A surgical ward of about 24 beds in a Norwegian hospital may have two to four consultants (specialists) permanently attached to the ward, in addition to five to eight doctors in educational positions working at the ward for six to 12 months. All doctors participate in a rota duty within their specialty that includes emergency calls and ambulatory duties. About 20 to 25 nurses and four to six auxiliaries working solely in the ward constitute the nursing staff.
Within a ward, working teams consisting of doctors, nurses and auxiliaries care for smaller groups of patients. Shifts and different working hours make such teams unstable, with alternating individuals. Establishing good working teams within the micro unit is a vital challenge for local leaders; managing the cultural diversity of professions is a central part of that challenge [21, 33]. To secure safety as well as flexibility in the work process, development of shared values, shared aims and a common language among the team members is vital. That the members of the three professional groups differed in their opinions as to what constituted the most important elements for their job satisfaction implies that leaders should take these differences into account in their efforts for motivation and team building.
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.