What Keeps Nurses Happy at Work? A Three-Country Study Points to Workload and Leadership

Nurses around the world share a striking amount of common ground when it comes to what makes them satisfied or dissatisfied with their jobs, according to a new multicenter study spanning hospital settings in Germany, Iran, and Canada. The research, published in BMC Nursing, surveyed 521 registered nurses working in four tertiary-care teaching hospitals and found that while overall satisfaction levels differed across sites, the underlying drivers of satisfaction—workload, leadership, communication, professional development, and work–life balance—appeared remarkably consistent across borders. At the same time, the authors caution that the differences they observed between countries cannot be read as national-level conclusions, because the participating hospitals differed in size, staffing, and the characteristics of the nurses who chose to respond.

The study was conducted between April 2017 and June 2019, a period that predates the COVID-19 pandemic and therefore offers a baseline picture of nurse morale before the extraordinary pressures that followed. Data were collected using a structured 50-item questionnaire designed to capture job satisfaction, workplace challenges, and sociodemographic characteristics. The instrument was built on established theoretical frameworks of job satisfaction and refined through expert review before deployment. Because satisfaction is a multidimensional construct, the researchers used principal component analysis, a statistical technique that reduces many correlated questionnaire items into a smaller set of underlying dimensions. This procedure identified eight distinct dimensions of job satisfaction among the respondents, allowing the team to examine not just a single global score but the specific facets of work life that shaped how nurses felt about their jobs.

The sample comprised 271 nurses from Iran, 186 from Germany, and 64 from Canada. This imbalance matters when interpreting the results, and the authors are explicit about it. Because the sites contributed different numbers of participants and likely differed in response rates and workforce composition, the team applied non-parametric statistical methods, which make fewer assumptions about the distribution of the data. This choice reflected observed deviations from normality in the dataset, a common feature of satisfaction ratings, which tend to cluster toward the favorable end of response scales. Robust comparative analyses were then used to test for differences between sites while limiting the influence of outliers and skewed distributions.

The headline finding was a clear gradient in overall job satisfaction across the three settings. Nurses at the participating Canadian hospital reported the highest levels of overall satisfaction, followed by their counterparts at the German hospital, with nurses at the Iranian hospital reporting the lowest levels. These differences were statistically significant, with p-values below 0.001, indicating that the probability of observing such differences by chance alone was extremely small. Significant differences also emerged in specific dimensions, including interpersonal relationships, leadership, perceived workload, and work–life balance, all again at p < 0.001. In practical terms, this means the sites were not merely separated by small statistical noise but by meaningful differences in how nurses experienced their daily working lives.

Beyond the between-country comparisons, the study identified individual-level patterns that held across settings. Higher job satisfaction was associated with older age, longer work experience, and fewer weekly working hours. The relationship with experience is consistent with a substantial body of occupational psychology research suggesting that career stage shapes expectations and coping capacity; more experienced nurses may have developed strategies for managing demanding clinical environments, or may have self-selected into roles and units that suit them better. The association with weekly hours is equally intuitive but carries significant policy weight: nurses working longer hours reported lower satisfaction, pointing to workload and scheduling as concrete, modifiable levers for improving retention.

Perhaps the most actionable part of the study concerns the correlations between overall satisfaction and specific organizational factors. Across all sites, satisfaction rose in parallel with supportive leadership, effective communication, manageable workload, opportunities for professional development, and work–life balance. Conversely, satisfaction fell as perceived workload climbed, and it was negatively correlated with intention to leave the profession or the workplace. The intention-to-leave finding is particularly consequential for health systems, since turnover among nurses is costly, disruptive to continuity of care, and increasingly recognized as a global workforce crisis. If dissatisfaction reliably precedes departure, then the organizational factors identified here become early-warning indicators that hospital administrators can monitor and address before staff walk out the door.

When asked about the challenges they faced, nurses across all three countries converged on two problems: insufficient income and administrative burden. These were consistently reported as key workplace challenges regardless of the setting, suggesting that some sources of frustration in nursing transcend differences in health system design, salary structures, and national culture. Income concerns are notable because two of the three countries—Germany and Canada—employ nurses within comparatively well-resourced systems, yet pay adequacy still registered as a problem. Administrative burden, meanwhile, has become a recurring theme in workforce research worldwide, as documentation requirements, electronic record systems, and regulatory paperwork increasingly compete with direct patient care for nurses’ time and attention.

The authors are careful to frame the cross-country differences with appropriate scientific humility. They note that the findings on site-specific differences should be interpreted cautiously due to variations in sample characteristics, response rates, and the absence of formal cross-cultural measurement equivalence testing. This last point is technically important: measurement equivalence testing asks whether a questionnaire functions the same way in different languages and cultural contexts. A phrase like manageable workload may anchor to different reference points for a nurse in Tehran than for one in Ontario, and without formal equivalence testing, one cannot be certain that a given score means the same thing in each country. The researchers also emphasize that, given the cross-sectional design and the sampling approach, the results should not be interpreted as representing national-level differences. The study compared selected hospital settings, not representative national samples of nurses.

Even with those caveats, the study’s central message is one that health system leaders can act on. The determinants of nurse satisfaction appear to be broadly similar across very different organizational contexts, but their relative influence may shift depending on local conditions. That points to a targeted rather than one-size-fits-all approach: interventions should focus on modifiable organizational factors—leadership practices, workload management, and flexible work arrangements—while being tailored to the specific pressures of each workplace. Supportive leadership, in particular, emerges as a low-cost, high-leverage target, since it correlates with satisfaction across all sites and can be cultivated through training and accountability structures without requiring major capital investment. Flexible scheduling and realistic staffing ratios similarly address the hours-worked and workload associations documented in the data.

The research arrives at a moment when nursing workforces in high-income countries are under sustained strain from post-pandemic burnout, aging populations, and chronic understaffing, making the search for retention levers more urgent than ever. By documenting that the same organizational levers matter in Tehran, Chemnitz, and Ontario-area hospitals, the study offers a shared vocabulary for improvement efforts while reminding the field that context still matters. The practical implication, as the authors put it in their implications for practice, is that efforts to improve nurse job satisfaction should focus on modifiable organizational factors, including leadership practices, workload management, and flexible work arrangements, while taking local workplace conditions into account. For a profession that forms the backbone of hospital care in every health system on earth, that may be the most valuable finding of all: the path to keeping nurses in their jobs runs through the everyday conditions of their work, and those conditions can be changed.

Subject of Research: Job satisfaction and its associated organizational factors among hospital nurses in Germany, Iran, and Canada

Article Title: A multicenter cross-sectional study of job satisfaction and associated factors among nurses in selected hospital settings in Germany, Iran, and Canada

Article References: Behjat, F., Aryamloo, P., Ranjbaran, S., Heinrich, J., Ramezanpoor, N., Dehghan, M., & Schulz, J. (2026). A multicenter cross-sectional study of job satisfaction and associated factors among nurses in selected hospital settings in Germany, Iran, and Canada. BMC Nursing, 25(1), Article 870. https://doi.org/10.1186/s12912-026-04879-3

Image Credits: AI Generated

DOI: 10.1186/s12912-026-04879-3

Keywords: nurses, job satisfaction, workload, leadership, work-life balance, cross-sectional study, multicenter study, nursing workforce, intention to leave, occupational health, hospital settings, Germany