Expat Nurse Job Dissatisfaction in Saudi Arabia

Chapter 1 - Introduction

1.1: Background

Job dissatisfaction is an important aspect of the operations of business organisations. It needs to be considered in the process of managing human resources efficiently and effectively. By satisfying the employees, the company can provide better products and services for the customers, thereby fulfilling their varied needs and demands. In recent years, it has been observed that job dissatisfaction among employees across industries has increased significantly (Alshmemri, 2014). The role of job satisfaction among expatriates is of great importance. They are the individuals who have left their home nations in order to find better job opportunities and subsequently improve their living standards as well. Similarly, the role of job satisfaction is imperative in cases of expat nurses. It is a well-known fact that health and social care industry is one of the most demanding job profiles. Employees tend to spend a considerable amount of hours at the workplace. In this regards, Saudi Arabia is one of the destinations in the United Arab Emirates regions that see a significant number of expatriates in the nursing field (Elamin, 2011). This puts a lot of pressure on the authorities to ensure that these individuals get a proper working environment. This way they will be able to perform better and also be satisfied with their job. There are a number of factors and forces that influence the motivation and dedication of the expat nurses working in Saudi Arabia. In order to ensure that these individuals perform better and are satisfied with their job and working conditions. Saudi Arabia traditionally has been known as a nation which has not provided adequate support to the expatriates. Studies and reports have revealed that expatriate nurses living and working in Saudi Arabia are not happy and satisfied with their jobs (McHugh, Kutney and Cimiotti, 2011). Due to this reason, they are not able to perform to the best of their skills and abilities. Job satisfaction is considered one of the most important parameters in measuring the performance of the employees. The more satisfied they are with their jobs, the better would be their performance. Various studies and reports have shown that job dissatisfaction level among the expat nurses is rampant, indicating that the nurses are neither happy with their jobs and nor with their working conditions. Through this study, the researcher has identified and thoroughly analysed the reasons for job dissatisfaction among the expatriate nurses in Saudi Arabia. In this study, the researcher has discussed the various factors that lead to dissatisfaction among expat nurses from their jobs (Bahnassy and et al., 2014). By conducting this study, the researcher has evaluated different job trends prevalent among expat nurses in Saudi Arabia. Through such information, the researcher has been able to get a more thorough and effective understanding of the current job market in the country. The health care system followed in Saudi Arabia is considered one of the most effective one around the world. It has been observed that a large number of people are migrating to the Arab country in hopes to find better job and living opportunities (Wanders, 2017). In this study, the researcher has discussed different factors that lead to dissatisfaction among expat nurses working in the Saudi healthcare sector.

1.2: Aim

The main aim of the current study is “To identify factors relating to expat nurse job dissatisfaction in Hali’s public hospitals in Saudi Arabia.”

1.3: Objectives

By fulfilling the following objectives, the aim of the study can be achieved:

To evaluate the job satisfaction level among expat nurses in Hali public hospital?

To determine the factors that dissatisfy expat nurses from their jobs in Hali public hospitals?

To suggest ways to improve the job satisfaction level of expat nurses.

1.4: Research Questions

What is the level of job satisfaction among expatriate nurses in the Hali public hospital?

What factors dissatisfy expatriate nurses off their jobs in Hali public hospital?

How can job satisfaction level of the expatriate nurses be improved?

CHAPTER 2 - LITERATURE REVIEW METHODOLOGY

A comprehensive systematic literature review search was done across a number of electronic databases from the Curtin University library including ProQuest, Science Direct, PubMed, and Medline using the search term expatriate nurses. Keywords and synonyms were identified and followed by the use of Boolean operators to construct a database (Appendix A). The terms were cross referenced with other terms such as job satisfaction and nursing turnover. The articles used where restricted to Saudi Arabia.

2.1: Inclusion and Exclusion Criteria

The inclusion criteria focused on only full accessible articles which discussed expatriate nursing in Saudi Arabia and the globe. Only peer reviewed articles published from 2008 to 2018 were used in the study. Studies outside Saudi Arabia were excluded. In addition, only full text English studies were utilized in the study. Study designs were not considered as a major factor determining the selection of studies.

2.2: Data Assessment

After application of the inclusion and exclusion measures, all selected articles were assessed for their relevance to the current topic under consideration. The studies were screened to eliminate duplicated information. The remaining articles were placed within the reference manager and evaluated on their relevance to the topic based on the information presented in the abstract. Any articles which failed to contain relevant information relating to the topic at hand was also eliminated. After the application of all relevant procedures indicated above seven articles were selected for analysis as indicated in the PRISMA diagram in Appendix B.

CHAPTER 3 - LITERATURE REVIEW

Nurse dissatisfaction is linked to a number of factors within clinical settings including extensive workloads (Zhou et al., 2015), lack of training and development opportunities (Kanai‐Pak, Aiken, Sloane, & Poghosyan, 2008), stringent policies on hiring nurses, extensive workloads (Cho et al., 2009), poor remuneration (Kanai‐Pak et al., 2008), poor health benefits compared to other practitioners and poor leadership and management skills among hospital administrative members(Lu, Barriball, Zhang, & While, 2012), As a consequence of the poor working conditions, most nurses leave their workplaces in search of better working conditions. At the same time, the number of students joining nursing school has decreased over the years increasing nursing shortages and at the same time signaling gap in the provision of essential nursing services in the coming years (Delobelle et al., 2011). Nursing Job dissatisfaction factors affecting healthcare system differ based on the level of development of the healthcare system. The United States, a developed country has the highest rates in the world currently standing at 41% followed by Scotland at 38% (McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011). Such values are significantly high despite the two healthcare system being recognized as some of the best in delivery of some services. Nurses from other countries with less opportunities may choose to look for greener pastures in such countries. When employees move from their country of origin to other countries and are either temporarily or permanently employed they become expatriate employees. One country which has witnessed an influx of nurses from other countries is Saudi Arabia. The number of expatriates in Saudi Arabia had grown too high to the point that the Royal Monarchy decreed the need to introduce a policy of “Saudinisation” to decrease the number of foreign workers in the state as well as reducing the number of the Saudi who are unemployed (Alboliteeh, Magarey, & Wiechula, 2017). Nonetheless, there is a substantial nursing population of expatriates working in Saudi Arabia. To clearly understand specific aspects related to job dissatisfaction in Saudi Arabia, there is need to understand critical aspects related to the Saudi Arabian culture before delving specific issues affecting nurses.

3.1: Saudi Arabia

3.1.1: Historical Information

Saudi Arabia is a comparatively young country in the Arabian Peninsula. It is also considered as the birthplace of Islam as well as one of the holiest lands ever to be grace by Prophet Mohammed. Islam as a religion was established by Prophet Muhammad over 1400 years ago and the first holy book, Quran written in Arabia. Islam remains the key religion in Saudi Arabia (U. S. Energy Information Administration, 2014). The Saudi monarchy was established in 1902 by King Abd Alaziz bin Abd Al Rahman Al Saud after some of the leaders in the Arabian Peninsula came together as a block. In 1932, it was declared a monarchy under the rule of King Abd Alaziz bin Abd al-Rahman, and Islam decreed as the official religion as well as the moral law of the land. Saudi Arabia was founded on desert regions of Middle East and as a result its people lived in huge tracts of dry land. During sandy storms, the populace was forced to move from one area to another. Due to the aforementioned conditions, Saudis prefer living in temporary structures with their domestic animals and move from one place to another in search of rain and water. The discovery of oil in the region significantly changed their lifestyle. More people moved from the poor Bedouin lifestyle to main cities such as Jeddah in the west, Dammam in the east and Riyadh which is considered as the Kingdoms capital. Jeddah contains the largest port and is the center of attraction due to its closeness to holy cities.

3.1.2 Demographic Information

According to World Population Overview (2018), Saudi Arabia is home to 33, 495, 659 people. Age wise, the 0-14 age group contains the highest population composed of 32.4 % of the total population. The next age group caters for the middle age which makes up to 64.8%, and the remaining age group makes up 2.8% of the population (World Population Overview, 2018). The sex ratio differs in each age group. At birth, the male to female ratio is 1.05 male to female (World Population Overview, 2018). For the under 15 group the same ratio is maintained while for the remaining age groups a 1.03 male to female ratio is present (World Population Overview, 2018). Overall the male to female ratio stands at 1.21 males per female (World Population Overview, 2018). The varying age groups for both males and females and the relevant populations are indicated below in figure 1

The number of foreigners in Saudi Arabia surged yearly from about 750,000 in the early 1970s to close to 13 million in 2017 while the number of Saudi nationals in the area has increased from 6 million in 1970s to 20 million in 2017 as shown in the table below.

The table indicates the population of Saudi Arabia in the early 1970s when the foreign population was approximately made of 750,000 Non-Saudi nationals to 2017 where there are more than 13 million foreigners.

3.1.3: Geographical Information

Saudi Arabia, a powerhouse in the Middle East is the largest country in the region and fourteenth largest globally. Saudi Arabia approximately covers a total of 2.25 million square kilometers (U. S. Energy Information Administration, 2014). Due to the vast differences in the region, the climate is relatively classified as being hot and dry. Saudi Arabia is currently divided into fourteen regions as shown in figure 2 below.

The different regions as indicated in the map include the eastern province, Naran, Riyadh, Asir, Jizan, Al-Bahah, Madinah, Makkah, Al-Qassim, Ha’ll, Tabuk, Al-Jawf, and Northern Borders. Initially, the country was divided into six regions before being expanded to the current number. Saudi Arabia borders the Red Sea to the west, Oman to the south Bahrain and Qatar to the east, and Kuwait, Iraq, and Jordan to the north.

3.1.4: Cultural Information

Saudi Arabia remains one of the society with deeply entrenched Islamic cultures. Like many different religions, most people in the country believe that health and illness comes from God or Allah. Some cultural practices affect whole systems within the society. For example, all Muslims in the country are expected to adhere to all principles under the Halal code which prescribes which form of meat is to eat. For example, the Halal code requires all animals meat including beef, camel, birds, and lamb eaten any Muslim be slaughtered under the Islamic law (Khalil, Jabeen, Jadoon, & Salman, 2016). Fish meat can be eaten without any issue although the use of pork products, and any contaminants such as alcohol use is strictly forbidden. Such cultural values have been passed since time immemorial and have been observed since then. All Muslims are also expected to observe the fasting month of Ramadhan which affects all of their eating behaviors health practices and lifestyles. The Ramadhan period is coupled with fasting from sunrise to sunset and at no point is one allowed to either smoke, eat or drink. Families are then expected to break the fast together in the evening and break the fast together in the morning. All Muslims are then expected to celebrate Aid Al Fater, a ceremony which marks the end of Ramadan (Khalil et al., 2016). The Islamic culture places more emphasis on specific values in the community including aspects such as honesty, mercy, loyalty, decency, and obedience (Khalil et al., 2016). Young members of the society are expected to make a social call to elder members society about once a weak. Such a move is normally considered as a sign of respect and care. The society has defined male and female roles. Women are primarily supposed to take care of the family while male members are expected to provide for their families. Previously, women were restricted from accessing education, and as a result, the number of educated women was significantly low (Khalil et al., 2016). In addition, women were previously banned from driving vehicles and from watching movies. Recently, the country changed its laws to allow women to enjoy some of the benefits which were traditionally conserved for males like driving cars and going out to the cinema. Today, the number of professional women within different workplaces has significantly improved as they have been provided with similar rights as men (Alamri, 2011). However, they are not expected to forget about cultural values in the society. Although different measures are being applied to ensure that males and females in the society have the same rights, there are still some restrictions which are still being implemented in the county. For example, the country has male and female universities unlike other countries of the world where students are allowed to be in the same university regardless of their sex (Alnahdi, 2014; Unesco International Bureau of Education, 2010). Another example of a segregate policy applied in the society is the voting rights for male and females within the society. Previously women were not allowed to vote, and as a result, there are very few women leaders in the county. Nonetheless, some progress is being made in the country as more emphasis is being placed on reducing the gender gap that previously existed across different settings. One of the prominent issues which have received substantial consideration over the years has been the implementation of fair educational standards (Alnahdi, 2014). Today, scholarship opportunities in the country are available for both male and female students and are provided on a merit basis and in some cases, equity principles are applied to reduce gender disparities.

3.1.5: Economic Information

Prior to oil discovery, Saudi Arabia economy relied on several activities including fishing, trading, religious visits to the holy mosques of Al Madina Al Mnoura and Makkah al Mukarrama and farming. After the government granted United States geologists an opportunity to prospect oil in eastern parts of the country and after the discovery of oil in the region, Saudi became one of the major powerhouses in the region. Today’s its economy is reliant on the oil. The use of oil has significantly boasted other areas of the economy including education, infrastructure, and healthcare as revenue generated from oil sales is pumped on other areas of interest in the country (Alkharashi, 2012). Other sectors of the economy which have benefited from the oil profits include the military, public and social services. Oil exploration and exploits have transformed the country from once the poor economy to a regional power house. Currently, Saudi Arabia remains one of the leading producers of oil in the country and with approximately 11-12 million oil barrels being produced on a daily basis (Alkharashi, 2012; Gukasyan, Aifary, Semenovich, & Mantsev, 2016). The country is also considered as one of the major oil depositors with annual deposits of approximately 263 million barrels per year (Alkharashi, 2012; Gukasyan et al., 2016). Another major source of income for the country comes from what is commonly referred to as religious tourism. Muslims flock to the country on an annual basis from all over 140 countries to visit the Holy mosque and make the pilgrimage from Makkah al Mukarrama to Al Madina Al Mnoura

3.2: Saudi Health System

3.2.1: Development

The healthcare system in Saudi Arabia has undergone tremendous change in past due to change in infrastructure, technology, and the ever-changing country’s economy. The government has specifically focused on several critical aspects which are more likely to improve the healthcare system and at the same time improve quality of care offered to its citizens. One of the considered approaches has been the creation of healthcare organizations which monitor the quality of care offered to patients. Some key healthcare organizations identified by the government to play such a critical role include government hospitals, Saudi ARAMCO hospitals, the National Guard of Health Affairs and public and private hospitals which are under the Ministry of Higher Education among others (Alkhamis, 2012). Healthcare workers are also being educated and being trained on new skills which will significantly improve health indicators which had been previously ignored by past regimes. The Ministry of Health has created one long-term which provides for scholarship opportunities as well as scholarship and other training opportunities for all workers and students in the medical fields (Walston, Al-Harbi, & Al-Omar, 2008). Skill development and specialty is expected to improve the health status across the country significantly. Some scholarship opportunities have been provided to students to study in countries with some of the best healthcare system. Such students are expected to join the Saudi healthcare system on completion of their training.

3.2.2: Services

The Saudi Arabia healthcare system offers a number of medical services to its population. The services range from acute based services where patients are treated for different disease conditions to home-based care where the condition of some patients is managed from their specific homes. Technology advancements in the country have resulted in the development of telehealth services where the nurses are expected to monitor patient condition from clinical settings (ALKADla’bl & Roudsari, 2013). Some private clinical settings also offer specialty based services for various diseases including cancer while other health care worker have placed more emphasis on the health promotion activities which aim to reduce incidences of various diseases in the country.

3.2.3: Level of health services

The Saudi Arabia healthcare system is defined by three essential service areas. Primary level services are present across the country and aid in the diagnosis of common disease across different communities. More people across the country have access to such medical facilities. Secondary level healthcare facilities are considered to be the public hospitals which are commonly funded by the government while the high level, tertiary levels are composed of healthcare facilities which provide specialized care to specific diseases (Yusuf, 2014). Most clinical settings across all sectors have trained medical personnel with consultants and specialists being primarily present in the higher tier of hospitals.

3.2.4: Public hospitals

Public hospitals have been classified as level two facilities in the healthcare systems. The government of the day has heavily invested in public hospitals in the county. The budget requirements for the hospitals have been increased on an annual basis. In addition, more emphasis has been placed on the development of new facilities by the healthcare ministry. Public hospitals are required to specifically deal with conditions presented by the members of the public (Ahmed, 2012). They are also required to provide some form of subsidized treatment compared to private hospitals. The number of healthcare professionals in public hospitals has also been gradually increased. The current healthcare system applied in Saudi Arabia has gained international recognition in managing various conditions. It has been severally acknowledged by the World Health Organization as one of the healthcare facility that is gradually changing the health status of people living in Saudi Arabia (Ahmed, 2012). With technological advancements in the healthcare system and increased investment by the government, there is an increased possibility that the Saudi Arabia system is destined for greater achievements in the future.

3.3: Nursing in Saudi Arabia

3.3.1: Nursing Education in Saudi Arabia

The number of qualified nurses in Saudi Arabia increases on an annual basis as more local citizen take up the profession. The low number of nurses in the country is attributed to segregate policies which limited the profession to males only. The first known bath of nursing students enrolled in the program as early as 1958 (Jradi, Zaidan, & Shehri, 2012). Women first joined the profession in 1961 after the establishment of two nursing units in Riyadh and Jeddah (Aldossary, While, & Barriball, 2008). The newly formulated institutes were tasked with training nurses and their aides. Six years later the Ministry of Health in creating an educational division which was tasked with the development of a nursing department which supervised all health institutes, developed nursing school programs an assessed the nursing curricula. A number of nursing schools and health institutes were also established after the educational division was set up. By 1992, Saudi Arabia boasted a total of 46 health units with 27 specifically dealing with women-related issues while the remaining death with male conditions (Jradi et al., 2012). The Ministry of Health went a step further to set up an additional junior college which specialized in nursing education for both males and females. By 2005, the country boasted of a total of 105 health units covering all of the 13 regions of Saudi Arabia (Aldossary et al., 2008). By 2008 all healthcare institutes in the country were transferred to one unit so that all activities could be synchronized from one point (Jradi et al., 2012). Some health units were upgraded during the side period while other offered higher degree education. Diploma in nursing remains the most common degree among many nurses in Saudi Arabia. New measures implemented by the government such as the development of bachelor of nursing curricula across different universities have increased the number of nurses with bachelor degrees. Few nurses in Saudi Arabia have been given scholarships to study abroad by the government with the condition that they will come back to train the remaining nurses in the country (Jradi et al., 2012). A steady increase has also been noted among specialist nurses over the years as they differentiate into specific nursing fields (Ahmed, 2012). Although the Ministry of Health has emphasized the need to develop nursing institutes, the country has witnessed very low enrolment rates among members of its populace in the process forcing the country to look for other viable option in addressing some of the huge healthcare gaps.

3.3.2: Nursing Profession

The Saudi Commission of Health Specialties is nursing professional body which accredits all nursing courses and defines the code of conduct for all nurses in Saudi Arabia (M. Almalki, G. Fitzgerald, & M. Clark, 2011). The body provides specific regulations for all nurses in Saudi Arabia. A major issue facing Saudi Commission of Health Specialties is the classification of nurses within the country (M. Almalki et al., 2011) (Almalki et al., 2011). Currently, the nurse title refers to any graduate from any secondary institute which are equivalent to high schools, health colleges and graduates from different universities who form a substantially low number of individuals (Ahmed, 2012). The nursing professional body also faces a new risk as the number of unaccredited organizations offering the course have increased overnight after the discovery of the existing health gaps.

3.3.3: Nursing Shortages

A significant proportion of nurses across the world is on the move searching for better working conditions and at the same time leaving a huge nursing gap in their country of origin. Ultimately, nursing standards are improved in specific regions of the world and continue to deteriorate in other regions. For example, in the United States alone, approximately 15% of all of the total nurse working population is made of foreign internationals who left their home base settings due to poor working conditions (Shaffer, Bakhshi, Dutka, & Phillips, 2016). The rates continue to soar in other countries including 18.2% in Australia which rose from the initial 14% noted in 2009. In New Zealand, the current foreign nursing population stands at 26.7% from 14.7% in 2002 (Shaffer et al., 2016). Gulf Cooperation Council has the highest number of expatriate nurses compared to other regions at 79% (Shaffer et al., 2016). The Gulf Cooperation is made up of a number of countries including Kuwait, Qatar, Bahrain, Saudi Arabia and the United Arab Emirates. Saudi Arabia has recorded high nurse turnover rates and shortages. As a result, the quality of care in most clinical settings has substantially reduced. Most healthcare organizations are in need of highly trained nursing staff who can meet the demands of the population which has in the past been affected by poor policies and systemic structures (Lamadah & Sayed, 2014). The turnover rates of nurses in Saudi Arabia is more likely to worsen in the coming years as more nurses leave the workforce. The nursing shortage will not only be felt in developing countries like Saudi Arabia but also in developed countries across the world. The nursing shortages increase the work demands for the remaining nurses who again opt to quit due to the excessive workforce (Mansour Saleh & Roger, 2014). A vicious cycle is being created where the number of nurses leaving the clinical setting in substantially higher compared to nurses who are joining the workforce. The increase in staffing shortages prominently caused by the high turnover rates recorded across different settings has also resulted in increased cases of absentees among nurses as well as accidents, and the current number of the nurse is unable to deal with the high patient population (Aldossary et al., 2008). Financially, the shortage puts a strain in the financial resources spent by the organization as core health activities such as quality improvement programs are either suspended or put on hold until organizations get the number of required nurses. Considerable resources are also used to recruit, train and hire new nurses who may also quit and in the process create an existing vicious cycle (Lamadah & Sayed, 2014). In such cases, negative health outcomes become the order of the day as a critical component of the healthcare system is absent.

3.4: Nursing Immigrants in the World and Saudi Arabia

Expatriate nurses or foreign based nurses form the largest portion of nurses who currently work and live in Saudi Arabia. Saudi national nurse’s form approximately 29.1% of the total nurse’s population in the area while expatriate nurses form the remaining numbers (Mansour Saleh & Roger, 2014). The number of Saudi based nurses is low in both public and private hospital with the private sponsored institutions recording even low numbers. The local nurses make up 4.1% of the total nurses in the private healthcare settings while the remaining proportion is strictly left to the expatriate nurses (Mansour Saleh & Roger, 2014). Therefore, private nursing in Saudi Arabia is generally driven by expatriate nurses. More nurses move to Saudi Arabia because of the many different benefits provided by the Saudi Arabian healthcare system compared to those present in their countries of origin. Saudi Arabia attracts higher remuneration to its nurses compared to other regions of the world, and as a result, more nurses across the world are tempted to join the system. For example, expatriate nurses in Saudi Arabia are paid approximately 800 pesos a day which translates to approximately $18 dollars, a rate which is significantly high compared to what other nurses across the world are paid (Aldossary et al., 2008). The number of expatriate nurses in Saudi Arabia continues to increase on an annual basis due to some of the benefits associated with the system. The table below indicates the number of Saudi and non-Saudi nurses across Saudi Arabia from 2005 to 2011 courtesy of the Ministry of Health. Table 1.2 indicates a surge in the number of both Saudi and Non-Saudi nationals although the number of foreign nurses is also higher. Table 1.3 shows the relative proportion of male and female Saudi and Non-Saudi nationals working across Saudi Arabia. The number of female non-Saudi nurses is significantly high compared to any other group. The low number of Saudi males in the nursing profession may be as a result of cultural beliefs that nursing is a traditional specialization area for women.

3.5: Job Satisfaction

Job satisfaction definition differs based on the subject’s context and its associated factors. It is common to find different definitions in nursing, medicine and even psychology. Nonetheless, it can be defined as positive work attitude towards a specific job. Various scholars have in the past attempted to provide a more elaborate definition of the term by defining it as the general feeling the employee has towards their job (Zhu, 2012). Determining job satisfaction within any organizational setting requires that different job aspects be considered. Such aspects include promotional opportunities, remuneration, supervision, leadership practices, training and development related opportunities and cultural practices of the organization among many other issues (Ghazzawi, 2008).Other scholars have defined job satisfaction as workers like and dislike within organizational settings (Cortese, Colombo, & Ghislieri, 2010). Different forms of literature may utilize different specific terms to define the term job satisfaction due to various factors which have to be considered.

3.5.1: Nurses’ Job Satisfaction

Nurse satisfaction may refer to the work attitudes, likes and dislike nurses have towards their job. Nurse satisfaction is a global issue as it is as one of factors associated with the low shortage of nurses across all continents. Developed countries are facing a huge nursing gap as the number of enrolled nurses within their clinical settings continue to dwindle while an increase is being noted in the turnover rates (Currie & Hill, 2012). Nurse satisfaction issues are predominantly the same across many countries but only defer by specific degrees to the applied policies and health care systems (Molinari & Monserud, 2008). There is an accepted commonality that the working conditions of nurses across the world has to be improved for significant inroads to be made in the current setting. Some common nurse satisfaction factors accepted globally include geographic factors, job-specific issues, and demographic characteristics. Other essential factors related to job satisfaction within nursing settings include job position, workplace environmental factors, health retirement plans, autonomy, supervision and coworker support among many other issues (Chen, 2008). Daehlen (2008) indicates that high group cohesion , autonomy, promotional opportunities, low work to family conflict, organizational support, and strong supervisor support are indicated as factors which are directly correlated with satisfaction.

3.5.2: Factors affecting nurses job satisfaction.

Various factors affect nurse satisfaction across the globe. Extensive workloads due to the shortage of nurses across the world result on nurses working for more hours to meet the health needs of the populace (Beswick, Hill, & Anderson, 2010). In some cases, the nursing schedules are quite rigid providing only for some few resting hours before nurses resume their duties. As a result, nurses lack adequate time to spend with their family members since they spend more time in clinical settings (Hoi, Ismail, Ong, & Kang, 2010). Consequently, there are increased incidences of strained family relationships due to the extensive workloads. Poor remuneration is another critical factor related to dissatisfaction. Nursing remains one of the professional practices with high qualifications across the globe. The practice also deals with specific aspects related to human life. Taking into consideration the extensive workloads and other vital roles nurses have to play in any organizational setting, nurses should be adequately paid. However, nursing remuneration remains quite poor across most clinical settings (Huffenberger, 2012). In addition, nurses are not provided with any new incentives or promotional opportunities for development within their setting, and as a result, most nurses feel stuck at their current organizational setting (An, Cha, Moon, Ruggiero, & Jang, 2016). In addition, there are few training and development opportunities which could be provided to the nurses to improve their skill set and as a result get better incomes. Most nurses have been restricted in their current organizational settings and as a result, receive the poor remuneration throughout their careers. Some nurses have opted out of such a system by looking for other opportunities outside the current scope. Leadership styles applied within organizational settings have a bearing on the nurse satisfaction rates. Transformational leadership style primarily defined by aspects of open communication and meeting intrinsic needs of nurses is the preferred by most nurses across clinical settings (Nelson, 2013). Autocratic leaders who authoritarian policies within organizational settings without necessarily consulting other parties result in high turnover rates (Murrells, Robinson, & Griffiths, 2008). Nurses prefer working in an environment which incorporates their views during decision making. Organizational visions and policies also play a critical role in job satisfaction. Nurses prefer working in organizational settings which have strict policies on healthcare management. Some clinical settings lack a quality of care vision to address common problems like nurse to patient ratio, implementation of new technologies provision of insurance plans for medical staff and implementation of promotional health activities (Cortese et al., 2010). Such poor working conditions result in higher turnover rates as nurses look for better working conditions.

3.6: Nurse Job Satisfaction in Saudi Arabia

Due to the nurse shortages reported in Saudi Arabia, more than 50% of all nurses in public hospitals are from overseas (Abualrub & Alghamdi, 2012; Aldrees, Al-Eissa, Badri, Aljuhayman, & Zamakhshary, 2015). The increased satisfaction rates in the country create a huge gap in providing some essential nursing services. Job satisfaction is indicated as one of the factors which may significantly reduce turnover rates and increase performance quality metrics of care offered by nurses. Some job satisfaction factors among nurses in Saudi Arabia include organizational commitment in meeting the nurse’s requirements, workloads, quality of life of the nurse within the setting, leadership style implemented and remuneration (AbdulatifBahnassy, AbdulazizFahadAlkaabba, & Al Ohaidib, 2014; Alshahrani & Baig, 2016; Ibrahim et al., 2016). Addressing the above factors would significantly improve health standards in Saudi Arabia.

3.7: Expatriates’ Nurses Job satisfaction in Saudi Arabia

Studies in Saudi Arabia have identified job satisfaction factors among expatriates. Yasin, Al-Hamad, Bélanger, Boucher, and AbuRubeiha (2017) identified several factors associated with satisfaction including working conditions, hospital policies, job security, and interpersonal relationships. Dagamseh MS (2016) identified work-family balance, lack of extrinsic needs as well as interaction with other co-workers as some of the critical aspects associated with satisfaction while Al-Ahmadi (2014) classified all factors related to satisfaction into based organizational factors and personal factors. Other studies indicated that job satisfaction among non-Saudi nurses was related to pay and working condition (Aljohani & Alomari, 2018), workload and promotion (Alasmari & Douglas, 2012), emotional exhaustion due to extensive workloads (Al-Turki et al., 2010), and infringe benefits and lack of opportunities (Al‐Dossary, Vail, & Macfarlane, 2012) The table below summarizes nurse satisfaction among Non-Saudi nationals. Job satisfaction among foreign based nurses is primarily driven by a number of aspects including better pay and remuneration. Most foreign based nurses leave their countries of origin in search of better working conditions. Clinical setting which provide such conditions show increased nurse retention while those which offer poor conditions where nurses are extensively over worked, the nurse to patient ratio is significantly low and no fringe benefits are more likely to look for other opportunities. Interestingly, cultural practices were not identified as a major satisfaction factor considering the predominance reliance of the Saudi’s on Islamic law. The high number of foreign nurses in the samples indicates some form of dependency on major Saudi clinical settings to foreign based workers. Provision of ideal conditions could reduce nurse turnover rates. The study contains some limitations. First, it only focused on sample populations which explicitly had non-Saudi nationals. Some excluded studies contained samples from both Saudi and Non-Saudi nurses while other specifically focused on Saudi nationals and could have provided more information. Secondly, the number of research articles used for analysis was significantly low as less research has been conducted on the satisfaction rates among Non-Saudi nationals. Overall, the strict methodology utilized increased the validity and reliability of the results and serves as a framework to conduct future studies.

3.8: Conclusion

Although the Saudi Arabia’s healthcare system has undergone tremendous changes over the years, it still faces a major nursing shortage gap which is primarily filled by foreign or expatriate nurses. The shortage of nurses in Saudi Arabia could be attributed to a number of factors including the segregate policies which were once implemented by the country resulting in low number of nurses. In addition, the country has witnessed very low enrolment in nursing over the years. As a result, the country struggles in meeting its healthcare targets. As an alternative, the country has opted to fill the current gap by foreign nurses. Today, foreign or expatriate nurses make the largest population of nurses in Saudi Arabia. Job satisfaction remains a critical factor determining whether nurses are retained or leave their clinical setting over the years. Some factors associated with job satisfaction factors among foreign nurses in Saudi Arabia include workloads, remuneration, working conditions (patient to nurse ratio), fringe benefits, leadership, supervision, and relationships with co-workers. By dealing with some of the above mentioned conditions the country can still retain some of its long term goals as it continues training and developing more Saudi nurses.

CHAPTER 4 - RESEARCH METHODOLOGY

4.1: Introduction

For any type of research study, the role of research methodology is integral. It enables the researcher to determine the best and most effective way through which the study can be carried out efficiently and effectively (Neuman, 2013). It is imperative for the researcher to identify and determine ways through which the study can be carried out in a proper manner. These are the tools and methods that enable the scholar to gain more control over the research process and thus conduct the study even more thoroughly. In the following paragraphs, different tools and methods used to carry out the research have been discussed.

4.2: Research Philosophy

In essence, research philosophy can be identified as the belief relating to the procedures used for collecting, analysing and using the data. It is an essential part of any research study and needs to be carried out in a proper manner. If any mistake is made by the scholar, then it would have a negative impact on the whole research process. Thereby Lewis (2015) rightly stated that it is an aspect that enables the researcher to determine the best way to collect and use the data. Ellingsen, Størksen and Stephens (2010) stated that it deals with the source, nature and development of knowledge in the context of the research topic. Saunders through the research onion stated that identifying the research philosophy is only the first step in conducting a research investigation. According to Vujaklija and et al. (2010), the main purpose of philosophy is to help the researcher in selecting the best and most suitable research approach. Thus the role of research philosophy is imperative in any type of research investigation.

In this study, the researcher has used positivism philosophy. Campbell, Herzinger and Gast (2010) stated that it is difficult to provide a precise definition and description of the positivism philosophy. Essentially it is based on the concept that everything can be provided only through science. Positivists argue that factual knowledge gained through observations can be trusted upon (Taylor, Bogdan and DeVault, 2015). This means in order to analyse and evaluate a subject matter thoroughly; the researcher has to use different scientific tools and methods. These can help in obtaining in-depth knowledge and understanding about the subject matter. By using this philosophy, the researcher can learn a great deal about the research topic and thus provide a comprehensive understanding of it. The positivism philosophy the researcher can explore different topics about the topic and analyse them in a thorough and detailed manner (Neuman, 2013). However, one of the main limitations of this philosophy is that herein the role of the researcher is only limited to collecting data and its interpretation in an objective way. This means that the researcher can only collect the relevant data and interpret it in such a manner that helps the readers in understanding the data in a much better and effective way. The main reason for selecting this philosophy is that it would limit the role of the researcher to only collecting and interpreting the data. This means that there are very fewer chances of this study getting affected due to personal bias of the researcher. Since the nature of the current investigation was quantitative, the positivism philosophy suited the current topic in the best manner (Lewis, 2015). Herein the focus was on identifying, understanding and then analysing experiences of the expat nurses working in Saudi Arabian hospitals. This way the researcher was able to quantify the findings in a better and more effective manner.

4.3: Nature of the study

It is imperative for the researcher to determine the nature of the investigation. This can be of great help in understanding the study efficiently and effectively. By understanding the nature of the research, the researcher can conduct the study appropriately and ensure attainment of its aim and objectives (Ellingsen, Størksen and Stephens, 2010). The importance of nature of the research work can be understood through the fact that it provides an opportunity to the researcher to plot the best course of action and determine the tools that could be most useful in conducting the study effectively. This study is quantitative in nature. Through this study the researcher aimed at assessing the level as well as the reasons for job dissatisfaction among expat nurses working in Saudi Arabia. By using such tools, the researcher was able to develop a thorough connection between the research and the information obtained through different sources. This enabled the researcher to get a better understanding of the research topic. In addition to this, by using quantitative methods, the researcher was in a position that helped in obtaining a large amount of information on the research topic (Vujaklija and et al., 2010). It essentially consists of a systematic analysis of the research topic by using different statistical and numerical figures. The main reason for using such methods is that it enabled the scholar to conduct a thorough and extensive analysis of the research topic. Use of different variables, null and alternative hypothesis through statistical analysis provided an opportunity to the researcher through which detailed amount of understanding pertaining to the topic was obtained and analysed (Campbell, Herzinger and Gast, 2010). Moreover, by using the quantitative methods, the researcher was able to thoroughly understand the research topic and also present it efficiently and effectively. In addition to this, use of such methods enabled the researcher to effectively evaluate the relationship between different variables thus helping to identify and understand the factors that lead to job dissatisfaction among expatriate nurses in Hali’s public hospitals in the country. Herein both independent and dependent variables pertaining to the research topic were evaluated in a thorough manner (Tong, Flemming and Craig, 2012). This provided a great opportunity to the scholar in evaluating and understanding the research topic. Tong, Flemming and Craig (2012) stated that in studies that focus on the nursing sector psychometric tools for data collection and analysis are very useful. It included factors such as job satisfaction, burnout, etc. They provided a great deal of knowledge and information related to the research topic in a thorough and detailed manner. In this study, the researcher has used a descriptive cross-sectional approach to describe and evaluate the correlation between the variables related to job satisfaction among expat nurses in Hali’s public hospitals. In addition, the researcher also focused on the intention to leave aspect, as it helped in understanding the research topic in a thorough and detailed manner.

4.4: Research Approach

Conducting a research investigation is a difficult process. There is a large number of aspects which have to be kept in mind by the scholar. It is imperative for the researcher to determine and select the best approach. Mackenzie, Hoverman and Baldwin (2012) stated that a research approach essentially is a guideline that enables the researcher to plot a course of action and ensure that it is closely followed. Anderson, Adey and Bevan (2010) defined the research approach as a plan or procedure that consists of different steps that must be taken in order to conduct the investigation efficiently and effectively. By developing a proper approach, the researcher can determine different aspects of the research topic that should be properly used and managed. In essence, it is the key for conducting any research investigation efficiently and effectively. If any mistake is made, then the research process will be affected in an adverse manner. Keightley (2010) stated that the researcher approach could be divided into two different categories – for data collection and data analysis. In this section of the current study research approach for data analysis has been considered. It consists of two types of approaches – inductive and deductive. In this study, the researcher has used the inductive approach. It is also known as inductive reasoning. Herein the focus of the researcher is on determining the best possible course that can enable effective use and analysis of the data. The key objective of this approach is to provide an opportunity to the researcher interpret the data while giving emphasis on the different areas of the research topic. The main reason behind selecting this approach was to help the researcher not only effectively conduct the investigation, but also to obtain a significant amount of knowledge and understanding of the phenomenon. Smith, Begley and Clarke (2011) stated that as opposed to the deductive approach, the inductive approach is more focused on developing a new theory relating to the subject matter. According to Riedl, Davis and Hevner (2014), the use of this theory does not indicate that the researcher is disregarding the existing theories and concepts on the research topic. Rather it indicates that the scholar is more focused on developing own theories that help in understanding the research topic in a better and more effective manner. In order to apply this approach, the researcher evaluated the existing theories and concepts of the topic. Access to such knowledge is very effective in developing a sound theoretical base and in obtaining a thorough conceptual clarity. The existing data and already available information were thoroughly observed (Anderson, Adey and Bevan, 2010). This was another opportunity that helped the researcher in understanding the research topic in a better and more effective manner. In this sense, it may not be wrong to say that through this approach the researcher was able to provide a thorough and critical analysis of the subject matter. Through such understanding about the topic, the researcher collected more quality data from both primary and secondary sources. In the lasts stage, the scholar developed own theory about the topic and thus was able to analyse it more thoroughly and extensively.

4.5: Data Collection

This is another important aspect of any research investigation. It is of great importance for the researcher to identify the methods and sources from which data and information about the topic can be obtained (Mackenzie, Hoverman and Baldwin, 2012). These can have a great impact on overall quality, efficiency and effectiveness of the research topic; therefore this step of the research process must be carefully planned and carried out. Data is the most crucial element of research, and therefore it is imperative for the researcher to prepare a thorough and effective plan to collect the data. Any mistake or miscalculation can have an adverse impact on the research process. Over the years experts and authors have developed different sources from which data pertaining to a research topic can be collected. They can largely be categorised into two – primary and secondary (Keightley, 2010). In this research, both these methods have been used and tested. Through these methods, the researcher was able to acquire a considerable amount of information regarding the subject matter. This helped in effectively conducting the research study. Role and importance of primary data for a research investigation can be understood through the fact that it enables the researcher to learn a great deal about the topic and thus can get in a position to analyse it in a thorough and detailed manner (Smith, Begley and Clarke, 2011). In this study, both the primary and secondary sources have been used to collect the data. Primary data was collected through a questionnaire survey of the expat nurses. Different survey instruments were used to collect primary data for this study: and the JSS (quantitative component). JSS questionnaire is highly reliable and valid as the nine sub-scales have moderate internal consistency between 0.60 and 0.90. Firstly, nurses were provided with a self-administrated JSS. The JSS was developed to analyse nine job satisfaction scales, each containing four subscales. The response format incorporated the validated six Likert scale ranging from ‘strongly agree’ to ‘strongly disagree’ (Riedl, Davis and Hevner, 2014). The nine scales include: “pay, promotion, supervision, fringe benefits, contingent rewards (performance-based rewards), operating procedures (required rules and procedures), co-workers, nature of work, and communication”. Expatriate nurses employed in three public Hali hospitals in Saudi Arabia were invited to participate in the quantitative component of this study, with the JSS being distributed by the nursing directors at the three public hospitals over a one-month period. Job Satisfaction Survey has been shown in Appendix 1. On the other hand, secondary data was collected by reviewing and analysing past books, journals, magazines, reports, articles, etc. on the subject matter. Herein focus was on gathering the studies that have been carried out in the past (Lewis, 2015). By using such information, the researcher was able to learn significantly about the topic. This further helped in effectively carrying out the research investigation.

4.6: Sampling

For any research that involves the collection of primary data, the section of sampling is important. Essentially it is a way through which the researcher can identify the sources, i.e. the individuals from whom the necessary data can be collected. It is an important section mainly because it helps the researcher in determining the best possible way to obtain primary data and use it to fulfil aim and objectives of the current investigation (Mackey and Gass, 2015). In the current study, this aspect is particularly important because of the fact that this is quantitative research, meaning that different statistical tools and methods have been used to perform this research investigation. Use of such methods can enable the researcher to lay more emphasis on determining ways that more useful information pertaining to the topic can be obtained. This can be of great use in conducting the study efficiently and effectively. Smith, Begley and Clarke (2011) state that it is a way to represent the target population in the research study. Thus by using the process of sampling the researcher can learn significantly about the target population, i.e. the individuals directly related to the research topic. By using such information, the researcher can investigate efficiently and effectively (Neuman, 2013). There are various types of sampling methods. However, in this study, the researcher has used total sampling. This method was selected by the researcher because it enabled the researcher to contact every target person and thus obtain deep insights into the research phenomenon. Moreover, the risk of missing a potential insight or detail from the member can be reduced by a great extent. Primarily there are two types of sampling methods – probability and non-probability (Riedl, Davis and Hevner, 2014). Total sampling is a part of probability sampling. This means that not every person from the target population has equal chances of being involved in the final study. Since the study is set in the nursing industry, by using total sampling the researcher made sure that all the expat nurses are included. Many nurses are working in the three public hospitals in Hali. One of the main traits of the sample population was the fact that they were expatriates (Tong, Flemming and Craig, 2012). Thus the sample was homogenous in nature. This enabled the researcher to focus extensively on the subject matter. The main reason for selecting this method of sampling was that it would have helped the researcher in saving a considerable amount of time and resources. Thus it was a very cost effective method as well (Campbell, Herzinger and Gast, 2010). In addition to this, there are only some expatriate nurses working in Hali’s public hospitals, indicating that the researcher had access to only a limited population base. By using total sampling, the scholar was able to narrow down the focus and ensure that the study is carried out efficiently and effectively.

4.7: Data Analysis

For any research study, this section is the most important one. As the name suggests, data collected from different sources is evaluated in this part. Through this section, the researcher is able to present and evaluate the data in such a manner that the target audience can understand it easily and effectively (Neuman, 2013). Essentially there are two ways through which data for a research investigation can be analysed – qualitative and quantitative. In the current study, the researcher has used the quantitative approach of the data analysis. By using this method, the researcher was able to thoroughly analyse the data collected from both primary and secondary sources. In this regard, the researcher was mainly dependent on using quantitative approach through statistical and numerical analysis technique (Mackey and Gass, 2015). This enabled the researcher to explore different aspects of the subject matter in a thorough and detailed manner. The statistical analysis enabled the scholar to analyse the data with great details and obtain a significant amount of information about the subject matter. This means that the scholar was able to gather more data and evaluate it in such a manner, which would lead to the development of a sound theoretical base as well as the fulfilment of aim and objectives of the current research investigation (Vujaklija and et al., 2010). This method was selected so that the researcher can pay more attention to aspects such as time consumed in collecting the data, reviewing the literature, etc. Through this technique of data analysis, the researcher can present the findings in such a manner that the readers can easily understand them. Therefore it can be said that the data analysis part is of prime importance to any research investigation (Anderson, Adey and Bevan, 2010). Thus tools and methods for this process must be determined and decided very carefully. In this regard, the STATA-14 software was used to analyse the quantitative data. Correlation between independent and dependent variables was analysed by using three statistical methods of analysis: simple t-test, analysis of variance (ANOVA) and Pearson’s correlation. This data was assessed for statistical significance between variables.

4.8: Ethical Considerations

The researcher applied to get the ethical approval from the Curtin Human Research Ethics Committee followed by the permission from the Saudi Ministry of Health to conduct this research in Hali’s public hospitals. The printed surveys were delivered together with a covering letter explaining the purpose of this study. Participants who participated in the interviews were asked to sign a consent form.

CHAPTER 5 - DATA ANALYSIS

5.1: Introduction

The purpose of conducting this research was to evaluate the level of job satisfaction among expatriate nurses in public hospitals in Hali. Through this study, the researcher has identified and assessed different factors and forces that influence the job satisfaction level among nurses who left their countries for better work opportunities (Wanders, 2017). Expatriates are those individuals who leave their home countries in order to search for new jobs that can provide them with a better life. Conducting this study enabled the researcher in identifying and understanding the various aspects that affect the motivation as well as job satisfaction levels of the expatriate nurses. The focus of this study was on healthcare employees. The necessary data was collected through a questionnaire survey of the selected sample respondents. The topic of job satisfaction level among expatriate nurses was selected because these individuals usually experience a lot of pressure than normal employees. The language barrier is one of the most common problems experienced by these individuals. Through this study the researcher aimed at examining and evaluating the satisfaction among expatriate nurses through their job. The decision makers can use the findings of this research in the healthcare industry in Saudi Arabia.

5.2: Research Questions

This study answers the following research questions.

What is the level of job satisfaction among expatriate nurses in the Hali public hospital?

What are the factors that dissatisfy expatriate nurses from their jobs in Hali public hospital?

How can job satisfaction level of the expatriate nurses be improved?

5.3: Descriptive Statistics

5.3.1: Reliability Analysis

In the current scenario, the reliability coefficient was computed at 0.84. Any figure above the mark of 0.70 indicates that the study and its findings are reliable (Smith, Begley and Clarke, 2011). On this basis, it can be said that the current study is reliable and it can be used by future scholars investigating the same topic. Moreover, the results of this research and the future study would not have too many variations. This improves the quality of the current research by a great margin.

5.3.2: Demographic Characteristics

All the participants in this study were female nurses who had left their home nations to Hali in search for better job opportunities in the field of health and social care. The following table shows different categories of hierarchical position on which the selected participants worked at. Herein it can be observed that majority of the participants were aged between 20-30 years and were working at the position of staff nurse. Out of the 100 married participants, 43 were at the position of Charge nurse, and only one of them was working as a director in the organisation. Further, more than 100 were of Filipino origin, and only 91 were Indian. 2 Filipino participants worked as a supervisor in the firm while one Indian was employed as a director. 185 Staff Nurses had a Bachelor’s degree. Similarly, 39 Charge Nurses were also educated till graduation level only. 76 staff nurses had experience of 1-3 years; while 40 of the charge nurses had working experience of more than 50 years. 48 Charge Nurses had a contract of 1 year with the organisation.

5.3.3: Quantitative Findings

The responses collected were put into the IBM’s Statistics Package for the Social Sciences (STATA).

Objective 1: The level of job satisfaction among expatriate nurses in Hali public hospitals.

The following table provides information about job satisfaction level among the research participants. Herein it can be observed that the majority of the participants are satisfied with their job. The table presents the number of observations and the mean value determined through the software. The answers for each of the ‘points’ ranged between 1 and 6. (1 = Disagree very much; 2 = Disagree moderately; 3 = Disagree slightly; 4 = Agree slightly; 5 = Agree moderately; 6 = Agree very much). Any value of the mean above 4 meant that the employees are happy and satisfied with their workplace. The level of job satisfaction for these individuals was higher. These categories were selected by the researcher to measure the job satisfaction levels, as they are considered as some of the key factors that affect the performance of the employees as well as their dedication towards the company.

On the basis of the table, it can be said that the participants were happy and content with their pay package with the mean computed at 4.07. The selected expatriate nurses were also very satisfied in terms of benefits that they get while working with the healthcare organisation. However, the table also reveals that the participants believe that the chances of promotion are very less. The mean here was calculated at 3.76, much less than the required mean of 4. Following are the graphs that show the responses of the participants.

Herein it can be observed that a large number of participants agreed with the statement that they are satisfied due to the benefits that they receive. Such benefits include the likes of bonuses, holidays, perks, etc. This motivates them to perform even better and contribute heavily towards the attainment of the organisational goals as well as on providing better services to the care users. Very few of the participants showed disagreement that they get a fair amount. This means that the majority of them believe they are paid according to their skills and the work they do. Due to this reason, they feel motivated and thus remain loyal towards the workplace.

Objective 2: The factors behind expatriate nurses job dissatisfaction in Hali public hospitals

The following table shows the results of t-test that was used to identify the factors that lead to job dissatisfaction among the expatriate nurses at Hali public hospital. The researcher decided to use t-test in the current study because they are simpler to interpret and require less amount of data than any other form of statistical tests and analysis. Herein, a p-value greater than 0.05 was considered significant (Riedl, Davis and Hevner, 2014). This means any of the factors that scored less than the threshold mark were the ones that caused dissatisfaction among the participants in relation to their job.

On the basis of the above table, it can be observed that there are a number of factors that caused dissatisfaction among expatriate nurses. Therefore, it can be said that there is a need for the authorities to determine ways in which they can satisfy these individuals so that their performance at the workplace can be improved and as a result, they can be motivated to carry out their roles and responsibilities in a better and more effective manner. If a proper solution is not developed, then there are chances that these employees will not be able to take better care of the patients and provide them with the necessary services. Almalki, FitzGerald and Clark (2012) observed that dissatisfied employees are not able to carry out their roles and responsibilities in a proper manner. This, in turn, has a direct and adverse impact on patient care. Herein it can be observed that the majority of the participants believed that their chances of getting a promotion were very less due to the fact that they were not native to the country. This was determined as one of the main factors that have an impact on the job satisfaction level of expatriates in the country. There have been many more studies which have concluded that those people who are native to one nation have very fewer chances of getting promotions at their workplace (Al‐Dossary, Vail and Macfarlane, 2012). Similarly, many of the participants stated that they are not happy with the benefits that they receive in the organisation. Upon further inspection of the data sets, it was noticed that expats do not get too many benefits in the host nations. This could be because the employers feel that such individuals are being allowed to work is a benefit in itself, and therefore they do not need any more of these. This finding can be supported through the responses given by the participants wherein they stated that their supervisors are unfair to them. Herein the majority of the respondents agreed and believed that their bosses and supervisors were not treating them properly. Their pay package was very less than their counterparts, i.e. the individuals who belonged to Saudi Arabia. Many of the expats also felt that they did not understand the goals and objectives of the organisation. Herein it can be said that there were a number of participants who opined that they were not satisfied at their workplace. For instance, a large number of the participants felt that there were very fewer chances for them to get a promotion in the organisation. This had an adverse impact on their motivation levels, and this affected their performance. The p-value obtained here was 0.00. However, a p-value above the threshold of 0.05 was significant. Furthermore, many participants also felt that their supervisors were unfair with them; many of the participants also added that they felt that the management did not appreciate their hard work and loyalty towards the organisation. This made them dissatisfied with the organisation and negatively affected their loyalty and performance at the workplace.

Objective 3: suggest some programs and strategies to improve the level of expatriate nurse’s job satisfaction.

It is imperative for the UAE authorities to identify ways in which they can improve the level of job satisfaction among the expatriate nurses. Just like any other employee in the organisation, they are an essential part of the workplace. By enhancing their satisfaction levels, the authorities can keep these individuals motivated and happy (Alam and Mohammad, 2010). This way they can make perform to the best of their skills and abilities, ensuring that the best health care services are provided to the patients. It is a well-known fact that supervision has a significant impact on the performance as well as the satisfaction level of the employees (McHugh, Kutney and Cimiotti, 2011). Supervision is a term that can even be replaced with the leadership here. Through proper leadership and guidance, the expat nurses can perform better and they can be even more useful for the organisation as they would provide better care services to the patients (Al‐Dossary, Vail and Macfarlane, 2012). During the study, it was noticed that the expat employees were under a lot of pressure in terms of work. The workload was too much on them. This affected their satisfaction level with the job. Therefore, the authorities should determine a way through which work pressure on these employees can be reduced. This would give them the time to get accustomed to the change in their situation and make adjustments in their lives. Such a task would motivate them, and as a result, their satisfaction level with the workplace would improve significantly (Almalki, FitzGerald and Clark, 2012). Through such steps, the authorities can make it easier for the expats to work in the healthcare industry and also be able to lead a comfortable life in the host nation. Taking such measures will enhance their capabilities and performance within the organisation, thus enabling them to contribute more towards its goals and objectives.

CHAPTER 6 - DISCUSSION

The aim of this study was to identify and analyse the factors leading to dissatisfaction among the expat nurses working in Hali’s public hospitals in Saudi Arabia. Through this study, the researcher thoroughly evaluated the current trends in relation to job dissatisfaction among expatriates, especially nurses. On the basis of the current study, it can be said that there are a number of causes and issues that have to lead to major job dissatisfaction among the participants. Through this study, the researcher has identified and assessed different factors and forces that influence the job satisfaction level among nurses who left their countries for better work opportunities. Expatriates are those individuals who leave their home countries in order to search for new jobs that can provide them with a better life. Conducting this study enabled the researcher in identifying and understanding the various aspects that affect the motivation as well as job satisfaction levels of the expatriate nurses. The focus of this study was on the nurses. The necessary data was collected through a questionnaire survey of the selected sample respondents. Understanding the job satisfaction level among expatriate nurses is important largely due to the reason that they have to experience a lot of pressure. The language barrier is one of the most common problems experienced by these individuals. Through this study, the researcher aimed at examining and evaluating the satisfaction among expatriate nurses about their job. The decision makers can use the findings of this research in the healthcare industry in Saudi Arabia. In order to conduct this study various statistical and numerical methods were used by the researcher. The reliability coefficient for descriptive statistics was computed at 0.84, above the threshold mark of 0.70. This indicated that the findings obtained in this research were very much reliable (Vujaklija et al., 2010). During the study, it was observed that out of the 100 married participants, 43 were at the position of Charge nurse and only one of them was working as a director in the organisation. Further, more than 100 were of Filipino origin, and only 91 were Indian. 2 Filipino participants worked as a supervisor in the firm while one Indian was employed as a director. 185 Staff Nurses had a Bachelor’s degree. Similarly, 39 Charge Nurses were also educated till graduation level only. 76 staff nurses had experience of 1-3 years; while 40 of the charge nurses had working experience of more than 50 years. 48 Charge Nurses had a contract of 1 year with the organisation. During the study, it was observed that one of the main causes of job dissatisfaction is work pressure. McHugh, Kutney and Cimiotti (2011) found in their study that the majority of health care workers such as the nurses are under a lot of pressure. This affects their ability to carry out their roles and responsibilities efficiently and effectively. Moreover, this also creates discord in their personal and professional lives. The findings of Bahnassy and et al. (2014) contradicted, as they stated that the expat nurses leave their families in order to search for better living and work opportunities. Therefore, too much work pressure is not a major issue in relation to expat nurses. They can easily manage their personal and professional lives. While conducting the current study, it was further observed that the healthcare industry is one of the most regulated markets in Saudi Arabia. The government gives a lot of emphasis on the performance of the nurses and other members of the workforce. Being such a highly regulated marketplace and due to extreme measures were taken by the government to control employee performance; the nurses tend to be under a lot of pressure. If they make any mistake, then its ramifications can be bad, and the same can be observed on their career graph as well. According to Almalki, FitzGerald and Clark (2012), expat nurses do not get proper recognition for their performance and efforts in the healthcare sector. This has a negative impact on their morale. Due to this reason, Al‐Dossary, Vail and Macfarlane (2012) stated that healthcare organisations as well the government should develop strict measures that analyse the performance of the expat nurses. Since these individuals are not the natives, they are exploited, as they are given too much work, which is beyond their capacity, and after this, they are not given the proper recognition as well. Instead, Alam and Mohammad (2010) argued that government and healthcare firms should motivate their efforts by way of recognising the hard work put in by the expat nurses. This will enable them to perform to the best of their abilities and contribute as much as they can towards the organisational goals and objectives. In the current study, it was observed that majority of the participants agreed that they do not get the proper recognition for the work that they do in the hospitals. This affects their morale as well as dedication level to work in the organisation. Due to this reason, they got de-motivated and dissatisfied with their job. The current study also revealed that relationship with co-workers is one of the main things that motivate these expat nurses to perform their tasks and duties efficiently and effectively. On the basis of the study, it can be said that this was one of the factors that did not cause any dissatisfaction among the expat nurses. Otherwise, many of the past studies have found that expatriate employees are not able to form healthy and effective relations with their co-workers. This has a negative impact on their morale as well as a dedication towards the workplace. They tend to get dissatisfied from the organisation very quickly, and the results of same can be observed in their performance. According to study Elamin (2011) job dissatisfaction among expatriates is directly proportional with the dynamic shared with the co-workers. Therefore Yasin and et al. (2017) suggested to companies that have expatriates in their workforce, to help these individuals build and maintain healthy relations with the co-workers. During the current study, it was also observed that factors such as fair amount, benefits, and relations with co-workers were some of the factors that satisfied the expat nurses from their jobs.

In this study, the researcher conducted t-tests to identify the factors that lead to job dissatisfaction among the expats at Hali’s public hospitals in Saudi Arabia. Herein it was observed that very few chances of getting a promotion were of the main causes of job dissatisfaction among the expat nurses. Here the p-value was 0.00, lower than the threshold requirement of 0.05. In this regard, Bahnassy and et al. (2014) had stated that since these individuals are not natives, authorities do not want to promote them to higher positions. This is because of reasons such as the risk of the expatriates wanting to return to their home countries, etc. Due to this reason, they try to avoid promoting the non-natives. However, then this causes dissatisfaction among the expats and discourages them from performing to the best of their skills and abilities. During the study benefits received by the expatriates was also one of the main reasons for large job dissatisfaction among the expat nurses. However, this finding was contradicted by the findings of McHugh, Kutney and Cimiotti (2011) which stated that as organisations are learning about the role and importance of human resources, more attention is being given to ensure that the expatriates also receive similar benefits to their counterparts. Organisations are using this as a means to motivate every single employee and ensure that they perform to the best of their skills and abilities. During the study, it was observed that job satisfaction levels among the nurses, especially expatriates tend to wavier a lot. It is dependent on a large variety of factors and forces. The information obtained during the study indicates that authorities have to pay a lot of attention on using different means and systems to satisfy the expatriate nurses and enable them to perform to the best of their skills and abilities. Most of the studies conducted over the years have stated that expatriate nurses face a lot of pressure at their workplace and they have to work harder than their counterparts who are native to the place. Moreover, the pay and growth opportunities they get are also very low. This affects their morale and job satisfaction levels. According to McHugh, Kutney and Cimiotti (2011), this is one of the main reasons that management of hospitals in the Saudi Arabia region have to give a lot of attention on managing the manpower in an efficient and effective manner. Findings obtained in this research are consistent with the findings of Riedl, Davis and Hevner (2014). In the current study, it is revealed that majority of the expat nurses are not satisfied with their job because they feel that they are not properly appreciated for their efforts. They also were of the opinion that they do not get growth opportunities because they are not natives to Saudi Arabia. In this regard Almalki, FitzGerald and Clark (2012) stated that such a form of discrimination and biases further affects the morale and job satisfaction level of the employees. During the study, it was observed that one of the main causes of job dissatisfaction is work pressure. McHugh, Kutney and Cimiotti (2011) found in their study that the majority of health care workers such as the nurses are under a lot of pressure. This affects their ability to carry out their roles and responsibilities efficiently and effectively. Moreover, this also creates discord in their personal and professional lives. The findings of Bahnassy and et al. (2014) contradicted, as they stated that the expat nurses leave their families in order to search for better living and work opportunities. Therefore, too much work pressure is not a major issue in relation to expat nurses. They can easily manage their personal and professional lives. While conducting the current study, it was further observed that the healthcare industry is one of the most regulated markets in Saudi Arabia. The government gives a lot of emphasis on the performance of the nurses and other members of the workforce. Being such a highly regulated marketplace and due to extreme measures were taken by the government to control employee performance; the nurses tend to be under a lot of pressure. If they make any mistake, then its ramifications can be bad, and the same can be observed on their career graph as well. Since these individuals are not the natives, they are exploited, as they are given too much work, which is beyond their capacity, and after this, they are not given the proper recognition as well. Instead, Alam and Mohammad (2010) argued that government and healthcare firms should motivate their efforts by way of recognising the hard work put in by the expat nurses. This will enable them to perform to the best of their abilities and contribute as much as they can towards the organisational goals and objectives. In the current study, it was observed that majority of the participants agreed that they do not get the proper recognition for the work that they do in the hospitals. This affects their morale as well as dedication level to work in the organisation. Due to this reason, they got de-motivated and dissatisfied with their job.

In this study, the researcher conducted t-tests to identify the factors that lead to job dissatisfaction among the expats at Hali’s public hospitals in Saudi Arabia. Herein it was observed that very few chances of getting a promotion were of the main causes of job dissatisfaction among the expat nurses. Here the p-value was 0.00, lower than the threshold requirement of 0.05. In this regard, Bahnassy and et al. (2014) had stated that since these individuals are not natives, authorities do not want to promote them to higher positions. This is because of reasons such as the risk of the expatriates wanting to return to their home countries, etc. Due to this reason, they try to avoid promoting the non-natives. All the participants in this study were female nurses who had left their home nations to Hali in search for better job opportunities in the field of health and social care. The following table shows different categories of hierarchical position on which the selected participants worked at. Herein it can be observed that majority of the participants were aged between 20-30 years and were working at the position of staff nurse. Out of the 100 married participants, 43 were at the position of Charge nurse, and only one of them was working as a director in the organisation. Further, more than 100 were of Filipino origin, and only 91 were Indian. 2 Filipino participants worked as a supervisor in the firm while one Indian was employed as a director. 185 Staff Nurses had a Bachelor’s degree. Similarly, 39 Charge Nurses were also educated till graduation level only. 76 staff nurses had experience of 1-3 years; while 40 of the charge nurses had working experience of more than 50 years. 48 Charge Nurses had a contract of 1 year with the organisation. The selected expatriate nurses were also very satisfied in terms of benefits that they get while working with the healthcare organisation. However, the table also reveals that the participants believe that the chances of promotion are very less. The mean here was calculated at 3.76, much less than the required mean of 4. Herein it can be observed that a large number of participants agreed with the statement that they are satisfied due to the benefits that they receive. Such benefits include the likes of bonuses, holidays, perks, etc. This motivates them to perform even better and contribute heavily towards the attainment of the organisational goals as well as on providing better services to the care users. Very few of the participants showed disagreement that they get a fair amount. This means that the majority of them believe they are paid according to their skills and the work they do. Due to this reason, they feel motivated and thus remain loyal towards the workplace. Here it can be observed that there are a number of factors that caused dissatisfaction among expatriate nurses. Therefore, it can be said that there is a need for the authorities to determine ways in which they can satisfy these individuals so that their performance at the workplace can be improved and as a result, they can be motivated to carry out their roles and responsibilities in a better and more effective manner. If a proper solution is not developed, then there are chances that these employees will not be able to take better care of the patients and provide them with the necessary services. Almalki, FitzGerald and Clark (2012) observed that dissatisfied employees are not able to carry out their roles and responsibilities in a proper manner. This, in turn, has a direct and adverse impact on patient care. Herein it can be observed that the majority of the participants believed that their chances of getting a promotion were very less due to the fact that they were not native to the country. This was determined as one of the main factors that have an impact on the job satisfaction level of expatriates in the country. There have been many more studies which have concluded that those people who are native to one nation have very fewer chances of getting promotions at their workplace (Al‐Dossary, Vail and Macfarlane, 2012). Similarly, many of the participants stated that they are not happy with the benefits that they receive in the organisation. Upon further inspection of the data sets, it was noticed that expats do not get too many benefits in the host nations.

CHAPTER 7 – CONCLUSION AND RECOMMENDATIONS

7.1: Conclusion

It is a well-known fact that health and social care industry is one of the most demanding job profiles. Employees tend to spend a considerable amount of hours at the workplace. Saudi Arabia is one of the destinations in the United Arab Emirates regions that see a significant number of expatriates in the nursing field. This puts a lot of pressure on the authorities to ensure that these individuals get a proper working environment. This way they will be able to perform better and also be satisfied with their job. There are a number of factors and forces that influence the motivation and dedication of the expat nurses working in Saudi Arabia. In order to ensure that these individuals perform better and are satisfied with their job and working conditions. Various studies and reports have shown that job dissatisfaction level among the expat nurses is rampant, indicating that the nurses are neither happy with their jobs and nor with their working conditions. Through this study, the researcher has identified and thoroughly analysed the reasons for job dissatisfaction among the expatriate nurses in Saudi Arabia. In this study, the researcher has discussed the various factors that lead to dissatisfaction among expat nurses from their jobs. By conducting this study, the researcher has evaluated different job trends prevalent among expat nurses in Saudi Arabia. Through such information, the researcher has been able to get a more thorough and effective understanding of the current job market in the country. The health care system followed in Saudi Arabia is considered one of the most effective one around the world. It has been observed that a large number of people are migrating to the Arab country in hopes to find better job and living opportunities. In this study, the researcher has discussed different factors that lead to dissatisfaction among expat nurses working in the Saudi healthcare sector. The researcher concluded that chances of getting a promotion were very less due to the fact that they were not native to the country. Also, nurses were not happy with the benefits that they receive in the organisation. That is, expats do not get too many benefits in the host nations. Further, it was found that their bosses and supervisors were not treating them properly. Their pay package was very less than their counterparts, i.e. the individuals who belonged to Saudi Arabia. Many of the expats also felt that they did not understand the goals and objectives of the organisation, so they were not satisfied at their workplace. Furthermore, it was also found that supervisors were unfair with expats; and the management did not appreciate their hard work and loyalty towards the organisation. This made them dissatisfied with the organisation and negatively affected their loyalty and performance at the workplace.

7.2: Recommendations

On the basis of the study, it can be suggested that public hospitals in Hali should provide different training and development programs, designed especially for expatriate nurses. This way the management can improve morale and job satisfaction levels of the nurses. In the long run, this will help in improving overall efficiency and effectiveness of operations of the hospital and make it a better workplace for the employees. Herein the authorities should also pay attention to determining ways through which they can measure the job satisfaction level among the expat nurses. This will help them in understanding the issues and experiences of the nurses. Moreover, through such information, they can also focus on determining ways to improve job satisfaction level of the nurses. Since the majority of the expat nurses had issues with the leadership style, the authorities should focus on ways to improve the same. This way the nurses can feel more secure and dedicated to the job. Through such measures, the authorities can significantly improve the satisfaction level among the expat nurses. They can also determine a way through which work pressure on expats can be reduced. This can be achieved by hiring an adequate number of employees with adequate knowledge. Trying to reduce employee turnover by facilitating them flexible working conditions, part-time working facilities so that they have a work-life balance. Facilities of transportation should be provided to female staff, so they do not have to rely on others. As per Herzberg’s motivation theory, award and reward system should be formed to reduce female nursing attrition. By developing a comprehensive education system so that female expats can enhance their knowledge and qualification.

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