Nursing shortages are a common problem in many countries worldwide (Chan et al., 2013). World Health Organization (2016) projects a shortage of 14 million in the global healthcare workforce by 2030. Many countries have developed strategies to combat the “crisis in the nursing workforce,” including recruiting foreign-educated nurses. Consequently, global migration and international recruitment have become a trend in the nursing profession. Migration is defined as “the movement of persons away from their place of usual residence, either across an international border or within a state” (International Organization for Migration, 2021). This drastic change in lifestyle to work abroad can be challenging for everyone, including foreign-educated nurses. The trauma of leaving home and loved ones, adapting to a new country and culture, building relationships with colleagues, and dealing with patients with different backgrounds can taxing for them (Li et al., 2014). These factors can profoundly affect their job satisfaction level (Li et al., 2014).
Job satisfaction refers to “the degree to which an individual feels positive or negative about a job” (Schermerhorn et al., 2010). Job satisfaction of foreign-educated nurses is a key indicator of hospital success in managing diversity in a multicultural workforce (Xiao et al., 2014). Ahmad and Oranye (2010) reported that higher job satisfaction would lead to better organizational commitment among the nurses. It helps ensure the nurses’ dedication to their job and provide the best services to the patients. Likewise, frustration and job dissatisfaction among foreign-educated nurses may lead to many problems such as absenteeism, tardiness, and turnover (Cheng & Liou, 2011).
The job satisfaction of migrant nurses can be measured in various dimensions. Self-esteem and self-respect are two dimensions associated with job satisfaction (An et al., 2016). A previous study reported that migrant nurses believed they could contribute to their professional work by caring for patients and family members, which gives them a sense of accomplishment (An et al., 2016). Furthermore, studies found that nurses who were able to provide person-centered, high-quality care reported higher levels of job satisfaction (Schwendimann et al., 2016; Wongboonsin et al., 2018). Job satisfaction is also strongly influenced by the working conditions such as working hours, working environment, and relationships with colleagues (Itzhaki et al., 2013; Goh & Lopez, 2016; Almansour et al., 2020). Chan et al. (2013) stated that work overtime and lack of communication with and support from doctors and colleagues contribute to dissatisfaction among the nurses.
Staempfli and Lamarche (2020) created a model to serve as a guideline for managers to assess the needs of their nurses and plan interventions to increase their nurses’ job satisfaction. The model describes that the removal of physiological needs (salary), safety (job security and physical safety), and a sense of belonging (social support and communication) causes high job dissatisfaction among nurses (Staempfli & Lamarche, 2020). Similarly, fulfillment of self-esteem needs such as supervisor and organizational support and self-actualization needs such as career advancement opportunities and personal growth improve nurses’ job satisfaction (Staempfli & Lamarche, 2020).
Career development and management support had a significant effect on the job satisfaction of foreign-educated nurses (Timilsina Bhandari et al., 2015; Goh & Lopez, 2016). It was reported that foreign-educated nurses’ job satisfaction decreased the longer they served in their host country, which may be contributed by the poor career development and lack of recognition of their knowledge and skills (Timilsina Bhandari et al., 2015). In addition, flexible employment systems that allow nurses to work part-time have a strong relationship with organizational commitment and satisfaction level among foreign-educated nurses (Ahmad & Oranye, 2010).
Additionally, language affected job satisfaction for foreign-educated nurses (Timilsina Bhandari et al., 2015). Non-English speaking migrant nurses encountered language barriers at work, making it difficult to interact with patients and colleagues (Timilsina Bhandari et al., 2015). Newton et al. (2012) also reported that communication and language barriers, feeling like an outsider, and disparities in nursing practice play a role in causing cultural displacement. As a result, it is challenging for nurses to manage and fulfill the high expectations of their patients (Newton et al., 2012).
Several studies on job satisfaction of foreign-educated nurses in countries such as Australia, Canada, and the United States reported a moderate-to-high degree of overall job satisfaction (Takeno, 2010; Itzhaki et al., 2013; An et al., 2016; Primeau et al., 2021). However, job satisfaction varies depending on geographic location, sociodemographic characteristics, and organizational setting (Itzhaki et al., 2013; Timilsina Bhandari et al., 2015; Primeau et al., 2021). For instance, Primeau et al. (2021) observed that male internally educated nurses showed a lower satisfaction than female nurses, while full-time nurses were more satisfied than part-time nurses. Furthermore, Chinese migrant nurses were reported to have the lowest work satisfaction rate in comparison to Filipino, Indian, and Malaysian migrant nurses (Goh & Lopez, 2016). These discrepancies may be related to language and cultural issues that the Chinese nurses face at work in the host country (Goh & Lopez, 2016). Moreover, Indian and Filipino nurses were reported to have higher job satisfaction, attributed to the extensive social network among foreign-educated nurses in the host country (Goh & Lopez, 2016).
Another study reported that most Filipino nurses in Thailand were satisfied with their current position and job scope, although they did not participate directly in clinical nursing care (Wongboonsin et al., 2018). Their job scope entailed answering inquiries and appointment takers, preparing medical reports, completing documents that needed to be submitted to embassies and insurance companies, and some were hired as educators in schools, colleges, and universities in Thailand (Wongboonsin et al., 2018). A total of 75% of the respondents rated “satisfied” or “very satisfied” in the job satisfaction dimensions of “working in other countries,” “relationship with superiors and co-workers,” “degree of self-worth,” and “being able to serve the sick and needy” (Wongboonsin et al., 2018). By contrast, it was found that the Philippine-educated nurses in Singapore have higher satisfaction levels than those in Thailand, particularly in “social status”, “working in other countries”, “salaries and benefits”, “ease of employment”, and “career development” (Carlos, 2018).
A clear understanding of job satisfaction among these migrant nurses is vital in facilitating the effective translation of nursing practice across the health system and cultures. It will help promote the nurses’ dedication to their job, providing optimum quality services to the patients in hospitals, clinics, nursing, or private homes. Many types of research on foreign-educated nurses’ job satisfaction and migration issues have been conducted, particularly in the United States, Canada, Australia, and Thailand, but this topic is rarely explored in Malaysia (Timilsina Bhandari et al., 2015; Carlos, 2018; Jurado & Saria, 2018; Primeau et al., 2021). Understanding the situation of foreign-educated nurses working in Malaysia and addressing their concerns will help employers and managers improve their working conditions, thus improving the country’s human resource development and health sector management. Therefore, this study aimed to examine the job satisfaction of the foreign-educated nurses in Malaysia, which includes the job satisfaction dimensions and the significant difference between sociodemographic status and job satisfaction.
This research adopted a cross-sectional study design and included foreign-educated nurses who were registered and unregistered with the Malaysian Nursing Board.
The focus group of the present study is migrant nurses based in private health care sectors in Malaysia because foreign-educated nurses are mainly employed by private institutions, including private hospitals, clinics, nursing homes, private homes, and hemodialysis centers. Participants selected for the study include those who (1) had completed nursing education in their home country, (2) had worked full time or part-time in clinical or patient-related areas, and (3) with or without a Malaysian nursing license. The exclusion criteria include (1) individuals who retired from the nursing profession, (2) individuals who worked in nursing education.
According to the list of foreign-educated nurses provided by the Malaysian Nursing Board, the total number of foreign-educated nurses registered with them is 52. The sample size required for the study was determined using Slovin’s formula n = N/(1+Ne2) (Ryan, 2013) – to be 46, with a confidence level of 95%. However, because the researchers included unregistered foreign-educated nurses who were not listed in the list provided by the Malaysian Nursing Board, the sample size is estimated to be greater than the number calculated for this study. As there is no complete list of foreign-educated nurses, purposive sampling and snowball sampling methods were employed to include as many foreign-educated nurses as possible. In total, 106 individuals consented to participate in the study, and 104 questionnaires were returned, indicating a response rate of 98%. Moreover, two respondents had to be excluded because they were retired; thus, the total number of respondents in this study was 102.
The structured questionnaire used to collect data was adapted from a study by Oda et al. (2016) entitled “Migration of nurses: the case of Kerala, India”. The questionnaire was developed and widely used to evaluate various aspects of nurse migration, including career advancement and job satisfaction (Oda et al., 2016; Rajan et al., 2017; Tsujita, 2017, 2018). The questionnaire was written in English; no translation was necessary because all foreign-educated nurses were literate in the language. The internal consistency of the questionnaire was shown to be high (Cronbach’s α = 0.83). A validity test was done using Pearson’s correlation coefficient. All items obtained a critical value > 0.19 with a degree of freedom of 100 and a 95% confidence interval (Field, 2015).
The questionnaire comprises three sections: the respondent profile, working abroad, and job satisfaction. Respondents were asked about their job satisfaction using eight-item satisfaction dimensions using a Likert scale ranging from 1 (dissatisfied) to 3 (satisfied). The eight job satisfaction dimensions were as follows: “serving the sick and needy,” “degree of self-respect,” relationship with fellow nurses & superior,” “working in other countries,” “career development,” “ease to finding employment,” “working conditions” and “salary and benefits.”
The survey was conducted between September 2017 to March 2018. The foreign-educated nurses on the Malaysian Nursing Board list were contacted and informed about the purpose of the study. Additional details were obtained from nurses who agreed to participate via phone call or email. Some of the unregistered nurses were introduced by registered nurses, and thus snowball sampling began with the sharing of contact from one person to another.
IBM SPSS version 25 was used to analyze the data collected in this study. Descriptive statistics, Mann-Whitney U test, and Kruskal-Wallis test were employed for quantitative analysis. The Shapiro-Wilk test revealed that the data were not normally distributed (p < 0.05).
Before the study was conducted, our study protocol for the research project was approved by the Institute of Developing Economies, Japan External Trade Organization (IDE-JETRO). All participants were voluntary, and consent was obtained before the participants answered the questionnaire. Furthermore, participants and hospitals were anonymized for the study. Codes (I001, P002, K003) were assigned for all questionnaires to identify the participants and their country of origin.
In this study, 79.4% (n = 81) of participants were not registered with the Malaysian Nursing Board, and most (75.5%, n = 77) worked in nursing or private homes. Female foreign-educated nurses comprised 68.6% (n =70) of the participants, while the remaining respondents were male. The majority of the participants were Christians (73.5%, n = 75), and most (67.7%, n = 69) were Filipinos. Table 1 indicates the demographic characteristics of the participants.
|Status of registration with Malaysian Nursing Board|
|Nursing / Private home||77||75.5|
|Country of origin|
Job Satisfaction of Participants
The overall job satisfaction analysis revealed that the participants had a median satisfaction score of 22 (IQR = 19 to 24). The study further analyzed the dimensions affecting satisfaction among the participants. It was found that the highest median satisfaction score (Median = 3, IQR = 3 to 3) was associated with serving the sick and needy and participants’ self-respect. In contrast, the median satisfaction scores for working conditions, salary and benefits were 2 (IQR = 1 to 3), the lowest of all dimensions. Table 2 presents the job satisfaction of the participants.
|Overall job satisfaction||22 (19 – 24)|
|Serving the sick and needy||3 (3 – 3)|
|Degree of self-respect||3 (3 – 3)|
|Relationship with fellow nurses and superiors||3 (2 – 3)|
|Working in other countries||3 (2 – 3)|
|Career development||3 (2 – 3)|
|Ease to finding work/employability||3 (2 – 3)|
|Working conditions||2 (1 – 3)|
|Salary and benefits||2 (1 – 3)|
Differences Between Sociodemographic Status and Job Satisfaction of the Participants
Table 3 shows the difference between the sociodemographic status and job satisfaction of the participants. Mann-Whitney U test and Kruskal-Wallis test were used to analyze the differences between sociodemographic status and job satisfaction, including the eight job satisfaction dimensions of the foreign-educated nurses in this study. Job satisfaction score distribution was not uniform for all groups, as assessed by visual inspection. Overall job satisfaction scores for males (mean rank = 63.28) were statistically significantly higher than for females (mean rank = 46.11), U = 743, z = -2.80, p = 0.01.
|Variables||Overall job satisfaction||Dimension 1||Dimension 2||Dimension 3||Dimension 4||Dimension 5||Dimension 6||Dimension 7||Dimension 8|
|Mean rank||p||Mean rank||p||Mean rank||p||Mean rank||p||Mean rank||p||Mean rank||p||Mean rank||p||Mean rank||p||Mean rank||p|
|Country of origin|
Notes: Kruskal Wallis test unless otherwise indicated.
Dimension 1, Serving the sick and needy; Dimension 2, Degree of self-respect; Dimension 3, Relationship with fellow nurses and superiors; Dimension 4, Working in other countries, Dimension 5, Career development; Dimension 6, Ease of finding employment; Dimension 7, Working conditions; Dimension 8, Salary and benefits.
In terms of job satisfaction dimensions, a statistically significantly difference between registered (mean rank = 62.5) and unregistered nurses (mean rank = 48.65), U = 1081.5, z = 2.30, p = 0.02) was observed only for working in other countries. Male participants showed a significantly higher satisfaction scores than female participants in terms of degree of self-respect (Mean rank 58.75 vs. 48.19; U = 888, z = -2.134, p = 0.03), relationship with fellow nurses and superiors (mean rank = 80.69 vs. 47.38; U = 826, z = -2.59, p = 0.01), working in other countries compared (mean rank = 60.88 vs. 47.21; U = 820, z = -2.61, p = 0.01, career development (mean rank = 60.98 vs. 47.16; U = 816, z = -2.61, p = 0.01), and ease of finding employment (mean rank = 62.84 vs. 48.91; U = 757, z = -3.09, p = 0.01).
Moreover, there was a statistically significant difference in job satisfaction scores between nurses from different countries of origin, in terms of working in other countries, χ2(2) = 7.82, p = 0.02, and relationships with fellow nurses and superiors, χ2(2) = 6.72, p = 0.04. Subsequently, pairwise comparisons were performed; adjusted p-values were presented. This posthoc analysis showed statistically significant differences in job satisfaction scores between Indian and Filipino participants in terms of working in other countries (mean rank = 60.36 vs. 46.88; p = 0.02), and relationship with fellow nurses and superiors (mean rank = 61.02 vs. 47.24; p = 0.04).
The present study assessed the job satisfaction of foreign-educated nurses, including the differences between sociodemographic status and job satisfaction (total score and its every dimension). The findings of this study indicated that most foreign-educated nurses in Malaysia were satisfied with their current position. Most foreign-educated nurses in Malaysia included in this study worked in nursing or private home, whereas a few worked in hospitals and clinics; nevertheless, their response regarding job satisfaction was positive. Similarly, Wongboonsin et al. (2018) found that foreign-educated nurses in Thailand were “satisfied” or “very satisfied” with their jobs even when they were not fully practicing in their profession.
Male foreign-educated nurses reported higher overall satisfaction scores than female foreign-educated nurses. This observation corroborates findings from a study conducted in Saudi Arabia (Al-Haroon & Al-Qahtani, 2020). The result of this study could be explained by the effect of the emotional status shield, which means that men can manage their emotions at work, are protected from the adverse impacts of covering emotion, and thus have a higher level of job satisfaction (Cottingham et al., 2015). However, Primeau et al. (2021) reported an opposite finding, indicating that male international educated nurses showed a lower job satisfaction than female nurses, possibly because male and female nurses use different constructs when evaluating career success.
The overall analysis of the job satisfaction dimensions suggested that serving the sick and needy and degree of self-respect were found to be the top two dimensions among the foreign-educated nurses. This finding demonstrates that foreign-educated nurses value recognition and appreciation from patients, colleagues, and employers. In addition, the foreign-educated nurses were empowered to make a decision while caring for the sick and needy, which significantly improved job satisfaction (Staempfli & Lamarche, 2020). Being respected and recognized by superiors and the community also fulfilled the self-esteem needs of foreign-educated nurses, motivating job satisfaction (Staempfli & Lamarche, 2020). Moreover, it was discovered that male foreign-educated nurses valued self-respect than female foreign-educated nurses. When male foreign-educated nurses felt appreciated by their patients, it increased their self-esteem and self-worth regarding their career (An et al., 2016).
Relationship with fellow nurses and superiors was also identified as an essential satisfaction dimension among the foreign-educated nurses. Most foreign-educated nurses enjoyed working with local nurses because they were friendly and supportive. This finding proves the importance of group cohesion in influencing job satisfaction (Staempfli & Lamarche, 2020). Furthermore, all foreign-educated nurses working in Malaysia were fluent in English, allowing them to communicate effectively with colleagues and other healthcare personnel and, most importantly, with their patients and their families. This finding is supported by Timilsina Bhandari et al. (2015), who reported that non-English-speaking nurses experienced lower job satisfaction than English-speaking nurses. They encountered language barriers in the workplace, which disrupted their interactions with patients and colleagues (Timilsina Bhandari et al., 2015). In addition to English proficiency, religion and cultural beliefs were critical contributors to the satisfaction among the foreign-educated nurses towards a relationship with fellow nurses and superiors, particularly among foreign-educated Indian nurses compared to foreign-educated Filipino nurses. Most Indian nurses were Christian and Hindu, with a strong support system among the Indian migration nurses (Goh & Lopez, 2016). Historically, Indians in Malaysia was originated from India and their migration to Malaya (before the formation of Malaysia) in the 1800s (Rajendra, 2007). Furthermore, Indians are currently the third-largest population in Malaysia (Department of Statistic Malaysia, 2015). Therefore, it is easier for Indian foreign-educated nurses to adapt and communicate with their Malaysian colleagues and superiors.
Foreign-educated nurses in this study also expressed their satisfaction regarding working in other countries, including Malaysia, and working abroad is a means of developing their careers. The advantages of working abroad included the opportunity to travel and explore different countries, meet new challenges, and gaining experiences (Palese et al., 2010). Troy et al. (2007) described the nursing profession as “a passport to the world” that allows nurses to work freely in any country they desire. In addition, they are provided numerous opportunities to develop their career by practicing and learning a high standard of nursing skills, which increases their job satisfaction and fulfills their self-actualization needs (Kline, 2003; Staempfli & Lamarche, 2020). Registered foreign-educated nurses demonstrated higher job satisfaction than unregistered foreign-educated nurses in this regard. Foreign-educated nurses registered with the Malaysian Nursing Board worked as full-time employees in private institutions (hospital and hemodialysis centers). Their employers made all the arrangements for them, ranging from paying the registration fee to managing the migration from their home country to Malaysia. These nurses were entitled to the institution’s employee benefits and career advancement opportunities. Two of the registered foreign-educated nurses included in this study were promoted to the nursing administrator position in renowned private hospitals in Malaysia.
In contrast, unregistered foreign-educated nurses were mostly part-timers in nursing or private homes, and they were introduced to the job through friends and family (Rajan et al., 2017). They were not entitled to the same benefits and career opportunities as registered foreign-educated nurses and had less job security than their registered colleagues. Staempfli and Lamarche (2020) explained that threats to job security and lack of career advancement would cause negative job satisfaction. This finding is consistent with the results of (Primeau et al., 2021), who reported that full-time foreign-educated nurses showed higher satisfaction than part-time foreign-educated nurses.
Working conditions and salary and benefits were perceived to offer less satisfaction than other job satisfaction dimensions, indicating that although economic and social rewards were essential, the compassionate attitude towards the sick and needy was far more rewarding to the foreign-educated nurses. These findings are supported by Tsujita (2018), who stated that nurses are motivated by the service-oriented nature of the job in addition to economic and social rewards. Nevertheless, a supportive work environment, high salaries, and benefits remain the key contributors to job satisfaction among foreign-educated nurses (Timilsina Bhandari et al., 2015).
The present study provides an overall picture of job satisfaction among the foreign-educated nurses in Malaysia. It emphasizes the important role of employers and managers in ensuring the satisfaction of foreign-educated nurses in their workplace. The management team should continue supporting these nurses and maintaining a positive working relationship with them. However, employers and managers should be more aware of the gaps that affect the job satisfaction of foreign-educated nurses. For instance, female foreign-educated nurses reported lower job satisfaction in the degree of self-respect, relationships with colleagues, and career development. The finding implies that the management team should prioritize this group of nurses, create a healthier working environment free of gender bias, and provide more career development opportunities. In addition, many countries, including Malaysia, are grappling with an aging population and a nurse shortage (Walani, 2015). More nurses are needed to serve the elderly, particularly in nursing homes and private homes. As a result, foreign-educated nurses should be recognized and appreciated by providing them with better job security to fulfill their basic needs.
The cross-sectional research design of this study provided information about the job satisfaction of foreign-educated nurses in Malaysia only at a particular point in time. Therefore, this design may have problems inferring changes and trends over time concerning the job satisfaction of foreign-educated nurses (Polit & Beck, 2018). Additionally, this study employed purposive and snowball sampling methods; thus, the findings may not be generalizable. In future studies, the data should be collected using a random sampling technique representing the total population of foreign-educated nurses in Malaysia. Furthermore, because a survey questionnaire was used, self-report bias such as dishonest answers and differences in understanding and interpretation of the questions is likely (Polit & Beck, 2018).
The findings of this study shed light on the job satisfaction levels in different dimensions as experienced by foreign-educated nurses in Malaysia. There was a significant difference between the nurses’ sociodemographic status and job satisfaction levels (overall satisfaction scores and scores across the eight dimensions). These findings serve as a guide to the management team in developing effective strategies, including fostering a healthier work environment, expanding career opportunities, and enhancing job security. As a result, issues such as nursing shortages will be addressed, and the quality of patient care will improve.