Need for Reconceptualization of Professional Satisfaction and / or Work E ff ects in Healthcare Organizations A

Introduction: It is imperative to research professional satisfactions in healthcare organization, since throughout the world job satisfaction in healthcare institution is decreasing, sometimes there is none or is at a very low level. Aim: Evaluation of components of employees’ job satisfaction in General Hospital Valjevo, Valjevo, Serbia, and evaluation of connection of components of their job satisfactions with the presence of anxiety, stress and job pressure. Methods: An observational cross-sectional study of employees’ satisfaction is conducted in General Hospital Valjevo, Valjevo, Serbia based on an anonymous survey from November 2016. Structure and construction validity evaluation of job satisfaction is performed by using Principal Component Analysis. The evaluation of the connection of the satisfaction components with the stress scale was performed by multinomial logistic regression. Results: Two job satisfaction components emerged: 1) extrinsic – environment, autonomy and transparency satisfaction and 2) intrinsic – work content satisfaction. We showed that fi nancial compensation satisfaction, extrinsic, as well as intrinsic component of their job satisfaction is signifi cantly connected with stress and anxiety level at work. Conclusion: It is necessary to conduct a reconceptualization of professional satisfaction and/or work effi ciency of health care employees in conditions where, in healthcare organization and/or at whole healthcare system level, the job satisfaction is low or there is none.


INTRODUCTION
Rational basis to examine the level of job satisfaction of healthcare employees comes from the fact that with better understanding of their satisfaction, higher level of motivation is acquired, which is directly connected to patients' satisfaction [1][2][3] To give the highest level of quality of healthcare services to as many users that need those services in a certain environment of social, material, fi nancial and human resources, is the main goal of health care and every healthcare organization or a unit inside an organization.To acquire that goal it is necessary to increase a high quality working power too in healthcare organizations.Th us, it is very important that a healthcare organization pays attention to human resources quality in diff erent stages of quality system development.To focus the attention to the job satisfaction of healthcare staff shows that the job satisfaction is fundamental component of human resources quality.To be more specifi c, many researchers showed a strong positive correlation between the medical staff job satisfaction in healthcare institution and patients' satisfaction that are being provided with corresponding healthcare services in the same institution [4][5][6][7][8].
Organization's effi ciency largely depends on employees' work moral [9].Job satisfaction and healthcare employees' work moral are on a worrisome low level throughout the world [10][11][12].Bad job satisfaction causes frequent changes in organization, which negatively aff ects the job satisfaction of treating and healthcare [13,14].Th erefore, by creating the environment that promotes job satisfaction, managers in healthcare organization can develop employees that are motivated, productive and fulfi lled.In return, it will bring better healthcare services and will increase patients' satisfaction [15].However, it is systematical mistake to treat the job satisfaction as an emotional reaction of an employee, instead of treating it as him presenting viewpoints through an evaluation process and this mistake results in discouraging and neglecting the study of real, true aff ective person's reaction to the job he performs [16].In correlation to previously said, this study's goals were: to evaluate employees' satisfaction components in a healthcare institution and to evaluate the connection of components of their professional satisfaction with the presence of anxiety, stress and pressure at work.

METHODS
An observational cross-sectional study of employees' satisfaction is conducted in General Hospital Valjevo, Valjevo, Serbia based on an anonymous survey from November 2016.Th e inquiry had 15 questions that referred to the level of employees' satisfaction, while one question referred to the level of anxiety (stress) at work.Th e items that referred to job satisfaction are presented by ordinal upward Likerttype scale from 1 (very dissatisfi ed) to 5 (very satisfi ed).Level of anxiety presence, job stress and pressure is also measured by the ordinal Likert-type scale as 1 (not at all), 2 (a little), 3 (moderately), 4 (a lot) and 5 (very much).Th e rest of the questions of the survey referred to demographic data recording of the employees (gender, age) by nominal scales.
Data by category variables are described by frequency and percentage.Ordinal variables are described by median and interquartile range, while the data sets measured by the moderate scale are presented by an arithmetic mean as a measure of the central tendency and by standard deviation as a measure of the data set variability.Structure and construction validity evaluation of job satisfaction is performed by using Principal Component Analysis.Questions with communalities lower than or equal to 0.5 are not held within the extracted satisfaction components and are treated as separate, specifi c satisfaction factors.Diff erence in the level of satisfaction evaluation between the extracted satisfaction components is evaluated by paired-samples Student T test.Th e evaluation of the connection of the satisfaction components with the stress scale was performed by multinomial logistic regression.Th e evaluated signifi cance level was 0.05.Data is processed by using the statistical package of IBM SPSS Statistics 20, NY.

RESULTS
Th ere were 587 employees participating in the research, 74.1% of which are women.Th e age range of the employees is presented in Table 1.Th e evaluated average satisfaction values in certain questions are presented in Table 2.
In question 7, 8 and 9, the employees are satisfi ed, which means that in these questions the average evaluations do not show a presence of dissatisfaction of employees (Table 2).In all the other questions (except for 11) the average was 3 (neither satisfi ed, nor dissatisfi ed).Th e average evaluation of satisfaction with fi nancial compensation for work (item 11) includes signifi cant level of dissatisfaction that and is 2 (dissatisfi ed) and moves in the range from 1 (very dissatisfi ed) to 3 (neither satisfi ed nor dissatisfi ed).
Th e Principal Component Analysis showed that there are two satisfaction components that construct employees' satisfaction by applying measurement instrument (Table 3).Totally explained variance for both compo-nents is around 69%. Constructional validity of the survey is very high (Kaiser-Meyer-Olkin adequacy coeffi cient = 0.929).Questions 4. Index (score) for the fi rst component is calculated as an average sum value of answers to the items 8, 7, 14, 12, 13, 6, 5, 4, while the index for the second component is calculated as an average sum value of answers to the items 1, 2, 3, 4 and 15.
Student t-test for paired values shows that there is more Effi ciency or work content satisfaction of the employees than Work environment, autonomy and transparency satisfaction (p=0.000) With multinomial logistic regression method it is shown that there are three independent, signifi cant predictors of stress level at work that are related in diff erent ways with certain categories of stress (and pressure) presence at work (

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we say that satisfaction is "attitude towards our job" and that it is an "aff ective response to our job", we actually talk about the same thing [23].
A wide number of authors, however, consider that there is a signifi cant diff erence between aff ective reactions and forming the attitude or any type of opinion or evaluation measures by the individual [16,24].In other words, affective conditions, moods and emotions have causes and consequences, that diff er from the cause and consequence that came aft er forming the attitude or any other evaluation process.Besides, aff ective conditions are nothing more than just that -a condition.Our moods will changes from positive to negative and will go back again to positive.Aff ective conditions have their impact to a person's behavior at the moment when the mentioned aff ective condition appears.Aff ective conditions can impact evaluation processes and a person's attitude on a long run, too.
In our study we have shown that the employees' satisfaction is very low or there is none.Th is is supported by their answers to the questions whose average is 3 (neither satisfi ed, nor dissatisfi ed).Also, by evaluating the average in main components, low level of satisfaction is shown in both, work environment, autonomy and transparency satisfaction and effi ciency or work content satisfaction.In these situations, we resort to alternative conceptualization of professional satisfaction and/ or work effi ciency.Th ese are actually three individual procedures (models) that imply: a) attitude reconceptualization (this is usually applied in cases where emotional impact to work effi ciency is evaluated or where job satisfaction is low or non-existent, where there appears logical questions why would positive emotions be predictors of effi ciency increase in conditions of lack of professional satisfaction) [25], b) reconceptualization of work effi ciency (this is necessary in cases where there is omission in defi ning work effi ciency or where certain aspects of employees' behavior are wrongly understood as effi ciency) [26] and c) organization level analysis (it is conducted in cases where measured satisfaction is low or nonexistent, where during the research they didn't consider aspects of employees' behavior that are commonly known to cause dissatisfaction) [8].
Our results show that there is a need to re-conceptualize employees' attitudes, considering that the lack of anxiety and stress at We have shown that by increasing work environment and effi ciency satisfaction, there is a lower chance that an employee will feel very much job pressure due to stress presence at work (Table 5).Also, by increasing environment satisfaction there is a reduced chance that the employee will feel a lot of job pressure because of the stress presence at work.What is interesting is that with every increase of fi nancial compensation in one whole degree, chance that the employee won't be anxious at all due to stress and job pressure is increased 1.8 times (Table 5).

DISCUSSION
Cranny et al 2002 suggested that there is a clear consensus in defi ning job satisfaction [17].Th eir "consensus" defi ned satisfaction as aff ective (emotional) reaction to job and comparison between actual outcomes that are real in relation with the ones that are wanted (expected, wanted, deserved, etc.).Th is defi nition is essentially the same as the one off ered by Locke 1969 who says that "job satisfaction is pleasant emotional condition that is result of individual evaluation that the work they perform encourages and affi rms their value" [18].On the other hand, job dissatisfaction is unpleasant emotional condition that is a result of their evaluation that their work is frustrating and blocking the affi rmation of their values.Locke continues to defi ne job satisfaction as "pleasant and positive emotional condition that is a result of individual evaluation of their working experience" [19].Besides the defi nitions that defi ne job satisfaction "by consensus" as emotional reaction above all, series of other prevailing job satisfaction defi nitions understand the attitudes toward work or job satisfaction as a complete equivalent of one to another [20,21].Going through other researches it seems clear that most of the researchers in the area of organizational science don't admit the importance of inconsistency between the defi nitions of "job satisfaction as emotional reaction" and "job satisfaction as an attitude or work ethics".For example, Smith et al developed in 1969 a job description index and they defi ned job satisfaction as "feeling or aff ective reaction to diff erent aspects in a specifi c situation", but in the same way they suggest that "problems related to satisfaction measurement are only a specifi c example of the ones they found at any person's attitude evaluation" [22].Th at way, if work is exclusively connected to the fi nancial compensation satisfaction increase, but not with work content satisfaction increase (Table 5).Th is result is paradox since the biggest salaries in healthcare in the Republic of Serbia, especially due to valorized stress level, have the employees that work in intensive care units, operational rooms and psychiatry.On the other hand, high work content or effi ciency satisfaction should be a result of internal motivation and high working moral of employees.Th is result can indicate damaged, most probably wronged or intrinsic motivational processes of employees "bribed" by higher fi nancial compensation, but also a low work moral due to ignoring or denying anxiety, stress and job pressure.Mention result also shows that potentially higher number of overtime working hours in the institution can generate higher satisfaction of employees by material compensation for their work, but without any signifi cant relations with their attitudes towards work content and thus quality of their performance.
We suggest that in this organization it is necessary to establish reconceptualization of work effi ciency, considering that employees' attitudes (satisfaction) toward fi nancial compensation are not correlating with work effi ciency (Table 3), neither with their attitudes toward work environment.Higher scores regarding attitudes toward work environment represent a more signifi cant protective factor than higher anxiety, stress and job pressure level (Table 5), therefore, it is necessary that this institution's management clearly defi nes what is understood by work effi ciency of an employee.In other words, paying employees in healthcare system of the Republic of Serbia doesn't off er neither work moral, nor fi nancial satisfaction to their employees, which positively correlates with the indicators of their work's quality.Namely, by analyzing healthcare professionals' attitudes, some authors showed that economy restrictions performed in healthcare system, on both fi nancial and management part, lead to neglecting the health care, but also neglecting the costs of quality in healthcare institutions [27][28][29].Vuković 2014 performed a study that showed that high level of fi nanciers and menagement's neglect of the costs of quality in healthcare system correlates with disordance in employees' behavior, low work moral, increase of irrational spending and causing the employees' to fall under suspicious encourage-ment by farmaceutical and other companies to use products with small or with no net benefi t at all, and increase judicial process costs started by healthcare services users or employees' of healthcare organizations [29].
At the organizational level, in the institution where our study was performed, it is necessary to include a team of experts to conduct an additional study about the imact of certain factors that can potentially generate employees' dissatisfaction, which wasn't possible to do with this research.Th ese factors, above all, are connected with potential presence of health problems of employees, such as increased mental and physical fatigue (higher incidence of burnout sindrom), higher anxiety, higher incidence of major depresive episodes or increased depression of healthcare employees.

CONCLUSION
It is necessary to conduct a reconceptualization of professional satisfaction and/or work effi ciency of healthcare employees in conditions where, in health care organization and/ or at whole healthcare system level, the job satisfaction is low or there is none.Employees' satisfaction in mentioned conditions is not an emotional refl ection, but it refl ects formation of bad attitudes toward work content and work environment.Th e latter inevitably leads to poor performance quality of employees, bad helath outcomes for patients and bad business performance of healthcare organizations.

Table 1 .
9, 10 and 11, because of low communalities, are treated as separated satisfaction factors that Respondent employees' distribution by age category www.hophonline.orgf %

Table 4 .
Evaluated descriptive parameters for indices of extracted components of employees' satisfaction