Factors affecting employees' job satisfaction in public hospitals

Factors affecting employees' job satisfaction in public hospitals Implications for recruitment and retention AN Mohammed Mosadegh Rad Lecturer, Health Policy and Management, School of Health, Tehran University of Medical Science, Iran and Doctoral Researcher, Public Services Management, Royal Holloway, University of London, UK

Ailson De Moraes Teaching Fellov/ and Associate Researcher, Public Services Management, Royal Holloway, University of London, UK

Job dissatisfaction is a major cause of absenteeism and turnover among healthcare employees, and as such, it affects employees' organisational commitment and the quality of healthcare services. However, little is known about which factors influence job satisfaction and dissatisfaction in hospital staff. The purpose of this study was to investigate specific factors associated with job satisfaction and dissatisfaction in employees at the Isfahan University Hospitals (lUHs) in Isfahan, Iran. This study also focuses on revealing homogeneous demographic characteristics that these employees exhibited, which affect their satisfaction level. Questionnaires were distributed among the 950 employees through a classified randomised sampling. Overall, employees were moderately satisfied with their jobs, and more satisfied with the following aspects of their current work situation: supervision, job identity and co-workers. The lowest satisfaction scores were found for benefits, contingent rewards, communication, salaries, work conditions and promotion. Motivating factors included loyalty to employees, job security, good pay, good working conditions, tactful discipline, involvement, recognition and promotion.

Introduction The healthcare industry increasingly requires a skilled workforce due to rapid advancements in medical technology, moral attitudes and demands for more sophisticated patient-care delivery methods. Job satisfaction is critical to attracting and retaining well-qualified personnel. Concerns about employee job satisfaction are just as — if not more — essential in knowledge-based sectors such as the healthcare industry as they are in other business sectors, particularly in professional and service-based organisations sucb as bospitals, wbere long-term specialist training and retention issues are highly important.

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Ali Mohammed Mosadegh Rad and Ailson De Moraes

Satisfied employees tend to be more productive, committed to their organisation and settled in their job (Irvine and Evans, 1995; Currivan, 1999; Griffeth et a/., 2000; Shader et al, 2001; Strachota et al, 2003; Al-Hussami, 2008). Job dissatisfaction has been found to be a strong and consistent predictor of intention to leave as well as actual turnover (Hellman, 1997; Lum etal, 1998; Ito etal, 2001; Sourdif, 2004). Employees' job satisfaction is also found to be positively related to quality of service and patient satisfaction in the healthcare setting (Kivimaki etal, 1994; McNeese-Smith, 1995; Leiter et al, 1998; Kaldenberg et al, 1999; Tzeng, 2002). Employees can directly influence customer satisfaction in a service-based industry like hospitals. Their involvement and interaction with customers plays a significant role in quality perceptions and customer satisfaction. Job satisfaction has been the most frequently investigated variable in organisational behaviour (Spector, 1997) and healthcare has not been ignored in job satisfaction research. Myriad studies have examined job satisfaction in the healthcare context (Al-Ahmadi, 2002; Bodur, 2002; Aronson et al, 2003; Chu et al, 2003; Lyons, 2003; Seo, 2004). This proliferation of research has focused attention on the need to understand job satisfaction of healthcare providers. Justification for the need to investigate employees' job satisfaction is exemplified in the relationship observed between the lower levels of job satisfaction and negative symptoms of absenteeism, grievance expression, tardiness, low morale and high turnover. Job satisfaction is important to managers because ofthe desire to retain a stable and skilled workforce. Researchers are interested in understanding the factors that influence an individual's decision to stay or leave an organisation. Iran's healthcare system is passing through a period of transformation. Since the early 2000s, the Ministry of Health has been working on a comprehensive healthcare reform programme, especially in hospitals. One ofthe aims of this reform programme is to strengthen healthcare management to improve the performance of healthcare organisations. However, human resource management is still not what it should be, and the human aspects relating to employee satisfaction and quality of work life, which affect productivity, are neglected. The results of the study presented in this paper will enable a better understanding of factors associated with job satisfaction and dissatisfaction of employees. Factors promoting job satisfaction can also be significant for attracting new employees to the organisation. Therefore, it is anticipated that a better understanding of these issues can aid further research, pinpoint better strategies for recruitment, promotion and training of future hospital managers and employees, and for reducing the level of turnover and absenteeism, particularly in Iran but perhaps in other societies as well.

Loterature revoew Employee job satisfaction is an attitude that people have about their jobs and the organisations in which they perform these jobs. Job satisfaction is defined as "the extent to which people like or dislike their jobs" (Spector, 1997, p. 2). It is an employee's affective reaction to a job, based on a comparison between desired and actual outcomes. Job satisfaction is generally recognised as a multifaceted construct that includes employee feelings about a variety of both

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Factors affecting employees' job satisfaction in public hospitals

intrinsic (e.g. job itself and opportunities for personal growth and accomplishment) and extrinsic (e.g. pay and benefits, company policies, supervision and support, co-workers, job security, chances for promotion) job elements (Misener et al, 1996). Two different categories of theories such as content and process theories help to conceptualise job satisfaction. While content theories focus on what motivates people, process theories focus on how people's needs influence their behaviour. The latter provide an opportunity to understand processes of motivation and reflect on the dynamic contextual and individual factors which constitute the employees' expectations, which in turn influence their behaviour. Combining these two theories gives a better insight in the understanding of motivation and job satisfaction of employees. Herzberg's (1966) two-factor theory and Maslow's (1970) Hierarchy of Needs exemplify content theories by identifying needs or values to be realised in order for an individual to be satisfied at work. For instance, Herzberg (1966) identified hygiene and motivating factors related to peoples' attitudes to work. Hygiene factors or "dissatisfiers" are those factors that affect job dissatisfaction. Examples of hygiene factors include salary, benefits, organisational policies, supervision, working conditions and relationships. Although their absence causes job dissatisfaction, they do not impact job satisfaction. On the other hand, motivators such as achievement, recognition, promotion, responsibility and work itself promote motivation and consequently satisfaction. Once hygiene factors are met, the motivation factors will promote job satisfaction. According to Maslow (1970), human needs form a five-level hierarchy ranging firom physiological needs, safety, love and esteem to self-actualisation. Once individuals have satisfied one need in the hierarchy, it ceases to motivate their behaviour and they are motivated by the need at the next level up the hierarchy. Based upon this theory, employees will seek to fulfil self-actualisation needs whenever their other' low-level needs have been met. Sources of low satisfaction are associated with low salaries and benefits, working with unskilled or inappropriately trained staff, laborious tasks such as documentation, repetition of duties, tensions within role expectations, role ambiguity, role conflict, job/patient care, feeling overloaded, the increasing need to be available for overtime, relations with co-workers and personal factors (McNeese-Smith, 1999; Furnham, 2002; Heywood etal, 2002; Chu et al, 2003; Gigantesco etal, 2003; Hies etal, 2003; Thyer, 2003; Navaie-Waliser et al, 2004). According to Glisson et al (1998) factors influencing job satisfaction can be divided into three main categories: job characteristics, organisational characteristics and characteristics of employees who perform the job. The theoretical framework used is shown in Figure 1 below. The study sought to examine the validity of this hypothesised model with a sample of Iranian hospital employees.

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Job satisfiers Job factors: • • • •

Job identity Variety in job Routinisation Workload

Individual factors: Age Gender Educational level Personality Experience years Marital status Financial status

Job satisfaction

Organisational factors: • • • • ' • • • • • •

Organisation structure Policies and procedures Management support Co-worker support Communication Management systems Working conditions Payment Promotion and recognition Fairness Training

Employees' outcome

Cultural factors: • Cultural values • Religious beliefs • Attitudes

I

Organisational commitment

Figure 1: Hypothesised relationship between job satisfaction and turnover

The study, whose purpose was to investigate specific factors associated with job satisfaction and dissatisfaction of employees in IUHs, utilised descriptive correlation design and cross sectional survey methodology. The healthcare settings for this study included 12 university hospitals in Isfahan, Iran. At the time ofthe study (2004), these hospitals employed 6,405 full time employees. Spector's (1997) Job Satisfaction Survey (JSS) was used to measure job satisfaction. Respondents rated each item on a six-point Likert scale from 1 (disagree very much) to 6 (agree very much). Spector reported coefficient alphas ranging from 0.60 for the co-worker facet to 0.91 for the overall measure. The JSS consists of 36 items within nine categories. Table 1 below shows a description of job satisfaction facets. Since hospital employees deal with very specific tasks on a daily basis, there may be a link between individuals' demographic characteristics and their job satisfaction. This part contained a standard set of socio-demographic and jobrelated questions addressing age, sex, education, position, years of experience and department, on which data was also gathered. Also, the questionnaire provided ten important job motivators. Employees were asked to prioritise these motivators according to their personal interests. Managers were asked to prioritise these motivators once according to their personal interests and another time according to their employees' interests to find out more about managers' knowledge of employees' perceptions of their most important motivators. Those motivators were listed as good pay, job security, good working conditions, involvement, recognition, promotion, interesting work, loyalty to employees, tactful discipline and help with personal problems. A detailed explanation ofthe validity, reliability and acceptability ofthe study can be found in Appendix A.

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Table 1: Description of job satisfaction facets Job satisfier factors

Description of facet

Pay

Satisfaction with pay and pay rises

Promotion

Satisfaction with promotion opportunities

Supervision

Satisfaction with the person's supervisor and manager

Fringe benefits

Satisfaction with fringe benefits

Contingent rewards

Satisfaction with given for good performance

Working conditions

Satisfaction with working rules and procedures

Co-workers

Satisfaction with co-workers

Nature of work

Satisfaction with type of work done

Communication

Satisfaction with communication within organisation

Results A total of 814 employees participated in this study. These included 665 employees, 127firstline managers (departments' heads), 11 middle managers (hospital managers) and 11 senior managers (hospital presidents). Respectively 51.5%, 87,4 %, 90,9% and 90.9% of employees, first line, middle and senior managers had permanent employment. There was no relationship between educational background and current organisational positions of hospital managers in 90,9 % cases. The mean age for employees, first line, middle and senior managers were 34.2, 41,8, 46,4 and 45.2 years respectively. The ages ranged from 18 to 58 year, Male employees were significantly older than female employees. Employees, first line, middle and senior managers on the average, had 10,6, 18.7, 20.2 and 17,7 years of working experiences respectively, Male employees, on the average, had 12.28 years of working experience while females averaged 9.30 years. Males had significantly more years of working experience than females. First line, middle and senior managers on the average had 8,7,11.8 and 8.7 years of managerial experiences respectively. The majority of employees of IUHs had attained a bachelor's degree (see Table 2 below). Total job satisfaction ofthe respondents was measured on a six-point scale, where 6 stood for highly satisfied and 1 for highly dissatisfied. The overall job satisfaction ofthe respondents was 3,26±0,56 point (moderate satisfaction). The mean score of job satisfaction of employees, first line, middle and senior managers was 3,21, 3,40, 3,97 and 3,73 from 6 credits respectively. Participant scores were lowest in the benefits, contingent rewards, communication, salaries, working conditions and promotion areas but scores were highest in the supervision, nature of the job and co-workers domains (Table 3 below). The differences between values of employees' job satisfaction in different hospitals were statistically significant (p = 0,038), The mean score of employees' job satisfaction in general and specialised hospitals was 3.19 and 3.37 respectively. The mean score of employees' job satisfaction in hospitals with the specialty in burn (3.08), psychiatry (3.29) and cancer (3.31) were low and in hospitals with the specialty in ophthalmology (3,42) and cardiology (3.52) was high.

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Table 2: Frequency and percentage of participants and the mean Í core of their job satisfaction Demographic parameters

Frequency and percent

Job satisfaction

Frequency

Percent

Mean

SD

Sex: Male Female

394 420

48.4 51.6

3.28 3.23

0.50 0.56

Marital status: Single Married

147 667

18 82

3.21 3.27

0.59 0.52

Graduation degree: Illiterate Under diploma Diploma Post diploma Bachelor of science Master of science or doctor of medicine Doctor of philosophy

23 97 62 202 325

2.8

24.8 39.9

58 47

7.2 5.8

3.58 3.23 3.28 3.21 3.24 3.15 3.37

0.54 0.65 0.59 0.58 0.62 0.50 0.43

Area of work: Managerial and clerical Ancillary or logistic Therapeutic Diagnostic

156 108 448 102

19.1 13.3 55.1 12.5

3.32 3.44 3.20 3.24

0.59 0.43 0.56 0.47

Age group: Under 20 years Between 20-30 years Between 31-40 years Between 41-50 years Between 51-60 years

3 234 340 217 20

0.4

28.7 41.8 26.6

4.04 3.25 3.21 3.30 3.50

0.33 0.53 0.54 0.48 0.69

Work experience years group: Under 1 year (6 months-1 year) Between 1-5 years Between 6-10 years Between 11-15 years Between 16-20 years Between 21-25 years Between 26-30 years

26 202 169 147 112 104 54

24.8 20.7 18.1 13.8 12.8 6.6

3.34 3.29 3.20 3.15 3.32 3.33 3.34

0.43 0.48 0.53 0.53 0.51 0.46 0.65

667 147

81.9 18.1

3.22 3.44

0.53 0.54

Received wages: < 1,500,000 RLS > 1,500,000 RLS

11.9 7.6

2.5

3.2

The mean score of employees' job satisfaction in the Central Storage Department (4.21), Secretarial Unit (4.05), Public Relations Office (3.91), Social Worker Office (3.90) and Material Supply Department (3.66) were high and in the Psychiatry Ward (2.55), Paediatrics Ward (2.63), Dialysis Ward (2.75), Urology Ward (2.85) and Medical Records Department, (2.88) were low. The employee's job satisfaction in therapeutic and diagnostic departments was lower than in administrative and ancillary departments. A statistically significant association was seen between employees' job satisfaction and their area of work or specialty (p < 0.01).

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Table 3: The mean score of employees' and managers' job satisfaction according to job satisfier factors Senior managers

Middle managers

First line managers

Employees

All employees

Pay

3.04

3.63

2.75

2.64

2.67

Promotion

3.95

3.59

3.09

2.85

2.91

Supervision

4.29

3.36

4.77

4.71

4.69

Fringe benefits

2.75

2.34

1.91

1.92

1.93

Contingent rewards

2.72

3.29

2.76

2.37

2.44

Working conditions

2.65

3.06

2.64

2.78

2.76

Co-workers

4.77

4.98

4.54

4.32

4.36

Nature of work

5.06

4.8

4.60

4.34

4.39

Communication

3.54

3.72

3.14

2.38

2.53

Overall job satisfaction

3.73

3.97

3.40

3.21

3.26

Job satisfier factors

Table 4: The level of employees' and managers' job satisfaction Low

Medium

High

Senior managers

9.1

63.6

27.3

Middle managers

27.2

45.5

27.3

First line managers

23.9

63.2

12.9

Employees

28

64.7

7.3

Job satisfier factors

As Table 5 (below) shows, motivators such as loyalty to employees, job security, good pay, good working conditions, tactful discipline and involvement were more important respectively for employees. From the viewpoint of first line managers, motivators such as tactful discipline, involvement, good working conditions, recognition, loyalty to employees and good pay were more important respectively. From the point of view of middle managers, motivators such as involvement, loyalty to employees, recognition, and tactful discipline were more important respectively. From the point of view of senior managers, motivators such as good working conditions, good pay, loyalty to employees, involvement and tactful discipline were important respectively. When managers were asked to prioritise their employees' job motivators from the viewpoint of their employees, first line and senior managers chose sufficient salaries and recognition and middle managers listed job security, promotion and involvement as important. Job satisfaction amongst male employees was found to be significantly higher amongst female employees (p < 0.001). Married employees reported higher job satisfaction rather than single employees. The differences between values were statistically significant (p < 0.05). There was strong correlation between the job satisfaction of employees and their age, years of work experience, organisational position and received salaries (p < 0.01). There was no statistically significant correlation between job satisfaction of employees and their graduation levels and type of employment: permanent or contract employment (p > 0.05). In


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Table 5: Motivators ranking from managers' points of view Motivators

Senior managers Middle managers

First line managers

Good working conditions

1

8

3

Involvement

4

1

2

Tactful discipline

5

4

1

Recognition

6

3

4

Loyalty to employees

3

2

5

Good pay

2

10

6

Promotion

9

9

8

Help with personal problems

8

6

10

Job security

7

7

7

10

5

9

Interesting work

Table 6: Employees' motivators ranking from themselves and managers' points of view Motivators

Employees

Senior managers

Middle managers

First line managers

Good working conditions

4

8

10

6

Involvement

7

6

3

4

Tactful discipline

6

9

7

8

Recognition

8

2

6

2

Managers' loyalty to employees

1

7

4

3

Good pay

3

1

8

1

Promotion

9

3

2

9

10

5

5

5

Job security

2

4

1

7

Interesting work

5

10

9

10

Help with personal problems

order to determine the main factors that cause satisfaction and/or dissatisfaction with work, the relationship between total job satisfaction and job satisfier factors was analysed. Calculations of Spearmen's ratios revealed the strongest correlation between total job satisfaction and such characteristics as salaries, 0.687; fringe benefits, 0.685; promotion, 0.673 and communications, 0.637. On the other hand. Work conditions, 0.468; nature of the job, 0.502; supervision, 0.536 and co-workers, 0.554 had less effect on employees' job satisfaction respectively. This relationship was statistically significant in all of cases (p < 0.001). The results ofthe simultaneous multiple regression model indicate that together, the employee demographics explain 11% ofthe variance in employees satisfaction (F = 2.767, p = 0.002). Age explained the largest amount of the variance, followed by work experience. Job and organisational factors explain 25% and 95% of the variance in employees'

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job satisfaction respectively. Therefore, a supportive environment is most important to the job satisfaction of employees.

Discussion The study evaluated both global job satisfaction and different dimensions of satisfaction. The results show that employees are moderately satisfied with their jobs. They demonstrated less satisfaction with benefits, contingent rewards, communication, salaries, work conditions and promotion. It is recommended that particular attention be given to improving employees' job satisfaction. Motivators such as managers' loyalty to employees, job security, good pay, good working conditions, discipline, involvement, recognition, promotion and help with personal problems were important respectively for employees. Hospital mangers, particularly in the public sector, do not often have ultimate decision-making power on job security and additional financial incentives, which could motivate employees to perform better. However, they could make effective efforts in other areas of motivation to improve employee morale and satisfaction. A good working environment is important to most employees. Creating a pleasant working environment with adequate resources and facilities reduces employees' job-related stress and increases their satisfaction. Employees need to know that their contributions and good performance are recognised and valued. This inspires them to work even harder. Training for additional knowledge and skills is also a great motivator for many employees; in addition, it also improves employees' performance and productivity. Employees' needs and consequently motivators are different. Therefore it is important to understand what satisfies them in their workplace and motivates them to improve performance. In this current study, variables such as employees' age, gender, marital status, work experience years, organisational position, and received salaries and benefits were seen as having significant effects on their job satisfaction. Education level was the only demographic variable that did not show a statistically significant association with employees' job satisfaction. It seems that job satisfier factors such as salaries, benefits and working conditions were more important in neutralising the effect of graduation level on job satisfaction. Also, the differences between employees benefit because of the differences in their education level is not too much. A higher level of job satisfaction in illiterate employees may be due to the fact that most of these individuals are old and have been working in the hospitals for many years. Therefore, they are receiving higher pay because of their length of service. Also, they do not do the more complex jobs in hospitals. The higher level of job satisfaction for employees with diplomas is because of the nature ofthe jobs they perform. In studied hospitals, such individuals do the paper work. However, those employees who fail to finished high school and do not have a diploma, have to do the hard and non-professional jobs in hospitals such as working in the laundry or cleaning patients' rooms and so on. As regards differences according to age and seniority, a curvilinear relationship has been observed. Scores were higher for the lowest and highest ages and seniority ranges and lower after five to 15 years of


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experience of working in the hospital. The U-formed relationship between age, seniority and job satisfaction requires two interpretations. Among younger employees, a higher level of satisfaction may be due to the fact that inexperienced employees have fewer duties and responsibilities, less pressure, and fewer demands from colleagues. They may also be less exposed to work-to-family conflicts. Among older employees, higher satisfaction could be explained by a better knowledge of hospital working, by benefits linked to seniority and by fewer external demands. It is also possible that older employees refocus their priorities to factors outside of the work setting, such as family, or planning for retirement. The current study showed that promotion opportunities were another significant predictor of job satisfaction among study participants. The greater the chances are for advancement within the organisation, the higher is likely to be level of job satisfaction expressed by the employee. This finding is consistent with other studies, which have shown that opportunities for personal and professional growth and achievement is one of the best predictors of job satisfaction (Al-Ahmadi, 2002; Lyons et ai, 2003; Wittig, 2003). As expected, satisfaction was higher among employees with higher occupational positions. This can be attributed to having more control over the job and more decisionmaking latitude, along with a more central position between healthcare professionals, a valued position within the hospital hierarchy, higher salaries and benefits linked to seniority and more social recognition. Hospital presidents (senior managers) expressed less job satisfaction than hospital managers (middle managers). Senior managers are medical practitioners who prefer to spend more of their time on professional medical practices instead of stressful managerial works. In addition, their benefit from managerial works is less than what they receive from professional medical practice. This study also demonstrates that those employees who work with patients had less job satisfaction. Employees working in psychiatry, paediatrics, haemodialysis and urology had less satisfaction. Job rotation could possibly be a good strategy for improving job satisfaction of these employees. The lower level of job satisfaction for employees working in the medical record department is likely also because ofthe specific nature ofthe jobs they perform and having more contacts with clients. Automation is not used in these hospitals, and these employees have to perform their duties manually. Documentation, repetition of duties and low salaries are the most important sources of dissatisfaction of employees in this department. It is recommended that management use job enrichment as a motivational strategy to satisfy these employees. It is also one way to ensure that employees enjoy responsibility and a sense of accomplishment. The motivational effect of job enrichment stems from the opportunities for personal achievement, challenge and recognition. Research findings also identified that the nature of the job is not an important motivator for either employees or managers. This has important implications for the universities which educate people in healthcare professions, A higher importance should be placed on the interest people need to have in working with patients before they choose such people-oriented careers in thefirstplace. Another major finding as to the cause of employee job dissatisfaction is the lack of respect and recognition they receive from hospital management.

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Recognition and respect are highly important, especially for employees who are in direct contact with patients, patients' relatives, peers and other healthcare team members. Recognition from managers for good performance is vital in increasing job satisfaction and is central to boosting morale. A supportive management style, demonstrated through open communication, respect and recognition can greatly improve the satisfaction of employees on the job. Possessing knowledge and information about employee motivation and their needs and wants helps managers understand how employees can be involved to achieve better performance in the workplace. While management thinks that good pay is the number one desire of the employees, the results of this survey show that this factor is usually in the middle of the ranking. It is interesting to note that the perceptions of managers of the importance of motivators for employees vary considerably from how employees view what motivates them.

DmplîcatDomis for maoagememit Employees are the most important assets in organisations (Dibble, 1999). Nevertheless, managers do not spend enough time learning more about human behaviour, communication and how their attitudes and behaviour impact employee performance. Management requires a keen understanding of human nature, the basic needs, wants and abilities of people. Managers at all levels cannot cause an employee to become motivated; they must create the environment for individuals to motivate themselves. Since job satisfaction has a strong correlation with job performance it is very important to reinforce this by applying the right human resources polices. If employees are highly satisfied with their work, supervision, co-workers and pay and derive a high level of overall job satisfaction with their jobs they are more likely to be committed to the organisation than if they are not satisfied. The results of this study suggest that management might be able to increase the level of job satisfaction in the organisation by increasing satisfaction with policies, work conditions and compensation. One way of addressing this could be by increasing the interactions with employees in staff meetings and hospital committees. Treating employees with respect, rewarding them appropriate to effort and value to the organisation and changing in organisational variables could help increase employees' job satisfaction and decrease employee turnover. If managers want to increase job satisfaction of employees, they must be more supportive and give staff opportunities for advancement. Unfair promotion pohcies (as perceived by employees) may negatively impact job satisfaction. It is therefore recommended that managers provide equal promotion opportunities for employees that would promote them to key positions and increase their involvement in decision-making. Such steps will help to increase the level of job satisfaction. Developing staff and empowering them to make decisions about their work is necessary to achieve a highquality, cost-effective outcome (Zwingman-Bagley, 1999). To motivate an individual, a job itself must be challenging, have scope for enrichment and be of interest. With regard to satisfaction with work itself, findings show that


6D


hospital employees were less satisfied with their work. It is recommended that management redesign employees' jobs to activate the achievement-oriented behaviour that characterises employees. This can be done by giving them more responsibility and by allowing them to make important decisions related to their works. This would enable them to fulfil their need for achievement and enhance their job satisfaction.

Lomiitatôons In this study, employees' participation was voluntary and was conducted at 12 university hospitals in Isfahan, Iran. These factors limit the possibility of generalising from the study findings. The results of the study can only be generalised to all employees employed in IUHs. So, the findings should be interpreted with caution since the participants were hospital employees from a particular province of Iran and do not represent all hospital employees in this country. This study may serve as a foundation for future studies in different countries, on a larger scale. It is certainly worth further exploration, especially within hospitals that are perhaps not as hierarchical as the public hospital surveyed in the current study.

Conclusooini In a cross-sectional study, specific factors associated with job satisfaction and dissatisfaction of employees in Isfahan University Hospitals, Isfahan, Iran were explored. The study provides information about the status of global and dimension-specific job satisfaction among hospital employees. Seventeen variables were found to contribute significantly to variance in hospital employees' job satisfaction. Factors that may influence the level of employees' job satisfaction are demographic variables of age, years of work experience, marital status, gender, organisational position, monthly salary, ' type of department, type of hospital and the nine sub-scales of job satisfier factors, as indicated in Table 3 above. The findings show that hospital employees are moderately satisfied with their jobs. Salaries, benefits, promotion, contingent rewards, interpersonal relationships and working conditions are the best predictors of job satisfaction among hospitals employees. Specific job satisfaction dimensions indicate that highest dissatisfaction levels occur in the area of benefits, contingent rewards, communication, salaries, work conditions and promotion. Areas of dissatisfaction are signals for change.

Acknowledgement This study was funded by the Isfahan University of Medical Sciences. The authors gratefully acknowledge the IUHs' managers and employees for their assistance in conducting this research.

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acceptabilüty of the study Independent variables Demographic variables play an important role in determining an employee's job satisfaction. In analyses, gender, marital status, age, tenure, educational level, type of employment and amount of salaries were included as control variables. Prior studies have demonstrated that these demographic variables are potential predictors of job satisfaction (Hespanhol etal, 1999; Al-Ahmadi, 2002; Bodur, 2002; Aronson et al, 2003; Chu et al, 2003; Lyons, 2003; Seo, 2004). Validation of research instruments Spector's (1997) lob Satisfaction Survey questionnaire was originally developed in English. A Persian translation of this questionnaire was developed by applying a sequential forward and backward translation approach. The final test version was then pilot-tested, using a random sample of 40 hospital employees, (not included in the sample) and found to be well accepted and easy to fill in. The pilot-testing showed that the instrument was simple and straightforward to complete, not time-consuming (approximately 15 minutes) and generally accepted by the interviewees. Reliability of research instruments Cronbach's alpha coefficient has been used for estimating the reliability of questionnaire. An alpha value of 0.70 or higher was considered as acceptable reliability for questions. The reliability coefficient for the questionnaire was 0.87, while the coefficients for the nine domains were as follows: wages and salaries, 0.76; fringe benefits, 0.83; promotion and achievement, 0.79; contingent rewards, 0.78; communication, 0.77; working conditions, 0.80; nature of work, 0.78; supervision, 0.89 and co-workers, 0.77. Acceptability of research instruments Acceptability was assessed in terms of refusal rates, and rates of missing responses. A total of 814 (85.68 %) hospital employees filled out the job satisfaction questionnaires. Organisation specific response rates varied from 91% to 100%. Missing data analysis showed that 92% respondents had no missing values for the entire set of 36 items. The main reasons for nonparticipation were either the refusal to take part in the study or absence. Data collection The sampling method was stratified random sampling. From 6,405 employees of hospitals, 950 persons were selected for this research after a pilot study by using the following formula (N == 6405, d = 0.03, z = 1.96 and s = 0.51). Employees who had less than 6 months working experience were excluded from this study. Erom the 950 distributed questionnaires, 832 questionnaires were returned and from those, 814 questionnaires were completely filled in showing a return rate of 85.68%.


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Analysis of data All data were analysed using the statistical package for the Social Sciences (SPSS 11). Appropriate statistical procedures for description and inference were used. The missing values were checked prior to further statistical analysis. In order to normalise the Likert scale on 1-6 scales for each domain, the sum of raw scores of items in each domain was divided by 4 and for overall job satisfaction; sum of raw scores of items was divided by 36. The possible justified scores were varied between 1 and 6. Scores of 2 or lower on the total scale indicate very low, scores between 2 and 2.99 indicate low, scores between 3 and 3.99 indicate moderate, scores between 4 and 4.99 indicate high and scores of 5 or higher indicate very high job satisfaction or commitment. Higher scores in the domains indicate better job satisfaction. The differences between groups were tested with the chi-square, T-Test, Mann-Whitney, one way ANOVAs and Kruskal Wallis tests. The correlation coefficients were calculated to evaluate the relationship between variables. Stepwise multiple regression analysis was used to identify the most important predictor domains in global satisfaction. Data were presented as the mean ± standard deviation (SD) and percentage (p values less than 0.05 were considered as significant).

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Ali Mohammad Mosadeghrad is a Lecturer in Health Policy and Management at Tehran University of Medical Sciences in the School of Health, and Doctoral Researcher, Public Services Management, School of Management, Royal Hollov/ay, University of London. He holds a Bachelor and Master's Degree in Healthcare Services Management. Ali has vi^ritten extensively on many aspects of Healthcare organisation and management. He has v/ritten three books, and more than 30 articles in journals. His research interests include strategic management, quality management and organisational change. Ailson De Moraes, Teaching Fellow and Associate Researcher completing his PhD thesis in Leadership and Strategic Management, Public Services Management, School of Management, Royal Holloway, University of London. Ailson holds visiting lectureship positions at the European School of Management (ESCP) and the Katholieke Hogeschool Leuven. Before entering academia, Ailson worked for a number of international organisations in the UK, Portugal and Brazil, including the Gerdau Group, the 13th largest steelmaker and the largest producer of long steel in the Americas.

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