The Effectiveness of Ideal Clinic System in Increasing Job Satisfaction in the Rural Areas: A Case in the Eastern Cape Province, South Africa

Globally, professional nurses are the “engine” of the healthcare system. Therefore, their job satisfaction needs to be taken into consideration as they have a very important duty to perform in health care facilities. In 2013, an Ideal Clinic System (ICS) was developed by the South African Department of Health to improve all healthcare facilities in the country. This was developed to standardise all healthcare facilities nationally and to address infrastructure gaps between the rural and urban healthcare facilities. The intention of the study was to determine the factors that affect the level of satisfaction of professional nurses ever since the implementation of the Ideal Clinic System in the rural Eastern Cape Province. The study will inform the Department of Health of the gaps in the formulation of policies and development of protocols in the implementation of the Ideal Clinic System process. Highlighting these gaps could contribute to job satisfaction amongst professional nurses and benefit lo-cal communities’ professional nurses. A grounded mixed research epistemolo-gy theory was utilized to determine cause-and-effect interactions between variables. Data were analysed using SPSS expand version. Findings indicated that female participants dominate the nursing profession. The model reveals that recognition and training are most influential in job satisfaction. The con-tribution/value-add of the study is to enhance job satisfaction, a framework for professional nurses must be formulated based on the above two aspects in relation to the working environment.


Introduction
According to Molefe and Sehularo (2015), there is a worldwide concern around the lack of job satisfaction among professional nurses in rural settings. South African professional nurses in the public sector (working for the Department of Health) are reportedly facing the same challenge with job satisfaction. As a result, several studies on the concept of job satisfaction have been carried out with the intention of identifying the factors contributing to productivity in the Department of Health.
According to Nelson and Quick (2013), job satisfaction is about measuring the feelings employees have about their jobs; these can be positive or negative feelings. However, the feeling differs from individual to individual, and what each prefers the most. Therefore, it is very important for employees to obtain what they expect to receive from their jobs. Failure to receive the expected returns from work results in job dissatisfaction and a negative attitude towards work (Werner & DeSimone, 2011). For example, in a case of the employee who like a clean and safe work environment, the employee is likely to be dissatisfied when the workplace is dirty and unsafe. Khunou and Davhana-Maselesele (2016) also observed an alarming rate of professional nurses leaving the rural public healthcare centres and migrating to cities: some are resigning and others are asking for internal transfers; others migrate to other countries in search of a conducive work environment. When an employee experiences job dissatisfaction, he or she may not be able to perform tasks effectively. Accordingly, it impacts negatively on the productivity and the expected level of service delivery for the organization. Therefore, the organizations' efficiency and effectiveness can be directly impacted by job satisfaction. This is the reason why the researcher in the current study was interested in ascertaining how satisfied the professional nurses were regarding the implementation of ICS.
Due to the perceived reasons for professional nurses migrating from the rural to urban areas, certain strategies were developed to prevent this process. In 2004, a rural allowance was introduced in South Africa as one of the strategies to retain professional nurses in rural health services (PHWSBC, 2004). In 2007 Occupation Specific Dispensation (OSD) was developed as another strategy for the purpose of retaining professional nurses (Ditlopo et al., 2013). After the implementation of these strategies, many studies have been undertaken by researchers to measure the effectiveness of these strategies. One of the studies by Makapela and Useh (2013) focused on the extent the Department of Health tried to provide allowances for professional nurses in rural healthcare centres so as to stop professional nurses from leaving the rural areas, as well as to establish the challenges faced by the health care professionals in these areas. Other studies based on the OSD by Ngozwana (2015), Khunou and Davhana-Maselesele (2016) investigated the effectiveness of OSD towards contributing to the professional nurses' job satisfaction levels. Both the rural allowance and OSD strategies were developed to retain professional nurses using financial allowances but little con-M. Mpongoshe Journal of Human Resource and Sustainability Studies sideration was given to the infrastructure of the work environment.
In 2013 the government, through the Health Department, developed an ICS.
The ICS was developed to standardise all healthcare facilities nationally to address the infrastructure gaps between the rural and urban healthcare facilities. This was because professional nurses were still migrating from the rural areas, even after the implementation of rural allowance and OSD retaining strategies.
Therefore, the focus of ICS was to improve the infrastructure gaps aimed to improve administrative processes which will ensure proper healthcare facilities in rural areas has the access to the latest available clinical policies guidelines, which assistance to rural health facilities' effectiveness and productivity as expected by members of society (May, 2016). However, even though the ICS was developed and implemented to address the gaps in the infrastructure between the rural and urban healthcare facilities, it was challenged by minimal resources.
Since there is a dearth of research regarding the ICS in the Province of the Eastern Cape South Africa in Chris Hani District, it was prudent that research regarding job satisfaction of professional nurses should be conducted. Chris Hani District is one of the 8 districts found in the Eastern Cape Province. The district constitutes a population of 873,362 people which accounts for 12% of the total population in the Eastern Cape Province and 1.5% of South Africa's total population (May, 2016). The district has 93 overall clinics which are divided into 5 sub-districts namely; Inxuba Yethemba, Enoch Mgijima, Intsika Yethu, Emalahleni, and Sakhisizwe Sub-district. The research was conducted in Sakhisizwe sub-district which consists of 14 clinics, but due to the distance between the clinics, only 6 clinics were chosen.
The implementation of the system undertaken explains that Eastern Cape is in SA and deep in rurality, with poor economic situation and perhaps a bit of historically under developed. The questions raised in this dissertation therefore are: to what degree does job satisfaction rate among professional nurses in reference to the ICS? What recommendations can be made by the professional nurses and the researcher regarding the implementation of this system?

Purpose of the Study
The intention was to determine the factors that affect professional nurses' level of satisfaction ever since the implementation of ICS in Eastern Cape Province.

Research Objectives
The main objectives were to examine the expected level of satisfaction that affect the performance and productivity of professional nurses in the rural Eastern Cape Province:  To explore the views of professional nurses about Ideal Clinic System (ICS) and their intention to migrate from the rural clinics due to implementation of this system.  To identify factors that prohibit the professional nurses on achieving the ex-Journal of Human Resource and Sustainability Studies pected outcomes of the ICS in the rural Eastern Cape Province.  To recommend on ways to improve the effectiveness of ICS to increase job satisfaction in the rural Eastern Cape Province.

Significance of the Study
Professional nurses should, at all times, be considered in the process of implementation of any healthcare program or system (Semachew et al., 2017). Therefore, in this study, the issues that made nurses to be satisfied will be identified.
The study will inform the Department of Health on the gaps in the formulation of policies and development of protocols in the implementation of the Ideal Clinic System process. It is hoped that if those gaps have been identified and addressed, the professional nurses, will be satisfied. Moreover, the community will benefit as it will be taken care of by satisfied nurses.

Reviews of Rural Professional Nurses Job Satisfaction in South Africa
The Department of Health's Annual Report by Mbengashe (2015) listed the following conditions that contribute to nursing job satisfaction in South Africa: availability of required resources, organizational climate, better compensation, working conditions, and managed care. Problems in these key areas decrease professional nurses' job satisfaction and the booming economy lured them away to other professions. For the efficiency, effectiveness and sustainability of the healthcare system to be achieved, professional nurses are required to play a pivotal role. It is, therefore, important for the employer, that is, the Department of Health, to ensure that it understands exactly what really motivates professional nurses and the extent to which the motivation can be kept at the highest level to ensure that professional nurses remain satisfied with their jobs (Ghawadra et al., 2019). Professional nurses play a very critical role in ensuring that there is effectiveness and efficiency in health care and this largely determines the patients' outcomes. Therefore, according to Khunou and Davhana-Maselesele (2016);Ugwa and Charity (2016), this requires that the variables that satisfy and motivate professional nurses must be known and identified by nursing managers. Professional nurses' job satisfaction has been a topic of interest worldwide since it has an effect on nurses' performance and healthcare service delivery. Job satisfaction is considered a significant phenomenon for healthcare institutions. Managers and supervisors should take note of all the factors that impact professional nurses' job satisfaction (Andrioti et al., 2017;Bekru et al., 2017;Ozkara San, 2015;Oktizulvia et al., 2017).

Health Status and Job Satisfaction
Health status has become a major challenge for employers as they are the ones expected to ensure good work conditions for the employees (Wushe & Shenje, Journal of Human Resource and Sustainability Studies 2019). The expected output at the workplace has a significant relationship with the physical and mental health of an employee (Goetzel et al., 2018). The mental and physical health of employees is important because it affects work performance. An employee in good health, who is not overworked, will perform well in the workplace and the opposite is true. It should be noted that health status is a vital issue for every organisation because of its tendency to contribute to employee inefficiency, absenteeism, turnover intentions and decreased job satisfaction (Goetzel et al., 2018). The health of employees in an organisation is positively impacted by the working environment (Mohan & Mulla, 2018).

Importance of Job Satisfaction
According to Khamisa et al. (2015), for high-quality to be ensured, job satisfaction is essential for healthcare employees. Research suggests that dissatisfied employees provide not only poor-quality services but distance themselves from their responsibilities (Ghawadra et al., 2019;Lambrou et al., 2010). According to Khamisa et al. (2015), in South Africa, professional nurses are generally dissatisfied with many aspects of their job such as remuneration, advancement and work settings. Furthermore, Khamisa et al. (2015) concluded that the important factors, once ignored by the Department of Health, turn out to be the major reasons for professional nurses to leave rural healthcare facilities for urban settings. At a later stage, this contributes to labour turnover in rural healthcare facilities. Therefore, retention strategies need to be developed so as to overcome such challenges. Globally, literature on job satisfaction among professional nurses seems to support Khamisa et al. (2015) findings. For example, a study undertaken in Iran found that approximately 37% of professional nurses were not satisfied with their jobs (Poursadeghiyan et al., 2016). A comparative study in Saudi Arabia seeking to examine the levels of job satisfaction/dissatisfaction among professional nurses and other qualified health practitioners revealed that other qualified health professionals were generally satisfied with their remuneration packages while registered professional nurses were not (Parveen et al., 2017).

Relationship with Co-Workers
According to Barlings and Burns (2015) found that relationships between coworkers may be a determinant of job satisfaction. Smart relationships among workers are non-exclusive within the work and people require trust, commitment, and reciprocity and shared interests (Anitha, 2014). Employee relationships are necessary and really valuable for each worker and therefore the organizations should permit workers to support and facilitate each other with the accomplishment of their work tasks, as this leads to reduction of labour stress, improved communication and co-operation. Once smart relationships and cooperation among workers exist within a given organization, it helps workers to feel comfortable with each other, so eliminating the sense of insecurity and uncertainty (Ozpehlivan & Acar, 2015). Work relationships will influence job satisfac-Journal of Human Resource and Sustainability Studies tion and encourage and predict satisfaction (Tayyar, 2014). Once workers inside the organization are friendly, collaborative and cooperative towards one another, it makes them happy and has a positive impact on job satisfaction (Kalliath & Morris, 2014). Job discontent is more likely within the organization wherever workers are isolated because of poor relationships (Tayyar, 2014).

Conceptual and Theoretical Framework
The theoretical framework adopted Herzberg's Theory of Motivation-Hygiene Factors (1959) for the analysis and interpretation of data. This theory is also supported by Helbing et al. (2017). Given the nature of the model, it is a suitable model to apply in this investigation. In this study, the model will be used to analyse the factors that affect professional nurses at work. The model will be utilised to measure the job satisfaction of professional nurses who were employed before the ICS was implemented and identify which factors could contribute to job satisfaction. Therefore, independent variables that apply to this study have been grouped as follows: compensation, working conditions, recognition, and training. However, work, also as a dependent variable has been identified as job satisfaction consisting of commitment, punctuality, and performance. Also, the intervening variable which refers to government policies has been identified. These mentioned variable factors can also be found and compared in Herzberg's theory recognised as hygiene factors which are identified as extrinsic and intrinsic factors which lead to satisfaction and dissatisfaction of employees (Helbing et al., 2017).

Research Hypothesis
According to Murphy (2016), a research hypothesis is speculation or theory based on insufficient evidence that lends itself to further testing and experimentation. In this study, the researcher articulated a null hypothesis and a positive hypothesis. A null hypothesis is a hypothesis that says there is the hypothesis that the researcher is trying to disprove. In comparison, an alternative hypothesis simply is the inverse, or opposite of the null hypothesis (Murphy, 2016).
Given this framework, the following hypotheses were formulated:  H1: Compensation predicts job satisfaction.
 H2: Working conditions predict job satisfaction.
 H5: The policies moderate the relationship between compensation, working conditions, recognition, training and job satisfaction.

Research Approach
The previous section introduced this study and introduced the concept of job satisfaction in relation to the nursing profession particularly in rural South Africa. Journal of Human Resource and Sustainability Studies The literature indicated that South African nurses in the rural areas are facing the challenge of job satisfaction leading to migration to better places. In this chapter, the researcher carries out a literature review on factors associated with job satisfaction of professional nurses.
A qualitative, quantitative, descriptive developmental design for theory generation was used in this study. The strategy in doing this research involved an empirical investigation of a particular phenomenon within its real-life context, using multiple sources of evidence (Collins & Stockton, 2018). The kind of design was used to determine the factors that affect professional nurses' level of satisfaction ever since the implementation of ICS in Eastern Cape Province. As mentioned that the study is quantitative and qualitative in nature. Collins and Stockton (2018) stated that the quantitative approach aims to determine how one thing affects another in a population by quantifying the relationship between variables. The quantitative method was applied in this study for the purpose of collecting statistical data related to the job satisfaction of professional nurses. Questionnaires were handed to professional nurses in the selected clinics at a comfortable place agreed upon by both parties (researcher and respondents).
Qualitative research is a descriptive, non-numerical way to collect and interpret information (Collins & Stockton, 2018). It involves investigating individuals and phenomena in their natural settings so as to gain a better understanding of the area (Ahmad et al., 2019). Open-ended questions were conducted with the aim of collecting information related to the opinions, views, and feelings of nurses, this further assisted the researcher in achieving an in-depth understanding of the job satisfaction situation in the rural healthcare facilities with the professional nurses of the sub-district.
The mixed-method approach permitted the researcher to investigate emerging themes or trends that arose when conducting quantitative research, and which could be further explored by means of qualitative research. According to Cresswell (2014), the mixed-method approach presents an opportunity to compare the quantitative statistical results with the qualitative thematic results.

Research Participants
The targeted 200 participants comprised professional nurses who were already employed during the implementation of ICS and were working at the clinics in the Eastern Cape Province (excluding those who were employed after the ICS was already in place). The reason for the selection was that they understood how the conditions were before the system was introduced. Thus, they could weigh the conditions and the level of satisfaction before and after the system came into effect. All participants were recruited through a process where all eligible participants had an equal opportunity of participating in the study. Probability-strati- According to Brink et al. (2013), a sample is a part or fraction of a whole or a subject of a larger set selected by the researcher to participate in a research study.
In this study, the sample size of 200 questionnaires was distributed and all were collected from respondents. According to Brink et al. (2013), the sample size can be 10% of the target population. However, in this study, the researcher selected the target population so as to be able to generalize the findings.

Descriptive Results
See Table 1.

Gender Distribution
The results shown in Table 1 reveal that females dominate in the health sector as shown by 82% being females and only a minor 18% were male. In other words, the nursing profession is mainly dominated by females. In this study, it has been revealed that females dominate in the nursing health sector possibly due to nursing profession being perceived as a female occupation or career with the title of Sister being associated with the nursing profession. It could also be because the population of women is generally higher than that of men (World Bank, 2017).

Age Distribution of the Respondents
Results shown in Table 2 reveal that respondents of 51 years and above as well as the middle-aged people of 36 -45 years were the majority in the nursing profession represented by 35% each; while the lower age category of 30 -35 years as well as the 46 -50 years are represented by 15% each.

Measuring Instruments
A Likert-type questionnaire where respondents could indicate the level of agreement with certain statements was used with this scale 5 = strongly agree; 4 = agree; 3 undertrain/neural; 2 = disagree; and 1 = strongly disagree. Journal of Human Resource and Sustainability Studies

Research Procedure and Ethical Considerations
Self-administered questionnaires were developed by the researcher with the aim to measure the professional nurses' satisfaction, in relation to the implementation of ICS. After all, required permissions were issued by the relevant office such as Eastern Cape Department Health Research Committee, the researcher administered questionnaires to the respondents. Confidentiality was maintained by keeping the forms anonymous, no names of respondents were written on the questionnaires. A researcher was liable for ensuring that prior to collecting data, a full ethical clearance has been received as data collection cannot begin until gatekeepers' letters are received and full ethics clearance is granted from the informants to maintain the integrity of the research process.

Statistical Analysis
The researcher was assisted by a statistician to analyse the data of 200 questionnaires after the responses from respondents were collected and a spreadsheet (Excel) was used for capturing of data. Inferential statistics such as the independent sample t-Test was calculated to establish an association between variables. The Shapiro Wilk's test was performed against all independent variables (IV) in relation to the dependent variable (DV) and the similar result of p = .000 was observed throughout, revealing that the independent variable IV and the dependent variable DV data violated the assumptions of normality. Given this outcome, when the simple linear regression analysis was performed with respect to H1 to H4, bootstrapped confidence intervals and their significance levels were used as these do not rely on assumptions of normality and heteroscedasticity (Field, 2013). Descriptive statistics that included frequencies and percentages were used for the analysis of data.

Results and Discussion of Findings
Descriptive statistics with respect to the respondents' demographic data will be presented according to the available number in genders and also be categorized in ages. In ages, results reveal that respondents of 51 years and above as well as the middle-aged people of 36 -45 years were the majority in the nursing profession represented by 35% each; while the lower age category of 30 -35 years, as well as the 46 -50 years are represented by 15% each. Journal of Human Resource and Sustainability Studies

Professional Nurses Regarding the Effectiveness of ICS
The findings indicated that professional nurses strongly recommended that ICS would work best if standardization could also be implemented, even on the allocation of resources. They further mentioned that since ICS was developed to standardize all healthcare facilities to the same standard, it would be best if the allocation of resources be standardized. The findings revealed that government policies do not moderate the relationship between the work environment (compensation, working conditions, recognition and training) and job satisfaction given b = .005, 95% CI [−.020 -.029], t = .372 and p = .710. With this finding, the study rejects the hypothesis that government policies moderate the relationship between compensation, working conditions, recognition, training and job satisfaction as there is not sufficient evidence to back this claim. In a study by Tosun and Ulusoy (2017) The findings of the study further revealed the influence of each work environment aspect on job satisfaction levels of professional nurses. From the stated findings, it can also be observed that, of the independent variables, the element of recognition has a greater impact on job satisfaction levels of professional nurses b1 = .519 followed by training b1 = .332. Working conditions surprisingly have the least influence on job satisfaction levels of professional nurses. In other words, if individuals, teams, and managers, as well as policymakers, would like to improve the overall job satisfaction of professional nurses in the workplace, intervention mechanisms around the aspects of recognition and training would have significant outcomes. Khamisa et al. (2015) stated that work satisfaction is also an essential part of ensuring high-quality care. Dissatisfied employees provide not only poor quality services, but there is also evidence found that professional nurses who are not satisfied with their work, in turn, distance themselves from patients.

Reliability and Validity
Reliability and validity are the ways of ensuring rigour in the research process M. Mpongoshe Journal of Human Resource and Sustainability Studies and findings (Brink et al., 2013). Reliability means that totals or outcomes generated from any tool used to collect and analyse the data are consistently trustworthy. The selected pilot sample possessed the same characteristics as other main targeted participants for the study. A self-developed questionnaire was used after validation for suitability was undertaken by the statistician and the research supervisor. The questionnaire used was specifically developed for the purpose of this study, and Cronbach's Alpha was utilized as the tool of testing for internal consistency of the instrument. To determine whether the scales used in this study to measure independent, dependent and the moderating variable were reliable the Cronbach Alpha coefficient was calculated for all the scales. Job satisfaction was measured through three dimensions, namely commitment, punctuality and performance. The commitment scale had four items with a reliability score of .744, punctuality had three scale items with a reliability score of .817 and performance had a five scale items with a reliability score of .731. Government policies scale had two items with a reliable score of .747, training had three scale items with a reliable score of .710, recognition had four items with a reliable score of .765 while compensation and working conditions had two scale items each with a reliable score of .743 and .703 respectively. All the scales were found to be above the minimum threshold of .7 as suggested by Nunnally (1978). Reliability test of the scales: to determine whether the scales used in this study to measure independent, dependent and the moderating variables were reliable, the Cronbach Alpha coefficient was calculated for all the scales. The model indicates that job satisfaction was measured using the following dimensions: commitment, punctuality, performance, government policies, training recognition, compensation, and working conditions. The commitment had four scale items with a reliability score of .744, punctuality had three scale items with a reliability score of .817 and performance had a five scale items with a reliability score of .731. Government policies scale had two items with a reliable score of .747, training had three scale items with a reliable score of .710, recognition had four items with a reliable score of .765 while compensation and working conditions had two scale items each with a reliable score of .743 and .703 respectively. All the scales were found to be above the minimum threshold of .7, which means the scales are reliable enough to formulate a hypotheses and reach a conclusion as suggested by Nunnally (1978).

Compensation as a Predictor of Job Satisfaction (Hypotheses 1)
The results of the simple linear regression model are shown in Tables 3-6. Whereas the results for parameter estimates are shown in Tables 7-9.
The analysis reveals that there is a weak but positive correlation between compensation and job satisfaction, r = .301. The analysis further reveals that compensation accounts for 9% variation in job satisfaction given R 2 = .090. In other words, there are other factors not measured in this model that explain at length (91%) the concept of job satisfaction. However, if we want to learn more Journal of Human Resource and Sustainability Studies      about job satisfaction, this result informs us that it is worth paying attention to the concept of compensation. We also observe that this model is significantly better at predicting job satisfaction as shown by the F-ratio where F = 9.688 and significant at p = .000. Hence we can rely on this model to predict job satisfaction as opposed to relying on the mean value of job satisfaction.
This provides estimates of the model parameter (beta values) and it can be observed that b 0 = 2.430 and b 1 = .165. From the stated values, b 1 = .165 represents Journal of Human Resource and Sustainability Studies a change in job satisfaction given a 1-unit increase in compensation. More importantly, this positive change is significant given p = .000. In other words, the study fails to reject the hypothesis stating that compensation predicts job satisfaction as there is enough evidence to substantiate this claim. The annual report by Mbengashe (2015) reported that many rural clinics in the Eastern Cape are short-staffed and battling to cope with the arrival of patients, with some patients having to wait for long periods to see a professional nurse. The study identified compensation as the main reason for the shortage of staff. Therefore, this indicates that in one way or another there is a link between compensation and job satisfaction.

Working Conditions as a Predictor of Job Satisfaction (Hypothesis 2)
A simple linear regression analysis with bootstrapped confidence intervals and significance levels were performed to test the hypothesis that working conditions predict job satisfaction. Analysis reveals that working conditions have a weak to a moderate positive correlation with job satisfaction, r = .465. Working conditions account for approximately 22% of the variation in job satisfaction, R 2 = .217.
In other words, the concept of working conditions is important when it comes to explaining job satisfaction in the workplace. The model further indicates that the model is significantly better at predicting job satisfaction as shown by the F-ratio where F = 54.756 and significant at p = .000. Therefore, we can rely on this model to predict job satisfaction as opposed to the use of job satisfaction's mean value.
Model in reveal estimates of the model parameter where b 0 = 2.463 and b 1 = .232. The model reveals that given a unit change in working conditions, there will be a corresponding positive change in job satisfaction equivalent to .232 units. More importantly, this positive change is significant given p = .000. Thus, with this finding, the study fails to reject the hypothesis stating that working conditions predict job satisfaction as there is enough evidence to back this claim. Ershad et al. (2020) conducted a study and found that professional nurses in the rural healthcare facilities had been found to be experiencing higher levels of stressful challenges in their job satisfaction as compared with other health professionals in the same sector due to the nature of their work. One of the major factors influencing job satisfaction among professional nurses in the rural areas found in this study was about the stressful working environment. The study further indicated that poor work conditions have a direct impact on the job satisfaction of professional nurses working in rural healthcare facilities. In all, it shows that indeed there is a relationship between working conditions and job satisfaction.

Recognition as a Predictor of Job Satisfaction (Hypothesis 3)
Simple linear regression analysis with bootstrapped confidence intervals and their significance levels were performed where recognition was the explanatory varia-M. Mpongoshe Journal of Human Resource and Sustainability Studies ble and job satisfaction was the outcome variable.
In the table recognition has a moderate to a strong positive correlation with job satisfaction, when, r = .605. The model also reveals that recognition explains approximately 37% of the variation in job satisfaction, R 2 = .366. This informs us that if we want to better understand the concept of job satisfaction in the workplace, recognition forms part of the major aspects that individuals, teams and managers must seriously pay attention to.
This provides estimates of the model parameter and b 0 = 1.371 whereas b 1 = .519. As explained earlier, b 1 represents a change in job satisfaction given a unit change in recognition. In this instance, with a unit change in recognition, there is an enormous positive increase equivalent to .519 units in job satisfaction. More importantly, this change is significant given p = .000. With this result, the study fails to reject the hypothesis that recognition predicts job satisfaction as there is enough evidence to support this claim. In validating this finding Khamisa et al. (2015) conducted a study and mention the extent to which recognition really motivates professional nurses. The study further stated that professional nurses play a pivotal role in determining the efficiency, effectiveness and sustainability of health care systems, it is therefore important for the employer (Department of Health) to ensure that it understands exactly what motivates professional nurses and the extent to which the motivation can be kept at the highest level for the professional nurses to remain satisfied with their jobs.

Training as a Predictor of Job Satisfaction (Hypothesis 4)
The model reveals the outcome of simple linear regression analysis with bootstrapped confidence intervals and their significance levels performed to test the hypothesis stating that training predicts job satisfaction. The model shows that training has a weak to moderate positive correlation with job satisfaction, when, r = .410. The result also indicates on model summary that training accounts for approximately 17% of the variation in job satisfaction, R 2 = .168. From Table 7, we are also provided with the F-ratio showing F = 39.93 and significant at p = .000. This finding means that the model is significantly better at predicting job satisfaction compared to relying on the mean value of job satisfaction.

Summary of Results
The findings reveal that all the scales used to measure the independent, dependent, and moderating variables were reliable as measured by the Cronbach Alpha. Inferential statistics indicated support for H1 to H5 while H5 was not supported. The resulting study model reveals that recognition and training are the most influential regarding the job satisfaction of nurses in the workplace. Therefore, any intervention measures meant to enhance job satisfaction for nurses must be formulated based on these two aspects. However, the study found that government policies seem not to play a significant role in influencing other work factors, for example, compensation, working conditions, recognition and train-Journal of Human Resource and Sustainability Studies ing towards enhanced job satisfaction among nurses besides the study's findings that these work environments factors have a major effect on job satisfaction. In other words, this objective was achieved.

Conclusion
Globally, professional nurses are the "engine" of the healthcare system. Therefore, this paper aims to provide the effectiveness of ICS to increase job satisfaction in the rural areas of Eastern Cape, South Africa. The intention is to determine the factors that affect professional nurses' level of satisfaction ever since the implementation of ICS in Eastern Cape Province. Arguably, if the job satisfaction of professional nurses is ignored, then productivity and the outcome of the health care system could be negatively affected. Thus, the health care facilities have the duty to keep the professional nurses satisfied in order to have good standards of care. In 2013, an ICS was developed by the South African government through the Department of Health to improve all healthcare facilities in the country. The ICS was developed to standardize all healthcare facilities nationally and to address gaps with regard to infrastructure between the rural and urban healthcare facilities. In relation to the implementation of ICS, no study has been conducted in the Eastern Cape Province, Chris Hani District to assess the job satisfaction of professional nurses. The questions raised therefore are: What is the level of job satisfaction amongst professional nurses with reference to the ICS? What recommendations can be made by the professional nurses and the researcher regarding the implementation of this system? On Achievement of Study: firstly, the views of professional nurses about ICS and their intention to leave working in the rural clinics due to the implementation of this system, extant literature was reviewed and primary quantitative data was gathered. Extant literature suggested that when an ICS was in place, the intent to leave may decline among professional nurses. However, the findings of the study as a result of quantitative data collected among professional nurses show that professional nurses are of the opinion that the ICS played no role in influencing other factors which are of significant value to them, for example, recognition and training as far as job satisfaction is concerned. With this finding, the intent to leave among professional nurses may remain unchanged unless other intervening measures are put in place. In other words, the study's second objective was also achieved. Objective number two sought to identify factors that prohibit professional nurses from achieving the expected outcomes of ICS. The paper proposed to single out the ICS factors. This identified issues around working conditions which seem to encourage others to look for a job in other provinces and beyond South Africa's borders. Thus, this study was achieved.

Recommendations of the Study
The study recommendations are as follows; environmental factors, namely; compensation, working conditions, recognition and training influence levels of nurses' Journal of Human Resource and Sustainability Studies

Demographic Data
Please circle the appropriate number that best describes your response for each of the following.