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American Journal of Public Health Research
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The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
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Anne Lanham, Lillian Mwanri

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Factors Influencing Job Performance among Nurses Who are Working in Saudi Mental Health Hospitals

Tariq Mosleh Al Marashi*, Muneeb Mohammad Al Zghool

Nursing, AlAmal Complex for Mental Health, Madinah, Saudi Arabia

Abstract: Aim: This study was aimed at exploring the factors that may influence the job performance of nurses who are working in mental health hospitals of Saudi Arabia. Specifically, the focus was on the demographic, organizational, environmental, socio-cultural, and economic factors that may contribute to the job performance. Method: Design: Mixed Method Triangulation (Both quantitative and qualitative methods). Sample: Selective sample N = 344 nurses who are working in Saudi mental health hospitals. Setting: Five mental health hospitals located in four cities in Saudi Arabia: Riyadh, Jeddah (2 hospitals), Madinah, and Buradah. Tool: A self-constructed questionnaire by the researcher used based on an extensive literature review, including 36 factors and one open-ended question. Conclusion: The results of this study, which was conducted in five mental health hospitals in four cities in Saudi Arabia, indicated that six main factors influence the performance of nurses who are working in mental health hospitals. These factors are the lack of managerial effort to improve the work environment of nurses, seeking perfectionism, support from the ward manager, salary, the relationship at work with other nurses, and the fairness of shift work between nurses. Additionally, other factors can almost be considered to be influencing factors (though they were in the neutral area), including relationships at work with other health team members, violent, and aggressive behavior of mentally ill patients. Therefore, further research studies are needed to support or refute the findings of this study.

Keywords: job performance, factors influencing job performance, mental health nurses, mental health nursing

Citation: Tariq Mosleh Al Marashi, Muneeb Mohammad Al Zghool, Factors Influencing Job Performance among Nurses Who are Working in Saudi Mental Health Hospitals. American Journal of Nursing Research, 6 (2). 67-81. January 2018. doi:10.12691/ajnr-6-2-5

1. Introduction

Nursing profession is considered by many researchers as more demanding, therefore more stressful than other health professions as pointed by Hamaideh [1]; Al-Ahmadi [2]; and Nakasis and Ouzouni [3]. Germain and Cummings, [4] defined the nursing performance as organizational behaviors centered on quality of care, which is largely measured by patient outcome and achievement of organization goals. Furthermore, Coleman and Broman [5] defined job performance as behavior that contributes directly to the organization's technical care and includes those activities that are typically recognized as part of a worker's job. Also, refers to those behaviors that maintain the broader social environment in which the technical core must, function and includes more discretionary behaviors that helps the hospital to function. In contrast, Evans [6] sees the main disadvantages of the behavioral approach is restricted the independence of the nurse in the decision-making. The majority of nursing leadership researches are mainly focusing on how the behavior of nursing supervisors or leaders influences nurses' job performance and the importance of self-assessment for mental health nurse as a tool, such tools believed to help or guide nurse researcher and leaders to follow the nursing process and enable them to perform required activities Germain and Cummings [4]; Parkes, [7]; Johnson et al. [8].

Fung et al. [9] suggested that in order to recognize the contributions of mental health nurses, it is crucial to re-examine their dimensions of practice, thus providing evidence of their role performance. On the other side, Khomeiran et al. [10] defined the influence factors as the process of developing professional competence in nursing extends across personal and extra-personal domains. In reviewing the literature, it was apparent that the factors influencing the job performance of nurses has been referenced by researchers Hamaideh [1]; Al-Ahmadi [2]; and Nakasis and Ouzouni [3] in several ways, and divided into several domains, including organizational, social, cultural, and economic. The workplace also pointed to in many forms, including organizational commitment, job satisfaction or burnout, and job turnover in order to determine influencing factors. Furthermore, the type of patients, workplaces, and the socioeconomic factors are all factors that seems to have an influence on the performance of nurses who are working in a variety of clinical nursing setting Al-Ahmadi [11]; AlAmri and Zuriqat [12]; AlSmemri and Shahwan [13]; and Alalyani [14].

Mental health nurses and nurses who are working in mental health settings are no exception, and one may argue that not only the above factors may influence mental health nurses' performance and their work satisfaction, but also may affect the quality of care provided for patients as pointed by Karanikola and Papathanassoglou [15]; Hamaideh [1]; Nakasis and Ouzouni [3]; Al-Ahmadi [2]; Jenkins and Elliott [16]; and Humpel and Caputi [17]. In her introduction of a study concerning factors affecting performance of hospital nurses, Al-Ahmadi [11] pointed out that researchers have been studying such factors in health institutions long time ago with emphasis on worker factors and work environment factors. She maintains that nurses constitute the vast majority of human resources in healthcare institutions, and therefore has a great influence on the quality of care and patient health outcomes.

In Saudi Arabia (SA), the government gives a great attention to mental health services since the mid of the twenty century, and the focus was mainly on providing and establishing major mental health institutions Koenig et al. [18]; Qureshi, et al. [19]. These institutions have increased rapidly with a total of (21 hospitals) in 13 regions under the supervision of the ministry of health which focuses on improving the integration of services through mental health action and policy development Qureshi et al. [19]; (MOH), [20]. Literature on mental health nurses and their performance in SA is very scarce and most of it not recent or updated Koenig, et al. [18]; Qureshi et al. [19]; Al-Ahmadi [2]. Although mental health services in SA are marking long strides toward addressing the mental health care needs of the people of this country, researchers, such as Koenig et al. [18] suggested that there is still a way to go on the extension of care, and that researchers are needed in SA to introduce the most effective treatments that Saudis are willing to accept according to their unique social and cultural background. Al-Ahmadi [2] examined the determinants of nurse turnover in psychiatric hospitals in SA. she points out that mental health hospitals are different in course from other health organizations, and often long-term services for this category with special requirements. She maintains that studies found that the workers in these hospitals in different countries of the world are subjected to large psychiatric stress reaches the extent of fatigue and burnout which reflected on job performance. She concluded that several studies found that the nurses who work in mental health hospitals show higher degrees of stress and degrees less than the job performance compared with workers in other types of health organizations.

Top [21] defined the organizational domain as organization variables, influenced nurses' job performance in different magnitude. Furthermore, there factors have administrative and institutional nature. Within the organizational domain, Hamaideh [1] suggests that the lack of technological support is influential on nurse performance. Also, organizations that suffer from a lack of technological support have a lower performance compared with organizations who have better technological support. Furthermore, Top [21] and Al-Makhaita et al. [22] suggest that the independence of the nurse in making his or her decisions within the organization's policy as an influence and organizational variables that effect. Also, Hamaideh et al. [23] conclude that allowing nurses to make decisions is important for enhancing the quality of nursing care and patient outcomes which reflects on the performance of the nurse, this is based on comparative studies of nurses' autonomy between American and Jordanian registered nurses. Hamaideh [1] emphasizes the need for continuous education of nurses as an effective factor in improving performance. The existence of opportunities for continuing education, especially for nursing in the organization, is reflected in the performance of the nurse; the lower these opportunities, the less motivated nurses are within that organization. Other factors of the organizational domain are the hospital size, the number of units, and the number of nurses in the institution [11,12,14]. In previous studies, emphasis has been on the shortage of nurses as an influence on the performance of staff, Soilkki et al. [24] suggest that a shortage of nurses is a major cause of poor performance in nursing. In addition, Qureshi et al. [19] discuss the shortage of staff in the field of mental health as a global problem, not only an issue in Saudi Arabia. Jenkins and Elliot [16] argue that the shortage of nursing staff in mental health hospitals, especially in acute units, can cause burnout or turnover, and not only influence nursing performance. Furthermore, researchers have identified the clarity of the nurse’s role as a factor that can influence performance, roles are most often characterized by ambiguity, and research and psychiatric nurses do not differ from general nurses in this Fung et al. [9]; Norman [25]; Zaglol and AlSuker [26]; Hamaideh [1]; [12]; Top [21], however, organizational factors can influence nurse performance and these factors cannot be ignored.

On the other hand, researches such as Hamaideh [1]; Al-Ahmadi [2] and Awases et al. [27] defined the environmental domain as factors may influence job performance inside clinical nursing setting, such as motivation, fairness, safe work environment and type of the hospital. The nature of a nursing job is stressful, and the most common contributing factor that influences nursing in SA is the nature of their work, as emphasized by Khalil and Ibrahim [28]. Furthermore, the nature of the work and the level of stress for nurses depends on the particular hospital, psychiatric nurses may have special requirements interact on a personal level with patients, which sometimes leads to increased workload and stress on the performance of psychiatric nurses Humpel and Caputi [17]; Al-Ahmadi [2]; Nakasis and Ouzouni [3]; Hamaideh, [1].

Humpel and Caputi [17] in Australia talk about share stress among general nurses and mental health nurses. Additionally, violent and aggressive behavior of patients with mental illness is an added stress for mental health nurses. Perhaps the safety of the environment in place that most likely to deal with patients with aggressive behavior, the safety of the nurses comes first. In the absence of safety standards of an institution and necessary requirements as official standards of service provision for the safety of the staff, the more career performance as indicated by Al-Ahmadi [2]. The Ministry of Health (MOH) of SA is keen to meet the highest standards of safety at its facilities without exception Koenig, et al. [18], Hamaideh [1] suggests an adequate cover in potentially dangerous environments is more response as stressful factors of nurses in mental health hospital in Jordan. Among mental health hospitals, lower level of calm is stressful, the researchers assured that lower level of quietness within hospital is an additional stress factor and workload in mental health nursing which influenced job performance Humpel and Caputi, [17]; Jenkins and Elliott [16]; Al-Ahmadi [2]; Hamaideh [1]. Bronkhorst, et al. [29] find that a good organizational environment is significantly associated with positive employee mental health outcomes such as lower levels of burnout and enhanced performance. They suggest that organizations will benefit from incorporating environmental factors into their health and safety policies. [1,2] Nakasis and Ouzouni [3] addressed the work environment in psychiatric hospitals as a stressful environment where nurses have a concomitant lack of motivation. They also looked at the role of motivation in the work environment which contributes to minimizing this stress and increases performance for mental health nurses. Furthermore, a motivating working environment has caused an increase in a nurse’s performance and reduced stress, as indicated by Sharma and Dohor [30]. On the other hand, care standards are evidence that guide the nurse in providing health services to patients within the health institution, the lack of standards or ambiguity are factors influencing their performance in that institution and have been referred by AlAmri and Zuriqat [12] for Saudi nursing in general. Mental health nurses are also having a lack of standard as suggested by Fung et al. [9]. Availability of standards of care contributes to the progress, guide and development of the nurses’ role in mental health nursing care services. Furthermore, long duties hours and fairness of shift work among nurses can also influence the performance of nursing staff, Awases et al. [27] suggest that this factor is very important for staff and neglect of this factor can contribute to reduced job performance for nurses and cause burnout or turnover, Ho et al. [31] pointed the job rotation is supposed to be fair between nurses which increase job satisfaction, organization's commitment and avoided burnout. Hamaideh and Ammouri [1] suggested the nurse who works 12 hours shift, less stress than who working 8 hour shift. In contrast, Alalyani [14] suggested that shift work should be reduced from 8 hours to 6 hours as the world standard for nurses and the number of hours per week for Saudi nurses is more than the standard hours for nurses in other countries; Saudi nurses work 48 hours per week, and in Australia the nurses work 36 hours per week, moreover, both studies were conducted in the stressful clinical area.

Also, there are social and cultural factors surrounding mental health nursing and its effect on job performance of nurse. Researches such Al-Ahmadi [11] and Gazzaz [32] Defined the culture domain as factor that may influence nursing job performance of Saudi nurse's as referred to the culture of Saudi community. And nurses, social relationships in health care organization as pointed by AbuAlRub [33] and Hamaideh [1]. Among those factors, stigma against mental illness and mental health patient often exists even Western societies as well as most Asian and African communities, as pointed out by Carrigan and Watson, [34]. This stigma directly or indirectly impacts the performance of the nurses who are working in a field where this stigma shouldn’t exist, or they are exposed to this negative stigma because of the nature of their job Carrigan and Watson, [34]. Furthermore, Gazzaz [32] pointed to Saudi’s socio-cultural factors and their influence on women nurses, mixed-gender work settings, and rotating shifts, work-related conditions all are contributions to lower performance as well as burnout and higher turnover rates. Al-Rabiah, [35] pointed the male Saudi nurse who is working in Ministry Of Health (MOH) transfer to administrative posts outside the nursing service. This explains why, as pointed out by AlYami and Watson, [36] many Saudi women do not choose the nursing profession and there is a negative image of nursing in the community in general for both genders. AbuAlRub [33] suggested that a good relationship between nurses also with other teams can reduce stress and enhance performance, thereby increasing outcomes for nurses. On the flip side, the lack of support from colleagues at work is one of the factors leading to job burnout and turnover of staff Al-Ahmadi, [2]; Hamaideh [1]; Alalyani [14]. There is near consensus of researchers in this field that relationships, whether between nurses or other members of the therapeutic team, are considered in nursing to be the most important factor affecting job performance. AlBougami [37] emphasizes the uniqueness of Saudi culture as a Muslim country considering the large number of contracts with non-Saudi staff in places that offer health care directly to Saudi nationals, linguistic and cultural barriers may affect the level of provider of health service. Furthermore, AlMutari and McCarthy [38] pointed that Saudi culture is influenced by Islam, also, multicultural nursing in Saudi Arabia contributed sometimes to cultural conflicted and barrier to provide nursing care. The reason for the acute shortage of nurses in those hospitals as indicated by AlMutari and McCarthy [38]; Alshmemri and Shahwan [13].

On the other side, AlAmri and Zuriqat [12] defined economic domain as factors may influence job performance of nurses related to the financial status of health care organization. Economic factors have emerged as factors affecting the performance of the nurse, AlAmri and Zuriqat [12]. Furthermore, The MOH has made efforts to meet the nursing shortage with financial incentives, although nursing in Saudi Arabia suffers from some ambiguity in the rewards with shortcomings surrounding some aspects of nursing work. Restilla [39] emphasizes a monthly salary as the most influential factor for nursing performance. Furthermore, Al-Ahmadi [2] suggests that salary as economic factor that can influence mental health nursing in terms of lack of financial resources for training, which contributes to lower levels of nursing education or poor outcomes of nursing performance in organizations. Hamaideh [1] suggests that the lack of resources for nursing training courses contributed to a decrease in the performance level of nurses and an increase in stress. The MOH is the largest mental health care provider in Saudi Arabia, special centers in psychiatric care are almost scarce, with growth, health insurance to create competition in the provision of health services and enhance the quality of care Qureshi et al. [19]; Koenig et al. [18]. Maybe it is difficult to assess the quality of health service considering that health services in this country are almost entirely dependent on the government, furthermore, the attitude of the Saudi community to the health insurance needs more research to identified who health insurance can affect mental health nurse performance Qureshi et al. [19].

Researchers such as Al-Ahmadi [2]; Hamaideh [1]; Jenkins and Elliott [16]; and Humpel and Caputi [17] defined the workplace and occupational domain such as a factor may influence job performance of nurse related to the mental health hospital and nature of patient care inside mental health hospital. Occupational factors such as workplace stress for nurses in mental health are additionally stressful, according to Humpel and Caputi [17] especially considering potential violent and aggressive behaviors of mentally ill people. They are also considered to be influential factors on performance that causing burnout and higher turnover rates among nurses in mental health hospitals Humpel and Caputi [17]; Jenkins and Eilliat [16]; Al-Ahmadi [2]; Hamaideh [1]. The relationships between stress and performance are negative, which reducing in stress would probably improve performance Al-Ahmadi [11]; and Hamaideh [1]. Farquharson et al. [40] examine the effect of nursing tasks on distress and job performance and suggested develop improved methods of investigation work- related stress additionally, there founded the negative relationship between work-related stress and performance. Another occupational factor is nursing leadership in institutions, Germain and Cummings [4] point out that the majority of nursing leadership research is mainly focused on how the behavior of nursing leaders influences nurses' performance. However, it has been identified that some of the factors are related to administrative efforts. Alalyani [14] emphasize the role of the head nurse on the environment of department, it is significant as a role in the work environment within the department and it is significant in influencing the performance of nursing staff, this role is also significant in resolving influencing the performance of nurses. The head nurse is supposed to be the working center nurse not to ignore staff nurse and be assisted in completing the nursing duties to the fullest, also respond to questions quickly at work Alalyani [14]. Furthermore, Hamaideh [1] recounts the lack of management in mental health administration from stress in mental health hospitals when he studied the occupational stress in Jordan, noting its significance as one of the factors affecting the performance of the nurse in the hospital. Also, Al-Ahmadi [2] pointed to the lack of managerial effort to improve the work environment of nurses as the main factor for causing turnover of Saudis specifically based on a study of determinants of nurse turnover in psychiatric hospitals in SA. Retention of staff nurses in hospital is the goal for any succession administration; however, Al Hosis et al. [41] suggested the effective succession planning for nurse managers is an influencing factor not only retention of staff nurses in SA also enhance recruitment, but still it's a major challenge for health services. Although, West et al. [42] suggested through the empowerment of nurse as possible under organization policies is the key factor for nursing management positively with staff nurses, also, can influence job performance and outcomes, additionally, leaders characterized such as flexible and collaborate with staff nurses can contribute to promote high performance. Another factor in occupational stress is when perfection is the pursuit of personally demanding standards, despite negative effects and sense of self-worth being based on achievement Philp et al. [43]. moreover, perfectionism deﬁned as “setting excessively high standards of performance in conjunction with a tendency to make overly critical self-evaluations Melrose [44]. Perfection is expected from the nurse, Philp, et al. [43] suggest that perfectionism is an important factor in burnout from work.

In conclusion studies in Saudi Arabia on the job performance of nurses who are working in mental health setting are scarce, particularly those studies which focus on the socio-cultural, economical, and environmental factors(domains) that may influence the performance of nurses in mental health settings. This study, therefore, is hoped to shed light on these factors and how may influence the quality of care provided for mentally ill people.

2. Conceptual Framework

Dubois, et al. [45] found a systematic and interpretive review that the current conceptualizations of nursing care performance mostly reflect a system that prospectively build on system theory, the earlier work of Donabedian’s on health care organization and that of Parsons’ theory of social action, moreover, conceptualizes nursing performance as resulting from many nursing subsystems that works together to achieve many functions. System theory based on dividing the factors that influencing of individual to several domains. Furthermore, Dubois, et al. [45] when referring to conceptualizations of nursing care performance they emphasis several influential factors revolve around nursing care such as organizational, environmental, economic, cultural and social, and finally occupational factors. Derived from these works, the nursing care performance framework that was developed by Dubois, et al. [45]. And influencing factors were divided into domains of factors that influence nurses' performance based on a review of literature from related articles and then repeated factors were identified. Also, then focused on Saudi nursing studies, particularly those studies which focus on the socio-cultural, economical, and environmental factors that may influence the performance of nurses in mental health settings. Furthermore, the organizational domain and occupational / work place domain focus in influencing factors in job performance among mental health hospital nurses see Figure 1.

3. Methodology

Design of This study utilized quantitative, qualitative approach (Triangulation) of data collection and analysis to add some in-depth to the collected data, and therefore to increase the credibility of the study findings. Setting of this study carried out in mental health hospitals in four cities of SA, These are, Riyadh, Madina, Jeddah and Buradiah cities. A purposive sample of nurses (n=344) who are working in mental health hospitals were selected to meet the purpose of this study.

And a self-constructed questionnaire was used based on an extensive literature review (see Figure 2). The study tool presented for a group of experts in the field of nursing by email so as to ascertain the extent of appropriate phrases and its relevance (Face and content validity). After reviewing the comments and suggestions of the experts, the researcher omitted and added items to the tool and then was finalized. The items (factors) were reduced from 65 items to 45 items. The internal consistency of the study tools applied on the ground on an exploratory sample 30 nurse who are working in mental health hospitals. The Pearson correlation coefficient was using to calculate the coefficient correlation between the degree of each factors of resolution with the domain. The results are illustrated in the Table A, in which reduced from 45 items to 36 items. To measure the reliability of the study tool, the researcher used Cronbach's alpha equation 0.910 see Table B. This study has gained approval from the Institutional Review Board (IRB) of the MOH in SA. To achieve the aim of the study and analysis of the data collected, appropriate statistical methods were used using (SPSS) version 21. And classified the responses of participants to 5 cells as following: From 1 to 1.80 marks Strongly Disagree (SD). From 1.81 even 2.60 marks Disagree (D). From 2.61 until 3.40 marks Neutral (N). From 3.41 and up 4.20 marks Agree (A). From 4.21 and until 5.00 marks Strongly Agree (SA). Finally, the tool consisted of 36 factors and one open-ended question. The databases which were used in this study are PubMed, Saudi digital library, google scholar, Wiley and EBSCO.

Figure 1. The pilot and main study steps

Figure 2. Methodological steps of factors

Table A. The Pearson correlation coefficient "Pearson Correlation"

Table B. Reliability Statistics

Figure 3. Domains response

4. Results and Discussion

The study aimed at exploring factors that may influence the job performance of nurses who are working in mental health hospitals. Specifically, the demographic, organizational, environmental, socio-cultural, and economic factors that may contribute to the job performance. The Response rate for this study was 52.44% with a total participants of 344 nurses. And the end of the questionnaire, responding of the open-ended question was 58 nurses responses to this question from (344) of the participants. The demographic factors influencing the job performance have been confirmed by nurses Tzeng [46] see Table 1. Researchers have suggested that mental health nurses have just as much nurses stress as others despite the differences in the work environment, in addition, gender differences between nurses play a role in how mental health services are provided Humpel and Caputi [17] since women have more emotional competence than men in these kinds of organizations. In Jordan Hamaideh [1] gave attention to such problems and proposed to deal with emotional exhaustion which causes job burnout among nurses who work in hospitals of mental health. Among the factors that would improve the job performance of mental health nurses are age and years of experience Jenkins and Elliatt [16]. Gorrosa et al. [47] suggested that the younger nurses showed a higher level of burnout than who old 30- 40 year. This was based on their study of the relationship between socio-demographic variables and job influenced factors such as stress and burnout in nurses. In mental health hospitals in the four cities in Saudi Arabia, there is a 55.2% lower rate of burnout among older nurses, more experienced nurses than new staff nurses. On other hand, the educational level of nurses accounts for a positive relationship with performance as pointed out by Humpel and Caputi [17] and Restilla [39]. Al-Ahmadi [11] however, suggested the level of education of nurses has a negative relationship with performance, and pointed to studies to prove this, which resulted in her own study looking at factors affecting nurse performance in Riyadh, this may be due to the increased number of diploma in MOH note they list to solve that problem through a bridging program when comparing the results of this study with Al-Ahmadi study [2], the number of nurses with a diploma degree have decreased, and those who have obtained a bachelor’s degree have doubled their numbers during the last 10 years. The percentage of nurses in this study holding diploma dropped to 72.1% from the 74.3% 10 years ago. Nurses with bachelor’s degrees increasing to 25.3% compared to ten years ago when only 12.8% held a bachelor’s degree. This means that the bridging program, which was started four years ago in cooperation between MOH and the Ministry of Education has started to show results. In the previous study Al-Ahmadi [2], the percentage of Saudis were almost half, while in this study, the percentage was 79.9%. This shows that it has improved because of the higher number of Saudi nurses on staff, the language barrier between nurses and psychiatric patients is weak and also indicates a better retention of nurses at these hospitals which can be considered a success for MOH in mental health care. Another interesting finding in this study is the change of the percentage of male and female patients in mental health hospitals. Ten years ago, 73.9% were men and 26.1% were women Al-Ahmadi [2], while in this study, 69.2% were men and 30.8% were women. In Jordan, Hamaideh [1] found that the percentage of men was 55.8%, while the percentage of women was 44.2%, and in England, the percentage of men was 16% and of women was 84%. This percentage is similar to Saudi studies focused on the factors affecting the job performance of the Saudi nurses but in public hospitals. Perhaps the reason for the spread of mental illness infested man than woman, for example, schizophrenia and might possibly be the stigma of mental health nurse plus nursing profession among Saudi women. Furthermore, it was interesting to note the high monthly income in this study compared to the study from 10 years ago Al-Ahmadi [2] where 46.8 % earned between 5000SR to 10000SR, and 45.3% earned 10000SR or more. This suggests an improved economy in KSA, the efforts by the mental health system to address the nursing deficit through Saudi wage increases, or maybe too high number of Saudis nurses in mental health hospitals. The monthly rotations as a factor influencing job performance of nurses have also been noted Al-Makhaita et al. [22] and Gazzaz, [32] with 49.8% of nurses having additional factors to those in this study. This means that almost half of the sample has additional factors that influence nurse performance.

Table 1. Demographic data response

Table 2. Organizational Domain

Figure 4. Organizational Domain response

The results showed the domains neutral responses, although, there factors inside the domain response was agree see Figure 3, which indicating a resistance by mental health nurses to those domains with a slight increase for occupational and work place domain from other domain. Organizational factors are affecting mental health nurses in SA, based on the mean scores are neutral. In this respect, one can argue that there are mental health system’s ongoing efforts to reduce the institutional factors that may influence the job performance of nurses and that some positive factors on performance are still in the neutral zone see Table 2 and Figure 4. The results show a neutral score for the lack of technological support in mental health nurses in Saudi Arabia. Furthermore, most nurses chosen in this study agree with 36.3%, but the mean average of the factor is neutral. In Jordan, Hamaideh [1] noted the lack of technological support as an influencing factor among mental health nurses. Also, Top [21] in Turkey concluded that the lack of technological support at work of organizational variables influences a nurse’s performance. However, mental health hospitals in SA didn't lack technological support, the results are almost close to the sample consent that is an influential factor in mental health hospitals. It could be argued that the influence could be either negative or positive, or the technology use and support is not the same in all hospitals. In this sense, the previous studies support the results of this study. Furthermore, Hamaideh et al. [23] concluded that the job autonomy of nurses is an influencing factor enhancing nursing outcomes for the patient. In this study, however, results show that the neutral mean scores among Saudi mental health nurses (31.4%). This study also shows that the participants believe that there are chances for continuous education as a neutral factor, although 49.2% of them agree and strongly agree on its effect. Hamaideh [1] pointed out that especially in motivating nurses the MOH didn't overlook this factor to determine the 5% chance to complete education for health institutions. Another interesting finding is the size and number of units in the hospitals in this study which shows a neutral average mean score. The researchers [11,12,14] have referenced the size and number of units or departments in the hospitals as influencing factors, while in this study, the results show that 31.4% agree and an additional 9.6 % strongly agree. Furthermore, these studies were conducted in public hospitals in Saudi Arabia. The results in this study related to the factor of the clarity of the nurse’s role show a neutral average mean. It also shows a high mean factor in organizational domain, although 50.6% were between agreeing and strongly agreeing to this as an influential factor. The clarity of the nurse’s role is referenced by numerous researchers Fung et al. [9]; Norman [25]; Zaglol and AlSuker [26]; Hamaideh [1]; AlAmri and Zuriqat [12]; Top [21]. Perhaps this is a sign of the inadequacy of clarifying the role of the nurse in mental health hospitals in Saudi Arabia, where the number of nurse's role as clear minded factor more than half of the study participants. Although, the results of this study show the career development and advancement in mental health hospitals as a neutral factor, 46.5% of the sample responded between agreeing and strongly agree with Al-Ahmadi [2], and Top [21] is influencing factor when account the career development and advancement in the organization as an influential factor leading to burnout and turnover. Furthermore, the results show that the factor adequate nursing staff has a neutral, although approximately one third of the sample chose to strongly agree (33.7%), and 22.4% strongly disagreeing. Mental health hospitals probably never reached the nursing shortage to some extent influence the job performance in spite of a lack of worldwide professional staff in mental health care, as indicated by Qureshi et al. [19].

The environmental factors, the average mean for the domain is indicating to neutral see Table 3 and Figure 5. However, within the domain the fairness of shift work between nurses is agreeing factors from the sample, this is indicated by Awases et al [27] as one of the factors affecting the performance of the nurses. This is probably a signal back to nursing management in those hospitals as pointed out by Germain and Cummings [4] to the importance of nursing management style of performance for the nurse. Another interesting finding is related to the availability of standards of nursing care which was perceived as a neutral factor with an average mean score. In other studies, 49.7% of the participants were between agreeing and strongly agree to the availability of standards of nursing care as a factor that may affect job performance as AlAmri and Zuriqat [12]. Also, Hamaideh [1] who concluded that the availability of standards of nursing care is an influential factor for mental health nurses. This means that almost touching not reached yet this factor as influential factors among mental health in this study. Furthermore, the results showed that a safe physical environment is a neutral factor as among mental health nurses in Saudi Arabia. This was not congruent with other studies were 50.6% of participants responded either agree or strongly agree to this as an influential Hamaideh [1] for mental health nurses in Jordan. It could be argued that it may be related to providing a safe working environment for nurses. Another environmental factor is the location of the hospital the results show that this factor is a neutral, where the highest percentage for the factor of consenting to the location of the hospital influenced job performance by 27%. This was indicated by Hamaideh [1] when he addressed the nurse’s time at home and with work to highlight the quality of life in mental health nursing in Jordan by 20.1% and consider this factor is normal. On the other hand, this study shows that motivation in the work environment among mental health nurses is neutral, this is supported by other studies where 30.5% of participants see motivation in the work environment as an influential factor as indicated by Sharma and Dohor [30], and 22.4% strongly disagree that this is an influential factor which may be due to increased stress as indicated by researchers Al-Ahmadi [2], Hamaideh [1], and Nakasis and Ouzouni [3]. The results also showed that the level of quietness within the hospital is a neutral factor, some studies suggests that among participants, 30.5% agree that the level of quietness is an influential factor, Bronkhorst et al [29] and 21.2% of participants see this factor as neutral in mental health hospitals, and 30% of participants responded either disagree or strongly disagree that this is an influencing factor in job performance within the mental health hospital work environment which supports the results of this study [1,2,16,17]. The results also showed that the type of patients and nature of their illness is a neutral factor as an average mean. Also, 28.2% of participants agree that this is an influencing factor Al-Ahmadi [2]; Hamaideh [1], and 23.5% of participants see the type of patients and nature of their illness as a natural factor, maybe because nurses feel they must accept the patient regardless of his illness. The results show that the type and nature of the hospital is a neutral factor. Among the participants, 41.8% agreeing that this factor influences performance. This result contradicts [1,2,16,17] who have indicated that the nature of the of hospital is affecting performance, however, 33.7% of the participants disagreed that this is a factor.

Moreover, the results of the study within the social and cultural factors have neutral see Table 4 and Figure 6. However, some factors agreed upon by participants as influencing factors, these were; the Relationship with nurses and other health professional at work, AbuAlRub [33] emphasized the importance of the relationship of nurses to other workers in hospitals, specific at mental health hospitals which was supported by Hamaideh [1] in Jordan and Al-Ahmadi [2] in SA. Furthermore, the results show that relationships at work with other health team members are almost an influential factor but it stills in neutral area with an average mean 54.6% of participants agreed and strongly agreed that relationships with other health team members are an influencing factor. This reflects the importance of social relationships among Saudi mental health nurses, whether between nurses or with other health team members. Although the results show that the social stigmatization of mentally ill people and mental illness is a neutral factor among mental health nurses with an average mean score in this study, 32% of participants in other studies see this factor as influences on performance as supported by Carrigan and Watson, [34] perhaps due to the Islamic tradition in the Saudi community which rejects stigmatization toward mental illness and mental health patients.

Table 3. Environmental Domain

Figure 5. Environmental Domain response

Table 4. Socio-cultural Domain

Figure 6. Socio-culture Domain response

The results of this study showed the economic domain, is neutral factor see Table 5 and Figure 7, however, within the domain some participants agree with influencing factors like salary on job performance. Another interesting finding is that monthly salary found to be an influential factor with an average mean score, and that this finding is supported by Resitall [39], Also, this factor was pointed as an influencing factor in job performance in mental health hospitals in Saudi Arabia more than 10 years ago by Al-Ahmadi [2].

The results suggests that within the occupational and workplace stress factors category that participants agree that three factors are influential, and they almost agree with the fourth, but it stills in neutral see Table 6 and Figure 8. The results shows a lack of managerial effort to improve the work environment of nurses as an influential factor in job performance, this factor was also pointed by Hamaideh [1] and Al-Ahmadi [2] as an influential factor for nurses who work in mental health hospitals in Saudi Arabia. Thus, it has to be on mental health decision makers to address this factor which has recurred since the time of the study in 2006. The mental health system should attract effective leaders with skills in order to improve the work environment. Another interesting finding in this study is related to support from ward managers as an influencing factor among mental health nurses. This finding is supported by Hamaideh [1] and Alalyani [14]. For instance, Alalyani [14] suggested that support from ward managers was an influencing factor for nurse performance in the Intensive Care Unite department in a public hospitals, and Jenkins and Eilliat [16] suggested that this factor played a role in a performance in the acute department in a mental health hospital; so, needing of support from ward managers may increase according to the severity of the ward. Another related to seeking perfectionism is reported as another factor that influences job performance among mental health nurses in this study. This finding, supported by Philp, et al. [32], when they suggested that seeking perfection despite this being a very important factor causing burnout from the ward. Also, the results showed that violent and aggressive behaviors from mentally ill people is a neutral factor with an average mean score 54.7% of participants see this as an influential factor in performance and is supported by numerous researchers [1,2,16,17].

Table 5. Economic Domain

Figure 7. Economic Domain response

Table 6. Occupational/Work place stress Domain

Figure 8. Occupational/Work place stress Domain response

Table 7. Responses of participants about open-ended question

In the open-ended question see Table 7, it was apparent that the lack of support and engagement from administration in a mental health hospitals received the highest frequency from participants as an influencing factor on nurses' performance in mental health hospitals, and it supported by Hamaideh [1], Al-Ahmadi [2], and Top [21]. Furthermore, reducing long working hours was suggested from participants; that was supported by Alalyani [14].

In addition, a motivating work environment, the absence of development programs, the lack of experience, competence of management, support from other departments, financial support, and fairness in a mental health hospitals, and the ambiguity of the nurse’s role in a mental health hospital were emphasized as an influential factors that were supported by Hamaideh [1], Al-Ahmadi [2], Top [21], and Awases et al [27].

5. Limitations

There were many limitations to this study. The first was related to exploring the factors that may influence the job performance rather than assessing the job performance of the nurses itself. Although the study was quantitative-qualitative one, the researcher can only suggest that the findings reflects only the participants’ perspectives, and the generalization is limited in the sample. The self-reporting and scarce of research in mental health nursing in Saudi Arabia are two further limitations to this study, however, the open-ended questions may have been added some in depth to the study. Therefore, the results may become more reliable and credible. However, further researches studies are needed to support or refute the finding of this study.

6. Conclusion

The results of this study, which were conducted in five mental health hospitals in four cities in Saudi Arabia indicate that six main factors influence the performance of nurses who are working in mental health hospitals. These factors are lack of managerial effort to improve the work environment of nurses, seeking perfectionism, support from the ward manager, salary, the relationship at work with other nurses, and fairness of shift work between nurses. Additionally, other factors can be considered to be influencing factors, which they are still in the natural area, including relationships at work with other health team members and aggressive behavior of mentally ill patients. Finally, the results of Content analysis are consistent with influencing factors which exploring in this study.

7. Implications to Nursing

7.1. Nursing Education

Nursing profession in the academic institutions focuses on preparing competitive, knowledgeable, and skillful nurses. Nevertheless, other factors during work may give insight into how nursing education should most appropriately be offered, this includes the factors that may influence the job performance and ultimately lead to providing a better continuing educational programs and quality care.

7.2. Nursing Practice

Improving workplace and job conditions will most likely reflected in the nurses' performance. The results of this study provide an opportunity for policy makers in a variety of clinical and institutional settings to understand the needs of nurses who are working in mental health hospitals, and therefore enabling them to provide a maximum quality health care.

7.3. Nursing Research

Research studies on the factors that may improve or hinders the job performance will enrich the body of knowledge that ultimately will contribute to a better understanding of the challenges that may face the practice of nursing based on scientific research studies. Further, such studies will be of great help to the future researchers who attempting to investigate issues related to the job performance and satisfaction.

7.4. Nursing Administration

The results of this study shed some light on the organizational and administrative factors. It is hoped that by exploring these factors, nurse administrators and policy makers in the health institutions and ultimately improve the quality of care provided to their patients.

8. Recommendations

In the light of the study findings, the following are recommended by researcher:

1. Considerations should be given to the physical environment and the work of nurses Saudi mental health hospitals.

2. It is therefore recommended that a more managerial effort should given attention to improve the work environment of nurses.

3. It is recommended that policy makers should give attention to issues such as seeking perfectionism, support from the ward manager, salary, the relationship at work with other nurses, and fairness of shift work between nurses.

4. Nurses represent the largest portion of the health team, it is therefore recommended that policy makers should always consider improving their work conditions. This includes the financial, work, health-related issues, and the social aspects of their life.

5. Specializing in mental health nursing programs should be a requirement, especially for new nurses in mental health hospitals. It is recommended that a bachelor’s in mental health nursing or postgraduate training certificate should be offered for graduates is insufficient. Nurses need more times and preparations in addition to salary motivations to improve succeed their job performance.

6. Strengthening social relationships in the hospital is another important contribution to reducing work stress in mental health hospitals. Establishing workshops highlighting the importance of social relationships may contribute to improved nursing performance.

Further research studies with larger sample are needed to support or refute the finding of this study.

Acknowledgement

We would like to thanks King Saud University Research center and Research and Studies General department of Ministry of health.

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