- Email: [email protected]
Improving job satisfaction of Chinese doctors: the positive effects of perceived organizational support and psychological capital
p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 9 4 6 e9 5 1
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Improving job satisfaction of Chinese doctors: the positive effects of perceived organizational support and psychological capital J. Fu, W. Sun, Y. Wang, X. Yang, L. Wang* Department of Social Medicine, School of Public Health, China Medical University, No. 92, Beier Road, Heping District, Shenyang, Liaoning 110001, People’s Republic of China
article info
summary
Article history:
Objectives: The huge population basic and the transformational changes to healthcare
Received 13 January 2012
system in China have gained wide public attention in recent years. Along with these issues
Received in revised form
is a growing literature about doctor’s job satisfaction; however, more is known about its
9 September 2012
negative related factors. Thus, this study was an attempt to assess the level of job sat-
Accepted 21 December 2012
isfaction among Chinese doctors and to explore factors that enhance their job satisfaction.
Available online 1 October 2013
Study design: Cross-sectional questionnaire-based survey. Methods: A cross-sectional study was conducted during the period of September/October
Keywords:
2010. A questionnaire containing job satisfaction assessed by Minnesota Satisfaction
Job satisfaction
Questionnaire (MSQ), demographic characteristics, work conditions, psychological capital
Perceived organizational support
(PsyCap) and perceived organizational support (POS) was distributed to 1300 registered
Psychological capital
doctors in Liaoning province. A total of 984 respondents became our subjects (effective
Chinese doctors
response rate 75.7%). Hierarchical regression was performed to explore the factors associated with satisfaction. Results: The average MSQ score was 65.86 (level ranking for MSQ, 20e100) in our study population. Hierarchical regression analysis showed that POS (b ¼ 0.412, P < 0.001), PsyCap (b ¼ 0.255, P < 0.001), incentive system (b ¼ 0.119, P < 0.001) and educational background (b ¼ 0.056, P ¼ 0.042) were positively associated with job satisfaction. Conclusions: The job satisfaction of Chinese doctors was at a moderate level. POS and PsyCap seemed to be the most crucial factors in relation to job satisfaction. Therefore, efficient measures such as building a supportive work environment and developing doctors’ PsyCap should be considered by health administrators in order to promote job satisfaction among Chinese doctors. ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ86 24 23256666 5404. E-mail address: [email protected] (L. Wang). 0033-3506/$ e see front matter ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2012.12.017
p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 9 4 6 e9 5 1
Introduction Job satisfaction can be defined as a global feeling that an individual has about his/her job,1 which has been studied in various professional fields.2 The job satisfaction of doctors, who are a particular occupational population, has gained increasing attention in recent years as it is not only associated with doctors’ burnout,3,4 mental health,3,5 and turnover intention,6e8 but also with the health outcomes of patients9 and the quality of health care in general. Although there are a number of research studies about job satisfaction, most have concentrated on the effects of demographic characteristics, work conditions and negative feelings10e12 on job satisfaction. However, the more positive aspects of psychological capital (PsyCap) and perceived organizational support (POS) have now become a growing research topic aimed at improving the level of job satisfaction. Based on both conceptual and empirical evidence, Luthans put forward the core construct of PsyCap and defined it as ‘an individual’s positive psychological state of development that is characterized by self-efficacy, optimism, hope and resiliency’.13 Although it has not been long since the composite higher-order concept of PsyCap was described there is evidence that PsyCap is positively related to job satisfaction.14,15 According to organizational support theorists, POS refers to employees’ general belief concerning the extent to which the organization values their contributions and cares about their well-being.16 As an organizational-based resource, it also can be seen as ‘assurance that aid will be available from the organization when it is needed to carry out one’s job effectively and to deal with stressful situations’.17 Although there were relatively few studies on POS until the mid 1990’s, research on POS has grown rapidly in the last few years. A meta-analysis of the relationship between POS and job outcomes indicated that POS has a strong, positive effect on employees’ work attitude, such as job satisfaction.18 With the huge population in China, the ratio of doctors to the general population is 1:735, which is lower than that in western countries (1:280e1:640).19 Thus, Chinese doctors have to deal with many more patients and take greater responsibility for critical decisions and therapeutic outcomes on a daily basis. It is reported that Chinese doctors experience extra shifts quite often20 and 57.5% of them work more than 40 h per week. A nationwide investigation by the Chinese Medical Doctor Association in 2009 indicated that 39.5% of Chinese doctors are not satisfied with their work environment.21 What is more, as China’s health care used to be described as too difficult to access, too expensive, and too variable in quality,22 China has started a major reform of health care to change the situation. Alongside the continuing health care reform and increasing health consciousness, the work life-style of Chinese doctors has changed immensely in recent years. All these mean that Chinese doctors are exposed to both heavy physical and psychological burdens which may lead them to be easily dissatisfied. Overall, we hypothesized that Chinese doctors would enjoy a low level of job satisfaction. However, few studies of job satisfaction were directed towards Chinese doctors. Therefore, the purpose of this study was to assess the level of job
947
satisfaction among Chinese doctors, and to explore positive effects of PsyCap and POS in improving their job satisfaction.
Methods Sampling and data collection A cross-sectional survey was conducted during September/ October 2010 in Liaoning province, northeast of China. As a heavy industrial base in China, the average income in Liaoning province is close to the national average. Furthermore, according to the statistics provided by China Yearbook, the proportion of doctors in the health workforce (34.5%)in Liaoning province is almost in the same level as the whole country’s (35.4%). For each of geographic regions of Liaoning province (eastern, western, southern, northern and central), we randomly selected one city. One large general hospital (>500 beds) was randomly selected in each sampled city, and one more large general hospital was randomly selected if the sampled city was a megalopolis (1,000,000 population). As the central city is a megalopolis, a total of six large general hospitals were finally sampled from the selected cities, and half of the doctors were randomly sampled from each selected hospital. After obtaining consent, a selfadministered anonymous questionnaire was distributed to 1300 eligible doctors. Finally, we received effective responses from 984 doctors (effective response rate: 75.7%). These doctors formed the final study sample.
Measurement of job satisfaction Job satisfaction was measured with the Minnesota Satisfaction Questionnaire (MSQ),23 which has been widely used in the Chinese population.24,25 The 20-item short form MSQ used a 5-point Likert-type scale ranging from 1 (very dissatisfied) to 5 (very satisfied). The short form of the MSQ can be seen as a composite of a number of job facets. Scores are created by summing items so as to show each participant’s satisfaction level ranging from 20 to 100. A score of 60 would indicate moderate, a score ranging from 61 to 79 would indicate ‘moderate to not fully satisfied’ and a score of 80 and above would indicate satisfied.26 The Cronbach’s alpha was 0.95 in this study.
Demographic characteristics Demographic characteristics included gender, age (<30, 30e40, >40), marital status and educational background. ‘Marital status’ was categorized as ‘married/cohabitation’ and ‘single/divorced/separated/widowed’. There are three levels of Chinese medical colleges: junior college course, undergraduate course, and graduate course. Therefore, ‘education’ was divided into ‘junior college course’ group, ‘undergraduate course’ group, and ‘graduate course’ group.19
Work conditions Work situations were assessed by three items: (1) job rank; (2) doctorepatient relationship and (3) incentive system. ‘Job
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p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 9 4 6 e9 5 1
rank’ was categorized as ‘basic doctor’ (the ordinary doctor of the department) and ‘head doctor’ (the chief of the department) by asking the question, ‘Are you a basic doctor or a head doctor?’ ‘Doctorepatient relationship’ was measured by asking the question, ‘How often have you felt bothered by patients at work?’ It was defined as ‘general degree’ if the doctors answered ‘never’, ‘rarely’, or ‘sometimes’, and as ‘serious degree’ if they answered ‘frequently’ or ‘always’.27 ‘Incentive system’ was worded ‘Are you satisfied with the hospital’s incentive system? with the answers (Not satisfied/Neither/ Satisfied)’.
Measurement of psychological capital The measurement of PsyCap was the psychological capital questionnaire (PCQ) which was developed by Luthans et al.13 The reliability and validity of PCQ have been demonstrated adequately in both foreign and Chinese populations.14,15,28 It used a six-point Likert-type scale with categories ranging from 1 (strongly disagree) to 6 (strongly agree). All responses for 24 questions were summed and averaged to get an average score as the indicator for total PsyCap. The Cronbach’s alpha was 0.91 in this study.
Measurement of perceived organizational support POS was examined via a shortened version of the Survey of Perceived Organizational Support,16 which has been used in both foreign and Chinese researches.29,30 It includes nine items with the highest factor loadings of the 36 items. Each item had seven response categories ranging from 1 ¼ strongly agree to 7 ¼ strongly disagree to indicate the extent of the respondents’ agreement with each statement. The Cronbach’s alpha was 0.89 in this study.
Statistical analysis The dimensions of job satisfaction by demographic characteristics and work conditions were tested by student t-test and one-way ANOVA. Correlations among MSQ, PsyCap and PCQ were done by Pearson correlation. Hierarchical regression analysis was used to estimate the association of job satisfaction with demographic characteristic, work conditions, PsyCap and POS. All data analysis were performed by SPSS for Windows, Ver. 17.0, and a two-tailed probability value of <0.05 was considered to be statistically significant.
Table 1 e Characteristics of the subjects and univariate analysis for the factors related to job satisfaction. Number of subjects n(%) MSQ Demographic characteristics Gender Male Female Age (years) <30 30e 40e Marital status Single/widow/divorced/ separated Married/cohabitation Educational background Junior college course Undergraduate course Graduate course Work conditions Job rank Basic doctor Head doctor Doctorepatient relationship General degree Serious degree Incentive satisfaction Not satisfied Neither Satisfied
Mean SD
P-value
984
65.86 12.83
437(44.4) 547(55.6)
65.43 13.24 66.69 12.36
0.133
292(29.7) 385(39.1) 307(31.2)
66.47 11.99 64.51 12.45 67.25 13.86
0.017
258(26.2)
67.40 11.40
0.077
726(73.8)
65.71 13.13
99(10.0) 572(58.1) 313(31.8)
65.77 12.95 65.26 12.47 67.49 13.13
0.055
874(88.8) 110(11.2)
65.47 12.14 69.88 15.59
0.007
458(46.5) 526(53.5)
68.79 12.72 63.64 12.23
<0.001
543(55.2) 314(31.9) 127 (12.9)
63.00 12.96 67.61 10.18 75.25 12.75
<0.001
The results of the hierarchical regression analysis of the main factors associated with job satisfaction are shown in Table 2. In the first step, demographic factors accounted for a small portion of the variance (DR2 ¼ 1.8%); in the second step, work conditions explain an additional 11.2% of the variance; in the third step, PsyCap accounted for 15.6% of the variance; in the final step, POS made up an additional 12.5% of the variance. Totally, all the predictors explained 41.1% of the variance in job satisfaction. Educational background, incentive system, PsyCap and POS were positively associated with job satisfaction.
Discussion Results
Main findings
Table 1 shows the characteristics of the study subjects. The average age was 36.15, SD 8.18 years. The mean MSQ score was 65.86, SD 12.83. The results of univariate analysis of MSQ in relation to the categorical variables are also shown in Table 1. Age, job rank, doctorepatient relationship and incentive system were significantly related to job satisfaction, while gender, marital status and educational background were not significantly related to it. Both PsyCap (r ¼ 0.432) and POS (r ¼ 0.571) were positively correlated with MSQ in our study population.
In the present study, the effective response rates of selected hospitals ranged from 71.1% to 76.2% which was very close to the overall response rate (75.7%). The result of this study showed that Chinese doctors enjoyed a moderate level of job satisfaction, which is lower than Turkish doctors31 (total score: 70.1), New England nurses26 (total score: 77.6), Chinese community health workers (total score: 68.2)24 and Chinese nurses32 (total score>68.8). The comparative results indicated Chinese doctors are not very satisfied with their job.
p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 9 4 6 e9 5 1
Table 2 e Hierarchical regression analysis for exploring associated factors of job satisfaction. Variables Model 1: Educational background Age (years) Marital status Model 2: Incentive system Doctorepatient relationship Educational background Marital status Model 3: PsyCap Incentive system Doctorepatient relationship Model 4: POS PsyCap Incentive system Educational background
R2
R2-changes
0.018
0.018
F
Beta
3.893** 0.095** 0.086* 0.083*
0.130
0.112
17.739*** 0.260*** 0.152*** 0.091** 0.081*
0.286
0.156
41.616*** 0.409*** 0.227*** 0.069*
0.411
0.125
64.218*** 0.412*** 0.255*** 0.119*** 0.056*
*P < 0.05, **P < 0.01, ***P < 0.001. POS, perceived organizational support; PsyCap, psychological capital. Note: Educational background (1 ¼ junior college course and under, 2 ¼ undergraduate course, 3 ¼ graduate course), marital status (1 ¼ single/widow/divorced/separated, 2 ¼ married/cohabitation), incentive system (1 ¼ not satisfied, 2 ¼ neither, 3 ¼ satisfied), doctorepatient relationship (1 ¼ general degree, 2 ¼ serious degree).
According to the hierarchical regression results, POS was positively associated with job satisfaction in our study, which is consistent with previous studies.33,34 PsyCap was found to be a positive predictor of job satisfaction in line with in previous studies.14,15 With respect to work conditions and demographic characteristics, a better incentive system and higher educational background were also positive effect factors of doctors’ job satisfaction, which is similar to the previous studies.35e37
Interpretation of the findings and policy implications Our subjects were sampled from large general hospitals (>500 beds) in every geographic region in Liaoning province and the effective response rates of selected hospitals were all greater than 70%, that has been a level reported to be normal and reasonable for a questionnaire survey.38 This provides a good representation of our study population and increases the generability of our study’s conclusions. China’s huge population accounts for more than one fifth of the world’s population. Consequently, the ratio of doctors to the general population is lower than that in other counties. In addition, China’s health care reform is a double-edged sword. On the one hand, it offers great opportunities for improvements in healthcare access, basic health infrastructure,
949
and high-quality health services; on the other hand, it brings immense changes of doctors’ work life-style. The burdens of Chinese doctors are greater than in other countries, which may lead them to be easily dissatisfied. Therefore, it is very important to improve Chinese doctors’ job satisfaction through its positive influence factors. POS was the strongest predictor of job satisfaction with the largest regression coefficient in our study. Social exchange theories indicates that if both the employee and the employer apply the reciprocity norm to their relationship, favourable treatment received by either party would lead to satisfied outcomes for both. Moreover, as a perception of the organization, POS can be influenced by a cluster of organizational factors. Thus, favourable treatment, such as meeting socioemotional needs, increasing performance-reward expectancies and providing the availability of aid when needed,39 would make doctors perceive more support in their work environment, which, in turn, would improve the level of their job satisfaction. PsyCap was a positive and potent predictor of job satisfaction in our study. Higher-order PsyCap includes four components: hope; efficacy; optimism; and resiliency. In other words, doctors with higher levels of PsyCap might be stronger willed and have more viable means to accomplish specific tasks or goals, be more confident about their abilities to successfully execute a challenging task and have more positive coping responses in the face of significant adverse or stressful situations. With this positive capital, the doctors are more likely to be satisfied with their job. As a derivative of POB, PsyCap is a positively oriented human resource strength and relatively malleable, and is open to development. Therefore, it could be an efficient approach to promote doctors’ job satisfaction by developing their PsyCap. One approach that can be considered is to arrange focus group discussions of doctors and managers. These meetings could usefully explore fiscal and manpower constraints associated with service delivery issues and that arise under headings such as doctor and manager wishes, needs, expectations and requirements. Reasonable incentive systems, such as rational bonuses, subsidies, insurances, vacations and so forth, are helpful to increase doctors’ initiatives and improve their job satisfaction. The nature of the doctor and the circumstance of China’s medical system usually lead to overtime work and over fatigue. Therefore, it is very necessary to establish some financial incentives for the extra hours and some constraints on overtime. Chinese doctors begin their medical education (dividing into two levels: junior college for three years and undergraduate course for five years) directly after they graduate from high school. Doctors who graduate from junior college can take further course (for two years) to get a bachelor degree, or they become a licensed assistant doctor firstly, and then experience years of medical practice to obtain a doctor’s license. Whereas, doctors who take the undergraduate course are able to obtain a bachelor degree and a doctor’s license directly after they graduate. Doctors with higher educational level are more likely to get a higher income and a better prospect. Therefore, providing further education and opportunities to do work within their abilities for lower educated doctors would increase their attainment and thus be helpful to improve their job satisfaction.
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Limitations of this study Firstly, as our study is a cross-sectional design, it is impossible to draw causal relations between job satisfaction and its related factors. To confirm the conclusions obtained in this study, longitudinal study should be conducted in the future. Secondly, participants in this study were limited to large general hospitals, where working conditions might be different from the other smaller-scale hospitals. Therefore, the small general hospitals and community health centres should be studied in future research to improve the representation of our study conclusions.
Acknowledgements The authors would like to thank Professor Eisenberger and Professor Chaoping Li for providing the details of the questionnaires, and the authors also wish to thank all the administrators in every selected hospital who helped to get the written informed consent about the conduct of this survey and to distribute the questionnaires to the subjects.
Ethical approval The procedures followed were in accordance with the ethical standards of the Committee on Human Experimentation of China Medical University.
Funding None declared.
Competing interests None declared.
references
1. Spector PE. Job satisfaction: application, assessment, causes, and consequences. 1st edn. London: SAGE Publications; 1997. 2. Judge TA, Parker S, Colbert AE, Heller D, Ilies R. Job satisfaction: a cross-cultural review. In: Anderson N, editor. Handbook of industrial, work and organizational psychology. Organizational psychology, vol. 2. Thousand Oaks: Sage; 2002. p. 25e52. 3. Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM. Mental health of hospital consultants: the effects of stress and satisfaction at work. Lancet 1996;347:724e8. 4. Linzer M, Visser MR, Oort FJ, Smets EM, McMurray JE, de Haes HC. Predicting and preventing physician burnout: results from the United States and Netherlands. Am J Med 2001;111:170e5. 5. Dowell AC, Westcott T, McLeod DK, Hamilton S. A survey of job satisfaction, sources of stress and psychological symptoms among New Zealand Health Professionals. NZ Med J 2001;114:540e3. 6. Buchbinder SB, Wilson M, Melick CF, Powe NR. Primary care physician job satisfaction and turnover. Am J Manag Care 2001;7:701e13.
7. Pathman DE, Konrad TR, Williams ES, Scheckler WE, Linzer M, Douglas J. Physician job satisfaction, dissatisfaction, and turnover. J Fam Pract 2002;51:593. 8. Landon BE, Reschovsky JD, Pham HH, Blumenthal D. Leaving medicine: the consequences of physician dissatisfaction. Med Care 2006;44:234e42. 9. DeVoe J, Fryer Jr GE, Straub A, McCann J, Fairbrother G. Congruent satisfaction: is there geographic correlation between patient and physician satisfaction? Med Care 2007;45:88e94. 10. Wetterneck TB, Linzer M, McMurray JE, Douglas J, Schwartz MD, Bigby J, Gerrity MS, Pathman DE, Karlson D, Rhodes E. Worklife and satisfaction of general internists. Arch Intern Med 2002;162:649e56. 11. Freeborn DK. Satisfaction, commitment, and psychological well-being among HMO physicians. West J Med 2001;174:13e8. 12. Fairbrother K, Warn J. Workplace dimensions, stress and job satisfaction. J Manag Psychol 2003;18:8e21. 13. Luthans F, Youssef CM, Avolio BJ. Psychological capital: developing the human competitive edge. Oxford, UK: Oxford University Press; 2007. 14. Luthans F, Avolio BJ, Avey JB, Norman SM. Positive psychological capital: measurement and relationship with performance and satisfaction. Pers Psychol 2007;60:541e72. 15. Luthans F, Norman SM, Avolio BJ, Avey JB. The mediating role of psychological capital in the supportive organizational climate-employee performance relationship. J Organ Behav 2009;29:219e38. 16. Eisenberger R, Huntington R, Hutchison S, Sowa D. Perceived organizational support. J Appl Psychol 1986;71:500e7. 17. George JM, Reed TF, Ballard KA, Colin J, Fielding J. Contact with AIDS patients as a source of work-related distress: effects of organizational and social support. Acad Manage J 1993;36:157e71. 18. Robert RJ, Diane ER, John HD. A meta-analysis of the relationship between perceived organizational support and job outcomes: 20 years of research. J Bus Res 2009;62:1027e30. 19. Wang Jia-Na, Sun Wei, Chi Tie-Shuang, Wu Hui. Prevalence and associated factors of depressive symptoms among Chinese doctors: a cross-sectional survey. Int Arch Occup Environ Health 2010;83:905e11. 20. Li CP, Shi K, Luo ZX, Yang Y. Survey on job burnout of physicians and nurses. Chin J Clin Psychol 2003;11:170e3. 21. Investigation on the practicing status of Chinese physicians. [http://news.sina.com.cn/c/2009-04-25/205217687889.shtml]. 22. Health-system reform in China. Lancet 2008;372:1437. 23. Weiss DJ, Dawis RV, England GW, Lofquist LH. Manual for the Minnesota satisfaction questionnaire, Minnesota studies in vocational rehabilitation. Minneapolis: The University of Minnesota Press; 1967. 24. Ge Cui X, Fu Jia L, Chang Ying, Wang Lie. Factors associated with job satisfaction among Chinese community health workers: a cross-sectional study. BMC Public Health 2011;11:884. 25. Tat Shing KWAN. Predicting job satisfaction with cultural self identity and organizational culture among Chinese employees in Hong Kong. Hong Kong: Department of Applied Social Studies; 2008. p. 1e60. 26. Sharp TP. Job satisfaction among psychiatric registered nurses in New England. J Psychiatr Ment Health Nurs 2008;15:374e8. 27. Shen HC, Cheng YW, Tsai PJ, Lee SHS, Guo YL. Occupational stress in nurses in psychiatric institutions in Taiwan. J Occup Health 2005;47:218e25. 28. Zhang K, Zhang S, Dong YH. Positive psychological capital: measurement and its association with mental health. Stud Psychol Behav 2010;8:58e64.
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29. Wayne SJ, Shore LM, Liden RC. Perceived organizational support and leader-member exchange: a social exchange perspective. Acad Manage J 1997;40:82e111. 30. Tan Xiaohong, Qin Qiwen, Pan Xiaofu. The relationship of organizational support, job satisfaction and turnover intention among Chinese employees. Psychol Sci 2007;30:441e3. 31. Ozyurt A, Hayran O, sur H. Predictors of burnout and job satisfaction among Turkish physicians. Q J Med 2006;99:161e9. 32. Ning Sun, Zhong He, Libo Wang, Qiujie Li. The impact of nurse empowerment on job satisfaction. J Adv Nurs 2009;65:2642e8. 33. Kwak Chanyeong, Yae Chung Bok, Xu Yu, Eun-Jung Cho. Relationship of job satisfaction with perceived organizational support and quality of care among South Korean nurses: a questionnaire survey. Int J Nurs Stud 2010;47:1292e8.
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34. AL-Hussami M. A study of nurses’ job satisfaction: the relationship to organizational commitment, perceived organizational support, transactional leadership, transformational leadership, and level of education. Eur J Sci Res 2008;22:286e95. 35. Scheurer D, McKean S, Miller J, Wetterneck T. U.S. physician satisfaction: a systematic review. J Hosp Med 2009;4:560e8. 36. Rambur B, McIntosh B, Palumbo MV, Reinier K. Education as a determinant of career retention and job satisfaction among registered nurses. J Nurs Scholarsh 2005;37:185e92. 37. Ingersoll GL, Olsan T, Drew-Cates J, DeVinney BC, Davies J. Nurses’ job satisfaction, organizational commitment, and career intent. J Nurs Adm 2002;32:250e63. 38. Aiken LR. Proportion of returns in survey research. Educ Psychol Meas 1981;41:1033e8. 39. Rhoades L, Eisenberger R. Perceived organizational support: a review of the literature. J Appl Psychol 2002;87:698e714.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Improving job satisfaction of Chinese doctors: the positive effects of perceived organizational support and psychological capital J. Fu, W. Sun, Y. Wang, X. Yang, L. Wang* Department of Social Medicine, School of Public Health, China Medical University, No. 92, Beier Road, Heping District, Shenyang, Liaoning 110001, People’s Republic of China
article info
summary
Article history:
Objectives: The huge population basic and the transformational changes to healthcare
Received 13 January 2012
system in China have gained wide public attention in recent years. Along with these issues
Received in revised form
is a growing literature about doctor’s job satisfaction; however, more is known about its
9 September 2012
negative related factors. Thus, this study was an attempt to assess the level of job sat-
Accepted 21 December 2012
isfaction among Chinese doctors and to explore factors that enhance their job satisfaction.
Available online 1 October 2013
Study design: Cross-sectional questionnaire-based survey. Methods: A cross-sectional study was conducted during the period of September/October
Keywords:
2010. A questionnaire containing job satisfaction assessed by Minnesota Satisfaction
Job satisfaction
Questionnaire (MSQ), demographic characteristics, work conditions, psychological capital
Perceived organizational support
(PsyCap) and perceived organizational support (POS) was distributed to 1300 registered
Psychological capital
doctors in Liaoning province. A total of 984 respondents became our subjects (effective
Chinese doctors
response rate 75.7%). Hierarchical regression was performed to explore the factors associated with satisfaction. Results: The average MSQ score was 65.86 (level ranking for MSQ, 20e100) in our study population. Hierarchical regression analysis showed that POS (b ¼ 0.412, P < 0.001), PsyCap (b ¼ 0.255, P < 0.001), incentive system (b ¼ 0.119, P < 0.001) and educational background (b ¼ 0.056, P ¼ 0.042) were positively associated with job satisfaction. Conclusions: The job satisfaction of Chinese doctors was at a moderate level. POS and PsyCap seemed to be the most crucial factors in relation to job satisfaction. Therefore, efficient measures such as building a supportive work environment and developing doctors’ PsyCap should be considered by health administrators in order to promote job satisfaction among Chinese doctors. ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ86 24 23256666 5404. E-mail address: [email protected] (L. Wang). 0033-3506/$ e see front matter ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2012.12.017
p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 9 4 6 e9 5 1
Introduction Job satisfaction can be defined as a global feeling that an individual has about his/her job,1 which has been studied in various professional fields.2 The job satisfaction of doctors, who are a particular occupational population, has gained increasing attention in recent years as it is not only associated with doctors’ burnout,3,4 mental health,3,5 and turnover intention,6e8 but also with the health outcomes of patients9 and the quality of health care in general. Although there are a number of research studies about job satisfaction, most have concentrated on the effects of demographic characteristics, work conditions and negative feelings10e12 on job satisfaction. However, the more positive aspects of psychological capital (PsyCap) and perceived organizational support (POS) have now become a growing research topic aimed at improving the level of job satisfaction. Based on both conceptual and empirical evidence, Luthans put forward the core construct of PsyCap and defined it as ‘an individual’s positive psychological state of development that is characterized by self-efficacy, optimism, hope and resiliency’.13 Although it has not been long since the composite higher-order concept of PsyCap was described there is evidence that PsyCap is positively related to job satisfaction.14,15 According to organizational support theorists, POS refers to employees’ general belief concerning the extent to which the organization values their contributions and cares about their well-being.16 As an organizational-based resource, it also can be seen as ‘assurance that aid will be available from the organization when it is needed to carry out one’s job effectively and to deal with stressful situations’.17 Although there were relatively few studies on POS until the mid 1990’s, research on POS has grown rapidly in the last few years. A meta-analysis of the relationship between POS and job outcomes indicated that POS has a strong, positive effect on employees’ work attitude, such as job satisfaction.18 With the huge population in China, the ratio of doctors to the general population is 1:735, which is lower than that in western countries (1:280e1:640).19 Thus, Chinese doctors have to deal with many more patients and take greater responsibility for critical decisions and therapeutic outcomes on a daily basis. It is reported that Chinese doctors experience extra shifts quite often20 and 57.5% of them work more than 40 h per week. A nationwide investigation by the Chinese Medical Doctor Association in 2009 indicated that 39.5% of Chinese doctors are not satisfied with their work environment.21 What is more, as China’s health care used to be described as too difficult to access, too expensive, and too variable in quality,22 China has started a major reform of health care to change the situation. Alongside the continuing health care reform and increasing health consciousness, the work life-style of Chinese doctors has changed immensely in recent years. All these mean that Chinese doctors are exposed to both heavy physical and psychological burdens which may lead them to be easily dissatisfied. Overall, we hypothesized that Chinese doctors would enjoy a low level of job satisfaction. However, few studies of job satisfaction were directed towards Chinese doctors. Therefore, the purpose of this study was to assess the level of job
947
satisfaction among Chinese doctors, and to explore positive effects of PsyCap and POS in improving their job satisfaction.
Methods Sampling and data collection A cross-sectional survey was conducted during September/ October 2010 in Liaoning province, northeast of China. As a heavy industrial base in China, the average income in Liaoning province is close to the national average. Furthermore, according to the statistics provided by China Yearbook, the proportion of doctors in the health workforce (34.5%)in Liaoning province is almost in the same level as the whole country’s (35.4%). For each of geographic regions of Liaoning province (eastern, western, southern, northern and central), we randomly selected one city. One large general hospital (>500 beds) was randomly selected in each sampled city, and one more large general hospital was randomly selected if the sampled city was a megalopolis (1,000,000 population). As the central city is a megalopolis, a total of six large general hospitals were finally sampled from the selected cities, and half of the doctors were randomly sampled from each selected hospital. After obtaining consent, a selfadministered anonymous questionnaire was distributed to 1300 eligible doctors. Finally, we received effective responses from 984 doctors (effective response rate: 75.7%). These doctors formed the final study sample.
Measurement of job satisfaction Job satisfaction was measured with the Minnesota Satisfaction Questionnaire (MSQ),23 which has been widely used in the Chinese population.24,25 The 20-item short form MSQ used a 5-point Likert-type scale ranging from 1 (very dissatisfied) to 5 (very satisfied). The short form of the MSQ can be seen as a composite of a number of job facets. Scores are created by summing items so as to show each participant’s satisfaction level ranging from 20 to 100. A score of 60 would indicate moderate, a score ranging from 61 to 79 would indicate ‘moderate to not fully satisfied’ and a score of 80 and above would indicate satisfied.26 The Cronbach’s alpha was 0.95 in this study.
Demographic characteristics Demographic characteristics included gender, age (<30, 30e40, >40), marital status and educational background. ‘Marital status’ was categorized as ‘married/cohabitation’ and ‘single/divorced/separated/widowed’. There are three levels of Chinese medical colleges: junior college course, undergraduate course, and graduate course. Therefore, ‘education’ was divided into ‘junior college course’ group, ‘undergraduate course’ group, and ‘graduate course’ group.19
Work conditions Work situations were assessed by three items: (1) job rank; (2) doctorepatient relationship and (3) incentive system. ‘Job
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rank’ was categorized as ‘basic doctor’ (the ordinary doctor of the department) and ‘head doctor’ (the chief of the department) by asking the question, ‘Are you a basic doctor or a head doctor?’ ‘Doctorepatient relationship’ was measured by asking the question, ‘How often have you felt bothered by patients at work?’ It was defined as ‘general degree’ if the doctors answered ‘never’, ‘rarely’, or ‘sometimes’, and as ‘serious degree’ if they answered ‘frequently’ or ‘always’.27 ‘Incentive system’ was worded ‘Are you satisfied with the hospital’s incentive system? with the answers (Not satisfied/Neither/ Satisfied)’.
Measurement of psychological capital The measurement of PsyCap was the psychological capital questionnaire (PCQ) which was developed by Luthans et al.13 The reliability and validity of PCQ have been demonstrated adequately in both foreign and Chinese populations.14,15,28 It used a six-point Likert-type scale with categories ranging from 1 (strongly disagree) to 6 (strongly agree). All responses for 24 questions were summed and averaged to get an average score as the indicator for total PsyCap. The Cronbach’s alpha was 0.91 in this study.
Measurement of perceived organizational support POS was examined via a shortened version of the Survey of Perceived Organizational Support,16 which has been used in both foreign and Chinese researches.29,30 It includes nine items with the highest factor loadings of the 36 items. Each item had seven response categories ranging from 1 ¼ strongly agree to 7 ¼ strongly disagree to indicate the extent of the respondents’ agreement with each statement. The Cronbach’s alpha was 0.89 in this study.
Statistical analysis The dimensions of job satisfaction by demographic characteristics and work conditions were tested by student t-test and one-way ANOVA. Correlations among MSQ, PsyCap and PCQ were done by Pearson correlation. Hierarchical regression analysis was used to estimate the association of job satisfaction with demographic characteristic, work conditions, PsyCap and POS. All data analysis were performed by SPSS for Windows, Ver. 17.0, and a two-tailed probability value of <0.05 was considered to be statistically significant.
Table 1 e Characteristics of the subjects and univariate analysis for the factors related to job satisfaction. Number of subjects n(%) MSQ Demographic characteristics Gender Male Female Age (years) <30 30e 40e Marital status Single/widow/divorced/ separated Married/cohabitation Educational background Junior college course Undergraduate course Graduate course Work conditions Job rank Basic doctor Head doctor Doctorepatient relationship General degree Serious degree Incentive satisfaction Not satisfied Neither Satisfied
Mean SD
P-value
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65.86 12.83
437(44.4) 547(55.6)
65.43 13.24 66.69 12.36
0.133
292(29.7) 385(39.1) 307(31.2)
66.47 11.99 64.51 12.45 67.25 13.86
0.017
258(26.2)
67.40 11.40
0.077
726(73.8)
65.71 13.13
99(10.0) 572(58.1) 313(31.8)
65.77 12.95 65.26 12.47 67.49 13.13
0.055
874(88.8) 110(11.2)
65.47 12.14 69.88 15.59
0.007
458(46.5) 526(53.5)
68.79 12.72 63.64 12.23
<0.001
543(55.2) 314(31.9) 127 (12.9)
63.00 12.96 67.61 10.18 75.25 12.75
<0.001
The results of the hierarchical regression analysis of the main factors associated with job satisfaction are shown in Table 2. In the first step, demographic factors accounted for a small portion of the variance (DR2 ¼ 1.8%); in the second step, work conditions explain an additional 11.2% of the variance; in the third step, PsyCap accounted for 15.6% of the variance; in the final step, POS made up an additional 12.5% of the variance. Totally, all the predictors explained 41.1% of the variance in job satisfaction. Educational background, incentive system, PsyCap and POS were positively associated with job satisfaction.
Discussion Results
Main findings
Table 1 shows the characteristics of the study subjects. The average age was 36.15, SD 8.18 years. The mean MSQ score was 65.86, SD 12.83. The results of univariate analysis of MSQ in relation to the categorical variables are also shown in Table 1. Age, job rank, doctorepatient relationship and incentive system were significantly related to job satisfaction, while gender, marital status and educational background were not significantly related to it. Both PsyCap (r ¼ 0.432) and POS (r ¼ 0.571) were positively correlated with MSQ in our study population.
In the present study, the effective response rates of selected hospitals ranged from 71.1% to 76.2% which was very close to the overall response rate (75.7%). The result of this study showed that Chinese doctors enjoyed a moderate level of job satisfaction, which is lower than Turkish doctors31 (total score: 70.1), New England nurses26 (total score: 77.6), Chinese community health workers (total score: 68.2)24 and Chinese nurses32 (total score>68.8). The comparative results indicated Chinese doctors are not very satisfied with their job.
p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 9 4 6 e9 5 1
Table 2 e Hierarchical regression analysis for exploring associated factors of job satisfaction. Variables Model 1: Educational background Age (years) Marital status Model 2: Incentive system Doctorepatient relationship Educational background Marital status Model 3: PsyCap Incentive system Doctorepatient relationship Model 4: POS PsyCap Incentive system Educational background
R2
R2-changes
0.018
0.018
F
Beta
3.893** 0.095** 0.086* 0.083*
0.130
0.112
17.739*** 0.260*** 0.152*** 0.091** 0.081*
0.286
0.156
41.616*** 0.409*** 0.227*** 0.069*
0.411
0.125
64.218*** 0.412*** 0.255*** 0.119*** 0.056*
*P < 0.05, **P < 0.01, ***P < 0.001. POS, perceived organizational support; PsyCap, psychological capital. Note: Educational background (1 ¼ junior college course and under, 2 ¼ undergraduate course, 3 ¼ graduate course), marital status (1 ¼ single/widow/divorced/separated, 2 ¼ married/cohabitation), incentive system (1 ¼ not satisfied, 2 ¼ neither, 3 ¼ satisfied), doctorepatient relationship (1 ¼ general degree, 2 ¼ serious degree).
According to the hierarchical regression results, POS was positively associated with job satisfaction in our study, which is consistent with previous studies.33,34 PsyCap was found to be a positive predictor of job satisfaction in line with in previous studies.14,15 With respect to work conditions and demographic characteristics, a better incentive system and higher educational background were also positive effect factors of doctors’ job satisfaction, which is similar to the previous studies.35e37
Interpretation of the findings and policy implications Our subjects were sampled from large general hospitals (>500 beds) in every geographic region in Liaoning province and the effective response rates of selected hospitals were all greater than 70%, that has been a level reported to be normal and reasonable for a questionnaire survey.38 This provides a good representation of our study population and increases the generability of our study’s conclusions. China’s huge population accounts for more than one fifth of the world’s population. Consequently, the ratio of doctors to the general population is lower than that in other counties. In addition, China’s health care reform is a double-edged sword. On the one hand, it offers great opportunities for improvements in healthcare access, basic health infrastructure,
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and high-quality health services; on the other hand, it brings immense changes of doctors’ work life-style. The burdens of Chinese doctors are greater than in other countries, which may lead them to be easily dissatisfied. Therefore, it is very important to improve Chinese doctors’ job satisfaction through its positive influence factors. POS was the strongest predictor of job satisfaction with the largest regression coefficient in our study. Social exchange theories indicates that if both the employee and the employer apply the reciprocity norm to their relationship, favourable treatment received by either party would lead to satisfied outcomes for both. Moreover, as a perception of the organization, POS can be influenced by a cluster of organizational factors. Thus, favourable treatment, such as meeting socioemotional needs, increasing performance-reward expectancies and providing the availability of aid when needed,39 would make doctors perceive more support in their work environment, which, in turn, would improve the level of their job satisfaction. PsyCap was a positive and potent predictor of job satisfaction in our study. Higher-order PsyCap includes four components: hope; efficacy; optimism; and resiliency. In other words, doctors with higher levels of PsyCap might be stronger willed and have more viable means to accomplish specific tasks or goals, be more confident about their abilities to successfully execute a challenging task and have more positive coping responses in the face of significant adverse or stressful situations. With this positive capital, the doctors are more likely to be satisfied with their job. As a derivative of POB, PsyCap is a positively oriented human resource strength and relatively malleable, and is open to development. Therefore, it could be an efficient approach to promote doctors’ job satisfaction by developing their PsyCap. One approach that can be considered is to arrange focus group discussions of doctors and managers. These meetings could usefully explore fiscal and manpower constraints associated with service delivery issues and that arise under headings such as doctor and manager wishes, needs, expectations and requirements. Reasonable incentive systems, such as rational bonuses, subsidies, insurances, vacations and so forth, are helpful to increase doctors’ initiatives and improve their job satisfaction. The nature of the doctor and the circumstance of China’s medical system usually lead to overtime work and over fatigue. Therefore, it is very necessary to establish some financial incentives for the extra hours and some constraints on overtime. Chinese doctors begin their medical education (dividing into two levels: junior college for three years and undergraduate course for five years) directly after they graduate from high school. Doctors who graduate from junior college can take further course (for two years) to get a bachelor degree, or they become a licensed assistant doctor firstly, and then experience years of medical practice to obtain a doctor’s license. Whereas, doctors who take the undergraduate course are able to obtain a bachelor degree and a doctor’s license directly after they graduate. Doctors with higher educational level are more likely to get a higher income and a better prospect. Therefore, providing further education and opportunities to do work within their abilities for lower educated doctors would increase their attainment and thus be helpful to improve their job satisfaction.
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Limitations of this study Firstly, as our study is a cross-sectional design, it is impossible to draw causal relations between job satisfaction and its related factors. To confirm the conclusions obtained in this study, longitudinal study should be conducted in the future. Secondly, participants in this study were limited to large general hospitals, where working conditions might be different from the other smaller-scale hospitals. Therefore, the small general hospitals and community health centres should be studied in future research to improve the representation of our study conclusions.
Acknowledgements The authors would like to thank Professor Eisenberger and Professor Chaoping Li for providing the details of the questionnaires, and the authors also wish to thank all the administrators in every selected hospital who helped to get the written informed consent about the conduct of this survey and to distribute the questionnaires to the subjects.
Ethical approval The procedures followed were in accordance with the ethical standards of the Committee on Human Experimentation of China Medical University.
Funding None declared.
Competing interests None declared.
references
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