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Surgeons' work engagement: Influencing factors and relations to job and life satisfaction
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Surgeons’ work engagement: Influencing factors and relations to job and life satisfaction Stefanie Mache a,b,c,*, Karin Vitzthum a, Burghard F. Klapp b, Gerhard Danzer b a
Institute of Occupational Medicine, Charite´ e Universita¨tsmedizin Berlin, Free University and Humboldt University, Thielallee 69-73, 14195 Berlin, Germany b Charite´ Center for Internal Medicine and Dermatology, Division of General Internal and Psychosomatic Medicine e Charite´-Universita¨tsmedizin Berlin, Campus Mitte, Berlin, Germany c Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
article info
abstract
Article history:
Background: Work engagement has become a topic of great interest in recent years. How-
Received 7 October 2013
ever, clinicians’ work engagement has rarely been studied and relatively little is known
Accepted 2 November 2013
about its predictors and consequences. Therefore the objective of this cross-sectional
Available online xxx
questionnaire study was to test a model of possible institutional and personal predictors and significant relations to job and life satisfaction.
Keywords:
Methods: 123 clinicians specializing in Surgery Medicine participated in the study. Self-
Institutional characteristics
administered questionnaires, including the Copenhagen Psychosocial Questionnaire, the
Job satisfaction
Utrecht Work Engagement Scale, the Brief Resilient Coping Scale and the Questionnaire for
Personal factors
Self-efficacy, Optimism and Pessimism, were administered. Bivariate analyses and a
Quality of life
stepwise regression analysis were performed.
Work engagement
Results: The whole sample of surgeons rated work engagement with a high mean of M ¼ 4.38; SD ¼ .91. Job satisfaction and perceived quality of life have been rated with moderate scores. The results show that job resources have a greater impact on surgeons’ work engagement than their job demands. Significant correlations between surgeons’ work engagement, their job satisfaction and quality of life were found. Moreover, work engagement mediated the relation between institutional factors and surgeons’ job satisfaction. Conclusion: Our research suggests that strengthening surgeons’ work engagement will contribute to a more sustainable workplace, in terms of both individual and hospital performance. Therefore, increasing work engagement among surgeons should be of concern for supervisors and hospital managers. Future research should focus on further predictors that may have an influence on health professionals’ work engagement. Another field for future research is to study potential effects of interventions on work engagement. ª 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Institute of Occupational Medicine, Charite´ e Universita¨tsmedizin Berlin, Humboldt Universita¨t zu Berlin und Freie Universita¨t Berlin, Thielallee 69-73, 14195 Berlin, Germany. Tel.: þ49 030 450529596; fax: þ49 030 450529952. E-mail address: [email protected] (S. Mache). 1479-666X/$ e see front matter ª 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.surge.2013.11.015
Please cite this article in press as: Mache S, et al., Surgeons’ work engagement: Influencing factors and relations to job and life satisfaction, The Surgeon (2013), http://dx.doi.org/10.1016/j.surge.2013.11.015
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Introduction During the last decade the German healthcare system has changed into a more dynamic and challenging system.1e3 Due to rising costs of healthcare, an aging population, accelerating progress in the development of medical technology, and greater public awareness for better quality of healthcare, pressures and demands on German clinicians have increased.4e6 The most affected are those ones who are asked to deal with increased demands for efficiency, cost awareness and improved healthcare quality.7,8 Research studies on Surgery demonstrated that the quality of medical treatment and care are closely related to the ability of clinics to guarantee medical services at the required professional standard. Surgeons play an important role for representing the hospitals’ competence. Their behaviors towards patients have significant influences upon patients’ satisfaction with care and treatment quality.9e11 Therefore, hospitals need highly competent physicians who are willing to work efficiently towards institutional goals.12 Due to the current organizational changes in hospitals with increases of job demands and job pressure13e15 surgeons are forced to enhance or build additional inner strengths in the form of psychological and organizational resources in order to keep able to cope with challenging and potentially distressing job tasks. Without these resources surgeons may develop negative health outcomes (i.e. stress related diseases, burnout).16 However, there are still surgeons who can be characterized by showing work engagement and job satisfaction even if their working situation impresses to be dissatisfying for an outstanding observer. The question is: why remain some surgeons highly motivated and work engaged despite such work conditions and others do not? Motivational concepts such as work engagement have not been studied sufficiently although discussed as important aspects for productivity and job performance.17,18 In consequence, there is a need to identify positive and motivating predictors for work outcomes such as job performance, especially for the health care services.
The aim of the current study among German surgeons was to examine whether work engagement, as a motivational concept, is associated with surgeons job satisfaction and perceived quality of work life, after adjusting for age, personal and work-related factors. In addition we aim to analyze on which and how surgeons’ job demands and resources operate as predictors of their work engagement. The hypothetical model this study is based on is depicted in Fig. 1.
Defining work engagement Work engagement is defined as a positive, fulfilling, workrelated state of mind that is characterized by vigor, dedication, and absorption.19,20 Engagement refers to a persistent and pervasive affectiveecognitive state that is not focused on any particular object, event, individual, or behavior. Vigor refers to high levels of energy and mental resilience while working. The working person feels high levels of energy and willingness to invest in work. Dedication is defined as feelings of enthusiasm, pride and inspiration about work. Absorption means being so fascinated, fully concentrated and engrossed in work that time passes very quickly and nothing else matters.17,19,21 Several studies investigated relations between different factors of work engagement.22 All of these studies illustrate that an employee with high work engagement shows better job outcomes: for instance, Halbesleben et al. and Hakanen et al. demonstrated that work engagement increases concentration on job tasks, job performance and institutional commitment.23,24 Furthermore, work engagement is related to organizational variables such as job satisfaction and turnover intentions.25e28 During the last decade, awareness on work engagement in the health sector has also grown. Health care professionals’ work engagement has become an increasingly important factor and a precondition for high-quality health care performance.29,30 For instance, Van Bogaert and colleagues examined relationships between practice environment ratings, workload, work engagement, job outcomes and
Fig. 1 e Research model. Please cite this article in press as: Mache S, et al., Surgeons’ work engagement: Influencing factors and relations to job and life satisfaction, The Surgeon (2013), http://dx.doi.org/10.1016/j.surge.2013.11.015
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assessments of quality of care in psychiatric hospitals.31 The findings showed that work environment factors positively influenced staff vigor, dedication, job satisfaction, and perceived quality of care.31
Predictors of work engagement The predictors of work engagement can be approached from the viewpoint of occupational psychology models. Our study is based on the theoretical assumptions of the Job DemandResources (JD-R) model developed by Demerouti et al. (2001).32 This model provides the basic assumption that the characteristics of employees’ work environments can usually be divided into two categories: job demands and job resources.33 Job demands are defined as ‘the degree to which the environment contains stimuli that peremptorily require attention and response.34 More specifically, job demands are those physical, psychological, social, or organizational aspects of the job that require sustained physical and/or psychological (i.e., cognitive or emotional) effort and are therefore associated with certain physiological and/or psychological costs. Job demands are not necessarily negative, but they may turn into job related stressors. Meeting those demands requires high effort and is therefore associated with high individual physiological and psychosocial costs that may elicit negative responses such as emotional exhaustion, frustration or symptoms of depression.20 In contrast, job resources refer to those physical, psychological, social, or institutional aspects of the job that either/or (1) reduce job demands and the associated physiological and psychosocial costs; (2) are functional in achieving work goals; (3) stimulate personal growth, learning and development. Job resources can include performance feedback, social support from colleagues and supervisory coaching. The Job DemandResources (JD-R) model also proposes that job demands (i.e., physical demands, time pressure) can be associated with exhaustion, whereas lacking job resources (i.e., job control, participation in decision making, social support) can be associated with disengagement.35 The JD-R model assumes two processes: (1) an energetic process of overtaxing and wearing out in which high job demands exhaust the employee’s energy backup; (2) a motivational process in which lacking recourses preclude dealing effectively with high job demands and foster mental withdrawal or disengagement.20 As stated in previous studies, the dimensions of work engagement share some conceptional similarities with motivational concepts. In line, work engagement could be seen as a motivational based reaction caused by the job characteristics.36 As results, we expect: Hypothesis 1: Surgeons’ job demands are negatively associated with their work engagement. Hypothesis 2: Surgeons’ job resources are positively related to their work engagement. Hypothesis 3: Job resources are stronger predictors of work engagement than job demands. In addition, personal resources such as resilience, selfefficacy and optimism have been demonstrated as having essential influence on employees’ well-being and their ability to cope with work related stress factors. Empirical studies have shown that personal resources such as self-efficacy and
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institutionally-modulated self-esteem are related to work engagement.37,38 Personal resources include positive selfevaluations that refer to individuals’ sense of their ability to control and impact their environment successfully.39 They are functional in achieving goals, stimulate personal development and can help to protect from threats. In addition, they have been found to relate to job satisfaction.40 In the concept of ‘psychological capital’ developed by Luthans et al.41 optimism, self-efficacy and resilience are also taken into account.41 Self-efficacy refers to individuals’ perception of their ability to meet demands in various contexts.42 A study by Salanova and colleagues found that selfefficacious employees experience higher levels of flow, a mental state of operation in which an employee-while performing an activity is fully immersed in a feeling of energized focus and enjoyment in the process of that activity.43,44 In line with these studies, investigations on optimism and self-efficacy in several work settings showed positive correlations with employees’ well-being, job performance and work ability.45e48 Resilience is defined as a “positive psychological capacity to rebound from adversity, uncertainty, conflict, failure, or even positive change”.49 Recent studies have found that people who describe themselves as resilient are more able to compete with job stress, multitasking demands and organizational changes.50e53 Bakker found that female school principals with high personal resources which include resilience, self-efficacy and optimism scored highest in work engagement.54 On the basis of this literature, we formulate the following hypothesis: Hypothesis 4: Surgeons’ personal resources relate significantly to work engagement.
Consequences of work engagement: perceptions of job satisfaction and quality of life As illustrated above, positive connections have been analyzed between employees’ work engagement and organizational performance.55 Along these lines, there are a number of reasons to expect that employees’ work engagement is related to individual behavior, intentions and attitudes as well as to institutional outcomes (e.g. productivity). As noted by Schaufeli et al. and Sonnentag, employees with high work engagement likely show a greater attachment to their organization, lower turnover intentions and a positive work affect.20,56 Salanova et al. (2005) found a strong relationship between work engagement and job performance.36 Previous studies have indicated poor work engagement to be related with reduced productivity at work,57 increased sickness absence,58,59 and early retirement.60 However, associations between work engagement and other outcome factors such as quality of life and/or job satisfaction have not been studied intensively. In conclusion, we predict that work engagement will be related to outcomes as follows: Hypothesis 5: Surgeons’ perceived job satisfaction is positively related to their work engagement. Hypothesis 6: Surgeons’ perception of quality of life is positively related to their work engagement. Finally, given that work engagement is predicted by the included variables as expected and work engagement itself
Please cite this article in press as: Mache S, et al., Surgeons’ work engagement: Influencing factors and relations to job and life satisfaction, The Surgeon (2013), http://dx.doi.org/10.1016/j.surge.2013.11.015
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predicts such consequences like job satisfaction, we assume that work engagement mediates associations between the variables and the consequences (see Fig. 2). Therefore, our final hypothesis is the following: Hypothesis 7: Work engagement mediates associations between the included institutional/personal variables and the consequences.
Methods Study design and setting We designed the study as a cross-sectional questionnaire evaluation. Data collection took place between 2009 and 2011 in hospital departments for Surgery in German Hospitals. The hospitals were chosen because of their similarities in specific care profile and in size (number of inpatient beds). Hospital departments were comparable in size, number of patients/ beds as far as employed medical staff (e.g. residents, juniordoctors, nurses).
Data collection In the beginning, we informed the clinic management and surgeons’ supervisors about our study for inclusion. After getting their agreement we asked surgeons working in the included hospitals for their participation in our voluntary study. Only clinical doctors who worked full-time and had at least one year of work experience in hospitals were included. Self-administered surveys were sent to the participating surgeons. A box was placed at each hospital department, questionnaires could be returned there. Reminders were sent by email after three weeks to increase the response rate. At the end, we received 123 questionnaires from contacted physicians (response rate of 63%).
Instruments Work engagement Work engagement has been evaluated by using the Utrecht Work Engagement Scale (UWES), which is a self-report questionnaire and consists of three subscales vigor, dedication, and absorption (in total 9 items).19,61 The questionnaire works with a 7-point Likert scale ranging from 0 (strongly disagree) to 6 (strongly agree). Items were summed and divided by the number of items in each (sub)scale. The higher each item was rated the higher the overall work engagement. Previous studies illustrated reference values: participants with a score 4.67 on the sum scale were considered as highly engaged,62 those who scored vigor with 4.81 as very vigorous, those with a dedication score of 4.91 as highly Predictors Job demands Job resources Personal resources
Work engagement Vigor Dedication Absorption
Consequences Job satisfaction Quality of life
Fig. 2 e A model of predictors and outcomes of work engagement.
dedicated. Scores 4.41 mean high absorption.62 Validity and reliability were proved and verified.19
Institutional resources The German version of the Copenhagen Psychosocial Questionnaire (COPSOQ) was used to evaluate job-related and psychosocial factors at work.63,64 The questionnaire includes 12 subscales measuring i.e., job demands (e.g. emotional and quantitative demands), job resources (i.e., quality of leadership, opportunities for development, social support), job satisfaction and quality of life. Items are scored on a Likert scale and transformed to a scale ranging from 0 (minimum value, e.g., “do not agree at all”) to 100 points (maximum value, e.g., “fully agree”). Previous investigations proved quality criteria of the COPSOQ.64 We also verified them: Cronbach’s alpha coefficients ranged between a ¼ .70 to a ¼ .81.
Variables Table 2 illustrates all included dimensions of the questionnaire set. We included institutional factors (e.g. job resources) as independent variables. Work engagement was the dependent outcome variable; subscales are vigor, dedication and absorption. Quality of life and job satisfaction were chosen as further dependent variables. Since physicians’ socio-demographic characteristics are expected to have an effect on their ratings; we controlled for gender, age, marital status, presence of children, years of work experience at the time of the study.
Statistical analysis Descriptive analysis (evaluation of medians and standard deviations (SD) were performed in the beginning of our analysis. The category “does not apply” and item non-response were coded as missing values. We proved whether the variables were normally distributed as a precondition for the correlation and regression analyses. Parametric and nonparametric tests were performed using the Pearson’s r or Spearman’s rho to examine correlations between variables. We performed stepwise multiple regression analyses to explore personal and institutional predictors of work engagement. Data collected on age, gender, number of years in training, presence of children and marital status were used as covariates. P-values of less than .05 were considered significant, all pvalues given were two-tailed.65 Data were calculated using the SPSS software package for social sciences; Version 18.0.
Ethical considerations Ethical approval was granted by the Humboldt University Berlin and the Free University ethic committees.
Results Characterization of the study sample Socio-demographic characteristics are given in Table 1. A total of 61% of the respondents were female physicians, 39% male.
Please cite this article in press as: Mache S, et al., Surgeons’ work engagement: Influencing factors and relations to job and life satisfaction, The Surgeon (2013), http://dx.doi.org/10.1016/j.surge.2013.11.015
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Table 1 e Demographic characteristics of the surgeons (n [ 123). N Gender Female Male Age <25 26e30 31e35 36e40 41e45 46e50 >50 Marital status Single Married/Partnership Children Child/children Without children
Table 2 e Studied dimensions of the questionnaire-set: Basic values of independent and dependent variables. %
75 48
61 39
0 35 26 22 16 13 11
0 28 21 18 13 11 9
46 77
37 63
37 86
30 70
Mean age was 32 years (SD ¼ 5.5 years). Years of work experience was rated with a mean score of 6 years (SD ¼ 5 years). Of the participants, 63% were married or lived in a partnership and 30% had children.
Key values for the dimensions under investigation Table 2 presents the means and standard deviations of the study variables. Work engagement was rated as follows: by the whole sample the sum score was scored high with a mean of M ¼ 4.38; SD ¼ .91, the subscale ‘Dedication’ scored highest with M ¼ 4.51; SD ¼ .85, ’Vigor’ showed an average score of M ¼ 4.12; SD ¼ .88. The subscale ’Absorption’ was scored with M ¼ 3.98, SD ¼ .94.
Institutional and personal factors: correlations with surgeons’ work engagement Table 3 illustrates all correlations between work engagement, its sub-dimensions and the included variables. Positive associations were found between work engagement and personal characteristics, which are supposed to be resources. So, we found correlations of work engagement (sum score) with surgeons’ resilient coping values (r ¼ .33; p ¼ .01), similarly with self-efficacy (r ¼ .32; p ¼ .02) or optimism (r ¼ .33; p ¼ .01) or negatively directed with pessimism (r ¼ .22; p ¼ .02). Correlations between institutional factors and work engagement (sum score and sub-dimensions) were revealed for almost all job resources significantly and positively in the range of r ¼ .20 to r ¼ .41. In contrast, job demands were negatively related (range: r ¼ .10 e r ¼ .36) (see Table 3).
Work engagement predicting personal and institutional factors At first, the sum score was set as the dependent variable in the hierarchical regression analysis. In step one, the sociodemographic variables gender, age, marital status, presence of children and years of experience were statistically controlled
Dimensions Job demands Quantitative demands Emotional demands Cognitive demands Demands for hiding emotions Job resources Possibilities for development Influence at work Degree of freedom at work Social relationships Sense of community Feedback Quality of leadership Personal factors Self-efficacy Optimism Pessimism Resilience Work engagement Vigor Dedication Absorption Job satisfaction Quality of life
M
SD
75.51 61.87 63.54 53.29
13.23 12.97 11.58 12.85
67.91 48.89 47.58 65.29 59.26 33.52 50.23
13.58 12.58 14.28 13.15 14.52 14.71 15.23
3.23 3.57 1.82 3.91 4.38 4.12 4.51 3.98 51.25 65.94
.71 .67 .79 .81 .91 .88 .85 .94 .17 .19
(see Table 4). By step two, the included personal resources accounted for an additional 16% of the variance (the R2 increased to .20). Self-efficacy was found to predict work engagement (ß ¼ .17, p < .01) in a positive sense, so did resilient coping (ß ¼ .19, p < .01) and optimism (ß ¼ .12; p < .01). The third step included the job demands: quantitative job demands showed a negative beta weight of (ß ¼ .19 p < .01). In step 4 e the four now included job resources revealed significantly positive beta weights: ‘influence at work’ ß ¼ .20, p < .01,‘possibilities for development’ ß ¼ .23, p < .01; ‘quality of leadership’ ß ¼ .18, p < .01; ‘sense of community’ ß ¼ .19, p < .01. The included job demands and job resources accounted for an additional 34% of variance (step 3 and 4), so the final model explained 54% of the variance. Further, we performed a stepwise multiple linear regression analysis to analyze institutional predictors for work engagement, using the three sub-dimensions of work engagement as dependent variables and the institutional factors as antecedents. As Table 4 indicates, job resources were, generally the best predictors of the three sub-dimensions of work engagement and seem to foster work engagement as the strongest predictors, this holds true specifically for ‘Possibilities for development’ and ‘Influence at work’. In all, the dimensions of vigor and dedication were better predicted than absorption. Job demands had generally slightly less predictive power than job resources on work engagement (explained variance being 09e12% for demands vs. 18e22% for resources). All these results provide support for Hypotheses 1, 2, 3 and 4.
Possibly mediated effects of work engagement in defined working circumstances As illustrated in Table 2 surgeons rated their job satisfaction and quality of life with moderate scores (JS: M ¼ 51.25,
Please cite this article in press as: Mache S, et al., Surgeons’ work engagement: Influencing factors and relations to job and life satisfaction, The Surgeon (2013), http://dx.doi.org/10.1016/j.surge.2013.11.015
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Table 3 e Bivariate correlations of work engagement and its subscales with a) job demands and resources, b) personal factors, c) job satisfaction, and d) quality of life. Dimensions Job demands Quantitative demands Emotional demands Cognitive demands Job resources Possibilities for development Influence at work Degree of freedom at work Sense of community Social support Feedback Quality of leadership Personal factors Self-efficacy Optimism Pessimism Resilience Job satisfaction Quality of life
Vigor (subscale)
Dedication (subscale)
Absorption (subscale)
Work engagement (sum scale)
.36** .14 .13
.33** .16 .12
.29* .10 .10
.35** .15 .12
.38** .34** .30** .25* .30** .25** .30**
.41** .38** .32** .25* .37** .34** .32**
.34** .37** .33** .23* .34** .20* .32**
.36** .33** .32** .22* .34** .23* .31**
.29** .30** .26* .35** .46** .30**
.33** .34** .23* .34** .45** .28**
.30** .30** .17 .28** .41** .26**
.32** .33** .22* .33** .48** .31**
Notes: Pearson’s r. p < .05; **p < .01.
SD ¼ .17; QOL: M ¼ 65.94, SD ¼ .19). To test the hypotheses for the possibly mediated effects of surgeons’ work engagement, regression analyses were conducted in which each of the outcomes (job satisfaction or quality of life) was regressed on work engagement. As shown in Tables 5 and 6, work engagement correlated significantly with the levels of job satisfaction (r ¼ 53; p < .001) or quality of life (r ¼ .34; p < .01). These results provide support for Hypothesis 5 and 6.
Mediating effects of work engagement In order to test for a mediation model in which work engagement mediates the relationship between the institutional variables and job satisfaction as well as quality of life an additional linear regression analysis was conducted in which job satisfaction or quality of life were regressed on these predictors alone and then again with the work engagement measure controlled (as an independent variable). First, we analyzed correlations between the independent variables (job demands, resources and work engagement) and dependent variables (job and life satisfaction). As indicated in Tables 5 and 6, the significant negative relations between job demands and job satisfaction as well as quality of life were retained (Model 2 compared to 1). However, the significant correlations between job resources and job satisfaction as well as quality of life were reduced (b-coefficients decreased in Model 2 compared to Model 1). This indicates that surgeons’ work engagement mediates the effects of their job resources but not their job demands on job satisfaction or quality of life. So, Hypothesis 7 is only partially supported, regarding job demands is has to be rejected.
Discussion There has been much interest in employees’ work engagement in recent years. Although much has been investigated about the importance of work engagement for institutional performance and business results, there is little empirical evidence on health professionals’ work engagement and its impact. Therefore, the primary aim of this article was to test a model of the predictors and possible mediators of work engagement in a sample of surgeons working in German hospitals. First, we found our sample of German surgeons reporting to be moderately engaged with their work and that work engagement was associated with institutional and personal factors. Secondly, in line with the hypotheses 1e4, this study found that a number of factors predict surgeons’ work engagement and that job resources are of greater importance for work engagement than job demands. Our findings showed that physicians who rated high for having ‘influence at work’, ‘opportunities for development’ and ‘quality of leadership’ also scored high values for work engagement. These results are in line with several other researchers demonstrating the importance of job resources for work engagement and job motivation.19,66e68 In addition, this study showed that social support and sense of community at work were associated with greater work engagement. One can conclude that their presence or perceiving in the workplace mediates the impact of stressors and decreases job demand perceptions.68 This result suggests that the institution should provide opportunities for teamwork and for promoting a sense of community among surgeons and the other staff members.69 As a consequence, employees’ work engagement and job satisfaction may increase.
Please cite this article in press as: Mache S, et al., Surgeons’ work engagement: Influencing factors and relations to job and life satisfaction, The Surgeon (2013), http://dx.doi.org/10.1016/j.surge.2013.11.015
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Table 4 e Predictors for sub-dimensions of work engagement. Predictors
Vigor ß
Dedication ß
Absorption ß
Work engagement (sum scale) ß
Step 1 Demographic variables Age Gender Marital status Children Years of experience DR2
.10 .12* .04 .08* .09 .03
.07 .09* .06 .06 .14* .05
.09* .10* .07 .03 .11* .05
.10* .08* .06 .05 .13* .04
Step 2 Personal resources Resilience Optimism Pessimism Self-efficacy DR2
.19** .09* .08* .16** .15
.15** .11* .06 .18** .17
.11* .13* .04 .16** .12
.19** .12* .06 .17** .16
Step 3 Job demands Quantitative demands DR2
.16** .10
.18** .12
.14** .09
.19** .14
Step 4 Job resources Influence at work Possibilities for development Degree of freedom at work Sense of community Feedback Quality of leadership Social support DR2
.23** .25** .18** .15** .11* .20 .13* .22
.19** .21** .15** .17** .07 18** .11* .19
.14** .17** .10* .20** .13* .11* .18** .18
.20** .23** .12* .19** .09* .18** .15* .20
Total R2
.50
.53
.44
.54
Third, our results indicate that work engagement is related to surgeons’ attitudes and behaviors, so supporting the hypotheses 5 and 6. In particular, the results indicate that increased work engagement will have a positive impact on surgeons’ job satisfaction and quality of life. This result is important as it underlines the relevance of the concept of
work engagement for research. According to previous studies, there is reason to believe that increased work engagement will lead to positive institutional outcomes. Job satisfaction is known to be associated with core measures of work and organizational research fields, such as job performance,70 organizational commitment71 and
Table 5 e Linear regression analysis measuring relations between institutional factors, work engagement and job satisfaction.
Table 6 e Linear regression analysis measuring relations between institutional factors, work engagement and quality of work life.
Model 0a Model 1b Model 2c
Model 0a Model 1b Model 2c
Job demands Quantitative demands Job resources Possibilities for development Influence at work Degree of freedom at work Sense of community Social support Feedback Quality of leadership Work engagement (sum score) Total R
2
.41**
.20**
.43** .35** .22** .39** .18* .25** .48** .53**
.24** .11 .03 .10 .19** .08 .15
.34
.24**
Job demands Quantitative demands Job resources Possibilities for development Influence at work Degree of freedom at work Sense of community Social support Feedback Quality of leadership Work engagement (sum score)
.45
Total R2
.22** .20* .09 .03 .09 .16* .05
*p < .05; **p < .01. a Bivariate correlations. b Multiple regression analysis, standardized beta-coefficients. c Regression coefficients adjusted for the effects of work engagement included in the regression model.
.31**
.19*
.18*
.27** .21** .19* .16 .19* .13 .18* .34**
.20* .18* .11 .10 .15 .09 .07
.15 .14 .09 .06 .13 .04 .05 .19*
.19
.21
*p < .05; **p < .01. a Bivariate correlations. b Multiple regression analysis, standardized beta-coefficients. c Regression coefficients adjusted for the effects of work engagement included in the regression model.
Please cite this article in press as: Mache S, et al., Surgeons’ work engagement: Influencing factors and relations to job and life satisfaction, The Surgeon (2013), http://dx.doi.org/10.1016/j.surge.2013.11.015
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innovation.72 We therefore hold that increasing health professionals’ work engagement should be a common goal for hospital management and supervisors. Fourth, the results of this study suggest that surgeons’ work engagement has a mediating effect on the relationship between certain institutional factors and job satisfaction as well as quality of life. Several studies in different fields of work have shown that job demands and resources are associated with work engagement and job satisfaction. The mediating effects of work engagement have been documented on positive job outcome factors such as organizational commitment and customer adherence.36,73
Limitations There are a few limitations in this study. First, the most important limitation is that conclusions regarding causal relations cannot be drawn, because the cross-sectional study design limits the causality of the findings.65 Further studies including longitudinal analyses are advised to present supplementary information for our results. Second, the sample size and the number of hospitals are relatively small, and therefore the results may not be generalized, but they give good hints. In future, studies are needed with larger samples of surgeons/ physicians working in additional hospitals and different specializations. Third, another limitation is that all measures are based on self-reports, that may cause measurement bias.65
Conclusions This study confirms our hypotheses, that both the level of physicians’ work engagement as well as their job satisfaction and quality of life are related to job demands, job and personal resources. Work engagement also seems to mediate the effects of surgeons’ job resources on their job satisfaction and quality of life but not the effects of surgeons’ job demands. Our findings, in turn, have major practical implications: Hospital management and supervisors should focus on increasing their employees’ work engagement by offering emotional and instrumental support, constructive performance feedback and opportunities for individual career development. Improved work ability can be the result which is linked to low sick leaves and higher productivity for high quality medicine. To say it as a hypothesis: Surgeons having successfully been trained are supposed to show greater work engagement and job performance. In a long-term perspective, it is important to identify factors that may encourage positive working attitudes and job performance as they directly affect the quality of medical treatment and the well-being of patients. Hospital management/administration should provide more resources just enough to enable health professionals to keep and develop their work engagement further on. Until now many empirical results suggest that job and personal resources are important predictors of work engagement. Future research should integrate further concepts with presumptive influence on work engagement. In particular, flexible work arrangements and training programs might also be essential predictors for physicians’ work engagement.
Notes: ß, standardized beta-coefficients from the final step of the model. R2, explanation rate. DR2, change in explanation rate in each step. *p < .05; **p < .01.
references
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39. Hobfoll SE, Johnson RJ, Ennis N, Jackson AP. Resource loss, resource gain, and emotional outcomes among inner city women. J Pers Soc Psychol 2003;84:632e43. 40. Judge TA, Van Vianen AEM, De Pater I. Emotional stability, core self-evaluations, and job outcomes: a review of the evidence and an agenda for future research. Hum Perform 2004;17:325e46. 41. Luthans F, Avey JB, Avolio BJ, Norman SM, Combs GM. Psychological capital development: toward a microintervention. J Organ Behav 2006;27:387e93. 42. Chen G, Gully SM, Eden D. Validation of a new general selfefficacy scale. Organizational Res Methods 2001;4. 43. Nakamura J, Csikszentmihalyi M. Flow theory and research. In: Snyder CR, Lopez SJ, editors. Handbook of positive psychology. Oxford: Oxford University Press; 2009. pp. 195e206. 44. Salanova M, Bakker AB, Llorens S. Flow at work: evidence for an upward spiral of personal and organizational resources. J Happiness Stud 2006;7:1e22. 45. Lecic-Tosevski D, Vukovic O, Stepanovic J. Stress and personality. Psychiatrike 2011;22:290e7. 46. Boldor N, Bar-Dayan Y, Rosenbloom T, Shemer J, BarDayan Y. Optimism of health care workers during a disaster: a review of the literature. Emerg Health Threats J 2012;5. 47. Chang Y, Wang PC, Li HH, Liu YC. Relations among depression, self-efficacy and optimism in a sample of nurses in Taiwan. J Nurs Manag 2011;19:769e76. 48. Chang YH, Li HH, Wu CM, Wang PC. The influence of personality traits on nurses’ job satisfaction in Taiwan. Int Nurs Rev 2010;57:478e84. 49. Luthans F. The need for and meaning of positive organizational behavior. J Organ Behav 2002;23:695e706. 50. Luthans KW, Lebsack SA, Lebsack RR. Positivity in healthcare: relation of optimism to performance. J Health Organ Manag 2008;22:178e88. 51. Petree RD, Broome KM, Bennett JB. Exploring and reducing stress in young restaurant workers: results of a randomized field trial. Am J Health Promot 2012;26:217e24. 52. Zwack J, Abel C, Schweitzer J. Physicians’ resilience e salutogenetic practices and attitudes of experienced physicians. Psychother Psychosom Med Psychol 2012;61:495e502. 53. Everly Jr GS, Davy JA, Smith KJ, Lating JM, Nucifora Jr FC. A defining aspect of human resilience in the workplace: a structural modeling approach. Disaster Med Public Health Prep 2011;5:98e105. 54. Bakker AB, Gieveld JH, Van Rijswijk K. A study on burnout, work engagement and performance. Diemens: Right Management Consultants; 2006. 55. Harter JK, Schmidt FL, Hayes TL. Business-unit-level relationship between employee satisfaction, employee engagement, and business outcomes: a meta-analysis. J Appl Psychol 2002;87:268e79. 56. Sonnentag S. Recovery, work engagement, and proactive behavior: a new look at the interface between nonwork and work. J Appl Psychol 2003;88:518e28. 57. van den Berg TI, Robroek SJ, Plat JF, Koopmanschap MA, Burdorf A. The importance of job control for workers with decreased work ability to remain productive at work. Int Arch Occup Environ Health 2011;84:705e12. 58. Ahlstrom L, Grimby-Ekman A, Hagberg M, Dellve L. The work ability index and single-item question: associations with sick leave, symptoms, and health e a prospective study of women on long-term sick leave. Scand J Work Environ Health 2010;36:404e12. 59. Kujala V, Tammelin T, Remes J, Vammavaara E, Ek E, Laitinen J. Work ability index of young employees and their sickness absence during the following year. Scand J Work Environ Health 2006;32:75e84.
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60. Feldt T, Hyvonen K, Makikangas A, Kinnunen U, Kokko K. Development trajectories of Finnish managers’ work ability over a 10-year follow-up period. Scand J Work Environ Health 2009;35:37e47. 61. Schaufeli WB, Bakker AB, Salanova M. The measurement of work engagement with a short questionnaire: a crossnational study. Educ Psychol Meas 2006;66:701e16. 62. Prins JT, Hoekstra-Weebers JE, Gazendam-Donofrio SM, Dillingh GS, Bakker AB, Huisman M, et al. Burnout and engagement among resident doctors in the Netherlands: a national study. Med Educ 2010;44:236e47. 63. Kristensen T, Hannerz H, Høgh A, Borg V. The Copenhagen Psychosocial Questionnaire (COPSOQ). A tool for the assessment and improvement of the psychosocial work environment. Scand J Work Environ Health 2005;31:438e49. 64. Nuebling M, Hasselhorn HM. The Copenhagen Psychosocial Questionnaire in Germany: from the validation of the instrument to the formation of a job-specific database of psychosocial factors at work. Scand J Public Health 2010;38:120e4. 65. Bortz J, Do¨ring N. Forschungsmethoden und Evaluation fu¨r Human- und Sozialwissenschaftler. Berlin, Heidelberg, New York: Springer; 2002. 66. Bakker AB, Demerouti E. Towards a model of work engagement. Career Dev Int 2008;13:209e23.
67. Leiter MP, Maslach C. Areas of worklife: a structured approach to organizational predictors of job burnout. In: Perrewe PL, Ganster DC, editors. Research in occupational stress and well-being, vol. 3. Oxford: Elsevier; 2004. pp. 91e134. 68. Maslach C, Leiter MP. Early predictors of job burnout and engagement. J Appl Psychol 2008;93:498e512. 69. Amabile TM. Motivational synergy: toward new conceptualizations of intrinsic and extrinsic motivation in the workplace. Hum Resour Manag Rev 1993;3. 70. Judge TA, Tharesen CJ, Bong JE, Patton GK. The job satisfaction e job performance relationship: a qualitative and quantitative review. Psychol Bull 2001;127:376e407. 71. Meyer JP, Stanley DJ, Herscovitch L. Affective, continuance, and normative commitment to the organization: a metaanalysis of antecedents, correlates, and consequences. J Vocat Behav 2002;61:20e52. 72. Shipton HJ, West MA, Parkes CL, Dawson JF, Patterson MG. When promoting positive feelings pays: aggregate job satisfaction, work design features, and innovation in manufacturing organizations. Eur J Work Organ Psychol 2006;15:404e30. 73. Hakanen JJ, Bakker AB, Schaufeli WB. Burnout and work engagement among teachers. J Sch Psychol 2006;43:495e513.
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Surgeons’ work engagement: Influencing factors and relations to job and life satisfaction Stefanie Mache a,b,c,*, Karin Vitzthum a, Burghard F. Klapp b, Gerhard Danzer b a
Institute of Occupational Medicine, Charite´ e Universita¨tsmedizin Berlin, Free University and Humboldt University, Thielallee 69-73, 14195 Berlin, Germany b Charite´ Center for Internal Medicine and Dermatology, Division of General Internal and Psychosomatic Medicine e Charite´-Universita¨tsmedizin Berlin, Campus Mitte, Berlin, Germany c Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
article info
abstract
Article history:
Background: Work engagement has become a topic of great interest in recent years. How-
Received 7 October 2013
ever, clinicians’ work engagement has rarely been studied and relatively little is known
Accepted 2 November 2013
about its predictors and consequences. Therefore the objective of this cross-sectional
Available online xxx
questionnaire study was to test a model of possible institutional and personal predictors and significant relations to job and life satisfaction.
Keywords:
Methods: 123 clinicians specializing in Surgery Medicine participated in the study. Self-
Institutional characteristics
administered questionnaires, including the Copenhagen Psychosocial Questionnaire, the
Job satisfaction
Utrecht Work Engagement Scale, the Brief Resilient Coping Scale and the Questionnaire for
Personal factors
Self-efficacy, Optimism and Pessimism, were administered. Bivariate analyses and a
Quality of life
stepwise regression analysis were performed.
Work engagement
Results: The whole sample of surgeons rated work engagement with a high mean of M ¼ 4.38; SD ¼ .91. Job satisfaction and perceived quality of life have been rated with moderate scores. The results show that job resources have a greater impact on surgeons’ work engagement than their job demands. Significant correlations between surgeons’ work engagement, their job satisfaction and quality of life were found. Moreover, work engagement mediated the relation between institutional factors and surgeons’ job satisfaction. Conclusion: Our research suggests that strengthening surgeons’ work engagement will contribute to a more sustainable workplace, in terms of both individual and hospital performance. Therefore, increasing work engagement among surgeons should be of concern for supervisors and hospital managers. Future research should focus on further predictors that may have an influence on health professionals’ work engagement. Another field for future research is to study potential effects of interventions on work engagement. ª 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Institute of Occupational Medicine, Charite´ e Universita¨tsmedizin Berlin, Humboldt Universita¨t zu Berlin und Freie Universita¨t Berlin, Thielallee 69-73, 14195 Berlin, Germany. Tel.: þ49 030 450529596; fax: þ49 030 450529952. E-mail address: [email protected] (S. Mache). 1479-666X/$ e see front matter ª 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.surge.2013.11.015
Please cite this article in press as: Mache S, et al., Surgeons’ work engagement: Influencing factors and relations to job and life satisfaction, The Surgeon (2013), http://dx.doi.org/10.1016/j.surge.2013.11.015
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Introduction During the last decade the German healthcare system has changed into a more dynamic and challenging system.1e3 Due to rising costs of healthcare, an aging population, accelerating progress in the development of medical technology, and greater public awareness for better quality of healthcare, pressures and demands on German clinicians have increased.4e6 The most affected are those ones who are asked to deal with increased demands for efficiency, cost awareness and improved healthcare quality.7,8 Research studies on Surgery demonstrated that the quality of medical treatment and care are closely related to the ability of clinics to guarantee medical services at the required professional standard. Surgeons play an important role for representing the hospitals’ competence. Their behaviors towards patients have significant influences upon patients’ satisfaction with care and treatment quality.9e11 Therefore, hospitals need highly competent physicians who are willing to work efficiently towards institutional goals.12 Due to the current organizational changes in hospitals with increases of job demands and job pressure13e15 surgeons are forced to enhance or build additional inner strengths in the form of psychological and organizational resources in order to keep able to cope with challenging and potentially distressing job tasks. Without these resources surgeons may develop negative health outcomes (i.e. stress related diseases, burnout).16 However, there are still surgeons who can be characterized by showing work engagement and job satisfaction even if their working situation impresses to be dissatisfying for an outstanding observer. The question is: why remain some surgeons highly motivated and work engaged despite such work conditions and others do not? Motivational concepts such as work engagement have not been studied sufficiently although discussed as important aspects for productivity and job performance.17,18 In consequence, there is a need to identify positive and motivating predictors for work outcomes such as job performance, especially for the health care services.
The aim of the current study among German surgeons was to examine whether work engagement, as a motivational concept, is associated with surgeons job satisfaction and perceived quality of work life, after adjusting for age, personal and work-related factors. In addition we aim to analyze on which and how surgeons’ job demands and resources operate as predictors of their work engagement. The hypothetical model this study is based on is depicted in Fig. 1.
Defining work engagement Work engagement is defined as a positive, fulfilling, workrelated state of mind that is characterized by vigor, dedication, and absorption.19,20 Engagement refers to a persistent and pervasive affectiveecognitive state that is not focused on any particular object, event, individual, or behavior. Vigor refers to high levels of energy and mental resilience while working. The working person feels high levels of energy and willingness to invest in work. Dedication is defined as feelings of enthusiasm, pride and inspiration about work. Absorption means being so fascinated, fully concentrated and engrossed in work that time passes very quickly and nothing else matters.17,19,21 Several studies investigated relations between different factors of work engagement.22 All of these studies illustrate that an employee with high work engagement shows better job outcomes: for instance, Halbesleben et al. and Hakanen et al. demonstrated that work engagement increases concentration on job tasks, job performance and institutional commitment.23,24 Furthermore, work engagement is related to organizational variables such as job satisfaction and turnover intentions.25e28 During the last decade, awareness on work engagement in the health sector has also grown. Health care professionals’ work engagement has become an increasingly important factor and a precondition for high-quality health care performance.29,30 For instance, Van Bogaert and colleagues examined relationships between practice environment ratings, workload, work engagement, job outcomes and
Fig. 1 e Research model. Please cite this article in press as: Mache S, et al., Surgeons’ work engagement: Influencing factors and relations to job and life satisfaction, The Surgeon (2013), http://dx.doi.org/10.1016/j.surge.2013.11.015
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assessments of quality of care in psychiatric hospitals.31 The findings showed that work environment factors positively influenced staff vigor, dedication, job satisfaction, and perceived quality of care.31
Predictors of work engagement The predictors of work engagement can be approached from the viewpoint of occupational psychology models. Our study is based on the theoretical assumptions of the Job DemandResources (JD-R) model developed by Demerouti et al. (2001).32 This model provides the basic assumption that the characteristics of employees’ work environments can usually be divided into two categories: job demands and job resources.33 Job demands are defined as ‘the degree to which the environment contains stimuli that peremptorily require attention and response.34 More specifically, job demands are those physical, psychological, social, or organizational aspects of the job that require sustained physical and/or psychological (i.e., cognitive or emotional) effort and are therefore associated with certain physiological and/or psychological costs. Job demands are not necessarily negative, but they may turn into job related stressors. Meeting those demands requires high effort and is therefore associated with high individual physiological and psychosocial costs that may elicit negative responses such as emotional exhaustion, frustration or symptoms of depression.20 In contrast, job resources refer to those physical, psychological, social, or institutional aspects of the job that either/or (1) reduce job demands and the associated physiological and psychosocial costs; (2) are functional in achieving work goals; (3) stimulate personal growth, learning and development. Job resources can include performance feedback, social support from colleagues and supervisory coaching. The Job DemandResources (JD-R) model also proposes that job demands (i.e., physical demands, time pressure) can be associated with exhaustion, whereas lacking job resources (i.e., job control, participation in decision making, social support) can be associated with disengagement.35 The JD-R model assumes two processes: (1) an energetic process of overtaxing and wearing out in which high job demands exhaust the employee’s energy backup; (2) a motivational process in which lacking recourses preclude dealing effectively with high job demands and foster mental withdrawal or disengagement.20 As stated in previous studies, the dimensions of work engagement share some conceptional similarities with motivational concepts. In line, work engagement could be seen as a motivational based reaction caused by the job characteristics.36 As results, we expect: Hypothesis 1: Surgeons’ job demands are negatively associated with their work engagement. Hypothesis 2: Surgeons’ job resources are positively related to their work engagement. Hypothesis 3: Job resources are stronger predictors of work engagement than job demands. In addition, personal resources such as resilience, selfefficacy and optimism have been demonstrated as having essential influence on employees’ well-being and their ability to cope with work related stress factors. Empirical studies have shown that personal resources such as self-efficacy and
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institutionally-modulated self-esteem are related to work engagement.37,38 Personal resources include positive selfevaluations that refer to individuals’ sense of their ability to control and impact their environment successfully.39 They are functional in achieving goals, stimulate personal development and can help to protect from threats. In addition, they have been found to relate to job satisfaction.40 In the concept of ‘psychological capital’ developed by Luthans et al.41 optimism, self-efficacy and resilience are also taken into account.41 Self-efficacy refers to individuals’ perception of their ability to meet demands in various contexts.42 A study by Salanova and colleagues found that selfefficacious employees experience higher levels of flow, a mental state of operation in which an employee-while performing an activity is fully immersed in a feeling of energized focus and enjoyment in the process of that activity.43,44 In line with these studies, investigations on optimism and self-efficacy in several work settings showed positive correlations with employees’ well-being, job performance and work ability.45e48 Resilience is defined as a “positive psychological capacity to rebound from adversity, uncertainty, conflict, failure, or even positive change”.49 Recent studies have found that people who describe themselves as resilient are more able to compete with job stress, multitasking demands and organizational changes.50e53 Bakker found that female school principals with high personal resources which include resilience, self-efficacy and optimism scored highest in work engagement.54 On the basis of this literature, we formulate the following hypothesis: Hypothesis 4: Surgeons’ personal resources relate significantly to work engagement.
Consequences of work engagement: perceptions of job satisfaction and quality of life As illustrated above, positive connections have been analyzed between employees’ work engagement and organizational performance.55 Along these lines, there are a number of reasons to expect that employees’ work engagement is related to individual behavior, intentions and attitudes as well as to institutional outcomes (e.g. productivity). As noted by Schaufeli et al. and Sonnentag, employees with high work engagement likely show a greater attachment to their organization, lower turnover intentions and a positive work affect.20,56 Salanova et al. (2005) found a strong relationship between work engagement and job performance.36 Previous studies have indicated poor work engagement to be related with reduced productivity at work,57 increased sickness absence,58,59 and early retirement.60 However, associations between work engagement and other outcome factors such as quality of life and/or job satisfaction have not been studied intensively. In conclusion, we predict that work engagement will be related to outcomes as follows: Hypothesis 5: Surgeons’ perceived job satisfaction is positively related to their work engagement. Hypothesis 6: Surgeons’ perception of quality of life is positively related to their work engagement. Finally, given that work engagement is predicted by the included variables as expected and work engagement itself
Please cite this article in press as: Mache S, et al., Surgeons’ work engagement: Influencing factors and relations to job and life satisfaction, The Surgeon (2013), http://dx.doi.org/10.1016/j.surge.2013.11.015
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predicts such consequences like job satisfaction, we assume that work engagement mediates associations between the variables and the consequences (see Fig. 2). Therefore, our final hypothesis is the following: Hypothesis 7: Work engagement mediates associations between the included institutional/personal variables and the consequences.
Methods Study design and setting We designed the study as a cross-sectional questionnaire evaluation. Data collection took place between 2009 and 2011 in hospital departments for Surgery in German Hospitals. The hospitals were chosen because of their similarities in specific care profile and in size (number of inpatient beds). Hospital departments were comparable in size, number of patients/ beds as far as employed medical staff (e.g. residents, juniordoctors, nurses).
Data collection In the beginning, we informed the clinic management and surgeons’ supervisors about our study for inclusion. After getting their agreement we asked surgeons working in the included hospitals for their participation in our voluntary study. Only clinical doctors who worked full-time and had at least one year of work experience in hospitals were included. Self-administered surveys were sent to the participating surgeons. A box was placed at each hospital department, questionnaires could be returned there. Reminders were sent by email after three weeks to increase the response rate. At the end, we received 123 questionnaires from contacted physicians (response rate of 63%).
Instruments Work engagement Work engagement has been evaluated by using the Utrecht Work Engagement Scale (UWES), which is a self-report questionnaire and consists of three subscales vigor, dedication, and absorption (in total 9 items).19,61 The questionnaire works with a 7-point Likert scale ranging from 0 (strongly disagree) to 6 (strongly agree). Items were summed and divided by the number of items in each (sub)scale. The higher each item was rated the higher the overall work engagement. Previous studies illustrated reference values: participants with a score 4.67 on the sum scale were considered as highly engaged,62 those who scored vigor with 4.81 as very vigorous, those with a dedication score of 4.91 as highly Predictors Job demands Job resources Personal resources
Work engagement Vigor Dedication Absorption
Consequences Job satisfaction Quality of life
Fig. 2 e A model of predictors and outcomes of work engagement.
dedicated. Scores 4.41 mean high absorption.62 Validity and reliability were proved and verified.19
Institutional resources The German version of the Copenhagen Psychosocial Questionnaire (COPSOQ) was used to evaluate job-related and psychosocial factors at work.63,64 The questionnaire includes 12 subscales measuring i.e., job demands (e.g. emotional and quantitative demands), job resources (i.e., quality of leadership, opportunities for development, social support), job satisfaction and quality of life. Items are scored on a Likert scale and transformed to a scale ranging from 0 (minimum value, e.g., “do not agree at all”) to 100 points (maximum value, e.g., “fully agree”). Previous investigations proved quality criteria of the COPSOQ.64 We also verified them: Cronbach’s alpha coefficients ranged between a ¼ .70 to a ¼ .81.
Variables Table 2 illustrates all included dimensions of the questionnaire set. We included institutional factors (e.g. job resources) as independent variables. Work engagement was the dependent outcome variable; subscales are vigor, dedication and absorption. Quality of life and job satisfaction were chosen as further dependent variables. Since physicians’ socio-demographic characteristics are expected to have an effect on their ratings; we controlled for gender, age, marital status, presence of children, years of work experience at the time of the study.
Statistical analysis Descriptive analysis (evaluation of medians and standard deviations (SD) were performed in the beginning of our analysis. The category “does not apply” and item non-response were coded as missing values. We proved whether the variables were normally distributed as a precondition for the correlation and regression analyses. Parametric and nonparametric tests were performed using the Pearson’s r or Spearman’s rho to examine correlations between variables. We performed stepwise multiple regression analyses to explore personal and institutional predictors of work engagement. Data collected on age, gender, number of years in training, presence of children and marital status were used as covariates. P-values of less than .05 were considered significant, all pvalues given were two-tailed.65 Data were calculated using the SPSS software package for social sciences; Version 18.0.
Ethical considerations Ethical approval was granted by the Humboldt University Berlin and the Free University ethic committees.
Results Characterization of the study sample Socio-demographic characteristics are given in Table 1. A total of 61% of the respondents were female physicians, 39% male.
Please cite this article in press as: Mache S, et al., Surgeons’ work engagement: Influencing factors and relations to job and life satisfaction, The Surgeon (2013), http://dx.doi.org/10.1016/j.surge.2013.11.015
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Table 1 e Demographic characteristics of the surgeons (n [ 123). N Gender Female Male Age <25 26e30 31e35 36e40 41e45 46e50 >50 Marital status Single Married/Partnership Children Child/children Without children
Table 2 e Studied dimensions of the questionnaire-set: Basic values of independent and dependent variables. %
75 48
61 39
0 35 26 22 16 13 11
0 28 21 18 13 11 9
46 77
37 63
37 86
30 70
Mean age was 32 years (SD ¼ 5.5 years). Years of work experience was rated with a mean score of 6 years (SD ¼ 5 years). Of the participants, 63% were married or lived in a partnership and 30% had children.
Key values for the dimensions under investigation Table 2 presents the means and standard deviations of the study variables. Work engagement was rated as follows: by the whole sample the sum score was scored high with a mean of M ¼ 4.38; SD ¼ .91, the subscale ‘Dedication’ scored highest with M ¼ 4.51; SD ¼ .85, ’Vigor’ showed an average score of M ¼ 4.12; SD ¼ .88. The subscale ’Absorption’ was scored with M ¼ 3.98, SD ¼ .94.
Institutional and personal factors: correlations with surgeons’ work engagement Table 3 illustrates all correlations between work engagement, its sub-dimensions and the included variables. Positive associations were found between work engagement and personal characteristics, which are supposed to be resources. So, we found correlations of work engagement (sum score) with surgeons’ resilient coping values (r ¼ .33; p ¼ .01), similarly with self-efficacy (r ¼ .32; p ¼ .02) or optimism (r ¼ .33; p ¼ .01) or negatively directed with pessimism (r ¼ .22; p ¼ .02). Correlations between institutional factors and work engagement (sum score and sub-dimensions) were revealed for almost all job resources significantly and positively in the range of r ¼ .20 to r ¼ .41. In contrast, job demands were negatively related (range: r ¼ .10 e r ¼ .36) (see Table 3).
Work engagement predicting personal and institutional factors At first, the sum score was set as the dependent variable in the hierarchical regression analysis. In step one, the sociodemographic variables gender, age, marital status, presence of children and years of experience were statistically controlled
Dimensions Job demands Quantitative demands Emotional demands Cognitive demands Demands for hiding emotions Job resources Possibilities for development Influence at work Degree of freedom at work Social relationships Sense of community Feedback Quality of leadership Personal factors Self-efficacy Optimism Pessimism Resilience Work engagement Vigor Dedication Absorption Job satisfaction Quality of life
M
SD
75.51 61.87 63.54 53.29
13.23 12.97 11.58 12.85
67.91 48.89 47.58 65.29 59.26 33.52 50.23
13.58 12.58 14.28 13.15 14.52 14.71 15.23
3.23 3.57 1.82 3.91 4.38 4.12 4.51 3.98 51.25 65.94
.71 .67 .79 .81 .91 .88 .85 .94 .17 .19
(see Table 4). By step two, the included personal resources accounted for an additional 16% of the variance (the R2 increased to .20). Self-efficacy was found to predict work engagement (ß ¼ .17, p < .01) in a positive sense, so did resilient coping (ß ¼ .19, p < .01) and optimism (ß ¼ .12; p < .01). The third step included the job demands: quantitative job demands showed a negative beta weight of (ß ¼ .19 p < .01). In step 4 e the four now included job resources revealed significantly positive beta weights: ‘influence at work’ ß ¼ .20, p < .01,‘possibilities for development’ ß ¼ .23, p < .01; ‘quality of leadership’ ß ¼ .18, p < .01; ‘sense of community’ ß ¼ .19, p < .01. The included job demands and job resources accounted for an additional 34% of variance (step 3 and 4), so the final model explained 54% of the variance. Further, we performed a stepwise multiple linear regression analysis to analyze institutional predictors for work engagement, using the three sub-dimensions of work engagement as dependent variables and the institutional factors as antecedents. As Table 4 indicates, job resources were, generally the best predictors of the three sub-dimensions of work engagement and seem to foster work engagement as the strongest predictors, this holds true specifically for ‘Possibilities for development’ and ‘Influence at work’. In all, the dimensions of vigor and dedication were better predicted than absorption. Job demands had generally slightly less predictive power than job resources on work engagement (explained variance being 09e12% for demands vs. 18e22% for resources). All these results provide support for Hypotheses 1, 2, 3 and 4.
Possibly mediated effects of work engagement in defined working circumstances As illustrated in Table 2 surgeons rated their job satisfaction and quality of life with moderate scores (JS: M ¼ 51.25,
Please cite this article in press as: Mache S, et al., Surgeons’ work engagement: Influencing factors and relations to job and life satisfaction, The Surgeon (2013), http://dx.doi.org/10.1016/j.surge.2013.11.015
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t h e s u r g e o n x x x ( 2 0 1 3 ) 1 e1 0
Table 3 e Bivariate correlations of work engagement and its subscales with a) job demands and resources, b) personal factors, c) job satisfaction, and d) quality of life. Dimensions Job demands Quantitative demands Emotional demands Cognitive demands Job resources Possibilities for development Influence at work Degree of freedom at work Sense of community Social support Feedback Quality of leadership Personal factors Self-efficacy Optimism Pessimism Resilience Job satisfaction Quality of life
Vigor (subscale)
Dedication (subscale)
Absorption (subscale)
Work engagement (sum scale)
.36** .14 .13
.33** .16 .12
.29* .10 .10
.35** .15 .12
.38** .34** .30** .25* .30** .25** .30**
.41** .38** .32** .25* .37** .34** .32**
.34** .37** .33** .23* .34** .20* .32**
.36** .33** .32** .22* .34** .23* .31**
.29** .30** .26* .35** .46** .30**
.33** .34** .23* .34** .45** .28**
.30** .30** .17 .28** .41** .26**
.32** .33** .22* .33** .48** .31**
Notes: Pearson’s r. p < .05; **p < .01.
SD ¼ .17; QOL: M ¼ 65.94, SD ¼ .19). To test the hypotheses for the possibly mediated effects of surgeons’ work engagement, regression analyses were conducted in which each of the outcomes (job satisfaction or quality of life) was regressed on work engagement. As shown in Tables 5 and 6, work engagement correlated significantly with the levels of job satisfaction (r ¼ 53; p < .001) or quality of life (r ¼ .34; p < .01). These results provide support for Hypothesis 5 and 6.
Mediating effects of work engagement In order to test for a mediation model in which work engagement mediates the relationship between the institutional variables and job satisfaction as well as quality of life an additional linear regression analysis was conducted in which job satisfaction or quality of life were regressed on these predictors alone and then again with the work engagement measure controlled (as an independent variable). First, we analyzed correlations between the independent variables (job demands, resources and work engagement) and dependent variables (job and life satisfaction). As indicated in Tables 5 and 6, the significant negative relations between job demands and job satisfaction as well as quality of life were retained (Model 2 compared to 1). However, the significant correlations between job resources and job satisfaction as well as quality of life were reduced (b-coefficients decreased in Model 2 compared to Model 1). This indicates that surgeons’ work engagement mediates the effects of their job resources but not their job demands on job satisfaction or quality of life. So, Hypothesis 7 is only partially supported, regarding job demands is has to be rejected.
Discussion There has been much interest in employees’ work engagement in recent years. Although much has been investigated about the importance of work engagement for institutional performance and business results, there is little empirical evidence on health professionals’ work engagement and its impact. Therefore, the primary aim of this article was to test a model of the predictors and possible mediators of work engagement in a sample of surgeons working in German hospitals. First, we found our sample of German surgeons reporting to be moderately engaged with their work and that work engagement was associated with institutional and personal factors. Secondly, in line with the hypotheses 1e4, this study found that a number of factors predict surgeons’ work engagement and that job resources are of greater importance for work engagement than job demands. Our findings showed that physicians who rated high for having ‘influence at work’, ‘opportunities for development’ and ‘quality of leadership’ also scored high values for work engagement. These results are in line with several other researchers demonstrating the importance of job resources for work engagement and job motivation.19,66e68 In addition, this study showed that social support and sense of community at work were associated with greater work engagement. One can conclude that their presence or perceiving in the workplace mediates the impact of stressors and decreases job demand perceptions.68 This result suggests that the institution should provide opportunities for teamwork and for promoting a sense of community among surgeons and the other staff members.69 As a consequence, employees’ work engagement and job satisfaction may increase.
Please cite this article in press as: Mache S, et al., Surgeons’ work engagement: Influencing factors and relations to job and life satisfaction, The Surgeon (2013), http://dx.doi.org/10.1016/j.surge.2013.11.015
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t h e s u r g e o n x x x ( 2 0 1 3 ) 1 e1 0
Table 4 e Predictors for sub-dimensions of work engagement. Predictors
Vigor ß
Dedication ß
Absorption ß
Work engagement (sum scale) ß
Step 1 Demographic variables Age Gender Marital status Children Years of experience DR2
.10 .12* .04 .08* .09 .03
.07 .09* .06 .06 .14* .05
.09* .10* .07 .03 .11* .05
.10* .08* .06 .05 .13* .04
Step 2 Personal resources Resilience Optimism Pessimism Self-efficacy DR2
.19** .09* .08* .16** .15
.15** .11* .06 .18** .17
.11* .13* .04 .16** .12
.19** .12* .06 .17** .16
Step 3 Job demands Quantitative demands DR2
.16** .10
.18** .12
.14** .09
.19** .14
Step 4 Job resources Influence at work Possibilities for development Degree of freedom at work Sense of community Feedback Quality of leadership Social support DR2
.23** .25** .18** .15** .11* .20 .13* .22
.19** .21** .15** .17** .07 18** .11* .19
.14** .17** .10* .20** .13* .11* .18** .18
.20** .23** .12* .19** .09* .18** .15* .20
Total R2
.50
.53
.44
.54
Third, our results indicate that work engagement is related to surgeons’ attitudes and behaviors, so supporting the hypotheses 5 and 6. In particular, the results indicate that increased work engagement will have a positive impact on surgeons’ job satisfaction and quality of life. This result is important as it underlines the relevance of the concept of
work engagement for research. According to previous studies, there is reason to believe that increased work engagement will lead to positive institutional outcomes. Job satisfaction is known to be associated with core measures of work and organizational research fields, such as job performance,70 organizational commitment71 and
Table 5 e Linear regression analysis measuring relations between institutional factors, work engagement and job satisfaction.
Table 6 e Linear regression analysis measuring relations between institutional factors, work engagement and quality of work life.
Model 0a Model 1b Model 2c
Model 0a Model 1b Model 2c
Job demands Quantitative demands Job resources Possibilities for development Influence at work Degree of freedom at work Sense of community Social support Feedback Quality of leadership Work engagement (sum score) Total R
2
.41**
.20**
.43** .35** .22** .39** .18* .25** .48** .53**
.24** .11 .03 .10 .19** .08 .15
.34
.24**
Job demands Quantitative demands Job resources Possibilities for development Influence at work Degree of freedom at work Sense of community Social support Feedback Quality of leadership Work engagement (sum score)
.45
Total R2
.22** .20* .09 .03 .09 .16* .05
*p < .05; **p < .01. a Bivariate correlations. b Multiple regression analysis, standardized beta-coefficients. c Regression coefficients adjusted for the effects of work engagement included in the regression model.
.31**
.19*
.18*
.27** .21** .19* .16 .19* .13 .18* .34**
.20* .18* .11 .10 .15 .09 .07
.15 .14 .09 .06 .13 .04 .05 .19*
.19
.21
*p < .05; **p < .01. a Bivariate correlations. b Multiple regression analysis, standardized beta-coefficients. c Regression coefficients adjusted for the effects of work engagement included in the regression model.
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t h e s u r g e o n x x x ( 2 0 1 3 ) 1 e1 0
innovation.72 We therefore hold that increasing health professionals’ work engagement should be a common goal for hospital management and supervisors. Fourth, the results of this study suggest that surgeons’ work engagement has a mediating effect on the relationship between certain institutional factors and job satisfaction as well as quality of life. Several studies in different fields of work have shown that job demands and resources are associated with work engagement and job satisfaction. The mediating effects of work engagement have been documented on positive job outcome factors such as organizational commitment and customer adherence.36,73
Limitations There are a few limitations in this study. First, the most important limitation is that conclusions regarding causal relations cannot be drawn, because the cross-sectional study design limits the causality of the findings.65 Further studies including longitudinal analyses are advised to present supplementary information for our results. Second, the sample size and the number of hospitals are relatively small, and therefore the results may not be generalized, but they give good hints. In future, studies are needed with larger samples of surgeons/ physicians working in additional hospitals and different specializations. Third, another limitation is that all measures are based on self-reports, that may cause measurement bias.65
Conclusions This study confirms our hypotheses, that both the level of physicians’ work engagement as well as their job satisfaction and quality of life are related to job demands, job and personal resources. Work engagement also seems to mediate the effects of surgeons’ job resources on their job satisfaction and quality of life but not the effects of surgeons’ job demands. Our findings, in turn, have major practical implications: Hospital management and supervisors should focus on increasing their employees’ work engagement by offering emotional and instrumental support, constructive performance feedback and opportunities for individual career development. Improved work ability can be the result which is linked to low sick leaves and higher productivity for high quality medicine. To say it as a hypothesis: Surgeons having successfully been trained are supposed to show greater work engagement and job performance. In a long-term perspective, it is important to identify factors that may encourage positive working attitudes and job performance as they directly affect the quality of medical treatment and the well-being of patients. Hospital management/administration should provide more resources just enough to enable health professionals to keep and develop their work engagement further on. Until now many empirical results suggest that job and personal resources are important predictors of work engagement. Future research should integrate further concepts with presumptive influence on work engagement. In particular, flexible work arrangements and training programs might also be essential predictors for physicians’ work engagement.
Notes: ß, standardized beta-coefficients from the final step of the model. R2, explanation rate. DR2, change in explanation rate in each step. *p < .05; **p < .01.
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Please cite this article in press as: Mache S, et al., Surgeons’ work engagement: Influencing factors and relations to job and life satisfaction, The Surgeon (2013), http://dx.doi.org/10.1016/j.surge.2013.11.015