Job Satisfaction of Health Service Providers Working in a Public Tertiary Care Hospital of Pakistan

Received: October 17, 2017 Revised: December 12, 2017 Accepted: December 28, 2017 Abstract: Background: An effectively working health system is not possible without a satisfied workforce. Each year many dis-satisfied professionals either quit their profession or leave jobs in search of better opportunities. This is why the subject of job satisfaction has gained attention in the public health care sector and human resources in Pakistan in the recent past. This particular study was done to assess the job satisfaction of healthcare employees in the public tertiary hospital to identify the various underlying factors.


INTRODUCTION
People around the globe demand Universal Health Coverage (UHC) of good quality to ensure their access to healthcare services for disease prevention and cure, palliation, health promotion, and rehabilitation, as and when needed which are not a financial burden for users [1].The dream of UHC can turn into realty through a well-functioning health system equipped with skilled workforce, as consumers of health system today are more aware of their rights; have higher expectations from their healthcare providers and demand improving standards of care as these customers are well aware of the fact that their satisfaction is the key to judging the quality of health services.This is why the health institutions of today emphasize more than ever to have an upgraded, well abreast with knowledge and skilled workforce which is satisfied with their jobs [2].These healthcare services providers are integral block of an efficient and effective healthcare system and their worldwide shortage is an impediment to achievement of Millennium Development Goals, more so in the low and middle-income countries.According to World Health Organization by the year 2035 the health workforce shortage will reach upto 12.9 million [3].
Pakistan a lower middle income country of WHO EMRO Region with population of 188.9 million ranks 147 amongst 188 countries in human development index [4].According to the constitution of Pakistan provision of health to its citizens is mainly the responsibility of the government.The health services in Pakistan are offered by both the public and private sectors.The country has a three tiered health system and various intervention programs.Amongst various other challenges faced by the health system of Pakistan, one is the health workforce crisis.There is a shortfall of nearly 179,711 doctors; 157,546 dentists; 1,304,835 nurses; 29,574 pharmacists; 3222 lady health visitors, 5000 registered midwives and 74,000 lady health workers.[5] Those cities or areas which have teaching hospitals and have residents willing to pay attract more healthcare staff as compared to the regions which are economically less developed or have fewer facilities [6].This shortage is attributed to a number of factors like less people enrolling for education in health related fields, change of profession by the healthcare workers, early retirement, misdistribution of human resources and brain drain.
In developing countries like Pakistan many of the healthcare workers are not satisfied with their salaries or job incentives, the quality of life they themselves or their families can have in their country.They believe that they lack opportunities to learn advanced technologies, have less chance of skills and career development, have poor working conditions, face violence at workplaces and are under political influences.These demotivated employees then in turn search for jobs in developed countries which have a higher pull force [7].The resources left behind in the countries facing brain drain are less skilled and dissatisfied with their current jobs.
The health care service providers' shortage is attributed to a number of factors for example less people enrolling for education in health related subjects, immigration of health workers, decisions regarding change of profession by the healthcare workers and early retirement as stated in a study done in Africa.It was concluded that one way to overcome this deficient health work force problem is by improving the working conditions and salary packages offered to these workers alongside other measures which can offer short term or long term solutions [8].
What is this job satisfaction?Various definitions have been given for the phenomenon of job satisfaction.Locke in 1976 referred to job satisfaction as a positive feeling that an individual holds towards his job, resulting from the appraisement he gets for his job or from various experiences which he experienced at his workplace [9].In 1991, Lofquist and Davis said that job satisfaction pertains to the employee's positive emotional reaction to target surroundings.According to the authors these positive emotional reactions are the result of worker's assessment as to what degree their needs are satisfied by their job surroundings [10].According to the Abraham Maslow's theory of job satisfaction employee's needs have a hierarchal nature.When an individual's certain needs are satisfied they no longer remain a motivation for the individual, and this activates the next level of needs depending on how much importance one gives to particular needs [11].
As stated in a study by Golshan et al.Herzberg in his motivation hygiene theory presented in 1959, stressed that factors which lead to job satisfaction are related to job content for example, the nature of work itself, the sense of accomplishment, recognition associated with the job, the responsibility that comes with a particular job and chances provided for further advancement and progress.The factors that cause job dissatisfaction on the other hand pertain to job context and he labeled them as hygiene factors such as employee's policies, salary, overall working conditions and relationships with colleagues as well as supervisors [12].The theory also had some drawbacks which faced criticism.Vroom criticized the theory by saying that Herzberg overlooked the difference between recall of satisfying events and actual observation of motivated behavior.In the expectancy theory presented by Vroom, the behavior strategies were evaluated on the basis of three variables namely link between effort and performance, link between performance and reward and temptation for the reward [13].Rodger in the reinforcement theory suggested that those employees who get regular feedback from the management concerning which behaviors will be rewarded, appreciated and expected from them, and which will be taken to task, then it helps in developing motivated behavior in the employees [14].
Various studies have been conducted globally to study the job satisfaction in healthcare workers.In a research done in Iran it was found out that the staff working in an organization has a different perspective when enquired about job satisfaction and management holds a different view point.According to the results of the study the disparity between the viewpoints and beliefs of employees and employers negatively affects employees' performance and in turn can lead to their turnover [15].A report regarding British Nurses and their satisfaction revealed that NHS (the National Health Services) keeps on losing its nursing workforce to the non NHS market.The opportunities for career development and promotion are the biggest motivators behind this decision [16].In Serbia in a cross sectional study carried out at nine rehabilitation centers involving doctors, nursing staff, speech therapists, occupational therapists, physiotherapists, psychologists and social workers.Out of 170 healthcare workers 22.4 percent were satisfied with their jobs with doctors being more satisfied than the nursing staff.Causes of dissatisfaction as quoted in this study were work environment, job designs, lack of personal or clinical autonomy not being part of decision making process.Most were not satisfied with the promotion opportunities provided at work places and felt that there are less chances for improving their education.The satisfying factors were personal relationship, politics related to the hospitals and the satisfaction of providing good quality services to the patients coming at these facilities [17].
In a cross sectional study done in Ethiopia various demographic factors were studied in conjunction with job satisfaction showing gender, age and educational level correlation with job satisfaction [18].In Norway good leadership, feedback and support from the seniors were viewed as key factors for job satisfaction [19].In Iran job satisfaction status of medical personnel working in the emergency departments was studied to find out the main determinants that lead to this feeling.The results showed moderate level of job satisfaction with freedom to make decisions pertaining to patient care having the highest score.Low scores were reported for factors such as the medical equipment and other resources available in the emergency department, coordination among the personnel, chance to participate in decisions pertaining to management and annual performance appraisal system based on fairness.In addition low to moderate levels of satisfaction were reported due to violence between the healthcare workers and caregivers of patients [20].
In a study done in two private medical colleges of Pakistan, more than 50 percent of the students said that they intended to leave their country and go abroad after their graduation as the students were not happy with the quality of training which they are offered in their country as well as the salary structure, the working environment conditions and the poor teaching standards in local teaching hospitals [21].A cross sectional study was conducted to assess job satisfaction among nurses who work in tertiary healthcare hospitals in capital city of Pakistan.Results showed that of all the respondents 86 per cent were dissatisfied with their jobs; with factors namely poor working conditions, lack of privileges, respect in their places of work and time pressure being mainly responsible [22].In a study done on hospital nursing staff commitment in a public hospital of Pakistan, it was found out that there is positive relationship between the nursing staff commitment and work and physical environment i.e. nurses are more committed and do their jobs more efficiently and have high satisfaction if the above mentioned variables are there in their hospitals [23] If the job we do is not able to fulfill our desires and does not help us achieve our personal goals what will be the result.The result will not only be lack of job satisfaction, desire to quit and poor job performance, it will also result in stress in our lives worsening our individual well-being and further deterioration in job performance.Being in health care profession it will not only negatively influence the health and performance of workers but will also affect the health system outcomes and patient satisfaction [24].Another problem reported in hospitals of Pakistan is of violence which can be physical as well as verbal, and aggression against the hospital staff.In a study conducted in various health facilities of capital city of Punjab, Lahore Pakistan it was found that inadequate security provided to the healthcare workers in the hospital settings leads to anxiety, emotional distress, dissatisfaction and even the desire to quit the profession.Good management policies, increased support by the seniors and good team work amongst colleagues and provision of better resources have been mentioned as ways of overcoming these incidences [25].
The problem with the health system of Pakistan is that only 4.73 of government expenditure is spent on public health which is about 1.01% of GDP.With so less spent on health system, of many other side effects, one side effect is that only 43.9% of doctors working in various public health hospitals of Pakistan said that they were satisfied with their salaries [26,27].In Pakistan public hospital staff is often heard complaining about overload and other factors because of which they are dissatisfied with their jobs and the situation further worsens if it is a teaching facility as the staff needs to pay attention to healthcare students as well as the patients.The geographic location of facility and satisfaction is also said to be related.The workers employed in the public as well as private sector of Punjab province are more satisfied as compared to the health professionals working in the capital city of Islamabad and other provinces namely Khyber Pakhtunkhawa, Balochistan and Sindh [28].Realizing the significance of job satisfaction for the health workers performance the particular study was conducted to assess the overall satisfaction of health service providers working in the public sector hospital and highlight various factors that cause job satisfaction or dissatisfaction, suggest recommendations that might improve the current situation and hence reduce the outflow of trained and skilled professionals from Pakistan.

Study Setting and Sample
A cross-sectional study using non-probability sampling method of convenience sampling was conducted in a public tertiary care teaching hospital in Rawalpindi which has more than 800 beds, but data regarding number of staff couldn't be found.All those who were either full time employees or employed on ad-hoc basis and were involved in patient care were considered as study population.The instrument used for data collection was Job Satisfaction Questionnaire encompassing both intrinsic and extrinsic factors affecting satisfaction of employees.The questionnaire developed by Spector furnishes information about nine dimensions of job namely, remuneration, performance based rewards, supervision, fringe benefits, promotion, communication, working conditions, coworkers and the nature of the job through 36 items in the Job Satisfaction Survey (JSS).A six point Likert Scale was used [29].Part 1 enquired about the socio-demographic characteristics.The internal validity of the questionnaire as calculated for a sample of 3,067 participants was found out to be 0.70 [30] while another study reported the reliability of the questionnaire as 0.86 employing the Cronbach's Alpha method [31].A pilot study was done with 30 participants to identify any problems regarding comprehensibility and as all questionnaires were returned with no problems reported, so no alterations were made in the questionnaire.The reliability of the survey was checked by Cronbach's alpha coefficient.The alpha coefficient was .78 for the pilot study as the value of .70 is acceptable; so the reliability of the instrument was verified.

Data Collection and Analysis
A total of 115 questionnaires were distributed and collected over a period of two months, out of which 89 had no missing values (response rate of 77%).The data was analyzed using SPSS version 18 with necessary precautions taken to ensure that there are no missing values.Frequency distribution and correlation analysis was used as suggested by the developer of questionnaire.

RESULTS
The study sample had 33 males and 56 females and 61.8% of them were in 31-50 years age group.61.8% were unmarried, 31.5% married and 6.7% were divorcees.49 doctors, 31 nurses, 4 pharmacists, 4 laboratory personnel and one vaccinator returned the filled questionnaire.29 worked in the hospital for less than a year, 35 for 1-5 years, 4 for 11-15 years and 16 -20 years and two had been there for more than 20 years with 8 diploma holders, 7 undergraduates, 58 graduates and 16 with advanced education (Table 1).Regarding the correlation between various variables and job satisfaction such as remuneration packages and developmental opportunities, benefits offered by the organization, job recognition most of the participants showed dissatisfaction.When questioned about supervisor's skills, his interest in solving the problems of those who work under his supervision and his fairness 58.4% were satisfied.77.5% of the study participants showed dissatisfaction with their work conditions.The relationships with colleagues have a vital role in work performance and the results showed that 78.7% were satisfied with the relations they have with their colleagues.Regarding the nature of work 68.5% were satisfied, 30.3% were satisfied with the communication in their organization with most of them showing satisfaction with the way work assignments were explained to them (Table 2).After calculating the total facet score for each of the nine aspects of job satisfaction the total score was calculated on a continuous scale from 36-216.The score values of 36-108 were considered as dissatisfied, scores ranging from 108-144 showed indecisiveness and those in range of 144-216 reflected satisfaction.Observing these values 18% of the participants considered overall were satisfied with their jobs, 27% were not satisfied and 55% of the employees were ambiguous (Fig. 1).Spearman's rho Coefficient was used to measure the strength of linear relationship between overall job satisfaction and the various nine facets pertaining to job satisfaction in the questionnaire as the responses were collected on Likert scale.Moderate positive correlation was found between promotion and career development opportunities, relations with coworkers, nature of work and communication in the organization and job satisfaction.A strong positive correlation was observed between the rewards the employees get in return for performing various duties at their job, benefits associated with the job and relation with supervisor and job satisfaction while weak correlation was observed between remuneration packages, work conditions and job satisfaction (Table 3) [32].

DISCUSSION
The health system of Pakistan is struggling with various blocks due to the economic, political and peace instability in the region and one of those pivotal blocks is human resources for health.There is increased dissatisfaction in all walks of life which is observed in this developing country and healthcare resources are no exception.This is something which cannot be overlooked as it will in the long run not only worsen the gap between the desired and the actual numbers of health care workers but will also adversely affect their performance, efficiency and effectiveness.
Only 18% of the study participants showed satisfaction with their jobs based on the absolute approach used for computing the job satisfaction scores ranging from 36-216.Low levels of job satisfaction were also reported in a job satisfaction study regarding Pakistan where 14% of the employees showed high dissatisfaction with their jobs [33].This has big implications for the public health system which is already facing shortage of financial resources and can't afford to lose the skilled workforce.Another study done in Lahore showed that only 31.1% of doctors were satisfied with their jobs [34].In another study it was observed that only 13% of the doctors were well contented with their jobs while a substantial number had either below average or average satisfaction [35].
This dissatisfied workforce will be further adding to the pool of workers who leave their country or their cities in search of better opportunities.It can be observed that previous studies conducted either in doctors or nurses to assess their job satisfaction showed similar results which is a clear evidence that despite being brought to the notice of people and policy makers still not much efforts have been put in to bring improvement in the satisfaction of health services employees who are part and parcel of the health system and without whom the delivery of healthcare services to the needy cannot be achieved.
Our study revealed that the participants had overall low satisfaction with various global dimensions of job with 55.1% dissatisfied with remuneration, 52.8% dissatisfied with their promotion chances, 55.1% dissatisfied with rewards.All these results regarding pay, promotion opportunities, benefits and rewards tally with the findings which were presented in the study reflecting job satisfaction in public health care workers in Pakistan [33].Low satisfaction with salaries, development opportunities was also reported in a study done in healthcare workers in Tanzania [36].The healthcare profession is different from other professions in the sense that here the biggest reward is the satisfaction of providing services to mankind and get appreciation in return but if the workers don't get their due reward this adds to their dissatisfaction and can negatively influence the quality of care which is provided.
The results for supervision showed that most of the respondents were satisfied with the capabilities of their supervisor, the role he plays in mentoring them and showed overall liking for their supervisor with 58.4% of the opinion that they like their supervisor.This is particularly important in regards to healthcare industry as the workers have to deal with patients not machines and learn skills to scale up their capabilities and if they believe that their supervisor lacks the ability to guide them and does not entrust them with tasks that can add to their skills they will be at a loss.68.5% of the healthcare workers were satisfied with the nature of work as they enjoy offering services to the mankind and think of this profession as an opportunity to serve humanity and take pride in their jobs.Also good satisfaction percentages were observed for the relationship with colleagues and most of the healthcare workers quoted that they enjoy working with them as they know that they can count on them for teamwork and support (78.5%).Similar results were reported in a job satisfaction study done to compare job satisfaction in doctors in teaching jobs with doctors who were in the clinical side showing the doctors in the clinical practice satisfied with their relationships with colleagues [27].These findings regarding supervisor, nature of work and relations with the coworkers were consistent as presented in the research by Kumar et al. [33].Similar findings showing good frequencies for job satisfaction in relation to colleagues, team work with them and cooperation, as well as nature of job were observed in a study where more than half of the participants stated that they were satisfied with their coworkers and also regarding the nature of work [36].The relations with colleagues are of significant importance as it promotes team work which in turn leads to client i.e. patient satisfaction.
The results regarding work conditions showed that 6.7% of the workers were satisfied with the rules and procedures in their hospital and felt that the red tapes in their departments were seldom preventing them from doing their jobs well while 77.5% were dissatisfied.These results are in line with the results observed by Kumar et al. (2013) and also with the study which was done to assess the job satisfaction in employees in a hospital of Iran [15].The work autonomy is a feature which distinguishes healthcare and other service industries.If the workers feel they are handcuffed due to the work conditions and believe that the procedures pose barriers in the performance of duties then the quality of services offered are also adversely affected as many treatment options or timely decisions cannot be taken due to these red tapes.
Regarding communication it was found that 42.7% were not sure, and 30.3% said that they were satisfied with the communication.Due to this lack of communication between the administration and the workers more problems and worse situation regarding satisfaction of workers can be expected in the future as the workers feel left out.Decisions regarding increments, performance evaluation, and intra as well as inter departmental rotations, renewal of contracts for ad hoc employees, health safety and benefits are made without the involvement of the employees.The decisions are made and conveyed to the employees without keeping in mind what the employees want and this further demotivates the employees.
The healthcare workers working in the public hospital of Rawalpindi showed overall dissatisfaction with their salaries, promotion and job development opportunities, benefit packages offered to them, recognition they receive for their work, conditions at their work places.This is an alarming situation as the unsatisfied employees are the ones who are in search of new jobs, ready to leave for better opportunities and hence the time and money spent by the hospital on their training and development is wasted.The new people hired to fill those gaps are naïve of organizational culture, need time to understand the management style and are not as competent as the ones who left and the cycle fruitlessly continues unable to yield the desired results of Universal Health Coverage.
Low rates of job satisfaction create an alarming situation for health policy makers and planners, as low job satisfaction then translates into poor ability to render services to the community and resultantly services which are offered ineffective and inefficient.the done in Pakistan so far have nearly similar findings to our study which shows that no rigorous efforts have been taken by the public health sector to bring improvement in the job satisfaction of employees.The results cannot be ignored because if the same attitude continues in the future Pakistan will keep on losing its skilled workforce to either foreign countries or people will be choosing other professions.Health sector workers undergo repetitive and vigorous training drills in order to keep themselves abreast with latest advancements in the field of health.This involves a lot of money as well effort so it will be an irreparable loss if the skilled and trained health care workers leave their jobs because of dissatisfaction with the factors discussed above.İn addition, all those who join an organization have the dream of growing with the organization where they render their services however if these dreams are not fulfilled its side effects can be seen as poor performance by the employees and poor performing health system with unstable and always changing workforce.

CONCLUSION
Lack of job satisfaction and resultant turnover of the employees is a global problem faced by all the health systems of the world, more so affects adversely the health systems of developing countries; with Pakistan being no exception.In Pakistan due to the limited health budget the public health sector has to make many trade-offs.Over the years this has worsened the quality of services offered by the public health care organizations and one of the reasons for this poor performance is the dissatisfied workforce.It is time that job satisfaction surveys should be conducted on regular basis in the provincial and federal sector public hospitals.The data collected will give an insight into the expectations of the workers as well as provide the employee's views regarding the shortcomings at their workplaces.These results can then be incorporated into human resources policies for health in order to provide better compensation packages, give a clear job description to the employees and these in turn will help improve satisfaction of workforce in future.It is advised that an all-inclusive approach be adapted to strengthen the policies addressing employee satisfaction to bring noticeable improvement in the quality and performance of organization.

LIMITATIONS OF THE STUDY
The study was conducted only in one of the public hospitals so the results cannot be generalized to the whole country.Due to time limitation and resources deficiency only questionnaire was used as a data collection tool which is another limitation to the study.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE
Prior permission was obtained by the Institutional Review Board at the parent organization of the principal investigator.A cover letter was attached with the questionnaire highlighting the aims of the study and its objectives reassuring the participants that their identity will be kept confidential.

HUMAN AND ANIMAL RIGHTS
No Animals/Humans were used for studies that are base of this research.