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Practice assistants in primary care in Germany – associations with organizational attributes on job satisfaction

Practice assistants in primary care in Germany – associations with organizational attributes on... Background: Job satisfaction and organizational attributes in primary care teams are important issues as they affect clinical outcomes and the quality of health care provided. As practice assistants are an integral part of these teams it is important to gain insight into their views on job satisfaction and organizational attributes. The aim of this study was to evaluate the job satisfaction of practice assistants and the organizational attributes within their general practices in Germany and to explore the existence of possible associations. Methods: This observational study was based on a job satisfaction survey and measurement of organizational attributes in general practices in the German federal state of Baden-Wuerttemberg. Job satisfaction was measured with the 10-item ‘Warr-Cook-Wall job satisfaction scale’. Organizational attributes were evaluated with the 21-items ‘survey of organizational attributes for primary care’ (SOAPC). Linear regression analyses were performed in which each of SOAPC scales and the overall score of SOAPC was treated as outcome variables. Results: 586 practice assistants out of 794 respondents (73.8%) from 234 general practices completed the questionnaire. Practice assistants were mostly satisfied with their colleagues and least of all satisfied with their income and recognition for their work. The regression analysis showed that ‘freedom of working method’ and ‘recognition of work’, the employment status of practice assistants and the mode of practice were almost always significantly associated with each subscale and overall score of SOAPC. Conclusions: Job satisfaction is highly associated with different aspects of organizational attributes for primary care (‘communication’, ‘decision-making’ and ‘stress’). Consequently, improved job satisfaction could lead to a better- organized primary care team. This implication should be investigated directly in further intervention studies with a special focus on improving the recognition for work and income. Keywords: General practice, Practice assistant, Organizational attributes, Job satisfaction, Primary health care Background for providing a good quality of care and positive health Within the last years more attention is given on the chan- outcomes for patients, while also improving the level of ging role of practice assistants in primary care. The substi- service capacity and accessibility [4]. Furthermore, the tution and diversification of their roles are related to strengthening of the role of practice assistants in primary outcomes of patient health, process of care or direct and care is expected to improve the quality of service provided indirect costs [1]. Moreover, it was found that task substi- by physicians via a reduction of their workload enabled by tution to practice assistants supports general practitioners a transfer of responsibilities to practice assistants [5]. to provide a good care [1-3]. Practice assistants are crucial Moreover, the changing role could have an impact on per- ception of own job satisfaction. Job satisfaction is an im- portant issue among health care professionals and is * Correspondence: katja.goetz@med.uni-heidelberg.de associated with suboptimal health care delivery and poor Department of General Practice and Health Services Research, University of Heidelberg, Heidelberg, Germany clinical outcomes, for instance adverse events and reduced Full list of author information is available at the end of the article © 2013 Gavartina et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Gavartina et al. BMC Family Practice 2013, 14:110 Page 2 of 6 http://www.biomedcentral.com/1471-2296/14/110 patient adherence [6]. Additionally, it is imperative to German validated version of the ‘survey of organizational maintain a high quality of care due to the demographic attributes for primary care’ (SOAPC) [13-15]. change, the increase of chronic diseases and continuous The job satisfaction scale consists of ten items rated medical progress. The demographic change, and with it on a 7-point Likert scale (1 = extreme dissatisfaction to the increase of chronic diseases, is relevant not only be- 7 = extreme satisfaction). The questionnaire comprises cause of the rising health costs but also in terms of items concerning the satisfaction with physical working personnel resources [7]. These developments, the chan- conditions, freedom to choose work methods, colleagues ging role of practice assistants and their impact on job sat- and fellow workers, recognition for work, amount of re- isfaction and the demographic change, play an important sponsibility, income, opportunity to use one’s abilities, role in light of prospective personnel retention. hours of work and amount of variety in the job as well Workforce shortages within the health care system are as the overall job satisfaction. A higher overall mean becoming a generic problem in several countries [8]. The score indicates a higher job satisfaction. The ‘WCW job evaluation of job satisfaction plays a significant role in this satisfaction scale’ is also regularly used in a primary care trend and dissatisfaction leading to a high turnover and a focus as shown in a literature review conducted by van shortage of non-physician employees [9]. This in turn has Ham et al. and by other studies [16-18], and can be detrimental effects, with a high turnover leading to a loss regarded as a reliable and validated instrument to meas- of continuity of care [7]. Moreover, it was found that con- ure job satisfaction. tinuity of care could also be influenced by organizational The German validated version of SOAPC is composed attributes in primary care [10]. However, there is a lack of of 21 items, which are subsumed in four subscales: ‘com- evidence regarding the relationship of organizational attri- munication’ consisting of four items, ‘decision-making’ butes and job satisfaction by practice assistants in primary consisting of eight items, ‘stress’ consisting of six items care. Currently, there are around 398,000 practice assis- and ‘change’ consisting of three items [14]. Each of the tants in primary care in Germany [11]. They are trained in items is rated on a 5-point Likert scale (1 = fully disagree supportive medical tasks, practice organisation and ad- to 5 = fully agree). This version was used in a primary ministration during a 3-year part-time curriculum at a vo- care focus before [15]. cational school [12]. Their range of tasks varies from Furthermore, socio-demographic data such as age, administrative tasks, assisting general practitioners and gender, employment status and practice characteristics performing various medical procedures. were collected. Practice characteristics contained the The aim of the study was to evaluate the job satisfaction mode of practice (single-handed and group practices) and organizational attributes of practice assistants in gen- and the location of the practice (urban, semi-urban and eral practices in Germany and to explore associations be- rural located practices). tween organizational attributes and job satisfaction. Data analysis Methods The analysis was performed with SPSS version 18.0 This observational study was based on a job satisfaction (SPSS Inc., Chicago IL, USA). First, a descriptive analysis survey and measurement of organizational attributes in was undertaken concerning characteristics of the study general practices in the German federal state of Baden- population. Furthermore, a descriptive analysis of job Wuerttemberg. satisfaction scale and scales of organizational attributes were conducted. The means, standard deviations and Participants 95% confidence intervals of these aspects are reported. From 2000 randomly selected general practices 234 took Finally, multivariate linear regression analyses for each part in the job satisfaction survey of practice assistants. of the organizational attributes were carried out. Each of From these 234 general practices 794 practice assistants the four scales of SOAPC and the overall score of were interested to take part in this study. Practice assis- SOAPC were treated as outcome variables, the individ- tants were asked to fill in a depersonalized paper-based ual and practice characteristics and the different items of questionnaire and to send it back to the study centre. the job satisfaction scale were used as independent vari- We provided a free-post envelope, but no further finan- ables. An alpha level of p < 0.05 was used for tests of cial incentives for practice assistants. statistical significance. Measures Data collection took place between June 2011 and Ethical approval August 2011. The questionnaire contains the German The study was fully approved by the ethics committees validated version of the ‘Warr-Cook-Wall (WCW) job of the Medical Faculty of the University of Heidelberg satisfaction scale’, developed by Warr et al. and the (S137/2011). Gavartina et al. BMC Family Practice 2013, 14:110 Page 3 of 6 http://www.biomedcentral.com/1471-2296/14/110 Table 1 Descriptive statistics factors of job satisfaction Results and of organizational attributes of practice assistants 586 practice assistants out of 794 respondents (73.8%) Mean (SD) CI (95%) completed the questionnaire. Almost all practice assis- tants were female (99.5%) with a mean age of 39.1 years Factors of job satisfaction (SD = 12.0). 44% of the practice assistants worked full Physical working condition 5.18 (1.32) 5.06 – 5.30 time. Over 40% of the general practices were single Freedom of working method 5.20 (1.35) 5.08 – 5.33 handed and 30.6% were located in rural areas. Colleagues and fellow workers 5.87 (1.28) 5.76 – 5.99 Recognition for work 5.07 (1.47) 4.94 – 5.21 Evaluation of job satisfaction and organizational Amount of responsibility 5.38 (1.33) 5.25 – 5.50 attributes Practice assistants were mostly satisfied with ‘colleagues Income 3.89 (1.79) 3.73 – 4.06 and fellow workers’ (mean = 5.87) and least satisfied with Opportunity to use abilities 5.26 (1.26) 5.14 – 5.37 the ‘recognition of their work’ (mean = 5.07) and their Hours of work 5.34 (1.49) 5.20 – 5.48 ‘income’ (mean = 3.89). The mean for the ‘overall job sat- Amount of variety in job 5.49 (1.22) 5.38 – 5.60 isfaction’ was 5.74 (SD = 1.19) meaning that practice as- Overall job satisfaction 5.74 (1.19) 5.63 – 5.85 sistants are satisfied with their job situation in general. Factors of organizational attributes The overall mean score for the factors of organizational attributes for practice assistants was 3.70 (SD = 0.48) in- Communication 3.92 (0.48) 3.86 – 3.98 dicating that there exist a functioning organizational cul- Decision making 3.95 (0.64) 3.89 – 4.00 ture within practices. However the subscale ‘history of Stress 3.53 (0.73) 3.46 – 3.59 change’ with a rating of 3.12 (SD = 0.79) as the lowest History of change 3.13 (0.79) 3.06 – 3.20 mean showed that practice assistants thought that there Overall score 3.70 (0.48) 3.66 – 3.75 were not sufficient changes in the work organization and SD Standard deviation, CI Confidence interval. teamwork. Nevertheless ‘decision making’ was rated the range from 1 “extreme dissatisfaction” to 7 “extreme satisfaction”. highest with a mean of 3.95 (SD = 0.64) showing that 2 range from 1 “fully disagree” to 5 “fully agree”. practice assistants thought that the practice works as a team concerning decision-making and the development of improvements regarding the quality of care within status of practice assistants and the mode of practice the practices. The subscale ‘stress’ had a mean of 3.53 were almost always significantly associated with each (SD = 0.73). A lower mean in this subscale means less subscale and overall score of SOAPC. stress. Practice assistants were moderately stressed meaning that the given working conditions are only moderately exhausting. Details are given in Table 1. Discussion The results of the study show how organizational attri- Factors associated with the outcome variables: butes and socio-demographic characteristics are associ- organizational attributes ated with the job satisfaction of practice assistants in The associations between the predictors of individual German primary care settings. As there is limited pub- and practice characteristics and factors job satisfaction lished research in this field so far this study contributes concerning the organizational attributes are presented in important issues to a field with increasing importance. Table 2. Higher scores of the different aspects of job satisfac- Three of the five regression models explained more tion compared to our data were found in studies which than 35% (R > 0.35) of the variance of the outcome vari- have also evaluated job satisfaction of practice assistants ables. These three subscales were ‘communication’, ‘deci- in general practices with the Warr-Cook-Wall question- sion-making’, and the ‘overall score’. As an example, the naire [17,18]. A possible explanation for higher scores predictors that were significantly associated with the could be the different study populations. All of the re- outcome ‘communication’ were three factors of job satis- spondents from these previous studies were members of faction: ‘freedom of working method’ (β = 0.127), ‘col- general practices participating in a quality management leagues and fellow workers’ (β = 0.397) and ‘recognition program. In a study conducted by Vail et al. it was also for work’ (β = 0.211). The ‘overall job satisfaction’ was shown that, despite a high overall satisfaction, practice no important predictor for each subscale and overall assistants were dissatisfied with their income, status and score of SOAPC. Of the 14 independent variables that career progression [19]. Practice assistants in Australia were entered into the regression models, two items of indeed showed higher scores for overall job satisfaction the job satisfaction scale being ‘freedom of working than in our study, but were also less satisfied with their method’ and ‘recognition of work’, the employment ‘income’ and ‘recognition for their work’ [20]. Gavartina et al. BMC Family Practice 2013, 14:110 Page 4 of 6 http://www.biomedcentral.com/1471-2296/14/110 Table 2 Associations on outcome variables of organizational attributes in primary care practices (results of linear regression analyses, under specification of standardized beta coefficient and 95% confidence interval (CI), α = 5%) Factors of organizational attributes of primary care practices Communication Decision-making Stress History of change Overall score β (p-value*) β (p-value*) β (p-value*) β (p-value*) β (p-value*) Practice characteristics Mode of practice (0 = single; 1 = group) −0.107 (0.01) −0.016 (0.66) −0.154 (<0.01) 0.160 (0.01) −0.068 (0.07) Location of practice (1 = urban; 2 = semi urban; 3 = rural) −0.024 (0.52) −0.015 (0.69) 0.055 (0.17) 0.024 (0.62) 0.018 (0.63) Individual characteristics Age −0.011 (0.80) 0.058 (0.17) −0.155 (0.01) 0.096 (0.07) −0.021 (0.62) Employment status (0 = full-time worker; 1 = part-time worker) 0.090 (0.04) 0.080 (0.06) 0.138 (0.01) −0.056 (0.30) 0.110 (0.01) Different factors of job satisfaction Physical working condition −0.033 (0.53) −0.015 (0.77) 0.356 (<0.01) −0.085 (0.19) 0.121 (0.02) Freedom of working method 0.127 (0.02) 0.243 (<0.01) 0.034 (0.54) 0.123 (0.06) 0.202 (<0.01) Colleagues and fellow workers 0.397 (<0.01) 0.082 (0.09) 0.038 (0.46) −0.106 (0.08) 0.141 (0.01) Recognition for work 0.211 (<0.01) 0.283 (<0.01) 0.081 (0.17) 0.006 (0.93) 0.238 (<0.01) Amount of responsibility −0.085 (0.15) −0.124 (0.03) −0.067 (0.28) 0.006 (0.94) −0.119 (0.04) Income 0.063 (0.16) −0.007 (0.88) 0.043 (0.37) 0.048 (0.40) 0.043 (0.33) Opportunity to use abilities 0.058 (0.36) 0.204 (0.01) 0.070 (0.31) −0.096 (0.23) 0.127 (0.04) Hours of work −0.044 (0.38) −0.020 (0.69) 0.013 (0.80) −0.027 (0.67) −0.021 (0.66) Amount of variety in job 0.026 (0.65) 0.046 (0.40) −0.092 (0.12) 0.095 (0.18) 0.015 (0.79) Overall job satisfaction −0.007 (0.91) 0.046 (0.50) 0.095 (0.20) −0.057 (0.51) 0.050 (0.46) Pseudo R 0.389 0.405 0.298 0.042 0.424 *Statistical significance of difference: P < 0.05. Gavartina et al. BMC Family Practice 2013, 14:110 Page 5 of 6 http://www.biomedcentral.com/1471-2296/14/110 One solution to the noticeable lack of recognition could or not interventions could have an impact on both be the reallocation of tasks giving practice assistants more organizational culture and job satisfaction. Additionally, responsibilities, which might not only strengthen the im- improved job satisfaction could lead to a better organized portance of their job but also reduce the workload of gen- primary care team. This association, which was also eral practitioners. It was shown that task substitution shown in other studies [15,29], is important as team-level could contribute to an improvement of quality of care as job satisfaction is a telling predictor for the effectiveness well as patient outcomes such as patient adherence to of how primary care teams manage patient care [15]. treatment, patient quality of life and patient satisfaction Kuokkanen et al. found that organizational commitment [21,22]. Moreover, a study of Dini et al. showed that 48% and job satisfaction are essential factors for empowerment. of general practitioners in Germany inclined to delegate With empowerment they mean “the process of personal home visit tasks to their practice assistants. The main dis- growth and development”, which is important in the con- advantage here was the related costs for training of the text of the attractiveness of the profession as well as the practice assistants, while the ability to save time was development of care, education and management [30]. named as the main advantage [23]. To realise task substi- Other factors instrumental for empowerment include a tution in Germany there are for example the so called low-hierarchy organization, a teamwork oriented ap- ‘AGnES-model projects’ in different federal states, which proach within a practice, sufficient capabilities and a man- transfer medical duties and house visits to qualified prac- agement which creates opportunities [31]. An important tice assistants. Results of these model projects showed that contribution to the job satisfaction of nurses could be set general practitioners feel exonerated and patient compli- in a meta-analysis from 1993 performed by Blegen et al., ance is improved through AGnES-employees [24]. which revealed that nurses’ job satisfaction was strongly As our data suggests colleagues make an important con- associated with declined work stress, organizational com- tribution to job satisfaction. These results are in accordance mitment, communication and recognition for work [32]. with other studies. Zangaro et al. for example showed that These findings are exposed and confirmed for practice as- through a high satisfaction with colleagues stress could be sistants by our study. It should be noted that ‘history of reduced leading to a more positive work environment [25]. change’ had only an explained variance of 4.2%. The rea- Moreover, a review of Van Laar et al. emphasized that in son for this might be due to the limited options of practice most of the researched 17 countries medical staff was assistants to initiate changes as the general practitioner stressed and incriminated. It was assumed that the nature of makes most of the final decisions. To confirm this as- work, numerous changes in organizational fields and the sumption and to address the question regarding the distri- growing workload lead to worse physical and mental condi- bution of decision-making in a team, further studies need tions which could deteriorate the quality of patient care [26]. to be conducted. Moreover, job dissatisfaction implicated more stress and burnout amongst health care workers [27]. This shows the Strengths and limitations importance of research evidence concerning organizational A main strength of our study is that we used internationally culture, job satisfaction and working conditions of practice validated measures for the evaluation of organizational attri- assistants. Our study found that the level of ‘stress’ was butes and job satisfaction of practice assistants [13,14]. Fur- moderate, with a lower mean indicating a lower stress level. thermore, there is little research for organizational attributes Moreover, there was a significant association between this of practice assistants, particularly for Germany. Therefore, subscaleand theage of theparticipants. A lower level of our study provides an important addition to this field of re- stress within the practices is associated with a younger age search. However, without being able to collect data from a of the practice assistants, group practices and practices with broader range of socio-demographic characteristics of prac- a higher level of satisfaction with physical working condi- tice assistants only limited conclusions regarding this area tion. This emphasizes the importance of the general trend are possible. In addition, as this was an exploratory study; p towards more group practices as a contribution to a reduc- values should be interpreted carefully. Significant results tion of the level of stress [28]. might be due to chance and will need to be confirmed in In our study we found a strong and significant associ- further targeted studies. ation between organizational attributes, job satisfaction and socio-demographic characteristics throughout the re- Conclusions gression models. This means that job satisfaction affects Different items of job satisfaction, such as ‘freedom of work- changes in the organizational culture within a general ing method’, ‘colleagues and fellow workers’ and ‘recognition practice concerning, for example, decision making, im- for work’, affect specific organizational attributes such as proving working conditions, teamwork, provided quality ‘communication’, ‘decision-making’ and ‘stress’.Furthermore, of care, reducing stress and exhaustion. In further inter- job satisfaction affects differences in the organizational cul- vention studies should be investigated to establish whether ture concerning of decisions made by the whole team, Gavartina et al. BMC Family Practice 2013, 14:110 Page 6 of 6 http://www.biomedcentral.com/1471-2296/14/110 working conditions, teamwork, the provided quality of care 10. 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Warr P, Cook J, Wall T: Scales for the measurement of some work attitudes and aspects of psychological well-being. J Occup Psychol 1979, ant basis for developing more and wider interventions 52:129–148. concerning the establishment and improvement of satisfied, 14. Ohman-Strickland PA, Orzano JA, Nutting PA, et al: Measuring extended and multidisciplinary primary care teams. Practice organizational attributes of primary care practices: development of a new instrument. Health Serv Res 2007, 42:1257–1273. assistants are an essential part of primary care teams and 15. Ose D, Freund T, Kunz CU, et al: Measuring organizational attributes in therefore, it is important to evaluate their job satisfaction. primary care: a validation study in Germany. J Eval Clin Pract 2010, However, the recognition for their work and their income 16:1289–1294. 16. Van Ham I, Verhoeven AA, Groenier KH, Groothoff JW, De Haan J: Job should be improved. 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KG coordinated the study. 2011, 12:29–41. AG, SZ and KG carried out data analysis. AG and KG wrote the manuscript. 20. Harris MF, Proudfoot JG, Jayasinghe UW, et al: Job satisfaction of staff and All authors (AG, SZ, JS, AM, DO, SC, KG) commented on the draft and the team environment in Australian general practice. Med J Aust 2007, approved the final version of the manuscript. 186:570–573. 21. Dennis S, May J, Perkins D, Zwar N, Sibbald B, Hasan I: What evidence is Acknowledgements there to support skill mix changes between GPs, pharmacists and The authors would like to thank the participating practices and their practice practice nurses in the care of elderly people living in the community? staff for filling in the questionnaire and taking an active part in the Aust New Zealand Health Policy 2009, 6:23. realisation of this study. 22. 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Practice assistants in primary care in Germany – associations with organizational attributes on job satisfaction

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Springer Journals
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Copyright © 2013 by Gavartina et al.; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1471-2296
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Abstract

Background: Job satisfaction and organizational attributes in primary care teams are important issues as they affect clinical outcomes and the quality of health care provided. As practice assistants are an integral part of these teams it is important to gain insight into their views on job satisfaction and organizational attributes. The aim of this study was to evaluate the job satisfaction of practice assistants and the organizational attributes within their general practices in Germany and to explore the existence of possible associations. Methods: This observational study was based on a job satisfaction survey and measurement of organizational attributes in general practices in the German federal state of Baden-Wuerttemberg. Job satisfaction was measured with the 10-item ‘Warr-Cook-Wall job satisfaction scale’. Organizational attributes were evaluated with the 21-items ‘survey of organizational attributes for primary care’ (SOAPC). Linear regression analyses were performed in which each of SOAPC scales and the overall score of SOAPC was treated as outcome variables. Results: 586 practice assistants out of 794 respondents (73.8%) from 234 general practices completed the questionnaire. Practice assistants were mostly satisfied with their colleagues and least of all satisfied with their income and recognition for their work. The regression analysis showed that ‘freedom of working method’ and ‘recognition of work’, the employment status of practice assistants and the mode of practice were almost always significantly associated with each subscale and overall score of SOAPC. Conclusions: Job satisfaction is highly associated with different aspects of organizational attributes for primary care (‘communication’, ‘decision-making’ and ‘stress’). Consequently, improved job satisfaction could lead to a better- organized primary care team. This implication should be investigated directly in further intervention studies with a special focus on improving the recognition for work and income. Keywords: General practice, Practice assistant, Organizational attributes, Job satisfaction, Primary health care Background for providing a good quality of care and positive health Within the last years more attention is given on the chan- outcomes for patients, while also improving the level of ging role of practice assistants in primary care. The substi- service capacity and accessibility [4]. Furthermore, the tution and diversification of their roles are related to strengthening of the role of practice assistants in primary outcomes of patient health, process of care or direct and care is expected to improve the quality of service provided indirect costs [1]. Moreover, it was found that task substi- by physicians via a reduction of their workload enabled by tution to practice assistants supports general practitioners a transfer of responsibilities to practice assistants [5]. to provide a good care [1-3]. Practice assistants are crucial Moreover, the changing role could have an impact on per- ception of own job satisfaction. Job satisfaction is an im- portant issue among health care professionals and is * Correspondence: katja.goetz@med.uni-heidelberg.de associated with suboptimal health care delivery and poor Department of General Practice and Health Services Research, University of Heidelberg, Heidelberg, Germany clinical outcomes, for instance adverse events and reduced Full list of author information is available at the end of the article © 2013 Gavartina et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Gavartina et al. BMC Family Practice 2013, 14:110 Page 2 of 6 http://www.biomedcentral.com/1471-2296/14/110 patient adherence [6]. Additionally, it is imperative to German validated version of the ‘survey of organizational maintain a high quality of care due to the demographic attributes for primary care’ (SOAPC) [13-15]. change, the increase of chronic diseases and continuous The job satisfaction scale consists of ten items rated medical progress. The demographic change, and with it on a 7-point Likert scale (1 = extreme dissatisfaction to the increase of chronic diseases, is relevant not only be- 7 = extreme satisfaction). The questionnaire comprises cause of the rising health costs but also in terms of items concerning the satisfaction with physical working personnel resources [7]. These developments, the chan- conditions, freedom to choose work methods, colleagues ging role of practice assistants and their impact on job sat- and fellow workers, recognition for work, amount of re- isfaction and the demographic change, play an important sponsibility, income, opportunity to use one’s abilities, role in light of prospective personnel retention. hours of work and amount of variety in the job as well Workforce shortages within the health care system are as the overall job satisfaction. A higher overall mean becoming a generic problem in several countries [8]. The score indicates a higher job satisfaction. The ‘WCW job evaluation of job satisfaction plays a significant role in this satisfaction scale’ is also regularly used in a primary care trend and dissatisfaction leading to a high turnover and a focus as shown in a literature review conducted by van shortage of non-physician employees [9]. This in turn has Ham et al. and by other studies [16-18], and can be detrimental effects, with a high turnover leading to a loss regarded as a reliable and validated instrument to meas- of continuity of care [7]. Moreover, it was found that con- ure job satisfaction. tinuity of care could also be influenced by organizational The German validated version of SOAPC is composed attributes in primary care [10]. However, there is a lack of of 21 items, which are subsumed in four subscales: ‘com- evidence regarding the relationship of organizational attri- munication’ consisting of four items, ‘decision-making’ butes and job satisfaction by practice assistants in primary consisting of eight items, ‘stress’ consisting of six items care. Currently, there are around 398,000 practice assis- and ‘change’ consisting of three items [14]. Each of the tants in primary care in Germany [11]. They are trained in items is rated on a 5-point Likert scale (1 = fully disagree supportive medical tasks, practice organisation and ad- to 5 = fully agree). This version was used in a primary ministration during a 3-year part-time curriculum at a vo- care focus before [15]. cational school [12]. Their range of tasks varies from Furthermore, socio-demographic data such as age, administrative tasks, assisting general practitioners and gender, employment status and practice characteristics performing various medical procedures. were collected. Practice characteristics contained the The aim of the study was to evaluate the job satisfaction mode of practice (single-handed and group practices) and organizational attributes of practice assistants in gen- and the location of the practice (urban, semi-urban and eral practices in Germany and to explore associations be- rural located practices). tween organizational attributes and job satisfaction. Data analysis Methods The analysis was performed with SPSS version 18.0 This observational study was based on a job satisfaction (SPSS Inc., Chicago IL, USA). First, a descriptive analysis survey and measurement of organizational attributes in was undertaken concerning characteristics of the study general practices in the German federal state of Baden- population. Furthermore, a descriptive analysis of job Wuerttemberg. satisfaction scale and scales of organizational attributes were conducted. The means, standard deviations and Participants 95% confidence intervals of these aspects are reported. From 2000 randomly selected general practices 234 took Finally, multivariate linear regression analyses for each part in the job satisfaction survey of practice assistants. of the organizational attributes were carried out. Each of From these 234 general practices 794 practice assistants the four scales of SOAPC and the overall score of were interested to take part in this study. Practice assis- SOAPC were treated as outcome variables, the individ- tants were asked to fill in a depersonalized paper-based ual and practice characteristics and the different items of questionnaire and to send it back to the study centre. the job satisfaction scale were used as independent vari- We provided a free-post envelope, but no further finan- ables. An alpha level of p < 0.05 was used for tests of cial incentives for practice assistants. statistical significance. Measures Data collection took place between June 2011 and Ethical approval August 2011. The questionnaire contains the German The study was fully approved by the ethics committees validated version of the ‘Warr-Cook-Wall (WCW) job of the Medical Faculty of the University of Heidelberg satisfaction scale’, developed by Warr et al. and the (S137/2011). Gavartina et al. BMC Family Practice 2013, 14:110 Page 3 of 6 http://www.biomedcentral.com/1471-2296/14/110 Table 1 Descriptive statistics factors of job satisfaction Results and of organizational attributes of practice assistants 586 practice assistants out of 794 respondents (73.8%) Mean (SD) CI (95%) completed the questionnaire. Almost all practice assis- tants were female (99.5%) with a mean age of 39.1 years Factors of job satisfaction (SD = 12.0). 44% of the practice assistants worked full Physical working condition 5.18 (1.32) 5.06 – 5.30 time. Over 40% of the general practices were single Freedom of working method 5.20 (1.35) 5.08 – 5.33 handed and 30.6% were located in rural areas. Colleagues and fellow workers 5.87 (1.28) 5.76 – 5.99 Recognition for work 5.07 (1.47) 4.94 – 5.21 Evaluation of job satisfaction and organizational Amount of responsibility 5.38 (1.33) 5.25 – 5.50 attributes Practice assistants were mostly satisfied with ‘colleagues Income 3.89 (1.79) 3.73 – 4.06 and fellow workers’ (mean = 5.87) and least satisfied with Opportunity to use abilities 5.26 (1.26) 5.14 – 5.37 the ‘recognition of their work’ (mean = 5.07) and their Hours of work 5.34 (1.49) 5.20 – 5.48 ‘income’ (mean = 3.89). The mean for the ‘overall job sat- Amount of variety in job 5.49 (1.22) 5.38 – 5.60 isfaction’ was 5.74 (SD = 1.19) meaning that practice as- Overall job satisfaction 5.74 (1.19) 5.63 – 5.85 sistants are satisfied with their job situation in general. Factors of organizational attributes The overall mean score for the factors of organizational attributes for practice assistants was 3.70 (SD = 0.48) in- Communication 3.92 (0.48) 3.86 – 3.98 dicating that there exist a functioning organizational cul- Decision making 3.95 (0.64) 3.89 – 4.00 ture within practices. However the subscale ‘history of Stress 3.53 (0.73) 3.46 – 3.59 change’ with a rating of 3.12 (SD = 0.79) as the lowest History of change 3.13 (0.79) 3.06 – 3.20 mean showed that practice assistants thought that there Overall score 3.70 (0.48) 3.66 – 3.75 were not sufficient changes in the work organization and SD Standard deviation, CI Confidence interval. teamwork. Nevertheless ‘decision making’ was rated the range from 1 “extreme dissatisfaction” to 7 “extreme satisfaction”. highest with a mean of 3.95 (SD = 0.64) showing that 2 range from 1 “fully disagree” to 5 “fully agree”. practice assistants thought that the practice works as a team concerning decision-making and the development of improvements regarding the quality of care within status of practice assistants and the mode of practice the practices. The subscale ‘stress’ had a mean of 3.53 were almost always significantly associated with each (SD = 0.73). A lower mean in this subscale means less subscale and overall score of SOAPC. stress. Practice assistants were moderately stressed meaning that the given working conditions are only moderately exhausting. Details are given in Table 1. Discussion The results of the study show how organizational attri- Factors associated with the outcome variables: butes and socio-demographic characteristics are associ- organizational attributes ated with the job satisfaction of practice assistants in The associations between the predictors of individual German primary care settings. As there is limited pub- and practice characteristics and factors job satisfaction lished research in this field so far this study contributes concerning the organizational attributes are presented in important issues to a field with increasing importance. Table 2. Higher scores of the different aspects of job satisfac- Three of the five regression models explained more tion compared to our data were found in studies which than 35% (R > 0.35) of the variance of the outcome vari- have also evaluated job satisfaction of practice assistants ables. These three subscales were ‘communication’, ‘deci- in general practices with the Warr-Cook-Wall question- sion-making’, and the ‘overall score’. As an example, the naire [17,18]. A possible explanation for higher scores predictors that were significantly associated with the could be the different study populations. All of the re- outcome ‘communication’ were three factors of job satis- spondents from these previous studies were members of faction: ‘freedom of working method’ (β = 0.127), ‘col- general practices participating in a quality management leagues and fellow workers’ (β = 0.397) and ‘recognition program. In a study conducted by Vail et al. it was also for work’ (β = 0.211). The ‘overall job satisfaction’ was shown that, despite a high overall satisfaction, practice no important predictor for each subscale and overall assistants were dissatisfied with their income, status and score of SOAPC. Of the 14 independent variables that career progression [19]. Practice assistants in Australia were entered into the regression models, two items of indeed showed higher scores for overall job satisfaction the job satisfaction scale being ‘freedom of working than in our study, but were also less satisfied with their method’ and ‘recognition of work’, the employment ‘income’ and ‘recognition for their work’ [20]. Gavartina et al. BMC Family Practice 2013, 14:110 Page 4 of 6 http://www.biomedcentral.com/1471-2296/14/110 Table 2 Associations on outcome variables of organizational attributes in primary care practices (results of linear regression analyses, under specification of standardized beta coefficient and 95% confidence interval (CI), α = 5%) Factors of organizational attributes of primary care practices Communication Decision-making Stress History of change Overall score β (p-value*) β (p-value*) β (p-value*) β (p-value*) β (p-value*) Practice characteristics Mode of practice (0 = single; 1 = group) −0.107 (0.01) −0.016 (0.66) −0.154 (<0.01) 0.160 (0.01) −0.068 (0.07) Location of practice (1 = urban; 2 = semi urban; 3 = rural) −0.024 (0.52) −0.015 (0.69) 0.055 (0.17) 0.024 (0.62) 0.018 (0.63) Individual characteristics Age −0.011 (0.80) 0.058 (0.17) −0.155 (0.01) 0.096 (0.07) −0.021 (0.62) Employment status (0 = full-time worker; 1 = part-time worker) 0.090 (0.04) 0.080 (0.06) 0.138 (0.01) −0.056 (0.30) 0.110 (0.01) Different factors of job satisfaction Physical working condition −0.033 (0.53) −0.015 (0.77) 0.356 (<0.01) −0.085 (0.19) 0.121 (0.02) Freedom of working method 0.127 (0.02) 0.243 (<0.01) 0.034 (0.54) 0.123 (0.06) 0.202 (<0.01) Colleagues and fellow workers 0.397 (<0.01) 0.082 (0.09) 0.038 (0.46) −0.106 (0.08) 0.141 (0.01) Recognition for work 0.211 (<0.01) 0.283 (<0.01) 0.081 (0.17) 0.006 (0.93) 0.238 (<0.01) Amount of responsibility −0.085 (0.15) −0.124 (0.03) −0.067 (0.28) 0.006 (0.94) −0.119 (0.04) Income 0.063 (0.16) −0.007 (0.88) 0.043 (0.37) 0.048 (0.40) 0.043 (0.33) Opportunity to use abilities 0.058 (0.36) 0.204 (0.01) 0.070 (0.31) −0.096 (0.23) 0.127 (0.04) Hours of work −0.044 (0.38) −0.020 (0.69) 0.013 (0.80) −0.027 (0.67) −0.021 (0.66) Amount of variety in job 0.026 (0.65) 0.046 (0.40) −0.092 (0.12) 0.095 (0.18) 0.015 (0.79) Overall job satisfaction −0.007 (0.91) 0.046 (0.50) 0.095 (0.20) −0.057 (0.51) 0.050 (0.46) Pseudo R 0.389 0.405 0.298 0.042 0.424 *Statistical significance of difference: P < 0.05. Gavartina et al. BMC Family Practice 2013, 14:110 Page 5 of 6 http://www.biomedcentral.com/1471-2296/14/110 One solution to the noticeable lack of recognition could or not interventions could have an impact on both be the reallocation of tasks giving practice assistants more organizational culture and job satisfaction. Additionally, responsibilities, which might not only strengthen the im- improved job satisfaction could lead to a better organized portance of their job but also reduce the workload of gen- primary care team. This association, which was also eral practitioners. It was shown that task substitution shown in other studies [15,29], is important as team-level could contribute to an improvement of quality of care as job satisfaction is a telling predictor for the effectiveness well as patient outcomes such as patient adherence to of how primary care teams manage patient care [15]. treatment, patient quality of life and patient satisfaction Kuokkanen et al. found that organizational commitment [21,22]. Moreover, a study of Dini et al. showed that 48% and job satisfaction are essential factors for empowerment. of general practitioners in Germany inclined to delegate With empowerment they mean “the process of personal home visit tasks to their practice assistants. The main dis- growth and development”, which is important in the con- advantage here was the related costs for training of the text of the attractiveness of the profession as well as the practice assistants, while the ability to save time was development of care, education and management [30]. named as the main advantage [23]. To realise task substi- Other factors instrumental for empowerment include a tution in Germany there are for example the so called low-hierarchy organization, a teamwork oriented ap- ‘AGnES-model projects’ in different federal states, which proach within a practice, sufficient capabilities and a man- transfer medical duties and house visits to qualified prac- agement which creates opportunities [31]. An important tice assistants. Results of these model projects showed that contribution to the job satisfaction of nurses could be set general practitioners feel exonerated and patient compli- in a meta-analysis from 1993 performed by Blegen et al., ance is improved through AGnES-employees [24]. which revealed that nurses’ job satisfaction was strongly As our data suggests colleagues make an important con- associated with declined work stress, organizational com- tribution to job satisfaction. These results are in accordance mitment, communication and recognition for work [32]. with other studies. Zangaro et al. for example showed that These findings are exposed and confirmed for practice as- through a high satisfaction with colleagues stress could be sistants by our study. It should be noted that ‘history of reduced leading to a more positive work environment [25]. change’ had only an explained variance of 4.2%. The rea- Moreover, a review of Van Laar et al. emphasized that in son for this might be due to the limited options of practice most of the researched 17 countries medical staff was assistants to initiate changes as the general practitioner stressed and incriminated. It was assumed that the nature of makes most of the final decisions. To confirm this as- work, numerous changes in organizational fields and the sumption and to address the question regarding the distri- growing workload lead to worse physical and mental condi- bution of decision-making in a team, further studies need tions which could deteriorate the quality of patient care [26]. to be conducted. Moreover, job dissatisfaction implicated more stress and burnout amongst health care workers [27]. This shows the Strengths and limitations importance of research evidence concerning organizational A main strength of our study is that we used internationally culture, job satisfaction and working conditions of practice validated measures for the evaluation of organizational attri- assistants. Our study found that the level of ‘stress’ was butes and job satisfaction of practice assistants [13,14]. Fur- moderate, with a lower mean indicating a lower stress level. thermore, there is little research for organizational attributes Moreover, there was a significant association between this of practice assistants, particularly for Germany. Therefore, subscaleand theage of theparticipants. A lower level of our study provides an important addition to this field of re- stress within the practices is associated with a younger age search. However, without being able to collect data from a of the practice assistants, group practices and practices with broader range of socio-demographic characteristics of prac- a higher level of satisfaction with physical working condi- tice assistants only limited conclusions regarding this area tion. This emphasizes the importance of the general trend are possible. In addition, as this was an exploratory study; p towards more group practices as a contribution to a reduc- values should be interpreted carefully. Significant results tion of the level of stress [28]. might be due to chance and will need to be confirmed in In our study we found a strong and significant associ- further targeted studies. ation between organizational attributes, job satisfaction and socio-demographic characteristics throughout the re- Conclusions gression models. This means that job satisfaction affects Different items of job satisfaction, such as ‘freedom of work- changes in the organizational culture within a general ing method’, ‘colleagues and fellow workers’ and ‘recognition practice concerning, for example, decision making, im- for work’, affect specific organizational attributes such as proving working conditions, teamwork, provided quality ‘communication’, ‘decision-making’ and ‘stress’.Furthermore, of care, reducing stress and exhaustion. In further inter- job satisfaction affects differences in the organizational cul- vention studies should be investigated to establish whether ture concerning of decisions made by the whole team, Gavartina et al. BMC Family Practice 2013, 14:110 Page 6 of 6 http://www.biomedcentral.com/1471-2296/14/110 working conditions, teamwork, the provided quality of care 10. 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Published: Aug 5, 2013

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