key: cord-0750014-pqhkw8qv
authors: Savitsky, Bella; Savitsky, Bella; Radomislensky, Irina; Hendel, Tova
title: Nurses` occupational satisfaction during Covid-19 pandemic
date: 2021-03-11
journal: Appl Nurs Res
DOI: 10.1016/j.apnr.2021.151416
sha: cc98a393152b2d0675fed2e21ee38257f30a33a0
doc_id: 750014
cord_uid: pqhkw8qv

BACKGROUND: Covid-19 has brought healthcare workers in general and nurses in particular into the limelight as never before. It is important to study the intensity of the impact of this pandemic on the profession. OBJECTIVE: This study aims to assess the occupational satisfaction during the pandemic of Covid-19 among the nurses in Israel, to shed light on conditions of work and to identify factors associated with low occupational satisfaction. METHODS: Cross-sectional study of 130 Israeli nurses. Minnesota Satisfaction and Measure of Job Satisfaction questionnaire with 28 items was used to assess occupational satisfaction. RESULTS: In the multivariable model, nurses working in the community had higher occupational satisfaction than those working in hospitals (β = 0.24, p = .032); nurses who took care of patients who tested positive for Covid-19 had significantly lower occupational satisfaction than others (β = −0.48, p = .009). Most of the sample reported lack of personal protective equipment (PPE). Nurses who experienced lack of PPE reported lower occupational satisfaction than those who did not (3.4 vs. 3.8, p = .039). Occupational satisfaction was mainly based on the component, built by the intrinsic characteristics of the occupation related to the personal accomplishment. Most of nurses had to increase their workload as a result of staff shortages, but the elevation of the workload was not associated with lower occupational satisfaction. CONCLUSION: Even under the circumstances of the pandemic, the most important nurses` occupational values are worthwhile accomplishments, importance of professional challenge, diversity and interest in the job, personal growth and development and independence in their practice.

The global workforce includes 27.9 million nurses, accounting for 59 percent of healthcare professionals worldwide (Bean, 2020) . Since the end of February, 2020 Covid-19 has become a most serious challenge for the Israeli population and especially for medical staff who found themselves on the front line. Overall at the time of writing (middle of January, 2021) 477,357 verified cases have been diagnosed in Israel and 3,596 patients have died since the pandemic started (Ministry of Health, 2020) . Although Israel started to vaccinate against coronavirus and more than more than one million people have already been vaccinated (12% of the population ("Coronavirus: Israel leads vaccine race with 12% given jab," 2020)), the epidemiologic situation in the country is threatening and on January 7 Israel entered its third nationwide lockdown.

A sudden onset of a potentially life-threatening illness such as Covid-19 leads to an extraordinary amount of pressure on nursing staff coupled with an increased workload, physical exhaustion, inadequate personal protective equipment, fear of being infected and infecting family members (Pappa et al., 2020) , disturbance of work-life balance, neglect of personal and family needs, and lack of updated information on a new disease (Raudenská et al., 2020) . The detrimental effect is most significant among nurses who were directly in contact with infected or suspected Covid-19 patients on the frontline (Nie, Su, Zhang, Guan, & Li, 2020) . Fear of infection among the health workers is based on awful statistics: at least 7,000 health workers have died around the world after being infected with SARS-Cov-2 (Amnesty, 2020) , while more than thousands of the infected were nurses. (Medical Press, 2020) The first medical professional who died of Covid-19 in Israel was a nurse, Suzy Levi, 65 years old (Winer, 2020) .

When the first mandatory lockdown was introduced in Israel lasting from the beginning of March till the middle of May 2020, schools and kindergartens were closed and lack of childcare facilities caused additional difficulties for parents who needed to work. This additional burden added to the stressful occupational situation of nurses. The meta-analysis of 13 studies conducted worldwide and combined data on 33,062 participants concluded that the prevalence of anxiety among the health workers exceeded 23%; a similar proportion (23%) suffered from depression and 39% suffered from insomnia (Pappa et al., 2020) . As a result of the combination of such multiple stressors destabilizing mental well-being, health care workers" experiences during the Covid-19 pandemic result in occupational burnout and post-traumatic stress disorder (Raudenská et al., 2020) .

In Israel the manpower in nursing suffered from a serious crisis even before an pandemic. The rate of nurses in Israel is lower than the average in OECD countries (5.0 nurses per 1,000 citizens J o u r n a l P r e -p r o o f Journal Pre-proof compared to 9.3 nurses per 1,000 in OECD countries (OECD, 2016) ). Moreover, in Israel there is a considerable gap between the number of nurses in the labor market and the number needed to serve the growing population (Eyal, Y; Grinstein-Cohen, 2014; Nirel, Grinstien-Cohen, Eyal, Samuel, & Ben-Shoham, 2015) . Thus, the shortage of nursing staff which existed even before the pandemic worsened as a result of the entry of nursing staff into quarantine following exposure to patients and sick staff members during the pandemic (Efrati, 2020) .

While discussing the detrimental influence of the pandemic situation on nurses, it is important to take into account that the most outstanding characteristics of the nursing profession, such as nurses" sense of duty, dedication to patient care, personal sacrifice and professional collegiality, is heightened during a pandemic or an "pandemic (Fernandez et al., 2020) . The pandemic influence on occupational satisfaction seems to be negative: in a survey, conducted among the nurses in US before the Covid-19 pandemic and in March 2020, frequency of nurses reported willing to find a new job was double (60%) in March 2020 in comparison with the situation before the pandemic, when 30% of nurses reported interest in finding a new job (Wolters Kluwer, 2020) . In an extensive UK study, conducted in April 2020, 60% of nurses reported being professionally dissatisfied and demoralized (Senek et al., 2020) .

In Israel little is known about occupational satisfaction during the Covid-19 pandemic. The aim of this study was to assess the occupational satisfaction during the pandemic of Covid-19 among the nurses in Israel, to shed light on conditions of work during the pandemic and to identify factors associated with low occupational satisfaction.

This research was conducted as a cross-sectional study with convenience sample of 130 Israeli nurses recruited to participate through several Facebook groups of nurses during June-September 2020. The study received approval from the Ethical Board of the Department of Nursing. Filling out the questionnaire reflected consent to participate.

Age (used as a continuous variable and as a dummy variable: ≤44; 45+); Gender (female; male); (Yakov, T., Davidovich, 2010) ), 17 items from Measure of Job Satisfaction (MJS) (Traynor & Wade, 1993) , three items which were identical in MSQ and MJS and four additional items which were included in the final version following the request of three senior nurses working in a general hospital. Items were rated on a 5point Likert-type scale (1 = to a very small degree to 5 = to a very high degree). Scores range from 1 to 140 with higher scores indicating higher occupational satisfaction.

In Traynor and Wade"s (1993) study, Cronbach's alpha for MSQ questionnaire was 0.93 (Traynor & Wade, 1993) . Cronbach's alpha in this study was 0.92 pointing to high internal consistency.

A mean occupational satisfaction score was calculated for each participant. The Kolmogorov-Smirnov test was used to test the normality of the distribution of the occupational satisfaction score. A t-test, Mann Whitney or ANOVA test was used to assess an association between demographic and occupational variables and the mean occupational satisfaction score. Multivariable linear regression model was used to assess the association of each variable found significantly associated with occupational satisfaction in univariable analysis. Before including independent variables in multivariable analysis, correlation between the variables were checked with Kendall's Tau coefficient.

Occupational satisfaction components were constructed using factor analysis with a varimax rotation and an unrestricted number of factors. Variables with factor loadings ≥0.5 were considered contributing variables to a given factor. A t-test was used to assess an association between nurses` characteristics and factors extracted using factor analysis. 

Most of the study population were married or living with a partner (75%); 58% were parents to children younger than 18 years (Table 1) . Among the study sample, 71% reported being secular, 20% reported being-traditional and 9% religious. Israeli born nurses comprised 54% of the study population; 46% were immigrants (78% of them from the Former Soviet Union [FSU] ).

Mean seniority in the profession was 12.6 years (SD=10.0). Community nurses had significantly longer length of occupational seniority (15.8 years at average vs. 11.3 years among hospital nurses). Most of the population (54%) worked full time with significant differences between community (40%) and hospital nurses (60%). A significantly higher proportion of the community nurses held managerial positions (50% vs. 12% among hospital nurses). The proportion of males was significantly higher among hospital nurses (21.2% vs. 7.5%).

The occupational satisfaction score was normally distributed with a mean of 3.6 (SD=0.6) and a median 3.7 (Interquartile Range [IQR] 3.2-4.1) (Kolmogorov-Smirnov test p=.2). No difference in occupational satisfaction was found by gender, family status, country of birth, age, population group, form of employment, level of religiosity, education or seniority in profession.

Place of work was found as significantly associated with occupational satisfaction, while community nurses had a higher mean satisfaction score than hospital nurses (3.9 vs. 3.5, p=.008).

Nurses who held managerial positions had higher occupational satisfaction (3.9 vs. 3.6, p=.006).

Although 67% of nurses had to increase their workload as a result of the quarantine of part of the nursing staff, those who experienced this increase or shortage of staff did not report lower occupational satisfaction.

Among the study sample, 10% (n=13) reported that they were planning to leave the profession within the next 5 years. Lower occupational satisfaction was reported by nurses who stated that they had a plan to leave the profession in comparison with those who were planning to stay (3.2 vs. 3.7, p=.011).

Among the study sample, 103 nurses (79%) reported lack of personal protective equipment (PPE), while 35% of them reported that they were exposed to the shortage of PPE during the first month (March) of the pandemic; 36% reported the shortage during the two first months (March and April 2020); 9% reported three months of shortage; and 19% reported much longer shortages of PPE.

The proportion of nurses reporting lack of PPE was the same in the hospitals and in the community. Masks (N95 and surgical) were the most frequent PPE which was lacking. Nurses J o u r n a l P r e -p r o o f Journal Pre-proof who worked with shortages of PPE had lower occupational satisfaction than those who were not exposed to work without PPE (3.4 vs. 3.8, p=.039) .

Nurses who reported work with patients who tested positive for Covid-19 (n=47, 36%) had significantly lower mean occupational satisfaction in comparison with nurses who reported working with patients who could potentially be positive for Covid-19 (n=67, 52%) and nurses who did not work with Covid-19 patients (n=15, 12%) (mean satisfaction 3.4, 3.7 and 3.9 respectively, p=.013).

Level of control over the work schedule was significantly associated with occupational satisfaction: nurses reporting a low level of control were less satisfied in comparison with those reporting medium and high level of satisfaction (3.2, 3.5, 3.8, p<.0001) .

As place of work (hospital vs. community) was strongly correlated with managerial positions and with the level of control over work schedule, managerial positions and with the level of control over work schedule were excluded from the multivariable model ( Table 2) .

Place of work, work in the condition of lacking PPE, and type of exposure to Covid-19 patients were included in the multivariable linear regression model.

After mutual adjustment, nurses working in the community had higher occupational satisfaction than those working in a hospital (β=0.24, p=.032). Nurses who took care of patients who tested positive for Covid-19 had significantly lower occupational satisfaction than others (β=-0.48, p=.009).

Four factors together explained 60% of variance. The components of each factor are depicted in Table 3 .

The first factor, referred to as Personal accomplishment, explained a very significant scope (34.4%) of variance. This factor was related to feelings of worthwhile accomplishment, challenge, the extent of diversity and interest in the occupational duties, personal growth and development, the use of skills, and the amount of independence and autonomy at work.

The only nurses" characteristic found significantly associated with this factor was a managerial position (Table 4) : satisfaction related to personal accomplishment was significantly higher among those nurses who had managerial positions.

The second factor, referred to as Workload explained 9.2% of the variance. This factor increased with an increase in satisfaction with the workload.

Significantly higher satisfaction with workload was reported by nurses with an MA degree and those who underwent advanced clinical nursing courses (Table 4 ).

The third factor, referred to as Professional support explained 8.4% of the variance. As satisfaction with relationship with the head nurse, nursing staff and multidisciplinary staff increased, this factor increased.

Younger nurses (≤44 years) were significantly more satisfied with professional support than those aged 45+. Nurses working in the community reported significantly higher satisfaction with this component in comparison to hospital nurses ( Table 4 ).

The fourth factor, referred to as Psychological reward, explained 7.4% of the variance. This factor was related to satisfaction from interaction with patients.

Nurses who were parents of children younger than 18 years reported significantly higher satisfaction with this component than those who did not have children (Table 4 ).

The current study aimed to study occupational satisfaction during the pandemic among Israeli nurses. Moderate/high mean occupational satisfaction was found in this study under the circumstances of the pandemic. The comparison with other studies is not always possible following different methodology in occupational satisfaction assessment; however, several studies using the same methodology were found. In an Israeli study conducted in 2014, the mean occupational satisfaction was 3.87 (DeKeyser Ganz & Toren, 2014). In a study from Finland (2012), very similar occupational satisfaction was found as in our study (mean=3.6) in the sample of Finnish nurses (Kvist et al., 2012) ; mean occupational satisfaction of 3.7 was found in a study from Lisbon, Portugal (Dinis & Fronteira, 2015) and mean occupational satisfaction of 3.3 was found among Chinese nurses in 2006 (Haijuan, W., Yongpin, N., Bibo, 2006) . All these studies were conducted under regular (non-pandemic) conditions. Studying components of occupational satisfaction revealed that the most extraordinary important component of occupational satisfaction in this study is the component related to personal accomplishment. This means that even under the circumstances of the pandemic, the most important nurses` occupational values are worthwhile accomplishments, importance of professional challenge, diversity and interest in the job, personal growth and development and independence in their practice. The same finding of the importance of the perception of the job`s merit along with a feeling of having delivered skilled and quality care to patients was reported in the study conducted in England in 1993, using similar methodology of factor analysis for revealing occupational satisfaction components (Traynor & Wade, 1993) . Other components of occupational satisfaction such as workload, work conditions, reward (extrinsic factors according to Frederick Herzberg"s two-factor theory (Herzberg, F. Bernard, S., Barbara, 1959) ) were significantly less important in comparison with much powerful components related to personal accomplishment (intrinsic characteristics, according to "two-factor" theory).

In our study sample, nurses working in the community reported higher occupational satisfaction than those working in a hospital. Previous studies also found that differences in occupational satisfaction exist between hospital and community nurses. Hospital nurses are more satisfied with payment (Cameron, Armstrong-Stassen, Bergeron, & Out, 2004; Campbell, Fowles, & Weber, 2004 ) than community nurses, but community nurses are more satisfied with the workload and working conditions (Halcomb, Smyth, & McInnes, 2018) . Investigation of this finding on differences between community and hospital nurses in our study revealed that the difference is explained by higher frequency of managerial positions among the community nurses in our sample and by higher control over the work schedule among the community nurses. Findings that nurses having high management positions have greater work satisfaction than assistance staff is consistent with other studies (Morton, 2018; Vicario-Merino, ., Mu oz-gustin, N., uiz-L pez, 2020) and with Frederick Herzberg"s two-factor theory. Following this theory, intrinsic factors such as work requiring high skill, recognition for better performance, responsibility, autonomy, meaningfulness, involvement in decision making are the motivators providing the employee positive satisfaction, arising from the intrinsic conditions of the job itself, such as recognition, achievement, and personal growth (Fauziah, Yusoff, Kian, Talha, & Idris, 2013) . We believe that managerial positions associated with higher independence/autonomy and responsibility provide higher satisfaction for those who hold them.

In our study nurses who took care of Covid-19 patients had lower occupational satisfaction than other nurses. We believe that this finding is partially explained by difficult work conditions during first months of the pandemic characterized by the lack of PPE. Occupational health principles establish that the employer should minimize health risks for employees. The scope and the transmission of the new disease were not anticipated by health organizations worldwide and this lack of knowledge and supply planning resulted in a lack of PPE for front-line health-care workers, as reported in 63 countries (McCauley & Hayes, 2020) . This shortage immediately resulted in increased risk of Covid-19: front-line health-care workers were at increased risk for positive Covid-19 tests compared with the general community (adjusted hazard ratio [HR] 3.4; 95% CI 3·37-3·43) (McCauley & Hayes, 2020) . A conflict existed between the duty of care and high perceived risk of infection, along with low agreement with infection control measures, thus creating more ethical problems and dilemmas for nurses (Sperling, 2020b) . In a recent Israeli study, it was found that nurses experienced significant personal risk and emotional burdens, but still conveyed strong dedication to providing care, although 41% reported that they were afraid of caring for Covid-19 patients (Sperling, 2020a) .

High occupational satisfaction is important for nurses" psychological wellbeing and physical health (Allan, Dexter, Kinsey, & Parker, 2018; Faragher, Cass, & Cooper, 2005; Satuf et al., 2018) and also prevents turnover and readiness to leave the profession (Baernholdt & Mark, 2009; Heijden, 2007; Mazurenko, Gupte, & Shan, 2015) . In this study nurses reporting readiness to leave the profession had lower mean occupational satisfaction scores. At a time of crises, it is time to take care of those who takes risks on the frontline. Covid-19 is a severe disease, exposing healthcare workers and their families to infection. Healthcare organizations should prevent any shortage of PPE which could compromise the basic values of the nursing professiontaking care of those who need care.

Although difficult work conditions could compromise the basics values of nursing, in reality this did not happen. This study shows that nurses are highly motivated and cling to the values of the profession even in difficult times and even then they are exposed to danger.

The demographic characteristics of the study population in comparison with the characteristics of the nursing workforce are presented in Table 5 . The proportion of males, nurses who underwent advanced clinical nursing courses, nurses working in the Tel-Aviv megapolis region and in Jerusalem region were similar in the study sample and in the workforce. On the other hand, the study sample is younger, more educated, has a lower percent of Arabs and higher proportion of nurses working in the community in comparison with the general Israeli nursing work force. As age, education and population group were not associated with occupational satisfaction, we believe that this under representation would not influence the results. There was overrepresentation of nursing who held managerial position among the community nurses. Higher occupational satisfaction found among community nursing and their higher proportion in the study sample could result in higher occupational satisfaction in this study than is reflected in reality. An additional limitation is that following cross sectional design of the study, drawing conclusions about the causality of the associations found in the study is problematic.

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We wish to thank Susan Holzman for her highly professional editing advices and her valuable and kind support on this project.J o u r n a l P r e -p r o o f