1. Nurse Dissatisfaction in a
Comparative Perspective:
UK and Thailand
Author: Chisa Radavoi
Supervisor: Christine Norgate

2. 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

3. 3
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. 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

5. 5
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

6. 6
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

7. 7
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.

8. 8
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”.

9. 9
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
UK
=
3
articles
TH
=
6
articles
Science
Direct
Initial
search:
job
+
satisfaction
+
Nurse
UK
=
1728
articles
TH
=
394
articles
ReCine
with:
burnout
+
shortage
+
turnover
UK
=
13
articles
TH
=
14
articles
Medline
Initial
search:
job
+
satisfaction
+
Nurse
UK
=
592
articles
TH
=
170
articles
ReCine
with:
burnout
+
shortage
+
turnover
UK
=
2
articles
TH
=
2
articles

10. 10
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

11. 11
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.

12. 12
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.

13. 13
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).

14. 14
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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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