Nurse Practitioners’ Job Satisfaction and Associated Factors among Nurses working at the University of Gondar Specialized Hospital: A Cross-sectional Survey study

Background Job satisfaction is an important measure of cognitive as well as a behavioral component of employees’ feelings of comfort in their particular work. It is also the outlook and spirit of certain professionals towards their work. Nurses’ job satisfaction is a signi�cant predictor of staff retention. Therefore, this study aimed to assess Nurse Practitioners’ Job Satisfaction and Associated Factors among Nurses Working at the University of Gondar Specialized Hospital Northwest Ethiopia. Methods A cross-sectional study design was employed from May 15–20/2019. A total of 416 nurses participated in the study. A simple random sampling technique was used to select each study participant. A pretested structured questionnaire was used to collect the data. A Minnesota satisfaction measurement tool was used to measure nurse practitioners’ job satisfaction. A binary logistic regression analysis was used. Variables having p-value < 0.05 in a multivariable analysis model were considered as statistically signi�cant and independently associated with the outcome variable. Result


Background
Job satisfaction is an important measure of cognitive as well as a behavioral component of employees' feelings of comfort in their particular work.It is also the outlook and spirit of certain professionals towards their work (1,2).The employee is an essential component in the process of achieving the mission and vision of the organization.They ought to meet the performance criteria set by the organization to ensure the quality of care for the larger community where they are employed (3).There are predetermined standards to meet by the organization for the employees to provide quality care.So that the employee needs a very safe working environment that allows them to give their best without problems that restrain them from performing up to the level of their full potential.This, in turn, could be the bridge for job satisfaction (4,5).
In the modern community, organizations are facing many more challenges due to the over changing nature of the working environment.Among the challenges for health organization is to satisfy its employees to come up with the ever-changing and evolving environment, to achieve success and remain in competition to give quality care(6).On the other hand; to increase e ciency, effectiveness, productivity, and job devotion of the employees, the organization must satisfy the needs of its employees by providing good working conditions (7,8).
Each year, there are substantial numbers of health professionals leave the health workforce, either temporarily or permanently.This could impose a shortage if they are not replaced and compromised the delivery and quality of health care service (9,10).There are numerous physiological and psychological factors for job satisfaction.Monthly payment, kind of supervision, low expectation of bene t, operating procedures, the nature of workload, coworkers, habit of team spirit or teamwork and communication had been among the physiological factors for job satisfaction (11,12).Job satisfaction is a motivational outcome in the health system research due to its relation to performance and turnover, so it is the concern for researchers and health service managers (13)(14)(15).The satisfaction of nurses on their job could also depend on nature, expectations of what their job provided them and others, and affective orientation that they have towards their job.It can be measured globally or in the multi-faceted way, with the former approach being used when the interest is on overall attitude towards the job employees have, and the latter when speci c job dissatisfaction are evaluated(8).The important facets of job satisfaction identi ed are salary, bene ts, career development, in-service training, work relationship, working environment, management, recognition, and supervision (7,9,14,16).
When the nurse practitioners dissatis ed they might preserve their activities and in that the quality and cost of patient care have been compromised (17).Evidences; showed that job satisfaction is a signi cant predictor of staff retention (18,19).Therefore, the study aimed to assess Nurse Practitioners' Job Satisfaction and Associated Factors among Nurses Working at the University of Gondar Specialized Hospital, Northwest Ethiopia.

Study design and setting
A cross-sectional study design was employed from May 15-20/2019.The study was conducted among nurses working in Northwest Amhara region referral hospital; namely the University of Gondar Specialized Hospital(UoGSH).There were around 590 nurses working in this referral hospital.

Source and Study population
All nurses working in Northwest Amhara region referral hospitals were considered as the source population whereas those nurses presented in the data collection period were taken as the study population.

Socio-demographic characteristics
A total of 416 study participants were used in the study with the response rate of 97.6%.The mean (SD) age of the study participants was 36.68 ± 9.4 years.One hundred seventy-six (43.3%) of study The sample size was determined using population proportion formula through the Epi info stat calc program with the assumption of 95% con dence level, 5% margin of error, and 43.6% of nurse practitioner job satisfaction (20).Taking these into consideration, the estimated sample size was 378.Considering, 10% non-response rate, the nal sample size was 416.The study participants were selected using simple random sampling technique.

Data collection tools and procedures
A pretested structured questionnaire was used to collect the data.It has two parts.The rst part contains socio-demographic variables and the second is nurse practitioner related questions.A Minnesota Satisfaction measurement tool was used to measure nurse practitioners' job satisfaction.It has 20 items.The question has ve-point Likert scale responses which are 1 = very dissatis ed, 2 = dissatis ed, 3 = neutral, 4 = satis ed and 5 = very satis ed (20).The satisfaction level was measured using the responses of each study participant.Taking the summed responses participants who scored below the mean were considered as dissatis ed whereas participants who score above or equal to the mean taken as satis ed related to their jobs.Furthermore, hygienic and motivational factors measurement tools also used.These tools have eleven sections.These are achievement, advancement, work itself, recognition, growth, organization policy, relationship, work security, relationship with supervisor, payment, and working condition.Each of this sub-sections has questions.The responses are given with ve-points Likert scale 1 (strongly disagree), 2 (disagree), 3(neutral), 4(agree), and 5(strongly agree).The Crombach alpha or reliability test was used.The mean of each subscale was calculated.The agreement level was measured using the responses of each study participant.Taking the summed responses participants who scored below the mean were considered as disagreed whereas participants who score above or equal to the mean taken as agreed related to their jobs.A total of three Midwives for data collection and three health o cers as supervisors were used.The self-administered method of data collection method was used.

Data Processing And Analysis
Data were cleaned, coded, and entered to Epi Info version 7, and exported into SPSS Version 22. Descriptive statistics such as mean, median, frequency, and percentage were used.Tables and bar-graphs were used to display the ndings.A binary logistic regression analysis was used.All variables were tted into the multivariable analysis.Crude odds ratio (COR) with 95% CI for binary logistic regression analysis and adjusted odds ratio (AOR) with 95% CI was calculated.Variables having p-value < 0.05 in a multivariable analysis model were considered as statistically signi cant and independently associated with the outcome variable.Hosmer's and Lemeshow goodness of t test was computed.
participants were with the age range of 30-39 years.The above half (51.7%) of study participants were female.Above two-thirds (70.4%) the study participants were married.The majority (77.3%) of study participants were degree holders and 81.8% of study participants had paid monthly income of ≥ 4000 Ethiopian Birr (Table 1).

Motivational and Hygienic Factors among Nurse Practitioner
Of the study participants; 54.2% disagree with professional advancement, 56.2% disagree with workplace recognition, 57.9% disagree to growth at work, 57.1% disagree to organizational policy, and 51.7% disagree with relation with supervisors (Fig. 2).

Bivariable and Multivariable Findings: Factors Associated with Nurses' Job Satisfaction
A binary logistic regression model was used to test the presence of a signi cant association.All independent variables were tted to bivariable and multivariable logistic regression analysis.Variables with a p-value < 0.05 with a 95% con dence level were taken as statistically signi cant.21), Gondar Ethiopia 46% (22).On the other hand, the nding of this study is lower than the study in Bahir Dar Ethiopia 56.4% (20), Harar Ethiopia 55.8% (23), and Mansoura Egypt 61.8% (24).The difference is due to the variation sample size, data collection period, tool and measurement.On the contrary, the nding of this study is higher than a study conducted in Ethiopia public health facilities 39.2% (25) Khyber Pakhtunkhwa, Pakistan 17%(26).The discrepancy is due to the former study is multicentered in nature, whereas the latter study in Pakistan uses a small sample size and differ in the measurement tool.
Motivational factors such as professional advancement, work itself, recognition at work, and growth at work were found the determinant factors of job satisfaction.Nurses who disagree with professional advancement were nearly 2.74 times more likely to dissatisfy to their job compared to those nurses agreed with professional advancement.This is supported by a study conducted in Bahir Dar City administrative advancement is positive reinforcement for nurses' job satisfaction (20,25).Career advancement is an important element for employee satisfaction and retention at work.It is one of a staff motivator and reduces anticipated turnover (27).Nurses who disagreed with the nurses' work itself were 4.25 times more likely dissatis ed compared to those nurses agreed with nurses work itself.The nursing profession needs a long term contact with the patient.It has a heavy workload as a result, most nurse professionals experience burnout.The nature of the work itself improves the level of satisfaction (25).
Nursing draw on the skills of emotional intelligence to meet the needs of direct patient care and cooperative with the multidisciplinary team.Nurses engage in emotional work to foster caring relationship with patients(28).Nurses who had no recognition at work were nearly 11.87 times more likely dissatis ed compared to those nurses who had recognition at the workplace.This is consistent with the study of Ethiopia.Recognition for once work is motivation (20,25).Meaningful recognition contributes to healthy work environments and is one of the keys to establishing and maintaining healthy work environments for nurses (29).Nonmonetary recognition practice particularly improves nurses job satisfaction (30).Nurses who had no professional growth at work were 6.27 times more likely to be dissatis ed compared to those who had professional growth at work.This is the fact that a limited opportunity for continuous professional development as well as implementing nurse's carrier rank affects the nurse job satisfaction.Lack of promotion is the major source of dissatisfaction.Lack of prospect for promotion is the means for nurse practitioners' dissatisfaction (31,32).
Furthermore, hygienic factors such as organizational policy, relationship with friends, work-security, relationship with supervisor, payment, and working conditions are found to be the factors associated with nurses' job satisfaction.Nurses who disagree with the organizational policy were 5.6 times more likely to be dissatis ed compared to those nurses who have agreed organizational policy.The organizational managerial policy has a direct impact on nurses' job satisfaction.Lack of knowledge in the organizational policy is the highly practiced discrimination which intern affected nurse job satisfaction (33).Nurses who had a poor relationship with their colleagues were nearly 6times morel likely to be dissatis ed compared to those nurses who had a good relationship with friends.Nursing needs collaborative care to the health care team.If there is no good relationship between nurse professional became dissatis ed to their work.Interpersonal con ict between nurses and their colleagues is the main source of dissatisfaction (32).Nurses who had work-insecurity were 6.56times more likely to be dissatis ed compared to those nurses who had work security.This is supported by a study conducted in Pakistan that job security is the main reason for job security(26).Nurses who had no good relationship with a supervisor were 5times more likely to be dissatis ed compared to those who have a good relationship with a supervisor.This is supported by the study in Egypt, deprivation supervisor support affects nurse job satisfaction (24).Nurses who have disagreed with the payment were nearly 6times more likely to be dissatis ed compared to those who agreed to payment.Payment has a signi cant in uence on job satisfaction (22,31,34).A study in Pakistan, salary is the main reason of satisfaction.Nurses who have an adequate salary 64% more likely to satisfy their job(26).Nurses who disagreed in working conditions were nearly 4 times more likely to be dissatis ed compared to those who agreed in working condition.A good working environment is a predictor of job satisfaction (23).High workload leads to a stressful environment (33).Some of the factors like working unit and behavioral factors like stress anxiety were not investigated.

Conclusions
In this study, one of every two nurses experienced job dissatisfaction.Motivational factors such as professional advancement, work itself, recognition at work, growth at work, and hygienic factors such as; organizational policy, relationship with friends, work security, relationship with supervisor, payment, and working conditions were the factors associated with nurses' job dissatisfaction.

Declarations
Ethics approval and consent to participate The study was approved the School of Nursing Research and Ethical review committee on the behalf of the University of Gondar Research and ethical review board.Written informed consent was obtained from each study participant.No personal identi ers such as name, ID number, and phone number were used.The information obtained from each study participants was kept secured, locked, and stored as electronic dataset.

Consent for publication
Not applicable Figures The proportion of nurse practitioners' job satisfaction among nurses at the University of Gondar Specialized Hospital Northwest Ethiopia, 2019, (n=406).

Table 1
Socio-demographic characteristics of nurses working at the University of Gondar Specialized.Northwest Ethiopia, 2019, (n = 406).

Table 2 (
Continued) Factors associated with nurse practitioner job satisfaction working at the University of Gondar Specialized.Northwest Ethiopia, 2019, (n = 406).3%-54.9%) of nurse practitioners were dissatis ed with their job.Of the study participants; 54.2% disagree with professional advancement, 56.2% disagree with workplace recognition, 57.9% disagree with growth at work, 57.1% disagree with organizational policy, and 51.7% disagree with relation with supervisors.The nding of this study is consistent with the study conducted in East Gojjam Ethiopia 45.8%( NB: ** p value < 0.001, * p-value < 0.05