Job Satisfaction Factors and Nurses’ Intention to Quit in Type C Hospitals

Aim: This study investigated the relationship among nurses’ job satisfaction factors and intention to quit in hospitals type C. Background: High nursing turnover is still becoming a problem facing many countries including Indonesia. The previous study in Indonesia showed that nurses more inclined to quit them and moving work to other hospitals or else. Methods: A cross sectional, correlational design was used. Data were collected by self-reported questionnaire and proportional random sampling of 183 nurses in three hospitals was conducted. The Job Satisfaction Survey (JSS) and a single question of intention to quit were used. Spearman rank correlation and multiple linear regression analyses were used to examine the data. Results: Half of nurses (51.9%) reporting that they “likely” and “very likely” intended to quit their workplace within the next year. The average of job satisfaction was found at 48.6% of nurses satisfied with their job. The job satisfaction factors were found to be significantly negatively correlated with nurses’ intention to quit. The communication is the most significant negatively factor associated toward nurse’s intention to quit. Conclusion: The results can be used as a basis for evaluation, early detection, and future planning for nursing managers and management. Results also highlight the need to emphasize positive factors to upgrade good communication between nurse’s and administrative management.


Introduction
Nursing turnover continues to be a global challenge facing the health-care sectors. High nurse turnover have a negative impact on patient safety, nurse's perception of psychological well-being and organizational effectiveness [1].
Consequently, high rates of nursing turnover are likely to lead to shortage of nursing staff and loss human capital of experienced and skilful nurses [2], who jeopardize the quality of patients care services receive [3]. Furthermore, high turnover rates might lead to higher rates of burnout and workplace injuries among nurses and higher rates of patient morbidity and mortality [2,[4][5][6].
According to a present report from OECD (Organization for Economic Co-operation and Development) the number of nurses per capita was highest in Switzerland, Norway, Denmark, Iceland and Finland, with more than 14 nurses per 1000 population and the lowest in Turkey (with less than 2 nurses per 1,000 population). Particularly in Asia, Indonesia was the lowest country that only 1.2 nurses per 1,000 population while India 1.3, China 2.0, Korea 5.2 and the highest Japan with 10.5 [7].
In recent studies, researchers acknowledged that the quality of patient care is correlated with higher staffing levels in nursing. Also, the quality of patient's healthcare service is associated to nurses' job satisfaction [8][9][10]. If nurses' job satisfaction continues to deteriorate, the present nursing shortage will worsen and nurses turnover creates problems that its impact to high and unpredictable replacement costs (advertising for recruitment, vacant positions, decreased productivity, advertising hiring procedures, termination costs, orientation and training of new employees) [11,12].
Job satisfaction is defined as a favourable or unfavourable aspect with employees view their work [13]. It is also defined as the degree to which an employee likes his/her work [14]. In the case of nurses' job satisfaction, earlier research showed that job satisfaction is statistically negatively connected with nurses' intention to quit the workplace as well as their nursing profession [15,16]. Thus, the experience of low job satisfaction is positively associated with turnover and consideration of other employment opportunities [17,18]. Therefore, knowledge about factors that contribute to nurses' job satisfaction is the great important to nurse managers and management to take necessary actions and considerable in human health care resource planning processes [19].
Researchers identified individual characteristics, work requirements and policies, professional status, pay, working environment, co-worker support, and administrative style as an important factors that influencing nurse' job satisfaction [20]. It is also hypothesized as the following six predictors of nurses intent to quit/stay in their professions, i.e., job satisfaction, personal characteristics of nurses, work group cohesion and collaboration, manager ability and support, burnout, and organizational commitment [21]. Others have also found that certain socio-demographic characteristics were related to nurses' intent to remain or quit their job. The previous study acknowledged that age, educational level, years of employment, and job position associated with nurses' intention to quit [22]. Past studies showed that job satisfaction was the primary predictor of intention to quit and organizational commitment [23,24].
Based on the survey in Indonesia, it was found that turnover rates in private hospitals are higher than public and educational hospitals. Also, in Indonesia there were many studies that reported nurses' high turnover in hospitals. Most studies about nurses' turnover conducted in private hospitals. Despite numerous studies in other countries, it's still sparse studies concerning nurses' job satisfaction factors and intention to quit in Indonesia, making it difficult to set exact nurse retention interventions and policies. Nurses' job satisfaction and dissatisfaction can have an effect on nursing practice in any health care setting. Furthermore, because of low density nurses in Indonesia, it is imperative to understand the factors that associated nurses' job satisfaction and intention to quit in different health care sectors. Therefore, this research was conducted in order to fill the knowledge gap regarding the factors related with Indonesian nurses' intention to quit the current employment in the type C hospitals. The healthcare systems in Indonesia consists of all medical care services -primary, secondary, and tertiary and classified into type A, B, C, D both government and private. The services are provided through different public (i.e., governmental), private, public, educational and military institution.

Study design and population
A cross sectional survey design was used to describe nurses' job satisfaction factors in relation to nurses' intention to quit. The sample consisted of nurses working in inpatient ward, outpatient ward, and emergency ward. Proportional random sampling was used to recruit eligible nurses (total 352 nurses) at three hospitals. A structure selfadministered questionnaire was distributed and a total of 183 nurses filled up the questionnaires. Three hospitals type C in Padang West Sumatra Province, Indonesia were selected to conduct the survey. This hospital is type of district hospital owned by district or private. The setting was three different hospitals: a public hospital, a military hospital, and a private hospital located in the same district.

Ethical considerations
Ethical approval for this study was obtained from the university's research board. All study works were accomplished and compliant with the national ethics regulations of Indonesia. Subjects participated in this research were voluntarily and anonymously. All subjects approached and assured by detail information and formal permission. All collected data is used for research purposes only. Data would be kept confidential and all participants provided their informed consent to participate in this research.

Measurements
A structured questionnaire was developed from the literature of earlier studies on nurse's job satisfaction. The questionnaire was divided into three parts. First part comprised with individual characteristics such as gender, age, years of working, marital status, current workplace, level of education, employment status and work unit. Second part comprised 36 items that are related to job satisfaction survey (JSS) [25]. The JSS consists of 36 structured (or 4 items for each of the scale) and randomly ordered items that measure nine dimensions of job satisfaction (i.e., pay, promotion, supervision, fringe benefits, contingent rewards, operating procedures, co-workers, nature of work, and communication). Nurses were asked to rate each item on a six-point scale ranging from "strongly disagree (1) to strongly agree (6)". Some items were written in a negative direction, so the scores on the negatively items must be reversed before analysis. For consistency, the nine dimensions related moderately to well between each other. Researchers retested the instrument of JSS whether the instrument suitable or not for the subjects. The last part comprised with one-item scale used to assess nurse's intention to quit the current work setting in the coming year. A rating scale of four-points was asked to rate that ranged from "very unlikely (4) to very likely (1)".

Data collection
After receiving approval from the university's research board, the researchers identified and contacted nursing management in the hospital and meet the nurses who met the research criteria, explained the purpose of study and requested their consent to complete the questionnaires. The questionnaire packages contained a cover letter, a permission form, and the purpose of the study with brief description and guidelines on how to fill up the questionnaire.

Data analysis
Data were entered and processed by using the statistical package for the social sciences (SPSS) version 22. Descriptive information for all included variable were presented. The researchers also used inferential statistical such as correlation analysis, regression, ANOVA, and posthoc tests to analyze the data. To examine the differences between group variables, t test was used. Spearman's rank correlation coefficient (rs) was calculated for correlation analysis among the variables. Finally, a multiple linear regression was used to analyze the predictor variables of the intention to quit. A level of significance 0.05 (p<0.05) was used as a cut-off for statistical significance.

Results
A total of 183 subjects (34 males and 149 females) completed and returned the questionnaires. In this study none of subjects refused or not returned the questionnaires. Among the subjects, respectively 52, 53 and 78 nurses were working in private, public, and military hospitals. The age range among the nurses who participated was 21-50 years with an average age of 30.21 (SD=5. 19). The years of working of these nurses ranged from 0-20 years with more than half were working ranged 0-5 years (66.1%). The descriptive of individual characteristics are shown in Table 1.   Table 1: Individual characteristics of the research subjects.
The job satisfaction factors items (JSS) were showed in ascending order in their subscales (facets). As in Table 2, for each item the mean and standard deviations were presented to rate the magnitude of each job satisfaction factor. Based on Spector 25, for the 4-item subscales as well as the 36-item total score, that scores with a mean item response of 4 or more represents satisfaction and mean responses of 3 or less represents dissatisfaction. Mean scores between 3 and 4 are ambivalence, thereby the percentage calculated by dividing the average on the maximum possible total (i.e., 6) that signify the satisfaction level for that item. In Table 2 also showed the percentages of subjects who gave responses of "agree moderately" or "agree very much" in order to definite the factors that related with the highest level of satisfaction.
Based on Table 2, it is showed that the mean satisfaction for all nurse respondents was 3.98 out of 6 (SD=0.54) and it means that the average satisfaction level among the nurses was 48.7% (3.98/6). Nurses response higher scores to the specific item, i.e., "I enjoy my coworkers", I like the people I work with", and "There is too much bickering and fighting at work". On the contrary, nurses assigned lower scores to item, i.e., "There is really too little chance for promotion on my job", "I have too much paperwork" and "People get ahead as fast here as they do in other places".
We also tested nurses' job satisfaction for female and male. Average job satisfaction for women was 3.97 (SD=0.54) and 4.05 (SD=0.52). Male's rating job satisfaction were slightly higher than female nurses but not significantly (t=0.87, p=0. 38  Furthermore, according to the results from Table 3, the highest satisfactory subscales were "co-workers", "communication" and "nature of work" while "operating conditions", "promotion" and "fringe benefits" were the least satisfactory facets among nurses.  The results for dependent variable of nurse's intention to quit the current employment with one-item question adapted from previous study "Are you going to change your employment setting in the next year"? The results are shown in Table 4. The mean score was 2.53 out of 4 (SD=0.84) which means that 51.9% reporting that they were "Likely" or "Very Likely" to quit their present job settings in the next year. Besides, it is showed that job satisfaction factors was moderately and negatively associated with nurse's intention to quit their work within one year (r=-0.453, p<0.01). For gender, average nurse's intention to quit for male participants was 2.50 (SD=0.75) and 2.54 (SD=0.87) for female participants. The female's rating of intention to quit were slightly but not significantly higher than male nurses (t=-0.24, p=0.82). Thus, the intention to quit level at public hospital was moderately higher 3.08 (SD=0.78) than nurses' intention to quit in private 2.42 (SD=0.89) and military settings 2.23 (SD=0.66), respectively (F=19.78, p=0.0005).  Next, Table 5 shows the correlation between job satisfaction factors and intention to quit. The Spearman's rank correlation coefficient (rs) was used to analyze the association between intention to quit and nine facets job satisfaction or individual characteristics. In addition, job satisfaction was significantly associated with age (r=-0.26, p<0.01), marital status (r=-0. 16 Table 5: The correlation between job satisfaction factors and intention to quit (using Spearman rank correlation).

Level n %
Then, in order to identify the relationship between job satisfaction factors and intention to quit, the researcher conducted a multiple regression analysis. As presented in Table 6, the regression equation of all predictions is strongly significant where R=0.56, R2=0.31, R2adj=0.28, F=8.66, p=0.000. These results revealed that multiple coefficients between the predictors and dependent variable were 56% with all predictors constituting 31% of the variation in intention to quit. Based on significant F-test, it is showed that the relationship between the dependent and independent variables is linear with the dependent variable significantly predicted by the model. Each predictor's contribution is displayed in Table 6 and describes the standard regression weight of each predictor in the regression equation.  Table 6: Results of multiple linear regression analysis.
As presented in Table 6, among the nine facets of job satisfaction, the most significant standardized beta coefficient was displayed by communication (=-0.338, t=-4.92, p=0.000) indicating that facet is the most significant intention to quit predictor. This predictor followed closely by pay (=-0.159, t=-2.173, p=0.031) and supervision (=-0.185, t=-2.11, p=0.036). Overall, the nine facets of job satisfaction impacted the dependent variable in the manner postulated in the hypotheses. Thereby, it can be stated that intention to quit occurs when nurses perceived a low level of pay, lack of promotion opportunities, low support of supervisor, low level of fringe benefits, lack of recognition, lack of work environment, lack of peer support, low of nature of work as a nurse, and finally lack of communication in organization.
In summary, this study revealed a statistically-significant negative relationship between the variables job satisfaction and intention to quit among the nurses. Moreover, intention to quit was statistically significantly explained by job satisfaction (p=0.000), where satisfaction with communication was the only and most facet that significantly explaining intention to quit (p<0.001).

Discussion
This research filled a significant gap in the existing knowledge of nurses' job satisfaction factors and their intention to quit in Indonesia. This research found that the average level nurses' job satisfaction was 3.98 out of 6. Therefore, the job satisfaction of Indonesian nurses was at moderate level. This result is consistent with several studies on nurses' job satisfaction [26][27][28]. The present research also concluded that job satisfaction among nurses is significantly and negatively associated with intention to quit. The result is similar to the study of Turkish nurses [26], Malaysian nurses [27], American nurses [15], study of Greek nurses [29], nurses in South Africa [30], and nurses working in Taiwan settings [31]. Additionally in this study, half of nurses (51.9%) reported strong intention to leave their work settings in the next year.
Among the nine subscales of job satisfaction survey, nurses reported high level satisfaction with co-workers, communication, and nature of work. However, they expressed low satisfaction in terms of operating conditions, promotion and fringe benefits; that were highly associated with their intention to leave their jobs. This result is also congruent who identified pay and fringe benefits as a causes of dissatisfaction and intention to quit among nurses consistent with this study [29,32]. In this study, the pay level of satisfaction was slightly, but not significantly higher than fringe benefits. Based on research, nurses who satisfied with the compensation and benefits received eight times prefer to stay in the organization than nurses who are not satisfied [22,33,34]. However, a significant need was identified to increase the contingent rewards and fringe benefits packages for nurses. This incentive is likely to improve nurses' job satisfaction as well as retention rates.
This recent study is also similar with past study who found low promotion as a trigger of nurse's intention turnover [31]. In addition, there were significant differences in intention groups (to leave or to stay) found that promotion was one major issue [35]. This also proposed that promotion opportunities had an influence on turnover decision through diverse approaches like present career level, upward mobility, and future career advancement [36]. In addition, the results of present study supports the finding of who identified that nurses felt more satisfaction and more likely to stay in hospitals when they 'perceived their co-workers as cohesive and supportive [21], high satisfaction with co-workers but dissatisfaction with their extrinsic rewards and professional opportunities [37,38] and also working condition and lacks of support management can be a predictor of nurses' intention to quit [39].
Research in the Netherlands explained that the lack of career development opportunities and poor working conditions increasing the nurse's intention to quit [40]. In addition, research indicated that major contributor nurses' intention to quit were excessive workload, work repetitive and poor working environment [41]. This result is consistent with the nurses working in Israel settings [42], nurses working in New Jersey [15], nurses working in Pennsylvania [43]. On the other hand, communication factor in this study has similarity with the human relations values and social climate of the workplace also has an effect on nurses' level of job satisfaction [44]. In addition, job satisfaction is strongly predicted by social and professional relationships within the workplace [45]. The relationship between communication and intention to quit is not often examined in the literatures. However, this research shows that it is an important reason.
The recent studies on nurses' job satisfaction indicate that pay, promotion, contingent rewards and fringe benefits play a significant role in job satisfaction [20,46] that are consistent with the present research. Commonly, most of nurses were not satisfied with their terms of promotion opportunities and fringe benefits. In Jordania, pension plan and fringe benefits plans including child care, elder care, food services, and travel also bring about job satisfaction and enhances employee retention while mitigating turnover intention [47,48]. In Korea, it is also reported that Korean nurses would become very unhappy if they perceived that nurses in the same position elsewhere were being better rewarded [14].
It was revealed that nurses' job satisfaction and their intention to quit the existing workplace are significantly influenced by individual characteristics of nurses. Job satisfaction level as a total score was related to age, marital status, work settings, and work units. In this study, nurses reported job satisfaction was significantly negatively moderate related to age while in Turkey nurse's job satisfaction and age was significantly positively associated. The present study found an insignificant correlation between nurses' intention to quit and nurses' age, which is not consistent with research by [30,49]. Furthermore, job satisfaction was also significantly positively associated with working settings. In this study, nurses in public hospital reporting low satisfaction than private and military hospitals.
The previous results also revealed that nurses' educational degrees are not strongly related to job satisfaction and intention to quit [37]. This study reveals an opposite result. Nurses with bachelor degrees were the most satisfied nurses with their job than nurses with diploma degrees. In addition, nurses with bachelor degrees have a higher level of intention to quit the present employment than others. Some prior research investigated that highly educated nurses are more likely to quit the existing workplace. They are aware of their career advancement, and seek alternative employment opportunities because of inadequate job opportunities and benefits in their current employment [30,50]. Thus, the present study rejects the finding of who revealed that higher education level (for example, master degree in nursing) is correlated with enhanced professional commitment and possibility of inclination to quit the existing employment as well as the nursing profession [51]. In similarity, also did not find any strong relation between nurse's job satisfaction and their educational qualification [52]. The Indonesian nurse's job satisfaction factors were investigated carefully to enrich their satisfaction in organizations. Consistently, the likelihood of inclination to quit among nurses will be reduced. As expected, the recent findings are congruent with previous studies conducted in other countries. The significant difference among the countries seems to be the ranking of certain job satisfaction variables over others and cultural and organization dissimilarities which is inherent in the healthcare delivery systems of different countries.

Conclusion
Job satisfaction is an important issue for ensuring proper nursing care in healthcare sector. Furthermore, job satisfaction factors will ensure better quality healthcare services and improvement their professional commitment. The present research investigated the important factors of job satisfaction among the nurses who were employed in private, educational, and military hospitals in Indonesia. Nurses reported that they had a moderate level of job satisfaction that did differ by work setting. The findings of this study emphasize the significance of promotion opportunities, fringe benefits and working operations as an important factor in improving job satisfaction and retention among nurses. Nurses were generally highly satisfied with their co-workers, communication and nature of work, suggesting that nurse supervisors used open communication in the organization. It is still seldom explained in the literature. Job satisfaction is also affected by individual characteristics. The findings of this study are comparable with other studies in different countries. According to previous researches, job satisfaction is negatively interrelated with intention to quit among nurses which is congruent with the contemporary studies. The higher nurse's levels on job satisfaction factors, the lower their intention to quit and increase the quality of healthcare services.

Implications
The results of this study have several implications. Implementation of appropriate motivation programs (e.g. improving communication) would enrich job satisfaction and decrease the inclination of Indonesian nurses to quit, which ultimately may increase healthcare service quality. Nursing supervisors can practice co-management models for nurses. Nurses can take part in professional activities such as contribution in decision making and sense of confidence in nursing practices to increase their sense of belonging in the organization [9,53]. Nurses need to be able to have open communication with other members of the healthcare team (group cohesion with peers, physicians, organizational characteristics, relationships a staff nurse has with the organization, supervisor and management, and the organization's commitment to professional values [54]. As consequences, their job satisfaction and nurses retention rates can be increased.
The findings of this study can be used by nursing administrators and managers to establish an on-going system of evaluation in organizations. Retaining the qualified nurses is a challenge in all organizations. To retain nurses, supervisors should take initiatives to identify and assess the job satisfaction factors of nurses. Managers ought to routinely screen for indications of dissatisfaction by conducting job satisfaction surveys. To increase job satisfaction and retention, managers ought to ensure professional opportunities such as working with skilled peers, providing unceasingly support to nurses, endorsing collaborative nurse-physician relationships, securing adequate staffing, advocating and helping control over nursing practice, increasing clinical autonomy, and promoting nurse education [55].
Highlighting the factors of nurses' job satisfaction, the present study suggests a suitable and strategic plan of professional development for Indonesian nurses in order to minimize of turnover intention from their current employment. Emphasis should be placed on positive factors to enhance employee's satisfaction. Negative factor should be addressed by hospital administrators and policy makers to assist in increasing the satisfaction level and diminishing nursing staff turnover. It is important to mitigate factors that have the potential to decrease and increase the level of job satisfaction and ultimately to improve staff retention.

Limitations of the Study and Future Study
In this study, the sample size was relatively small and limited to nurses who were employed among the private, public, and military hospitals in Padang, Indonesia. In addition, the literature on job satisfaction factors and turnover intention in Indonesia is limited. The findings of the current research reflect the situation during the research period, so more research are needed to confirm this problem in Indonesia. Future research should include a larger sample of hospitals to allow for greater generalization. Because of the multidimensionality of job satisfaction as a concept, this could be better addressed using a mix methods or qualitative research approach to convey their needs and experiences. This approach may permit the researchers to gain a comprehensive understanding of both personal and cultural nurses' point of perspectives.