Psychological distress, work environment quality, and motivation levels among nurses working in Saudi Arabia

Study design and setting

A cross-sectional, descriptive-correlational study was conducted with nurses working at four hospitals in Saudi Arabia. With this design, we collected data at a single time point (cross-sectional) and then analyzed them to determine whether there were relationships among the variables (descriptive-correlational) (Afrasiabifar et al., 2021). Hospitals were coded as A, B, C, and D for confidentiality. The included hospitals are university hospitals, which are healthcare facilities affiliated with universities, located in the Riyadh region. They are also considered teaching hospitals, where students are trained and work alongside experienced healthcare professionals. One hospital (D) is a dental hospital, while the other three are general hospitals that treat all medical conditions. The bed capacities of the four hospitals vary but are no less than 500 beds per hospital. These hospitals were selected because they were conveniently accessible.

Sampling

A convenience sampling method was used to contact nurses working at the above hospitals. We aimed to recruit participants from a diverse range of hospital settings to reduce the potential for sampling bias and enhance the generalizability of our findings. Hence, Saudi and non-Saudi male and female nurses who had been working at one of the above hospitals for at least one year were eligible to participate in our study. Nurses working in all positions were eligible to participate, as they could provide rich knowledge that could contribute to improved productivity in nursing. However, those with limited English proficiency were excluded, as they may not have understood the survey questions sufficiently. Further, nurses who chose not to participate were excluded. Using the G*Power tool (Heinrich-Heine-Universität, Düsseldorf, Germany), with the statistical power level set at 0.8, an effect size of 0.15, a Cronbach’s α of 0.05, and 10 explanatory variables (age, gender, nationality, marital status, educational level, years of work experience, department of work, current position, shift type, and hospital name), a minimum required sample of 118 participants was estimated. To address missing data, 20% was added, which resulted in a final minimum sample size of 142 participants.

Instrumentation

The questionnaire included demographic questions about participants’ age, gender, nationality, marital status, educational level, years of work experience, department of work, current position, shift type, and hospital name. It also included questions assessing participants’ psychological distress (Kessler et al., 2003), work environment quality (Sansó et al., 2021), and motivation level (Gagné et al., 2015).

Psychological distress was assessed using the Kessler Psychological Distress Scale-6. This tool includes six items that measure distress caused in the preceding 30 days (e.g., How often did you feel nervous?) (Kessler et al., 2003). Responses are rated using a five-point Likert scale with possible answers of 1 = all the time, 2 = most of the time, 3 = some of the time, 4 = a little of the time, and 5 = none of the time, with higher scores indicating low psychological distress. The instrument has been used internationally and tested in several cultures and languages, including Arabic. The Arabic version has acceptable reliability, and the cutoff point was determined to be 16.25 (Cronbach’s α = 0.81) (Easton et al., 2017). The Kessler Psychological Distress Scale-6 is available for free use (https://www.hcp.med.harvard.edu/ncs/k6_scales.php). We also obtained permission to use the validated version of the scale if needed (S. Easton, personal communication, 2019).

The Brief Nurses’ Practice Environment Scale was used to measure the work environment quality variable (Sansó et al., 2021). The scale comprises five statements that represent the five dimensions of the Practice Environment Scale of Nursing Work Index. The five statements of the tool are rated using a four-point Likert-type scale, with responses ranging from 1 = completely disagree to 4 = completely agree. The total score is computed by summing the scores for the five statements and ranges from 5 to 20 (Sansó et al., 2021). The reliability of the Brief Nurses’ Practice Environment Scale has been established, and it has a Cronbach’s α of 0.702. The confirmatory factor analysis of the scale has an excellent fit that evidences its internal validity (Sansó et al., 2021). Finally, a cutoff score of <12 means that the practice environment is unfavorable, while a score of >15 means that the practice environment is favorable (Sansó et al., 2021). The factors tested in this scale have been shown to be effective in determining nurses’ experiences with high burnout and low satisfaction with their work, particularly when they perceive their practice environment to be unfavorable. Our third author (G.B.) obtained permission to use the scale (L. Galiana, personal communication, 2022).

The motivation level of nurses was assessed using the Multidimensional Work Motivation Scale. This scale includes 19 items with six dimensions and the same factor structure across seven languages (Gagné et al., 2015). The scale is answered on a seven-point Likert-type scale, with responses of 1 = not at all, 2 = very little, 3 = a little, 4 = moderately, 5 = strongly, 6 = very strongly, and 7 = completely (Gagné et al., 2015). Scores range from 19 to 133, with higher scores indicating higher motivation levels. The reliability of the tool is below 0.70 only in German but above 0.80 in the other six languages in which it is available, including Chinese, Dutch, English, French, Indonesian, and Norwegian. Our third author (G.B.) obtained permission to use the scale (M. Gagne, personal communication, 2022).

Data collection and analysis

Data were collected using an anonymous online questionnaire in a standardized and systematic manner to ensure their validity and reliability. Prior to distributing the questionnaire form, we reviewed the scales’ items to ensure their clarity and identify any potential issues. We also addressed factors that may have discouraged potential participants from completing the questionnaire, such as its length and the wording of the items. We collectively confirmed that the items were appropriate and easy to understand. Social media, personal references, and word of mouth were all utilized to help distribute the questionnaire form, as the goal was to reach a large sample.

Data were collected between October 2022 and February 2023, then analyzed using SPSS version 28. Frequency distribution analyses were conducted to identify missing data or errors and to describe the study’s sample characteristics and variables. Only the “years of work experience” variable had missing data, which we addressed using the mean imputation method. We nevertheless included “years of work experience” in the analysis, as it could provide insights into the levels of expertise and knowledge that nurses obtain over time. Bivariate analyses, including the independent samples t-test, Pearson coefficient correlation (r), and one-way analysis of variance (ANOVA), were all conducted as appropriate. Further, multiple linear regression analysis was conducted to determine the relationships among nurses’ psychological distress, work environment quality, and motivation level while controlling for the demographic variables. Some demographic variables with several categories were combined into a twofold format for the regression analyses. We also assessed the internal consistency of our structured questionnaire using a commonly used statistical measure called Cronbach’s alpha.

Ethical considerations

Ethical approval was obtained from the institutional review boards of both Princess Nourah bint Abdulrahman University (Ref. number: 22-0445) and King Saud University (Ref. number: 19/0737/IRB). All participants gave their informed consent. Due to limited access to obtain in-person signatures, we provided an online consent form that included the statement, “Your completion of the survey indicates your agreement to participate. Thank you!” Participants were also informed that their participation was voluntary and that they had the right to withdraw from the study at any time without penalty. The collected data were kept confidential and only accessed by the research team members.

Sample characteristics

Table 1 provides the sample characteristics of the study (N = 204). Participants’ mean age was 35.81 years (SD ± 8.14 years; range: 22–58 years). Most participants were women (86.6%), married (58.8%), non-Saudi (69.6%), held a bachelor’s degree in nursing (75.5%), and worked at hospital A (66.7%). The mean number of years of work experience in nursing was approximately 12 (SD ± 7.64 years; range: 1–35 years). Close to half of the participants (46%) worked in the medical, surgical, or critical unit of their hospital. Most of the sample (68.6%) who worked 12-hour shifts were bedside nurses. Levels were moderate for psychological distress (M = 19.99, SD = 5.63, range: 6–30), work environment quality (M = 13.70, SD = 2.90, range: 5–20), and motivation (M = 72.77, SD = 19.95, range: 19–123). The Cronbach’s α of our structured scale was determined to be .86.

Statistical analyses

Necessary bivariate analysis results are presented in Tables 2 and 3. No statistical differences were found (p >.05) when conducting the independent samples t-test (Table 2). The Pearson coefficient test reported statistically significant relationships between age and both years of work experience (r = .711, p = .001) and psychological distress (r = .140, p = .046). A significant, positive, and moderate relationship was also found between psychological distress and work environment quality (r = .505, p = .001). More details are presented in Table 3.

When conducting the one-way ANOVA, the results varied for psychological distress, work environment quality, motivation level, and some demographic variables, including marital status, educational level, department, current position, shift type, and hospital. That is, no significant differences were reported between these demographic variables and psychological distress. However, the department (F [3,203] = 3.670, p = .013) and hospital (F [3,203] = 3.723, p = .012) were both statistically associated with work environment quality. Further, only nurses’ educational level (F [2,203] = 3.779, p = .024) was statistically associated with their motivation level.

Tables 4, 5 and 6 show the results of the regression analyses of psychological distress, work environment quality, and motivation levels while controlling for the demographic variables. The psychological distress (F [12,203] = 7.927, p < .001, R ² = .332), work environment quality (F [12,203] = 7.806, p < .001, R ² = .329), and motivation level (F [12,203] = 1.827, p = .046, R ² = .103) models were all statistically significant. In Table 4, only nurses’ nationality (β = .200, p = .013), current position (β = .143, p = .037), and work environment quality (β = .492, p < .001) significantly influenced their psychological distress. Table 5 shows that nurses’ hospital (β =  − .188, p = .007) and psychological distress (β = .492, p < .001) significantly influenced their work environment quality. As shown in Table 6, no variable was found to influence motivation levels.

Limitations of the study

Although our study provides valuable findings, it had a few limitations. First, a cross-sectional design can only be used to identify relationships among variables. Second, the use of self-administered questionnaires may have introduced response biases. Third, the generalizability of the findings may have been affected by our collecting data from only four institutions. Finally, using non-probability sampling (convenience sampling) might have led to selection bias. A replication of the study with a larger sample that represents more of the population can establish the findings’ generalizability and external validity (Matthay & Glymour, 2020). Future studies should also be conducted on more public and private institutions, as well as in different cities. This would provide a better understanding of the disparities within the sample and serve as a foundation for improving the performance of nurses. Moreover, the findings of this study indicate potential areas that warrant further investigation related to the three studied variables and their potential predictors.

Study implications

The study’s findings suggest several strategies that nurse managers and leaders might employ in the work environment to increase motivation among nurses. These include establishing a workplace that promotes nurses’ involvement in decision-making, improves the work environment quality, expands internal opportunities, utilizes a reward and incentive system, and provides a greater work–life balance. Hence, to produce empowered and motivated nurses, healthcare organizations are advised to improve their work environment. Since nurses will function at their best when they have optimal mental health, administrators should attempt to assist nurses in maintaining psychological stability. Stakeholders should also take care of their nurses and teach them problem-solving skills and stress management strategies.

Further, developing strategies that limit the psychological distress among nurses can be helpful. Nurse managers may also support nurses by establishing fair work schedules, offering compassionate care, implementing group intervention tools like mindfulness classes, and promoting the use of healthy coping mechanisms to reduce levels of psychological distress and improve mental health. They can also prioritize reducing the psychological stress experienced by nurses since doing so will contribute to the improved quality of healthcare services and nurses’ wellbeing.