Predictors of job satisfaction among doctors, nurses and auxiliaries in Norwegian hospitals: relevance for micro unit culture

Data collection

A postal survey including all types of personnel at 11 acute somatic hospitals across Norway was performed in 2000. The participating hospitals represented two out of the five university hospitals in Norway, three out of the 12 county hospitals and six local hospitals in the country. All five health regions in Norway were represented.

Nurses (three years' college education) and auxiliary nurses (18 months' vocational training) are employed at ward level in Norway. Their immediate leader is a head nurse. Doctors are employed at department level but they usually have their daily work in one particular ward together with the nursing staff. The immediate leader for doctors is most often a specialist or consultant.

For the purpose of this article we included in the sample all doctors, nurses and auxiliary nurses working more than 50 % of full time. Names and addresses were obtained through the personnel administration systems of the participating hospitals. Non-respondents received one reminder after two to three weeks. Due to the aims of anonymity of the study, our only information about non-respondents retained after the reminder procedure was profession and hospital.

The questionnaire

Work experiences were measured by the Work Research and Quality Improvement questionnaire (WORQUA). As one major interest was to investigate organizational issues of hospital work, which is more multifaceted and not easy to transfer from one health care system to another, this questionnaire combined items and scales from established job-satisfaction questionnaires [28–30] with additional items designed to map the Nordic model of hospital work organization [31].

After a large-scale study in 1998 that included 15 hospitals, the questionnaire was modified to strengthen the dimensions of work organization and professional development before the 2000 study [32]. All items were recoded so that higher numerical values represented higher levels of satisfaction. For this article, five indices of work experiences were constructed on the basis of factor analysis and theoretical considerations. Items and attributes of each scale are listed in Table 4.

Statistical analysis

According to our suggestion that cultural values and assumptions may be interpreted from what constitutes job satisfaction, we set up a multiple linear regression model to analyse the relative contributions of five indices on the dependent variable: "All things considered, how satisfied are you with your job?" The five indices were top management, local leadership, competence, work organization and professional development. The dependent variable was measured on a five-point Likert scale ranging from "very dissatisfied" to "very satisfied". Self-reported age was included in the regression as the controlling variable because earlier analyses show that increasing age significantly contributes to job satisfaction [32]. Sex is not included as a correcting variable, because the fact that almost all nurses were female and doctors mostly male is a characteristic of the sample that should not be "corrected". Separate regression models were specified for each of the three professions.

We expected the three professions to differ in their explanatory models. If the three groups did not differ on the level of indices, we wanted to explore whether there were differences at a more detailed level, by doing a second regression using single items as explanatory variables. Again, separate analyses for each professional group were conducted. Explanatory models are summarized by Adjusted R-squares. Statistical analyses were performed using SPSS 11.5 software for Windows.

Respondents

Statistical analysis

The five indices used in the first regression models showed acceptable internal consistency, with Cronbach coefficient alphas above the critical value of 0.70 for all indices (Table 4). The dependent variable was checked for satisfactory distribution of standardized residuals.

First regression models

For auxiliaries the prime predictor for job satisfaction was working in a culture of professional development. Competence and local leadership also were important for their job satisfaction (Adjusted R² = 0.25).

The strongest predictor of high job satisfaction for doctors was to work in a culture of professional development. Job satisfaction also increased with positive perceptions of the local leader. Age showed a negative effect on job satisfactions for doctors. Adjusted R² for the model was 0.37. The only index that was a significant predictor for all three groups was the domain of local leadership.

Second regression models

Interpreting nurses' regression models

The predictors of job satisfaction of nurses included organizational and professional as well as personal dimensions. The first regression showed the importance of leadership and organization. Focusing on local leadership, the importance of being encouraged and supported by the nearest leader points to a need to be seen and appreciated. Aiken and others found that nurses experience frustration and burnout because of lack of control over work conditions that determine the job for which they are responsible [34, 35]. Other studies have shown that nurses felt they were not treated as clinicians or peers by doctors and hospital managers but as assistants, at risk of being replaced by less-qualified personnel who cost less to employ [20, 36].

Studies of nurse burnout and magnet hospitals in the United States concluded that professional development, cooperation with medical staff and managerial support were highly important for nurses [37, 38]. In this study the influence of good opportunities for professional development on nurses' job satisfaction was not significant, seen in combination with other factors. One interpretation may be that competence and professional development are closely intertwined with the local organization of work.

The significant predictors of the nurses' explanatory model included the local leader's knowing the work situation and providing support and feedback. The head nurse is, among other things, responsible for the local education and fostering of new nurses. Professional development might therefore be seen as taken care of through the local leader.

Work organization (Index 4) was also an important predictor for nurses' job satisfaction. This is in line with findings that cohesive working relationships, cooperation with medical staff and appropriateness of the system of nursing was important for nurse job satisfaction in the United Kingdom [39].

Nurses seem to be concerned about the vertical as well as horizontal organizational coherence in their work, which may reflect the multidimensionality of nurses' work. Because nurses have a coordinating role, the responsibility for shuttling between professional, organizational and relational tasks makes them utterly aware of organizational gaps and inconsistencies. Nurses inhabit an organizational position from which they overlook the local system's impact on professional competence as well as cooperation and workflow. Their system competence is an important asset in the micro team and should be used by managers.

Interpreting auxiliaries' regression models

Auxiliaries are the group with the least professional authority. In our data 98% of the auxiliaries were female, 75% were above 40 years of age and 60% worked part-time. They are however, also the most stable group in hospital wards, thus representing long experience and considerable informal knowledge about their local patient groups as well as the hospital organization.

It may seem surprising that professional development and working in a unit with high competence is important for their job satisfaction, while professional feedback is not a significant predictor. One interpretation is that auxiliaries draw their professional identity and loyalty more from the collective of the micro unit than from their own professional group. Having little chance of formal promotion, their prospects for professional acknowledgement and respect lie in building informal competence and local reputation. For the micro team these kinds of local skills and loyalties are vital. In building an interdependent care team, a leader's task should be to develop the collective aspect of the ward's total situational competence and hence to make the other professional groups acknowledge this resource as an asset.

Interpreting doctors' regression models

The strongest predictor of doctors' job satisfaction was working in a culture of professional development. Having a leader who knows the work situation and gives feedback on the work was also seen as important. The nearest superior for doctors is usually a consultant or a clinical manager. Knowing the work situation means understanding the difficulty and variation of clinical assessment and having the capacity to give professional feedback. The most striking cultural trait emerging from the doctors' results is the noticeable importance of the profession. The doctors' explanatory model reflects loyalties, authorities and motivation linked to the medical profession only. Studying trends in the doctor – manager relationships in the United Kingdom, Davies et al. support the picture of doctors' loyalty: Doctors reproduce a professional and individualistic authority [40, 41]. In the perspective of an interdependent ward culture, the doctors' knowledge and professional responsibility are valuable contributions. The challenge for leaders could be to extend this professional loyalty and responsibility to the multiprofessional team as an investment in the collective assets of the ward.

Implications for quality improvement

A common strategy for bridging the gap between managerial and clinical rationalities in hospitals has been to train doctors and nurses in managerial theory and methods. The undesirable side effects of losing clinical responsibility and caring morale integrated in the clinical cultures have hardly been discussed [42, 43]. A supplementary strategy would be to teach managers to recognize clinical values and cultures and thus to use the strength of each professional group. The respondents in our study pointed clearly to the importance of having leaders know and understand the different working situations. We also suggest that leaders pay attention to the values of the different professions of the micro team. This supports the point in what Firth-Cozens calls a fundamental conflict of leadership for quality: the necessity for hospital leaders to get close to the patient and staff experience [6].

By exploring what predicted their job satisfaction, we have shed some light upon the values and the underlying assumptions of the different clinical professions at ward level. Such insights may be used as motivation through differing strategies tailored for each profession. Some crucial points may be to strengthen confidence and motivation at the local level by rewarding doctors for their professionalism but also urging them to share their knowledge and to expand their professional responsibility to the micro team as a whole. Nurses and auxiliaries could be used systematically as informants on the functioning of the micro- and meso-level of the hospital infrastructure. The coordinating role of nurses and the stability and local experience of auxiliaries give them an organizational overview that obviously is useful in quality improvement strategies.

Strengths and limitations

The response rate of the study was < 70%, which may be considered low. As our sample was made unidentifiable after the inclusion procedure, our knowledge about non-respondents is limited. All regions and hospital sizes in Norway were represented, however, with all three professions in the study; there is no reason to believe that our sample was in any way biased.

The use of identical questions to different professions risks differing interpretations from the various groups. This may represent a validity problem, but on the other hand it also allows direct comparison between professional groups. The fact that gender still is closely linked to professions represents some interpretation problems. We cannot say that the values described are rooted in professions and not in gender. On a group level, though, we may state that professionalism is a cultural trait of hospital physicians.

Hospital staff work within hospitals, departments and wards and thus share experiences and attitudes with their local colleagues. This would lead to underestimated standard errors and thus an inflated type I error rate. As we were not able to link all professional groups to ward levels of work, which is the most likely level of clustering, multilevel analysis could not be performed.

To interpret a survey of work experiences as cultural information requires caution. We do not recommend the method for cultural studies as such. We do, however, defend the possibility of searching such material to identify characteristics reflecting cultural main vectors at a relatively basic level. In a setting of managing quality improvement, this level might be sufficient for practical purposes.