literature review of job dissatisfaction

Two Factor Theory of Motivation and Satisfaction: An Empirical Verification

• Published: 30 March 2016
• Volume 3 , pages 155–173, ( 2016 )

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• M. A. Sanjeev   ORCID: orcid.org/0000-0002-6309-0758 1 &
• A. V. Surya 2  

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Effective talent management is imperative for organisational success. This involves acquiring, deploying, developing, engaging and retaining talent in the organisation there by providing a stable staff for achieving organisational objectives. Herzberg’s two factor theory of motivation and satisfaction was proposed in 1959 and has been widely tested empirically with mixed results. The purpose of this research is to verify the ‘two factor theory’ in the modern day context using exploratory and confirmatory factor analysis. The study is done among pharmaceutical sales and marketing professionals. The findings confirm the existence of two factor structure of motivation and satisfaction. The employees are satisfied in the presence of motivating factors only and hygiene factors do not have any influence on satisfaction levels. The motivating factors however, are not fully intrinsic in nature and consists of certain extrinsic elements also as classified by Herzberg. The factors are also not fully independent with a high amount of shared variance between them.

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Annexure 1: Motives (Job Attributes) and Their Functional Definition

Annexure 2: survey instrument.

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Sanjeev, M.A., Surya, A.V. Two Factor Theory of Motivation and Satisfaction: An Empirical Verification. Ann. Data. Sci. 3 , 155–173 (2016). https://doi.org/10.1007/s40745-016-0077-9

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Received : 03 March 2016

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DOI : https://doi.org/10.1007/s40745-016-0077-9

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ORIGINAL RESEARCH article

Investigating the employment motivation, job satisfaction, and dissatisfaction of international high school teachers in china: the impact of the covid-19 pandemic.

• 1 School of Foreign Languages, Soochow University, Suzhou, China
• 2 School of City Culture and Communication, Suzhou City University, Suzhou, China
• 3 Centre for English Language Education, The University of Nottingham Ningbo, Ningbo, China

International education has become increasingly challenging to manage in an unpredictable world beset by pandemics, regional disputes, and evolving market practices. The last few decades have seen a huge demand for international education in China, and numerous acclaimed international brand names set up operations in China’s K12 schooling sector. However, the COVID-19 pandemic exerted a noticeably negative impact on international high schools and their staff in China, and exacerbated a difficult period of management for these institutions. Interestingly, but perhaps unsurprisingly, the actual operation of these educational workplaces remains under investigated in academic studies. This paper therefore attempts to examine international high schools in China by focusing on their teachers and their associated employment motivation, job satisfaction, and dissatisfaction which has been perceptibly influenced by the impact of the COVID-19 pandemic. Through a qualitative, case-study approach which adopted semi-structured interviews, an acclaimed British high school, now closed, was investigated. The study found that international high school teachers were driven by diverse work motives such as the school’s reputation, values, salary, environment, and chances for career development. Their job satisfaction was also multi-faceted, and their dissatisfaction in certain areas concerning. That is, they derived an early satisfaction from a range of facets, such as the students, class sizes, initial workloads, autonomy and collegiality. However, these early feelings were replaced by a sense of dissatisfaction and noticeable unhappiness resulting from leadership changes and subsequent management practices, increased workload, unmet employment package expectations and obligations, as well as limited professional development opportunities. This study highlights the importance of recruiting well, generating the right starting and longer-term conditions, retaining key staff and managing astutely. The work will be of interest to policy makers, investors, leaders, managers and staff alike. It will also extend educational research in the areas of teacher motivation, satisfaction and dissatisfaction, and in particular in China in international K12 settings.

1 Introduction

International schools are an important component of educational globalization and this area has gained increased social attention in the 21st Century where the hunt for high-caliber staff can be a continuous cycle. This has led in recent years to a huge demand for international schools worldwide with enrollment having increased 53% in the past decade ( ISC Research, 2023 ). According to international school data for 2022 released by ISC Research ( Hingston, 2022 ), the global enrollment rate of the K12 International School Group increased by 70% from 2017 to 2022, and this is despite a global pandemic. The growth of international schools in China has also been exponential, and in 2019 80% of schools opened by British institutions were in China ( Staton, 2023 ). That said, this trend was affected by the COVID-19 pandemic and evolving educational policies nationwide. Thanks to the rapid development of the Chinese economy, an increasing number of Chinese families have subsequently acquired the financial ability to choose diverse educational forms and venues for their children. The large size of China’s population, its ever-growing middle class, and the resulting overwhelming examination pressure has led to an increasing number of Chinese parents considering international education as this opens up overseas university and emigration opportunities as Li (2016) highlights. It can also facilitate a smoother entry into domestic higher education. This can be seen from the trend of Chinese children starting to receive an international education from an increasingly young age. According to the 2021 Report on Chinese Students’ Overseas Study ( New Oriental School, 2021 ), the percentage of Chinese students who plan to study in foreign middle and high schools rose from 20% in 2019 to 29% in 2021. This is an important figure given the potential student numbers involved.

With the rapid growth of international schools, teachers working for them have also become an emerging field of inquiry ( Poole and Bunnell, 2023 ). As the mainstay of international education, these teachers are, to a large extent, expected to bring about educational success. This is especially the case with international high school teachers who are under greater pressure than their counterparts at the other stages of the K12 education to help their students to secure a high score in college entrance examinations or receive a good offer from a prestigious foreign university. Despite the important role that international high school teachers may play, they have not yet received due attention in academic investigations. Consequently, they remain largely under researched as a working demographic group. For example, what motivates teachers to seek employment in international high schools in China and to what extent they are satisfied or dissatisfied with their job are questions that are important to know for a wide range of reasons.

Thinking back to the past couple of years, and mindful of what might happen in the future, the then unexpected COVID-19 pandemic sparked a significant global educational crisis ( Reyes-Guerra et al., 2021 ). Indeed, Staton (2023) was reporting that by the start of January 2023 the percentage of schools opened by British institutions in China had dropped to 15% highlighting just how great the impact was in this context. For the first time in decades no longer was it business as usual. For many teachers this was a period when online teaching and hybrid learning featured prominently, learner engagement proved variable and pedagogic effectiveness questionable. It was a period in time that was additionally epitomized by the emergence of a new work/life balance. As Allen et al. (2020) point out, the COVID-19 pandemic severely disrupted schooling, and placed additional demands on teachers. The pandemic also created numerous additional challenges such as how to prepare students for high stakes exams, adapt to changing domestic policies, and recruit and retain high quality staff ( Nickerson and Sulkowski, 2021 ). For some international schools the pandemic resulted in an existential crisis, leading educational leaders to grapple with unprecedented volatility, uncertainty, complexity, and ambiguity ( Kaiser, 2020 ). Although some studies have been carried out to investigate how the pandemic impacted international high school students in China ( Shen, 2022 ), very few efforts have been made to study their teachers.

This study considers the case of one very high-profile British school that opened in China in 2021. Given the crucial role that teachers may play in the operation of international schools, this study is focused on the employment motivation, job satisfaction and dissatisfaction of teachers working in this British branded high school in China, and the massive impact that the COVID-19 pandemic exerted on them as it exceeded what might have been predicted. An educated guess would have expected some disruption and difficulties, but a closure and complete upheaval provided both opportunities and numerous challenges that were certainly unforeseen at the time.

2 Literature review

2.1 motivation.

Motivation refers to the driving force or stimulus that propels an individual toward a particular course of action. It has significant associations with job satisfaction and has been the subject of numerous early and contemporary theories. Some early theories include Freud’s (1949) work on the subconscious and unconscious thought processes, Hull’s (1943) drive reduction theory, and Maslow’s (1970) hierarchy of needs. These have laid the foundation for further research on individual-oriented theories, such as Vroom’s (1964) expectancy theory, Adams’ (1965) equity theory, Atkinson and Raynor’s (1974) achievement or competence theory, Bandura’s (1977) self-efficacy theory, Deci and Ryan’s (1985) self-determination theory, Locke and Latham’s (1990) goal setting theory, and Kubanyiova’s (2019) teacher self-theory. Motivation also intersects with management theory, as evidenced by Herzberg’s (1959) argument against force and his emphasis on the maintenance of incentives through his motivation hygiene theory. Additionally, McGregor’s (2006) theory posits that employees are likely to either require supervision and a more stringent management approach or will be internally motivated, which enables a softer, more participative management style.

2.2 Teacher motivation

The field of teacher motivation is understandably complex and multifaceted, as highlighted by Shoaib (2004) , with influences stemming from various global, contextual, and situational factors, as well as cultural and social elements, as outlined by Vallerand and Ratelle (2002) and Ushioda (2007) , respectively. Furthermore, motivations are emergent, dynamic, and multifaceted, as argued by Dörnyei et al. (2014) and Dörnyei and Ushioda (2010) , with specific motives for a particular course of action easier to identify than those for prolonged activity engagement. For teachers, motives may include a range of push and pull factors, as suggested by Cai and Hall (2015) , Karavas (2010) , Kissau et al. (2019) , and Trembath (2016) . Additionally, intrinsic and extrinsic factors, altruistic motives, and non-work-related elements may impact teacher motivation, as noted by Morris (2021) . For the purpose of this study, given the few theoretical constructs to comprehensively address teacher employment motivation, Morris’ (2021) framework has been adopted. He suggests that work-based motivation requires an assessment of employment-based and personal factors, as well as move convenience. Employment-based factors relate to the work, context and contract. Personal considerations consider an individual’s personal circumstances. Convenience is how easy it is to actually make the move (see Figure 1 ).

Figure 1 . Teacher employment motivation framework ( Morris, 2021 ).

2.3 Satisfaction

In contrast to motivation, which pertains to the driving force behind our actions, satisfaction refers to our perception of past events ( Carr, 2005 ), and the extent to which our expectations were met ( Robson, 2022 ). It relates to a positive affective or emotional state resulting from work appraisals and experiences ( Kreitner and Kinicki, 2012 ), with cognitive evaluations crucial in our assessment of whether actual outcomes meet or exceed our desired or expected designs, as Sharma and Jyoti (2009) suggest. Job satisfaction is a multifaceted and dynamic concept ( Griva et al., 2012 ), as too is motivation, and its importance for teachers should not be underestimated ( Judge et al., 2002 ), as it can impact performance ( Arifin, 2015 ), effectiveness ( Selmer and Lauring, 2011 ), discipline ( Sungu et al., 2014 ), and retention ( Yoshihara, 2018 ). Furthermore, it is linked to organizational effectiveness and retention ( Morris, 2021 ).

2.4 Teacher satisfaction

Teacher satisfaction can be influenced by a plethora of factors. Altruistic and intrinsic fulfillment is one of the most important, as emphasized by Afshar and Doosti (2016) . Personal interactions and relationships with co-workers and students also play a critical role in job satisfaction ( Wilkins and Neri, 2019 ). The overall environment and community ethos are also significant contributing factors ( You et al., 2015 ; Aldridge and Fraser, 2016 ). Teaching and learning aspects, such as job or task characteristics ( Naumann, 1993 ), novelty and variety ( Jonasson et al., 2017 ), and perceived interest ( Wilkins and Neri, 2019 ) are highly influential as well. Additionally, autonomy, challenge, meaningfulness, responsibility, and creativity are key factors that can impact satisfaction levels ( Morris, 2021 ). Recognition and opportunities for progression, along with the employment package, are also essential variables ( Morris, 2021 ). Finally, non-work-related factors, such as personal relationships with loved ones, should not be overlooked, as the spillover effect can be powerful ( Morris, 2021 ; Cacioppo, 2022 ).

2.5 Teacher dissatisfaction

Similar to teacher satisfaction, teacher dissatisfaction can arise from a diverse range of factors. Morris (2021) categorizes these factors into negative personal interactions, teaching and learning factors, lack of recognition and career progression, and employment package, in addition to external personal considerations. Morris (2021) notes that disengaged students, challenging relationships with colleagues, administrators and management, and an unfavorable working environment are influential factors in personal interactions. Workload and job responsibility are typically related to teaching and learning factors, while limited opportunities for professional development, promotion, and career growth contribute to dissatisfaction concerning recognition and progression. Morris (2021) also emphasizes that working conditions, unstable job security, and perceived or actual issues are relevant. Compensation commonly features in concerns related to the employment package, while family issues and societal influences may influence external personal considerations among teachers and their families (see Figure 2 ).

Figure 2 . Teacher job satisfaction and dissatisfaction framework ( Morris, 2021 ).

2.6 Impact of the COVID-19 pandemic on teachers

Numerous studies have revealed that the COVID-19 pandemic has had a negative impact on teachers. According to Baker et al. (2021) , teachers, in general, encountered more stressful than protective factors during the pandemic. Teachers found lack of connection and online teaching challenges to be the most difficult aspects of their profession. However, they identified support from co-workers and administrators as the most helpful factor in managing these challenges. Likewise, Vargas Rubilar and Oros (2021) found that the majority of teachers reported experiencing high and moderately high levels of stress during this period. The primary stress factors identified were uncertainty regarding the consequences of the pandemic, work overload, and an inadequate working environment. There was a positive correlation between perceived stress levels and the manifestation of undesired psychophysical symptoms. Furthermore, teachers with higher stress levels and more indicators of discomfort exhibited heightened susceptibility for professional burnout.

Of course, studies of pandemic impact on teachers are not all negative. There was a positive note in some studies. Sacré et al. (2023) found that despite experiencing emotional exhaustion during the pandemic, teachers expressed satisfaction with their occupation. Bailey (2021) found that although the pandemic had worsened certain aspects of precarity for international teachers, some elements of privilege persisted.

In this study, it was anticipated that the respondents would demonstrate a variety of employment motives for joining the K12 provider. The brand name, renowned reputation and a diverse and high-quality initial staffing range of profiles, alongside a competitive employment package and the opportunity to improve were likely to have been attractive pull features. It was also anticipated that despite early satisfaction given all of these elements, the fact that the school closed within a couple of years would mean that dissatisfaction would set in across a range of areas and to varying degrees.

3 Methodology

3.1 research purpose.

The purpose of this investigation was to examine the underlying motivations that drive educators to pursue careers at international high schools in China and assess the level of job satisfaction or dissatisfaction they experience in their roles. Furthermore, the study aimed to investigate the effects of the COVID-19 pandemic on these educators, who are at the vanguard of international education in China. The paradigmatic stance of this study is pragmatic, as defined by Dörnyei (2007) and Johnson and Onwuegbuzie (2004) , with research design determined by the goals of the research. Ontologically and epistemologically, the study adopted a relativist position, following the ideas presented by Grix (2010) , while simultaneously influenced by the principles of social constructivism expounded by Vygotsky (1978) .

3.2 Research questions

This study sought answers to four research questions:

RQ1. What motivates teachers to seek employment in international high schools in China?

RQ2. To what extent, and in which areas, are these teachers satisfied with their job?

RQ3. To what extent, and in which areas, are these teachers dissatisfied with their job?

RQ4. To what extent, and in which areas, are these teachers impacted by the COVID-19 pandemic?

3.3 Research context and participants

This study was carried out in a modern affluent city in eastern China. This city is not only an economic powerhouse, but also a pioneer in international education in the country. A number of well-known international schools are also located in this metropolis.

The international high school under investigation in this study was part of a conglomerate of institutions. The institution in China had its own locally operated governance, with the UK school providing annual academic quality assurance checks, and providing advice to the investors and onsite senior leadership team.

The participants of this study were four teachers working in the international school under investigation. They were selected on a purposive premise as advocated by Creswell and Creswell (2018) , with individual selection on the premise that they are willing to share their stories and express their viewpoints so as to provide insights which can help explore the concepts under evaluation at the case study institution, namely employment motivation, job satisfaction, job dissatisfaction and pandemic impact. There was also an element of convenience to the sampling as all four teachers were still accessible and had not cut off all ties to the past. The demographic backgrounds of the participants bore many similarities to other teachers at the school in that they covered a wide range of ages, experience levels and job roles and responsibilities. To maintain their confidentiality and anonymity, number codes were assigned to them when they were mentioned in this paper (see Table 1 ).

Table 1 . Participant profiles.

P1 was a mid-career professional who had a wealth of international teaching and leadership experience. P1 was a well-qualified long-standing teacher. This was P1’s first experience of working in K12 in China. P1 was used to working in large and well-established schools.

P2 had worked in many schools in China. In one of these workplaces P2 had seen a number of affiliated international branches come and go over the course of a few years. This move was a step up.

P3 was a highly experienced teacher from the province in which the city is located. Like P2, P3 had worked in a number of schools. P3 was highly experienced with local educational practices and management approaches and coming to the school held a lot of career promise, and potentially represented a step up.

P4 was relatively new to teaching. P4 had worked in private educational businesses previously and acquired a range of valuable skills in these institutions. P4 was also a highly qualified graduate. This job was a perfect stepping stone opportunity.

3.4 Research methods

The present research design employed an exploratory methodology, which is deemed useful for identifying and establishing the factors and situations that influence individuals ( Morris, 2021 ). A notable strength of this study was the opportunity for both researchers to engage with the research participants on an insider’s level, as Dörnyei (2007) highlights as advantageous. The research method selected for this study was the multiple case study approach, which is believed to offer a comprehensive, in-depth analysis and good readability ( Duff, 2007 ). Additionally, this study employed semi-structured interviews, which are deemed beneficial in grasping interviewee perspectives and maintaining research focus ( Morris, 2021 ). The interview guide was based on Morris’ (2021) research on the employment motivation and job satisfaction of educators in China and drew inspiration from Khan (2011) . Indeed, the work of Morris (2021) contains a sample, illustrative, questionnaire in the appendix and this was designed to align to his theoretical frameworks which this study has adopted. It was also enhanced by having a follow-up data collection phase in which participant answers were further explored a few months later through discussion on points of interest. This added layers of research depth and broadened knowledge. The research also drew on authentic secondary sources of information to add further depth to the work and enhance the analytical accuracy. In this instance, ‘Glassdoor’, a well-regarded anonymous job review website, was accessed, and the insights gleaned and presented.

3.5 Data collection and analysis

The data of this study were collected in July 2023 by interviewing the four participants in English on an individual basis. To ensure a thorough analysis, the interviews were transcribed and a thematic analysis employed which involved data familiarization, coding, theme identification, reviewing and naming as Nowell et al. (2017) advocate. As Caulfield (2019) also suggests, a period of familiarization preceded the coding stage. The coding procedure involved a dual inductive and deductive approach, as advocated by Miles and Huberman (1994) and Sahakyan et al. (2018) .

As noted earlier, a secondary data phase of data clarification and expansion in any area of interest was also undertaken which was facilitated by an additional round of exploratory questioning. The benefit of this was that it enabled the researchers to revisit and expand on areas of interest having first considered the data in its entirety and with additional insights from literature and secondary sources considered. To ensure that no concerns arose over potential inter-rater reliability, both researchers considered the data together having first analyzed the findings individually, reaching a consensus in all instances. The opportunity to check meaning and accuracy with the participants was also available throughout the research study as open lines of communication were in place.

4.1 Diverse employment motives

The motives for joining the international high school aligned with the employment factors, personal and convenience considerations identified by Morris (2021) , but in particular it was the employment elements that were appealing. Delving further into these elements they were also multifaceted, of which the school’s reputation, values, salary, environment and chances for career development were highlighted. P2 decided to work at the school because it was a branch campus of a highly reputable UK school with a strong academic record. P2 was especially impressed with the ethos, noting:

The school vision and values attracted me [P2].

The values were the same as the UK institution, namely that endeavor, breadth and balance, intellectual curiosity and scholarship and respect for one another and the environment were all core beliefs. The last point emphasized the importance of a kind, caring and considerate community. P3 also was attracted by the brand name, but at the same time by the financial package.

It was a good brand and the salary met my expectations [P3].

In contrast, P4 saw a move as a career stepping stone. P4 actually hoped to work elsewhere but needed experience. P1 nicely summarized a more holistic evaluation which echoed the sentiments of the other staff:

It seemed like it had an amazing potential. It had recruited high caliber teachers, had a good leadership team, and the school was affiliated to one in the UK which has a world-class reputation [P1].

4.2 Distinctive job satisfaction features

Most of the teachers highlighted similar aspects of the work regarding what satisfied them. They also tended to identify the teaching and learning and personal interaction side of the job that Morris (2021) stresses as being important. P2 and P3 noted how they enjoyed seeing students improve, and knowing they played a role in this. P3 mentioned that the classes had good students and their enthusiasm and energy brightened up the days. P1 also liked teaching-related features and was content when creating and teaching good classes which promoted learning which was enjoyable. P4 added to these points, noting how preparing lessons and giving students feedback was rewarding. P4 also enjoyed seeing student progress and went on to note:

The workload was OK. The class size was 5–1 which is good. Most students here are also good and so too is the relationship with colleagues [P4].

Reinforcing these points, one of the two anonymous posts of the job evaluation website ‘Glassdoor’ posted in February 2023 highlighted the small size of the school (with less than 70 pupils) and classes of less than 10 as a plus. Echoing the comments about colleagues, whom P3 also felt could be nice, but building on the previous points, P1 emphasized:

In terms of the positive aspects, most of the students were respectful, and most tried their best. The classes were also small which was great. I also had plenty of autonomy with my work, and input regarding day-to-day decision making. Good work was generally acknowledged and some of my colleagues were also very friendly and experienced. In fact, one of the main reasons I joined was because of the quality of the people on paper [P1].

Beyond the students and staff, P3 felt that the school had a beautiful campus and time in which one could develop one’s self. P3 also felt the direct line manager provided professional development opportunities for the team. P4 also felt that the school provided opportunities in which to develop. They stated:

I like being a teacher and I hope to be more professional and get promoted in the future [P3].

After finishing my master’s working here was a good choice as I could learn a lot [P4].

For P2, the most rewarding aspects were line manager, parent and student recognition. P2 noted that in his opinion additional positive features included the working conditions and resources and effort acknowledgment, while the workload, autonomy, advancement opportunities, management support and employment package were reasonable.

4.3 Rise and effect of job dissatisfaction

Despite the numerous positives there were also plenty of areas in which dissatisfaction arose. Areas of dissatisfaction focused a lot on deteriorating personal interactions, alongside the employment package issues and amendments. The interviews also highlighted how dissatisfaction extended to the teaching and learning sphere and recognition and progression, another area identified by the satisfaction and dissatisfaction framework of Morris (2021) . P2 noted that dissatisfaction grew quickly despite early job satisfaction.

When I first joined the school I was quite satisfied with my job and career, but due to the frequent changes in senior management and the working environment I’m not satisfied with my job now [P2].

P3 had thoughts on the employment package:

I think the salary is OK, but I cannot afford a decent life [P3].

P1 stressed the role that negative interactions can have, noting a dislike for situations in which the workplace was not friendly, people acted aggressively, or when people were simply being difficult. P1 added that uninterested students were also dispiriting before concluding:

On the flip side, some of my colleagues became very unhappy early on with what the working reality morphed into, especially after two senior figures left during the first semester. This led to numerous staff suffering from anxiety, unhappiness, and stress [P1].

P2 continued the theme about personal interactions highlighting that some of the students created more trouble than was normal. P2 was also unhappy with his treatment at the hands of one of the leadership figures:

Sometimes I feel under privileged because one of the senior managers is very aggressive and critical [P2].

Both the February and June 2023 ‘Glassdoor’ reviews stressed equal concerns. The first highlighted that management at the school had been inexperienced and arrogant, and that there were no clear lines of responsibility at the site. It also suggested that there were no standardized policies and procedures enacted in reality. Coupled with sudden and changing workloads, no professional development opportunities, and poor inter-school relationships born out of fear of upsetting the investors, a budget absence, shrinking staff and student numbers, the suggestion was to close the school. P4 and P1 also drew attention to some of these points:

The leadership gives me too many lessons a day to teach which makes me tired. I would have additionally liked to have refused work arranged for the weekend, but it might not have been appropriate. I’m also not satisfied that I had no medical provision, and I would like to have had more professional development opportunities. Ultimately, the job here is not stable and I do not have promotion opportunities [P4].

The workload became excessive. It just kept building with staffing cuts, and this led to burnout in some cases. There was also very little funding and resources were scarce and only got scarcer despite the early suggestions that these were not issues. This had an impact on everything from professional development opportunities which disappeared as the funding wasn’t there, to job security. As cuts came, people were not always replaced, and jobs moved from full time to part time. It felt like a revolving door at times. It was sad because by the end trust was completely eroded and the environment oscillated from toxic and fractious to despondent and apathetic [P1].

The second ‘Glassdoor’ review was even more damning. It claimed horrendous mismanagement was taking place in July 2023, and that the school was closing. It claimed that the sister school had been aware of concerns in the area of health and safety, safeguarding and staff mistreatment with lawsuits against former students and also those filed by former employees known for trying to leave a failing school or for failing to adhere to legal obligations. It finished with an even stronger rebuke which likely led to this post’s later removal.

P2 echoed some of these concerns mentioning the evaluation and promotion of staff, the job security and the staff and management collegiality was not good. The omission of a medical examination was also irresponsible. More concerning was when P2 stated:

I would not recommend this school to anyone else because it’s no longer like it used to be after so many changes [P2].

P3 added that as a private institution the work was unstable, and job security was problematic:

I do not feel secure in my work environment because of some bad management. In the beginning it was a good brand and we had professional leaders so the teachers were motivated and active. The principal was nice and supportive during the journey. Now the school is going to shut down and I feel insecure [P3].

P3 added that they would not recommend the school, and that there had been times when they did not want to be there anymore.

4.4 Severe impact of the COVID-19 pandemic

All of the staff participants stated that they felt that the pandemic had influenced subsequent developments. P2 stressed the impact that it had on his teaching and the need for training in order to adapt and upskill:

I needed to spend more time searching for teaching materials, mastering course skills and revising lesson plans. I also needed to adjust my teaching methods and learn how to organize online teaching and use different software and apps [P2].

P3 also highlighted the importance of training and time in developing the new skills to be mastered during the pandemic. P3 mentioned how these had built up over time enhancing competencies and resilience, but felt it had taken an emotional and psychological toll:

At first the pandemic caused me anxiety because I could no longer go to school and follow my usual work schedule on campus. The virus also made us feel unsafe and insecure both mentally and physically. If there had been lectures guiding us about how to maintain mental health it would have been much better. The online lessons helped ease the anxiety in me because the technology made it possible to connect with students and colleagues. However, the need to use the new technology and fulfil my teaching requirements also made me anxious. If there had been more training I believe it would have made life easier [P3].

P1 summarized the impact more broadly on a holistic operational level:

The pandemic almost certainly had a massive financial impact which meant that the school was always playing catch up. The cost cutting that ensued in an attempt to better balance the books almost certainly also led to the rapid decline of the institution because quality inevitably suffered, trust went, tempers frayed and people voted with their feet. Teaching online had some advantages at times as it saved on a long daily commute. That being said, learning suffered. I feel that this job is really a case of what might have been because the school is closing, and it feels like a massive missed opportunity given how successful the school might have been had things been done differently and different decisions made at certain junctures. This could have been an amazing school. What a missed opportunity [P1].

5 Discussion

5.1 pull factors as a powerful motivational force.

A number of factors proved influential in motivating these staff to seek employment at this particular institution initially. The first was the power of the UK sister school’s brand and values. This struck a chord with the majority of the participants in this study, as P1, P2, and P3 mentioned. A brand promise that identifies who a group of people are and what they stand for collectively is regarded as an expression of a company’s vision and acts as a powerful pull motive due to the emotional engagement it can generate as Barlow (2019) highlights. Many people want to work for well-regarded employers and this one carried a powerful name within education circles. Part of the explicit appeal also lay in the values which promoted respect and kindness. The importance of kindness to individuals is well documented as Ferrucci (2007) detailed, and working within a respectful environment is also important to educators both generally and in the city in which this study took place, as the work of Morris (2021) highlighted. There was also the potential implicit, and subconscious, motivational allure of working for an employer that could enhance individual “mianzi” or face, as well as act as a useful career stepping stone. Beyond the promise of what the employer potentially stood for, and the perceived alignment between personal and professional values, additional employment factors were also deemed to be important. The financial package was competitive, albeit nothing too exciting as far as P3 was concerned, and opportunities for career advancement were in evidence as P4 alluded to. These are important points among a multitude as Morris and Mo (2023) stressed. Finally, the opportunity to work with what appeared to be an exciting team of professionals was another motivational pull factor.

5.2 Early job satisfaction existing in numerous areas

There is a wide array of factors which can satisfy employees once they begin to work for an employer, and in this case study numerous overlaps with existing findings were evidenced. Zembylas and Papanastasiou (2006) highlighted the importance that making a social contribution can have, and all of the teachers derived a sense of happiness in helping the students they taught to progress. Wilkins and Neri (2019) also explicitly drew attention to the importance that personal interactions and associated relationships can have for job satisfaction, and the value placed on collegiality between colleagues was also mentioned by all of the staff. P4 and P1 stated how pleasant it was initially to work with friendly teachers and administrative staff, and P3 mentioned how he got on well with his line managers. Beyond personal interactions, a number of teaching and learning features were also well regarded. The small class sizes were a source of contentment, although how sustainable they were from a financial standpoint was debatable, as bespoke sessions of one or two were an excellent advertising feature, but also potentially suggested a recruitment concern despite the relatively high student fees. Being able to be creative was also important, and Morris (2021) collated a range of teaching and learning elements which satisfy staff, among which is autonomy, agency and trust, alongside an ability to have one’s voice heard as far as decision making is concerned. The traditional, small but green campus also appealed. Recognition and progression in contrast was less of a source of work satisfaction, although for early career professionals like P4 opportunities were available sooner than staff who might have experienced them elsewhere had the school been more stable. The importance of career opportunities is mentioned by Jonasson et al. (2017) . Having some time for professional development was another attractive feature, but this was more because of the work diversity and variety rather than the number of free hours in the working day. Despite the salary not being overly praiseworthy as far as P3 was concerned, for expatriate staff, as P1 alluded to, the employment package was competitive on paper.

5.3 Changes to be staged and managed carefully

Despite the fact that the staff were satisfied by a variety of employment features covering a range of areas, it was also evident that this initial satisfaction declined over time for some, as dissatisfaction grew in others. This might have been due to expectations, some potentially subconscious, no longer being met, but it had a powerful and detrimental impact as Robson (2022) draws attention to. Perhaps the area of the biggest concern was in terms of personal interactions, and most notably senior management as P2, P3 and P1 noted. Almost certainly there was a sense of evolving situation and context not aligning with the anticipated reality, which, as Robson (2022) noted, shape our experiences. Some senior management figures were used to working in European international schools with experienced practitioners where the expectations were very clear. Other leadership figures came from a more localized management mindset in which total subordination was expected, which upset practitioners used to being, and wanting to be, treated with respect. The motivational lessons of inspirational leadership advocated by Sinek (2017) , and indeed Carnegie (2022) , went unheard as time progressed and pressure mounted and default positions were reverted to. The aggressive and critical leadership that P2 noted partially contributed to the feelings of unhappiness and anxiety P1 mentioned. Teaching and learning changes also led to dissatisfaction. The seemingly ever-increasing workload as P4 and P1 discussed, and anonymous job site reviews, the employment package not being honored, and the absence of a medical insurance for locally recruited staff all added to the sense of discontent and frustration. The loss of professional development opportunities and funding, and a lack of promotion pathways meant that progression and recognition also faltered. This ran counter to the expectations of staff, which are a highly powerful emotive feature as Robson (2022) draws attention to. With little to endear the school publicly, and with an internal sense of fractiousness, toxicity and apathy, as P1 alluded to, the difficult task of navigating a period of policy changes and pandemic challenges fast became impossible.

5.4 The pandemic legacy requires smart navigation

Undoubtedly, the pandemic had a significant impact on this case study institution as it delayed the opening by an academic year, meaning a period of lost revenue resulted. Consequently, a second round of staffing recruitment was necessitated and left a number of practitioners unhappy about early cost cutting which led to numerous administrative employees being made redundant. Many accounts of the pandemic discuss the impacts on students’ lost education and the legacy of this, as Broom (2022) illustrates. Other works consider the far-reaching impact on the education industry of this period, including increased educator workloads, mental health and stress level increases, digital skills gap, and funding deficits ( Staples., 2021 ). For private investors the pandemic tested the ability and desire to either play the long game or short one, with rapid cost cutting a risk with a brand built around quality and stability. The lack of senior leadership retention in this situation as lockdowns wore on, increasingly prevalent cuts, and an inexperienced and heavy-handed management style caused, in part, by the situation also exacerbated the issues. So too did the difficulties presented by the sister school not having any real oversight over proceedings, as the study participants alluded to. Inevitably, policy changes were also influential on the eventual school closure, but like many developments were not insurmountable obstacles in themselves as other business enterprises proved.

6 Conclusion

6.1 major findings and implications.

This study has considered the employment motives, job satisfaction and dissatisfaction of four international high school teachers at a British branded institution in China. The study has highlighted that a variety of motivational forces influenced these educators. Some notable motives included the brand, its purported values, the employment package, the people and the potential. When employed at the school early satisfaction was derived from a range of facets, such as the students, class sizes, initial workloads, autonomy and collegiality. However, the results also show these early feelings were replaced by a sense of dissatisfaction over time and noticeable unhappiness by the end. Dissatisfaction resulted from leadership changes and subsequent management practices, increased workload, unmet employment package expectations and obligations, as well as limited professional development opportunities and resources became increasingly scarce. The outbreak of the COVID-19 pandemic also had a detrimental effect on international high school teachers in China as the educational business landscape was adversely affected, increasing their negative experiences, a point to which these teachers alluded.

This research suggests a number of recommendations based on the findings and through consideration of the literature. First, the diverse employment motives of international high school teachers should be recognized. And there is also often an extrinsic consideration as Munyengabe et al. (2017) draw attention to. Second, the finding that international high teachers’ job satisfaction ebbed away while job dissatisfaction mounted with the passing of time should serve as a cautionary tale for businesses, educational providers, leaders and educators alike. Thirdly, the severe impact of the pandemic on international high school teachers should be given due acknowledgement by policy makers, investors, school administrators and staff alike.

6.2 Limitations and future research directions

Inevitably, there were some limitations in this study. Firstly, the size of the data was not sufficient to provide a panoramic view of work-related issues faced by international high school teachers. This study only investigated a single institution and a small number of teachers. This is, of course, attributive to the exploratory nature of the case study, which was well justified. Secondly, the research method mainly comprised of qualitative interviews, despite the fact that this study also considered comments left on external job sites such as ‘Glassdoor’. Consequently, the methodological approach of this study was largely unitary. In addition, the research considered the motivation, satisfaction and dissatisfaction based on the explicitly stated responses of the teachers. It is possible that there were implicit, likely subconscious, drives and factors that also influenced the participants, and their feelings and perceptions, but to explore this would expand the scope of this work beyond what is possible in this study.

There are a number of possibilities for future research. Firstly, it would be good to broaden the scope and collect more information from additional K12 providers and their academic teaching teams. Studies could also investigate administrative staff’s perspectives. Secondly, future research in the same area, and with similar participants, could also utilize different or additional data collection approaches based on this exploratory study’s insights. For example, a quantitative approach such as a large-scale survey will generate a more holistic view. It could also delve into complementary fields, such as leadership and psychology, and explore alternative perspectives and possible contributory factors. Thirdly, research could also be extended to other international high schools in China, not necessarily linked to a British brand or located solely within the immediate locality, with more voices being heard. Additional temporal moments could also be considered. In brief, it would be good to broaden the scope and expand the method so as to gain more insights into the work and minds of teachers working in the international high schools in China and, indeed, throughout the world.

Data availability statement

The original contributions presented in the study are included in the article/ Supplementary material , further inquiries can be directed to the corresponding author.

Ethics statement

The studies involving humans were approved by the Department Ethics Committee of Soochow University, Suzhou, Jiangsu. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

JM: Writing – original draft. GM: Writing – original draft.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This research was funded by the Humanities and Social Sciences Interdisciplinary Research Team of Soochow University (Grant No: 5033720623).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2024.1271604/full#supplementary-material

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Keywords: international high school teachers, employment motivation, job satisfaction, job dissatisfaction, pandemic impact, teacher development

Citation: Mo J and Morris G (2024) Investigating the employment motivation, job satisfaction, and dissatisfaction of international high school teachers in China: the impact of the COVID-19 pandemic. Front. Psychol . 15:1271604. doi: 10.3389/fpsyg.2024.1271604

Received: 31 August 2023; Accepted: 22 January 2024; Published: 07 February 2024.

Reviewed by:

Copyright © 2024 Mo and Morris. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Gareth Morris, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• Research article
• Open access
• Published: 18 September 2020

Determinants of nurse job dissatisfaction - findings from a cross-sectional survey analysis in the UK

• Michaela Senek   ORCID: orcid.org/0000-0003-4226-2220 1 ,
• Steven Robertson 1 ,
• Tony Ryan 1 ,
• Rachel King 1 ,
• Emily Wood 1 ,
• Bethany Taylor 1 &
• Angela Tod 1  

BMC Nursing volume  19 , Article number:  88 ( 2020 ) Cite this article

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A lower recruitment and high turnover rate of registered nurses have resulted in a global shortage of nurses. In the UK, prior to the COVID-19 epidemic, nurses’ intention to leave rates were between 30 and 50% suggesting a high level of job dissatisfaction.

In this study, we analysed data from a cross-sectional mixed-methods survey developed by the Royal College of Nursing and administered to the nursing workforce across all four UK nations, to explore the levels of dissatisfaction and demoralisation- one of the predictors of nurses’ intention to leave. We carried out logistic regression analysis on available data in order to determine what impacts job dissatisfaction.

In total, 1742 nurses responded to questions about working conditions on their last shift. We found that nearly two-thirds of respondents were demoralised . Nurses were five times more likely (OR 5.08, 95% CI: 3.82–6.60) to feel demoralised if they reported missed care. A perceived lack of support had nearly the same impact on the level of demoralisation (OR 4.8, 95% CI: 3.67–6.38). These findings were reflected in the qualitative findings where RNs reported how staffing issues and failures in leadership , left them feeling disempowered and demoralised.

A large proportion of nurses reported feeling dissatisfied and demoralised. In order to reduce the negative impact of dissatisfaction and improve retention, more research needs to investigate the relationship dynamics within healthcare teams and how the burden experienced by RNs when unsupported by managers impacts on their ability to provide safe, good-quality care. These findings predate the current Covid-19 pandemic outbreak which may have had a further detrimental effect on job satisfaction in the UK and other nation’s nursing workforce.

Peer Review reports

The shortage of registered nurses (RNs) is a pressing issue across all four countries within the UK, with a similar trend and concern being observed across Europe and globally [ 1 , 2 ]. In the UK, a drop in recruitment and retention of qualified nursing staff, as well as a rise in patient acuity, have been identified as main reasons for this workforce crisis [ 3 ]. The Rising Pressure report by the Health Foundation in 2017 showed that there was a 0.2% drop in the number of registered nurses, with a median leaver rate of around 15% in National Health Service (NHS) organisations [ 4 ]. Similarly, the Royal College of Nursing, UK, reported that from September 2017 to September 2018 there were 2532 more RN leavers than joiners in the nursing workforce. As a result, there were approximately 40,000 unfilled RN vacancies in 2019 [ 5 ]. Globally, the shortage of RNs was estimated to be 5.8 million [ 6 ].

Such shortages place health care systems under a burden during what might be termed ‘typical’ conditions. However, these systems come under extraordinary strain when hospital and community services are placed under ‘atypical’ conditions, such as those witnessed during the recent Covid-19 outbreak.

A review of systematic reviews of determinants of nurses’ intention to leave, found that the majority of included studies made a distinction between individual and organisational determinants of intention to leave. Individual determinants include age, gender, marital status, educational attainment, stress, burnout, commitment, job satisfaction, low serum cholesterol, weight and sleep disturbance [ 7 ]. Organisational determinants have centred on malfunctioning management and lack of supervision [ 8 ]. On an individual level, among all the multiple determinants of turnover in adult nursing, job dissatisfaction and nurse stress were some of the most important factors identified in the literature. For instance, individual studies by Larrabee et al., have shown that job dissatisfaction is predictive of both the intention to leave as well as actual turnover [ 9 ].

Whilst several studies have sought to address the range of predictors of intention to leave, some have furthered the field by use of a theoretical approach. One such attempt provides a link between job satisfaction and nurse turnover behaviour [ 10 ]. The theory categorised economic factors (pay, job market and training), structural factors (work environment, work context), and individual factors (psychological, demographic) as major determinants of nurses’ job satisfaction that influence behavioural intentions and turnover [ 11 ].

Further, a review by Coomper et al., that explored the components of job satisfaction and their impact on intention to leave, identified stress and leadership as main components that have the strongest impact on dissatisfaction among adult nurses and turnover. Whilst education and level of pay were found to be inconsistent, stress and leadership were identified as the best predictors of lack of satisfaction and intention to leave [ 10 ]. Previous literature has demonstrated the importance of leadership which is ethical and fair. Ozden et al. have raised the importance of fair leadership and leaders’ awareness of power-sharing and their effect on nurses’ job satisfaction in challenging times [ 12 ]. The findings showed that lack of fairness and ethical leadership can have particularly bad consequences on nurses during difficult times such as the COVID-19 pandemic [ 13 ].

Prevalence of job dissatisfaction among RNs was further highlighted through findings of a cross-sectional survey of 488 hospitals across Europe and the United States, which explored the level of dissatisfaction among RNs and associated outcomes. It found that job dissatisfaction was highest in Greece (56%), followed by Ireland (42%) and England (39%). Notably, a higher patient to nurse ratio (more than 10:1 in Greece and more than 8:1 for the latter two), as well as poor work environment, was reported in these countries [ 14 ].

A recent review of systematic reviews, exploring interventions to reduce adult nursing turnover, concluded that more high-quality primary research is needed to inform decision-making by human resource managers and organisations to improve retention strategies. The study included 9 systematic reviews in total. The review did not have definite findings due to the poor quality of evidence. Seven reviews were rated as moderate and two as being of poor quality. The main reasons for reviews being in the moderate rather than strong evidence category were the lack of publication of a review protocol , unclear search strategy performed , the failure to have two reviewers check the selection and data extraction and not providing a list of both included and excluded primary studies. More high-quality research would allow a better understanding the current main causes of RNs dissatisfaction based on primary research and is therefore pivotal to address this issue [ 15 ].

The aim of this study was to undertake a secondary analysis of a large UK wide data set in order to assess a set of self-reported individual and organisational predictors of nurses’ satisfaction/ dissatisfaction. We defined overall job satisfaction as a sum of all individual and organisational determinants and proposed to test a set of potential determinants, both individual and organisational, to see if and how they are associated with overall self-reported RN satisfaction. These data were collected during 2017, ahead of recent global pandemic conditions. Research about the determinants of dissatisfaction, as one of the predictors of nurses’ intention to leave is becomes even more relevant during a pandemic crisis such as COVID-19.

Whilst we recognise that there are many factors involved in nurses’ intention to leave, we have used the data available to us. In this study, we cannot predict ‘intention to leave’ but we are exploring job satisfaction as one of the previously known determinants of the intention to leave within a cohort of adult acute RNs.

This study presents findings from a secondary analysis of an online-based cross-sectional survey of registered nurses from across the UK developed and administered by the RCN in May 2017 [ 16 ]. The RCN is the UK’s largest professional nursing body consisting of 450,000 members of registered and non-registered nursing and health care staff. A report from the survey, produced by the RCN and covering all questionnaire domains, is available on the RCN website [ 5 ].

We deployed an explanatory mixed methods study design. We began by descriptively exploring responses in the first part of the questionnaire. We then conducted a multivariate logistic regression modelling of the available data. From this, we initially developed a framework, and subsequently a thematic analysis, of the qualitative data. Finally, we (re)applied this to the quantitative data in a cyclical manner. The method therefore followed a process closely aligned with abductive reasoning. Definitions of abductive reasoning vary, however, all recognise it as a process where there is a cyclical and creative movement between the formulation of hypotheses and observed phenomena [ 17 , 18 ]. While some identify the challenges of utilising abduction in qualitative studies [ 19 ], it is a form of reasoning well suited to mixed methods research as it develops claims supported from both deductive and inductively sourced evidence, in situations where the research is not driven exclusively by theory or by data [ 20 ].

Study population

In May 2017, a staff survey of RN’s was carried out by the Royal College of Nursing (RCN). The survey was developed by the RCN, sent to all RCN members and was advertised on social media. The sample therefore consisted of both RCN members and non-members across the UK. The final sample responses comprised of 29,345 nurses. For the purpose of analysis, we identified from the data base and then included adult acute care nurses, which comprised 7040 RNs in total. In the UK, adult acute care covers all aspects of medical and surgical hospital in-patient care for those over 18 years of age but does not usually include in-patient mental health care. In order to provide a clear research focus on a specific group of RNs, we excluded RNs from the community, children’s nursing, mental health nursing and learning disabilities sectors. These settings will be analysed in subsequent pieces of work. The questionnaire did not ask the respondents to identify the specific hospital that they worked in for reasons of anonymity. It also did not ask for any demographic details. As a result, we were unable to carry out our analysis at the level of hospital and NHS trusts or consider the impact of demographics.

Data sharing agreement and ethics

Before work commenced, a data sharing agreement was obtained between The University of Sheffield and the RCN. All data was anonymised prior to being shared with the research team. Ethical approval was obtained on 27/08/2019 from the University of Sheffield (Reference Number 026774) to conduct a secondary analysis of the anonymised RCN survey.

Measured outcomes

We aimed to assess the determinants of the overall nurse dissatisfaction (with the job). In the survey, all responses were relating to RNs experience of their most recent shift.

The binary outcome of Demoralised or Not Demoralised was derived from response to the question: I felt demoralised (after my last shift). The RCN designed the survey and chose the phrasing of this question. The respondents could Agree, Strongly Agree, Disagree, Strongly Disagree with the statement. The Agree and Strongly Agree were merged as was Disagree and Strongly Disagree. We use the term Demoralisation , whilst recognising that Dissatisfaction is the more common variable used to predict intention to leave and turnover . However, respondents were in fact reporting on feeling Demoralised, which is a much stronger sentiment.

We aimed to test all independent variables available from the survey that have been identified in previous literature as determinants of nurse job dissatisfaction and demoralisation. The dependent variable was tested against all available independent variables in Table  1 .

Respondents were also requested to respond to an open question asking them to describe and/or give examples of their last shift and any concerns or challenges they were able to observe. There was no word limit set on the length of replies to the open response question. These varied considerably in length and the amount of detail provided from a couple of sentences to 1–2 paragraphs. Due to the large amount of data from 1747 responses, 400 pages, we randomly sampled 10 pages of data for the analysis. This resulted in descriptive, narrative data from 368 individuals (20%) in total. While no formal test of data saturation was performed, a member of the team checked the emerging coding against a further 10 pages of data and no new codes were noted. In addition, Braun & Clarke suggest that for qualitative analysis of open question survey responses, a sample size of over 100 respondents is required for a large project [ 21 ]. We are therefore confident that with the responses from 368 individuals, and from checking an additional 10% of the data, that data saturation was achieved.

Data analysis

An explanatory analysis was used to draw conclusions about the findings from the survey. In the first part of the analysis, we conducted univariate analysis with independent variables from the survey in order to assess the relationship and best model for predicting job dissatisfaction and demoralisation. A normality test showed that data was normally distributed for all responses. We then carried out a backwards logistic regression in order to select variables that best predict the model in order to determine which variables most affect nurses feeling Demoralised/Not Demoralised. We identified determinants that were most associated with affecting demoralisation.

From this point, a set of categories based on the findings from the regression modelling were used as an initial framework to organise and explore the qualitative data. Specifically, narratives around what led to dissatisfaction and feeling demoralised within this data set were considered. The qualitative data set was then further coded into sub themes and then overarching themes. Quirkos (v2.3) was used to assist in this phase of the analysis.

For the qualitative analysis, responses were analysed from 368 respondents who were representative of the overall respondents in terms of their clinical setting e.g. medicine, surgery. No analysis was performed to break down findings by these two clinical settings. Three researchers [SR, TR, MS] coded the responses.

The final stage of analysis was to more fully integrate the two data sets. Following processes of abduction [ 17 ], we aimed to understand the complexity of the interrelationships that exist between our data sets and the interpretations of them. We did this in order to integrate surface (semantic) and deep (latent) structures of a phenomenon; in this case understanding the determinants of job satisfaction. In practice, this process was achieved by research team meetings to iteratively align the quantitative and qualitative data sets and their analysis while simultaneously incorporating previous empirical work into these critical discussions. Again, in line with abduction, this allowed the juxtaposition of what is familiar with that not so familiar in order to generate robust explanations (that can be further tested) [ 17 ].

For reasons of flow and clarity, the results are presented as the two separate data sets and the more integrative analytical work is presented in the discussion.

Initially there were 7040 Adult Acute RNs in our sample. Out of those, 67.6% responded to the question on whether they felt demoralised ( N  = 4770), whilst the remaining 32.4% chose ‘Neither Agree or Disagree’ option, which was treated as ‘choose not to say’ and therefore as a missing value. Of the 4770 responses, 63.8% of RNs reported feeling demoralised , whilst 36.2% reported feeling not demoralised (see Table  2 ).

To test the associations with nurses’ demoralisation we included the following determinants in the model:

In the binary logistic regression analysis, there were 3023 missing cases, or ‘neither agree or disagree’ options selected for at least one of the variables. These were treated as ‘no response/ ‘choose not to say’ due to the nature of the question and was therefore noted as ‘missing response’. The respondents who chose not to respond to this question could therefore not be included in the analysis. As a result, in total, 1747 valid cases were in the final analysis.

The overall model was statistically significant x 2 (6) = 959,519, p  < 0.001, predicting 82.7% of all cases.

Missed care ( p  < 0.001), lack of adequate support and supervision ( p  < 0.001), understaffed shift ( p  = 0.001), inability to take a break (p < 0.001), worked overtime ( p  < 0.001), action taken when concerns were raised ( p  < 0.001), were all significantly related to demoralisation.

Respondents who reported missed care, that is having to leave necessary care undone , were five times more likely to report being Demoralised (OR [5.02] 95% CI:3.67, 6.38). The RNs were 4.8 times more likely to be demoralised if there was a lack of support (OR [4.8], 95% CI: 3.67, 6.38). Other factors that were significantly associated were; whether action was taken after they raised concern , if they could not take a break , if they had to work overtime and if the shift was understaffed (see Table  3 ). Perceived high absence/sickness, percentage of temporary staff on the shift and number of patients seen, were excluded from the model.

Qualitative findings

Responses were analysed from 368 respondents who were representative of the overall respondents in terms of their clinical setting e.g. medicine, surgery. No analysis was performed to break down findings by these two clinical settings. Three researchers [SR, TR, MS] coded the responses and those codes were subsequently grouped into 16 sub-themes. Further analysis revealed four main themes; Staffing Issues , Lack of Support , Risk , and Personal Impact (see Fig.  1 ). We describe each of the four themes below, using extracts from the data set to illuminate and confirm theme meanings. While each of these themes were reasonably equally weighted in terms of the number of responses made, as we will show, the first three seem to act synergistically to produce the depth of feeling expressed in the fourth theme. It is important to note that the analysis here, like the quantitative analysis, focused on dissatisfaction and demoralisation. Positive data, particularly relating to the first two themes, was also present and likely reflects the experiences of those 36% of RN’s who did not report feeing demoralised.

• Staffing issues

All respondents discussed staffing issues in their daily work and the challenges faced as a result. They spoke about a lack of adequate staff numbers, which resulted in higher than manageable patient to nurse ratios, and of the detrimental impact of this for both patients and staff:

‘We are chronically understaffed, and I feel this regularly has a negative impact on patient care and staff wellbeing. We have patients that deteriorate quickly as well as a number of confused and high falls risk patients. I believe the lack of staff contributes to not being able to provide the highest level of care.’

An aspect of this theme is the reference to personal, physical and emotional consequences of maintaining one’s professional role under such conditions and how these impact upon the quality of care provided:

‘All staff are human and can only take so much of doing more than their workload. People end up being off sick due to exhaustion and stress. It's an impossible situation. Bottom line is understaffing to save money is as good as a chocolate tea pot. Eventually the staff left will melt and we'll be left with nothing but a mess.’

Respondents described challenges which resulted from rota gaps as well as instances where, if they did have a full complement of staff, staffing resources would then be moved to cover gaps in other areas of the hospital. They described attempts to fill such rota gaps with temporary agency and bank staff. This posed a separate set of challenges due to the temporary nurse’s lack of familiarity with the ward and the patients:

‘I have to work with a different nurse every shift. It's stressful trying to supervise bank or agency nurses as well as doing my own work. They aren't allowed to use certain pieces of equipment such as blood sugar monitoring or infusion pumps.’

This theme demonstrates the challenging situations faced by RNs in their daily work. It demonstrates the complexity of this issue that leads to feelings of frustration and despair due to a lack of staff who are adequately trained and familiar with the ward setting.

Failures in leadership and Organisational support

This theme describes the negative feelings attributed to a lack of support from hospital management, as experienced by respondents. This lack of support was experienced in a range of ways from simple disregard to being made to feel incompetent and even blamed for the poor state of patient care. The disregard encountered by RN’s was not only for themselves but also, they felt, extended to a disregard for patient’s needs:

‘I feel our patients are behind us, but I do feel that upper management are disengaged with patients & staff’s real concerns and issues.’

This apparent disconnect and disregard led to struggles with respondents trying to secure necessary staff or develop systems to help cope with excess workload. Such efforts were often undermined by managers leaving respondents disempowered and dissatisfied:

‘Our site manager is unable to help us and refuses to let us save beds the night before knowing that we have these patients coming in.’ ‘I have seen a large number of staff leave due to the pressures of being understaffed and the ward manager not helping on the ward. Nurses feel quite negative about matrons as they are not seen to do anything about understaffing.’

At its worst, this disregard of concerns, and struggle to get support in providing quality patient care, was reflected back on the respondents in ways that led to stress, blame and feelings of professional vulnerability:

‘Staff are made to feel incompetent by management when things are not done. It gets put down to poor time management on the nurses’ part. Went home from that shift feeling sad for the patients, angry with the management, absolutely exhausted and dreading the next shift.’ ‘I try to do everything, but nothing is achieved. And yet the threat of disciplinary action hangs over nurses if anything goes wrong. […] We don't challenge and yet we are being challenged by the government and hospital bosses.’

What is being described in this theme are broken relationships between respondents in the clinical area and those senior managers they rely on to provide practical and emotional support in delivering safe and effective care. Rather than being heard by those with the ability to help, many respondents report a perceived lack of action, or worse, actions that challenge their commitment and leave them feeling intimidated and demoralised.

Risk to self/others

The understaffing and lack of support noted above generate risks to both the respondents and the patients they care for. In this theme, respondents give detailed accounts of the ways in which necessary care is left undone and the risk this poses to patients as well as the risks that they face during their day-to-day work. Examples provided point to the immediate risks to patient well-being and to the subsequent impact on the wider health care system.

‘Looking after 15 patients you cannot meet patients’ needs, results in cutting corners and not always delivering safe care. This results in extra pressures due to the bigger patient workload. Wound dressings are not being renewed when they should be which results in further infections and extra time in hospital.’ ‘I often have to look after 10 patients and the medication round takes so long to administer, some patients have medication up to 2 hours late. I also cannot check observations as frequently as I would prefer.’

As well as describing observations about the increased risk of adverse events to patients, RNs described risks to themselves. They noted that whilst they tried to care for their patients, their own health and safety was not prioritised and was therefore at risk. They often described putting themselves in situations where their own safety was being jeopardized:

‘I received a needle stick injury at work. Patient who was needle phobic knocked needle into me. I was unable to follow correct procedures after injury. No staff cover for me to go to A&E straight away (I had to go 2 days later- waited 3hrs to be seen) to have procedural blood tests done.’

Respondents noted the primary and secondary impact of not being afforded enough resources to carry out the care they aspire to. The primary impact is noted in relation to patient care, with a secondary consequence for themselves:

‘I am feeling sick with stress and fear for patient safety.’

The respondents spoke about being in situations where they had to make choices between their own safety, versus the safety of their patients. The situation described below is an example where highly vulnerable patients, and a vulnerable staff member, were left risk-exposed by chronic under-resourcing:

‘When I left work there was no night nurse to hand over to for the 2 bays of patients I was looking after, should have been one bay and a side room. I'm 36 weeks pregnant in an acute respiratory ward. I stayed for half an hour to wait whilst they tried to find a cover nurse but sadly the whole hospital was in the same situation. I was told to go by the nurse in charge that shift. This left 2 nurses looking after 35 patients. 4 of which are high dependency on NIV. Not safe!’

This theme demonstrates the awareness of a heightened risk of adverse outcomes when staffing resources are short. Respondents recounted not only awareness of times when they were failing to deliver adequate patient care but also of the times when they had to make choices between safe patient care and their own wellbeing – usually erring toward neglecting their own wellbeing and putting patients first. This compromise between the patients care and safety and their own wellbeing led to mental distress, anxiety and extreme feeling of dissatisfaction; in short, it had a significant personal impact for these nurses.

Personal impact

The three themes described above point to a set of resource and organisational conditions that often resulted in the failure to deliver the best care. Collectively, these have huge personal impact on the respondents with concomitant consequences for their wellbeing and job satisfaction. Respondents described strong feelings of despair and being demoralised and highlighted how these feelings about their job impacted both their personal and their professional lives:

‘Emotionally exhausted after shift, being in a bad mood to family, crying at home because of the pressures. Feeling physically unwell during shift as no time to rest/take break for air or drink of water. Depressing knowing that you won't leave work on time. Busy workdays are good and can make you feel energised and positive but being overstretched on every single shift and worrying about mistakes being made is exhausting.’

They described scenarios which lead them to consider ways in which they can leave or change their professions. They also described scenarios which had led their colleagues to leave the profession:

‘We stated that 2 registered nurses to look after 19 patients (11 of whom were post-operative) and 10 of whom needed discharging later in the day… I have been qualified for one year and I have already started the process of going into a different career. I will have given up nursing within the next 18 months.’

The observations which the respondents describe suggest that the obstacles faced during work have a profound negative influence on their lives. The negative experiences during their working hours diffuses into their after-work hours impacting their personal and home life to an extent that they are struggling to deal with. The situations which form an overall experience leave them feeling a sense of despair and hopelessness; these then form the basis for their intentions to leave. The quote below draws together findings from the first three themes showing how they collectively build to create strong feelings of dissatisfaction and demoralisation that impact on personal life:

‘Some days nursing affects my whole life. I'm tired, I'm demoralised and I'm stressed. I try my hardest to give my best to my patients, but every day is like spinning plates and it feels like if my concerns are raised to managers then I am to blame for not coping or managing my workload properly. It affects my family life as some days I wake up at 2am worrying about something work related. We have a high sickness rate, so we are down on staff and we have a high turnover of staff as people are always leaving.’

Ultimately, as this quote and theme suggest, intentions to leave may become actions once the personal and professional situation becomes unmanageable and the losses become far more than benefits of doing a job that they describe as one that they once loved.

Summary of findings

The results from the survey show that nurses were most likely to feel demoralised if they missed care, followed by if they reported lack of support and Lack of action when concerns are raised . Being Unable to take a break, Understaffing , and Having to work overtime were also significant factors.

Qualitative findings demonstrate significant concerns about inadequate staffing and how this leads to demoralisation and dissatisfaction when safe and effective care cannot be provided. These feeling are compounded by a lack of managerial support which can lead to feelings of stress, blame and professional vulnerability. Staff often have to make choices between risks to the patient and risk to their own wellbeing. In such situations nurses tend to prioritise patients. The inability to provide quality care, have concerns addressed by management, take breaks and finish on time take a personal toll on nurses leading them to consider leaving the job and the profession.

Results here provide a picture of the factors that generated demoralisation among nurses in the UK in the period leading up to the COVID-19 pandemic. A recent review of the experience of nurses during epidemics associated with respiratory conditions, revealed that the quality of leadership and organisational factors, as well as staffing resources, leading into such events has a significant impact upon how the health care system is able to perform [ 22 ]. With this in mind, our paper is useful in being in a position to describe the conditions many nurses were working under at the time of the Covid-19 pandemic onset, and from which we can begin to understand the healthcare system’s operational performance during these events.

While our quantitative data showed that leaving necessary care undone and lack of support were the factors most likely to impact on feeling demoralised (and therefore on job dissatisfaction), the qualitative data suggest a strong emphasis on adequate staffing. On closer consideration, it becomes apparent that it is not understaffing per se that is the main issue of concern but the consequences of this and the lack of support to avoid or prevent these consequences. The primary focus of the nurse is on the ability to provide safe and effective patient care and dissatisfaction and feeling demoralised occurs when this cannot be achieved and those in more senior positions do not respond to their expressed concerns. Given that missed care has been seen as the mediator linking lower registered nurse staffing levels with increased patient mortality [ 23 ], it seems no surprise that not being able to provide adequate care is one of the greatest predictors of job dissatisfaction among the respondents [ 24 ].

In light of our findings of the impact of missed care on dissatisfaction and feeling demoralised, any approach aimed at increasing RNs’ satisfaction and retention should focus on interventions which allow RN’s to provide safe and effective nursing care. In addition to evidence that understaffing increases the occurrence of missed care and therefore job satisfaction, Senek et al. have recently demonstrated that ensuring adequate staffing numbers by covering rota gaps only with temporary staff (agency and bank staff) does not necessarily lower the occurrence of missed care [ 25 ]. In recent years, a solution to severe understaffing has been to deploy temporary agency and bank RNs, who often rotate between specialities and hospital sites. This temporary deployment means that they are often not familiar with the setting, staff or patient groups they are working with. Not surprisingly then, it has been shown that there is more missed care on shifts that have higher proportions of temporary staff than on understaffed shifts [ 25 ]. Therefore, in order to ensure that RNs can achieve a satisfactory level of quality care provision, it is not only adequate staffing levels but also the right type of permanent staff, which allows for continuity of care and team building that can reduce the occurrence of missed care. As indicated by our findings, this has a significant impact on RN’s satisfaction, and the likelihood of RN’s remaining in the profession [ 10 ].

The importance of not being able to take a break (OR = 2.0) and working overtime (OR = 1.8) can also be accounted for in this way. The quotes provided mention these issues, but they are a secondary narrative to the primary concern of being able to provide adequate, safe and effective care. These also link into another important finding, that of the choices nurses are forced to make when staffing levels are low, support is lacking and patient care is therefore at risk. Missing breaks and working overtime are resorted to in order to ensure necessary patient care is not missed, or at least to minimise the amount that is missed. In this way, they represent a secondary, but still important, mechanism in generating job dissatisfaction by forcing nurses to choose between their own needs and those of their patients. This resonates with previous findings which showed that nurses’ inability to take breaks was due to patient load , unpredictability of patient needs and reluctance to burden other nurses [ 26 ].

Collectively, the inability to provide quality care, have concerns addressed by management, take breaks and finish on time take a personal toll on nurses. It impacts their physical and mental wellbeing. It leaves them feeling undervalued, disempowered, intimidated, and vulnerable to committing clinical errors and the professional and personal consequence of this. It affects their relationships outside of work and, ultimately, it leads them to consider whether to leave the job and even the profession. Similar findings have been reported where psychological disempowerment of RNs resulted in job dissatisfaction, lack of organisational trust and staff nurse burnout [ 27 , 28 ]. Although the questionnaire did not specifically ask whether the respondent intends to leave the profession, these factors have previously been reported to contribute to RNs job dissatisfaction which is a predictor of intention to leave [ 7 ].

These findings have relevance for how managers and organisations may consider staffing and supporting nurses. Sellgren et al. have shown that nurses job satisfaction is lower when managers are ‘invisible’ whereas strong facilitative leadership behaviours create an environment that increases job satisfaction [ 29 ]. They further note that when managers lead with kindness and respect, and in ways that demonstrate ethical leadership [ 12 , 13 ], it is more likely that staff also demonstrate the same behaviour towards the patients. Similarly, Morsiani et al. demonstrated that when managers adopted leadership styles focused on monitoring and intervening to correct errors it has negative impact on nurses’ levels of job satisfaction whereas transformational leadership styles that involve respect and care for others improve staff satisfaction [ 30 ]. It may also be worth managers taking a collective nursing team view on what constitutes sufficient numbers and mix of staff when planning the nursing roster. Adams and Bond showed that when staff considered there were sufficient numbers of skilled staff rostered and organized appropriately, nurses’ job satisfaction was greater [ 31 ]. Importantly, they also linked this to non-hierarchical leadership styles and management that was respectful and patient-centred [ 32 ].

We have reported on the level of RNs work morale before the COVID-19 pandemic. During and post pandemic it is predicted that strain and work-related stress are much greater, as reported in previous health emergencies. For instance, during and following the Severe Acute Respiratory Syndrome (SARS) outbreak, Taiwanese RNs reported high levels of stress, even more so in moderate-risk areas than those working in high-risk areas [ 33 ]. A cross-sectional survey reported that nearly 8% of the nurses thought they should not care for SARS patients and considered resignation, mainly due to increased work stress and perceived risk of fatality. These findings are important in view of the current COVID-19 pandemic and any future impending outbreaks [ 34 ]. Prior to the COVID-19 pandemic, UK RNs intention to leave rates were reported to be between 30 and 50%. The evidence-base from studies on SARS and Middle Eastern Respiratory Syndrome (MERS) epidemic outbreaks in South Korea [ 35 ] suggests that this phenomenon is exacerbated in a deadly disease outbreak. Currently, in the UK, concerns over safety, reported lack of personal protective equipment and high fatality rate of health care professionals will further increase work-related stress during the COVID-19 pandemic. The unprecedented crisis caused by the pandemic may therefore have a further negative impact on nurse retention.

Limitations

The variables that were tested from the survey were mainly job-related, interpersonal, and organisational factors. The personal and individual factors such as age, gender and level of experience were not available to us and could therefore not be included in the analysis. Similarly, we cannot be sure that the qualitative data represents an accurate spread of views from across the adult nursing population.

Future direction of research

It seems clear that further research is needed to address the root causes of RN’s dissatisfaction. Future work should investigate the relationship dynamics within healthcare teams and how the burden experienced by RNs when unsupported by managers impacts on their ability to provide safe and effective care. Our data shows that RNs feel that there is limited recognition of the wider issue of understaffing and, when the issue is raised, they are often intimidated into continuing to work under these difficult conditions. In this instance, we have demonstrated their issues with management, but we recognise that RNs are part of a health care team that consists of many different roles. Therefore, to address this wider issue, there needs to be involvement of the whole team and all stakeholders involved. However, these issues will forever remain if RNs are experiencing severe workloads and poor staffing levels that put their patients at risk due to missed care [ 36 ]. Understaffing is an underlying issue, which needs to be recognised. For this to be dealt with effectively, it is not enough to train more people to be nurses when the dissatisfaction and the leaving-rate is high for those who are currently in the profession.

A high proportion of feeling demoralised and dissatisfied was reported by registered nurses and was most likely to occur as a result of missed care and lack of support and action when concerns were raised about this. Whilst some of these findings are consistent with those from previous studies, their level of impact and the mechanisms by which they cause a detrimental effect on nurses’ moral and job satisfaction have not previously been fully discussed. Addressing the issues highlighted here will be important in addressing the root causes of RN dissatisfaction and thereby improving retention and reducing the high turnover rate among nurses. We intend that this paper contributes to the national and international debate about how the profession is regarded by governments and organisations involved in healthcare, both during pandemic conditions and during periods of recovery.

Availability of data and materials

The survey data analysed in this study was not publicly available. The data that support the findings of this study are available from Royal College of Nursing, but restrictions apply to the availability of these data. To access the data, we obtained a Data Sharing Agreement and Ethical Approval for the current study.

Abbreviations

National Health Service

Registered Nurse

Royal College of Nursing

Severe Acute Respiratory Syndrome

Middle East Respiratory Syndrome

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Acknowledgements

We would like to thank the Royal College of Nursing for allowing us to complete this secondary analysis of their data and to acknowledge Claire Helm and Julian Russell for their role in the design of the original survey. We would also like to thank the Statistical Service Unit, University of Sheffield for their support and guidance with the statistical analysis.

The project was funded by the Royal College of Nursing (RCN) as part of the Strategic Research Alliance (SRA) between the RCN and the University of Sheffield. The views expressed are those of the author(s), and not necessarily those of the RCN or the University of Sheffield.

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Senek, M., Robertson, S., Ryan, T. et al. Determinants of nurse job dissatisfaction - findings from a cross-sectional survey analysis in the UK. BMC Nurs 19 , 88 (2020). https://doi.org/10.1186/s12912-020-00481-3

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It's not just about the money: recruitment and retention of clinical staff in general dental practice - part 1: dentists

Affiliations.

• 1 Jessica A. Holloway MChD/BChD, MPH, PhD, FHEA Specialty Registrar in Dental Public Health, Public Health Wales, Cardiff, UK.
• 2 Ivor G. Chestnutt BDS, MPH, PhD, FDS(DPH)RCSEd, FDS RCSEng, FDS RCPSGlas, FFPH, DDPH RCS ENG, FHEA Professor and Honorary Consultant in Dental Public Health, Cardiff University, Cardiff, UK.
• PMID: 38520198
• DOI: 10.1177/20501684241232212

Increasing difficulties in recruitment and retention of dentists and dental care professionals in general dental practice in the UK is affecting delivery of NHS dental services. Reports of dissatisfaction among the general dental practice workforce indicate there is a significant risk to the future dental workforce supply which will affect access to dental care and worsen oral health inequalities. Understanding the factors related to job satisfaction and dissatisfaction of dental professionals would be useful in managing recruitment and retention issues and ensure a dental workforce exists which is able to meet the needs of the population. The aim of this literature review was to identify factors which contribute to job satisfaction and dissatisfaction of clinical staff in general dental practice. Database searching was conducted systematically through PubMed/Medline, Scopus, Ovid, and the National Grey Literature Collection. Part 1 of this two-part series discusses the factors relating to dentists. Twenty-two relevant articles were identified, which were qualitatively analysed using Herzberg's motivation-hygiene theory as an analysis tool. Target-driven and restrictive contractual arrangements are a major factor contributing to dissatisfaction of dentists, as well as time pressures, poor quality equipment, and unfair remuneration. Dental contract reform should aim to minimise factors contributing to dissatisfaction and increase factors which increase satisfaction, if sufficient numbers of dentists are to be persuaded to continue to provide state-funded dentistry.

Keywords: Recruitment; dentists; retention; satisfaction.

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• General Practice, Dental*

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Job Dissatisfaction and Its Predictors among Healthcare Workers of ‘Type 2 Health Clinics’ in North-Eastern Malaysia

Mohd ikhwan azmi.

1 Department of Community Medicine, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kota Bharu 16150, Kelantan, Malaysia

Mohd Nazri Shafei

Anees abdul hamid.

2 Kelantan State Health Department, Ministry of Health Malaysia, Kota Bharu 15200, Kelantan, Malaysia

Associated Data

There is no reported data.

It is crucial to comprehend factors associated to job dissatisfaction among healthcare workers (HCWs) in Malaysia’s primary health clinics, especially those working in ‘Type 2 Health Clinics’ which cater for populations of >50,000 and a daily average number of patients between 500 and 800. It is essential to ensure that effective strategies can be proposed to promote job satisfaction. A total of 314 HCWs from ‘Type 2 Health Clinics’ in north-eastern Malaysia consented to participate in this cross-sectional study, conducted between October 2020 and December 2021. The Job Satisfaction Survey was used to assess job dissatisfaction. The prevalence of job dissatisfaction was 35.7%. The significant factors associated with job dissatisfaction were younger age and those who were dissatisfied with their yearly performance mark. Targeted interventional activities for young HCWs and for those who are dissatisfied with their yearly performance mark are recommended to improve job satisfaction.

1. Introduction

Job dissatisfaction consists of one’s cognitive, emotional, and behavioral response to their job [ 1 ]. It was discovered that agreeableness (the traits of cooperation and likeableness), extraversions (the traits of being assertive, enthusiastic, and energetic), and conscientiousness (the traits of high level of organization, hard work, and goal persuasion) are related to job satisfaction, whereas neuroticism (the traits of lack of emotional stability and lack of positive psychological adjustment) and lack of openness to experience (the trait of unconventionality) are related to job dissatisfaction [ 2 ]. Apart from that, job dissatisfaction also has been linked to workers’ level of autonomy in how they act, given their skill set and work expectations. It also has to do with employees’ psychological challenges in carrying out their duties [ 3 ]. Job dissatisfaction can have a negative impact on both the organization and the people receiving the services. It can jeopardize patients’ safety and treatment, being related to poor job performance and absenteeism amongst healthcare workers (HCWs) [ 4 ]. Hence, it is important to determine job dissatisfaction, especially among HCWs.

In Malaysia, the primary health clinic is an important structure in the public healthcare system as it provides curative, promotive, and rehabilitative care services. However, there is a noticeable shortage of HCWs in primary health clinics, as most of them leave for the private sector or leave the healthcare system entirely [ 5 ]. This can lead to an imbalance between those who provide healthcare services and those who require healthcare services, which contributes to occupational stress and leads to job dissatisfaction, which later leads to quitting [ 6 , 7 ]. Apart from that, poor job performance may jeopardize patients’ safety and care [ 4 ]. Hence, it is important to determine the prevalence of job dissatisfaction and to identify its predictors among HCWs in Malaysia.

2. Literature Review

2.1. job dissatisfaction and healthcare workers.

Internationally, two studies conducted in Ethiopia found that the prevalence of job dissatisfaction was around 46% [ 8 , 9 ]. However, Behmann et al. (2012) found that the prevalence of job dissatisfaction among primary care physicians in Germany was slightly lower at 36% [ 10 ]. In a local Malaysian context, Manan et al. (2015) reported that 48% of pharmacists in Negeri Sembilan, Selangor, and Perak were unsatisfied with their job, and found that HCWs aged 35 and older and who had worked more than seven years’ experience are more likely to be satisfied with their jobs [ 11 ]. Aidalina M. (2015), who studied the brain drain phenomenon of physicians in the public and private sector in Selangor and Kuala Lumpur, found that 35.6% were dissatisfied with their work and 55% of those respondents felt neutral about public-sector job satisfaction, driving them to leave the public sector to work in the private sector [ 12 ].

Numerous factors can contribute to job dissatisfaction, such as co-workers, supervisors, work, and promotion [ 13 ]. Job dissatisfaction was found to be associated with age when being both a young and an old worker (near retirement age) [ 11 , 14 ]. Interestingly, looking at the years of employment, it was noted that the longer the worker’s work experience, the more satisfied they were with their job [ 14 , 15 ]. However, it was also found that those who work for more than ten years are less satisfied than young workers [ 10 ]. Other than that, gender dominance is subjected to conflicting studies in regards to job dissatisfaction. There were studies that found no gender difference with job dissatisfaction [ 10 , 11 , 14 ] and studies that also found that females were more prone to job dissatisfaction than males [ 12 , 16 ].

One of the elements that influenced job satisfaction for public servants in Malaysia was satisfaction with their yearly performance mark, which is an annual assessment report, often known as ‘Laporan Nilaian Prestasi Tahunan’ (LNPT). LNPT, according to Malaysia’s Public Service Department, aims to improve employee motivation and performance and identify employee potential, and can be used for employee promotion, training, and placement, as well as to effect salary increment. The supervisor evaluated the workers once a year as a means of providing feedback in which they try to identify their subordinates’ areas for improvement, assist them with further training, and help them learn new skills to accomplish their job [ 17 ]. A study in Indonesia discovered a high link between perceived supervisor support and job satisfaction, indicating a meaningful association [ 18 ]. Aside from reducing worker burnout and increasing job happiness, excellent support also helps employees feel more secure in achieving their work goals [ 19 ].

Apart from that, job-related factors also contributed to job dissatisfaction [ 20 ]. In depth, they can be divided into intrinsic variables of co-workers, supervision, and work itself, and extrinsic variables of salary and advancement [ 13 ]. Working environment plays an important role as an unfavorable working environment contributes to job dissatisfaction [ 10 , 16 ]. Aside from that, those working under appropriate and supportive supervision and colleagues are more pleased with their job compared to those who do not [ 9 , 21 ]. In a local context, job-related factors also play a role in job dissatisfaction as a study involving Malaysia’s family physicians in 2016 found that Malaysian family physicians were dissatisfied with their salary, recognition, and their working conditions [ 22 ].

2.2. Primary Health Clinic in Malaysia

According to the Family Health Development Unit, Ministry of Health, Malaysia under the Primer Infrastructure Development Sector, a health clinic can be divided into seven types depending on its catchment population and daily average number of patients. It provides services such as the out-patient department, accident and emergency, maternal and child health, dental, rehabilitation, radiography, laboratories, and pharmacy [ 23 ]. Table 1 shows the types of primary health clinic in Malaysia

Primary health clinic types in Malaysia.

3. Materials and Methods

3.1. study design and population.

A cross-sectional study was conducted between October 2020 and December 2021. It was held at all ‘Type 2 Health Clinics’ in north-eastern Malaysia which also have two different clinic working systems. Two of the clinics adopt a shift system, namely Health Clinic A and Health Clinic B, and two adopt a non-shift system, namely Health Clinic C and Health Clinic D. These clinics were chosen as their catchment population was >50,000 and their daily average number of patients was between 500 and 800 [ 23 ]. Using a two-proportion formula, with a 95% confidence interval, 5% precision, and allowing a 10% non-response rate or data entry error, the required sample size was 335 ( p = 0.63) [ 24 ]. All available HCWs were included in the study as the required sample size exceeded the number of the workers in those clinics.

3.2. Data Collection and Research Tool

A proforma as attached in Appendix A was designed to gather sociodemographic data such as age, education level, and years of employment. The Job Satisfaction Survey (JSS) was used to assess job satisfaction among the respondents. The JSS was developed by Paul E. Spector in 1985 and is commonly used in many fields, including healthcare services. It has nine facets and a 36-item scale to evaluate employee attitudes toward their job and its various aspects. The facets were pay, promotion, contingent rewards, operating procedures, supervision, nature of work, fringe benefits, communication, and co-workers. Each item had six options, varying from “strongly disagree” to “strongly agree” [ 25 ]. In this study, the JSS scored the Likert scale of minimum and maximum score as satisfied (144–216) and dissatisfied (36–143). Based on a systemic review conducted in 2003, it was found that the JSS has adequate validity and reliability. The discriminant validity was 0.19–0.59 and convergent validity was 0.61–0.80, whereas the internal consistency was 0.91 and test–retest was 0.71 [ 26 ]. The Malay language version was translated by Tan Soo Luan in 2010 with reported similar internal consistency of Cronbach’s α 0.84 when compared to its English version [ 27 ]. Permission to use the questionnaire was obtained before conducting the study.

In this study, a HCW was defined as a person whose work involves contact with a patient or with blood or other body fluids from a patient in a healthcare, laboratory, or public safety situation at a health clinic [ 28 ]. We included all ‘Type 2 Health Clinics’ HCWs aged 18 and above who had worked for at least three months in the current clinic’s working system. Those who did not complete at least 80% of the questionnaire data were excluded.

3.3. Procedure

The questionnaire was distributed to all HCWs working in all ‘Type 2 Health Clinics’ in north-eastern Malaysia. Initially, the selected health clinics were informed through a letter that was sent through the ‘Kelantan State Health Department’ explaining the study that will be conducted to the clinic’s manager, who will convey the information to all HCWs at their clinic. The research team then scheduled a face-to-face session with the help of the clinic’s manager with their respective HCWs. The session explained the research objectives and procedures, voluntariness, and anonymity. They were then given enough time to consider their participation, signed the consent form, and answered the questionnaire given. Any questions that arose were entertained by the research team during the session.

3.4. Data Analyses

For data entry and analysis, IBM SPSS version 26.0 was used. Data were checked and cleaned once they were entered. In descriptive analyses, data were analyzed and presented as frequency ( n ) and percentage (%). Simple and multiple logistic regression was used to find the predictor of job dissatisfaction as the outcome was categorical and binary of either job dissatisfaction or job satisfaction. Forward LR and Backward LR were used to compare and identify the final model of factors associated with job dissatisfaction. It was then checked for multicollinearity, interaction, and the model’s fitness. The final model was presented as a p -value and adjusted OR. A p -value of less than 0.05 was set as the level of significance.

3.5. Ethical Consideration

Ethical approval for this study was obtained from the Medical Research and Ethics Committee (MREC), Ministry of Health, Malaysia, with identification number NMRR-20-2574-57270 (IIR). Ethical approval was also obtained from the Human Research Ethics Committee (JEPeM), Universiti Sains Malaysia (USM), (USM/JEPeM/2 0110577). Written consent was obtained from participants prior to the study. Only the researcher can access the data and participant anonymity was applied to ensure the confidentiality of the data.

The respond rate was 84.9% (314/370). The mean (SD) age of the HCWs was 40.6 (7.81) years old, and duration of employment was 15.7 (7.58) years. A total of 219 (69.7%) of them completed tertiary education and 284 (90.4%) were satisfied with their yearly performance mark. Table 2 shows the sociodemographic characteristics of the respondents.

Sociodemographic characteristics of the healthcare workers in ‘Type 2 Health Clinics’ in north-eastern Malaysia ( n = 314).

A total of 69 (22.0%) of the HCWs in the shift clinics’ working system and 43 (13.7%) in the non-shift clinics’ working system in ‘Type 2 Health Clinics’ in north-eastern Malaysia were dissatisfied with their job. Table 3 provides the details.

Proportion of job dissatisfaction among healthcare workers working in different health clinics’ working systems ( n = 314).

The top two job dissatisfaction factors among HCWs in ‘Type 2 Health Clinics’ in north-eastern Malaysia according to JSS facets were related to operating conditions (61.8%) and benefits (55.4%). Table 4 provides the details.

Proportion of various levels of satisfaction towards job-related factors among healthcare workers in ‘Type 2 Health Clinics’ ( n = 314).

The variables from simple logistic regression with a p -value less than 0.25, which were age, gender, race, monthly income, and yearly performance mark, were selected and further analyzed using multiple logistic regression to determine the associated factors. Multiple logistic regression shows that age in years (Adj. OR 0.91; 95% CI: 0.83,0.99, p = 0.037) and dissatisfaction with yearly performance mark (Adj. OR 14.80; 95% CI: 3.43,63.763, p < 0.001) predicts job dissatisfaction. It can be interpretated as the HCWs working in ‘Type 2 Health Clinics’ in north-eastern Malaysia had 9.4% lower odds of job dissatisfaction as they got older, and those dissatisfied with their yearly performance mark were 14.8 times more likely to develop job dissatisfaction after being adjusted for age. Table 5 shows the details for both simple and multiple logistic regressions.

Simple and multiple logistic regression analysis for factors associated with job dissatisfaction among healthcare workers working in ‘Type 2 Health Clinics’ in north-eastern Malaysia.

a Simple Logistic Regression; b Multiple Logistic Regression; Constant = 0.601; Forward LR and Backward LR method; No interaction and no multicollinearity; Hosmer–Lemeshow Test is not significant, p -value = 0.465; Classification Table 93.5%; Area Receiver Operating Characteristics (ROC) 76.4%.

5. Discussion

Our study showed that 35.7% of HCWs in ‘Type 2 Health Clinics’ in north-eastern Malaysia were dissatisfied. This finding, however, shows a lower prevalence as compared to the international and local studies where the prevalence of job dissatisfaction ranged from 46% to 48% [ 8 , 9 ]. The prevalence of dissatisfaction in this study may be contributed by the differences in the HCWs studied in terms of health system organization, geographical area, and socioeconomic population that the healthcare workers served. This could also be because a particular HCW was hired based on their qualifications for specific job tasks where the qualifications met the job requirements. According to another local study, management must ensure that their employees are placed based on their skills, qualifications, and abilities. If they are not, job dissatisfaction may arise, and stress and burnout may result [ 11 ].

Apart from that, looking specifically into the clinics’ working systems, it was found that only 22.0% of respondents were dissatisfied with the shift clinics’ working system and 13.7% with the non-shift system health clinics. Although the shift clinics’ working system was newly introduced in June 2020 amidst the COVID-19 pandemic, the HCWs already seem to be adapting themselves well, as showed by the lower proportion of job dissatisfaction comparing to those in the non-shift clinics’ working system [ 29 ]. A study discovered that, although there were varieties of factors that can influence the length of an employee’s adaptation process to a new working system, the process itself usually takes approximately one month to a year [ 30 ].

Age was one of the factors linked with job dissatisfaction among HCWs. Both being a young and an old professional (nearing retirement age) were linked to job dissatisfaction. Numerous types of research have been conducted on the topic of age and job dissatisfaction. These studies found that HCWs under 35 are more likely than those 35 and older to be dissatisfied with their jobs [ 11 , 14 ]. However, other studies showed that HCWs beyond the age of 40 are more likely to be dissatisfied with their jobs [ 10 , 31 ]. This study found that age is one of the factors that contributed to job dissatisfaction among HCWs in ‘Type 2 Health Clinics’ in north-eastern Malaysia. It was found that the HCWs with older age were 9.4% less likely to develop job dissatisfaction than those with younger age by a year after being adjusted for the yearly performance mark. Similarly, a study conducted in Greece and Ireland discovered that as one gets older, satisfaction improves [ 21 , 32 ]. This finding may also have been influenced by the fact that as their age increases, the HCWs become more accustomed to the job and working conditions and have more authority over it. This finding was in line with a local study that discovered worker satisfaction was related to working conditions, career development, and freedom from supervision [ 33 ].

Laura L. Carstensen’s socioemotional selectivity theory stated that, following ageing, a shift in motivation influences cognitive processing more positively. Hence, older people are more likely to experience positive emotions. Ng and Feldman (2010) found that age is linked to job attitudes, and their meta-analysis found that age is positively related to job satisfaction [ 34 ]. Our finding could be attributed to Malaysia’s functioning healthcare system, which is built on time-based promotion, especially for doctors, dental officers, and pharmacists [ 5 ]. This method ensures that those who enter the workforce are given a job scope or description appropriate for their entry-level position, allowing them to adjust gradually to the job’s demand. The job scope would gradually increase with seniority and the potential to advance, thus decreasing job dissatisfaction.

This study also discovered that there was a link between job dissatisfaction and yearly performance marks. The yearly performance mark was a type of feedback from a supervisor to a supervisee about their work performance, which influenced promotions, additional training, and pay increase [ 17 ]. After being adjusted for age, it was discovered that HCWs in the surveyed health clinics who were unsatisfied with their yearly performance mark were 14.8 times more likely to develop job dissatisfaction than those who were satisfied. Several studies have found a strong correlation between supervisor support and job satisfaction. According to studies conducted in Greece and Ethiopia, healthcare workers who received enough support were more satisfied with their jobs than those who did not receive such support [ 4 , 21 ]. Winarto and Chalidyanto (2020) revealed a substantial link between the job satisfaction of employees with solid supervisory support compared to employees who lacked support. Furthermore, competent supervision assists employees by preventing employee burnout and confidently fulfilling work objectives [ 18 ].

Looking into job-related factors, working conditions and benefits were the top two factors from JSS facets that scored the highest proportion related to job dissatisfaction. These findings were in line with several job dissatisfaction studies that found most of the job dissatisfaction was related to working conditions and benefits [ 10 , 16 ]. In this essence, when implementing certain policies and procedures, they must be adaptable in accordance with the worker’s workload and working conditions, for example, by ensuring the physical environment and equipment are suitable for the new policy to be implemented. Aside from that, the HCWs in this study may have found that the benefits that they received from their job were insufficient compared to their workload or to those of a worker from another place. Hence, it was critical to assign appropriate personnel to specific jobs based on their qualifications and skills with comparable benefits as other places, for example by ensuring the benefit was comparable between the public and private healthcare system.

Data from the Human Resources for Health Country Profiles 2015 Malaysia showed that females dominate Malaysia’s healthcare system. They discovered that females make up 97% of nurses, 75% of pharmacists, and 60% of doctors [ 35 ]. This study found that 73.9% of our respondents were females and no significant association was found between gender and job dissatisfaction. Similarly, several local and overseas studies also found no significant association between gender and job satisfaction [ 15 , 36 , 37 ]. A workforce dominated by a certain gender seems to provide greater support and understanding of each other’s physiological and psychological requirements. However, looking at our and other findings, it appears that this does not affect satisfaction or dissatisfaction in the workplace.

Some studies discovered a link between minority races and job dissatisfaction. Hispanic and Black nurses were found to be more likely than White nurses to resign in a study of nurses in the United States. Black nurses were also more dissatisfied with their jobs than White nurses [ 38 ]. Female and non-Bumiputera doctors were three times more likely to leave the public health service in Malaysia. This was due to dissatisfaction with several factors including benefits, compensation, promotions, work operations, family obligations, and personal challenges [ 12 ]. However, this study found no association between race and job dissatisfaction. The respondents’ geography and religion could explain this. The majority race in Malaysia and most respondents in this study in the north-eastern region were Malay–Muslim Bumiputera. Hence, they share a standard belief system and practices, leading to increased understanding and tolerance in the workplace.

All in all, a well-defined job scope of a certain job category at the clinic must be established and maintained to improve present healthcare services and increase job satisfaction. Younger workers must be trained regularly to help them appreciate and understand their jobs better, increasing their level of satisfaction. Regular meetings between employees and bosses should be held to review and discuss issues as they arise. Furthermore, any adjustments or new implementations of specific programs must be thoroughly addressed so that all employees understand the objective and why the changes are necessary to gain their complete support and reduce dissatisfaction.

6. Conclusions

Job dissatisfaction among HCWs at ‘Type 2 Health Clinics’ in north-eastern Malaysia was moderately high. Actions taken to reduce job dissatisfaction must be targeted at young HCWs and those that are dissatisfied with their yearly performance mark to ensure that job satisfaction improves. It is important to ensure they can retain workers in the healthcare system amidst the shortage of HCWs in public primary healthcare in Malaysia.

There were a few limitations for this study. First, this study was conducted at a selected type of health clinic according to their catchment population and services provided in north-eastern Malaysia. This can limit the findings on the associated factors since the findings are specific to types of health clinic and location, which may influence the factors. Additionally, it employed primary data collection methods which were influenced by the honesty and accuracy of the respondents’ answers.

Future research can be conducted among healthcare workers at health clinics, particularly those with different working systems such as shift and non-shift working systems, to fully understand the level of dissatisfaction, associated factors, and how to improve it. This type of study can be conducted with a bigger sample size and population to fully comprehend the dissatisfaction among healthcare workers at health clinics. We also recommend future qualitative research to fully grasp why job dissatisfaction occurs and the healthcare workers’ opinions on improving the situation. This permits fresh insights for policymakers to improve job satisfaction.

Acknowledgments

The authors would like to take this opportunity to thank Universiti Sains Malaysia and Kelantan State Health Department for the ethical clearance and opportunity to conduct this study. We also would like to thank the Director General of Health, Malaysia, for his permission to publish this article.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, M.I.A., A.D., M.N.S. and A.A.H.; Formal analysis, M.I.A. and A.D.; Investigation, M.I.A., A.D. and A.A.H.; Methodology, M.I.A., A.D., M.N.S. and A.A.H.; Supervision, A.D. and M.N.S.; Writing—original draft, M.I.A., A.D., M.N.S. and A.A.H.; Writing—review and editing, M.I.A., A.D., M.N.S. and A.A.H. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) of the Medical Research and Ethics Committee (MREC), Ministry of Health, Malaysia, with identification number NMRR-20-2574-57270 (IIR) on 30 December 2020. Ethical approval was also obtained from the Human Research Ethics Committee (JEPeM), Universiti Sains Malaysia (USM), (USM/JEPeM/2 0110577) on 11 January 2021.

Informed Consent Statement

Informed consent and consent to published was obtained from all participants involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Teachers’ Job Satisfaction in Developing Countries: A Literature Review

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Office of Teaching, Learning, and Technology

Ai-assisted literature reviews.

ChatGPT has a reputation for generating hallucinations, or false information. So can an Artificial Intelligence (AI) platform be trusted to assist in a literature review? Yes, if the tool you are using is the right one for the job. ChatGPT and Copilot are not designed to provide accurate citations. Instead, use them to brainstorm research questions. Keep alert for misinformation, hallucinations, and bias that could be part of the generative AI’s responses. Be aware of historical biases in the literature, which can also influence the output you encounter. 

Be sure to keep track of what tools you use, your purpose for using them, and the output from your interactions. Be prepared to disclose the AI tools, databases, and criteria used to select and analyze sources. Remember you are the one ultimately responsible for anything you create, generative AI is only your assistant.  

Try these five AI platforms to assist you in your literature reviews and academic research: 

• Copilot . Many people are exploring the ways that AI can be used to improve research. Even with a general generative AI platform like Copilot, you can use AI to help you brainstorm or discover new perspectives on research topics. An example prompt for this purpose can be found in David Maslach's article, "Generative AI Can Supercharge Your Academic Research," “I am thinking about [insert topic], but this is not a very novel idea. Can you help me find innovative papers and research from the last 10 years that has discussed [insert topic]?”  
• Elicit . This AI research assistant helps in evidence synthesis and text extraction. Users can enter a research question, and the AI identifies top papers in the field, even without perfect keyword matching. Elicit only includes academic papers, since Elicit is designed around finding and analyzing academic papers specifically. Elicit pulls from over 126 million papers through Semantic Scholar. Elicit organizes papers into an easy-to-use table and provides features for brainstorming research questions. 
• Consensus . This is an AI-powered search engine that pulls answers from research papers. Consensus is  not meant to be used to ask questions about basic facts such as, “How many people live in Europe?” or “When is the next leap year?” as there would likely not be research dedicated to investigating these subjects. Consensus is more effective with research questions on topics that have likely been studied by researchers. Yes/No questions will generate a “Consensus” from papers on the topic. Papers in Consensus also are from Semantic Scholar. Results in a Consensus search can be filtered by sample size of the study, population studied, study types, and more. This makes Consensus an interesting tool for finding related literature on your search topic. 
• Research Rabbit . An AI research assistant designed to assist researchers in literature research, discovering and organizing academic papers efficiently. It offers features such as interactive visualizations, collaborative exploration, and personalized recommendations. Users can create collections of papers, visualize networks of papers and co-authorships, and explore research questions. Unlike the previous two platforms listed, Research Rabbit doesn’t start with a question, but a paper that already is known. You need to have a starting article to go down a “rabbit hole” to see connections between papers. 
• Litmaps . A similar tool to Research Rabbit, a Litmap shows the relationships between the articles in your collection in the form of connecting lines which trace the citations for you. It allows a user to start with a citation, or a seed, and then through a simple interface, investigate connections between papers. 

For further reading, see " How to Write AI-Powered Literature Reviews: Balancing Speed, Depth, and Breadth in Academic Research " which includes a helpful table comparing the different tools that specialize in literature searching. And check out the February 2024 webinar, " Unlock the Power of AI for Academic Research " hosted by Tracy Mendolia-Moore and Brett Christie for more information on this topic.