Relationship of Job Satisfaction with Perceived Organizational Support and Quality of Care among Saudi Nurses

Background: Both, job satisfaction with quality of provided health care is considered the main issue which directly influences the health care field be-cause if nurses do not give the quality care to their patients then the patient dissatisfaction increased. Job satisfaction is defined as the extent of workers’ contentedness with their job, either they like the job or individual aspects or facets of jobs, such as type of work or regulation. Objective: To assess nurses’ job satisfaction and perceived organizational support with their effect on quality of provided health care in Saudi Arabia. Methods: Nurses in Saudi Arabia governmental hospitals during the period from 1st March to 30th April 2020 were invited and consecutively included. Data were collected using online questionnaire. Results: The study included 355 nurses with their ages ranged from 25 to 55 years old. Females were 216 (60.8%) of the total participants. Exact of 267 (75.2%) nurses reported that they like the type of work they do, 245 (69%) provided with satisfactory equipment to accomplish my task. There was a significant relation between organizational support and job satisfaction with their effect on quality of care. Conclusion: Organizational support positively affected nonsatisfaction which in turn positively affected quality of delivered care.


Introduction
Job satisfaction is the degree of workers' convenience with their job, whether they like the job or individual issue or facets of jobs, such as type of work or care [1]. Job satisfaction includes cognitive, affective, and behavioral components [2]. Job satisfaction methods are different in the degree that they measure emotions about the job (affective job satisfaction) [3] or perceptions of the job (cognitive job satisfaction) [4]. Locke (1976) addressed one of the most known definitions, who defines job satisfaction as "a pleasant or positive emotional state emerging from the appraisal of one's job or job experiences" [5]. Others have defined it as simply how content an individual is with his or her job, whether he or she likes the job or not [6]. It is evaluated at both the global level where the individual is satisfied with the job overall, or at the facet level, whether the individual is satisfied with different features of the job [7].
Managers and administrators at nursing field are usually exposed to stress to overcome their nurse turnover rate keeping acceptable level of quality at the provided health care [8]. Further, the new concept of evidence-based practice has also necessitated the lack of research considering the staffing relationships, nurse satisfaction and preservation besides quality of provide health care [9]. Job satisfaction is the outcome of different correlating aspects including economic, social, and psychological factors that are an issue for three major areas for assessment: professional job attributes, organizational characteristics and impacts on patient outcomes and quality of health care [10]. Professional job characteristics include factors associated with working as a nurse such as staffing, work hours, or workload that significantly correlate with job satisfaction [11] [12].
Perceived organizational support (POS) is defined as the extent to which employees trust that their organization consider their effort and cares about their well-being and achieves their socioemotional needs [13] [14]. With POS, employees tend to do better to reciprocate given incentives and favorable dealing [15]. In the last few years, a new term was used in the literature named organizational citizenship behaviors [16]. It has been defined as personal behavior that is flexible, not directly or explicitly identified by the official reward system and that in aggregate supporting the effective functioning of the organization.
Studying the job satisfaction at nurses and its correlates mainly organizational support will positively affect organizational their loyalty which in turn will be reflected on the quality of provided health care. This can be achieved by knowing the main motives to improve nurses' level of satisfaction and organizational barriers against being at healthy work environment [17] [18]. No similar study was conducted in Saudi Arabia. Nearly all conducted studies focused on only one topic (nurses' satisfaction, organizational support, or quality of care) or on the direct relation between any two of them. None studied the indirect effect of organizational support on quality of care through affecting job satisfaction using path analysis. The current study aimed to assess nurses' job satisfaction and perceived organizational support with their effect on quality of provided health care in Saudi Arabia through assessing direct and indirect relations.

Subjects and Methods
A correlational cross-sectional approach was applied to target all accessible nurses who work at the main governmental hospitals in Saudi Arabia during the period from 1st March to 30th April 2020. Nurses worked at the hospital for at least 6 months, accept to participate in the study, and in direct relation with the patients were included. Nurses at administrative jobs and those who had chronic health problems were excluded. A minimal sample of 350 nurses was required to estimate expected job satisfaction rate of 69% with precision of 7% at 95% confidence level and design effect = 2 which will cover the required sample for expected correlation coefficient between job satisfaction and perceived organizational support of 0.36 [19].  [19]. Each item was answered using 5-point liker scale ranging from strongly agree (scored 5 points) to strongly disagree (score 1 point). Higher score means higher nurses job satisfaction. Perceived organizational support was measured using the 8-item Survey of Perceived Organizational Support [20]. The eight items were answered based on 7-point Likert scale ranging from strongly disagree (scored 0 points) to strongly agree (scored 6 points). Higher score means higher organizational support. The study questionnaire was distributed at nearly most areas in the kingdom to have as much as possible representative sample to avoid bias and improve study external validity.

Data Analysis
Once data were collected, it was filtered, coded, and introduced to statistical software IBM SPSS version 22 (SPSS, Inc. Chicago, IL). All missing data were addressed using multiple imputation methods. All statistical methods based two tailed tests. P-value less than 0.05 was statistically significant. For job satisfaction, quality of care, and organizational support scales, discrete scores for the scale items were summed to get total score. The nurse who had total score less than 60% of the maximum score was considered to have low scores for satisfaction and organizational support and poor scores for quality of care. Those who had total score of 60% or above of the maximum score were considered to have high or good scores. Descriptive analysis based on frequency and percent distribution was done for all variables including demographic data, job satisfaction, organizational support, and quality of care. Cross tabulation was used to assess

Results
The study had 355 nurses with their ages ranged from 25 to 55 years old. Females were 216 (60.8%) of the total participants. Exact of 206 nurses (58%) were married and 180 (50.7%) had bachelor's degree and 133 (37.5%) had diploma. Experience years were more than 10 years among 164 nurses (46.2%) and 211 (59.4%) of the nurses were in their departments for 3 -4 years. Exact of 171 (48.2%) nurses worked morning shifts and 180 (50.7%) worked morning and evening shifts. Considering number of patients cared per shift, 241 (67.9%) of the nurses recorded less than 10 patients and 71 (20%) recorded 10 -29 patients ( Table 1). Table 2 illustrates Job satisfaction among respondent nurses in Saudi Arabia. Exact of 267 (75.2%) nurses reported that they like the type of work they do, 245 (69%) provided with adequate supplies to achieve their task, 225 (63.4%) were treated by their managers in respect, 202 (56.9%) like the staff they work with them, and 201 (56.6%) considered as one of the team they work with. Exact of 160 nurses (45.1%) had autonomy to make decisions I need to accomplish my tasks. Overall, 36.1% of the nurses are very satisfied with their work. In total, high job satisfaction was recorded among 133 nurses (37.5%).
Considering quality of care (Table 3), 315 (88.7%) of the nurses believe that the quality of care they provide is affected by nurses' job satisfaction and 297 (83.7%) believe that performance is affected their job satisfaction. Patient Safety as a main priority at this hospital was reported by 213 nurses (60%). Exact of 159 (44.8%) of the nurses reported that the quality of care at this hospital is more than needed. Totally, good quality of care was reported by 306 (86.2%) of the nurses. Table 4 demonstrates Organizational support as recorded by respondent nurses in Saudi Arabia. Exact of 259 (71.9%) of the nurses reported that the organization shows very little concern for them, 256 (71.1%) complained that the organization would fail to notice their high effort. Also, 245 nurses (68.1%) reported that the organization fails to appreciate any extra effort from them and 227 (63.2%) reported that the organization would ignore any complaint from them. Nurses contribution to the organization ideals was reported by 153 (42.6%) of the nurses and 126 (35%) reported that the organization cares about their general satisfaction at work. In total, high organizational support was recorded among 123 nurses (34.6%).

Discussion
The current study designed to evaluate nurses job satisfaction level and its association with organizational support. Also, to assess the nurse's satisfaction effect on quality of care in Saudi Arabia. The study revealed that the most respondent nurses were females at young age. They are mostly the category who had smart phones with continuous online access. Regarding nurse's satisfaction, one out of each three nurses were highly satisfied which is not satisfactory level as this means that two thirds of the nurses had barriers or obstacles affecting their job satisfaction which will in turn affect their quality of care. This mostly was due to that nurses' work at risky environment with no consideration for that from their work setting. This can be proved by that the least recorded satisfaction was for that physical working conditions are not good, and hospital does not offer a good benefits package for the nurses. Also, nurses feel that they are not fairly compensated for their works. This resulted in that two thirds of the nurses reported they will not recommend employment at their hospital to others. The higher satisfaction was recorded for old aged nurses with higher educational level (mostly those who ad high salaries), nurses who live near their work settings as they are mostly had low burden of being at their work. Also, nurses who work morning shift only recorded higher satisfaction than others as they had stable S. M. Assiri et al. and that the organization shows very little concern for them. All these negative organizational managerial factors affected nurses feeling of being supported and appreciated which was reflected in the low satisfaction level. Golbasi et al. conducted a cross sectional survey to assess association between coping strategies, individual traits, and job satisfaction among group of hospital nurses [21]. The researchers recorded a fairy low satisfaction level among Turkish nurses. Nurses with a higher education have been shown to be more satisfied with their job than those with lower education [22]. In Saudi Arabia, Al-Dossary R et al., 2012 conducted a survey to assess nurses' job satisfaction of university teaching hospital nursing staff in Saudi Arabia and to clarify the affecting factors [23]. The researchers found that nurses fairly satisfied with their jobs. The main factors of dissatisfaction were pay, fringe benefits, contingent rewards, and operating conditions.
Regarding quality of care, the current study revealed that quality of provided job satisfaction and quality of their delivered care, with barriers to a quality care.
The researcher concluded that there is a direct correlation between nurses' job satisfaction and the quality of provided health care. Workload, staff timetabling, and stress were the most reported issues that affect the quality of provided health care. Moreover, pay/compensation, work environment and care quality are found to be the factors that affect nurses' job satisfaction most.

Study limitation
The main limitation was that the data collection using online tool which may target nurses who are interested and not faced by high burnout and those who have smart phones and internet accessibility. This may to some extent affect the precision of results and conclusions, but the current situation of COVID-19 pandemic gives us no other method. Researchers tried to cover most areas in the kingdom and to have the most available number of participants to release some limitations.

Conclusions and Recommendations
In conclusion, the study revealed that nurses were dissatisfied and lacking feeling of being supported by their organizations. Although, the quality of delivered care is not affected by their poor satisfaction. Most nurses feel working too much with low benefits and being unconsidered. Health care setting managers should be educated and trained for good leadership styles and how to evaluate support subordinates by continuous rewarding and encouragement.

Role of Authors
First author: Selecting the topic title, background writing with data collection.
Second author: Methodology preparation and data analysis. Results presentation and he is the corresponding author.
Third author: help in data collection, discussion review and manuscript editing.