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IJHCQA
22,1 Factors affecting performance of
hospital nurses in Riyadh Region,
Saudi Arabia
40
Hanan Al-Ahmadi
Institute of Public Administration, Riyadh, Saudi Arabia
Received 13 February 2008
Revised 17 February 2008
Accepted 17 February 2008
Abstract
Purpose – The purpose of this paper is to identify factors influencing performance of hospital nurses
in Riyadh Region, Saudi Arabia. Specific objectives were to estimate self-reported performance, and
determine whether differences in employee demographics, job satisfaction, and organizational
commitment, influenced performance.
Design/methodology/approach – In total, 15 hospitals were randomly selected. The questionnaire
was sent to all nurses (1,834) in these facilities and 923 nurses responded. Statistical analysis included
correlation, t-test, and regression analysis.
Findings – The study finds that job performance is positively correlated with organizational
commitment, job satisfaction and personal and professional variables. Both job satisfaction and
organizational commitment are strong predictors of nurses’ performance. Job performance is
positively related to some personal factors, including years of experience, nationality, gender, and
marital status. Level of education is negatively related to performance.
Research limitations/implications – The findings of this study have a limited generalisability
due to the fact that all measures used are based on self-reports. Future research may be directed to
other objective measures of performance.
Practical implications – Emphasis should be placed on effective supervision, empowerment, and a
better reward system. Cultural diversity is a reality for most health organizations in Saudi Arabia;
therefore, they need to adopt effective human resources strategies that aim to improve commitment
and retention of qualified workers, and build a high performance organizational culture based on
empowerment, open communication, and appreciation of impact of national culture on work attitudes.
Originality/value – This study fulfills a research gap in the area of nursing performance, and its
relationship with work attitudes in Saudi Arabia. The paper also highlights the impact of national
culture on job performance and work attitude among nurses in Saudi Arabia, and other countries
facing the issue of multi-national work force.
Keywords Nurses, Performance management, Saudi Arabia, Job satisfaction
Paper type Research paper

Introduction
For decades, researchers have been studying factors influencing performance in health
organizations with emphasis on worker factors and work environment factors. Nurses
constitute the largest human resource element in healthcare organizations, and
therefore have a great impact on quality of care and patient outcomes. Job performance
International Journal of Health Care has often been examined in light of work attitudes such as job satisfaction and
Quality Assurance organizational commitment. Nurses’ attitudes towards their jobs; and commitment to
Vol. 22 No. 1, 2009
pp. 40-54 their employing organizations have been compelling to researchers due to their impact
q Emerald Group Publishing Limited
0952-6862
on behavior at work and quality of patient care. In Saudi Arabia, interest has been
DOI 10.1108/09526860910927943 growing on issues related to performance in health organizations, as a reflection of the
increasing interest in quality improvement. This study examines job performance of Factors affecting
hospital nurses in Riyadh, Saudi Arabia, focusing on the impact of job satisfaction, performance
organizational commitment and personal characteristics.
of nurses
Literature review
Nursing performance 41
Nursing care is an integral component of patient care and is an important determinant
of quality of healthcare services. Several scholars have investigated performance of
nurses (Parker and Kulik, 1995; Borda and Norman, 1997; Judge et al., 2001; Siu, 2002;
Abualrub, 2004; Tzeng, 2004; Fort and Voltero, 2004; Yang and Huang, 2005; Mrayyan,
2006; Hall, 2007). Some studies focused on the contribution of nursing care to patient
outcomes such as quality of care and patient satisfaction. In Canada, a nursing role
effectiveness model linking nursing role performance to patient outcomes was
examined. The study found that nurse structural variables such as level of education
and hospital experience influence several aspects of performance: coordination of care
and quality of communication with patients. Unit structural variables such as level of
autonomy, amount of time available for care, and role tension affected nursing
performance. In Taiwan, staff nurses’ morale was found to be a predictor of patient
satisfaction (Yang and Huang, 2005). In Jordan, Mrayyan (2006) examined patient
satisfaction, nurse job satisfaction, and quality of care, and concluded that nurses had
borderline level of job satisfaction, while patients reported moderate levels of
satisfaction with care, and head nurses reported satisfaction with quality of nursing
care.
Job performance is often examined in relation to stress and burnout associated with
nursing practice. Parker and Kulik(1995) found that burnout is associated with poor
self-rating as well as supervisor rating of performance, more sick leave, and more
absence for mental health reasons. In Jordan, Abualrub (2004) found that perceived
social support from co-workers enhanced job performance and decreased job stress. In
Hong Kong, Siu (2002) found that organizational climate (both physical conditions and
social aspects) to influence job satisfaction and absenteeism among hospital nurses.
Supportive management practices were crucial to achieve high nursing performance
(Drach-Zahavy, 2004). A recent study has also found a positive correlation between
perceived supervisor support and nurse occupation-related outcomes (Hall, 2007).
The relationship between job performance with personal characteristics of
employees such as competence, education, and years of experience were investigated
by some researchers. In a study of maternal healthcare providers in Armenia, Fort and
Voltero (2004) examined a conventional performance improvement model that outlined
five key factors believed to influence performance outcomes: job expectations,
performance feedback, environment and tools, motivation and incentives, and
knowledge and skills. The study included 285 nurses and midwives, and utilized
interview and observation methods to identify factors affecting performance. Results
show that performance is influenced by several factors: training in the use of clinical
tools, receiving recognition from employer or patient, and receiving feedback on
performance (Fort and Voltero, 2004). In Taiwan, Tzeng (2004) found that nursing
performance is related to nursing competencies, and suggested that education and
training are essential for improving performance of nurses.
IJHCQA The effect of national culture on job attitudes and performance has been the subject
22,1 of investigation by several researchers (Al-Meer, 1995; Al-Otaibi, 1993; Yousef, 2000).
Yousef (2000) stressed that multiculturalism is a dominant feature of the workforce in
some countries, therefore, the effect of national culture on job attitudes should be
investigated. In his study, Yousef (2000) found that national culture moderates the
relationship of leadership behavior with job satisfaction and performance. Other
42 researchers have also identified differences among different nationalities with respect
to organizational commitment and job performance (Al-Meer, 1995; Al-Otaibi, 1993).

Performance and job satisfaction

Several organizational theories are based on the notion that organizations that are able
to create a positive environment and make their employees happy will have more
productive employees. Over the years, scholars examined this idea that a happy
worker is a productive worker; however, evidence is not yet conclusive on this regard.
Empirical studies have produced several conflicting viewpoints on the relationship
between job satisfaction and performance.
The idea that job satisfaction leads to better performance is supported by Vrooms’
(1964) work which is based on the notion that performance is a natural product of
satisfying the needs of employees. Empirical evidence from research on nurses found
job satisfaction to be linked to several aspects of job performance, including: patient
satisfaction (Krugman and Preheim, 1999), overall job performance (Judge et al., 2001),
turnover; productivity (Butler and Parsons, 1989; Robinson et al., 1991).
In Jordan, Al-Badayneh and Sonnad (1993) studied job satisfaction of a sample of
(303) registered nurses in five government and five private hospitals. The study
identified a strong relationship between nurses overall effectiveness and overall
satisfaction, as well as a moderate relationship between nurses’ job satisfaction and
performance. Knoop (1995) found that job satisfaction leads to a number of
consequences among nurses, more productivity, high quality of care, and intent to
remain in the organization.
Job dissatisfaction on the other hand was found to lead to absenteeism, grievances
(Shader et al., 2001), decreased productivity and poor performance (Butler and Parsons,
1989; Robinson et al., 1991). In a review of literature, Borda and Norman (1997)
concluded that job satisfaction affects turnover intentions as well as absenteeism
among nurses. In a meta-analysis of the literature, Judge et al. (2001) found a positive
correlation between job satisfaction and job performance of nurses. In North Vietnam,
Dieleman et al. (2003) conducted a qualitative study to identify factors for job
motivation of rural health workers, and recommend strategies for performance
improvement. The study showed that motivation is influenced by both financial and
non-financial incentives; however, the main motivating factors were appreciation by
managers, colleagues and community, a stable job and income, and training. The main
discouraging factors were related to low salaries and difficult working conditions.
Researchers have examined the relationship between performance and various aspects
of job satisfaction. Abdel-Halim (1980) reported a correlation between performance and
satisfaction with several aspects of the job: work, supervision, coworkers, pay, and
promotion. Some earlier research found a significant correlation between overall
effectiveness and several aspects of job satisfaction: pay, coworkers, supervisor, job
security, promotion, benefits, hours, and work conditions. Correlation was identified
also between overall job satisfaction and specific aspects of job performance of nurses: Factors affecting
technical competence; ability to organize workload; planning nursing care; attendance; performance
amount of work performed; adaptability to emergencies; completing work on schedule;
quality of work; willingness to perform duties; observation of rules; communication of nurses
skills; and overall effectiveness.
Some researchers supported the notion that performance causes satisfaction, and
found a low but consistent relationship existed between performance and job 43
satisfaction. Their argument is that performance leads to extrinsic and intrinsic
rewards, which eventually lead to satisfaction. Extrinsic reward (pay, promotion), and
intrinsic reward (recognition and self-actualization) lead to satisfaction.
Some researchers found no relationship between job performance and job
satisfaction. Packard and Motowidlo (1987) studied the relationship of subjective
stress, job satisfaction, and job performance among hospital nurses, through self
reports that were obtained from 366 nurses, and performance ratings from 165
supervisors and 139 co-workers nominated by the original respondents. The findings
were that stress, primarily acting through depression, is associated with lower levels of
job performance, and that job satisfaction is unrelated to job performance.
The controversy regarding the satisfaction-performance relationship is not fully
resolved, as each approach has been supported by a number of empirical studies.

Organizational commitment and job performance

Interest in organizational commitment is based on the assumption that employees who
feel attached to, and identify with their organizations, work harder. Organizational
commitment is characterized as a strong belief in and acceptance of the organization’s
goals and values, a willingness to exert considerable effort on behalf of the
organization, and a strong desire to maintain membership in an organization (Mowday
et al., 1982). Mathieu and Zajac (1990) see commitment as an attitude reflecting the
nature and quality of the linkage between an employee and an organization. Mowday
et al. (1982) define commitment which portrays a committed individual as one who has:
a string belief in and acceptance of the organization’s goals and values; a willingness to
exert considerable effort on behalf of the organization; and a strong desire to maintain
membership in the organization.
Meyer et al. (1989) identified three types of organizational commitment: affective,
continuance, and normative commitment.
Several scholars identified a positive relationship between organizational
commitment and job performance (Mathieu and Zajac, 1990; Al-Otaibi, 1993; Ward
and Davis, 1995; Yousef, 2000; Samad, 2005). Meyer et al. (1989) found a relationship
between job performance and commitment, however; they concluded that the direction
of the relationship depended on the type of commitment. Affective commitment was
found to have a positive relationship with job performance, while a negative
relationship was found between continuance commitment and performance.
Mathieu and Zajac (1990) found low positive correlation between organizational
commitment and performance, which lead to the belief that there are moderating
variables that moderate this relationship. Similarly, Samad (2005) found a moderate
positive relationship between organizational commitment and job performance, and
concluded that job satisfaction moderates the relationship between organizational
commitment and job performance, indicating that employees, who are committed to
IJHCQA their organizations, would have better job performance if they were satisfied in their
22,1 jobs. Samad (2005) emphasized the importance of motivational factors, such as
relationship with supervision and peers, the quality of supervision, policy and
administration, job security, working conditions, salary and the nature of work itself,
achievement, and possibility of growth.
In the United Arab Emirates, Yousef (2000) examined the mediating role of
44 organizational commitment in the relationships of leadership behavior with job
satisfaction and job performance. The study concluded that employees who perceive their
superiors as adopting consultative or participative leadership behavior are more
committed to their organizations, more satisfied with their jobs, and their performance is
high. In nursing, leadership behavior was found to have a great influence over
organizational commitment and productivity. Organizational commitment was found
related to leadership behavior, and that several aspects of leadership behavior influence
commitment, including clear vision, empowerment of workers, motivation, recognition,
and effective communication (McNeese-Smith, 1997). In Taiwan, organizational
commitment and intention to leave among 2,197 hospital nurses was studied and it
was concluded that organizational commitment is positively related to performance and
productivity, and that it is one of the determinants of intention to leave the organization.
Luchak and Gellatly (2007) found a positive relationship between affective
commitment and three commonly studied work outcomes (turnover cognitions,
absenteeism, and job performance). Wright and Bonett (2002) conducted a
meta-analysis to investigate the relationship between attitudinal commitment and
job performance for 3,630 employees obtained from 27 independent studies. The study
found that tenure had a very strong moderating effect on the commitment-performance
correlation. Job performance was found to be influenced positively by both professional
and team commitment as well as by perceived organizational and team support
(Bishop, 1998). Intention to quit the organization went down as organizational support
and commitment went up, and intention to leave the profession similarly was related to
team support and commitment.
The majority of previous studies were carried out in Western contexts and there is a
growing concern over whether Western business practices and management theories are
appropriate for non-Western settings (Yousef, 2000). Thus, the purpose of this study was
to identify factors influencing performance of hospital nurses in Riyadh Region, Saudi
Arabia. Specific objectives were to estimate self reported performance, and determine
whether differences in employee demographics, and work-related attitudes, specifically
job satisfaction, and organizational commitment, influenced performance.

Methods
Population and sample
The study was conducted in 15 randomly selected Ministry of Health hospitals in
Riyadh region, Saudi Arabia. All nurses (1,834) in these facilities were asked to respond
anonymously to the questionnaire. Completed surveys were received from 923 nurses
(return rate ¼ 50 per cent).

Measurement
Performance was measured using the performance appraisal form used in the Ministry
of Health for annual review of health professionals. The measure contains nine items in
which respondents rate their own performance using a Likert-type scale with five Factors affecting
responses (1 ¼ very poor, 2 ¼ poor, 3 ¼ good, 4 ¼ very good, and 5 ¼ excellent). performance
Self-rating to measure performance is used by several researchers (Al-Badayneh and
Subhash, 1993; Yousef, 2000; Tzeng, 2004). Al-Badayneh and Subhash (1993) have of nurses
emphasized the importance of self rating to provide a culture of continuous
development, which places major emphasis on personal growth, self motivation, and
organizational potential of the employees. The scores were averaged so as to show each 45
participant’s performance level ranging from 0 to 5. The performance measure was
found reliable, with a Cronbach’s of 0.83 in this study sample.
Job satisfaction was measured using the short form of the Minnesota Satisfaction
Questionnaire (MSQ) (Weiss et al., 1967). This instrument utilized a 25-dimension
Likert-type scale with five responses (1 ¼ very dissatisfied, 2 ¼ dissatisfied,
3 ¼ neutral, 4 ¼ satisfied, and 5 ¼ very satisfied). The short form of the MSQ was
translated and adapted into Arabic by the researcher, and was tested for validity and
reliability. The MSQ was reliable, with a Cronbach’s of 0.87 in this study sample. The
scores were averaged so as to show each participant’s satisfaction level ranging from 0
to 5.
Organizational commitment was measured by using the Organizational
Commitment Questionnaire (OCQ) developed by Mowday et al. (1979). It uses 15
items to describe “global” organizational commitment. Responses are obtained using a
five-point scale, where 1 ¼ strongly disagree, 2 ¼ disagree, 3 ¼ neither disagree nor
agree, 4 ¼ agree, 5 ¼ strongly agree. This measure was found reliable, with a
Cronbach’s of 0.85 in this study sample.
Demographic variables examined in this study included age, gender, nationality,
marital status, monthly salary, educational level, and years of experience.

Data analysis
The Statistical Package for Social Sciences (SPSS) was used to analyze the data. The
initial analysis was conducted by calculating descriptive statistics including
frequencies, mean scores and standard deviations. Pearson’s Production Moment
Correlation analysis was used to determine the correlation of each of the independent
variables with job performance at 0.05 level of significance. After this, multiple
regression analysis was performed to determine the weight of each variable in the
prediction of self rated job performance of employees.

Results
A total of 923 (50 per cent) questionnaires were returned. Demographic and
work-related characteristics of study respondents are reported in Table I. The majority
of the sample (90 per cent) were women, most of the respondents (94 per cent) were not
Saudi nationals, few (6 per cent) were from other Arab countries, most (64 per cent)
were from Southeast Asian countries, and (12 per cent) were from Western countries.
The education of the respondents was as follows: health institutes (high school
equivalent) (13.2 per cent), college diploma (two years) (17 per cent), bachelor’s degree
(41 per cent), and graduate degree (9.6 per cent). The majority of subjects (37.4 per cent)
had five to ten years’ experience, (33 per cent) had less than five years of experience,
and (29 per cent) had more than ten years experience. Monthly salary was less than
4,000 Saudi Riyals ($1,066) for the majority of respondents (96 per cent).
IJHCQA
Frequency Percent
22,1
Gender
Male 89 9.6
Female 834 90.4
Marital status
46 Married 630 68.3
Unmarried 293 31.7
Nationality
Saudi 55 6
Non-Saudi 868 94
Educational level
Health institute 122 13.2
Nursing college 157 17
Bachelors 378 41
Graduate 89 9.6
Other 177 19.2
Age (years)
Less than 20 38 4.1
20 to less than 30 420 45.5
30 to less than 40 319 34.6
40-less than 50 128 13.9
50 or more 18 2
Monthly salary (SR)
, 2,000 391 48
2,000 to , 4,000 390 47.9
4,000 to , 6,000 13 1.6
6,000 to , 8,000 7 0.9
. 8,000 13 1.6
Years of experience
,1 72 7.8
Table I. 1 to , 5 236 25.6
Sample personal and 5 to , 10 345 37.4
professional 10 to , 15 142 15.4
characteristics 15 , 128 13.9

Table II shows descriptive statistics of self-rated performance using single and total
measures. Average scores were obtained for each item as well as an overall measure
was obtained by calculating the total average for all items. Overall performance is
rated at (3.52), which corresponds to good or average performance on the five-point
scale used in this study. Self-rated performance was rated above average for most
items, highest scores was reported for attendance and punctuality (3.92), while lowest
score were reported for sick and emergency leave (2.82). Improving work methods and
improving personal skills were among the weakest points of performance at (3.41) and
(3.4) respectively.
Job satisfaction and organizational commitment scores are also presented in Table II
to provide an overall picture of these two independent variables. The data show that
 Factors affecting
Variables Mean Std deviation
performance
Overall performance 3.52 0.48 of nurses
Performance items Attendance and punctuality 3.92 0.61
Sick and emergency leave 2.82 1.16
Improving your personal skills 3.40 0.74
Relationship with patients 3.69 0.66 47
Quality of work 3.60 0.66
Relationship with superiors 3.54 0.72
Relationship with colleagues 3.77 0.64
Improving work methods 3.41 0.71
Your overall performance as compared to your
coworkers 3.61 0.60
Overall satisfaction 3.35 0.57
Facet satisfaction Satisfaction with supervision 3.3476 0.8074
Satisfaction with promotion 2.9870 0.8974
Pay satisfaction 2.5742 1.1345
Satisfaction with work conditions 3.3603 0.7672 Table II.
Satisfaction with the job itself 3.6386 0.7569 Work attitudes and job
Satisfaction with relationships at work 3.7089 0.7021 performance descriptive
Organizational commitment 3.30 0.64 statistics

moderate levels of job satisfaction and organizational commitment exist among nurses
in this study. Highest satisfaction was reported with relationship at work at (3.7), and
lowest satisfaction was reported with opportunity for pay at (2.57).
To obtain an overall picture of self-rated performance according to personal
characteristics of nurses, t-test was conducted as shown in Table III. Self-reported
performance was significantly higher among male than female nurses, married
compared to unmarried, Saudi as compared to all other nationalities. Job satisfaction
was found significantly higher among males, and married nurses, however, was not
significantly different between Saudi and Non Saudi. Organizational commitment was
found significantly higher among Saudis, among male and among married nurses.
Pearson’s Production Moment Correlation analysis was used to determine the
correlation of each of the independent variables (organizational commitment, overall
satisfaction, facet satisfaction, monthly salary, educational level, nationality, marital
status, and years of experience) with overall job performance at 0.05 level of significance.
The results of this analysis show a significant positive relationship between job
performance and organizational commitment, job satisfaction, all six job satisfaction
facets, marital status, monthly salary, and years of experience (Table IV). Results also
indicate a negative correlation exist between level of education and job performance.
Table V summarizes the results of the regression analysis. Regression analysis
procedure designed to gain a better understanding of the strength of association
between self-rated performance and the independent variables: supervision, promotion,
pay, work conditions, the job itself, and relationships at work, organizational
commitment, educational level, years of experience, and overall satisfaction. The
regression coefficients (b) indicate a change in performance, measured on a five-point
scale, associated with a one-unit change in the independent variable.
 48
22,1

factors
Table III.
IJHCQA

Results of t-test for

to selected personal
comparison of means of
work attitudes according
Performance Satisfaction COMMITT
Variables Mean Std deviation t Mean Std deviation t Mean Std deviation t

Nationality
Saudi 3.7111 0.4032 2.915 * 3.2937 0.6297 20.708 3.5040 0.7205 2.106 *
Non-Saudi 3.5168 0.4839 3.3553 0.5669 3.2944 0.6372
Gender
Male 3.6692 0.4544 3.057 * 3.5527 0.6336 3.182 * 3.6442 0.7270 5.274 *
Female 3.5133 0.4821 3.3302 0.597 3.2709 0.6243
Marital status
Married 3.5737 0.4715 4.180 * 3.3944 0.562 3.285 * 630 3.3721 4.533 *
Single 3.4308 0.4890 3.2597 0.5910 293 3.1665
Note: * Correlation is significant at the 0.01 level (two-tailed)
 Factors affecting
Correlation coefficient r self-rated overall
performance performance
Organizational commitment 0.307 * *
of nurses
Overall job satisfaction 0.310 * *
Supervision 0.244 * *
Promotion 0.196 * * 49
Pay 0.084 *
Work conditions 0.203 * *
The job itself 0.319 * *
Relationship at work 0.268 * * Table IV.
Monthly salary 0.152 * * Correlations between
Educational level 2 0.108 * * self-rated overall
Years of experience 0.147 * * performance, work
attitudes, and
Notes: * Correlation is significant at the 0.05 level (two-tailed); * * correlation is significant at the 0.01 professional
level (two-tailed) characteristics

Std error Standardized coefficients beta t Sig.

(Constant) 0.163 16.654 0.000

Supervision 0.050 2 0.198 2 2.244 0.025
Promotion 0.043 2 0.230 2 2.789 0.005
Pay 0.031 2 0.309 2 4.242 0.000
Work conditions 0.064 2 0.311 2 2.943 0.003
The job itself 0.058 2 0.041 2 0.436 0.663
Relationships at work 0.044 2 0.073 2 1.092 0.275
Educational level 0.019 2 0.022 2 0.620 0.535
Years of experience 0.003 0.089 2.583 0.010 Table V.
Nationality 0.068 2 0.130 2 3.508 0.000 Regression analysis for
Organizational commitment 0.033 0.255 5.567 0.000 the relationship between
Overall satisfaction 0.261 0.948 2.980 0.003 job performance, work
attitudes, and selected
Note: Adjusted R 2 (0.19), (R ¼ 0:45), (F ¼ 16:845), (p ¼ 0:000) personal characteristics

Results of the regression analysis indicate that several variables contribute to overall
self-rated performance: satisfaction with: supervision, promotion, pay, work
conditions. Organizational commitment, overall satisfaction, and years of experience
also influence performance. Other factors examined were not shown to be predictors of
job performance, including educational level, satisfaction with the job itself, and
relationship at work. The model explained 19 per cent of the variance in self-rated
performance as measured by the adjusted R 2.

Discussion
This study attempted to shed light on an important issue for health organizations
today, which is nursing performance. The study examines self-rated performance
levels among nurses working in Ministry of Health hospitals in Riyadh Region, Saudi
Arabia. Moderate levels of job performance were identified, however, some aspects of
performance are lacking, specifically, ability to improve personal skills, and the ability
IJHCQA to improve work methods. The fact that these two aspects of performance received the
22,1 lowest self-rating is an indication of lack of motivation for personal development and
creativity among nurses in this study. It may also be a reflection of the limited
opportunity available for improving nursing skills and competencies, and lack of a
professional climate that stimulates ambition among nurses.
Consistent with prior research, job performance was found positively correlated
50 with overall job satisfaction as well as facet satisfaction including: Satisfaction with
the job itself, supervision, relationship at work, satisfaction with pay and promotion
opportunity, and work conditions (Knoop, 1995; Borda and Norman, 1997; Shader et al.,
2001; Judge et al., 2001).
Performance is influenced by relationships at work, including patient appreciation
of nurses, cooperation among staff, as well as physicians’ respect towards nurses and
the decisions they make. This finding confirms the findings of other researchers, that
perceived social support enhances job performance (Abualrub, 2004), and that patient
recognition of nurses influence their performance (Fort and Voltero, 2004).
The nature of the job itself was found positively correlated with performance, which
indicates that satisfaction with the amount of variety and challenge in one’s job
actually influence performance. The sense of job significance, feeling important in the
eyes of others, realizing ones’ competence, and freedom to make decisions are
positively related to performance.
Job performance was also positively correlated with organizational commitment,
which confirms findings by prior researchers that organizational commitment is a
strong determinant of performance (Al-Meer, 1995). The positive relationship between
organizational commitment and performance indicates that increased loyalty leads
individuals to exert more effort at work and increases productivity and performance
(Yousef, 1999). Samad (2005), found that several motivational factors moderate the
positive relationship between performance and commitment, including relationship
with supervisors and colleagues, organizational policies, work conditions, salary,
nature of the job, achievement, job security, and possibility of growth.
Results of this study show that level of education is negatively correlated with job
performance, indicating that the higher the level of education, the lower job
performance of nurses. This is contrary to findings by prior researchers that education
has a positive influence on job performance. We may attempt to explain this negative
relationship between education and performance to be a result of lower motivation
among highly qualified nurses due to the low level of compensation associated with
higher education, and limited opportunities for career advancement. The data
presented in this study show that nurses are dissatisfied with their salaries as well as
opportunity for promotion It is also possible that given that 94 per cent of the sample
were non-Saudis, and building on research in other countries, migrant nurses may face
unequal opportunities in career advancement and skill development (Alexis et al., 2006)
This is only speculation given the limited data on this issue, however; further
research is needed to investigate causes of the negative correlation between education
and performance.
One of the main objectives of this study was to identify determinants of nursing
performance, focusing on job satisfaction, organizational commitment, and selected
personal characteristics. Both job satisfaction and organizational commitment were
found to be strong predictors of nurses’ performance. Results further show that some
aspects of job satisfaction are more able to predict job performance than others, Factors affecting
specifically satisfaction with pay, supervision, promotion, and work conditions. performance
These results confirm findings by other researchers that supportive and leadership
behavior have positive effect on job performance (Hall, 2007; Drach-Zahavy, 2004; of nurses
Abdel-Halim, 1980). Employees who perceive their supervisors to be adopting
consulting behavior, and participating leadership style are more committed to their
jobs and satisfied, and have higher levels of performance (Yousef, 2000). Dieleman et al., 51
2003, stressed that although financial and non-financial rewards are important
motivating factors, the main motivators are appreciation by managers, colleagues and
community, a stable job and income, and training.
The fact that pay satisfaction is found to be an important determinant of
performance of nurses in this study is also confirmed by other researchers in the region
(Yousef, 1999; Al-Meer, 1995). Considering the levels of monthly salary received by
nurses in this study that were less than SR4000 for more than half of respondents as
shown in Table I, there is a need to re-examine salary scales for nurses in Ministry of
Health hospitals. Other researchers stressed the need to improve financial reward
associated with nursing practice in Saudi Arabia (Saeed, 1995; Jackson and Gary, 1991;
Al-Omar, 2003).
Promotion as a form of reward was found to be a predictor of job performance,
which confirms the conclusion of (Dieleman et al., 2003) that motivation is influenced
by both financial and non-financial incentives, and that the main discouraging factors
for nurses were related to low salaries and difficult working conditions. In this study,
job performance was found to be affected with satisfaction with several aspects of
work conditions, including working hours, hospital policies, shifts, physical
surroundings, and access to supplies and equipments as a significant predictor of
job performance.
Finally, consistent with earlier studies, years of experience were found to be strong
predictors of job performance, indicating that work experience influences performance
(Yousef, 1999; Al-Meer, 1995). Consistent with previous research, nationality was also
found to be a strong predictor of job performance, indicating that national culture has a
strong impact on work attitudes (Yousef, 2000).
This study has several implications for health organizations seeking improvement
of nursing performance. Performance improvement is not only a result of well
functioning systems, but also depends on effective human resources strategies that
succeed in recruiting and maintaining a committed and motivated workforce. Health
organizations need to focus on factors that contribute to job satisfaction and
organizational commitment of nurses as the largest group of professionals in direct
contact with patients. Creating a positive organizational culture and better work
environment would eventually enhance motivation and performance. Developing and
implementing effective supervisory skills is essential to support, empower, and
motivate professionals towards better performance. Financial and non-financial
incentives should be improved taking into consideration the hardships nurses go
through and the need to retain qualified nurses given the large shortage of nurses
throughout the world. Work conditions in nursing, such working hours, shifts, and
policies need to be re-examined to create more suitable work situation that motivate
nurses into better performance. Physical environment, as well as availability of
job-related materials and supplies needs to be improved to facilitate better
IJHCQA performance. Human resources policies need to focus on development of nursing staff
22,1 knowledge and skills. Effort should be directed towards enhancing initiative and
creativity among nurses. Nurses must have access to updated information, learning
resources, and continuous educational opportunities. The findings regarding the
relationship between nationality and job performance indicate that health
organizations need to recognize the impact of national culture on work attitudes,
52 and direct their effort to create a high performance culture that is based on
empowerment, effective open communication, and respect of cultural differences.
Cultural diversity is a reality for most health organizations in Saudi Arabia, as in many
countries, therefore, organizations need to adopt effective human resources strategies,
that aim to improve commitment and retention of qualified workers.
The findings of this study should be interpreted keeping in mind that it has its
limitations due to the fact that all measures used are based on self-reports, which might
have the problem of common method variance, and social desirability effects. This
limitation is viewed as an opportunity for future research on work attitudes and their
impact on performance in health organizations.

References
Abdel-Halim, A. (1980), “Effects of higher order need strength on the job performance-job
satisfaction relationship”, Personnel Psychology, Vol. 33 No. 2, pp. 335-47.
Abualrub, R. (2004), “Job stress, job performance, and social support among hospital nurses”,
Journal of Nursing Scholarship, Vol. 36 No. 1, pp. 73-8.
Al-Badayneh, D. and Subhash, S. (1993), “An analysis of performance and satisfaction
relationship among nurses in Jordanian hospitals”, Abhath AL-Yarmok Journal, Vol. 9
No. 1, pp. 29-66.
Alexis, O., Vydelingum, V. and Robbins, I. (2006), “Overseas nurses’ experiences of equal
opportunities in the NHS in England”, Journal of Health Organization and Management,
Vol. 20 Nos 2-3, pp. 130-9.
Al-Meer, A.A. (1995), “The relationships of work stress to organizational commitment,
job performance, job satisfaction and individual differences: a comparative study”, Public
Administration, Vol. 35 No. 2, pp. 207-52 (in Arabic).
Al-Omar, B.A. (2003), “Job dissatisfaction and nursing withdrawal from hospitals in Saudi
Arabia”, Journal of King Saud University (Admin Sciences), Vol. 15 No. 1, pp. 1-24.
Al-Otaibi, A.G. (1993), “The effect of organizational commitment on job performance for
Kuwaitis and expatriates in the public sector in Kuwait”, Arab Journal of Administrative
Sciences, Vol. 1 No. 1, pp. 109-34 (in Arabic).
Bishop, J.W. (1998), “Performance and retention of professional employees who work in teams:
the effects of commitment and support”, Clinical Laboratory Management Review, Vol. 12
No. 3, pp. 150-8.
Borda, R.G. and Norman, I.J. (1997), “Factors influencing turnover and absence of nurses:
a research review”, International Journal of Nursing Studies, Vol. 34 No. 6, pp. 385-94.
Butler, J. and Parsons, R. (1989), “Hospital perceptions of job satisfaction”, Nursing Management,
Vol. 20 No. 8, pp. 45-8.
Dieleman, M., Viet Cuong, P., Anh, L. and Martineau, T. (2003), “Identifying factors for job
motivation of rural health workers in North Vietnam”, Human Resources for Health, Vol. 1
No. 10, available at: www.human-resources-health.com/content/1/1/10
Drach-Zahavy, A. (2004), “Primary nurses’ performance: role of supportive management”, Factors affecting
Journal of Advanced Nursing, Vol. 45 No. 1, pp. 7-16.
performance
Fort, A. and Voltero, L. (2004), “Factors affecting the performance of maternal health care
providers in Armenia”, Human Resources for Health, Vol. 2 No. 8, available at: www. of nurses
human-resources-health.com/content/2/1/8
Hall, D.S. (2007), “The relationship between supervisor support and registered nurse outcomes in
nursing care units”, Nursing Administration Quarterly, Vol. 31 No. 1, pp. 68-80. 53
Jackson, C. and Gary, R. (1991), “Nursing attitudes, perceptions, and strategies for progress in
Saudi Arabia”, Annals of Saudi Medicine, Vol. 11 No. 4, pp. 452-8.
Judge, T.A., Thoresen, C.J., Bono, J.E. and Patton, G.K. (2001), “The job satisfaction-job
performance relationship: a qualitative and quantitative review”, Psychological Bulletin,
Vol. 127 No. 3, pp. 376-407.
Knoop, R. (1995), “Relationships among job involvement, job satisfaction, and organizational
commitment for nurses”, Journal of Psychology, Vol. 129 No. 6, pp. 643-9.
Krugman, M. and Preheim, G. (1999), “Longitudinal evaluation of professional nursing practice
redesign”, Journal of Nursing Administration, Vol. 29 No. 5, pp. 10-20.
Luchak, A.A. and Gellatly, I.R. (2007), “Comparison of linear and nonlinear relations between
organizational commitment and work outcomes”, Journal of Applied Psychology, Vol. 92
No. 3, pp. 786-93.
McNeese-Smith, D. (1997), “The influence of manger behavior on nurse’s job satisfaction,
productivity, and commitment”, Journal of Nursing Administration, Vol. 27 No. 9,
pp. 47-55.
Mathieu, J. and Zajac, D. (1990), “A review and meta analysis of antecedents, correlates, and
consequences of organizational commitment”, Psychology Bulletin, Vol. 108, pp. 171-94.
Meyer, J.P., Paunonen, S.V., Gellatly, I.R., Goffin, R.D. and Jackson, D.N. (1989), “Organizational
commitment and job performance: it’s the nature of the commitment that counts”, Journal
of Applied Psychology, Vol. 74 No. 1, pp. 152-6.
Mowday, R.T., Porter, L.W. and Steers, R.M. (1982), Employees’ Organizational Commitment
Linkages: The Psychology of Commitment, Absenteeism, and Turnover, Academic Press,
New York, NY.
Mowday, R.T., Steers, R.M. and Porter, L.W. (1979), “The measurement of organizational
commitment”, Journal of Vocational Behavior, Vol. 14 No. 2, pp. 224-47.
Mrayyan, M.T. (2006), “Jordanian nurses’ job satisfaction, patients’ satisfaction and quality of
nursing care”, International Nursing Review, Vol. 53 No. 3, pp. 224-30.
Packard, J.S. and Motowidlo, S.J. (1987), “Subjective stress, job satisfaction, and job performance
of hospital nurses”, Research in Nursing and Health, Vol. 10 No. 4, pp. 253-61.
Parker, P.A. and Kulik, J.A. (1995), “Burnout, self- and supervisor-rated job performance, and
absenteeism among nurses”, Journal of Behavioral Medicine, Vol. 18 No. 6, pp. 581-99.
Robinson, S., Roth, S., Keim, J., Levenson, M., Flentje, J. and Bashor, K. (1991), “Nurse burnout:
work related and demographic factors as culprits”, Research in Nursing and Health, Vol. 14
No. 3, pp. 223-8.
Saeed, K. (1995), “Factors which influence the nurse’s decision to leave the hospital, Riyadh City,
Saudi Arabia”, Journal of King Saud University (Admin Sciences), Vol. 7 No. 2, pp. 85-105.
Samad, S. (2005), “Unraveling the organizational commitment and job performance relationship”,
The Business Review, Vol. 4 No. 2, pp. 79-84.
IJHCQA Shader, K., Broome, M.E., Broome, C.D., West, M.E. and Nash, M. (2001), “Factors influencing
satisfaction and anticipated turnover for nurses in an academic medical center”, Journal of
22,1 Nursing Administration, Vol. 31 No. 4, pp. 210-6.
Siu, O. (2002), “Predictors of job satisfaction and absenteeism in two samples of Hong Kong
nurses”, Journal of Advanced Nursing, Vol. 40 No. 2, pp. 218-29.
Tzeng, H. (2004), “Nurses’ self-assessment of their nursing competencies, job demands and job
54 performance in the Taiwan hospital system”, International Journal of Nursing Studies,
Vol. 41 No. 5, pp. 487-96.
Vroom, V. (1964), Work and Motivation, Wiley, New York, NY.
Ward, E.A. and Davis, E. (1995), “The effect of benefit satisfaction on organizational
commitment”, Compensation and Benefit Management, Vol. 11 No. 3, pp. 35-40.
Weiss, D.J., Dawis, R.V., England, G.W. and Lofquist, L.H. (1967), “Minnesota studies in
vocational rehabilitation”, Manual for the Minnesota Satisfaction Questionnaire,
Industrial Relations Center, University of Minnesota, Minneapolis, MN.
Wright, T.A. and Bonett, D.G. (2002), “The moderating effects of employee tenure on the relation
between organizational commitment and job performance: a meta-analysis”, Journal of
Applied Psychology, Vol. 87 No. 6, pp. 1183-90.
Yang, K.P. and Huang, C.K. (2005), “The effects of staff nurses’ morale on patient satisfaction”,
Journal of Nursing Research, Vol. 3 No. 2, pp. 41-52.
Yousef, D.A. (1999), “Relationship between internal work motivation, organizational
commitment, job performance, and personal variables, and empirical study”, Public
Administration Journal, Vol. 39 No. 1, pp. 6-24.
Yousef, D.A. (2000), “Organizational commitment: a mediator of the relationships of leadership
behavior with job satisfaction and performance in a non-western country”, Journal of
Managerial Psychology, Vol. 15 No. 1, pp. 6-24.

Further reading
Irvine, D. and Evans, M. (1995), “Job satisfaction and turnover among nurses: integrating
research findings across studies”, Nursing Research – New York, Vol. 44 No. 4, pp. 246-53.
Mira, J.J., Vitaller, J., Buil, J.A., Aranaz, J.M. and Herrero, J.F. (1992), “Absenteeism as a symptom
of occupational ill-health in hospitals and its repercussion on quality assurance”, Quality,
Vol. 4 No. 4, pp. 273-87.

Corresponding author
Hanan Al-Ahmadi can be contacted at: h_alahmadi@yahoo.com

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