chisa thesis bedford

Nurse Dissatisfaction in a

Comparative Perspective:

UK and Thailand

Author: Chisa Radavoi

Supervisor: Christine Norgate

2

TABLE OF CONTENTS

ABSTRACT 3 INTRODUCTION 3 Background of the study 3 Research questions 7 SAMPLE SELECTION 8 Identifying relevant articles in medical databases 8 Refining the list following inclusion/exclusion criteria 9 The final list of 8 studies for each country 11 Heterogeneity of the sample 12 RESULTS OF THE REVIEW 13 Primary research on nurse dissatisfaction in UK 14 Primary research on nurse dissatisfaction in Thailand 19 DISCUSSION 24 Salary and other incentives 24 Workload 26 Human relations at work 27 Work environment 28 Specificity of the nursing profession 29 Researchers’ approach as indicative of cultural differences 30 CONCLUSION AND RECOMMENDATIONS 32 Relevant cultural differences in nurse dissatisfaction 32 The utility for supervisors and managers 33 The utility for researchers 34 Limitations 35 REFLECTION ON PERSONAL ACHIEVEMENTS 35 REFERENCES 39 Primary research in UK 39 Primary Research in Thailand 40 General references 41

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Abstract

Job satisfaction in nursing is arguably more important than in other

professional fields, as a low level of satisfaction impacts the quality of

healthcare delivery. The topic is well researched and shows high levels of

dissatisfaction everywhere in the world, but no study analyses the

phenomenon in a comparative, East/West perspective. Beyond the mere

academic interest, such an approach may have practical importance in the

interconnected world of today, when high proportions of the nursing workforce

in the Western countries come from Asia and Africa. Taking United Kingdom

and Thailand as representative for the Western and Eastern cultures

respectively, this study explores the cultural differences in nurse

dissatisfaction (primary research question) and in the researchers’ approach

of this topic (secondary research question). The study is designed as a

systematic review, using a sample of eight primary research articles from

each of the two countries. The objectives of the study were to data on sources

of nurse dissatisfaction in the two countries and to comparatively analyse

them in order to find differences and similarities, which in turn are used for

providing recommendations for healthcare policy makers and hospital

managers in the Western countries. The study finds that although the sources

of nurse dissatisfaction are the same, the way each dissatisfaction factor is

constructed varies among cultures. Concomitantly, the study emphasises the

different focus of researches in the two countries when dealing with this topic,

which in itself is indicative of cultural differences.

4

Introduction

Background of the study

Job satisfaction refers to a worker’s fulfillment of expectations in the job and is

generally defined as attitude towards the company, co-workers and, finally,

the job itself (Sypniewska, 2013). According to Lephalala et al (2008, citing

Herzberg’s two-factor theory, 1964), the main factors with possible negative

impact on job satisfaction are working conditions, salary, organisation

/administration policies, supervision and interpersonal relations.

While factors like salary or supervision have more or less the same impact

regardless of the industry, the ‘working conditions’ have their specificity, and

in nursing there are at least two very peculiar aspects. First, a nurse has to

deal with death and dying, which is identified in many studies as a major

factor of job stress (see for example Lambert et al, 2004). Second, most

countries experience a nurse shortage; in US for example, the shortage of

registered nurses is projected to spread across the country until 2030

(Juraschek, 2012). Unavailability of a sufficient number of nurses adds to the

already high workload and leads to increased stress and job dissatisfaction.

Although a subjective attitude, satisfaction at work inevitably reflects in the

quality of work, and therefore understanding job satisfaction in the specific

field of nursing, where people’s health and even life are at stake, is perhaps

more important than in other professions. Nurse job satisfaction is

fundamental to the quality of health care, as low levels of satisfaction may

lead to negative outcomes such as labour disputes, risk to patients by low

quality of care, and pressure on the health system by shortage in nurse

supply (McHugh et al, 2011). Authors who dedicated numerous publications

to this phenomenon do not refrain from using big words to describe its

importance: according to Murrels et al (2009, p. 121), the implications of nurse

satisfaction for staff retention and patient care are ‘immense’.

In the interconnected world of today, the phenomenon deserves a

comparative approach as well, aside from the country specific studies. Some

studies investigating nurse dissatisfaction went indeed beyond the boundaries

of a particular country (for example Aiken et al, 2001), but none has so far

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went beyond the boundaries of a particular culture. Cross-cultural studies on

job dissatisfaction were undertaken generally, without a specific profession in

focus (such as Thomas and Au, 2002; Khan and Ali, 2013) or with focus on

particular professions (such as Pors 2003 for library managers) – but not with

regard to the nursing profession.

This is not to say that cultural differences and their impact on the nursing

profession were not investigated at all. Studies concerning the immigrant

nurse hardships are quite numerous (see for instance Dhaliwal and McKay

2008; Shields and Price 2002). However, the starting point of the present

study is that cultural incongruence in nurse dissatisfaction should be as well

analysed prior to immigration, when the potentially-migrant nurse is still in her

own cultural setup. With US and Western Europe in need of nurses, and with

Asia as a traditional source of well-qualified nurses, the phenomenon of nurse

dissatisfaction requires analysis in a comparative perspective. Hospital

managers may need to know for example whether the post-migration migrant

nurse’s dissatisfaction has deeper roots, for example unachieved

expectations relative to the reasons that made her leave own country.

‘Culture’ is a vague and all-encompassing term, with hundreds of definitions

given in the literature (Shah 2004). This paper relies on Hofstede (2003, p.

101, cited in Shah 2004, p. 555) observation that ‘the way people think, feel

and act in many different kinds of situations is somehow affected by the

country they are from’; in this study perspective, the general assumption that

Asia and Western Europe display vast cultural differences is a sufficiently

solid hypothesis. For example, as confirmed by a meta-analysis of 83 studies

(Oyserman et al, 2002), traditional Asian societies score higher in collectivism

and lower on individualism when compared to US and Western Europe: the

group benefit outweighs the individual’s, strict hierarchies are in place, people

adhere to societal and organisational norms without questioning them.

The phenomenon of nurse dissatisfaction is well researched in the Western

societies. Several ample surveys done in the Western countries in the last 15

years emphasized acute job dissatisfaction among nurses. Although the

healthcare systems vary across the countries that were the subject of cross-

country primary research (for example, US, UK, Germany in the study of

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Aiken et al, 2001) the problems identified are the same: nurses complain

about heavy workload due to hospital cost cuts especially after the economic

crises, about stressful conditions that sometimes lead to mistakes for which

they are severely punished, about low income compared to their

responsibilities. Due to all these, the proportion of nurses who want to quit

their job in the next years is significant: around 30% in a survey in US (AMN

2012).

The research in Asia is less substantial, but the existing articles show a

similar situation. For example, 45 per cent of the Chinese nurses are

dissatisfied at work, according to You et al (2013), while in Macau, 39 per cent

of nurses have shown intention to leave in the study of Chan et al (2008).

Choong et al (2012), although not offering precise figures on this

phenomenon in Malaysia, describe it as significant and focus their study on

the predictors of intention to leave, of which nurse dissatisfaction is the main

one.

Interestingly, the large majority of studies addressing nurse dissatisfaction in

both West and East see it through the lens of its most likely consequence: the

turnover intention. This is normal given the interest of policy makers in the

context of the general nurse shortage. But a comparative approach may shed

light on a less obvious aspect: an immigrant nurse does not have the freedom

of choice of a native nurse, therefore her dissatisfaction may not necessarily

translate into intention to leave, but perhaps into other outcomes, such as

poorer performance at work.

As shown above, the levels of nurse dissatisfaction are equally high in the

Western and Eastern societies, but are the underlying reasons the same?

This is what this study is trying to find out, by using Great Britain and Thailand

as units to be compared. The two countries were chose for being

representative for Western and Eastern cultures respectively, with solid and

respected healthcare systems, but also for reasons related to the author: a

nurse with practice in Thailand and education in UK.

The particular focus of this study on immigrant nurses and on the gap

between their aspirations and what they find in the host country - in other

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words, between West/East motives of dissatisfaction – is important in the

context of increased absorption of Asian nurses in Western hospitals.

Knowing the cultural differences (if any) is important for the health policy

makers and managers in the host country, in order to better understand

migrant nurses’ difficulties in adapting to the new country, and to better use

their potential. But it is equally important for managers in the home country of

the potential nurse emigrants, in their effort to prevent nurse emigration to the

West. Finally, it may be also of use to potential nurse emigrants, to open their

eyes on the real situation at their intended destination.

The following section narrows down the topic towards the research question,

in the ‘funnel’ approach suggested by Bettany-Saltikov (2012, p. 40) and

briefly introduces the methodology.

Research question

In spite of the rather non-appealing circumstances mentioned above,

practicing this job in the West is still a mirage for the majority of Thai nurses;

this is a hypothesis derived by the author from her own experience in Thai

hospitals and from articles in the media, in Thailand. What drives Thai nurses

towards dreaming of working in the West, when nurses there seem rather

unhappy? Could it be that they are unaware of the hardships of being a nurse

in the West? Or rather, the sources of dissatisfaction in the two cultures are

so different, that a Thai nurse in UK can be quite happy in circumstances that

would make a Western nurse unhappy?

The answer could be provided by a systematic review (White & Schmidt

2005). Systematic reviews have become an essential aid for informed

decision-making in healthcare (Centre for Reviews and Dissemination 2009)

and some authors consider them the best form of evidence available to

clinicians (Wright et al 2007). The research topic of this systematic review is

nurse dissatisfaction; as explained above, this topic could bear significance

for health policy makers and hospital management, as nurse dissatisfaction

may lead to a poor quality of care and in extreme cases, even to malpractice

and loss of lives.

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Since the study is a comparative one, the research problem is the gap in

sources of nurse dissatisfaction, in a Western and Eastern setup. From here,

the research aim will be to find out whether there are significant differences. In

order to attain this aim, the research objectives will be:

-‐ Collect data on nurse dissatisfaction in Great Britain

-‐ Collect data on nurse dissatisfaction in Thailand

-‐ Compare the data from the two sets of Populations

-‐ Provide recommendations for policy makers and health managers in

Great Britain on how to take into account the study results

Since the study has a more qualitative touch, the PEO (Population/Problem –

Exposure – Outcome) is more suitable than the PICO approach (Bettany-

Saltikov 2012, p. 22). ‘Population’, in this study, is the nurse seen in the

Western and the Eastern setup, and the ‘Problem’ is the nurse dissatisfaction

as a phenomenon generally recognized in the medical literature. ‘Exposure’ is

the nurse day-to-day activity as care provider, while the ‘Outcome’ is their

views as expressed in primary studies. The systematic review will collect the

outcomes and analyse them in a comparative perspective. The research

question, in light of all the above arguments, is:

“What, if any, are the key differences in sources of nurse dissatisfaction

between UK and Thailand?”

This systematic review is exploratory in nature, and therefore it will try to

derive a hypothesis related to possible differences in the outcomes of the two

populations under study, i.e. British and Thai nurses.

Sample selection

Identifying relevant articles in databases

According to section 1.2 of the Cochrane Handbook for Systematic Reviews

(available online at http://www.cochrane.org/handbook), a systematic review

“attempts to identify, appraise and synthesize all the empirical evidence that

meets pre-specified eligibility criteria to answer a given research question”.

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With the research question already introduced in the previous paragraph, this

section will carry on by discussing some methodological aspects.

The first essential step is the selection of the primary research articles to be

included in the review. The search for articles relevant to the research

question was done in the medical electronic data bases (CINAHL,

ScienceDirect, Medline- full text) using initially the following keywords: ‘nurse

+ job + satisfaction + UK’; ‘nurse + job + satisfaction + Thailand.’ Each

database provided several hundred results, so further queries refined the

search by adding key words like ‘burnout’, ‘turnover intention’, and ‘shortage’.

In the end, a provisional list of 40 articles was retained, to be further reduced

by the inclusion/exclusion criteria. The process is described in the graph

below:

Refining the list following inclusion/exclusion criteria

The inclusion and exclusion criteria are presented here in a template provided

in the course notes (Systematic Reviews, Part A):

CINAHL

Initial search: job + satisfaction + Nurse

UK = 261 articles TH = 601 articles

ReCine with: burnout + shortage + turnover


Science Direct





Medline





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Inclusion criteria Exclusion criteria

1. Primary research studies 1. Secondary research studies

2. Studies that have collected data on

nurse dissatisfaction (reasons and/or

manifestations)

2. Studies that have not collected

data on nurse dissatisfaction

3. Studies that have segregated data

on the issue in UK and/or Thailand

3. Studies that do not have

segregated data on either of UK and

Thailand

4. Studies published in English

language

4. Studies not published in English

language

5. Studies published in peer-reviewed

publications

5. Studies not published in peer-

reviewed publications

6. Studies published after 2000 6. Studies published before 2000

The criteria (1) and (5) in the table above are first hand indications of the

studies validity and academic accuracy, while the criterion (2) naturally comes

from this review’s topic. Criterion (3) was added due to the fact that many

studies take for example a regional or another cross-country approach,

discussing the issue in an Asian, Southeast Asian (for Thailand), European,

Commonwealth or Anglo-Saxon (for UK) context. But not all of these studies

have separated data for Thailand or UK, therefore the general studies had to

be excluded.

Criterion (4) was added after careful consideration of the opposite solution,

namely to include articles written in Thai as well. As the author of this

dissertation is a Thai native, it would have been easy to find relevant articles

in Thai language medical publications. This was not done for two reasons.

First, there is a concern among the medical world in Thailand that the Thai

language medical publications, even if peer-reviewed, are not at the academic

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level of Thai publications in English, having Western doctors or scholars in

their editorial board. Second, introducing data collected and translated from a

Thai language publication would have made this dissertation unverifiable by

the university teachers who are called to grade it.

Criterion (6) was again a difficult choice, as it is usually recommended to not

include articles older than ten years. However, unlike primary research on

strict clinical issues like factors favouring a particular disease, or a medical

protocol in dealing with a particular disease, or the use of a certain drug, the

topic of the present study invites for its consideration over a longer period.

The phenomenon of nurse dissatisfaction seems to be resilient over time. For

example, the initial set of 40 articles selected from the medical databases

included articles from the 1980s, and those articles were dealing with the

same issues as more recent articles do. Therefore, although preference was

given to articles not older than 10 years, the limit for inclusion was fixed at the

year 2000.

The final list of 8 studies for each country

A second problem was that the school guidelines for the present dissertation

indicate that 8 to 10 articles should be selected for systematic review. But a

selection of four articles for Thailand and four for UK, to lead to a total of

eight, would have led to insufficient data on each country. Since this thesis

does a comparative review, there were two queries in the medical databases:

one for UK, and one for Thailand.

In a way, we may say that this study does two systematic reviews, so the

school recommendation was interpreted as referring to each query, and it was

respected in the sense that 8 articles were selected for each country. After

screening the 40 articles, especially their abstracts and findings sections, to

verify their match with this systematic review aim, a list of 16 (8+8) articles

was selected, and is presented in the References section, before the general

list of sources used in this research.

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Heterogeneity of the sample

One problem is that the list of 16 articles shows high heterogeneity. The

inclusion criteria allowed for the selection of studies with a particular focus

within the wider research topic: for example, one study analysed the nurse

happiness in strict relation to the salary, and another one was focused only on

early career nurse dissatisfaction. As a researcher puts it in her study on

designing research strategies - the pond you fish in determines the fish you

catch (Suzuki et al, 2007).

Under these circumstances, the quantitative assessment of the presence in

primary research of a particular factor defining nurse dissatisfaction would be

a risky endeavour, because the articles apply different methods to different

samples with different aims: some articles focus only on particular nursing

branches, some only on early career nurses, some only want to explore

organizational factors of stress, and so on. An illustration of this fallacy is the

research of Sriratanaprapat and Songwathana (2011) on the concept of nurse

job dissatisfaction in Asia; the authors too easily establish that ‘social

relations’ is the main influencing factor, perhaps driven by a desire to link it to

the collectivist feature of Asian cultures. In reality, the fact that ‘social

relations’ were mentioned 11 times in the articles they reviewed – same

frequency as the ‘workload’ factor, but more than the ‘incentives’ factor (8) – is

not that relevant given that the screened articles came from a variety of Asian

countries and had various segments of the nursing profession in focus.

While commonalities among the reviewed articles should be looked at, simply

establishing rankings derived from the frequency of a certain factor is risky,

especially given the low number of studies under review. In the ‘Discussion’

section, this dissertation will discuss the commonalities without assessing

them quantitatively. With this approach, including dissimilar studies actually

strengthen the systematic review’s external validity (Wright et al 2007), as it

makes sure that no relevant manifestations of the nurse dissatisfaction

phenomenon are left outside.

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Results of review

As the review is on a qualitative issue, the dissertation will synthesise and

then analyse the results in a narrative manner, with the text organised along

themes, following the recommendation provided in the course notes.

The first step is the synthesis of the sixteen articles, which was done in two

tables, one for each country. The tables succinctly introduce the methods,

identify some of the articles’ strengths and limitations, and present the results.

Given the already discussed aspect of articles’ heterogeneity, this phase of

synthesis could not be done with the results organized along themes, so the

results were presented as the authors delivered them. The ‘theme’ approach

will be done in the Discussion section.

The articles reviewed use various instruments developed for measuring job

satisfaction, in general (for example the Organization Job Satisfaction Scale ,

OJSS) or in the nursing field (for example the Nurses’ Job Satisfaction Scale,

NJSS).

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UNITED KINGDOM

Study Study details (method,

population etc.)

Strengths and weaknesses Findings on motives of dissatisfaction

Adams

and

Bond,

2000

Postal survey in UK on

nurse job satisfaction.

834 nurses

participated.

The study has

considered how job

satisfaction

(independent variable)

is influenced by both

nurses' individual

characteristics and

their perceptions of

organizational aspects

of the workplace

(dependent variables).

+ Analysis at ward level, a

significant unit where nurse

feelings about her work are

expressed.

- The study results, although

somehow to be expected (for

example it was found that

satisfaction is correlated with

level of the facilities in the

ward) are claimed as new

discoveries.

Organisational (ward) aspects

outweigh personal aspects when it

comes to job satisfaction.

The number of available staff, their

skill mix, the care organization and the

ward's workload has a major influence

on nurse job satisfaction.

Human relations in the ward and

support from other hospital units are

highly correlated with job satisfaction.

Among nurse individual

characteristics, only clinical grade was

found to influence job satisfaction

(dissatisfaction more likely for higher

grades).

Aiken et

al, 2001

A cross-country survey

that included England

(5,000 respondents)

and Scotland (4,721

respondents).

The aim of the survey

was to find out

whether the problems

in the US healthcare

system are

encountered in other

systems.

Questionnaires

included issues like

nurse perception of

her working

environment, job

dissatisfaction and

feelings of job burnout.

+ The sample is very large,

allowing for generalizability.

+ The research takes age

into consideration, dividing

the sample in under/over 30

years old.

- The sample is local in US

(only nurses in Pennsylvania)

and national in the other

countries.

- Germany seems randomly

included, as all other

countries are English

speaking. Besides, the

sample in Germany is very

low (only 2,681).

- The decision of showing

separate results for England

and Scotland is not

explained, and is confusing

since the profession in all UK

Less than 45% agree that nurses’

contribution to public care is publicly

acknowledged.

Less than 35% agree that nurse has a

chance to participate in management

decisions.

Over 85% consider the nurse –

physician relation as good.

Over 85% consider fellow nurses as

competent.

Less than 25% see salaries as

adequate.

Less than 45% agree that nurses have

opportunity for advancement.

Less than 40% agreed that the staffing

is sufficient (in England, less than

30%)

___

More than 30% of nurses in England

15

is regulated by NMC. and Scotland were planning on leaving

in the next year (the percentage is

higher in the case of nurses under 30)

Lephalala

et al,

2008

A quantitative

descriptive survey

used self-completion

questionnaires to

study factors

influencing nurses’ job

satisfaction in private

hospitals.

85 nurses in randomly

selected hospitals

participated.

+ The factors influencing job

satisfactions are divided in

intrinsic (Achievements,

Recognition, Responsibility,

the nature of work,

advancement) and extrinsic

(working conditions, salary,

administration policies,

supervision, interpersonal

relations).

- The sample is small and

unbalanced in terms of age

and experience: only 8% of

the interviewees have less

than 10 years of practice,

and only 3.5% are under the

age of 30.

Main intrinsic source of dissatisfaction:

promotions (90%). Other sources:

participation in decision-making (52%),

workload (48%) and disruptions in

social life due to workload (55%).

Main extrinsic source of

dissatisfaction: salary (55% feel

treated unfairly as compared to NHS

nurses). Other sources: 40% unhappy

with the respect accorded by the

management.

___

67% would leave that job for better

salary.

Murrels

et al,

2009

The 5-step method of

Spector was used to

longitudinally (6

month, 18 month and

3 years) assess job

satisfaction variation

across nurses at early

career stage in 4

branches: Adult,

Child, Mental Health,

Learning Disability.

There were 2524

respondents at 6

months, than numbers

decreased by around

20% at each further

stage.

+ The accuracy of the

questionnaires, with 34 items

at 6 month and with items

added subsequently, when

they became more relevant.

+ The fact that variations are

studied both horizontally

(among branches) and

vertically (within the same

branch, in time)

- the number of respondents

decline progressively and

significantly in time and it is

not known whether these

nurses abandoned the

profession due to high

dissatisfaction. If yes, that

The results in the branch of learning

disability did not prove consistent over

time or with the other branches.

The other 3 branches displayed similar

results, with the highest scores on:

- Ratio of qualified to unqualified staff

- Availability of equipment

- Opportunity to go to courses

- Proportion of time spent on

paperwork (significantly lower at 3

years than at 6 month)

- Opportunity to reflect on practice with

someone in a higher position

- Quality of working relationship with

16

The method consists

in developing the

questionnaires by

using initial qualitative

steps, such as

interviews with a

smaller sample, to

ensure the relevance

of the questions in the

quantitative stage.

would significantly impact the

final figures of the study.

- the study is focused on

finding variances and not

investigating the depth of the

issue.

colleagues

- Combining work hours with social life

(significantly higher at 3 years than at

6 months).

Newman

et al,

2002

Exploratory qualitative

primary research

based on in-depth

semi-structured face-

to-face interviews,

conducted between

February and May

2000 with 131 clinical

hands-on nurses and

midwives in six main

specialties in four NHS

acute Trusts in

London, on the main

factors influencing

nurse satisfaction and

retention.

+ The semi-structured

character of the interview

allows nurses to indicate

some issues left uncovered

by more structured

quantitative research. The

researcher can get a deeper

understanding of the

problems.

+ The article’s approach is

very practical in that each

factor of nurse dissatisfaction

is discussed from the

management perspective,

and retention strategies are

proposed.

- The specificity of London

hospitals could affect the

study generalizability.

First reason of job dissatisfaction was

the shortage of staff, and ranking

second was dissatisfaction with poor

management, with its many

manifestations: discriminations, shifts

inflexibility, lack of recognition, poor

communication, and unsupportive

management.

Nurses indicated as source of job

satisfaction: patients, specificity of

nursing job and ‘people I work with’.

When asked what would keep them in

the profession, better working

conditions, followed by more pay and

better management outranked

improved training and education and

better career prospects.

Nearly 60 per cent of interviewees had

thought of leaving nursing and 34 per

cent had thought of leaving the NHS.

Robinson

et al,

2005

A longitudinal study (6

month interval)

investigating whether

plans expressed at

one time point by early

career mental

healthcare nurses

+ Provides an accurate

image due to numerous

moderating variables:

gender, age (>/<30),

ethnicity, education, having a

spouse, having children living

at home, time in first nursing

Proportions of dissatisfied early career

nurses:

58% due to low pay in relation to level

of responsibility.

50% due to heavy paperwork.

17

were fulfilled and to

identify career stages

at which certain factors

may influence

retention.

3 questions addressed

to recently graduated

nurses: career

pathways during the

first 6 months at work,

experiences during the

first 6 months, and

looking ahead.

554 answers filled-in

questionnaires, data

analysed with SPSS.

post.

- In the Discussion section,

the study pays almost no

attention to the specificity of

mental healthcare nursing,

although only nurses in this

branch were the subject of

the study.

- 6 month may not be a long

enough period for a nurse to

clearly define her reasons of

satisfaction at work and

plans for future.

-The ethnic structure of the

respondents does not reflect

the ethnic structure of

working force (for example,

only 1% of respondents were

of Asian origin)

43% due to low frequency of

discussions on career development.

42% due to availability of equipment.

42% due to little chance to go to

courses other than in study days.

38% due to combining responsibilities

at work with time spent with spouse.

35% due to number of staff in usual

days.

35% due to combining responsibilities

at work and with children.

32% due to lack of opportunities to

bring changes to practice

At the other end, only 6% were

unhappy with the working relations.

___

Nurses who were satisfied with

support from their immediate line

manager were the group most likely to

anticipate remaining in nursing.

10% of nurses dissatisfied with low

pay intend to leave.

8% of nurses dissatisfied with high

paperwork intend to leave

6% of nurses dissatisfied with the

amount of time spent with spouses

intend to leave.

Sheward

et al,

2005

A total of nearly

10,000 nurses from 29

hospitals in England

and Scotland

completed a

questionnaire meant to

explore the

relationship between

+ A large sample with

balanced territorial

distribution.

+ The mean age of the

respondents was 34,

meaning that nurses were

experienced enough to have

an informed opinion, but

Over 60% of nurses were satisfied with

being a nurse and with their current

post. One third was planning of leaving

the current post over the next year.

A highly statistically significant

relationship between staffing and

emotional exhaustion. Increasing

numbers of patients to nurses was

18

nurse outcomes

(dissatisfaction and

emotional exhaustion)

and nurse workload,

nurse characteristics

and hospital variables.

Data was further

analysed with SPSS.

young enough to consider a

career change.

- 90% of the respondents

present themselves as

‘white’, which is good from

the perspective of this

dissertation, but raise doubts

on the study validity since

this does not reflect the race

balance in the nursing

profession in UK.

associated with increasing risk of

emotional exhaustion and

dissatisfaction with current job.

Shields et

al, 2002

Postal questionnaires

sent to a random wide

sample of nurses, of

which 1203

questionnaires where

further analysed,

namely those

completed by nurses

aged 21-60, who

reported their ethnicity

as being other than

white.

Respondents were

asked whether staff or

patients + families

behaved

inappropriately due to

race.

+ A wide sample with

balanced racial distribution

(38% Black Carribean, 27%

Black African, 15% South

Asian, 20% Southeast

Asian). The sample was also

spread widely across nursing

branches.

+ Unlike other studies

discussing racial harassment

at work, this one analyses

two sources of harassment:

workmates (including

superiors) and patients.

Nearly 40% of ethnic minority nurses

report experiencing racial harassment

from work colleagues, while more than

64% report suffering racial harassment

from patients. Such racial harassment

is found to lead to a significant

reduction in job satisfaction, which, in

turn, increases nurses' intentions to

quit their job.

Black African nurses are the most

likely to have been racially harassed

by work colleagues, with more than

48% of them having suffered such

behaviour in their careers.

South Asian nurses are the most likely

to experience such abuse on a

frequent basis (8.4%), while Southeast

Asians have the lowest incidence of

frequent or infrequent racial

harassment from staff.

19

THAILAND

Study Study details

(method, population

etc.)

Strengths and weaknesses Findings on motives of dissatisfaction

Intaraprasong

et al, 2012

Cross-sectional

analytical study was

conducted on 128

head nurses working

in hospitals under the

jurisdiction of the

Royal Thai Army.

Data were collected

by mailed

questionnaires.

-The generalizability is

reduced due to the specificity

of nursing in an army

controlled hospital

-Many of the sources cited are

students’ thesis.

-The quality of writing shows

the necessity of having the

published text edited by native-

level speakers

+ The findings on sources of

nurse dissatisfaction are

useful.

75% of the interviewees show low

and very low satisfaction with the

compensation.

Only 19% show low or very low

satisfaction with the working

conditions, probably meaning that

army hospitals are well equipped.

Only 8% show low satisfaction with

co-workers (none has shown very

low satisfaction)

Kunaviktikul et

al, 2000

This study ascertains

relationships

between conflict,

level of job

satisfaction and

intent to stay. The

sample was 354

professional nurses

employed in four

regional hospitals in

Thailand.

Questionnaires

targeted facets of job

satisfaction and

separately, to

measure cause and

level of conflict.

+ A balanced sample

composed of professional

nurses in four regional

hospitals in each part of the

country who worked in direct

patient care in a variety of

units and for six months.

+ A discussion of conflict

avoidance in the Buddhist

culture.

- When analyzing in parallel

the two sets of data (on conflict

and dissatisfaction) the study

simply mentions conflict as

cause and dissatisfaction as

effect, but ignores that the

relation could also go the

opposite way.

A difference in the characteristics of

co-workers was the most frequent

cause of conflict (97.9%).

Most of the subjects (144 subjects or

41.2%) used the accommodation

style most frequently to manage

conflict, followed by 102 subjects

(29.2%) who used compromise.

Most subjects had a high intent to

stay in their present jobs for 1 year

(97.1%) but intent to stay for the next

5 years decreased (78.8%).

Highest source of dissatisfaction was

salary. Other sources are described

as ‘moderate’, but no figures are

given (although figures are given for

the other variables – intent to stay

and conflict!).

20

Lambert et al,

2004

The research

examined work

stressors, ways of

coping and

demographic

characteristics as

predictors of physical

and mental health

among hospital

nurses from Japan,

South Korea,

Thailand and the

USA (Hawaii). 1554

hospital-based

nurses were

administered self-

report

questionnaires.

+ It is the only one study found

that attempts to cross-

culturally discuss the issue of

nurse dissatisfaction (its

causes and its consequences).

- Hawaii may not be

representative for the whole

US, as its culture is influenced

by Asia. Besides, only 16% of

the Hawaiian nurses returned

the questionnaire.

The main stressors indicated by Thai

nurses were workload, conflict with

physicians and dealing with

death/dying.

As for the demographic

characteristics: the expectation that

women being responsible for

meeting the daily needs of the

members of the household appeared

to have an impact on the physical

and mental health of the Thai nurses.

This would be understandable given

that the Thai nurses had more

people (average of 4.98) residing

with their households compared to

nurses from the other cultures.

The main ways of coping were

positive reappraisal, self-control,

planful problem solving and seeking

social support (and these were the

main ways of coping in all the four

countries, but in Thailand self-control

and positive reappraisal are the

highest, and this influences mental

health).

Nantsupawat

et al, 2011

The sample

consisted of 5,247

nurses who provided

direct care for

patients across 39

public hospitals in

Thailand. Multivariate

logistic regression

was used to estimate

the impact of nurse

work environment

and staffing on nurse

outcomes and quality

+ The study has a solid

sample with balanced

distribution across the country.

+ The study focuses on the

workload and work conditions

as predictors of burnout, and

on the connection between

burnout and conditions of care.

- In spite of what is claimed in

the introduction, the study

does not pay much attention to

individual factors affecting job

20% of nurses were dissatisfied with

their job and close to 40%

experienced high burnout.

Inadequate staffing and resources

were nurses’ major concerns, while

nurse-physician relationships were

generally positive (still high though in

the ranking of reasons for

discontent).

Nurse work environment and nurse

staffing is shown to be associated

with outcomes– job dissatisfaction,

21

of care. satisfaction. high emotional exhaustion, and poor

quality of care.

Pongruengpha

nt et al, 2000

A sample of 200

nurses were asked to

rate their

occupational stress,

job satisfaction, and

crying as a coping

strategy.

+ Approaching the issue from

an unexpected angle (the

cathartic release of emotions).

-The results were not as

expected so the ‘Discussion’

section is a little confusing.

As a coping strategy, nurses in

Thailand did not cry very frequently,

but when they cried it was a

symptom of stress. Only about 15%

cry more than ``frequently''. Crying

was significantly correlated with the

Nurse Stress Index and, in particular,

was symptomatic of home/work

conflicts, dealing with patients, and

role confidence.

The study found that crying might be

a symptom or a buffer of stress

depending on the source of stress

and job satisfaction. Workload was

significantly and directly related to

crying when nurses were intrinsically

satisfied with their job, but it was

found to be ineffective as a coping

strategy.

As for nurses overall dissatisfied with

their job, crying was not found to

have a correlation with sources of

dissatisfaction.

Sriratanaprapa

t et al, 2012

In-depth interviews.

The sample consists

of 963 randomly-

selected nurses from

12 general hospitals,

administered by the

government, that

represented all

regions of Thailand.

Subjects had to have

at least 1 year

experience.

+ The study develops an

instrument for measuring

nurse job satisfaction based on

an analysis of the concept of

job satisfaction within the

context of Asian cultures, for

example by taking into account

the concept of Kreng Jai (not

causing discomfort or

inconvenience to others).

+ A rigorous process involving

a development stage and a

Incentives (pay, promotion) were

found as main factors, similar to

other instruments assessing nurse

satisfaction.

Autonomy and recognition were

found as having low importance and

this was explained by the fact that

culture does not create in the nurse

the expectation to exercise

autonomy.

Nursing supervising was found

important and explained through

22

Initially, three

experienced nurses

who took part in the

domain identification

stage. The, a

reliability verification

involved 30 nurses.

psychometric stage.

-In the desire of being

accurate, the tool developed

107 items, which are difficult to

follow by the subjects of

research. In addition, the 107

items are divided into o groups

(‘factors’) of which some refer

to sources of dissatisfaction

but some rather to

manifestations.

collectivism, which makes the nurse

see the head nurse as part of the

same group (as opposed to

physician or managers).

Tyson and

Phongruenpha

ng 2004

A longitudinal

perspective on 14

hospitals in Thailand

examined sources of

occupational stress,

coping strategies,

and job satisfaction.

A sample of 200

nurses was

compared to 147

nurses sampled from

the same hospital

wards after 5 years.

+ Longitudinal studies are

relevant in a profession where

policies often change,

especially in a Thai context.

+ The analysis is divided along

private/public hospitals.

-The sample being different

(not the same nurses), intrinsic

sources and individual

perception of stress may affect

the validity of the study.

Initially, working in public hospitals

reported more stress than nurses in

private hospitals, but after 5 years

there were improvements in public

hospitals. A major source of stress

among nurses was management’s

misunderstanding of the needs of the

hospital ward, but this form of

organizational stress decreased in

public hospitals, while remaining the

same in private hospitals.

In public hospitals, lack of support

from senior staff improved slightly,

but was still significantly higher than

private hospitals. Support from senior

staff in private hospitals deteriorated.

Fluctuations in workload also

improved among nurses working in

public hospitals, but became

considerably more stressful in private

hospitals.

In both public and private hospitals,

nurses found their workload

increased.

Stress associated with deciding

priorities increased slightly in public

23

hospitals and substantially in private

hospitals. A major change in stress

after 5 years in both types of

hospitals was from supervisors

asking nurses to perform doctor’s

functions.

Wang et al,

2003

A cross-sectional

and descriptive study

having as target 145

staff nurses who

performed for at least

one year in Sakaeo

Provincial Hospital,

Thailand.

+ The focus on perceptions of

head nurse performance is

useful, in light of other studies

indicating this as an important

factor of Thai nurse

satisfaction.

+ The positive association

between work experience and

satisfaction is interesting.

- Poor English editing makes it

difficult to read.

The percent of staff nurses on their

job satisfaction was at a moderate

level (73.10%).

A significant positive correlation was

found between nurse job satisfaction

and perception of the head nurse

leadership.

Most of socio-demographic

characteristics have no significant

association with job satisfaction (the

authors explain that nurses see

these as personal problems, not

related to work).

There was a significant positive

association between staff nurses’ job

satisfaction and duration of working

as a nurse as well as duration of

working in this hospital (the authors

explain by nurse having the time to

understand and adapt).

24

Discussion: cultural differences in nurse dissatisfaction and the researchers’ approach

As discussed in the ‘Sample Selection’ chapter, this dissertation

acknowledges that the heterogeneity (in terms of methods, sample size and

structure, focus) of the reviewed articles makes quantitative analysis

irrelevant. Besides, the factors leading to low job satisfaction are more or less

the same in all studies regardless of the country; if one seeks to find cultural

differences without doing a cross-cultural research, than s/he should check

how these factors are constructed – by nurses themselves, if the

questionnaires or interviews allow them this option, or by the researchers.

This chapter attempts to answer the research question by discussing the

common themes and some culturally relevant differences in the approach to

research on nurse dissatisfaction in the two countries.

Salary and other incentives

Dissatisfaction with pay is mentioned in most of the studies, in both countries,

so it can be inferred that financial incentives for work transcends cultures. For

Thailand, Kunaviktikul et al (2000) finds it as the main factor, and the same

ranking was found by two studies in UK (Robinson et al, 2005; Lephalala at al,

2008). Although this dissertation aims for identifying differences, this similarity

is worthy of emphasizing. Cross-cultural research was criticised for too often

ignoring similarities found in the process of data collection, which was

explained by the fact that scholars tend to examine only information

supportive of differences, and downplay other information (Ofori-Dankwa and

Ricks, 2000).

In our case, this similarity interestingly comes against the cultural stereotype

that Asian, and especially Buddhist cultures, are less concerned with material

aspects. Thai nurse have the same attitude to the pay factor like their British

counterparts, and it is interesting to note that the salaries are more or less at

the same level if we compare their net value while having in mind the average

salary and the cost of living in each country. Indeed, a brief search of the job

agencies in the two countries reveals that a nurse is paid roughly 20-30

25

GBP/hour in UK, and 2-3 GBP/hour, which is ten times less, in Thailand. The

average monthly salaries (UNECE Statistical Database) are around 3,500

USD in UK and 500 USD in Thailand, which is seven times higher in UK. So

as a proportion in the average salary, a British nurse is paid better, but this

factor is attenuated by the higher cost of living, significantly higher in UK.

In a rough approximation, we may say that nurses’ pay is in the end the same

– and this raises some questions on why a Thai nurse would want to migrate

to UK, and in general to a Western European country. A primary research

among immigrant Thai nurses in the West may reveal that a high proportion of

them migrated in order to support numerous families at home: if so, the nurse

would adopt an extremely frugal style of life in the country of destination,

which allows her to save a high proportion of her salary. But this self-sacrifice

may in the end lead to more job dissatisfaction, especially about payment.

Another incentive for being a nurse is the opportunity to promote, of which

attending professional courses is an important component (Rambur et al,

2005). This factor shows a marked difference between the two countries.

Most of the British studies show a significant dissatisfaction emerging from

lack of promotion and educational opportunities. For example, Aiken et al

(2001) found that less than 45% agree they have opportunities for promotion;

Lephalala et al (2008) found that 90% are dissatisfied with lact of promotion

opportunities; Murrels et al (2009) found the lack of opportunities of going to

courses ranking high of reasons for dissatisfaction; Newman et al (2002)

found better career prospects as a major requirement of nurses; Robinson et

al (2005) found almost half of the nurses upset with lack of opportunities in

their career. The situation, as reflected in the Thai studies, is totally different:

only one study finds nurses relating lack of promotion opportunities to job

dissatisfaction, but figures are not provided. Although this systematic review

does not provide sufficient elements for a conclusion that Western nurses are

more ambitious than their Asian counterparts, this imbalance in how

promotion opportunities ranks high in British research and is inexistent in Thai

research is worthy of further research.

Finally, in a stressful profession like nursing, dominated by high

responsibilities, the need for recognition can be an important incentive (Ernst

26

et al, 2004). Recognition can come from various sources: head nurse,

physician, hospital management, patient families or society as a whole. For

example, Aiken et al (2001) found that less than 45% in their sample agree

that nurses’ contribution to public care is publicly acknowledged. Other

studies (Newman et al, 2002; Sriratanaprapat et al, 2012) discuss recognition

in a way that brings it closer to the notion of nurse empowerment, an aspect

that will be dealt with below, in the ‘Work environment’ section.

Workload

Workload is mentioned as a major source of dissatisfaction in all the British

studies in the sample, but only in three of the Thai studies selected, which

may be a reflection of the hardworking character of the Asians (not to be

understood that Europeans are not!), but may also have other explanations

related to the studies’ focus or how and where the ‘workload’ factor was

researched. For example, Tyson and Phongruenphang (2004) found that

nurses in private hospitals are significantly more dissatisfied with workload

fluctuations than public hospital nurses. These fluctuations may be a

consequence of the profit oriented character of private hospitals: the budget,

and from here the staffing and the workload, depends on how the business is

going, so it is not constant.

But more relevant is analysis of how the discussion on workload is conducted

in the two countries. For the British nurses, the main contributor factor to high

workload seems to be insufficient staffing (Adams and Bond, 2000; Aiken et

al, 2001; Murrels et al, 2009; Robinson et al, 2005; Sheward et al, 2005),

while in Thailand, only one study specifically mentions staffing as a problem

(Nantsupawat et al, 2011). This sharp difference may either be explained by

the economic conditions of the two countries, with Thai public hospitals not

having the budgetary pressures of their European counterparts, or by societal

factors: in Thailand, as revealed by these studies, the intention to leave is

significantly lower than in UK. True, numerous Thai nurses chose to practice

abroad, especially in the Middle East, but the supply from the nursing colleges

can easily compensate. A third explanation for the workload appearing

27

separate from staffing problems in the Thai studies may be found in the Thai

obedience and respect for hierarchies: if the management decided for a

particular number of nurses in a certain department, it is not for the nurse to

question this decision.

Another striking difference refers to workload being or not seen as related to

excessive paperwork. Nearly half of the British studies mention paperwork as

a source of upsetting workload, while this aspect is totally absent from the

Thai studies. This may be due to the Asians’ patience with details and the

more bureaucratic character of their societies. It may equally be due to the

fact that Thai researchers simply did not think of this aspect, and neither did

the nurses. But the second explanation in reality is no different from the first

one: if the researchers did not think of exploring this aspect, and the nurses

have not mentioned it in the open questionnaires, that must mean it is not

perceived as a source of heavy and unpleasant workload.

Finally, socio-demographic characteristics influencing (and being influenced)

by dissatisfaction with heavy workload also reveal some differences, but there

are not conclusive due to the low number of studies in Thailand addressing

this issue. In UK, half of the studies in the sample discuss this aspect and find

that disruptions in social life due to high workload are an important source of

dissatisfaction. In Thailand, only two studies attempted to find out the degree

of correlation between socio-demographic indicators, workload and

dissatisfaction, and their results were opposite. Wang et al (2003) found no

correlation, and explained this finding by the ability of nurses to put a fence

between professional and personal life, whereas Lambert et al (2004) on the

contrary found a significant correlation, and explained it by the high number of

members in a Thai household and the role of woman in the family.

Human relations at work

With the stress inherent to working in direct contact with patients, when health

and even life is at stake, it is normal that the quality of human relations is an

essential contributor to nurse satisfaction – and this is what nearly all studies

in the sample have found. Relations referred to in the studies are between

28

nurses themselves, between staff nurses and head nurse, and between

nurses and physicians. No study in both countries has found a relevant

source of dissatisfaction in the relation with colleagues, showing perhaps that

the stressful working conditions strengthen relations among nurses.

The relation with the head nurse is not at all addressed in the British studies in

the sample, but it is debated in two Thai studies (Sriratanaprapat et al, 2012;

Wang et al, 2003). Both have found a high correlation between head nurse

performance and job satisfaction, and the explanation was that with the

collectivist nature of the Thai society, staff nurses perceive the head nurse

failure as a breach of a duty towards the group, since she is ‘one of them’.

The nurse-physician relation was demonstrated to be a potential source of job

dissatisfaction (see for example Manojlovich, 2005 or Anderson, 1996) but it

is addressed in only two studies in the present sample, thus not allowing a

relevant comparison. Both British and Thai researchers (Aiken et al, 2001;

Nantsupawat et al, 2011) found that nurses had no complain about the

relation with doctors.

But interestingly enough, the Thai nurses in both public and private hospitals

lately complained about taking up too much of the responsibilities that were

previously seen as doctors’ (Tyson and Phongruenphang, 2004). However,

this was seen as dissatisfaction derived from the head nurse who had such

requirements, rather than from doctors, perhaps as an indication of the high

status the doctor has in the relation with the nurse in Thailand. The authors do

not specify what these responsibilities are, but from the author of this

dissertation’s experience as a nurse in Thailand, it may refer to the fact that

patients often are shy to ask details from the doctors, and turn to nurses

(perceived as having a closer social status) for explanations on the case.

Work environment

Adams and Bond (2000) found that organisational (ward) aspects outweigh

personal aspects when it comes to job satisfaction, which is consistent with

Kanter’s theory (1997, cited in Laschinger et al, 2001) positing that the impact

of organisational structures on employee behaviour is far greater than the

29

impact of employee’s characteristic personality (although the latter should still

not be ignored, as warned by De Gieter et al, 2011). Among organisational

aspects, empowerment is one exercising high impact on nurse satisfaction

(Laschinger et al, 2011). Empowerment has two components: structural

empowerment, referring to a workplace with access to resources, information,

support and opportunities to learn, and psychological empowerment, defined

as the employee’s response with a sense of autonomy, competence and a

sense of self-efficacy (Laschinger et al, 2011).

The comparative analysis of this dissertation’s sample shows a clear divide

between cultures, as far as empowerment as a factor influencing job

satisfaction is concerned: most of the studies in UK mention it, but only one

among the Thai ones. Moreover, the Thai study that investigated the weight of

empowerment in the nurses’ level of job satisfaction (Sriratanaprapat et al,

2012) founds it as low and explains this by the fact that culture does not

create in the nurse the expectation to exercise autonomy.

At the other end, the British studies reveal that lack of empowerment ranks

very high in sources of dissatisfaction. In the study of Aiken et al (2001), less

than 35% agree that nurse has a chance to participate in management

decisions. Similarly, 52% in the study of Lephalala et al (2008) where

dissatisfied with their level of participation in decision-making, and lack of

recognition from management was second in the top of nurse dissatisfaction,

in the study of Newman et al (2002).

Aside from the human aspects of organisational management, which reveal

as shown above a wide gap between nurse dissatisfaction in the two cultures,

work conditions can also refer to material aspects like availability of

equipment, and some studies in both countries found these relevant (for

example Robinson et al, 2005; Nantsupawat et al, 2011).

Specificity of the nursing profession

Nurses in many healthcare sectors, such as oncology, AIDS, intensive care or

ambulance, regularly encounter death and trauma, and this has a profound

effect on their emotional well being (Sorensen and Iedema, 2009). Even for

30

those working in other sectors, encountering and responding to human

suffering by providing care is common. The ‘caring’ component of the nurse

profession is the main source of its specificity (Kirpal, 2004), and at the same

time an important influencer of job satisfaction. However, its impact is

ambivalent, as the studies in this systematic review show: Newman et al

(2002) found it as s source of job satisfaction, while the nurses in the Lambert

et al (2005) study mentioned it as a source of stress.

Both positive and negative impacts of nursing specificity on nurses’ feelings

have clear intuitive explanations: while providing help to people in need is

fulfilling, the fear of doing a mistake with serious consequences for someone’s

health is stressing; moreover, as Sorensen and Iedema (2009, p. 6) note, for

nurses, ‘anxiety can attach to their connection to individual patients and the

powerlessness they feel in bearing witness to often futile treatment’. Kirpal

(2004) further explains this ambivalence by the fact that although ‘wanting to

help others’ provide inspiration, motivation and satisfaction to nurses, these

feelings are counterbalanced by negative factors like the low status of the

profession (within the medical field and in society), time pressure, heavy daily

work loads and the fact that the job is physically and psychologically

extremely demanding. The conflict between these facets of the nursing

profession identity is deeply embedded in the profession itself, so from this

systematic review’s perspective, culture is not relevant to it.

Researchers’ approach as indicative of cultural differences

Researchers investigating job dissatisfaction in nursing perform at the border

between (applied) social research and medical research. The goal for basic

social research is to produce or verify theories, while its ‘applied’ version has

the goal of solving real-world problems (Steele and Price, 2007). Research on

job dissatisfaction in general and nurse dissatisfaction in particular is applied

research, as it tries to solve the problems generated by this phenomenon,

such as low efficiency of the employees and, in the particular case of nursing,

high intentions to leave leading to shortage of nurses.

31

Therefore, what exactly researchers are investigating is indicative of what is

perceived as a problem in the society. In this perspective, it is of high

relevance that British and Thai researchers of nurse dissatisfaction focus on

different aspects; in the following, this section will highlight some of the

differences.

One topic that is thoroughly researched in UK (see for example Shields et al,

2002, in the sample of this study, but also Alexis and Vydelingum, 2007 or

Dhaliwal and McKay, 2008) but no study so far discussed it in Thailand is the

situation of ethnic minority nurses. True, the proportion of ethnic minorities

among nurses in UK is far greater than in Thailand, but the latter also has

significant minorities in the North (for example the Karen) and in the South,

inhabited in majority by Muslims of Malay origins. While not finding these

aspects as worthy of investigation, Thai researchers chose to inquiry on the

situation of Army hospitals nurses (see Intaraprasong et al, 2012), which may

be a reflection of the high esteem shown to the military by Thai people.

Another interesting choice of Thai researchers, not found in the British and in

general the Western scholarship, is found in the area of nurse strategies for

coping with stress. Pongruengphant et al (2000) discussed crying as coping

strategy, and although they found no relation with job dissatisfaction, their

choice may be still indicative for the different ways Western and Eastern

nurses, mostly females in both cultures, are expected to release emotions.

The age of nurses is also a variable seen very differently in the two

countries/cultures. Numerous studies in UK focus on early career nurses (for

example Murrels et al, 2009, in the sample of this study); besides, the studies

not focused only on recently graduate nurses almost always address this

segment, emphasising the specific problems it encounters. Thai studies, on

the contrary, specifically require that nurses in the sample have a certain

amount of experience (one year required in two of the studies in the sample:

Sriratanaprapat et al, 2012, and Wang et al, 2003). This may have some

connection to the Asian culture of deriving hierarchies not only from social

status but also from age, with the youngsters not being seen as entitled to

having a voice until they gain experience in a particular field.

32

Finally, an aspect not necessarily related to researchers’ choices but rather to

the process of research is worthy of being mentioned, as relevant for cultural

differences: while the rate of returned questionnaires was between 30% and

60% in UK, in Thailand it was usually around 90%, like in the studies of

Intaraprasong et al (2012) or Pongruengphant (2000), and even reached 98%

in the research of Kunaviktikul (2000). It appears that the Asian sense of

discipline finds its manifestation even in filling questionnaires.

Conclusion and recommendations

Relevant cultural differences in nurse dissatisfaction

The systematic review of 16 primary research studies (8 in Thailand and 8 in

UK) revealed that although the factors leading to nurse dissatisfaction are in

general the same, how these factors are constructed and their weight in the

overall level of job satisfaction may vary across cultures. The factors showing

the highest gap are the opportunity for promotion (with high influence on

British nurses’ job satisfaction, but irrelevant to Thai nurses), workload

(although a high influencer in both countries, it is differently construed, being

mostly related to staffing in UK but with more diffuse sources in Thailand),

approach to paperwork (an important source of dissatisfaction in UK but

irrelevant to Thai nurses), or empowerment (its low level provokes

dissatisfaction in UK but does not matter to Thai nurses). Some significant

similarities were also found, for example low salary is a main source of

dissatisfaction in both countries, and the nurse-physician relation is generally

good.

The above-mentioned differences and similarities were identified directly, by

comparatively analysing the themes recurrent in British and Thai job nurse

dissatisfaction literature. But this systematic review also found indirect

indication of cultural differences, by analysing what exactly the researchers in

the two cultures are after. As applied research, studies on nurse

dissatisfaction are meant to resolve real life problems, therefore it is fair to

infer that the researchers’ focus indicates the existence and magnitude of a

particular problem. This paper for example found that there is no research in

33

Thailand on the specific motives of ethnic minority nurse dissatisfaction, while

in UK the subject is well researched.

The importance of nurse satisfaction to the healthcare process is crucial, as

explained in the introductory chapter, and that is why the following three

sections of this chapter identify the groups that should be interested in the

present systematic review’s findings.

The utility for supervisors and managers

The main beneficiaries of systematic reviews are generally the practitioners,

as it helps them manage the rapid increase in available evidence (Chalmers

1993). Systematic reviews were developed as a tool to collate, filter,

synthesize and disseminate the evidence for the effectiveness of treatment

options on a topic for practitioners (Higgins & Green 2011). This systematic

review is different in that it does not address a clinical issue, but a problem

more generally related to the quality of healthcare; therefore, its beneficiaries

are not necessarily the physicians, but the nurses’ supervisors – from head

nurse to higher levels of hospital management.

According to the statistics of the Health and Social Care Information Centre

(HSCIC), cited by The Guardian (26 Jan 2014), the proportion of foreign

nationals increased for professionally qualified clinical staff to 14%, with the

highest number of qualified foreign nurses coming from Philippines. The

statistics do not take into account the already naturalized qualified health

workers, so the proportion of nurses having been educated and trained in

another culture is in reality higher than these figures. Knowing the cultural

differences in factors leading to job dissatisfaction and in coping strategies

can prove useful for the management; for example, it can show them ways of

better using the foreign workforce, and it can help them avoiding

misunderstandings, or defusing tensions.

In order to get to their possible beneficiaries, results of systematic reviews

need proper dissemination, by tools that Chambers et al (2011) term

‘knowledge-translation resources’. The underlying idea is the same that

motivates the use of systematic reviews in the first place: managers, as well

34

as practitioners, would not have the time to read and analyze all the relevant

information, so the knowledge needs to be appraised, summarized, analyzed

but in the end, it also needs to be ‘translated’.

The three tools that ‘translate’ systematic reviews’ findings are (Chambers et

al, 2011) summaries (which encapsulates essential findings of a particular

systematic review), overviews (which systematically identify and review

systematic reviews on a given topic) and policy briefs. In the present case, a

summary would contain the essential findings of the ‘Discussion’ chapter, in a

more condensed form.

The utility for researchers undertaking cross-country studies

A second category that may be interested in the results of this systematic

review is the one of researchers. This study was designed as an exploratory

one because the heterogeneity of its sample does not allow categorical

conclusions on the cultural differences it identified. The sample heterogeneity

was a result of the rather broad topic (nurse dissatisfaction) which in turn was

dictated by the scarcity of the studies addressing only one factor of nurse

dissatisfaction; if for example the research question had referred only to how

the weight of the salary factor in job satisfaction varies among cultures, than

not more than two or three primary research articles would have been

available for each country. That is why the author chose to keep the

discussion at the general level of nurse dissatisfaction, with all factors

included, and from here, the study became inherently exploratory in nature,

thus inviting further research on the hypotheses it established.

One of the advantages of systematic reviews is that they can demonstrate

where knowledge is lacking, which can then be used to guide future research

(CRD, 2009). In this perspective, any of the differences found by this

systematic review can turn into a hypothesis for cross-country quantitative

research of a more evaluatory, descriptive or explanatory nature. With similar

samples and research methods simultaneously applied in two or more

countries perceived as culturally different, such a study could confirm (or

infirm) the findings of this systematic review. This is actually what one study in

35

this systematic review’s sample attempted (Lambert et al, 2005), but due to

the reasons already discussed at page 23 above, it cannot really count as a

cross-cultural study. Aside from that article, only one cross-cultural primary

research addressing nurse dissatisfaction was found in the medical

databases: a comparative analysis of nurse job stressors in India and Norway

(Pal and Saksvik, 2008).

Limitations of this study

The main problem to deal with is bias, which in this case may come from

various sources. First, there is the bias that may be contained in the study

under survey, either resulting from methodological flaws, or from interests of

research sponsors, investigators, peer-reviewers and editors - the so-called

publication bias (Song et al 2010). Second, there is the bias in the process of

the systematic review itself, which could mainly come from flawed or

incomplete selection of articles, for example the non-inclusion of articles in

Thai language (Sterne et al 2001). Finally, there is an inherent bias related to

the person of the researcher, a Thai nurse with a long experience in which

she encountered her own reasons of dissatisfaction. This last aspect is

detailed in the Reflections chapter.

Reflection on what I learned

The school’s guidance on how to develop this section relies on two pillars: the

students were required to consider the entire process in the development of

the systematic review and its values in contributing to their own personal

development and professional expertise (1) and to use a reflective model of

their choice and offer a critical analysis of what they have learned during the

development of this project option (2). However, the problem with the second

requirement is that the literature deals with reflective practice: the intention of

reflection is ‘to enable the practitioners to tell their stones of practice and to

identify, confront and resolve the contradictions between what the

practitioners aim to achieve and actual practice, with the intent to achieve

more desirable and effective work’ (Johns, 1995, p. 230). Using a model of

36

reflection is important as it helps me structuring the reflection – which

otherwise may comprise just disparate thoughts – and not missing any detail.

But a first challenge was choosing the model, as all the ones I checked

seemed to refer to practice, that is to say, direct experiences with patients.

I resolved this dilemma in two steps. First I looked for a wider definition of

reflection in the nursing literature, and I found it as ‘active, purposeful thought

applied to an experience to understand the meaning of that experience for the

individual’ (Ashby, 2006, p. 28). Second, I explored to which extent a

reflective practice model can be expanded, from reflective practice to

reflective research. To take Gibbs Reflective Cycle (graph from Ashby, 2006):

Like other reflective practice models, Gibbs has in mind a particular event

related to healthcare practice, while in my case, it was a long process of

researching, analysing and writing, so I will follow the model only to the extent

it can apply to my case. I will rather be guided by the general school

requirement of describing how I improved as a person and as a professional.

Description

I had to do a systematic review for the first time in my life, based on the

classes we were taught during the master course at Bedfordshire University.

37

Feelings

I was overwhelmed by anxiety and doubts whether I can manage. In the

beginning I had mixed feelings about the topic I chose: on the one hand, with

spending many years abroad lately, I developed a passion for cultural

differences impacting on healthcare, but on the other hand, I was tempted

towards a simpler topic, with focus on some disease, drug or protocol. The

more I was advancing with research, I was feeling more confident with the

topic I chose, but I was worried about other things related to developing the

dissertation.

Evaluation

Each step, once completed, gave me a deep satisfaction, and that was the

best thing about working on this dissertation. The bad thing was the constant

tension I felt during the whole process, mainly because I was doing this for the

first time.

Analysis

As said before, the first challenge was the topic, which is at the border

between the healthcare field and the social science field. Once I chose this

field, a major problem was that I am not familiar with social science research,

and I my sample I encountered methodology, especially quantitative, that I

was not familiar with. Although I read all articles in the sample carefully, I have

to confess that in some of them, I did not follow the methodology in detail. It

was simply beyond my power of understanding, with the skills I acquired so

far. But I made sure that I understand the broad picture, the essence of the

method.

A further challenge was to keep under control my own views on the topic. In

my many years as a registered nurse, most of them in the emergency room, I

often encountered the feelings I was now reading about. My mind would go

permanently ahead of what I was reading, something like ‘I know that, I was

this situation once!’ Fighting the tendency of putting my experience and

myself in the middle was really difficult.

The quality gap between researches in the two countries was also a

challenge. If I overemphasised it, I was afraid it may create a negative feeling

38

among my Thai colleagues who may happen to read it – we tend to be

oversensitive to what others say about us, the ‘saving face’ Asian attitude is

already well known abroad. So I tried to mention this aspect in a discrete way.

Conclusions

I learned tremendously from this experience, both at a personal and a

professional level. Professionally, the whole Master experience in general,

and the dissertation in particular, made me confident that I am ready for taking

a head-nurse position back in Thailand – a position that I turned down before,

as I felt unprepared. The experience in UK, and the dissertation in particular,

has changed my view.

The first condition for leading and supervising is to know the people in your

team, and the topic of my dissertation took me deep into subjects related to

nurses’ problems at work. I understood what makes a Thai job satisfied at

work, and as a head-nurse, many of the factors contributing to this aim are in

my hand.

Writing the dissertation also contributed to my professional development by

improving my critical reading skills. If until now, I was struggling to understand

academic writing, now I read fasted, deeper and more critical. This, combined

with my better understanding of the importance of evidence-based practice,

will be of great help during my practice in Thailand. I will be a more informed

practitioner, and I will mentor nurses under my supervision to become the

same.

As for the personal achievements, this research opened a whole new world to

me. Until now I was at the other end of the ‘nurse dissatisfaction’ research

process – I was the nurse, with her struggle between the desire to help the

patient and her profession’s pressures. All of a sudden, the nurse became not

who I am, but my object of research, and I found this transformation

fascinating. During the research process, I learned about patience, tenacity,

keeping your mind open, accepting various views, understanding bias,

thinking how to relate and compare data, or how to use some theoretical

findings for practical solutions. Other collateral benefits were my improved

English skills, and those in using the Word software.

39

As mentioned above, the reflective practice models, including the Gibbs

model I used, guide the individual to think over his/her practice experience in

order to improve the performance in future, similar situations. Although in my

reflections above I used Gibbs model to some extent, I cannot apply it in all its

dimensions, because I do not intend to do more research in the future. This is

the limit in extending a reflective practice to my situation: what I learned by

doing this research I will use not for further research, so not from the same

event that generated the knowledge, but for practice. It is said that knowledge

is power; I really feel now equipped with a magic wand and I cannot wait to

return to my practice and use this wand.

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chisa thesis bedford

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