Relationship between Staff Satisfaction, Productivity and Patients’ Satisfaction

Relationship between Staff

Satisfaction, Productivity and Patients’ Satisfaction

- A Study in Physical Rehabilitation Services -

By: Isabelle C. N. Devreux

Supervised by: Professor Agnes Jacquerye

10/1/2012

Research for obtaining the degree of Doctor in Public Health Sciences UNIVERSITE LIBRE DE BRUXELLES –POLE SANTE

Ecole de Santé Publique

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ACKNOWLEDGEMENTS

My deepest respect and gratitude goes to all the members of the guidance committee; Prof.

Alain Deccache, Prof. Alain De Wever, Prof. France Kittel, Prof. Jean-Jacques Moraine, and more specifically Prof. Agnes Jacquerye for seeing through all the stages of this project as well as to Prof. Filomena Valente for their precious expertise.

I would like to express my greatest appreciation for their time, guidance, critique and encouragement enabling me to persevere and gradually improve my research work.

I would also like to express my sincere thanks to all the department heads and staffs that participated to the survey and collaborated with the feedback intervention as without their willingness to participate, this project would not have been completed.

Finally, my wholehearted gratitude goes to my husband and children, family and colleagues for all their precious support, encouragements and belief in me.

Special thanks are also addressed to Ms. Menchie Callos and Ms. Bridget Somers for their

assistance.

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Table of Contents

Abstract ... 1

Summary ... 2

Articles ... 4

Chapter I Introduction ... 37

1. Statement of the Problem ... 39

2. Significance of the Study ... 39

3. Delimitations and Limitations of the Study ... 40

4. Purpose of the Study... 41

5. Hypothesis ... 41

6. Definitions ... 42

Chapter II Literature Review ... 44

1. Concept of Job Satisfaction ... 48

2. Staff Satisfaction in Health Care ... 50

3. Dimensions of Satisfaction in Rehabilitation Professions ... 51

4. Productivity of the Rehabilitation Services Staff ... 55

5. Dimensions of Satisfaction of Patients in Rehabilitation Services ... 56

6. Correlates of Patients’ Satisfaction ... 57

7. Conclusion ... 58

Chapter III Methodology ... 59

1. Study Population ... 60

2. Methods ... 60

2.1 Survey Questionnaire Design ... 61

2.1.1 Staff Job Satisfaction Questionnaire ... 61

2.1.2 Patients Satisfaction Questionnaire ... 63

2.1.3 Head of Department Questionnaire ... 64

2.2 Questionnaire Distribution and Collection ... 67

2.3 Questionnaire Results Analysis ... 68

Chapter IV Results ... 70

Chapter V Discussion ... 183

Chapter VI Conclusion and Recommendations ... 205

Overall References ... 209

Appendix ... 216

1. Survey Questionnaires: – Staff Satisfaction Survey Questionnaires……….…….. 217

– Department / Hospital Information Questionnaire………..226

– Patient Satisfaction Questionnaire………228

- Head of Department Feedback Questionnaire………. 232

2. Summary of Non Significant Correlations of ERI Ratio and Job Satisfaction Variables……..…..235

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Abstract

Patient and staff satisfaction are considered as important indicators to monitor quality in healthcare. In rehabilitation services the patient and therapist encounters are of significant value by the amount of time, the therapeutic approach but also the personal relations in the care process. The aim of the research was to evaluate the staff job satisfaction in physical rehabilitation services and the work related variables as well as its correlations to patients’

satisfaction.

A cross sectional survey approach in the rehabilitation services has measured the job satisfaction and the related elements of productivity. Simultaneously a survey of the patients’

satisfaction was performed. As the research in the physical rehabilitation services was conducted in ten different health care facilities of the Jeddah region, a common assessment tool was utilized based on the Effort-Reward Imbalance (ERI) model and complementary information were collected using specifically developed survey questionnaires. Socio- demographic variables such as age, nationality, work specialty, educational levels, as well as the caseload and workload appeared also as significantly influencing job satisfaction.

The findings confirmed a positive correlation between the Effort-Reward Imbalance and the quantitative performance (productivity) of the rehabilitation staffs. It is supported by the level of job satisfaction of the therapists which is related to the number of patients per day, caseload, hours of work and high productivity measures. From the aspects of positive rewards, the role of the supervisor and doctors appear as important motivators. It was also found that therapists valued the fact of being given the opportunity to participate and discuss opinions in the patient management and quality improvement.

While no evidence confirmed a positive correlation between patients’ satisfaction about their treatment or the rehabilitation process and the staff job satisfaction, both measured patients’

and staff satisfaction varied significantly according to the hospital type.

Essential determinants of patients’ satisfaction appeared however related to the therapists' input, such as the ability to reassure or the quality of information given in the treatment plan and have to be taken into account when delivering the patients’ care.

All the results allowed the design of a systemic model of staff job satisfaction resuming the

significant related elements of work efforts and rewards in the rehabilitation services and

could be utilized to inspire the hospital leaders, managers and executive directors to promote

a healthy work life environment based on a valued human resources approach.

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Summary

The background situation of the present survey in Saudi Arabia can be resumed in three axes.

A development of the secondary health care system with an increase in the number of rehabilitation services has been noted over the last years with a steady rise in the number of beneficiaries. However, a worldwide staff shortage of qualified rehabilitation staff was to be observed with difficulties in staffing the departments with a sufficient number respiratory therapists or occupational therapists as well as qualified physical therapists in all rehabilitation specialties. Finally, as a third simultaneous element corresponds the imposed objectives of control of resources as well as performance improvement and quality monitoring which have been also gradually stressed on all healthcare departments.

Consequently with the aim of high efficiency in hospitals but also due to qualified staff shortage, rehabilitation services professionals are expected to see a large number of patients.

This situation could lead some rehabilitation staff to complain of the physical workload which may subsequently contribute to higher levels of stress and dissatisfaction (Wittig et al, 2003).

The notions of job satisfaction and work-related stress appear therefore as essential measures in human resources management in healthcare services and have been recognized as core element of a quality improvement program in health care services.

As job satisfaction is defined by the fulfillment, gratification and enjoyment that comes with work and focuses on the feelings that an individual has about his/her job with the affective orientation towards work (Price, 2001) and it is a concept related to the feeling, attitudes or preferences of individuals regarding job (Chen, 2008).

While job satisfaction is definitely representing a wide subject, it was also apparent that staff working in the physical rehabilitation valued their role and reported to like their work as they felt being able to contribute to patients improvements and well being ( Cortese, 2007).

From a similar perspective, one might presume that if health care providers are more satisfied, the patients' satisfaction with therapy could also be improved. This could be justified as patient satisfaction is related to the perception with the received treatment and might not only depend on the treatment outcomes but could also be linked to the therapeutic encounter and the therapists’ personal attributes (Cleary et al., 1988;Hills et al., 2007).

Considering the above mentioned background situation, the aim of the present research was

to study the staffs’ job satisfaction and the work-related variables as well as the relations to

patients’ satisfaction in the rehabilitation services. It appeared of importance to determine the

correlations between job satisfaction and the quantitative performance of the staff and

secondarily to the level of satisfaction of the beneficiaries of these services.

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Complementary to job satisfaction measures, the approach of work stress based on the model of Effort-Reward Imbalance (ERI) was utilized which précises the risk of developing sustained stress responses due to failed reciprocity in terms of high efforts spent and low rewards at work (Siegrist J. 1996, 2000, 2002). The Over-commitment level of the therapist corresponding to the excessive striving and inability to withdraw from obligations as an intrinsic element of the Effort-Reward Imbalance was also measured (Siegrist J. ,2004.)

The survey was conducted in ten randomly selected healthcare facilities of the private, academic and public sectors in the large town of Jeddah and was based on three survey questionnaires for the evaluation of job satisfaction, work related variables to identify the departments’ organizational aspects and the quantitative performance of the therapists. A last questionnaire was addressed to patients and evaluated the elements related to their satisfaction in treatment.

While the study group was characterized by a young and multinational population, results have outlined a positive relation between the job stress and quantitative performance of the therapists. Differences in job satisfaction and level of Effort-Reward Imbalance varied per demographic variables such as nationality, educational level, and age of the therapists.

Organizational variables such as schedule types and hours of work were significantly correlated and the type and caseload complexity affected the level of job stress in physical rehabilitation services were also of importance. Over-commitment of the staff was identified as related to additional sick leave, medical consultation reflecting work- related musculoskeletal complaints highlighting the risk linked to long working hours and the occupational load for some individuals.

Extrinsic variables of satisfaction, with primarily the salary and salary equity, job security were identified as major elements contributing to job satisfaction. Positive team work and the support of supervisors, departments’ managers and referring physician were also evidenced as essential variables in job satisfaction. An increased role autonomy of the therapists in quality improvement education and management as well as in cases management and in professional development appeared also of significance.

While significant differences in appeared per hospital types, rehabilitation specialties for staff and patient satisfaction as well as the productivity, the present research did not however identify a correlation between the patients’ satisfaction and the staff satisfaction. The patient reassurance and received information about therapeutic planning appeared however of importance to all the patients.

The interest of the present study was to evidence the link between staffs’ job satisfaction, and the work-related variables in the rehabilitation services. Their relation with the patients’

satisfaction was not identified though highlights the importance of all these factors for

hospitals’ and departments’ managers or educators of healthcare professionals.

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Articles

The related articles to the present research had the objectives to summarize the significant results and information based on the main identified dimensions; job satisfaction and work stress, environment of work and patients satisfaction in physical rehabilitation services.

The first article resumes the general situation of work satisfaction and job stress of the rehabilitation services staff. The summarised information is based on the Effort- Reward Imbalance measure and job satisfaction of rehabilitation staff and the related socio-demographic and work related variables. The article provides detailed information about job stress and satisfaction amongst the physical, occupational and respiratory therapists. A summary of the literature review, results, and the discussion resumed that job satisfaction varied in accordance with the nationality, age as well as the educational level of the staff. Additional variations of job stress appeared between work specialties, schedules of work but also with the number and the types of treated patients. The effort and workload can be considered as essential elements related to the staff satisfaction and have to be taken into consideration in the organization of the work in physical rehabilitation services.

Motivated by the fact that the survey was made in several hospitals, the second article aims at giving additional details on the factors affecting job satisfaction. The determinants of job satisfaction and their relation with the type of hospitals, appears to us a unique and interesting subject.. The resumed analysis found that job satisfaction of the rehabilitation services staff appeared to vary according to the hospital types (private, public of teaching type) and the related motivation factors in work were also discussed.

The third article resumes the dimension related to the customer and the analysis of the patients’

satisfaction with the services received in rehabilitation. The questions that were related to the therapists input in treatment were analyzed per hospital type and the main variables affecting patient satisfaction were identified and discussed. This last article has the interest to resume the patient’s perception and the factors that could affect satisfaction in rehabilitation services of all the surveyed hospitals.

The fourth article resumes the significant variables identified in relation to the work related musculo-

skeletal disorders expressed by the therapists from our study. The main work- related complaints were

back pain and generalized myalgia but also were severe to be causing sick leave and to be referred to a

medical consultant. The symptoms were analyzed from the aspect of Over- Commitment which is a

measure of exaggerated stress at work and a high significance was reported between the days of sick

leave and the musculoskeletal complaints of rehabilitation therapists in Jeddah.

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The articles related to the present research were the following and can be found in the present section in their original version as they were accepted for publication.

1. Measurement of Rehabilitation Services Staffs' Job Satisfaction Using the Effort Reward Imbalance Model in Saudi Arabia I. Devreux, A. Jacquerye, F. Kittel, A. Almazrooa and B. Al-Awa

Research Journal of Medical Sciences 2012;6(3):87-92.

2. Determinants of Rehabilitation Services Staffs' Job Satisfaction (by Effort-Reward Imbalance ) and Variations in Teaching, Profit Making and Non Profit Hospitals I. Devreux

A. Jacquerye, F. Kittel, K. Mamdouh and B. Al-Awa

Research Journal of Medical Sciences; July-Aug-2012:Vol.6-4:154-158.ISSN: 1815- 9346.

3. Benchmarking of patient satisfaction with physical rehabilitation services in various hospitals of Jeddah

Isabelle CN Devreux, Agnes Jacquerye, France Kittel, Enas Elsayed, & Bahjat Al- Awa.

Life Science J 2012;9(3):73-78.ISSN:1097-8135.

www.lifesciencesite.com/lsj/life0903/011_9115life0903_73_78.pdf

4. Relation of Work-related Musculoskeletal Disorders and Over-commitment of Rehabilitation Staff in Saudi Arabia

Isabelle C.N. Devreux, Bahjat Al-Awa, Khaled Mamdouh and Enas Elsayed Life Sci J 2012;9(3):781-785. (ISSN:1097-8135). http://www.lifesciencesite.com.

www.lifesciencesite.com/lsj/life0903/111_10053life0903_781_785.pdf

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Article 1: Measurement of Rehabilitation Services Staffs' Job Satisfaction Using the Effort Reward Imbalance Model in Saudi Arabia

Devreux I

, Jacquerye A

, Kittel F

, Almazrooa A

and Al-Awa B

1

College of Applied Medical Sciences Department of Physical Therapy, King Abdul Aziz University; Jeddah, Kingdom of Saudi Arabia.

2

Université Libre de Bruxelles, Ecole de Santé Publique; Brussels, Belgium.

3

King Abdul Aziz University; Jeddah, Kingdom of Saudi Arabia.

Background and Objective: To evaluate the level of work satisfaction of staff working in rehabilitation services based on the Effort-Reward Imbalance model. Settings and Design: A cross-sectional study among rehabilitation services staff working in 10 healthcare facilities in Jeddah. Subjects and Method: 166 therapists and assistants working in the departments of Physical Therapy, Occupational Therapy and Respiratory Therapy are recruited from 10 healthcare facilities of the Jeddah area. The Effort-Reward Imbalance and staff job satisfaction were measured using self-administered survey questionnaires. Results: A comparatively higher Effort Reward Imbalance Ratio and low satisfaction level in work is seen for foreign nationals, respiratory therapists and night schedule workers. The age, higher educational levels of the therapists and adult, geriatric and inpatients’ caseloads are also positively associated with a high Effort Reward Imbalance Ratio. Conclusions: Job satisfaction of rehabilitation services staff based on the Effort Reward Imbalance model is significantly correlated to the variables of age, nationality, rehabilitation specialty, work schedule and the type of patients treated which reflects an increased work stress for these professional categories. Workload, professional growth and financial benefits are essential determinants of job satisfaction of rehabilitation services staff.

Keywords: Job satisfaction, Effort-Reward Imbalance, rehabilitation services.

__________________________________________________________________________

INTRODUCTION

With the increased awareness on the role of rehabilitation services in Saudi Arabia, the last decade has seen the growth of the health care professions in this part of the world by the progression of the quantity of available services and by the growing number of beneficiaries.

However, in a context of worldwide shortage of qualified health care providers in general and more specifically professionals with expertise in rehabilitation, and with the increasing workload and control of resources, it is thought that rehabilitation services professionals are under work related stress. While the number of patients increases, occupational stress could develop amongst rehabilitation professionals represented by the high percentage of burn-out in health care professions with eventually resulting in a decreased job performance (Bakker, 2000;

Piko, 2006). Burnout levels in physiotherapists in Cyprus ranged from low to moderate

(Pavlakis et al., 2010) and affects 53% of young Australian physical therapists (Scutter and

Goold, 1995) while 4% of the Spanish physiotherapists have been found to present signs of

severe burnout (Sarrano Gisbert et al, 2008). It is essential to be aware of the potential causes

of work related stress before it develops for preventing detrimental effects on the patient,

therapist and facility in which the therapist is employed. As in many other countries, health

professionals retention is a serious problem in the Kingdom of Saudi Arabia and hospital

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administrations need to provide evidences to justify the allocation of specific resources to improve staff satisfaction.

At a regional level in the Kingdom of Saudi Arabia, the interest of the research is to provide a picture of the level of satisfaction of rehabilitation professionals in a multinational population practicing in the region of Jeddah which could differ from the work motivating factors in other countries of the world. This research might hopefully assist managers to use the information as a baseline for developing a quality improvement program and considering the value of staff satisfaction to allocate time, resources and set related monitoring strategies.

MATERIAL AND METHODS

Subjects

The study is related to a population of 166 rehabilitation professionals (therapists and assistants in physical therapy, occupational therapy and respiratory therapy that are employed on a full time basis) practicing in the various public and private health care settings of the Jeddah area. Sub-groups per professional category and nationality have been made during the data analysis and the results’ correlation. The surveyed therapists are working in university hospitals or public hospitals related to the Ministry of Health as well as from private health care facilities, hospitals, rehabilitation centers and large outpatient clinics. The hospital sizes varies in average from 700 inpatients beds to smaller dimensions of 250 beds while several healthcare facilities that only treat outpatients were also included in the survey after a random selection.

Survey Design

A survey prospective design by self administered questionnaires to the targeted population of therapists and technicians was used. Two hundred twenty two (222) survey questionnaires were distributed to all the staff of the ten rehabilitation services of the Jeddah area. The questionnaires were specifically adapted for this research which consisted of the evaluation the rehabilitation staffs’ satisfaction in work. It is based on three sections; a first one resuming the socio-demographic information related to the therapists and assistants, the second section is evaluating the Effort and Reward Imbalance Ratio and over-commitment of the staff (Siegrist, 1996). A third section is a questionnaire is based on some specific questions related to the practice of work in rehabilitation.

Job Satisfaction Measures

Job satisfaction has been generally defined as an attitudinal variable which is how people

feel about their jobs and different aspects of their jobs. It is the extent to which people like

(satisfaction) or dislike (dissatisfaction) their jobs (Spector, 1997) and is also the affective

orientation that an employee has about his work (Price, 2001). The study of several intrinsic and

extrinsic variables are identified and utilized such as workload, salary and benefits, professional

growth, working relationships, role and job autonomy, environment of care, work recognition,

security and supervision, involvement in quality improvement ( Shelledy et al. 1992; Okerlund

et al.,1994 ; Lopopolo, 2002; Moore KL, 2006).

8 Work Stress Measures (ERI and Overcommitment)

The model of Effort-Reward Imbalance (ERI) claims that failed reciprocity in terms of high efforts spent and low rewards received in turn is likely to elicit recurrent negative emotions and sustained stress responses. Conversely, positive emotions evoked by appropriate social rewards promote well being, health and survival (Siegrist, 2002).With reference to the literature review a questionnaire for rehabilitation services personnel was adapted and included a validated approach to measure psycho-social work stress based on the High-Effort/ Low-Reward Imbalance ratio (Siegrist, 1996) and an associated over-commitment scale which sum both in total composed of twenty three questions without modifications from the original standardized questionnaire. The sum of the values of the efforts is related to the rewards and a ratio of 1 is indicated as the optimal reference value. A recent version of the Effort and Reward Imbalance questionnaire is using a Likert scale of 4 points instead of five to avoid a neutral type of answer.

The last part of the Effort-Reward Questionnaire is including questions related to the affective commitment of the person to the organization (Siegrist et al., 2004).

Data Analysis

The questionnaires' results and collected data are first encoded in an Excel format and in the SPSS (Statistical Package for Social Sciences, Version 16) program for analysis. Data were computed by descriptive statistics and by correlation analyses. P-values less than 0.05 are considered as significant. Results per hospital as well as hospital category were summarized, compared and correlated. Normality test of the distribution by one-sample Kolmogorov- Smirnov test was made. Pearson test for significance and Kruskall Wallis nonparametric tests for ranks were made and the Spearman-rho test was applied with numerical variables (age, number of patients per day and working hours).

RESULTS

Summary of the Study Population Characteristics

The survey obtained a response rate of 74.9% and the study population is by 76% composed of physical therapists and by 77% of bachelors in their field. The mean (SD) age of the surveyed rehabilitation staffs is of 32 (7.6) years old and more than half of the population (53%) is composed of females while 44% of the subjects are single persons. Forty four percent (44%) of the concerned rehabilitation professionals are Filipino nationals and 25% are Saudi nationals.

Their work experience is in average of 8.3 years and 4.6 years in the actual hospitals . For 69%

of the subjects a therapist position is held and the most frequent salary ranges between 2001 SR and 4000 SR (Mode= 1000 US$).Concerning the leave days, an average of 20 vacation days, 2.25 sick leave days, of 3.5 educational leave days and of 0.21 unjustified absence days are taken per subject per year.

A Kruskall Wallis test showed a significant 2-tailed correlation (P≤.025) between the age of

the therapists and the Effort Reward Imbalance Ratio with a general increase of imbalance if the

staff is older.

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Table 1: Effort- reward imbalance (ERI) ratio of rehabilitation staff per nationality

(n= 160)

Nationality N=

160

ERI Ratio

P-value Post hoc

Mean (±SD) Median Min. Max.

Filipino 71 1.55 ±.56 1.47 0.71 3.24 P ≤ 0.001 P1 ≤ 0.001 P2≤ 0.033

Other 20 1.22 ±.34 0.74 0.73 1.97

Middle East 29 1.21 ±.36 1.22 0.58 1.83

Saudi 40 1.11 ±.40 1.01 0.52 2.33

Total 160 1.34 ±.50 1.26 0.52 3.24

P1: Saudi >< Filipino P2: Filipino ><Middle East

Table (1) is highlighting the significant differences between the median ERI values per nationality. It appears by Kruskall Wallis analysis that the Filipino nationals have a higher Effort Reward Imbalance ratio than the other nationalities (French, American, Czech, South African and Thai therapists) and the Middle Eastern staff.

Rehabilitation Specialties

Results show a significant difference (P ≤ .001) between the median ERI values for the professionals working in the surveyed specialties. The group of respiratory therapists is presenting in average a higher median Effort Reward Imbalance value of 1.79 compared to the other professionals in rehabilitation services (P ≤ .001). However, the difference between the Occupational Therapists’ median ERI ratio of 1.08 and Physical Therapists’ median ERI ratio of 1.22 is not significant.

Educational Level

Statistical analysis shows that the ERI ratio is correlated to a higher educational degree. The lowest Effort Reward Imbalance value is observed in average amongst Diploma holders with a mean (SD) of 1.12 (0.32) and median of 1.60, while a mean (SD) value of 1.3 (0.53) and median of 1.30 is seen for persons with a Bachelor degree. The highest stress and dissatisfaction is seen if the person has a Master or a PHD degree with a mean Effort Reward Imbalance ratio (SD) of 1.57 (0.39) and median value of 1.60. This difference is significant between groups and using the Kruskall Wallis test between the Diploma and Bachelor degrees (P ≤ .009, P2 (Diploma versus Masters +PhD.) ≤ .022 and P3 (Diploma versus Bachelor degree) ≤ .035).

Work Schedule

It has been noticed a significant difference (P ≤ .029) of ERI ratio between the staffs that

perform night duties and the therapists having a straight work schedule in the daytime. In

addition, therapists having split duties (as in the morning and the evening) are related to a higher

ERI ratio (median= 1.40).Pertaining to the areas of practice, a significant difference is identified

between the ERI ratio of the professionals that treat in majority inpatients (n=28) as compared

to the ones having an outpatients caseload (ERI median=1.24, n=50). The Kruskall Wallis test

demonstrated significant differences between groups (P ≤ .038) and between the staff treating

inpatients (P2 ≤ .041) and the other staff categories. The ERI ratio is in average higher for the

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personnel working exclusively with inpatients. While the majority (52%) of the staff in our survey are working in both the in-patients and out-patients services, their work stress measure (median= 1.24) is comparatively lower and the ERI ratio is the lowest for staff working with outpatients (median= 1.19).

Figure 1: Effort-reward imbalance ratio of rehabilitation staff per adult/pediatric caseloads

Results showed that 83% of the therapists are in majority working more with adults and have in average a significantly higher (P ≤ .032) median Effort and Reward Imbalance ratio of 1.31 compared to the persons working with a pediatric caseload ( median= 1.19).

Table 2: ERI ratio of rehabilitation staff per types of medical cases (n=160)

Types of Medical Caseloads

Number of Respondents

ERI Ratio P-value Post hoc

Mean ±SD Median Min. Max.

Geriatric Cases 8 1.88 ±.64 2.02 .81 3.00

P ≤ .011 P1≤.006*

P2≤.036*

P3≤.010*

P4≤ .007

Others 22 1.52 ±.54 1.36 .80 2.96

Orthopedic Cases 67 1.30 ±.43 1.22 .52 2.88

Neurological Cases 51 1.27 ±.53 1.19 .58 3.24

Developmental Delay 12 1.14 ±.37 1.27 .63 1.63

P1: Orthopedic >< Geriatric caseload P2: Orthopedic >< Neurological caseload P3: Geriatric cases >< Neurological caseload P4: Geriatric >< Developmental Delay caseload

From the present results, therapists treating a majority of geriatric cases (P ≤ .004) have in average a significantly higher ERI ratio compared to the orthopedic (P1 ≤ .006), neurologic caseloads (P3 ≤ .010) and with treating developmental delayed patients (P4 ≤ .007). There is no significant difference of the median ERI ratios between the other four groups excepted between the staff with orthopedic compared to the neurologic caseloads (P2 ≤ .036).

In the studied population, a Spearman-rho analysis revealed a highly significant two tailed

correlation (P ≤ .001) between the Effort Reward Imbalance ratio and the variables of number of

patients per day and working hours per week. The ERI ratio increases in average with a higher

number of working hours and an increased number of patients per therapist. Results show that

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the average (SD) patients/therapist ratio per day is of 10.3 (3.9) and the average working hours per week (SD) is 47 (8.2).

Figure 2: Effort-reward imbalance ratios of rehabilitation staff per number of patients per therapist/ day

The number of unjustified absence leave days and shift work are significantly correlated (P ≤ .008 and P ≤ .014 on n=142) with the ERI ratio with a Spearman’s rho correlation analysis.

There is a reverse correlation between the ERI ratio and the number of unjustified absence leave days of the concerned staff as the more the staff is having unjustified absence; the lesser the Effort-Reward Imbalance ratio appears.

In relation to the working situation, the correlations of the components of work organization have been studied with the Effort-Reward Imbalance ratio such as the variables of work schedule and overtime hours and no correlation has been drawn between the overtime and the work stress measure by the Effort-Reward Imbalance ratio.

The results analysis did not identify significant differences of the ERI ratio for the variables of gender, position, marital status, years of experience and salary. The fact of performing overtime or an additional occupation did not show any difference reflected in the median ERI ratio. There appears to be also no difference per categories of annual leave days, sick leave and educational leave days.

DISCUSSION

In the area of Jeddah in the Kingdom of Saudi Arabia, the surveyed rehabilitation

departments are composed of 70% foreigners and 30% Saudi nationals. Our results analysis

identified that foreign nationals have in general a higher Effort Reward Imbalance ratio which

indicates a higher work stress and lower job satisfaction compared to the Saudi staffs. This is

possibly explained by the high patient caseload in addition to perceived lower salaries and

cultural differences reflected by the feeling of communication difficulties and a language

barrier. Previous research identified the stress which often accompanies organizational change

as a significant variable to job satisfaction in physiotherapists and influences the perception of

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job security (Lopopolo, 2002) and this element appears also of increased importance to foreign staff compared to Saudi therapists.

Differences of Effort- Reward Imbalance ratios were identified between the specialties of the rehabilitation services as Respiratory Therapists have in average higher ERI ratios. This is both linked to the staffs' nationality but also work practice characteristics with a high patient/

staff ratio and workload in inpatient clinical areas. Results are in accordance to previous research which identified job distress related to the perception of unsafe staffing may be related to career dissatisfaction and job turnover of respiratory therapists (Schwenzer and Wang, 2006).

An essential aspect related to job satisfaction is the workload measured by the average number of patients treated per therapist per day and it appears recommended to managers to maintain a realistic workload as there is a highly significant correlation between the patient/

therapist ratio and the Effort-Reward Imbalance ratio. As concluded in previous research, our results point out that high caseloads are linked to decreased job satisfaction amongst allied health professionals (Fortune and Ryan, 1996; Al-Almadi, 2002; Cawthorn and Rybak, 2008). There is however no significant difference with the ERI ratio between the types of positions, the effective salary or the categories of leave days. Similarly to other researches, the surveyed subjects’ job satisfaction does not differ significantly in relation to socio-demographic variables such as the years of experience, gender and marital status of the surveyed staff (Meade et al., 2005).

However, the Effort and Reward Imbalance seems to increase with the age of the therapists and could be related to possible difficulties to cope with the physical burden of the profession or higher expectations in work as it was expressed through the open questions of our questionnaire.

Another aspect affecting job satisfaction is related to the work schedules. Levels of dissatisfaction were associated with split schedules of work and this mainly at night compared to day schedules or straight schedule of work. Staff rotation from split shift schedules to straight schedules of work should be encouraged as this was reported by the surveyed staff to be associated with physical fatigue due to night duty; longer times spend in displacements between the home and work in addition to frustrations linked to the absence of financial compensation in the surveyed hospitals. It appeared however that working for longer hours (paid overtime) or having an additional occupation was not related to job dissatisfaction as they are associated to increased financial benefits.

Consistent with other research, our survey identified that with higher educational levels, the Effort and Reward Imbalance tends in average to increase which reflects a lower job satisfaction level. This is possibly due to the staff expectations of what the job should provide or possible increased stress and responsibilities (Hong Lu et al., 2005).

The results analysis reveals that the main areas of dissatisfaction are in relation to the salary,

salary equity and professional growth which is similar to the results of a Turkish survey (Eker

et al., 2004) and also a Saudi survey amongst nurses (Al-Ahmadi, 2002). Pay and benefits and

opportunities for career development are major determinants of staff retention (Okerlund et al.,

1994; Randolph et al., 2005) and this aspect is possibly increased for foreign therapists who are

mainly motivated for working abroad by the financial aspects. Measures for developing rewards

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by increasing salaries in a consistently fair and steadily progressive manner based on universal salary scales would be indicated in addition to the recognition and financial compensation of hardship and difficult working conditions.

The variables that affect job satisfaction measured by the Effort- Reward Imbalance are also related to the treated cases as rehabilitation staffs are in general more dissatisfied in work when having mainly adults, geriatric cases or inpatients caseload. We can expect these categories of patients not to improve so rapidly and to present more limited outcomes in therapy thus increasing frustrations. Geriatric patients have often a more limited rehabilitation potential and are possibly more demanding while some of the patients’ relatives tend also to express high expectations in rehabilitation. However, there is no significant difference identified between the levels of satisfaction of therapists working mainly with chronic or acute pathologies which can be found amongst both the inpatients and outpatients cases in the studied healthcare facilities.

As confirmed in previous studies, job satisfaction is more related to the nature of the work as in the inpatients settings with a high caseload per therapist and possibly more difficult or complex cases to treat (Speakman et al., 1996; Lindsay et al., 2008; Santosa et al., 2010). In addition to improving rewards, the monitoring of intrinsic efforts and an optimal caseload management could contribute in improving job satisfaction in Physical, Occupational or Respiratory Therapy ( Fortune & Ryan, 1996; Erlenson & Modrow, 2003 ; Cawthorn & Rybak, 2008).

CONCLUSION

The research in the physical rehabilitation services of ten health care facilities of the Jeddah region has been conducted to evaluate the level of job satisfaction of 166 physical, occupational and respiratory therapists. Effort-Reward Imbalance ratio and correlations were calculated.

Results indicate a significant correlation between job satisfaction measured by the Effort Reward Imbalance ratio with the variables of age, nationality, work specialty, educational levels, caseload types and the number of patients treated daily per therapist. Decreased job satisfaction with a significantly higher Effort Reward Imbalance ratio in work is in average expressed by foreign nationals, respiratory therapists, night schedule workers and therapists having a high workload or adult, geriatric or inpatients' caseloads. The effort or workload as well as the need of professional growth and financial benefits appear as essential determinants of job satisfaction and have to be taken into consideration in human resources management of rehabilitation services staff.

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31(4): 884–891. DOI: 10.1046/j.1365-2648.2000.01361.x

Cawthorn L and Rybak D. Workload measurement in a community care program. Nurs Economics 2008;26(1):45-48.

Eker L,Tüzün EH, Daskapan A, Sürenkök O.Predictors of job satisfaction amongst physiotherapists in Turkey, J Occup Health 2004; 46(6):500-5.

Erlenson P and Modrow R. National Guidelines for rehabilitation staffing levels: a literature review. Healthcare Management Forum 2003;16(2):18-25.

Hong Lu et al. Job satisfaction amongst nurses: a literature review, Int J Nurs Studies 2005;42: 211-27.

14

Lindsay R et al. Workplace stressors experienced by physiotherapists working in regional public hospitals, Aust J Rural Health 2008; 16(4):194-200.

Lopopolo RB. The relationship of role-related variables to job satisfaction and commitment to the organization in a restructured hospital environment, Phys Ther. 2002 Oct; 82(10):984-99.

Meade I, Brown GT, Trevan-Hawke J. Female and male occupational therapists: A comparison of their job satisfaction level. Aust Occ Ther J 2005; 52(2):136–148. DOI: 10.1111/j.1440-1630.2005.00480.x

Moore KA, Cruickshank M and Haas M. Job satisfaction in Occupational Therapy: A qualitative investigation in urban Australia. Australian Occupational Therapy Journal 2006; 53(1):18-26.

Okerlund VW, Jackson PB and Parsons RJ. Factors Affecting Recruitment of Physical Therapy Personnel in Utah. Physical Therapy 1994- 74 (2): 177-184

Pavlakis A et al. Burnout syndrome in Cypriot physiotherapists: a national survey. Health Care Manag Pr 2010.

Piko BF. Burnout, role conflict, job satisfaction and psychological health among Hungarian health care staff, Int J Nurs Stud. 2006;43(3):311-8.

Price JL. Reflection on determinants of Voluntary Turnover, Int J of Manpower 2001; 22(7):600-624.

Randolph DS, Doisy E and Doisy M. Predicting the effect of extrinsic and intrinsic job satisfaction factors on recruitment and retention of rehabilitation professionals, J of Healthcare Manag 2005;50(1):49-60.

Santosa MC, Barrosb L and Carolinoa E. Occupational Stress and coping resources in physiotherapists: a survey of physiotherapists in three different hospitals, Physiotherapy 2010; 96(4):303-10.

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Siegrist J. Effort-Reward Imbalance at Work and Health. In:P Perrewe & D Ganster (Eds.).Research in Occupational Stress and Well Being,(2): Historical and Current Perspectives on Stress.NY: JAI Elsevier 2002, 261-291.

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15

Article 2: Determinants of Rehabilitation Services Staffs' Job Satisfaction (by Effort-Reward Imbalance )

and Variations in Teaching, Profit Making and Non Profit Hospitals Devreux I

, Jacquerye A

, Kittel F

, Mamdouh K

and Al-Awa B

1

Department of Physical Therapy, College of Applied Medical Sciences.

King Abdul Aziz University- Jeddah, Kingdom of Saudi Arabia.

2

Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium.

3

King Abdul Aziz University, Jeddah, Kingdom of Saudi Arabia.

Objective: To evaluate the level of work satisfaction based on the Effort-Reward Imbalance model of staff working in rehabilitation services of different categories (in teaching, profit making and non-profit making hospitals). Methods: Participants were 166 therapists and assistants working in the departments of Physical Therapy, Occupational Therapy and Respiratory Therapy from 10 hospital centers classified per three different categories in the Jeddah area. Effort-Reward Imbalance and staff satisfaction with intrinsic and extrinsic variables were measured by a self-administered questionnaire. Results: There is a significant difference of level of job satisfaction measured by Effort and Reward Imbalance between the therapists and assistant therapists working in the teaching, private or non- profit making health care facilities. In comparison by hospital type, the surveyed rehabilitation staffs presented a higher mean Effort-Reward Imbalance in the teaching hospitals but higher job satisfaction with their salary, their perception of salary comparatively to others, yearly performance appraisal grading and affective commitment. In the rehabilitation services of non-profit making hospitals, the surveyed therapists and assistant therapists had the lowest mean Effort-Reward Imbalance ratio explained by their satisfaction with the variables of patient/ staff ratio and emotional attachment to the organization. In the profit making healthcare facilities, the surveyed staffs are comparatively more satisfied with the variables of doctors’ respect, involvement in quality improvement or educational lectures and transportation to/from work. Conclusion:

Rehabilitation services staffs working in teaching hospitals and profit making hospitals had in general a higher Effort- Reward Imbalance ratio with work stress and low satisfaction in work compared to the non-profit hospital facilities. Job satisfaction of the rehabilitation staff varies according to the type of health care facility.

Keywords: Job satisfaction, effort-reward imbalance, rehabilitation services INTRODUCTION

Physical rehabilitation services in Saudi Arabia are found in health care facilities which can be categorized in private or profit making, public or non-profit making and teaching hospitals. While the public sector plays an essential role in the management and regulation of curative services, the private healthcare sector has an increased role in the provision of rehabilitation care. However, therapists and assistant therapists working in the rehabilitation services may have different perceptions of satisfaction about their work depending on their working conditions and situation. The interest of the research is to identify the possible variables that could affect job satisfaction in the three healthcare facilities categories.

Accordingly, the main aim of this study is to identify components of job satisfaction based on the Effort and Reward Imbalance model and compare the job satisfaction level of employees working in the different types of health care facilities in the Jeddah area.

Job satisfaction has been defined as "the match between an individual's expectations and

the perceived reality of the job as a whole" (Smith et al., 1969).

16

Other theorists have viewed job satisfaction as a bi-dimensional concept consisting of intrinsic and extrinsic dimensions (Herzberg et al., 1959) and distinguish between satisfiers and dissatisfiers.

Previous research has studied the effects of socio-demographic factors and work-related factors (work activities, working hours, salary and positions) on job satisfaction. Demographic factors such as age, sex and educational levels have been seen determining the level of job satisfaction though some research showed contradictory results (Al-Ahmadi, 2002) .

The intrinsic factors of work are seen to be affecting motivation and job satisfaction in work. Some researchers have found that physiotherapist agreed that the work is challenging in a positive sense and enabled them to use their skills and abilities with enough independence and autonomy in decision making (Speakman et al., 1996) but also found that physiotherapists were overloaded and mentally stressed. In particular, dissatisfied employees are likely to leave their jobs (Dogan, 2009; Campo et al., 2009).Thus the understanding of employee job satisfaction and its contributing variables are important for any organization to exist and prosper (Mrayyan, 2005).

Hospital administrators have noticed the importance of job satisfaction on a variety of organizational variables (Chu et al., 2003). These variables of organization differ from one hospital type to another depending on the motivating aspects and the mission of the healthcare facility and may be reflected on the staffs' work inputs and work-role outputs (Sousa-Poza, 2000) and on the Effort-Reward Imbalance at work (Siegrist, 2002).

MATERIALS AND METHODS

The survey is concerned with the study of a population of 222 rehabilitation professionals (therapists and assistants in physical therapy, occupational therapy and respiratory therapy that are employed on a full time basis) practicing in the various public and private health care settings of the Jeddah area. The therapists addressed by the survey are working in university hospitals or public hospitals related to the Ministry of Health as well as in private health care facilities, hospitals, rehabilitation centers and large outpatient clinics.

This research utilizes a prospective two dimensional survey approach (studying the patients and staff satisfaction) by questionnaires to the targeted populations in randomly selected hospitals of the Jeddah area and received a 75% of answering rate. The questionnaires are at first resuming the socio-demographic information of the therapists and assistants. A second section of the survey questionnaire evaluates the Effort and Reward Imbalance Score and over- commitment of the staff and a third section is based on some specific questions related to the practice of work in rehabilitation (Siegrist, 1996).

With reference to the literature review a questionnaire for rehabilitation services

personnel was made and included validated approach to measure psycho-social work stress

based on the High-Effort/ Low-Reward Imbalance (ERI) (Siegrist, 1996) completed by an over-

commitment scale (Siegrist, 1996). The Effort Reward Imbalance ratio is calculated and if this

score is higher than “1” it indicates an imbalance between the effort given and the reward

received by the professional. The aim of utilizing the ERI evaluation score is that it is possible

to correlate results and compare them with other health care facilities. The last part of the

17

Effort-Reward Imbalance questionnaire is including questions related to the affective commitment of the person to the organization.

The third part of the staff job satisfaction survey questionnaire is based on the Minnesota Job Satisfaction Survey questionnaire (Weiss et al., 1967) and additional questions were designed to identify specific variables potentially affecting the work of physical therapists or technicians such as teamwork and communication, work environment and equipments and the involvement in the quality improvement process. It is based on the literature review presenting the following variables of staff satisfaction in rehabilitation services: workload, autonomy of practice, professional growth, working relationship, environment of care, salary and benefits, professional role and overcommitment. Descriptive statistics and correlations analyses were made; Pearson Chi

tests and Kruskall Wallis with a Bonferroni correction were used. P-values less than 0.05 were considered as significant.

RESULTS

The mean (SD) Effort and Reward Imbalance Ratio for 166 surveyed rehabilitation staff is of 1.34 (.51). The median values (Figure 1) are significantly different between hospital categories (P ≤ .001) and with a Kruskall Wallis test between the teaching and non-profit hospitals (P2 ≤ .001) as well as between the profit making and non-profit making hospitals (P3 ≤ .001). However the difference within groups of the teaching and profit making hospitals categories is not statistically significant.

Figure 1: Median ERI ratio of rehabilitation staff per hospital category

Table (1) resumes the frequencies of positive answers by “I agree and I strongly agree” to the questions of satisfaction in work per hospital category. Out of 56 questions on variables of job satisfaction, 10 showed a significant difference within categories. More precisely, results are significantly different between the teaching hospitals and the nonprofit hospitals (P2 ≤ .005) concerning the satisfaction with the patient/ therapist ratio where globally 48.8% of the therapists are in average satisfied with their job and more specifically 58.5% of the therapists in the public sector.

1.58

1.44

1.15

0.00 0.50 1.00 1.50 2.00

Teaching Profit Making Non Profit

M e d ian Value o f E R i R atio

Hospital Category

N=166

18

Table 1: Percentage of Satisfied Staffs by Hospital Category (Part 1)

N=163 Variables of

Satisfaction

Satisfied Staffs by Hospital Category

P-value Post Hoc Teaching Profit Making Non Profit

n % n % n %

Average patient- therapist ratio

n=36 n=46 n=82

11 30.6 21 45.7 48 58.5 0.018 P2 ≤.015

Salary and benefits

n=35 n=45 n=82

16 45.7 8 17.8 22 26.8 0.021 P1 ≤ .021

Comparative Salary

n=35 n=46 n=81

P1 ≤ .012

P2 ≤ .011

16 45.7 9 19.6 18 22.2 0.014

Transportation

n=33 n=43 n=73

19 57.6 28 65.1 23 31.5 0.001 P2 ≤ .011 P3 ≤ .001 P1: Teaching and Profit Hospitals P2: Teaching and Non-Profit Hospitals P3: Profit and Non-Profit Hospitals

Concerning the salary and benefits satisfaction, there appearsa difference between the teaching and profit hospitals with a much higher percentage of satisfaction in the teaching hospitals compared to the nonprofit hospitals. Comparatively, there is a significant difference between the teaching and profit making hospitals and between the non-profit hospitals for the comparative salary satisfaction. The teaching hospitals are having a higher number of positive answers compared to the other hospital categories regarding the perception of their salary in comparison to the ones in other hospitals. Using a Kruskall Wallis test, all previously mentioned differences remained except for the salary and benefits between the teaching and nonprofit hospitals and for the salary and comparative salary between profit and nonprofit making hospitals.

Results in Table (2) resumed that the nonprofit hospital category has the lowest percentage of satisfaction compared to the other hospital categories for the variables such as yearly feedback on performance, doctors/ staffs’ respect and orientation to infection control policies. For these pre-cited variables, the teaching hospital staffs have expressed more satisfaction excepted with the doctors/other staff respect which is higher in the nonprofit hospitals.

Satisfaction in educational lectures in quality management is expressed for 65.2% of the staffs in the profit hospitals, while the lowest level of satisfaction is in the non profit hospital group (for 45.1%).

Staff satisfaction with an emotional attachment and the feeling of being part of a family in

the organization is higher in the nonprofit hospitals with a percentage of 31% and 30% percent

of positive answers per hospital category. The rehabilitation staffs' satisfaction with a feeling of

emotional attachment appears to be less (11%) in the profit making hospitals than in other

categories.

19

Table 2: Percentage of Satisfied Staff Compared by Hospital Category (Part 2) N = 163 Variables of

Satisfaction

Satisfied Staff by Hospital Category

Chi

P-value

Post Hoc Test Teaching Profit Making Non Profit

n % n % n %

Yearly performance evaluation

n=34 n=46 n=82

29 30.6 30 65.2 45 54.9 0.002 P2 ≤ .002*

Doctors' and other staff'

respect

n=36 n= 46 n= 82

22 61.1 37 80.4 22 54.9 0.015 P3 ≤ .004*

Orientation to infection control policies

n=36 n= 46 n= 82

16 45.7 36 78.3 44 53.7 0.007 P3 ≤ .006*

Educational lectures in quality management

n=36 n= 46 n= 82

19 57.6 30 65.2 37 45.1 0.050 P1≤ .035 P3 ≤ .030 Feeling like part of a

"family"

n=36 n= 45 n= 81

4 11.1 6 13.3 25 30.9 0.007 P2≤ .023*

P3≤ .029 Feeling emotionally

attached

n=36 n= 45 n= 81

9 25.5 5 11.1 26 31.7 0.037 P3≤ .010*

P1 = Teaching and Profit Hospitals P2 = Teaching and Non-Profit Hospitals P3 = Profit and Non-Profit Hospitals *=significance remains after Bonferroni correction

In comparison by hospital types, staff satisfaction measured a median ERI ratio (1.58;

P ≤ .001) is in average lower in the teaching hospitals but the percentage of satisfied staff is higher with regards to the salary (P ≤ .021), perception of their salary compared to others (P ≤ .014), the yearly performance appraisal (P ≤ .002) and the affective commitment score. In the nonprofit making hospitals, the average ERI ratio is lower (P ≤ .001) and satisfaction is the highest with the variables of patient/ staff ratio and feeling emotionally attached to the organization (P ≤ .010). In the profit making hospitals, rehabilitation services staff appear comparatively more satisfied with the variables of doctors respect (P ≤ .004), involvement in quality improvement or educational lectures (P ≤ .030) and transportation modalities (P ≤ .001).

DISCUSSION

From the present survey, it appears that there is a higher Effort-Reward Imbalance ratio in

the teaching hospitals category, with a lower value in the profit making hospital category. The

lowest median ERI ratio is found in the nonprofit hospital category where the lowest job stress

is in average expressed. The positive satisfaction answers of rehabilitation services staffs

concerning job satisfaction variables have been compared from one hospital category to

another. Results confirm the importance of the workload as intrinsic variable significantly

affecting job satisfaction of rehabilitation services staff. Concerning the average

patient/therapist ratio satisfaction, it appears that the staffs are in general more satisfied in the

public hospitals where previous data have found that the effective average number of patients

per therapist per day is less compared to the other sectors. The satisfaction with transportation

has shown a significant difference between hospital categories which could be linked to the

20

different type of nationalities and positions as foreign and junior staff expressed that they felt this aspect as important to them.

Less than one third of the staffs are satisfied with their salary and benefits and with their perceived comparative salary. This situation is especially expressed by the therapists working in the private healthcare facilities who are effectively less paid than in the teaching hospitals.

Results are consistent to previous research made amongst other healthcare professionals in the region which identify the salary and benefits as significant extrinsic variables related to job satisfaction (Al-Enazi et al., 2000; Al-Ahmadi, 2002).

In the private hospitals, staffs are more satisfied in work with the variables of doctors’ and colleagues’ respect and could be justified by the fact that they apparently work very closely together with the referring physicians. Another factor explaining this aspect is the smaller sizes of the private facilities promoting a tight link in the referral process and in the patient management.

A strong emotional attachment and feeling as part of the organization tends to be more marked in the public hospitals. Underlying differences are due to the type of work contracts (more permanent) and the proportion of Saudi nationals employed in this sector being naturally more attached to their environment compared to foreign staffs. In the same line, increased work prospects of local nationals, possibilities of job advancement and professional recognition have also been outlined as important determinants of staff satisfaction and are consistent with findings of other research (Wittig et al., 2003; Eker et al., 2004).

Educational lectures and quality management orientation are appreciated by a comparatively higher number of staffs working in the profit making hospitals. Educational lectures is seen as an important motivator in work as helping to improve their professional skills and knowledge in a very competitive work environment.

Differences of staff satisfaction with the yearly performance appraisals between hospitals’

types suppose that it is strongly related to supervisors’ demand of a high quantitative output and increased productivity as aimed in profit making facilities. It appears that job satisfaction of rehabilitation staff varies per hospital type and the specific mission of the health care facilities.

CONCLUSION

Rehabilitation services staffs working in teaching hospitals and profit making hospitals had in general a higher Effort-Reward Imbalance ratio compared to the non-profit hospital facilities.

In comparison by hospital type, the surveyed rehabilitation staffs in the teaching hospitals

presented a higher job satisfaction with their salary, their perception of salary comparatively to

others, yearly performance appraisal grading and affective commitment to the organization. In

the rehabilitation services of non-profit making hospitals, the surveyed therapists had the lowest

median Effort-Reward Imbalance ratio explained by their satisfaction with the variables of

patient/ staff ratio and emotional attachment to the organization. In the surveyed profit making

healthcare facilities however, rehabilitation services staffs were comparatively more satisfied

with the variables of doctors’ respect, involvement in quality improvement or educational

lectures and transportation to/from their work place. Job satisfaction of rehabilitation staff

appears to vary according to the hospital types and it is thus important to consider the specific

and related variables of staff job satisfaction in hospital management strategies and planning.

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