1. Background
Nursing care, founded on the multifaceted concept of caring, is central to positive patient outcomes. Caring encompasses both physical and psychosocial dimensions (1), manifesting in behaviors that provide holistic support—physical, emotional, spiritual, social, and psychological—to expedite patient recovery and enhance comfort (2, 3). However, a discrepancy exists between nurses' perceptions of their caring behaviors and patients' reported experiences (4), underscoring the need to identify factors influencing the quality of care delivery.
Nurse happiness is a potentially significant factor, as it has been linked to improved organizational performance and potentially enhanced patient-centered care (5). Happiness, defined as a confluence of life satisfaction, positive emotions, and the absence of negative emotions (6), fosters positive attributes such as optimism, self-efficacy, and effective decision-making (7). Given nurses' extensive time commitment to their work environments, their happiness is intrinsically tied to workplace factors and may profoundly influence their performance (8, 9).
Studies indicate that Iranian nurses experience moderate to low levels of happiness (10, 11), attributable to factors including challenging work conditions, inadequate support, and limited career advancement opportunities (11). These factors contribute to negative emotions and potentially compromise the quality of care provided (11, 12). Therefore, understanding the determinants of happiness among Iranian nurses is crucial.
Considering the pivotal role nurses play in patient health, the demonstration of high-quality caring behaviors is paramount. Given the limited research in this area within Iran, this descriptive-analytical study investigates the factors influencing Iranian nurses' happiness and examines the association between happiness and the quality of their caring behaviors.
2. Objectives
This study examines the factors that affect the happiness of Iranian nurses and explores whether increased happiness correlates with improved caring behaviors.
3. Methods
3.1. Study Design
This descriptive, correlational-analytical study aimed to investigate the relationship between happiness and caring behaviors in nurses working in hospitals affiliated with Isfahan University of Medical Sciences in 2024. The sampling process was conducted from February 2024 to April 2024.
3.2. Study Setting and Participants
A sample of 220 clinical nurses was randomly selected from four major teaching hospitals affiliated with Isfahan University of Medical Sciences: Al-Zahra, Khorshid, Chamran, and Feiz, using Cochran’s formula. The inclusion criteria included willingness and informed consent to participate, at least one year of clinical experience, no recent crisis (such as the death of a close relative, divorce, or a serious illness in the past six months, as self-reported), no known psychological disorders (self-reported), and no use of psychotropic or narcotic drugs (self-reported). The exclusion criterion was incomplete questionnaire responses.
Based on random sampling, a list of nurses who met the inclusion criteria in the four hospitals was prepared, and 220 individuals were randomly selected using a random number table. The researcher visited the nurses during appropriate times on morning, afternoon, and night shifts. After introducing themselves and providing a detailed explanation of the study, written informed consent was obtained from the nurses. Subsequently, the demographic, happiness, and Caring Behaviors Questionnaires were distributed to the participants.
3.3. Data Collection and Measurement
Data collection was conducted using three questionnaires: A Demographic Information Questionnaire (nine questions), the short form of the Oxford Happiness Questionnaire (eight questions), and the Caring Behaviors Inventory (CBI-16). The face and content validity of the Demographic Questionnaire were confirmed by ten faculty members.
The short form of the Oxford Happiness Questionnaire, developed by Hills and Argyle (2002), is based on a Six-Point Likert Scale (ranging from strongly disagree to strongly agree), with three items being reverse-scored (items 1, 4, and 8). Scores range from 8 to 48, with higher scores indicating greater happiness (13). This questionnaire was translated into Persian by Dehshiri et al. in 2015, with its face and content validity confirmed, and a Cronbach’s alpha of 0.71 reported in that study (13).
The CBI-16, developed by Wolf in 2017, consists of 16 items scored on a Six-Point Likert Scale, with a total score ranging from 16 to 96. The questionnaire encompasses four subscales: Respect for others, ensuring human presence, communication and positive attitude, and professional knowledge and skills (14). The Cronbach’s alpha for this questionnaire was reported as greater than 0.7 in the study by Ghafouri et al. (14). The verbs in this questionnaire were phrased in the first person for nurses. This tool is designed to be completed by both nurses and patients (15-17). In the study by Alikari et al., the first-person phrasing was used for nurses, and the face and content validity of the questionnaire were confirmed, with a Cronbach’s alpha coefficient reported at 0.96 (15).
3.4. Data Analysis
Statistical analysis was performed using SPSS version 23. Descriptive statistics were employed to calculate the mean scores for happiness and caring behaviors. The relationship between happiness and demographic variables was assessed using independent t-tests and ANOVA, while the association between happiness and caring behaviors was evaluated using the Pearson correlation coefficient. A significance level of (P < 0.05) was applied to determine statistical significance.
3.5. Ethical Considerations
The necessary approvals and ethics code IR.MUI.NUREMA.REC.1402.045 were obtained from the Ethics Committee of Isfahan University of Medical Sciences. Informed consent was secured from the participating nurses after providing a detailed explanation of the study's objectives and procedures. Participants were assured that their involvement was entirely voluntary, their information would remain confidential, and they would be informed of the study's results.
4. Results
The mean age of the participants was 32 years. Table 1 presents the demographic characteristics of the study sample. The findings revealed that the mean happiness score among Iranian nurses was 34.48 ± 5.82, and the mean score for caring behaviors was 82.53 ± 9.97. Table 2 provides the mean scores of the study variables.
Table 1.The Demographic Information of the Nurses
| Variables | No. (%) |
|---|---|
| Healthcare center | |
| Alzahra | 26 (11.8) |
| Feiz | 10 (4.5) |
| Khorshid | 31 (14.1) |
| Chamran | 153 (69.5) |
| Education level | |
| Bachelor | 194 (88.2) |
| Master | 26 (11.8) |
| Gender | |
| Female | 159 (72.3) |
| Male | 61 (27.7) |
| Marital status | |
| Single | 83 (37.7) |
| Married | 137 (62.3) |
| Age | |
| 20 - 29 | 86 (39.1) |
| 30 - 39 | 92 (41.8) |
| 40 - 49 | 33 (15) |
| > 50 | 9 (4.1) |
| Employment status | |
| Official | 68 (30.9) |
| Contractual | 121 (55) |
| Temporary | 29 (13.2) |
| Work experience (y) | |
| < 5 | 85 (39.5) |
| 5 - 10 | 68 (30.9) |
| 10 - 15 | 37 (16.8) |
| 15 - 20 | 15 (6.8) |
| 20 - 26 | 9 (4.1) |
| > 26 | 6 (2.7) |
| Income (million Rials) | |
| < 100 | 18 (8.2) |
| 100 - 150 | 187 (85) |
| 150 - 200 | 6 (2.7) |
| > 200 | 9 (4.1) |
| Ward | |
| Internal medicine | 74 (33.6) |
| Surgery | 50 (22.7) |
| CCU, ICU, emergency | 96 (43.6) |
Table 2.Relationship Between Happiness and Demographic Information a
| Variables and Categories | Happiness | P -Value |
|---|---|---|
| Age (y) | 0.028 b | |
| 20 - 29 | 34.14 ± 5.72 | |
| 30 - 39 | 34.07 ± 5.78 | |
| 40 - 49 | 35.94 ± 6.45 | |
| > 50 | 36.44 ± 4.03 | |
| Gender | 0.042 c | |
| Male | 35.80 ± 5.03 | |
| Female | 33.99 ± 6.03 | |
| Marital status | 0.206 c | |
| Married | 23.62 ± 5.57 | |
| Single | 24.83 ± 7.38 | |
| Education level | 0.031 c | |
| Bachelor | 34.42 ± 6.44 | |
| Master | 21.11 ± 5.02 | |
| Employment status | 0.195 b | |
| Official | 33.47 ± 6.67 | |
| Contractual | 35.08 ± 5.54 | |
| Temporary | 34.28 ± 4.87 | |
| Work experience (y) | 0.033 b | |
| < 5 | 34.80 ± 5.62 | |
| 5 - 10 | 34.73 ± 6.23 | |
| 10 - 15 | 32.91 ± 5.14 | |
| 15 - 20 | 35.67 ± 5.64 | |
| 20 - 26 | 36.22 ± 6.57 | |
| > 26 | 41.00 ± 0.89 | |
| Healthcare center | 0.09 b | |
| Alzahra | 35.00 ± 4.47 | |
| Feiz | 37.3 ± 4.32 | |
| Khorshid | 36.06 ± 7.08 | |
| Chamran | 33.87 ± 5.75 | |
| Income (million Rials) | 0.022 b | |
| < 10 | 34.72 ± 3.96 | |
| 10 - 15 | 34.22 ± 5.82 | |
| 15 - 20 | 41.67 ± 3.61 | |
| > 20 | 34.71 ± 8.09 | |
| Ward | 0.356 b | |
| Internal medicine | 35.26 ± 5.79 | |
| Surgery | 34.26 ± 5.09 | |
| CCU, ICU, emergency | 33.98 ± 6.20 |
a Values are expressed as mean ± SD.
b One way ANOVA.
c Independent t-test.
The results indicated a significant relationship between happiness and factors such as gender, work experience, and income. However, variables such as age, marital status, education level, employment type, and hospital department did not significantly influence the level of happiness. Table 3 outlines the relationship between these variables and happiness in the study sample.
Additionally, happiness demonstrated a positive and significant correlation with caring behaviors and its subdomains. Table 2 highlights the relationship between happiness and caring behaviors, including its subdomains.
Table 3.Relationship Between Happiness and Caring Behaviors
| Variables | Mean ± SD | Pearson Correlation Test | |
|---|---|---|---|
| r | P-Value | ||
| Happiness | 34.48 ± 5.82 | - | - |
| Caring behaviors | 82.53 ± 9.97 | 0.24 | 0.001 |
| Subscales 1 (communicating respectfully) | 31.23 ± 3.73 | 0.215 | 0.002 |
| Subscales 2 (ensuring human presence) | 5.25 ± 0.83 | 0.213 | 0.002 |
| Subscales 3 (communication and positive attitude) | 25.99 ± 3.58 | 0.174 | 0.011 |
| Subscales 4 (professional knowledge and skill) | 15.40 ± 2.27 | 0.21 | 0.002 |
5. Discussion
The mean happiness score among Iranian nurses was found to be above average. This finding aligns with studies conducted by Gurdogan and Uslusoy and Meng et al., which also reported above-average happiness levels among nurses (18, 19). Similarly, research conducted in Iran by Javanmardnejad et al., Khosrojerdi et al., Mousavi et al., and Vakili et al. yielded comparable results (20-23). In contrast, a study by Yosefi reported significantly lower happiness levels among nurses (24). In Yosefi's study, 300 female nurses working in oncology, obstetrics and gynecology, and internal medicine wards were surveyed, whereas the present study included 220 male and female nurses from internal medicine, surgery, and intensive care units. Additionally, Yosefi employed the Munsh Questionnaire to assess happiness, while the present study utilized the Oxford Happiness Questionnaire.
There was a significant relationship between gender, work experience, income, and happiness, while factors such as age, marital status, education level, employment type, and hospital department showed no significant effect on happiness. Consistent with the present research, the study by Gurdogan et al. indicated that male nurses exhibited higher levels of happiness than their female counterparts. The higher happiness levels among male nurses in Iran may be attributed to traditional gender roles, reduced workplace discrimination, more career advancement opportunities, better access to support systems, and a healthier work-life balance (11, 23, 25). In contrast, female nurses may experience more stress due to social pressures, increased home responsibilities, and workplace discrimination, contributing to lower levels of satisfaction and happiness. However, Meng et al. found that female nurses had higher levels of happiness (18, 19). This discrepancy could stem from geographical differences (West Asia compared to East Asia) or the fact that Meng’s study was conducted in military hospitals. It is important to note that indicators and factors related to happiness evolve with social changes over time. If Meng’s study were replicated today, the results might align with those of the present study or the one conducted by Gurdogan two years ago.
Additionally, Baghdadi et al. conducted their study on nursing students, a population distinct from the present study (26). Since nursing students are generally at the beginning of their professional careers, the levels of happiness and influencing factors in this group may differ from those of employed nurses. Baghdadi’s study also reported no significant relationship between gender and happiness (26).
The results indicate that longer work experience is associated with higher levels of happiness, consistent with the findings of Khosrojerdi et al. (21). However, studies conducted by Javadi Sharif et al. and Bagheri et al. found no significant relationship between work experience and happiness (27, 28), which contrasts with our findings. One possible explanation for this discrepancy is that nurses with more experience may have started their careers during periods when economic, social, and working conditions were more favorable, providing them with a higher social status. These experienced nurses may now enjoy greater stability in their personal and professional lives. In contrast, less experienced nurses often face challenges such as adverse economic and social conditions, increased stress due to staffing shortages, and lower salaries. As a result, they may experience greater anxiety about the future and instability in their lives, leading to lower levels of happiness compared to their more experienced colleagues (29).
Javanmardnejad et al., Khosrojerdi et al., and Kumar et al. also identified a significant relationship between income and happiness (20, 21, 30), aligning with our findings. Income level is highlighted as a crucial factor in global studies as well (31, 32). However, the concept of happiness and the factors contributing to it vary across countries and cultures. Language, geography, and culture play significant roles in shaping the definition of happiness and can influence its levels (33). Additional factors identified in the literature that contribute to variations in the meaning of happiness include corruption, perceptions of freedom and free choice, social support (34, 35), income inequality, economic conditions, urban versus rural residency, and health (31, 32). Furthermore, marital status, social participation and support, and health conditions have been emphasized as significant factors (36, 37).
The findings indicated that the mean score for caring behaviors was above average. Safa et al. reported that the majority of patients expressed satisfaction with nurses' caring behaviors (38). Similarly, Barkhordari-Sharifabad et al., Hosseinzadeh et al., Ferede et al., Gheybi and Zeinali also found that nurses demonstrated above-average caring behaviors (2, 17, 39, 40). However, Zare revealed a disparity: While nurses believed they were providing good care, patients felt their expectations and needs were not fully met (4). In contrast, studies by Ahmed et al. and Kibret et al. reported low levels of caring behaviors among nurses, findings that contradict the results of this study (41, 42).
There was a significant relationship between happiness and caregiving behavior, including all its subdomains. A study by Baghdadi et al. highlighted that happiness could influence the caregiving behavior of nursing students (26). Similarly, Abou Zeid et al. reported comparable findings, suggesting that a positive and enhanced sense of happiness is essential for improving nurses' caregiving behaviors (43). A positive work environment can contribute to increased happiness among nurses, motivating them to exhibit better caregiving behaviors. In general, it can be concluded that happier nurses demonstrate greater commitment to caregiving behaviors, and increased happiness enhances the quality of care provided by nurses.
5.1. Conclusions
Nurses with higher levels of happiness are more likely to provide better care. Considering the pivotal role nursing care plays in patient recovery, it is imperative for healthcare organizations and governments to prioritize initiatives aimed at enhancing nurse happiness. Offering greater financial support, promoting gender equality in the workplace, and ensuring job security to retain nurses can create a solid foundation for improving the quality of nursing care. Furthermore, since happiness is not a fixed trait and can be influenced by various factors, future research should focus on identifying additional elements that impact nurse happiness to develop targeted interventions that further enhance their well-being and caregiving effectiveness.
