A comparative study on the level of satisfaction among regular and contractual health-care workers in a Northern city of India.

INTRODUCTION: Job satisfaction greatly determines the productivity and efficiency of human resources for health. The current study aims to assess the level of satisfaction and factors influencing the job satisfaction among regular and contractual health-care workers.
MATERIALS AND METHODS: A cross-sectional quantitative study was conducted from January to June 2015 among health care workers (n = 354) at all levels of public health-care facilities of Chandigarh. The correlation between variables with overall level of satisfaction was computed for regular and contractual health-care workers. Stepwise multiple linear regression was done to elucidate the major factors influencing job satisfaction.
RESULTS: Majority of the regular health-care staff was highly satisfied (86.9%) as compared to contractual staff (10.5%), which however was moderately satisfied (55.9%). Stepwise regression model showed that work-related matters (β = 1.370, P < 0.01), organizational facilities (β = 1.586, P < 0.01), privileges attached to the job (β = 0.530, P < 0.01), attention to the suggestions (β = 0.515, P < 0.01), chance of promotion (β = 0.703, P < 0.01), and human resource issues (β = 1.0721, P < 0.01) are strong predictors of overall satisfaction level.
CONCLUSION: Under the National Rural Health Mission, contract appointments have improved the overall availability of health-care staff at all levels of public health facilities. However, there are concerns regarding their level of motivation with various aspects related to the job, which need to be urgently addressed so as to improve the effectiveness and efficiency of health services.

Introduction

Job satisfaction is a significant predictor of the quality and efficiency of the health-care systems.[123456] It refers to the perception of health-care workers regarding various aspects of their work, such as physical atmosphere, privileges attached to the job, work-related issues, attitude of boss and coworkers, promotion opportunities, career growth, and human resource issues.[145] Job satisfaction affects employees' organizational commitment and consequently the quality of health services.[7] In health sector, the job satisfaction of health-care workers has a positive and strong association with patients' satisfaction and contributes to the continuity of care.[89] Conversely, job dissatisfaction has a negative impact on the structure and workflows of organizations such as nonconformance with procedures and policies, increase in work accidents, organizational conflicts,[10] increase in rate of medical errors,[11] increased burnout and turnover of health-care staff, thus jeopardizing patient safety.[1213]

Health-care professionals in public sector of India seem to be less satisfied with the policies of the health-care institutions. Several strikes and protests by the health-care professionals in India in the recent past are the testimony of the fact.[14] This has raised a continuous threat of attrition of medical professionals in public health-care sector. National Health Mission (NHM) has emphasized on increasing the level of satisfaction of health-care workers by providing better incentives and working environment and decreasing the workload by recruitment of more staff. One strategy to increase the effectiveness and efficacy of health-care services formulated by the National Rural Health Mission is contractualization of staff in health centers. However, increasing attrition of contractual staff is a big question mark for the sustainability of contractual model in health-care system. The present study is the first study in North India which compared the level of job satisfaction among regular and contractual health-care workers.

Materials and Methods

Study settings

It was a cross-sectional, quantitative study carried out in public health care facilities of Chandigarh city in the northern part of India from January to June 2015. Besides tertiary care services, the government health facility network in Chandigarh includes two community health centers (CHCs), 1 polyclinic, 26 civil dispensaries, 20 AYUSH dispensaries, 16 subcenters, and 1 district hospital. As per the rural health statistics 2015, there are 24 auxiliary nurse midwives (ANMs) at a subcenter and primary health center (PHC) level, 99 nursing staff at PHC and CHC levels, 27 specialists at CHCs, and 17 pharmacists and 19 laboratory technicians at PHC and CHC levels in Chandigarh region.

Sample size and sampling procedure

A minimum estimated sample size of 354 was calculated on the basis of mean satisfaction level as 70%,[15] absolute error of 5%, 95% confidence interval, and nonresponse rate as 5%. The sampling frame consisted of all government health facilities in Chandigarh. The health-care workers were selected proportionately to their numbers (Probability proportional to size sampling) in the sampling frame. Thus, medical officers (78), ANMs, staff nurses, lady health visitors (LHVs), trained birth attendants (TBHVs), and multipurpose health workers (MPHW) (168), pharmacists (83), laboratory technicians (19), and public health consultants (6) in both regular and contractual positions were selected randomly ensuring at least 30% cadre strength for each category.

Data collection instrument

An interview schedule based on Kumar and Khan scale[16] and Kaur et al. scale[17] was developed after suitable modifications. The questionnaire comprised of two main parts: sociodemographic profile and domains of job satisfaction. Demographic profile included information on gender, age, designation, educational qualification, and experience whereas job satisfaction part consisted of 49 items in nine key domains such as organizational facilities, privileges attached to the job, interpersonal relations, work, relationship between management and employees, career development, chance of promotion, human resource issues, and attention to the suggestions. For each item, a respondent had an option to choose from a five-point Likert scale representing various degrees of satisfaction: 1-extremely dissatisfied, 2-dissatisfied, 3-not sure, 4-satisfied, and 5-extremely satisfied.

Data collection

Prior permission from the office of the NHM, Chandigarh, was obtained after briefing them the above objectives and intent of the study.

Pilot testing of the instrument

A subset of 20 health-care workers employed in government health facility (not in main study) was interviewed using the tool developed for the study. No potential problems were found in the administration of instrument by a field investigator. The structure of questionnaire remained the same after this stage (i.e. 49 items, nine domains).

Main study

The trained investigator visited each health facility of Chandigarh on a fixed date and time after obtaining prior permission from in-charge of health center. After explaining the objectives of the study, an interview schedule was administered to them. The respondents were ensured about anonymity and confidentiality of his/her information. The average time for interviewing each respondent was 30 min.

Data analysis

The filled questionnaires were checked for missing information (data mining), which was followed by coding of variables and data entry in MS Excel. Reliability test using Cronbach's alpha was done to measure the internal consistency of the scale; the value = 0.910 shows that the scale is highly consistent. The data was exported to Statistical Package for the Social Science (SPSS) for Windows Version 16.0 Chicago, SPSS Inc. for statistical analysis. Chi-square test was applied to find association of sociodemographic characteristics and level of satisfaction and to assess the difference in satisfaction scores of contractual and regular staff. Overall level of job satisfaction was calculated by recoding the five-point Likert scale data into two categories: 0 and 1 (0 = extremely dissatisfied, dissatisfied, not sure and 1 = extremely satisfied and satisfied) and thus computing the sum of the scores for answer to each of the variables. Overall satisfaction score was categorized into three, i.e., highly satisfied (>60%), moderately satisfied (40%–60%), and least satisfied (<40%). Multiple linear regression models (stepwise method) were used to test predictive power of independent variable on overall job satisfaction. Wilcoxon one-sample signed-rank test was applied on all 49 items to test whether a sample median differs significantly from a hypothesized value, which reduced the number of variables from 49 to 36. Pearson's correlation coefficient was computed for each of the nine domains to find out the strength of association of overall job satisfaction with nine domains. All analyses were conducted at 95% confidence interval with allowable a margin of error as 5%. Level of significance for inferential statistics was set at P < 0.05.

Inclusion/exclusion criteria

All health-care workers listed under “Study population” employed at health-care facilities in Chandigarh and contractual employees with at least 6 months experience at the post and regular employees with over 2 years' experience in government service were included in the study. Administrative staff and all other health-care workers who do not provide clinical health-care services were excluded from the study.

Results

In the study, 247 (69.8%) contractual and 107 (30.2%) regular health-care staff participated. Of all the participants, 231 (65.3%) were employed in civil dispensaries, 47 (13.3%) in CHCs, 29 (8.2%) in subcenters, and 22 (6.2%) in PHCs. Over three-fourth (75.7%) were graduate and above and over half (52%) had more than 6 years of experience at health facility. Majority of the contractual staff were in the age group of 25–35 years (54.6%) and had <10 years' experience (90%) while 57% regular staff were above 45 years of age and had over 10 years' experience (82.2%). Other sociodemographic characteristics of contractual and regular staff were statistically similar [Table 1].

Table 1

Background profile of health-care workers in government health-care facilities of Chandigarh, 2015 (n=354)

Table 2 shows that majority (86.9%) of the regular health-care staff were highly satisfied with overall health-care facilities while contractual staff were moderately satisfied (55.9%). Employees above 45 years of age (86%), those having experience of over 10 years (74.3%), and male respondents (52.9%) were found to be highly satisfied as compared to their counterparts. As per designation, ANMs, MPHWs, staff nurses, LHVs, TBHVs were found to be moderately satisfied (51.8%) whereas doctors (44.9%) and pharmacists (54.2%) were highly satisfied.

Table 2

Association between the level of job satisfaction and sociodemographic variables among health-care workers

Variables such as work-related issues (0.750) and organizational facilities (0.730) have very strong positive relationship with overall level of satisfaction. Other variables such as privileges attached to the job (0.576), chance of promotion (0.541), interpersonal relations (0.505), attention to the suggestions (0.498), and relationship between management and employees (0.417) have moderately positive relationship while career development (0.333) and human resource issues (0.231) have weakly positive relationship with level of satisfaction [Table 3].

Table 3

Correlation of variables with the level of satisfaction among regular and contractual health-care workers

The stepwise regression model showed that work-related matters (β = 1.370, P < 0.01), organizational facilities (β = 1.586, P < 0.01), privileges attached to the job (β = 0.530, P < 0.01), attention to the suggestions (β = 0.515, P < 0.01), chance of promotion (β = 0.703, P < 0.01), and human resource issues (β = 1.0721, P < 0.01) are strong predictors of overall satisfaction level. However, other dimensions, i.e., interpersonal relations, relationship between management and its employees, and career development, were not found to be significant as their P values were 0.127, 0.671, and 0.711, respectively (i.e., more than 0.05) [Table 4].

Table 4

Stepwise multiple linear regression for various determinants affecting overall level of job satisfaction

The regression equation so formed can be written as:

y = α + β1α1+ β2α2+ β3α3+ β4α4+ β5α5+ β6α6

Where α is constant and α1–α6 are independent variables, β1–β6 are regression coefficients of all the variables, and y is overall level of satisfaction (dependent variable).

Thus, the overall level of satisfaction can be written as:

Overall job satisfaction level = −32.908 + 1.3 (work-related issues) +1.586 (organizational facilities) +0.530 (privileges attached to the job) +0.515 (attention to the suggestions) +0.703 (chance of promotion) +1.072 (human resource issues).

In-depth interviews of respondents revealed that most of the contractual health-care staff were dissatisfied with privileges attached to the job, particularly, salary and allowances, maternity leave benefits, residential accommodation, pension benefits, transportation reimbursement, excessive workload, children education assistance, lack of promotion opportunities, and attention not paid to their suggestions. However, contractual staff was relatively more satisfied with certain domains such as attitude of boss towards work and other staff (interpersonal relations). The verbatims of respondents in the study are presented in Box 1.

Box 1

Verbatims of respondents in the study

Discussion

The present study revealed significant difference in the level of satisfaction between regular and contractual health-care workers with respect to sociodemographic determinants and factors influencing the job satisfaction level. The majority of the regular health-care staff (86.9%) were highly satisfied as compared to only 10.5% contractual health-care workers, who were however moderately satisfied (55%). These results were found to be consistent with the results of studies by Kumar et al. and Bhandari et al. conducted at primary urban health centers and central government health scheme dispensaries, Delhi, respectively.[1819] These findings may be attributable to the greater degree of independence associated with the work of the regular staff as compared to contractual staff. Sathyajith et al in their study regarding job satisfaction among nurses of private hospitals in Kerala found that 15% are highly satisfied on their job, 72% are moderately satisfied, and 13% shows low level of satisfaction.[20]

The results of our study showed that employees above 45 years of age and those having experience of over 10 years were highly satisfied as compared to their counterparts. Similar results were found by Brown et al., (1993), Clark et al. (1996), and Al Juhani and Kishk (2006).[212223] Al-Eisa et al. attributed the higher levels of satisfaction among older employees to better adjustment at work, greater rewards, less conflict between work and personal life.[24] Another quantitative study conducted by Liu et al. in China (2010) observed that eight domains, viz., job significance (88.2), job competency (87.9), and teamwork (87.7), as compared with work reward (72.9) and working conditions (79.7) were important parameters for satisfaction.[25] Further, the findings of the study by Khamlub et al. (2013) in Lao PDR also reiterated the fact that health-care workers who put in longer hours accumulate more experience and maturity, which tends to foster a better adjustment to the work environment.[26]

In consonance with other studies,[27] our study shows that males were significantly satisfied (52.9%) as compared to females. This can be due to the fact that women tend to have higher expectations and insecurity than men.

The results of the present study showed that organizational facilities have statistically significant influence on the level of job satisfaction. Similar findings was found in a study conducted by Sharma et al in ESI dispensaries where doctors were found to be dissatisfied with the working conditions.[28] Another study by Khamlub et al. in Lao PDR indicated that health-care workers were generally satisfied with their job, primarily due to comfortable working environment, good infrastructure, and a convenient life.[26] Agyepong et al. stressed the lack of essential tools and equipment as major barriers of satisfaction for health-care workers.[29]

Dissatisfaction with one's salary in our findings seems to be a common issue that is also evident in several other studies which suggest that health-care systems should provide a suitable salary and fringe benefits to satisfy their workers. Tran et al. in their study conducted in Vietnam demonstrated that respondents were least satisfied with salary and incentives (24.0%), benefit packages (25.1%), equipment (35.7%), and environment (41.8%).[30] However, Franco et al. found that being intrinsically satisfied (work recognition by seniors/colleagues or social recognition and reward) increases the overall satisfaction even in the absence of extrinsic factors such as working conditions, salary and other benefits.[31]

The effect of interpersonal relations on the level of job satisfaction was observed in present study was in consonence with other study by Kumar et al. in Delhi in 2014.[18] More concerns were shown by contractual staff as compared to regular staff which has led them to find better job opportunities in other organizations. Ramasodi et al in South Africa and Jathanna et al. found that job satisfaction was associated with good interpersonal relations.[3233] Similarly, Khamlub et al. in their study conducted at Vientiane found that conflict resolution at work, support from one's supervisor, and relationship with coworkers influence health-care workers' overall job satisfaction.[26] Julian Montoro-Rodriguez and Chen et al also concluded that job satisfaction can be achieved by adopting participative leadership styles that encourage the workers to do decision-making.[3435] Also, another study by Sharma et al found that attitude of immediate boss, salary incentives and attention paid to the suggestions are the leading indicators for estimating satisfaction or dissatisfcation of physicians.[36]

A highly significant relationship between factors such as work recognition, working hours, travelling time, flexibility in scheduling, paid vacation, and satisfaction was observed. Bodur et al in his study at health centers of Turkey had observed a positive relationship between job satisfaction score of midwives with items such as salary, getting along with coworkers, putting health policy into practice, work recognition, freedom of self-judgment, and trying their own methods.[37] Al Juhani and Kishk highlighted that lack of professional opportunities, patient care, and financial rewards were primary deterrent for physicians while nursing staff were dissatisfied with lack of professional opportunities, overload of work, and lack of appreciation.[23] Bonenberger et al. in Ghana revealed that health workers were found to be least satisfied with the remuneration, career development, management, and work environment.[38]

The study results after regression analysis of factors influencing job satisfaction concluded that work-related matters, organizational facilities, privileges attached to the job, attention to the suggestions, chance of promotion, and human resource issues play a major role in enhancing job satisfaction level. Similarly, Blegen et al. meta-analyzed factors influencing nurses' job satisfaction namely stress, commitment, communication (with supervisor and peers), autonomy, recognition, routinization, and fairness.[39] Mohite et al. in their study at Krishna Hospital, Karad, found that majority of nurses were highly satisfied with respect to all jobs reinforcing factors[40] Another study by Shinde et al in Maharashtra found social service, supervision, working conditions, compensation, and independence to be major factors for higher satisfaction among health care professionals.[41]

A study by Kumar et al. among nurses in Pakistan showed that most (86%) respondents were dissatisfied because of poor working environment, fringe benefits, lack of dignity and responsibility at workplace, and time-pressure concerns.[42] Jaiswal et al. in their study in Maharashtra concluded nine critical factors, viz., communication, pay/salary, working conditions, organization supervision system, coworkers, workload, benefits, career aspects, and rewards impact level of satisfaction among health-care workers.[43] Jain et al. in their study found that dentists had significantly higher job satisfaction scores than dental auxiliaries for income, recognition, opportunity to develop professionally, and quality of care.[44] Saini et al. found workload, inadequate supervisor support, less learning opportunities, and inappropriate feedback to be significant predictors of stress among nurses, thus affecting the overall job satisfaction.[45] Another study conducted among community health workers in Haryana concluded that non-financial motivators such as interpersonal relations, family support, skill and career development opportunities are key factors influencing their job satisfaction.[46]

Conclusion

Majority of the regular health-care staff was highly satisfied (86.9%) as compared to contractual staff (10.5%) who were however moderately satisfied (55.9%). The lack of job satisfaction was primarily due to poor organizational facilities, disparity in salary and allowances, pension benefits, residential accommodation, transportation facility, lack of promotion, and future career opportunities. Under the NHM, contract appointments have improved the overall availability of health-care staff; however, their level of motivation needs to be enhanced to improve the effectiveness and efficiency of health-care services. The principle of “equal pay for equal work” should be exercised wherein contractual health-care workers should get similar salary as regular health-care workers. Formal and informal meetings should be held on regular basis and suggestions of all the employees must be given due importance. There should be equal promotional opportunities for all regular and contractual health-care workers.

The results of the present study should be seen in the light of few limitations. Since it was a cross-sectional study, it provided a snapshot of health-care workers perspectives. Further, the causal relationships between job satisfaction and various determinants influencing level of satisfaction may not be established. The data might also be affected by social desirability bias as respondents might have answered questions in a way that would be viewed favorably by the interviewer. However, the study has the strength of enrolling all the major categories of health-care workers in proportionate to their size. Moreover, the study tool was comprehensively designed taking into view global and local contextual factors affecting job satisfaction.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.