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International Journal for Quality in Health Care 16:253-261 (2004)
International Journal for Quality in Health Care vol. 16 no. 3 © International Society for Quality in Health Care and Oxford University Press 2004; all rights reserved

The progress of reforms: job satisfaction in a typical hospital in Estonia

Marina Kaarna, Kaja Põlluste1, Rein Lepnurm2 and Maie Thetloff3

North-Estonia Regional Hospital, Tallinn, 1 Department of Public Health, University of Tartu, 3 Estonian Health Insurance Fund, Tallinn, Estonia, 2 Department of Management and Marketing, University of Saskatchewan, Canada

Objective. To evaluate the level of job satisfaction among the staff at an Estonian hospital and to describe factors related to their job satisfaction.

Design. Questionnaire survey.

Setting. Pärnu County Hospital in Estonia.

Study participants. All staff members of the Pärnu County Hospital (n = 673), except 56 staff members who were away from work during the study.

Results. Respondents (n = 473) indicated an average job satisfaction level of 3.86 ± 0.81 on a 5-point scale. The efficiency of hospital management as measured by planning, relationships with supervisors, knowledge and communication regarding hospital goals, plans, quality of services, budgetary situation, and staffing problems was positively correlated with job satisfaction. Stress and unrealistic expectations were negatively correlated with job satisfaction. The feeling of being part of the organization was also correlated with job satisfaction. Recognition from supervisors and discussions with colleagues were found to be weakly correlated with job satisfaction. There were differences between occupational categories.

Conclusion. The management of Pärnu County Hospital has been able to create good supervisory relationships with staff by providing sufficient information about the goals of the hospital, the quality of services, the budgetary situation, and staffing problems that arise. Stress levels reported are not excessive and staff are loyal to their hospital.

Keywords: hospital staff, job satisfaction, motivating factors

Address reprint requests to: Marina Kaarna, North-Estonia Regional Hospital, 19 J. Sütiste tee, 13419 Tallinn, Estonia. E-mail: marina.kaarna{at}regionaalhaigla.ee

Accepted for publication February 2, 2004.

Hospital personnel have difficulties in meeting the needs of their patients if their own needs are not met [1,2]; therefore hospital managers have responsibilities to both staff and patients [3]. Managers of health services organizations must elicit cooperation and performance from their employees in order to ensure quality of care to patients. Eliciting such commitment from staff is not easy to obtain under uncertain working conditions. Since 1991, the Estonian health care system has been undergoing: (i) consolidation of the hospital system; (ii) reductions in the number of doctors and nurses; and (iii) decentralization of management to counties and to individual health care institutions.

The hospital system in 1991 had a capacity considered to be in excess of the needs of the population. During the Soviet period, hospital capacities were increased for strategic military reasons. In 1991, there were 120 hospitals providing services for the Estonian population of 1.44 million, a ratio of 9.2 hospital beds per 1000 population. In comparison, there were 4.3 hospital beds per 1000 population in Denmark, 3.8 in Norway, 4.1 in Sweden, and 4.3 in Finland [4]. Beginning in 1991, the numbers of hospitals and hospital beds in Estonia were reduced considerably. By 1998 there were 78 hospitals in Estonia, with a ratio of 6.0 hospital beds per 1000 population, compared with 3.3 hospital beds per 1000 population in Norway, 2.7 in Sweden, and 2.4 in Finland [4].

During the last decade, the number of doctors has also decreased continually. In 1990, there were 3.5 doctors per 1000 population in Estonia. By 1998 the number of physicians per 1000 population was 3.0 in Estonia compared with 4.1 doctors per 1000 population in Norway, 3.1 in Sweden, and 3.0 in Finland. The number of nurses also declined in Estonia, from 8.5 per 1000 population in 1991 to 6.2 per 1000 population in 1998. The reduction in the numbers of nurses may reflect poor salaries and low professional status in comparison with the numbers of nurses in Scandinavian countries. In 1998, there were 18.4 nurses per 1000 in Norway, 8.2 in Sweden, and 21.6 in Finland [4]. During the reorganization of health care personnel in Estonia, the number of nurses has declined faster than the number of physicians. The present ratio of nurses to physicians is 2:1, which is thought to be too low. The Ministry of Social Affairs of Estonia plans to achieve a ratio of 4:1 in the next few years.

In addition to the consolidation of the hospital system and reductions in health personnel, decentralization of management also occurred in 1992 [4]. Administratively, Estonia was divided into 15 counties, one of which is Pärnu (4806 km2) with an estimated population of 95000. There is at least one central hospital in each county. Pärnu County Hospital is representative of a typical hospital in Estonia, providing secondary care through an in-patient unit and a separate outpatient clinic. The hospital has 470 beds and provides a variety of specialized services such as internal medicine, cardiology, surgery/orthopedics, obstetrics/gynecology, pediatrics, and neurology. In December 1998, the in-patient unit and the outpatient clinic were integrated. After integration there was a total of 729 staff members, including 123 physicians, 300 nurses, 174 nursing assistants, and 132 non-health-related staff.

Within individual health care institutions the tasks of management changed from the application of centralized procedures to the development of staff and patient care policies. In an effort to be more responsive to patients, quality assurance programs, including patient satisfaction surveys, were implemented in many hospitals in Estonia. Despite the big changes in the work environment, which could be expected to increase stress among hospital staff [5], there were no systematic efforts to measure staff satisfaction in Estonian hospitals. According to the literature, job satisfaction in health care organizations is related to many factors: optimal work arrangements; the possibility of participating actively in the decision-making process; effective communication among staff and supervisors; and the ability to express opinions freely. Collective problem solving and the attitude of management are important to the satisfaction of the employees [6–8].

Job satisfaction can be increased by attending to motivating factors, such as making work more interesting, requiring more initiative, creativity, and planning [9,10]. This is especially relevant when budget constraints limit increases in pay and benefits [11].

Managers who grasp the importance of factors affecting the well-being of staff [9,10,12] are more likely to gain improved performance from the various groups of hospital staff [11]. It is of the utmost importance to seek the opinions of employees and to include them in decision-making and problem-solving processes [13]. This will improve satisfaction among the employees and make them feel that they are part of the organization [3,7].

Pärnu County Hospital is the first health care establishment in Estonia where analysis of employees’ satisfaction was initiated simultaneously with investigating patients’ satisfaction, as part of the hospital quality assurance program. In implementing the quality assurance program at the hospital, employee satisfaction was evaluated by means of staff satisfaction surveys.


   Subjects and methods
Top
 Subjects and methods
Results
 Discussion
 Conclusions
 References
 
Study design
The opinions of staff regarding satisfaction with their jobs were studied using a questionnaire, which was distributed to all 673 staff members of the hospital during the first 2 weeks of November 1998. During this time, 56 employees were either on holiday, on a business trip or sick leave, and therefore did not participate in the study. Every unit or work place had an appointed person responsible for distributing the questionnaire. The questionnaires were sealed by the respondents and placed by the respondent into a secure drop-box that was located at the reception/cloakroom area of the hospital. This location was chosen because all staff passed through this area at the beginning and end of their workday. At the end of the second week of December, the drop-box was closed and sent by courier to the Department of Public Health at the University of Tartu. The envelopes and the questionnaire forms contained no name or code for the individual. Respondents were assured that their questionnaires would be used only for research purposes and that individual answers or identities would not be disclosed.

Methods
The respondents were divided into five occupational categories: physicians, nurses, and nursing assistants, other health professionals, administrative staff, and support staff. The questionnaire used was an Estonian version of the Norwegian Medical Association’s job satisfaction questionnaire, which was specifically designed for health care organizations [14]. Job satisfaction was measured using the responses to a single item on the questionnaire using a 5-point scale (1 = very dissatisfied to 5 = very satisfied). The use of a single-item measure of job satisfaction was reviewed by Scarpello and Campbell [15] and Wanous et al. [16]. These researchers found that the correlations between the single-item and the summed score of multiple items were 0.65 and 0.67, respectively. Both groups concluded that when respondents have little time and when space on the questionnaire is limited, the use of a single item is justified. Nevertheless, the questionnaire also contained a set of four additional items related to job satisfaction, each one measured on a 5-point scale (see above): ‘I am proud that I am working at Pärnu Hospital’; ‘I am willing to put in an extra effort to help the hospital’; ‘I don’t feel part of this hospital, nothing here depends on me’; and ‘My future and that of the hospital are not compatible’. These items were used in this study by summing them to create a variable called the ‘nature of satisfaction’. The Cronbach’s reliability score for this scale was {alpha} = 0.60, and the Pearson correlation between job satisfaction and nature of satisfaction was found to be 0.63. Job satisfaction is the main dependent variable and nature of satisfaction is used as a corroborating dependent variable. Eight independent variables were defined for the study, of which seven combined two or more items from the questionnaire and one represented a single item.

All items were scored on 3-, 4- or 5-point scales as follows:

  1. ‘Planning’ consisted of three items (‘Hospital administration is well informed about our work’; ‘The hospital leaders have clear goals’; and ‘My department head has clear objectives’), which were summed with a Cronbach’s reliability score of {alpha} = 0.70.
  2. ‘Relationship with supervisor’ consisted of five items (‘I have the opportunity to talk with my boss’; ‘I can trust my boss with personal as well as work related concerns’; ‘My boss is well informed about my work’; ‘My boss is supportive and builds up my confidence’; and ‘My boss tells me when I am doing a good job’), which were summed with a Cronbach’s reliability score of {alpha} = 0.89.
  3. ‘Knowledge’ consisted of five items (‘I have knowledge about hospital goals’; ‘I have knowledge about future plans’; ‘I have knowledge about the budget situation’; ‘I have knowledge about results achieved and progress toward goals’; and ‘I have knowledge about staffing problems among workers in my department’), which were summed with a Cronbach’s reliability score of {alpha} = 0.84.
  4. ‘Work stress’ consisted of six items (‘How often do you have so much work that you feel restless and nervous?’; ‘How physically tiring is your work?’; ‘How mentally tiring is your work?’; ‘How often does thinking about problems at work disturb your sleep?’; ‘How often are you so tired after work that you have difficulty dealing with responsibilities at home, visiting friends or pursuing a hobby?’; and ‘How often have you been depressed or disturbed by conflicts arising at work?’), which were summed with a Cronbach’s reliability score of {alpha} = 0.77.
  5. ‘Unrealistic expectations’ consisted of five items (‘How often did superiors/colleagues/colleagues at other institutions/patients and their families/bureaucrats at the ministry present unrealistic expectations’), which were summed with a Cronbach’s reliability score of {alpha} = 0.72.
  6. ‘Collegial relationships’ consisted of two items (‘Colleagues support me when needed’; and ‘My colleagues trust me’), which were summed with a Cronbach’s reliability score of {alpha} = 0.75.
  7. ‘Discussions with colleagues’ consisted of three items (‘How often do you discuss diagnosis/treatments with your colleagues?’; ‘How often do you discuss patient care plans with your colleagues?’; and ‘How often do you discuss patients’ or their families’ problems with your colleagues?’), which were summed with a Cronbach’s reliability score of {alpha} = 0.80.
  8. ‘Recognition’ consisted of three items (‘How often do colleagues/superiors/patients express praise for your efforts?’), which were summed with a Cronbach’s reliability score of {alpha} = 0.67.
  9. ‘Sense of belonging to organization’ consisted of a single item (‘The hospital is a complex organization. How much do you feel that you are an integral part of the hospital?’), measured on a 5-point Likert scale.

All these variables can be treated as continuous measures, since their scales set ‘equal appearing interval’ choices for each item on the survey instrument [17]. In essence, the analysis is a series of bivariate tests between continuous variables, for which Pearson’s correlation is appropriate [18]. Scheffe’s F-test was used to conduct a post hoc analysis of variances between categories of workers.


   Results
Top
 Subjects and methods
 Results
Discussion
 Conclusions
 References
 
By the end of the data collection period, 473 out of 617 staff members at Pärnu Hospital had completed the questionnaires, yielding a response rate of 77.0%. The average age of the respondents was 44.3 ± 13 years (the youngest being 19 years and the oldest 78 years). Most of the respondents were women (95.9%). Of the respondents: 96 were physicians; 166 were nurses; 95 were nursing assistants; 50 were therapeutic or diagnostic staff; and 66 were administrative and support staff. The administrative and support staff group was further subdivided into executive and support staff. Of these, 33 were in executive positions (one chief doctor, one deputy chief doctor, one senior nursing officer, eight department heads, 16 departmental senior nursing officers, one financial director, one catering manager, one chief accountant, one personnel manager, one chief engineer, and one chief laboratory technician). The average rating of job satisfaction was 3.86 out of a possible 5 points, with significant differences between categories of staff (Table 1). Furthermore, a significant difference in job satisfaction rating was revealed between the executives (4.15 ± 0.57) and the staff (3.81 ± 0.83).


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  		Table 1 Job satisfaction by occupational category measured on a 5-point scale

 

For the hospital staff as a whole, job satisfaction was positively correlated with the variables: ‘planning’, ‘relationship with the supervisor’, and ‘feeling part of the organization’. These positive correlations were confirmed using nature of satisfaction as a corroborating dependent variable. Equally important are the significant negative correlations found between job satisfaction and knowledge, work stress, and unrealistic expectations. Again, these negative correlations were confirmed using nature of satisfaction (Table 2). These same positive and negative correlations were significant for nurses.


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  		Table 2 Correlation of work environment factors with job satisfaction and nature of satisfaction variables for all staff

 

Recognition was significantly positively correlated with the job satisfaction variable, but this relationship was not confirmed using the corroborating dependent variable of nature of satisfaction. Similarly, discussions with colleagues were significantly positively correlated with nature of satisfaction, but not with the primary variable of job satisfaction. Collegial relationships were not significantly correlated with either job satisfaction or nature of satisfaction.

It is also important to consider which factors are correlated with satisfaction for nurses, doctors, nursing assistants, and the other categories of hospital staff. Planning appeared to be equally important to all groups of staff; all reported that management was only moderately clear in its goals, plans, and objectives, scoring 10.2–10.9 out of a possible 15.0 (Table 3).


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  		Table 3 Scores of the five categories of Pärnu Hospital staff for the ‘planning’ variable

 

Some groups reported better relationships with their supervisor than others. Doctors reported the lowest scores in ‘relationship with their supervisor’ (15.7/25) and nursing assistants reported the highest scores (19.5/25); the differences were significant. Nurses and other staff reported similar scores in their relationships with their bosses, in the range of 17.8 to 18.6 (Table 4). Similarly, doctors reported significantly lower scores in knowledge of hospital goals, plans, budget, results, and staffing problems, scoring 12 out of a possible 16 points compared with 12.8 for nurses, 13.1 for nursing assistants, 13.2 for other health staff and 12.5 for non-health staff (Table 5).


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  		Table 4 ‘Relationship with supervisor’ scores for the five categories of Pärnu Hospital staff

 

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  		Table 5 ‘Knowledge’ variable scores for the five categories of Pärnu Hospital staff

 

Despite the restructuring of hospitals and reduction of hospital beds reported in Estonia [19] and anticipated high stress levels [5], the staff at Pärnu Hospital all reported medium levels of work stress, from 14.1 to 15.8 out of a possible 30 points, with no significant differences between groups (Table 6). Similarly, none of the categories of hospital staff reported that their supervisors, patients/patients’ families or colleagues presented unrealistic expectations. The unrealistic expectation scores were all relatively low, ranging from 6.4 for non-health workers to 7.3 for nurses, out of a possible 20 points, with no significant differences between categories (Table 7).


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  		Table 6 ‘Work stress’ scores for the five categories of Pärnu Hospital staff

 

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  		Table 7 ‘Unrealistic expectations’ scores for the five categories of Pärnu Hospital staff

 

Finally, feeling a part of the organization was significantly correlated with satisfaction by all categories of staff (Table 8). However, all categories of staff at Pärnu Hospital reported only medium to moderate levels of belonging, with scores ranging from 2.5 to 2.9 out of 5 points.


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  		Table 8 ‘Sense of belonging to the organization’ scores for the five categories of hospital staff

 


   Discussion
Top
 Subjects and methods
 Results
 Discussion
Conclusions
 References
 
It was expected that the effect of restructuring of hospitals in Estonia would give rise to high ratings of work stress and low ratings of job satisfaction, as predicted by previous studies in Canada [20], the United States [21], and Finland [22,23]. However, the levels of work stress reported were at medium levels for all categories of workers. Levels of job satisfaction were moderately high. Moreover, excessive job demands or unrealistic expectations from supervisors, patients/patients’ families, and colleagues were not reported at high levels. These effects have been reported by hospital staff in studies of restructuring within Canadian hospitals [20] with longer-term effects on anxiety, depression, and emotional exhaustion.

Job insecurity does not arise without reasons. Hospital staff recognize organizational efficiency (or lack thereof) and this study measured and found that hospital staff were knowledgeable about quality of services, the goals, plans, budgetary situation, and staffing problems, as the studies in Finland had found [22,23]. This study found that stress at work is negatively correlated with job satisfaction. The items related to sleep disturbance and conflicts at work were particularly significant. Canadian [20] and Finnish studies [22] also found that the effect of downsizing was related to sleep disturbances and conflicts arising from work.

Hospitals are complex organizations to manage, particularly during a time of consolidation and restructuring with very limited budgets. Nevertheless, this study reaffirms the two classical motivation theories of Maslow [12] and Herzberg [9]. Management at Pärnu Hospital appeared to have clear plans, provided sufficient knowledge about the goals and situation of the hospital, paid sufficient attention to supervisory relationships, and attended to stressful situations and working conditions which could erode job satisfaction.

Physicians
Each category of staff has distinct responsibilities. Therefore, it is expected that different sources of satisfaction will motivate doctors, nurses, and other health care personnel. Compared with other positions, the work of physicians was characterized by a higher degree of independence in work planning and decision making; however, this entailed a higher degree of responsibility [24,25]. To be satisfied with their work, doctors need, first and foremost, information on the economic situation of the hospital, which would allow them to plan optimal treatment for their patients [24]. Inadequate resources at a doctor’s disposal might be one of the factors causing ‘dissatisfaction’ [25].

Although being informed about the economic situation of the hospital was by far the most important factor for job satisfaction for doctors, relationships with supervisors significantly affected doctors’ satisfaction with their job. The immediate supervisor’s being adequately informed of the doctor’s work and being available to talk about the problems encountered by the doctor in his or her work were nevertheless important factors with respect to job satisfaction. Similarly, findings from previous studies indicate that positive feedback and acknowledgement of work done are factors that increase a doctor’s job satisfaction, whereas indifference by supervisors may lead to feelings of dissatisfaction in their subordinates [9,14,24,25].

In the other positions (those of nurses, nursing assistants, therapy and diagnostic personnel, and administrative or support staff), the common factors affecting satisfaction were a heavy workload and an uncertain or stressful work environment.

Nurses
A heavy workload was the most influential variable in determining job satisfaction for nurses. Furthermore, studies of work-related stress in nurses have shown that irregular working hours, often involving overtime, is the main source of stress and that excessive stress at work may be one of the factors causing dissatisfaction [1]. Nurses are in constant communication with their patients, listening to their problems and enabling them to feel comfortable during the entire period of treatment. The great responsibility involved, the high workload, and the little latitude in the decision-making process increases work-related stress [26].

For nurses, important prerequisites of job satisfaction are support and encouragement from one’s immediate supervisor and the possibility of confiding one’s professional and personal concerns to one’s immediate supervisor. Nursing managers must allow nurses latitude to decide what is relevant in order to achieve the objectives of the treatment plans of their patients, because nurses value the work itself as much as recognition, status, and job security [27].

Furthermore, important factors contributing to job satisfaction were perceiving oneself to be an integral part of the hospital as a unified organization, and having the freedom to decide on the sequence of fulfilling professional duties. Moreover, being disagreeably treated by supervisors and conflicts at work were factors that negatively influenced job satisfaction.

Nursing assistants
The work of nursing assistants was tiring and their workload high; however, neither factor had much impact on job satisfaction. Often, the work of nursing assistants was not considered to be important, and was not given the appreciation it was due. Unlike workers with higher status, for nursing assistants the attitude of fellow workers had the greatest impact on job satisfaction. Once basic job security and pay issues are settled, the most important sources of satisfaction for lower and middle level workers are relationships with co-workers and supervisors [27,28]. Being disagreeably treated by fellow workers was the most important reason for dissatisfaction among nursing assistants. A nursing assistant’s immediate supervisor being informed about her work helped the nursing assistant to sense the importance of her work and was therefore a significant factor promoting job satisfaction. To a small extent, being informed about the future plans of the hospital also influenced job satisfaction for nursing assistants.

Therapeutics and diagnostic staff
Health professionals in the therapies, such as instructors of remedial gymnastics and physiotherapy, and diagnostics personnel such as laboratory technicians, radiologists, and other functional diagnosticians, worked mostly by themselves and their professional duties were more objectively defined than the duties of doctors, nurses, and nursing assistants. Health care workers in this group considered the sense of belonging to the hospital as a unified organization to be the most important factor in facilitating job satisfaction. Work environment and high workload had a smaller effect on job satisfaction. The literature suggests that the existence of an organizational structure acceptable to workers and the possibility of regulating one’s workload increase job satisfaction in laboratory workers [7,9].

Administrative and support staff positions
The professional duties of those working in administrative and support positions (such as accountants, secretaries, and operations personnel) were quite different from those in health care positions. Job satisfaction among non-health personnel was influenced to the greatest extent by physical and mental exhaustion, along with high workloads. When the employees working in these positions were able to talk to their immediate supervisor about their work-related difficulties, and supervisors expressed their opinions concerning the results of the work of the subordinates, job satisfaction among workers outside the health care provider categories increased. Attending to the needs of administrative and support staff for recognition and resolving their work-related problems is the most important task for the managers of those professionals who are not involved in the provision of care to patients [9,28].

For many of those working in administrative or support positions, being disagreeably treated by their fellow workers was also a factor causing dissatisfaction. At first glance, a surprising finding of this study was these individuals regarded compliments or recognition from patients and patients’ families as important to their job satisfaction. However, considering the efforts made by administrative and managerial professionals in recent years to improve hospital conditions in Estonia, it should not be surprising that they would seek recognition for their efforts.

Executives
The top managers and leaders of structural units at the hospital formed a distinct group. Their ratings of job satisfaction were considerably higher than those of all the other employees. The job satisfaction of those working in leading positions was influenced by the availability of refresher courses and the freedom to manage their large workloads. By virtue of their positions of authority, senior executives are most motivated by possibilities for growth and the achievement of objectives [29,30].


   Conclusions
Top
 Subjects and methods
 Results
 Discussion
 Conclusions
References
 
The management of Pärnu Hospital seems to have captured the commitment of the staff to the hospital, as indicated by predominantly positive responses to the items ‘Proud to be working at the hospital’ and ‘Willingness to make the extra effort’, along with the predominantly negative responses to the items ‘Nothing here depends on me’ and ‘My future and that of the hospital are not and will not become compatible’. These four items were shown to be important to organizational commitment in the studies of American hospital staff by Luthans and Sommers, most likely due to good relationships with their supervisors [21]. They also feel that they are an integral part of the hospital [21]. However, there appears to be room for improvement in the satisfaction ratings of the staff at Pärnu Hospital. Collegial relationships and recognition were measured in this study and found to have little significant impact on job satisfaction, except for workers in lower paid positions. Finnish studies [23] have also confirmed the importance of collegiality and supportive supervisory relationships. Feeling a part of the organization was found to be significant in this study.

Managing hospitals during a time of consolidation is challenging, and organizational efficiency and commitment can make the difference between a hospital remaining open and being closed. The community also plays an important role in supporting its hospital. Hospital staff cannot provide quality services in an efficient manner if the majority of the people in the immediate and surrounding communities choose to receive their services in another hospital [31]. Effective managers communicate the successes of their hospital, attend to the difficulties, and support their staff in every way possible. And for their part, hospital staff should be committed to the work of their hospital, giving extra effort in periods of difficulty and being devoted to the care of patients and their families.

The findings of this study suggest that the management of a health care institution that is informed about the expectations and daily work-related problems of their employees is better able to understand the needs of their employees. Management should: (i) build up effective relationships between management and staff; (ii) identify negative working conditions that affect staff; (iii) appropriately delegate authority to personnel, and hold them accountable for the work done in their organizational units; (iv) keep staff informed about changes that will affect them; and (v) express appreciation and recognition for the efforts of staff members in accomplishing the work of the health care organization. In doing this, management will create a favorable working environment for hospital staff.

Although this study conducted in Pärnu, Estonia, was of cross-sectional design, it drew upon the insights of international longitudinal studies. Estonia is a re-emerging democracy and, as such, exploratory and descriptive methods are within the budgetary limits of researchers at this time. Certainly, the insights of this study will be used to design more rigorous longitudinal studies, as cross-sectional designs generally cannot provide predictive explanations [32].


   References
Top
 Subjects and methods
 Results
 Discussion
 Conclusions
 References
 

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