Job satisfaction among Syrian health workers in refugee health centres in Turkey

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Job satisfaction among Syrian health workers

in refugee health centres in Turkey

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ABSTRACT

Achieving universal health coverage is subject to the availability, accessibility, acceptability and quality of health workers. A health workforce aligned to population needs is critical to making progress towards universal health coverage. Countries that host refugees and migrants strengthen the capacity of their health systems to increase access to services, including engaging refugees and migrants as health workers. The employment, integration, retention and performance of migrant health workers are key to their success in contributing to the health-care system. This report presents the results of an assessment of job satisfaction among Syrian physicians and nurses working in refugee health centres in Turkey and the factors that influence job satisfaction. The analysis of job satisfaction in this category of migrant health workers contributes to the wider evidence on human resources for health.

© World Health Organization 2021

Art-direction and layout: www.freightdesign.co.uk

KEYWORDS JOB SATISFACTION HEALTH WORKERS PHYSICIANS REFUGEE

MIGRANT NURSES SYRIAN TURKEY

Document number: WHO/EURO:2020-1576-41327-56246

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Job satisfaction

among Syrian health workers in refugee

health centres in Turkey

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Preface iv

Acknowledgements vi

Abbreviations vii

Executive summary ix

Introduction 1

Background 2

Methodology 5

Study questionnaires and variables 5

Results 7

Sociodemographic and occupational 7

characteristics of participants

Work characteristics and work environment 10

Job satisfaction 10

Determinants of job satisfaction 14

Work environment 17

Profession, experience and income 17

Discussion 19

Conclusions 22

References 23

Annex 1. Five-point responses 26 to the 20-item MSQ

iii

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Preface

The conflict in the Syrian Arab Republic has caused one of the world’s largest and most dynamic

displacement crises, affecting millions of lives. WHO is supporting the response to the crisis through its operations in Turkey, which comprise a cross-border response from the field office in Gaziantep and a health response to refugees in Turkey, coordinated from the WHO Country Office in Ankara.

In north-western Syria, WHO is implementing interventions such as the delivery of vital medicines and medical supplies and providing support for the operational costs of health facilities and capacity- building of health staff. Through the Refugee Health Programme in Turkey, efforts have been made to strengthen the national health system through integrating Syrian health workers and translators, build capacity for mental health care, provide linguistic and culturally sensitive health services, and support home care for older refugees and those with disabilities.

Activities of the programme are defined within the scope of the Regional Refugee and Resilience Plan (3RP) 2018–2019, a broad partnership platform for over 270 development and humanitarian partners to provide coordinated support in

countries bordering Syria that are heavily impacted by the influx of refugees. This platform capitalizes on the knowledge, capacities and resources of humanitarian and development actors to provide a single strategic, multisectoral and resilience-based response. Supported by several donors, WHO’s activities are complementary to the Ministry of Health's SIHHAT (Improving the health status of the Syrian population under temporary protection and related services provided by Turkish authorities) project, a joint initiative by the European Union and Ministry of Health of the Republic of Turkey that aims to improve health-care services for Syrian refugees in the country. This project operates under the European Union’s Facility for Refugees in Turkey and focuses on strengthening the provision of primary and secondary health-care services to Syrian refugees, building and supporting a network of refugee health centres across the country, and employing additional health personnel, including Syrian doctors and nurses.

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In November 2018 the Refugee Health Programme conducted the Workshop on Refugee and Migrant Health in Turkey: Survey and Research Consultation to identify gaps in the information and evidence required for programme development and adaptation and for informing policies on migrant health in Turkey. The Workshop brought together more than 57 national and international experts from academia, Ministry of Health, United Nations agencies and WHO collaborating centres and led to the formulation of the programme’s research framework. Within this framework, a series of studies were implemented in the fields of mental health, health literacy, women and child health, health workforce and noncommunicable diseases.

This study, Job satisfaction among Syrian health workers in refugee health centres in Turkey, is one of the studies implemented within the Refugee Health Programme research framework.

v

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Acknowledgements

The WHO Health Emergencies team in Turkey would like to thank Kanuni Keklik and Habibe Özdemir of the Ministry of Health of the Republic of Turkey for their leadership and guidance in implementing the study.

The WHO Health Emergencies team in Turkey would like to thank Kanuni Keklik and Habibe Özdemir of the Ministry of Health of the Republic of Turkey for their leadership and guidance in implementing the study. Thanks also go to Pelin Cebeci, Çetin Doğan Dikmen, Elif Göksu, Nurtaç Kavukcu, Melda Keçik, Kadriye Küçükbalci, Altin Malaj and Mustafa Bahadir Sucakli of WHO and Mehmet Balcılar, Alpaslan Girayalp, Burçin Tahtacıoğlu and Sarp Üner of PGlobal Global Advisory and Training Services for their valuable contributions to data collection, data analysis and the overall implementation of the study.

Authors

The principal authors of this report are Monica Zikusooka and Omur Cinar Elci, WHO Regional Office for Europe.

Peer reviewer

The report was peer-reviewed by Nazmi Bilir, formerly with the Department of Cancer Control, Ministry of Health, Ankara, Turkey; Founding Director of the National Committee on Smoking and Health, Turkey; and Director of the Institute of Public Health, Hacettepe University, Ankara, Turkey.

This report was produced with financial assistance of the Government of Germany through KfW Development Bank.

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Abbreviations

CI confidence interval

MSQ Minnesota Satisfaction Questionnaire RHC refugee health centre

RHTC refugee health training centre SD standard deviation

SIHHAT Improving the health status of the Syrian population under temporary protection and related services provided by Turkish authorities (project)

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Executive summary

Turkey hosts about 3.6 million Syrian refugees, who are given access to free primary health-care services through refugee health centres (RHCs). RHCs are supported through the Turkish Ministry of Health’s Improving the health status of the Syrian population under temporary protection and related services

provided by Turkish authorities (SIHHAT) project, which is funded by the European Union.

The SIHHAT project is operational in 29 provinces with a high population density of Syrian refugees.

As of June 2020 712 Syrian physicians, 977 Syrian nurses and 1148 patient guides were employed via SIHHAT project resources to provide language and culturally appropriate services to Syrian refugees.

This study aimed to assess job satisfaction and the factors that determine job satisfaction among refugee physicians and nurses working in RHCs to generate evidence for actions to improve and maintain the motivation, job satisfaction and job performance of health workers, with the ultimate aim of improving the quality of health care.

The study was a quantitative cross-sectional survey targeting all Syrian physicians and nurses working in RHCs in Turkey. Job satisfaction was assessed using a short-form Minnesota Satisfaction Questionnaire (MSQ), which has been used to measure job satisfaction in health-care professionals in other studies. Additionally, data on the potential determinants of job satisfaction were collected using a questionnaire developed from literature reviews on the factors influencing job satisfaction in health workers. The two

questionnaires were combined into a single online self-administered questionnaire in Arabic.

Of the targeted 1577 health workers, 891

participated in the study, giving an overall response rate of 56.5%. Most participants were nurses/

midwives (62.3%), and 65.2% of the participants were male. The highest proportion of participants were in the 30–39 years age group (37.8%). In all, 47.3% of participants were Syrian with Turkish citizenship. Almost half (41.2%) reported having five or fewer years of work experience in Syria, while most (64.5%) reported having worked in the SIHHAT project for two years or less. The mean (± standard deviation (SD)) score for general job satisfaction was 63.3 ± 14.6 for general physicians, 65.9 ± 13.2 for the specialist physicians and 74.9

± 11.0 for nurses. Multivariate analyses revealed a significant difference in general job satisfaction between physicians and nurses (P < 0.001). Of all 20 items in the MSQ, participants reported having the highest satisfaction level in security (26.5%).

ix

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The level of job satisfaction was higher among health workers aged between 40 and 49 years and those without Turkish citizenship. Job satisfaction was also higher among those who reported having access to the resources needed for their work, those who worked in refugee health training centres (RHTCs) and those who perceived teamwork and team management to be good in their RHC. Job satisfaction was also higher among those who had had less work experience in Syria and those who perceived their income from the RHC to be good. The level of job satisfaction was shown to decrease with increasing numbers of patients per day. However, multivariate analyses revealed that the only factors significantly influencing job satisfaction among health workers in RHCs were their profession in Turkey (i.e. general physician, specialist physician, or nurse or midwife), income, teamwork and team management.

The study provides evidence of a need to

improve work engagement for physicians and for maintaining good teamwork and management in RHCs. The results also indicate a need to consider adjustment for the annual cost of living in the salaries of health workers coupled with non- financial incentives to maintain high levels of job satisfaction and motivation. Overall, managers of RHCs and the SIHHAT project can consider these issues in developing policies and strategies for human resources in RHCs to improve and maintain high levels of job satisfaction.

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Introduction

Turkey hosts the largest number Syrian refugees, with an estimated population of 3.6 million (1). In 2018 the Ministry of Health of the Republic of Turkey, through the SIHHAT project, established the RHC mechanism to provide culturally and linguistically sensitive primary health-care services for Syrian refugees.

The SIHHAT project is operational in 29 provinces with the highest population densities of Syrian refugees. In 2016 the Ministry of Health established the RHC mechanism to provide culturally and linguistically competent primary health-care services to Syrian refugees. The Ministry of Health further developed and extended this mechanism through the SIHHAT project. By December 2019 there were 178 active RHCs across Turkey. Since becoming operational, RHCs have provided more than 1 270 000 patient consultations. As of June 2020, the SIHHAT project employed 712 Syrian physicians, 977 Syrian nurses and 1148 patient guides. This study aimed to collect evidence on job satisfaction and the factors influencing job satisfaction among refugee physicians and nurses working in RHCs. This report presents the findings of the job satisfaction study among Syrian health workers in RHCs.

Job satisfaction among Syrian health workers in refugee health centres in Turkey 1

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Background

National health system and RHC mechanism Health-sector partners of the 2019–2020 Regional Refugee and Resilience Plan (3RP) framework for Turkey have committed to supporting the Ministry of Health in building health system resilience to ensure that the needs of Syrians under temporary protection and host communities are met (2).

Primary health care is the route to achieving universal health coverage and the Sustainable Development Goals (3) but to make progress countries need a primary health workforce aligned to its population’s needs (4). The primary health- care workforce includes health workers engaged along the continuum of health promotion, disease prevention, treatment, rehabilitation and palliative care, and those engaged in addressing the social determinants of health (4).

In Turkey, primary health care is provided through community health centres and family health centres; in addition, RHCs have been established as part of the network of community health centres by the Ministry of Health to meet the primary health-care needs of the Syrian refugee population within the scope of the SIHHAT project. The RHC mechanism was planned and implemented based on the organization of primary health-care services in Turkey. RHCs comprise Refugee Health Units, with each consisting of a physician and nurse pair.

The mechanism also has extended RHCs that additionally provide internal medicine, paediatrics, obstetrics and gynaecology, oral and dental health, and psychosocial support services, and simple imaging and laboratory services. In addition to RHCs and extended RHCs, there are seven RHTCs that, in addition to providing all of the services of extended RHCs, have training facilities for health workers and are jointly managed by the Ministry of Health and WHO.

2 Job satisfaction among Syrian health workers in refugee health centres in Turkey

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The RHC mechanism differs from the national health system in how it is financed and its health- worker profile and target population. In the Turkish health system, primary health-care services are financed through the general social security system’s general health insurance budget and all health services are provided by Turkish nationals or foreigners who have accreditation. In contrast, RHCs are financed through the SIHHAT project (with funding from the European Union and support from other external donors) and health- care service providers are primarily Syrian nationals, who are authorized to work only in RHCs. Syrian nurses, midwives and general physicians work at the same level as they did in Syria, but specialist physicians are mostly employed as general physicians – only a small proportion continue to work as specialists. Although RHCs primarily provide services to Syrian refugees, like all health- care facilities in Turkey they provide services related to communicable disease prevention (such as vaccination) and emergency health services to those in need, regardless of their nationality and registration status¹. Before employment, Syrian health workers are trained and oriented to work in the Turkish health-care system through a tailored adaptation training programme implemented by WHO in collaboration with the Ministry of Health.

WHO and Ministry of Health joint adaptation training is delivered in WHO-managed RHTCs located in seven provinces (Ankara, Gaziantep, Hatay, Istanbul, Izmir, Mersin and Sanliurfa).

Through this action, WHO aims to fill a human resources gap in the primary health-care service delivery to Syrian refugees in order to increase access to quality and equitable health care for all.

As of March 2020, WHO and the Ministry of Health have trained 638 physicians, 806 nurses, 927 translators and 337 auxiliary staff providing services in 178 RHCs located in 29 provinces, and over 1 270 000 Syrian refugees have received health-care services in RHCs.

Syrian health workers who are employed in the Turkish health system find contextual differences to which they have to adapt, as established in a WHO field assessment on the employability of Syrian health workers in Turkey (Factors affecting employability of trained Syrian health-care professionals in Turkey, WHO Regional Office for Europe, unpublished data, 2020). In Syria, upon completion of their training, physicians and

1 That is, as a as a Syrian under temporary protection.

nurses move to their home towns or a nearby location to work in public or private hospitals, with no centralized Ministry of Health appointment system (as there is in Turkey). Working in their own communities allows them to receive social support. In Syria, besides working in hospitals, physicians could work in private clinics and employ nurses, enabling them to gain additional income. Compared with Turkey, health workers in Syria worked fewer hours, worked in their own communities and had access to additional income through private practice. As such, refugee health workers have to adapt to new working and living environments in Turkey.

Physicians’ job satisfaction and patients’ satisfaction

Studies have shown that physicians’ satisfaction with their work and work environment may impact the quality of patient care (5), patients’ satisfaction with their health care (6), patients’ adherence to medical instructions (7) and physicians’

commitment to staying in the job (5,8). The higher turnover rates for physicians due to poor job satisfaction may disrupt care provision and access to health care, while recruitment and replacement efforts may increase the overall health-care costs.

Jobs satisfaction among physicians is related to a range of factors. A systematic review of studies on factors affecting job satisfaction of physicians working in European countries showed that some factors affecting job satisfaction relate to the individual, such as age, gender, marital status and work experience, while others are intrinsic to the nature of the job, such as specialization, patient interactions and work engagement (9).

Yet other factors can relate to the job context, such as workload, job security and income level, or to the work environment, such as type of health centre, management, professional development, teamwork and access to resources.

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Patient satisfaction may be influenced by the values, attitudes and expectations of individual patients, but may also depend on the job satisfaction level of physicians. For instance, one study reported that patients of physicians with a high level of professional satisfaction were more satisfied with the health care they received compared with the patients of physicians with lower satisfaction levels (6). Another study found that job satisfaction among nurses correlated positively with patient satisfaction (8). Specific aspects of health workers’ experiences that reduce patient satisfaction levels include having too little time to accomplish their tasks (10), high work pressure for staff, staff perceptions of unequal treatment, discrimination and physical violence (11). However, another study did not find a correlation between patient satisfaction and the job satisfaction of physicians working in primary health care (12). Instead, they found a correlation between patient satisfaction and job satisfaction of non- physician staff (practice nurses, practice managers or secretaries/administrators), suggesting that patients may be more concerned about the overall service quality than the just the physician’s performance.

Several studies have investigated job satisfaction in migrant health workers, with varying levels of job satisfaction reported compared with national professionals (i.e. citizens of the host country).

A study in Spain showed that being foreign born was a significant predictor of job satisfaction among physicians, with foreign physicians being more satisfied than national physicians (11).

Similarly, a study in Singapore reported high levels of satisfaction among 495 migrant nurses, which correlated negatively with the work environment (13). However, other studies have reported the difficulties experienced by migrant health workers:

for example, a qualitative study among migrant physicians in Germany reported that the challenges experienced by foreign workers were related

to the organization of health-care institutions, such as regulation of licensure, legal norms and distribution of tasks, and difficulties with their own competencies, such as language and understanding the organization of the health-care system (14). The study also reported that physicians face difficulties related to their patients, colleagues and superiors, and said they felt discriminated against as foreigners. An integrative review of studies into the experiences of internationally

recruited nurses in the United Kingdom reported some positive experiences but also reported that many nurses had negative experiences related to not feeling valued or respected professionally (15).

Overall, these studies indicated the value of migrant health workers in the health-care systems of host countries – irrespective of the reason for migration.

Existing evidence on migrant health workers largely relates to migrants who are integrated into the host country’s health system and provide services to the host population. However, Syrian refugee health workers working within the Turkish health system provide culturally and language-sensitive services only to the Syrian refugee population through the RHC mechanism. Although there might be similarities between the experiences of Syrian refugee health workers in Turkey and migrant health workers elsewhere, understanding job satisfaction in this unique context could contribute to human resource planning and providing

universal health coverage in health systems in other countries with large refugee and migrant populations.

Study aim and objectives

WHO field assessments indicate that, despite their importance in scaling up human resource capacity and adherence to Turkish Labour Regulations, which includes 45 working hours per week, Syrian physicians and nurses complain that they face challenges such as high workload, limited opportunities for specialization, challenging working environments and managing the cost of living. Such challenges may impact their motivation, satisfaction and ability to effectively deliver quality health care and reduce their work performance. However, no study has yet been conducted to generate evidence on the level of job satisfaction among physicians and nurses working in RHCs. The objectives of the study were to (i) establish the level of job satisfaction and (ii) identify the factors that determine job satisfaction in Syrian physicians and nurses working in RHCs in Turkey.

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Methodology Study design

This study was a quantitative cross-sectional survey that targeted all Syrian physicians and nurses working in RHCs across Turkey. According to Ministry of Health figures, at the time of the survey 681 physicians and 896 nurses were employed in RHCs across Turkey. Sample size estimation using WinPepi (version 11.65) at a 95%

confidence interval (CI), 0.01 error margin and 5% loss to follow-up yielded a sample size of 630 physicians and 783 nurses.

Study questionnaires and variables Job satisfaction questionnaire

Job satisfaction was assessed using the General Job Satisfaction scale based on the short-form MSQ (16) and included 20 items on job

satisfaction: ability utilization, achievement, activity, advancement, authority, company policies, compensation, co-workers, creativity, independence, moral values, recognition,

responsibility, security, social status, social service, supervision – human relations, supervision – technical, variety and working conditions. The version used in this study was translated into Arabic.

The MSQ is a product of research on adjustment to work within the theory of work adjustment, which postulates that work fit depends on a match between the individual skills and work environment (16). The short-form MSQ was used in this study because it has been widely adapted to other health-care settings (17–19) and can be self- administered within five to 10 minutes.

Determinants of job satisfaction questionnaire Based on literature reviews (6,7,9,17) and

other assessments in RHCs (Factors affecting employability of trained Syrian health care professionals in Turkey, WHO Regional Office for Europe, unpublished data, 2020), the following potential determinants of job satisfaction were considered: sociodemographic factors (age, gender, education, marital status, nationality, residency in Turkey), characteristics of the work (working hours per day, workload/number of patients per day), work environment (type of health-care centre (RHC, extended RHC and RHTC), teamwork and team leadership/management), profession (general physician, specialist physician and nurse/midwife), length of experience (years of experience in Syria) and income.

Since most specialist physicians work as general practitioners at the RHCs, the profession variable was especially important in this study.

The questionnaire on determinants of job satisfaction was developed following a literature review that included a systematic review on quantitative research that assessed factors influencing job satisfaction in health workers (9).

In addition to these factors, the questionnaire included factors identified in other WHO

assessments that might also affect job satisfaction in health-care professionals working in RHCs (Factors affecting employability of trained Syrian health care professionals in Turkey, WHO Regional Office for Europe, unpublished data, 2020). Prior to use, the questionnaire was translated from English to Arabic and then re-translated to English by a different translator in line with the principles of cultural adaptation (20). Discrepancies between the two English versions (original and translated from Arabic) were resolved to finalize the Arabic version.

Prior to data collection, the questionnaire was pretested in 10 respondents to check the suitability of the Arabic dialect for the study population, clarity of meaning, clarity and interpretation of questions, and the questionnaire flow. Following the pretest, minor adjustments were made and the final version was adapted into an online survey tool using Kobo Toolbox.

Data collection

Data were collected through the self-administered questionnaire between 9 October and 1 December 2019. A link to the online questionnaire was sent to all physicians and nurses working in RHCs by the Ministry of Health in an official letter to ensure the anonymity of participants. The questionnaire did not include any personal or other information that could be used to identify the study participants. To improve the response rate, all study participants were sent weekly reminders by the Department of Migration, Ministry of Health, via the head physician for each RHC.

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Data cleaning and analysis

Collected data was securely stored in a password- encrypted server, checked against all entry errors and discrepancies, and cleaned before data analyses. A descriptive analysis was conducted to describe the distribution of study variables and determine the level of job satisfaction. Due to the non-parametric nature of the data, relationships between different variables and the job satisfaction score were assessed using the Mann–Whitney U test and the Kruskal–Wallis test. For variables that had three groups, Dunn’s pairwise tests with adjustment using Bonferroni correction was conducted after the Kruskal–Wallis test to identify groups with significantly different levels of job satisfaction. Linear regression analysis was also conducted to determine the factors that influenced job satisfaction. Data were analysed using IBM SPSS Statistics version 25.

Ethical approval

Ethical approval for this study was obtained from the WHO Ethical Review Committee, Gazi University Ethical Board and Ministry of Health Ethical Board in Turkey.

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Results

This study was conducted to determine the level of job satisfaction among refugee physicians and

nurses working in RHCs and to identify which factors determine job satisfaction.

Of the targeted 1577 health workers, 891 completed the questionnaires (555 nurse/midwives, 259 general physicians and 77 specialist physicians), giving an overall response rate of 56.5% (61.9% for nurses and 49.3% for physicians).

Sociodemographic and occupational characteristics of participants

Most of the participants were nurses/midwives (62%). Approximately two thirds of respondents were men (65.2%), a similar proportion were younger than 40 years of age (56.7%) and 86.9% were married. In all, 47.3% of participants were Syrians with Turkish citizenship; the majority of those with Turkish citizenship were physicians (Table 1). Most health workers had an undergraduate degree or higher; however, for 28.8% of nurses, the highest education level was high school. Almost half (41.2%) of study

participants had five or less years of work

experience in Syria, and most (64.5%) had worked in the SIHHAT project for two years or less.

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Table 1. Sociodemographic and occupational characteristics of respondents Characteristic

General physician

(n = 259) Specialist physician

(n = 77) Nurse/midwife

(n = 555) Total

(n = 891)

n % n % n % n %

Sex

Male 209 80.7 58 75.3 314 56.6 581 65.2

Female 50 19.3 19 24.7 241 43.4 310 34.8

Age group (years)

20–29 41 15.8 0 0.0 127 22.9 168 18.9

30–39 100 38.6 24 31.2 213 38.4 337 37.8

40–49 56 21.6 34 44.2 159 28.6 249 27.9

≥ 50 62 23.9 19 24.7 56 10.1 137 15.4

Marital status

Not married 37 14.3 3 3.9 77 13.9 117 13.1

Married 222 85.7 74 96.1 478 86.1 774 86.9

Nationality

Syrian 111 42.9 31 40.3 328 59.1 470 52.7

Syrian with Turkish citizenship 148 57.1 46 59.7 227 40.9 421 47.3

Education

High school 0 0.0 0 0.0 160 28.8 160 18.0

Undergraduate degree 166 64.1 16 20.8 386 69.5 568 63.7

Masters/postgraduate degree 93 35.9 61 79.2 9 1.6 163 18.3

Profession in Syria

General physician 184 71.0 0 0.0 0 0.0 184 20.7

Specialist physician 75 29.0 77 100.0 0 0.0 152 17.1

Nurse/midwife 0 0.0 0 0.0 555 100.0 555 62.3

Years worked in Syria

0–5 134 51.7 20 26.0 213 38.4 367 41.2

6–10 53 20.5 21 27.3 123 22.2 197 22.1

> 10 72 27.8 36 46.8 219 39.5 327 36.7

Years worked in Turkey*

0–2 172 66.4 42 54.5 361 65.0 575 64.5

> 2 87 33.6 35 45.5 194 35.0 316 35.5

* In the SIHHAT project.

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Table 2. Work characteristics and work environment of respondents Characteristic

General physician

(n = 259) Specialist physician

(n = 77) Nurse/midwife

(n = 555) Total

(n = 891)

n % n % n % n %

Type of health centre

RHTC 23 8.9 11 14.3 42 7.6 76 8.5

RHC 215 83.0 56 72.7 491 88.5 762 85.5

Extended RHC 21 8.1 10 13.0 22 4.0 53 5.9

Average number of patients/day

< 21 3 1.2 3 3.9 68 12.3 74 8.3

21–40 40 15.4 18 23.4 256 46.1 314 35.2

41–60 95 36.7 26 33.8 153 27.6 274 30.8

≥ 61 121 46.7 30 39.0 78 14.1 229 25.7

Access to resources needed for work

Yes 196 75.7 49 63.6 489 88.1 734 82.4

No 63 24.3 28 36.4 66 11.9 157 17.6

Know how to use equipment/other materials

Yes 256 98.8 77 100.0 551 99.3 884 99.2

No 3 1.2 0 0.0 4 0.7 7 0.8

Teamwork

Poor 11 4.2 2 2.6 8 1.4 21 2.4

Average 34 13.1 7 9.1 43 7.7 84 9.4

Good 214 82.6 68 88.3 504 90.8 786 88.2

Team management

Poor 34 13.1 8 10.4 27 4.9 69 7.7

Average 49 18.9 15 19.5 66 11.9 130 14.6

Good 176 68.0 54 70.1 462 83.2 692 77.7

Income

Poor 118 45.6 23 29.9 73 13.2 214 24.0

Average 111 42.9 43 55.8 257 46.3 411 46.1

Good 30 11.6 11 14.3 225 40.5 266 29.9

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Work characteristics and work environment Over 85% of study participants worked in RHCs (Table 2). Almost half of the nurses/midwives (46.1%) reported seeing an average of 21–40 patients per day; in comparison, the highest proportions of both general and specialist physicians reported seeing more than 61 patients per day (46.7% and 39.0%, respectively). Most participants reported having access to the resources required for their work and knowing how to use the equipment and materials at their disposal. Among all participants, 88.2%

rated the level of teamwork as good. A slightly lower proportion of all participants (77.7%) rated their team management as good, and the lowest proportion of participants giving this assessment were general physicians (68.0%). Of the three professional groups, nurses were the most positive about their teamwork and team management.

Overall, 46.1% of participants rated their income as average; this rating was reflected among the specialist physicians and nurses, while the highest proportion of general physicians assessed their income as poor.

Job satisfaction

Nurses/midwives reported the highest level of general job satisfaction, followed by specialist physicians and then general physicians (Table 3).

Kruskal–Wallis testing provided a strong support that job satisfaction levels differed between the three professional groups (P < 0.001); a follow-up Dunn’s pairwise test revealed that job satisfaction scores were significantly higher in nurses than in physicians (both general and specialist; P < 0.001).

Further analysis revealed that physicians who had worked as specialists in Syria but were now working as general physicians in Turkey had the lowest satisfaction levels (Fig. 2). However, the difference in job satisfaction between groups of physicians was not significant.

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Table 3. Job satisfaction by profession

Profession Participants (n) Mean SD 95% CI Range

General physician 259 63.3 14.6 61.5–65.1 20.0–100.0

Specialist physician 77 65.9 13.2 63.2–69.0 29.0–88.0

Nurse/midwife 555 74.9 11.0 74.0–75.8 20.0–100.0

Total 891 70.8 13.4 69.9–71.7 20.0–100.0

Fig. 2. Job satisfaction level by profession and country of work

General physician

in Syria and Turkey Specialist physician in Syria and General physician in Turkey

Specialist physician

in Syria and Turkey Nurse/midwife in Syria and Turkey 0

20 40 60 100

80

General Job Satisfaction score

66

77

***

* 62 69

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100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Co-workers Authority Social service Achievement Supervision – human relations Creativity Independence Supervision – technical Ability utilization Social status Recognition Responsibility Security Work conditions Variety Advancement Activity Moral values Company policy and practice Compensation

Fig. 3. Satisfaction levels related to the 20 items of the MSQ: physicians

Satisfied Neutral Dissatisfied

0% 20% 40% 60% 80% 100% 120%

Social service Ability utilization Co-workers Authority Achievement Supervision – human relations Advancement Creativity Security Work conditions Supervision – technical Recognition Company policy and practice Variety Responsibility Social status Independence Compensation Activity Moral values

Fig. 4. Satisfaction levels related to the 20 items of the MSQ: nurses

Satisfied Neutral Dissatisfied

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As there was no significant difference in job satisfaction between general and specialist physicians, data for both groups were combined in the analysis of satisfaction on the items of the MSQ. Levels of satisfaction on the 20 items on the MSQ also varied among the different groups of participants (Figs 3 and 4). Responses for the five-point scale (Annex 1) were combined into three categories: satisfied (satisfied and very satisfied), neutral and dissatisfied (dissatisfied and very dissatisfied). Physicians were most satisfied with the co-workers, authority and social service items and least satisfied with the compensation, workplace policy/practice and moral values items. Nurses were most satisfied with the social services, professional ability utilization and co-workers items and least satisfied with the moral values, compensation and independence items. Physicians were more dissatisfied than nurses with compensation.

Determinants of job satisfaction Sociodemographic factors

Sociodemographic factors included age, gender, education and nationality (Turkish citizenship).

Statistically significant variation was found in the mean general job satisfaction score between age groups (P < 0.003), education levels (P < 0.001) and citizenship categories (P = 0.002; Table 4). When analysed by age group, the mean general job satisfaction score was highest among those aged 40–49 years, and when analysed by education l evel, it was highest among those with high school as the highest level of education. Job satisfaction scores were higher for health workers without Turkish citizenship than those with Turkish citizenship (P = 0.002).

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Work characteristics

The work characteristics assessed in this study were number of patient consultations per day, access to resources (e.g. equipment and supplies) needed for work and knowing how to use the available equipment and other materials (Table 5).

Job satisfaction scores were significantly different according to the number of patients seen per day scores were highest among health workers who saw fewer than 21 patients per day (P < 0.001).

There was a significant inverse relationship between the number of patients seen per day and job satisfaction scores (P < 0.001). Participants who reported having access to necessary

resources also had significantly higher job satisfaction scores (P < 0.001).

Table 4. Relationship between general job satisfaction scores and sociodemographic factors Sociodemographic

factor Participants (n) General Job

Satisfaction scale SD P value

Sex^a

Male 581 70.29 13.6 0.135

Female 310 71.68 13.0

Age group (years)^b

20–29 168 70.57 14.4 0.003*

30–39 337 68.69 14.2

40–49 249 73.15 12.1

≥ 50 137 71.77 11.7

Education^b

High school 160 76.87 10.5 < 0.001*

Undergraduate

degree 568 70.76 13.1

Masters/

postgraduate

degree 163 64.83 14.3

Marital status^a

Not married 117 68.79 16.7 0.449

Married 774 71.07 12.8

Citizenship^a

Syrian 470 72.00 13.2 0.002*

Syrian with Turkish

citizenship 421 69.40 13.6 *: P < 0.05.

a Differences were analysed using the Mann–Whitney U test.

b Differences were analysed using the Kruskal–Wallis test.

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Table 5. Relationship between general job satisfaction score and work characteristics Work characteristic Participants (n) General Job

Patients/day (n)a

< 21 74 75.39 11.0 < 0.001*

21–40 314 73.33 10.9

41–60 274 70.89 13.3

≥ 61 229 65.64 15.8

Access to resourcesb

Yes 734 72.82 12.2 < 0.001*

No 157 61.22 14.9

Know how to use equipment/other materialsb

Yes 884 70.79 13.4 0.444

No 7 68.43 16.4 *: P < 0.05.

a Differences were analysed using the Kruskal–Wallis test.

b Differences were analysed using the Mann–Whitney U test.

Table 6. Relationship between general job satisfaction scores and the work environment Work environment Participants (n) General Job

Type of health centre

RHTC 76 73.07 11.5 0.007*

RHC 762 70.90 13.4

Extended RHC 53 65.64 14.6

Teamwork

Poor 21 41.90 18.6 < 0.001*

Average 84 60.61 14.6

Good 786 72.63 11.7

Team management

Poor 69 49.59 15.6 < 0.001*

Average 130 60.61 11.6

Good 692 74.79 10.1 *: P < 0.05.

Note: differences were analysed using the Kruskal–Wallis test.

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Work environment

The factors used to assess the work environment of Syrian physicians and nurses were type of health centre and the participants’ perceptions of teamwork and team management. Job satisfaction scores were significantly influenced by all three factors (Table 6). The mean job satisfaction score was significantly lower for those working in

extended RTCs (P = 0.007) and significantly higher among those who rated teamwork and team management as good.

Profession, experience and income

The mean job satisfaction scores were significantly higher in nurses than in the two groups of

physicians. (P < 0.001; Table 7). Job satisfaction scores also differed significantly different by the number of years worked in Syria (P < 0.001) but not by the number of years working in the SIHHAT project in Turkey (P = 0.19). Compared with the other categories for years worked in Syria, participants who had over 10 years of experience had the highest mean job satisfaction scores.

The mean job satisfaction score was directly associated with the perception of income earned from working in the RHCs (from poor to good;

P < 0.001).

Multiple regression analysis was used to determine which factors were associated with job satisfaction.

Variables included in the analysis were age group, nationality, number of patients per day, type of health centre, teamwork, team management, job in Turkey, number of working years in Syria and income. Out of these factors, only profession in Turkey and perception of income, teamwork and team management were significantly associated with job satisfaction (Table 8).

Table 7. Relationships between general job satisfaction scores and job type, work experience and income Profession and

experience Participants (n) General Job

Job in Turkey^a

General physician 259 63.35 14.6 < 0.001*

Specialist physician 77 65.95 13.2

Nurse/midwife 555 74.91 11.0

Years worked in Syria^a

0–5 367 68.53 14.5 < 0.001*

6–10 197 70.57 13.9

> 10 327 73.40 11.2

Years worked in Turkey^b,c

0–2 575 71.01 13.5 0.19

> 2 316 70.34 13.2

Income^a

Poor 214 60.26 15.2 < 0.001*

Average 411 71.49 11.3

Good 266 78.12 8.6 *: P < 0.05.

a Differences were analysed using the Kruskal–Wallis test.

b Differences were analysed using the Mann–Whitney U test.

c In the SIHHAT project.

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Table 8. Multiple regression analysis of factors associated with the general job satisfaction score

Variable B 95% CI SE P value

Lower bound Upper bound Age group (years) (ref. ≥ 50)

20–29 −4.32 −7.53 −1.12 1.634 0.008*

30–39 −4.61 −7.28 −1.94 1.361 0.001*

40–49 −0.48 −2.59 1.62 1.070 0.651

Nationality (ref. Syrian with Turkish

citizenship) 0.32 −0.97 1.61 0.655 0.626

Education (ref. High school)

Undergraduate degree −0.52 −2.45 1.42 0.984 0.600

Masters/postgraduate degree −0.31 −3.12 2.50 1.432 0.829

Number of patients/day (ref. < 20)

21–40 −0.81 −3.26 1.63 1.247 0.515

41–60 −0.45 −2.97 2.07 1.285 0.725

≥ 61 −1.52 −4.19 1.15 1.361 0.265

Type of health centre (ref. RHTC)

RHC −1.65 −3.93 0.63 1.161 0.156

Extended RHC −2.00 −5.38 1.38 1.721 0.245

Teamwork (ref. Good)

Poor −13.44 −18.11 −8.77 2.379 0.000*

Average −3.82 −6.13 −1.51 1.178 0.001*

Team management (ref. Good)

Poor −15.85 −18.63 −13.08 1.412 0.000*

Average −9.31 −11.27 −7.35 0.998 0.000*

Profession (ref. Nurse/midwife)

General physician −6.84 −8.81 −4.88 1.000 0.000*

Specialist physician −6.60 −9.59 −3.62 1.522 0.000*

Years worked in Syria (ref. > 10)

0–5 1.99 −0.37 4.35 1.202 0.099

6–10 2.26 0.05 4.48 1.130 0.045*

Income (ref. Good)

Poor −7.79 −9.77 −5.81 1.009 0.000*

Average −3.24 −4.77 −1.72 0.777 0.000*

B: unstandardized coefficient; Ref: reference category; SE: standard error; *: P < 0.05.

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Discussion

Syrian health workers in RHCs provide a critical human resource in response to the health needs of Syrian refugees in Turkey. Previous assessments among Syrian health workers showed that physicians and nurses valued the opportunity to work in Turkey because, as well as continuing to work in their

profession, they can also earn a livelihood and serve their fellow nationals.

Most of the respondents were nurses/midwives (62.0%), men (65.2%), younger than 40 years old (61.3%), married (86.9%) and had worked in the SIHHAT project for two years or less (64.5%).

Although only 56% of the target population

responded, the analysis revealed important results on job satisfaction and related factors among Syrian health professionals in Turkey. The level of job satisfaction was highest among nurses, health workers aged between 40 and 49 years, and those without Turkish citizenship. Mean job satisfaction was highest in respondents who reported having access to the resources required to do their work, those working in RHTCs, and those who rated teamwork and team management as good in their RHC. Multivariate analyses identified factors that significantly influenced job satisfaction among health workers in RHCs as their profession in Turkey (i.e. general physician, specialist physician or nurse), income, teamwork and team management.

The study found that levels of job satisfaction were higher in nurses than in physicians. Factors that most contributed to job satisfaction in nurses were service, ability to apply their skills and teamwork, while those for physicians were teamwork, having authority and the social status accorded by their job. Work characteristics for nurses working in RHCs are similar to those in Syria, but perhaps the more advanced health system in Turkey provides more opportunities to apply their skills. In comparison, physicians working in RHCs provide only primary health-care services, which limits their ability to apply their skills, especially for specialists. Although the difference was not statistically significant, physicians who had worked as specialists in Syria but were working as general physicians in Turkey had lower job satisfaction than those who continued to work as specialists in Turkey. Previous studies in health workers reported that work engagement is associated with job satisfaction (7,20). Indeed, profession in Turkey was a significant determinant of job satisfaction for health workers in RHCs.

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The RHC mechanism and SIHHAT project provide a time-bound response to health service provision to Syrian refugees under temporary protection in Turkey. However, there is no mechanism for professional advancement of Syrian health workers. In this context, it is unsurprising that physicians expressed dissatisfaction with the lack of opportunities for advancement. Other studies have demonstrated that opportunities for advancement influence staff motivation and job satisfaction among health workers (19). Improving work engagement for physicians in RHCs could improve their job satisfaction levels, motivation and intention to stay in the job, and have a positive impact on job performance in terms of effectiveness of care, quality of care and patient satisfaction.

The mean job satisfaction score increased with perception of income adequacy. Most study participants said their income was average.

Evidence of inadequate income from working at all three types of health centres (RHCs, extended RHCs and RTHCs) was provided by the low rating for compensation by both nurses and physicians,

but particularly by physicians. Income was a significant predictor of job satisfaction: compared with those who rated their income as good, the job satisfaction score was 7.7 points lower among those who rated it as poor and 3.4 points lower among for those who rated it as average. A qualitative study on factors affecting the employability of Syrian health workers revealed that the cost of living, not having other salary supplements, the costs of transportation, lunch and child care, and not being allowed to supplement their work with private practice limited the adequacy of their income from RHCs (Factors affecting employability of trained Syrian health care professionals in Turkey, WHO Regional Office for Europe, unpublished data, 2020). These factors may explain the importance of income in determining job satisfaction in health workers in RHCs. In addition, comparing their own income with that of Turkish physicians working in hospitals and not those working in primary health care may influence their perception of income adequacy. Studies conducted elsewhere showed that remuneration influences job

satisfaction (21) and that non-monetary incentives increased levels of professional and performance