needs to be given to the education of local staff regarding cultural differences of overseas nurses to support their adaptation to the workplace.
Acknowledgements This manuscript is from the first author’s master thesis which was completed in School of Nursing & Midwifery, Flinders University of Australia in 2013. The authors wish to thank all the participants from five public hospitals in Adelaide, South Australia.
Author contributions KTB designed the research, developed study conception, collected, analysed and interpreted data, and developed the draft manuscript. LDX supervised this study and contributed to the design of the study, statistical expertise, data analyses and interpretation, and made significant revision for the manuscript. IB supervised this study and contributed to the design of the study, statistical expertise and made significant revision for the manuscript.
References AIHW (2009) Nursing and midwifery labour force 2007. Canberra, Australian Institute of Health and Welfare. Aiken, L.H. & Patrician, P.A. (2000) Measuring organizational traits of hospitals: the revised nursing work index. Nursing Research, 49 (3), 146–153. Alexis, O. & Vydelingum, V. (2009) Experiences in the UK National Health Service: the overseas nurses’ workforce. Health Policy, 90 (2–3), 320–328. Allan, H.T., Cowie, H. & Smith, P. (2009) Overseas nurses’ experiences of discrimination: a case of racist bullying? Journal of Nursing Management, 17 (7), 898–906. Australian Bureau of Statistics (ABS) (2013) Australian Social Trends. Canberra, Australian Bureau of Statistics. Australian Department of Immigration and Citizenship (2011) Visa options for nurses. Australian Department of Immigration and Citizenship, Caberra. Available at: http://www.australia-migration.com/page/ Options_for_Nurses/39 (accessed 5 November 2014). Bae, S.H. (2013) Organizational socialization of international nurses in the New York metropolitan area. (vol 59, pg 81, 2012). International Nursing Review, 60 (2), 275. Castaneda, G.A. & Scanlan, J.M. (2014) Job satisfaction in nursing: a concept analysis. Nursing Forum, 49 (2), 130–138. doi: 10.1111/ nuf.12056. Cheng, C.-Y. & Liou, S.-R. (2011) Intention to leave of Asian nurses in US hospitals: does cultural orientation matter? Journal of Clinical Nursing, 20 (13–14), 2033–2042.
72
K. K. Timilsina Bhandari et al.
Cummins, T. (2009) Migrant nurses’ perceptions and attitudes of integration into the perioperative setting. Journal of Advanced Nursing, 65 (8), 1611–1616. Ea, E.E., Griffin, M.Q., L’Eplattenier, N. & Fitzpatrick, J.J. (2008) Job satisfaction and acculturation among Filipino registered nurses. Journal of Nursing Scholarship, 40 (1), 46–51. Hayne, A.N., Gerhardt, C. & Davis, J. (2009) Filipino nurses in the United States recruitment, retention, occupational stress, and job satisfaction. Journal of Transcultural Nursing, 20 (3), 313–322. International Council of Nurses (2014) International Centre on Nurse Migration. International Council of Nurses. Available at: http:// www.intlnursemigration.org/sections/about/aboutus.shtml (accessed 2 September 2014). Itzhaki, M., Ea, E., Ehrenfeld, M. & Fitzpatrick, J.J. (2013) Job satisfaction among immigrant nurses in Israel and the United States of America. International Nursing Review, 60 (1), 122–128. Jose, M.M. (2011) Lived experiences of internationally educated nurses in hospitals in the United States of America. International Nursing Review, 58 (1), 123–129. Kline, P. (2013) Handbook of Psychological Testing. Routledge, New York. Mapedzahama, V., Rudge, T., West, S. & Perron, A. (2012) Black nurse in white space? Rethinking the in/visibility of race within the Australian nursing workplace. Nursing Inquiry, 19 (2), 153–164. McHugh, M.D., et al. (2011) Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs, 30 (2), 202–210. Mueller, C.W. & McCloskey, J.C. (1990) Nurses job-satisfaction – a proposed measure. Nursing Research, 39 (2), 113–117. NMBA (2011) Nursing and Midwifery English Language Skills Registration Standard. Nursing and Midwifery Board Australia, Canberra. Available at: http://www.nursingmidwiferyboard.gov.au/RegistrationStandards.aspx (accessed 20 October 2011).
© 2014 International Council of Nurses
Polit, D.F. (2010) Statistics and Data Analysis for Nursing Research. Person Education, Boston. Polit, D.F. & Beck, C.T. (2012a) Measurement and data quality. In Nursing Research: Generating and Assessing Evidence for Nursing Practice, 9th edn (Polit, DF, Beck, CT, ed.). Lippincott Williams & Wilkins, Philadelphia, pp. 328–350. Polit, D.F. & Beck, C.T. (2012b) Qualitative research design and approaches. In Nursing Research: Generating and Assessing Evidence for Nursing Practice, 9th edn (Polit, DF, Beck, CT, ed.). Lippincott Williams & Wilkins, Philadelphia, pp. 487–514. Smith, C.D.A., Fisher, C. & Mercer, A. (2011) Rediscovering nursing: a study of overseas nurses working in Western Australia. Nursing & Health Sciences, 13 (3), 289–295. Stamp, P. (1997) Nurses and Work Satisfaction: An Index for Measurement. Health Administration Press, Chicago. Tabachnick, B.G. & Fidell, L.S. (2007) Using Multivariate Statistics, 6th edn. Pearson, Sydney. Worthington, R.L. & Whittaker, T.A. (2006) Scale development research – a content analysis and recommendations for best practices. Counseling Psychologist, 34 (6), 806–838. Xiao, L.D., Willis, E. & Jeffers, L. (2014) Factors affecting the integration of immigrant nurses into the nursing workforce: a double hermeneutic study. International Journal of Nursing Studies, 51 (4), 640–653. Xu, Y., Gutierrez, A. & Kim, S.H. (2008) Adaptation and transformation through (un)learning: lived experiences of immigrant Chinese nurses in US healthcare environment. ANS. Advances in Nursing Science, 31 (2), E33–E47. Zhou, Y., Windsor, C., Theobald, K. & Coyer, F. (2011) The concept of difference and the experience of China-educated nurses working in Australia: a symbolic interactionist exploration. International Journal of Nursing Studies, 48 (11), 1420–1428.
Job satisfaction of overseas-qualified nurses
73
Appendix 1 Items newly developed or adapted in the Job Satisfaction of Overseas-Qualified Nurses instrument development Items under each factor Supportive work environment I have an opportunity to work in my specialty area that I developed in my home country I have an opportunity to select my annual leave I feel included in staff meetings and/or any discussion within my ward/unit The team leader is always fair in allocating patient load to nursing staff I am always assigned the shift that I requested My supervisor is fair in selecting staff for education and training programs regardless of their background My supervisor encourages me to undertake a higher degree study My performance in my current workplace is acknowledged by my supervisors My current work environment is pleasant and comfortable to me The organization recognizes my previous skills and experiences in nursing and appointed me at an appropriate level My nurse manager is very supportive of me My supervisor encourages me to organize in-services in the ward I feel that I am treated fairly in my current workplace of employment I can negotiate my workload with the team leader or nurse manager I have the same opportunity to attend seminars, training and workshops as Australian nurses Interpersonal relationships My colleagues always communicate and explain what they mean if I don’t understand them I can share my ideas with other interdisciplinary members in my hospital My work is valued by my colleagues at work I have colleagues to discuss work-related issues within my current workplace My colleagues always show their tolerance to my accent I received fair treatment and respect from my colleagues I feel comfortable in communicating with my colleagues in my current workplace I have opportunities to socialize with my colleagues during breaks Communication in English Language is not a barrier for me in communicating with patients The use of Australian slang words by patients does not frustrate me I feel confident to talk to the family members on the phone I can understand the different accents and Australian words used by family members of patients I interact well with my patients Patients show their tolerance to my accent and communication difference Salary and salary-related benefits I am satisfied with the benefits (remunerations) offered to me through this job I am paid fairly in this hospital as Australian-educated nurse I am satisfied with the salary scale offered to me in this job Open-ended questions What are your feelings and experiences about working and living in Australia? In your opinion, what are the areas that needed to be addressed in order to create a sound working environment for overseas-qualified nurses? Does your hospital provide special program for the overseas-qualified nurses? If yes, please specify what sort of program your hospital provides for overseas-qualified nurses.
New
Adapted
New New New New MMS, 5 New NWRI, 30 NWRI, 18 New New NWRI, 4 NWRI, 30 MMS, 23 New New New NWRI, 11 MMSS, 25 MMSS, 19 New New New MMSS, 17 New New New New New New MMSS, 3 New MMSS, 1 Hayne et al. 2009 New New
IWS, Index of Work Satisfaction (Stamp 1997); NWI-R, Nursing Work Index-R (Aiken & Patrician 2000); MMSS, Mueller & McCloskey Satisfaction Scale (Mueller & McCloskey 1990).
© 2014 International Council of Nurses
74
K. K. Timilsina Bhandari et al.
Appendix 2 Factor loadings on 32 items
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Items
F1
My supervisor is fair in selecting staff for education and training programs regardless of their background I have an opportunity to select my annual leave I am always assigned the shift that I requested The team leader is always fair in allocating patient load to nursing staff My supervisor encourages me to undertake a higher degree study My performance in my current workplace is acknowledged by my supervisors My supervisor encourages me to organize in-services in the ward I feel included in staff meetings and/or in any discussion within my ward/unit The organization recognizes my previous skills and experiences in nursing and appointed me at an appropriate level My nurse manager is very supportive of me I have an opportunity to work in my specialty area that I developed in my home country My current work environment is pleasant and comfortable for me I feel that I am treated fairly in my current workplace of employment I can negotiate my workload with the team leader or nurse manager I have the same opportunity to attend seminars, training and workshops as Australian nurses Language is not a barrier for me in communicating with patients The use of Australian slang words by patients does not frustrate me I feel confident to talk to the family members on the phone I can understand the different accents and Australian words used by family members of patients I interact well with my patients Patients show their tolerance to my accent and communication difference My colleagues always communicate and explain what they mean if I don’t understand them. I can share my ideas with other interdisciplinary members in my hospital My work is valued by my colleagues at work I have colleagues to discuss work-related issues within my current workplace My colleagues always show their tolerance to my accent I received fair treatment and respect from my colleagues I feel comfortable in communicating with my colleagues in my current workplace I have opportunities to socialize with my colleagues during breaks I am satisfied with the benefits (remunerations) offered to me through this job I am paid fairly in this hospital as Australian-educated nurse I am satisfied with the salary scale offered to me in this job
0.857 0.791 0.685 0.678 0.670 0.653 0.631 0.562 0.546 0.527 0.511 0.468 0.440 0.422 0.419
F2
F3
F4
0.845 0.779 0.731 0.716 0.500 0.463 −0.721 −0.695 −0.685 −0.658 −0.633 −0.565 −0.562 −0.547 0.778 0.621 0.563
F1, factor 1 – supportive work environment; F2, factor 2 – interpersonal relationship; F3, factor 3 – communication in English; F4, factor 4 – salary and salary-related benefits.
Appendix 3 Correlation between demographic variables and job satisfaction Categories
Work environment
Communication in English
Interpersonal relationship
Financial rewards
Demographics Age Length of stay in Australia Years worked in the hospital
ESB 0.13 0.27 0.58
ESB 0.25 0.17 0.30
ESB −0.35 −0.16 −0.10
ESB −0.35 −0.36 −0.25
NESB −0.06 −0.20* −0.08
NESB −0.04 −0.15
*Correlation significant at the 0.05 level (two tailed) using Spearman’s correlation.
© 2014 International Council of Nurses
NESB −0.11 −0.14 0.03
NESB −0.05 −0.07 −0.05
Copyright of International Nursing Review is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
