Professional Quality of Life, Work-Related Stress, and Job Satisfaction among Nurses in Saudi Arabia: A Structural Equation Modelling Approach

Objective To examine the interrelated impacts of work-related stress, compassion satisfaction (CS), and job satisfaction on burnout (BO) and secondary traumatic stress (STS) among nurses using structural equation modelling (SEM). Methods A cross-sectional design was used to survey 727 nurses at a teaching hospital in eastern Saudi Arabia. Three scales were used: the Quality of Life (ProQOL) scale, the Nursing Stress Scale (NSS), and the Job Satisfaction Survey (JSS). Data were analysed using SPSS and Analysis of Moment Structures (AMOS), and SEM analysis was conducted to confirm the interrelations among variables. Results The final model had a good fit for the obtained data (X2 = 2.726, RMSEA = 0.032). Stress is directly related to BO and STS, and the following variables were directly related to STS: job satisfaction, BO, and CS. Lastly, BO mediated the relationship between stress and STS. Conclusion It is crucial to analyze the effect of stress, CS, and job satisfaction which seems to have a positive and negative impact on nurses' BO and STS. Therefore, implementing a management strategy to manage stress and satisfaction can enhance nurses' quality of life, support the maintenance of positive attitudes, and enhance the standard of patient care.


Introduction
Nursing is fundamentally a caring science, and nurses are the frontline healthcare professionals who deliver the most personalized care for various service users [1]. Teir work in hospitals is afected by numerous factors, including the amount of work delegated to them, the way they are managed by their supervisors, and their interactions or interrelationships at work as part of multidisciplinary healthcare teams and in liaising with service users [2]. Such work factors shape and infuence their professional quality of life (QoL) either positively or negatively [3].
Due to the high rates of burnout (BO), absenteeism, and turnover among healthcare professionals worldwide, researchers have devoted increasing attention to exploring the status of professional QoL among caregivers and ways to improve it. Prolonged fatigue, emotional attrition, and a lack of perceived personal achievement can cause negative symptoms among employees [4]. On the other hand, the positive impact of altruism creates feelings of enjoyment from helping others, which is called compassion satisfaction (CS) [5]. According to Hegney et al. [6], self-efcacy beliefs, the feeling of being part of a community, and efective coping with diferent life situations are directly associated with CS. CS, obtained from caring and showing kindness and empathy for others, enhances the "professional and personal lives" of caregivers [7].
Compassion fatigue (CF) arises when nurses feel exhausted from delivering nonmedical aspects of nursing care to service users, which undermines their QoL as well as the quality of care they can provide [8]. CF encompasses two specifc conditions, namely BO and STS [9]. It occurs gradually and is characterized by an inability to relate to and cooperate with people to whom they are entrusted to render service [10]. While BO originates from the person of the nurse experiencing stress, STS springs from caring for or attending to patients and families who experienced traumatic events frst-hand. Te trauma of patients and their families engenders anxiety, pressure, and other negative feelings among nurses during their interactions with service users [11].
Positive or negative impacts on professional QoL afect healthcare professionals' capacity to render safe, highquality patient care [12]. In the midst of the plethora of nursing stressors, there are still factors in the job that render satisfaction to nurses, such as job environment, relations with colleagues and leaders, salary, promotion, security of employment, responsibility, and working hours [13]. Nevertheless, if a milieu of dissatisfaction outweighs these factors, nurses tend to leave their position, resulting in increased turnover, which represents a massive cost for healthcare systems worldwide [14].
Work-related stress, job satisfaction, and professional quality of life all play a substantial role in how well nurses accomplish their duties, which in turn afects patient outcomes and the efectiveness of the healthcare system [15]. Signifcant patient alienation, the development of negative attitudes toward job performance, a loss of compassion for patients, delays, and generally the substandard job performance are all efects of CF [16].
In order to understand the present aspect of nurses' experiences at work and to give a clear view of whether they are experiencing CF or CS, which afects the quality of patient care provided, it is important to explore nurses' professional QoL [17]. Te nurse's level of stress could be measured to provide a baseline for developing intervention strategies to improve job satisfaction and orient nurses in relation to CS. Te framework for enhancing the nursing workforce and services within the healthcare system could be strengthened by such knowledge. In order to alleviate work-related concerns for nurses and consequently enhance patient outcomes, nursing care quality, and health system efectiveness, considerable research in a variety of nursing contexts is necessary.

Study Variables.
Healthcare is regarded as one of the most stressful occupations to work in [18], and nurses who work in a clinical setting are frequently confronted with extremely upsetting and stressful circumstances, such as deteriorating patient conditions and deaths [19,20], which increase their burnout level and reduce their satisfaction with their work [21]. Te National Institute for Occupational Safety and Health defnes job stress as "the undesirable physical and emotional reactions that happen when the job specifcations do not match the worker's capabilities, resources, or needs." Workplace stress can result in poor wellbeing and even harm [22]. Burnout is characterized by exhaustion, cynicism, and inefcacy, described as three characteristics of a protracted response to ongoing workplace pressures [23]. Some studies have explored the relationships between work stress, job satisfaction, and CS with BO and STS [9,24,25]. Many studies have linked job stress to burnout [26][27][28][29] and job satisfaction [27,30]. A prospective cohort study carried out by the Korea Nurses' Health Study (KNHS) among 10,305 nurses found a strong positive correlation between stress and burnout [31]. A meta-analysis found that stress had a weak positive correlation with burnout [32]. Among mental health nurses, it was found that burnout was positively correlated with job stress and was mediated by psychological capital [33].
In addition to relation between stress and BO, other researchers such as Back et al. confrmed the relation between nurses' stress and burnout with their job satisfaction and turnover intention [34,35]. Locke defnes job satisfaction as a pleasant or positive afection state that develops as a result of evaluating an individual's work experience [36]. According to the literature, job dissatisfaction is strongly linked to emotional exhaustion in healthcare workers, who are at high risk of burnout and work-related traumatic stress [37]. Among 620 nurses working in critical care units, job satisfaction was found to be associated with burnout [38]. Among critical care nurses in Saudi Arabia, Alharbi et al. [39] found that burnout is a predictor of job satisfaction. A study by Wu et al. involving 1464 banking professionals found that their job stress and burnout were mediated by job satisfaction [30]. In Greece, a study of 186 physicians and nurses reported that occupational stress was positively correlated with both burnout and STS [40].
Professional QoL (ProQOL) includes positive and negative traits. Te infuencing impacts or interacting dynamics between burnout, STS, and compassion fulflment must be taken into account when talking about the workrelated QoL of nurses [31]. CS is a positive emotion that shows the benefts of caring for others, which are also widely experienced by nurses. Working with patients and their families and obtaining good emotional benefts like satisfaction, joy, and hope results in CS [41]. However, in the course of caring for patients, nurses commonly experience STS, which is characterized by negative emotional responses (including fear and trauma) in response to witnessing negative events in the workplace. When nurses experience work-related trauma, usually a particular egregious occurrence, STS can occur [11].
Te relation between ProQOL subscales was confrmed by Azizkhani et al. [42], who found that CS had a negative relationship with CF and BO. Tis result was proved by a meta-analysis which found that CS had a moderately negative correlation with burnout [32]. Zhang stated that reduced job satisfaction, compassion fatigue, and burnout are all directly correlated with the nursing profession's inherent stress and traumatic events [32]. Job satisfaction had a negative correlation with STS and CF [43,44]. Several studies found that stress is related to or afects STS and CS [45,46]. A study in Korea among 10,305 nurses found that both STS and CS both had a role in mediating the association between stress and burnout, which was found to be strongly mediated by stress [47].
Despite this tentative literature, there is still a dearth of studies confrming the association between ProQOL (CS, STS, and BO) subscales and work stress and job satisfaction, especially in particular contexts such as Saudi Arabia. Te relation between stress and job satisfaction with ProQOL remains unclear; thus, this study explores mediators for this relationship.
We are not aware of any research that investigated the relation between CS, job satisfaction, and stress in the nursing feld combined with BO and STS. As a result, this study is the frst to connect CS, BO, stress, and job satisfaction into a unifed model in order to better understand the dynamics of the working conditions as a whole and look at the BO as a mediator. In addition, this study is the frst to identify such variables among Saudi Arabian nurses, and its fndings serve as a standard for subsequent comparison.
Tis study provided an important opportunity to advance the understanding of the complex relationship between stress, CS, and job satisfaction in BO and STS, which was investigated in this study using SEM. We hypothesized that stress, CS, and JSS would have both direct and indirect impacts on BO and STS.

Study Context. Saudi Arabia is a high-income Eastern
Mediterranean country [48], with USD 19,937 GDP per capita [49]. In 2021, the total population was 34.1 million, 36.4% of whom were non-Saudis [50]. Te Ministry of Health (MOH), Other Government Healthcare (OGH), and Private Healthcare Sector (PHS) make up Saudi Arabia's healthcare system. Te MOH provides the majority of healthcare services (60%), while the OGH and PHS each contribute 20%. Over 75% of all health spending in the Kingdom is state-funded, including the PHS [51].
In 2020, the total annual budget of the MOH was SAR 82 billion (USD 21.822 billion), which represents 8.2% of the general national budget. Te ratios of hospital beds, physicians, and nurses per 10,000 people are 22.4, 27.2, and 54.9, respectively [52]. Since the MOH is the primary provider of medical services, a large portion of the population obtains care through the Ministry, which is in charge of delivering healthcare to the nation's residents [53]. Primary, secondary, and tertiary care are the three levels at which the MOH ofers its public healthcare services. Primary healthcare services are the access point to additional healthcare facilities, whereas secondary and tertiary care are ofered in general and specialty hospitals, accordingly.

Design and Setting.
Tis cross-sectional, correlation study design was conducted at a university hospital in the Eastern Region of Saudi Arabia. Te hospital has 491 beds and employs 727 nurses, providing services for 12,088 inpatients and 315,456 outpatients [54]. Te study was part of a research project entitled "Assessing Compassion Satisfaction, Compassion Fatigue, Stress and Job Satisfaction Among Nurses."

Sampling and Sampling Criteria.
Te sample comprised nurses from diferent units at all shifts in both critical and noncritical units. Participants from critical units represented MICU, SICU, Burn Unit, CCU NICU, and PICU. Te purposive sampling method was used; inclusion criteria stipulated that participants had to be registered nurses (RNs) with at least a diploma, employed as staf nurses in hospitals. Nurses with less than six months' experience were excluded from the study.
Te survey was administered through the survey program QuestionPro (http://www.questionpro.com), a service for conducting online research. Survey links were sent via email to 727 full-time RNs who had a diploma, an associate, a baccalaureate, or a master's degree and had been working in their current unit for more than six months.

Survey Instruments.
Te survey was in the English language (the professional language of healthcare professionals in Saudi Arabia) and consisted of four parts. Te frst part gathered nurses' demographic and professional variables. Te second part evaluated CS and CF using the Professional Quality of Life (ProQOL) scale. Te third part evaluated stress level using the Nursing Stress Scale (NSS), and the fnal part evaluated job satisfaction using the Job Satisfaction Survey (JSS).
ProQOL evaluates CS and CF with 30 Likert-type items, with responses ranging from 1 (never) to 5 (very often). ProQOL is divided into three scales, CS, BO, and STS. Participants are asked to evaluate their experience with patients over the last 30 days [55]. Te average score of CS, BO, and STS is 50, and alpha scale reliability was 0.88, 0.75, and 0.81, respectively [11]. In this study, the STS, CS, and BO dimensions have alpha scale reliability values of 0.86, 0.84, and 0.77, respectively. Te Kaiser-Meyer-Olkin (KMO) value was 0.87, above the recommended value of 0.6 [56,57], and Bartlett's test of sphericity [58] achieved statistical signifcance. Convergent validity was assessed using the average variance extracted (AVE), with a value of 0.5.
Te NSS is widely used to measure nurses' stress. It includes 34 Likert-type items ranging from 0 (never) to 4 (very frequent), with a Cronbach's alpha coefcient of 0.89. Te scale is divided into seven subscales: death and dying, confict with physicians, inadequate preparation, lack of support, confict with other nurses, workload, and uncertainty concerning treatment [59]. In our study, alpha scale reliability was 0.94. Te KMO value was 0.89, above the recommended value of 0.6 [56,57], and Bartlett's test of sphericity [58] reached statistical signifcance. Convergent validity was assessed using the AVE, with a value of 0.4.
Te JSS is used to evaluate employees' attitudes about their job. It includes 36 items to evaluate nine dimensions of job satisfaction: pay, promotion, supervision, fringe benefts, contingent rewards, operating conditions, coworkers, nature of work, and communication. Te scale uses Likert-type answers, ranging from 1 (disagree very much) to 6 (agree very much) [60]. In this study, the alpha scale reliability was 0.88. Te KMO value was 0.83, above the recommended Journal of Environmental and Public Health value of 0.6 [56,57], and Bartlett's test of sphericity [58] attained statistical signifcance. Convergent validity was assessed using the AVE, with a value of 0.5.

Ethical Consideration.
Approval to carry out the study was obtained from the Institutional Review Board at the university where the research team is established. Te invitation email sent to participants explained the voluntary nature of participation and that they could refuse to participate or subsequently withdraw prior to submitting the completed questionnaire. Tey were informed that their answers would remain anonymous and would only be used for academic purposes and that no personal identifying information was included in the survey. By completing the online survey and submitting it, they indicated that they understood their rights and voluntarily consented to participate.

Data Collection.
Te questionnaire was sent to nurses working on all shifts (morning, evening, and night) via their ofcial email accounts. Data collection took place over three months.
3.6. Data Analysis. Questionnaire data were transferred from QuestionPro as an SPSS fle. Data were stored and analysed using SPSS version 22.0 and Analysis of Moment Structures (AMOS) version 21. Te questionnaires used in the study were assessed for reliability and validity in terms of internal consistency (Cronbach's alpha), and convergent validity was assessed using AVE, as explained above. Categorical variables were presented by frequencies and percentages, while continuous variables were presented by mean and standard deviation (SD). Pearson correlation analysis was used to evaluate the relation between ProQOL, stress, and job satisfaction. An alpha level of p < 0.05 was set as signifcant in all analyses. SEM was used to test the relations between the study variables.
SEM is a type of multivariate analysis which was applied to check the theoretically built model that includes the domains of CS, BO, stress, and job satisfaction, with STS domains. Te chi-square statistic provides a test of the null hypothesis that the theoretical model fts the data. Te criteria for model ft were a relative chi-square statistic less than or equal to 2.0, a goodness-of-ft index (GFI) statistic equal to or greater than 0.95, an adjusted goodness-of-ft index (AGFI) statistic equal to or greater than 0.90, a comparative ft index (CFI) equal to or greater than 0.90, and a root mean square error of approximation (RMSEA) less than or equal to 0.8. A higher Parsimony ratio (PRatio) suggests that the model is more parsimonious. Total, direct, and indirect efects of stress, job satisfaction, CS, and BO on STS were calculated using the standardized regression weights of each pathway.

Correlation Coefcients.
A Pearson product-moment correlation was performed to examine the relationships between STS, CS, BO, stress, and job satisfaction. STS has a moderately positive relation to BO (r � −0.53, p < 0.01), which is stronger than its relationship with stress (r � 0.44, p < 0.01), and the lowest relation is with job satisfaction (r � 0.13, p < 0.05). STS was moderately negatively related to CS (r � −0.23, p < 0.01).

Signifcant Relationships between Observed Variables.
Te results of the signifcant relationships between stress, job satisfaction, BO, CS, and STS are shown in Table 3. Stress is directly related to BO (b � 0.17; p < 0.001) and STS (b � 0.17; p < 0.001). Job satisfaction is directly related to STS (b � 0.13; p < 0.004). BO and CS are directly related to STS (b � 0.40; p < 0.001, and b � −0.16; p < 0.001, respectively).

Discussion
Te current study fndings provide crucial insights into exploring interrelationships among various components of the ProQOL, thereby increasing understanding of these components. Tis provides stakeholders with a comprehensive picture of nurses' ProQOL, in order to consider proper management strategies to improve their working conditions, which in turn would contribute to enhancing their ProQOL, improving the quality of care they provide, and increasing healthcare system efciency. Te results of this study indicate that CS is inversely associated with STS. Unexpectedly, the results indicated that CS and BO were not signifcantly associated. In addition, stress was associated directly and indirectly through BO with STS. Consequently, BO was a mediator in the relationship between stress and STS. Another important fnding is that job satisfaction was directly associated with STS.
Te most important fnding in ProQOL was that CS was directly and inversely associated with STS; thus, increased CS predicts lower STS. Preserving nurses' compassion for their job signifcantly infuences their practice (i.e., the   Journal of Environmental and Public Health quality of service delivery). Many studies explored the relationship between CS and the levels of STS they may experience. Tis fnding was incongruent with many studies [7,61,62]; only one study was found which reported that CS is positively correlated with STS [63]. Tis may be attributable to hospital settings having a signifcant impact on the CS level among nurses, whereby nurses who receive positive support in their job do not complain about any signifcant fears. Nurses are more likely to enjoy dealing with patients who need them and are appreciative of their help [11]. Contrary to expectations, CS and BO were not signifcantly associated. Te reason behind this might be that the participants have coping mechanisms to deal with stressful working conditions. Also, most of the nurses who participated in our study were non-Saudis, which means that they are essentially economic migrants primarily motivated to work abroad in a challenging environment due to fnancial motivations. Consequently, they may accept hard and stressful working conditions in order to preserve their fnancial resources, especially during the COVID-19 pandemic, in which many workers have lost their jobs all over the world. Put simply, they are primarily motivated by the economic goal of supporting their socioeconomically deprived families in their homelands and not by a quest for their own personal, professional, or individual satisfaction.
Our results are in line with a previous study, which found that CS was not associated with CF (BO and STS) [64]. However, this is inconsistent with other literature, as many studies revealed a signifcant association between CS and BO. For example, a study conducted in India to explore healthcare providers' ProQOL and associated factors found a negative correlation between CS and BO and a positive correlation between BO and STS [65]. A recent study conducted in Jordan to fnd out the level of CF, BO, and CS among oncology nurses showed that BO was signifcantly related to CF [66]. Similarly, a negative association was found between CS and BO [67].
In addition, stress was associated directly and indirectly through BO with STS, so increased stress predicts increased BO and STS. Previous studies confrmed that higher stress is linked with high CF and low CS [8]. Job stress is mainly connected with physical and psychological stress among nurses [68]. Moreover, stress is linked with higher BO and lower levels of CS [69]. According to Fiore, extended stress can lead to BO, health issues, and turnover. Tus, stress can negatively impact [70] professional QoL and increase attrition among the nursing workforce. Numerous studies have demonstrated that stress has direct and indirect relationships with BO, STS [31,71], and CF [19]. Surprisingly, Itzhaki et al. [68] found that work stress was not associated with STS. Tis may be due to the high number of female nurses among participants; usually, females have poorer health and lower QoL than males [72]. In addition, during the peak of the COVID-19 pandemic, healthcare providers had higher levels of CF and stress and lower CS [8].
We found that BO mediates the relationship between stress and STS, corresponding with a study which found that STS and CS mediate the relationship between stress and BO [31]. Other study results reported that STS is predicted by high scores of BO and CF [73]. Nevertheless, the interrelations between BO, STS, and stress are expected. CF has been found to mediate the relation between stress and CS [19]. Stress was associated with BO and mediated by STS [31]. Nurses lacked time to care for patients because their workload experienced high STS [45].
Moreover, job satisfaction was directly associated with STS, whereby increased job satisfaction increases STS. Our fnding was in keeping with previous literature [62,72,74,75]. In addition, Ogińska-Bulik et al. [76] found that the main predictor of STS symptoms is job satisfaction. Job satisfaction can be difcult to assay among nurses, as nurses can be highly efective at biomedical aspects of nursing care delivery, taking their roles seriously, while experiencing reluctance or even fear of engaging with service users and with other healthcare staf. Nurses in this category beneft from encouragement to build on their feelings of altruism and beliefs that they are providing good quality care to their patients [11]. It is recommended to establish an efcient management plan to lessen nurses' BO in a way that reduces stress and increases CS.

Conclusion
Tis study examined the efect of stress, CS, and job satisfaction on BO and STS. One of the more signifcant fndings to emerge from this study is that CS is inversely associated with STS; thus, increased CS predicts lower STS. Unexpectedly, CS and BO were not signifcantly associated. In addition, stress was associated directly and indirectly through BO with STS; thus, stress predicts increased BO and STS. Terefore, BO mediates the relationship between stress and STS. Moreover, job satisfaction was directly associated with STS.
Te fndings of this study have a number of implications, the most obvious of which is that nursing managers should be more aware of the factors afecting CS, BO, and STS, and they should seek to evaluate the level of stress and satisfaction. Nurses provide medical, psychological, and spiritual care for their patients, yet they themselves can be afected negatively by their responsibilities and interactions with patients. Consequently, nurses who receive the necessary help and support will be in a better position to provide care for patients. Managers must be concerned about the negative impacts on care due to nurses sufering from BO and STS and seek to reduce these efects by fostering more supportive working conditions and environments, which improve employee satisfaction, increase quality of care, improve patient outcomes, and reduce health system costs and inefciencies. Positive impacts of caring, such as CS, should be deliberately promoted in inspirational and motivational ways. Hospital managers should design interventions to reduce BO, STS, and stress and to improve CS and job satisfaction through education on using coping strategies, and they should ofer more healthy working conditions. Nurse managers and policymakers should emphasize forming healthy and stress-free working conditions to provide a better quality of services.

. Limitations
Several limitations of this study need to be acknowledged. First, the study was conducted at a single institution, and participants were restricted to nurses in one teaching hospital, which limits the generalizability of results. Future studies are encouraged to involve nurses from other health sectors. In addition, the data collection used a self-administered questionnaire to refect nurses' feelings, which can vary over time. Also, future studies should focus on working conditions and other factors that can afect ProQOL.
Our study focused on stress, job satisfaction, and burnout, which are intrinsically related to nursing work, but future research should explore diferentiating between sources of stress (e.g., work-related or family-related). Personal stressors such as family problems, fnancial status, and difcult relationships should be investigated in relation to work-related stress, burnout, job satisfaction, and nurses' overall health [77]. More research is required to address the underlying causes of nurse dissatisfaction [78].
Cross-sectional surveys, whereby each participant's exposure and outcome are determined at the same time, make causal inferences difcult. Random and large-scale sampling is needed to ensure that each person has a similar chance of being included in the study and that the recruited sample represents the study population. Tis limitation necessitates additional longitudinal research into the mediating efects between ProQOL, stress, and job satisfaction among nurses [79].
Although the fndings should be interpreted with caution, this study has several strengths, including the combination of stress and job satisfaction in the ProQOL framework as one construct because of the interaction between those factors. Moreover, involving nurses from different units helps represent both the critical and noncritical care units, which are represented in the results. It is recommended that further research implement this approach in diferent clinical sites, and a longitudinal study evaluating ProQOL over time would be very useful.

Data Availability
Data are available from the corresponding authors upon reasonable request.

Conflicts of Interest
Te authors declare that they have no conficts of interest.