examining the relationship between patient orientation and job satisfaction in health care: evidence...
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Examining the Relationship Between PatientOrientation and Job Satisfaction in Health Care:Evidence from the Nursing ProfessionEric G. Harris PhD a , Richard Dearth JD b & Shipra Paul MBA ca Department of Management and Marketing , Pittsburg State University , Pittsburg, KS,66762b Department of Management and Marketing , Pittsburg State University , Pittsburg, KS,66762 E-mail:c Department of Management and Marketing , Pittsburg State University , Pittsburg, KS,66762 E-mail:Published online: 11 Oct 2008.
To cite this article: Eric G. Harris PhD , Richard Dearth JD & Shipra Paul MBA (2007) Examining the Relationship BetweenPatient Orientation and Job Satisfaction in Health Care: Evidence from the Nursing Profession, Health Marketing Quarterly,24:1-2, 1-14, DOI: 10.1080/07359680802125709
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Examining the RelationshipBetween Patient Orientation
and Job Satisfactionin Health Care:
Evidence from the Nursing Profession
Eric G. Harris, PhDRichard Dearth, JDShipra Paul, MBA
ABSTRACT. It is well-known that the United States faces a serious nurs-ing shortage. A number of factors have contributed to the problem includ-ing an aging nursing workforce, fewer nursing job candidates, the aging ofthe baby boom population, and increased nurse dissatisfaction. The currentwork addresses one issue that is central to the problem: nursing satisfaction/dissatisfaction. Drawing from previous research in the services marketingliterature, the work introduces the “patient orientation” construct and sug-gests that it is a critical motivational factor that is related to nursing satisfac-tion. Results from an empirical study reveal that the construct is positivelyrelated to overall nursing satisfaction while controlling for external factorsincluding pay, benefits, supervisor, and reward satisfaction. Implicationsfor healthcare managers and suggestions for future research are discussed.
Eric G. Harris is Assistant Professor of Marketing; Richard Dearth (E-mail: [email protected]) is Interim Dean; Shipra Paul (E-mail: [email protected]) is Lecturer;all are affiliated with Department of Management and Marketing, Pittsburg StateUniversity, Pittsburg, KS 66762.
Address correspondence to: Eric G. Harris at the above address (E-mail: [email protected]).
Health Marketing Quarterly, Vol. 24(1/2) 2007Available online at http://hmq.haworthpress.com
© 2007 by The Haworth Press. All rights reserved.doi:10.1080/07359680802125709 1
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KEYWORDS. Patient orientation, nursing, satisfaction/dissatisfaction,health care
INTRODUCTION
It is well-documented that the United States faces a serious nursingshortage. As many as thirty states are currently experiencing nursingshortfalls and the Health Resources and Services Administration esti-mates that the nation as a whole will face a shortage of 1 million FTERNs by the year 2020 (HRSA, 2007a). A recent report by the GeneralAccounting Office highlights the many factors that have contributedto the problem (GAO, 2001). An aging nurse population, fewer new ap-plicants, increased demand from aging baby boomers, and increased jobdissatisfaction have all contributed to the shortage.
A number of attempts have been made to curtail the problem, with themost notable action coming from the federal government. The principallegislative attempt to deal with the issue has been the Nursing Reinvest-ment Act of 2002 (Public Law 107-205). The act, which was signed byPresident Bush in August 2002, seeks both to enhance the recruitmentof nursing professionals and the retention of those already in the fieldby providing support for career development. The act provides schol-arships and loan repayment to encourage nursing school graduation;increased funding for retaining existing nurses through career develop-ment and career ladders; and provides for a loan forgiveness programto encourage nurses to become nurse educators.
At the organizational level, administrators have responded to the short-age by implementing programs aimed at boosting retention rates. Forexample, a number of hospitals have begun paying student loan debts andlicensure fees of nursing staff (Hollmer, 2004). These efforts are notsurprising when one considers that the estimated cost of replacing a lostnurse is nearly 100% of the outgoing nurse’s salary (Kosel and Olivo,2002). Indirect costs associated with turnover include decreased levelsof service quality, increased job burnout for incumbent nurses, and lowerlevels of employee morale and satisfaction (Brice, 2006; Wilson, 2006).
In today’s environment, healthcare managers face two important is-sues. First, they must attract strong nursing candidates. Second, and asmentioned above, the manager must gain a better understanding of thefactors that lead to nursing turnover and retention. Nursing dissatisfac-tion is one well-known predictor of intentions to leave the healthcare or-
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ganization, and a 2004 HRSA study found that nursing dissatisfaction isindeed a serious issue (HRSA, 2007b). In fact, a recent study by Aikenand colleagues (2001) revealed that more than 40% of nurse respondentsreported dissatisfaction with their current positions, and that job dissat-isfaction among nurses is higher than the dissatisfaction levels found inother professional positions. This leads to the obvious question of: Whatexactly contributes to nursing satisfaction?
Nursing job satisfaction has a well-established research tradition, andprevious work suggests that factors that lead to increased levels ofsatisfaction may be categorized into external and internal categories(Grieshaber, Parker, and Deering, 1995). External factors that influencejob satisfaction and retention include pay satisfaction (Lum et al., 1998),rewards for work performance (Friedrich, 2001), supervisor relations(Friedrich, 2001), and benefits (Wilson, 2006). These influencers arequite popular and tend to be effective in promoting both satisfaction andretention. From a motivational perspective, if external rewards are valuedby nurses, then they will contribute to improved job effort, work satisfac-tion, and ultimately, retention (Vroom, 1964). Internal factors also playan important role in nursing job satisfaction. Quite simply, nurses wantto deliver high quality patient care, and the enjoyment and sense of ac-complishment that comes from service delivery impacts job satisfaction(Albaugh, 2003). This inherent desire to help others is a critical factorin healthcare marketing. Healthcare marketers must deliver high-valueofferings in order to ensure patient satisfaction. This is a core principlefound in the marketing concept: focus on the end-user and their needs,satisfy those needs, and long-term survival and profitability will follow.
Although numerous studies have revealed that job satisfaction is influ-enced by external rewards (e.g., pay, bonuses, achievement awards.),what appears to be lacking is work that examines the influence of internalfactors on nursing job satisfaction. One issue for healthcare researcherscenters on determining the extent to which the inherent motivation tocare for patients is related to job satisfaction. Given that both employeesand patients play critical roles in the delivery of healthcare services, andthat service employees are the service in the eyes of customers (Bitner,1990), this issue needs to be addressed.
The current study addresses this issue by examining what we refer toas the “patient orientation” construct and its relationship with overallnursing job satisfaction. Specifically, the study addresses the followingresearch question: What is the relationship between patient orientationand nursing job satisfaction while controlling for well-known externalinfluencers? For healthcare managers, this work signals the impor-
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tance that internal factors play in overall job satisfaction and employeeretention, and helps to create perspective when considering the role ofincreased monetary incentives, benefits, and rewards. For healthcareresearchers, this line of work opens a number of opportunities for gainingan improved understanding of the factors that lead to high quality ser-vice delivery.
Our work is structured as follows. First, we discuss the patient orien-tation construct, a construct that is adapted from extant marketing re-search. Second, we develop hypotheses that (1) pertain to the influence ofexternal factors and patient orientation on overall nursing job satisfac-tion, and (2) seek to corroborate previous research that delineates the re-lationship between overall job satisfaction, organizational commitment,and turnover intentions. Third, we detail the results of an empirical studythat addresses our research hypotheses. We conclude with a discussion ofour findings, their managerial implications, research limitations, and sug-gests for further work in the area. We begin with a discussion of the pa-tient orientation construct.
What Is “Patient Orientation?”
The satisfaction that comes from taking care of patients is a majordeterminant in the decision to enter the nursing profession. In fact, it isimportant to note that research suggests that taking care of patients is themost enjoyable aspect of being a nurse (Joint Commission, 2005). Fornurses, having empathy for patients and attending to their needs is obvi-ously critical. Nurses want, and need, to give quality patient care (Albaugh,2005), and the ability to deliver quality patient care is a major factor inoverall job performance and satisfaction (Albaugh, 2003).
A well-developed stream of research in the services marketing litera-ture focuses on the “customer orientation” construct. To be customer-oriented means that one has a true desire to care for customer’s needs andenjoy taking care of customers (Brown et al., 2002). This is an especiallyimportant trait for nurses as they care for patients. That is, the desire to at-tend to patient needs is critical to long-term happiness and success in thenursing profession. Borrowing from the customer orientation literature,we therefore suggest that being “patient-oriented” is a fundamental partof being successful in the healthcare field.
We note that the customer orientation construct was originally intro-duced into the marketing literature as a central component to personalselling success. Saxe and Weitz (1982) originally conceptualized cus-tomer orientation as “the practice of the marketing concept at the level
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of the individual salesperson and customer” (p. 343). Essentially, to becustomer-oriented means that one puts the interests of the customerabove all other considerations under the rationale that long-term businesssuccess hinges upon customer satisfaction.
Although the construct was originally framed from a personal sellingperspective, customer orientation has been re-positioned in the servicesmarketing literature as a determinant of high quality service delivery, andit is seen as an integral part of an employee’s personality. For example,Brown et al. (2002) expanded the original conceptualization of the con-struct by defining customer orientation as “an individual’s tendency orpredisposition to meet customer needs in an on-the-job context” (p. 111).The authors also developed an updated measure for customer orienta-tion that included two dimensions: a “needs” dimension, which assessesindividuals’ beliefs about their abilities to satisfy customer needs, andan “enjoyment” dimension, which assesses the degree to which inter-actions with customers are inherently enjoyable for service employees.Customer orientation, therefore, is seen as a personality trait that is “cen-tral to a service organization’s ability to be market orientation” (Brownet al., 2002, p. 110).
The adaptation of the customer orientation construct from the salesliterature to the services marketing literature is important for our pur-poses. Service employees must respond to the needs of customers and(hopefully) derive enjoyment from serving those needs. As noted earlier,these characteristics are critical in the nursing environment. Having em-pathy for patient needs and responding to those needs are focal elementsof the nursing profession. As noted in a Joint Commission report (2005),taking care of patients tends to be one of the most enjoyable aspects ofthe nursing profession.
Borrowing from the customer orientation literature, we conceptualizepatient orientation as being an important individual-level trait that iscomposed of both the “needs” and “enjoyment” dimensions found inthe work of Brown et al. (2002). As discussed previously, research indi-cates that taking care of patients is the most enjoyable aspect of beinga nurse and having empathy for patients and attending to their needs areimportant determinants of performance and satisfaction (Albaugh, 2003).
Effects on Job Satisfaction
As noted previously, job satisfaction has a well-established researchtradition. Satisfaction is an important job-related construct that has beenshown to influence job performance (Judge et al., 2001), organizational
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commitment (Bluedorn, 1982), and employee turnover intentions(Lambert, Hogan, and Barton, 2001). In the current healthcare market-ing environment, employee job satisfaction is a very important determi-nant of organizational performance.
Both external and internal factors influence nursing job satisfaction.Pay satisfaction is one important determinant (Meltz and Marzetti, 1988),but pay is not the only factor that leads to nursing job satisfaction andturnover (Cangelosi, Markham, and Bounds, 1998). Benefits, supervisorrelations, and rewards for work performance all influence job satisfaction.For example, Wilson (2006) asserts that in addition to compensation,nurses desire flexible schedules as well as other rewards for performance(such as paid-time off and service awards). From an equity theory per-spective (Adams, 1963), nurses compare the ratio of their outcomes/inputs to the perceived ratio of outcomes/inputs of another party. Whenthe equity of this comparison is not realized, dissatisfaction occurs.Nurses view the outcomes of their work (including their rewards) vis-à-vis their effort and arrive at decisions regarding the fairness of theirwork environment. If they feel that inequitable exchanges are occurring,dissatisfaction can be expected to increase.
Patient orientation, an internal factor, is also expected to influencenursing job satisfaction. As noted, previous research indicates that cus-tomer orientation is a significant predictor of job satisfaction in servicesmarketing (Donavan et al., 2004). Utilizing a sample of home healthcareemployees, Hoffman and Ingram (1992) also found that customer orien-tation is positively related to job satisfaction.
Based on the above, we expect to find that patient orientation is posi-tively associated with nursing job satisfaction. Furthermore, because bothinternal and external factors influence satisfaction, we expect to findthis relationship while controlling for the effects of external factors in-cluding pay satisfaction, reward fairness, benefit satisfaction, and satisfac-tion with supervisor relationships. We again note that previous healthcareresearch supports the notion that intrinsic aspects of the work environ-ment play a major role in satisfaction as compared with external aspects.For example, Grieshaber, Parker, and Deering (1995) found that intrinsicaspects of job satisfaction were rated higher than extrinsic aspects ofsatisfaction in a long-term patient care environment. Formally, we hypoth-esize the following:
H1: Controlling for the influence of satisfaction with pay, supervi-sors, benefits, and perceptions of reward fairness, patient orienta-tion is positively related to nursing job satisfaction.
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Job Satisfaction, Organizational Commitment,and Turnover Intentions
In addition to investigating the relationship between patient orientationand nursing job satisfaction, the current work also seeks to corroborateprevious work that delineates the relationship between job satisfaction,organizational commitment, and turnover intentions. Given that the focusof HR plans is currently on nurse retention, we must expand our frame-work beyond a focus on satisfaction to the ultimate goal for managers:retention.
Previous work by Lum et al. (1998) reveals that organizational com-mitment mediates the influence of job satisfaction on intentions to leavethe organization. Our work attempts to replicate this finding. We note thatthe healthcare industry has changed over the last decade (as is seen with thepassage of the Nursing Reinvestment Act of 2002) and it is thereforeappropriate to re-examine this relationship in the current environment.Based on the work of Lum et al. (1998), we therefore hypothesize thatorganizational commitment mediates the job satisfaction on turnoverintentions relationship:
H2: Organizational commitment mediates the influence of jobsatisfaction on turnover intentions.
METHOD
Participants in our study were front-line nursing personnel at a me-dium sized hospital (< 300 employees) located in the southeastern UnitedStates. The study was a part of a larger data collection effort. A sampleof 108 front-line nurses were given a survey instrument that containedconstructs related to the study as well as several unrelated measures. Atotal of 54 nurses returned the survey in usable form for a response rateof exactly 50%. The average age of the nurses was 41 years, the averagetenure at the hospital was 6 years, and the average tenure in health carewas 15 years. Eighty-two percent (82%) of the respondents were femaleand fifteen percent (15%) of the respondents were male (two respondentsfailed to indicate their gender). A non-response analysis revealed thatrespondents did not differ from non-respondents on various demo-graphic factors, including age and tenure with the firm. The measuresthat were utilized in the study are discussed below.
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Measures
Patient orientation. The patient orientation measure was adapted fromthe Brown et al. (2002) measure of customer orientation. This measure,included two facets: “enjoy” taking care of patients and attend to patient“needs.” Each facet was asset via a 6-item, 9-point Likert scale. The “en-joy” facet included items such as: “I really enjoy serving my patients,”“I get satisfaction from making my patients happy,” “It comes naturallyfor me to have empathy for my patients.” The “needs” facet includeditems such as “I keep the best interests of my patients in mind,” “I get pa-tients to talk about their personal needs with me,” and “I achieve my owngoals by satisfying my patients.” To form a measure an overall measureof patient orientation, a composite score across the dimensions was formedby taking the average response scores for each item. The coefficient al-pha for the combined scale was � = .74 [enjoy] and � = .83 [needs]. The� = .74 for the enjoy dimension, while relatively low, does exceed gen-erally accepted lower limits for the statistic (Hair et al., 1998).
Overall job satisfaction. The overall job satisfaction measure was asingle-item measure worded as “How satisfied are you with your over-all job?” This was assessed on a 9-point scale anchored by “extremelydissatisfied [1]” and “extremely satisfied [9].”
Facets of work satisfaction. Similar to the overall job satisfactionmeasure, each facet of work-related job satisfaction was measure via sin-gle-item, 9-point measures. These items included “Please indicate yourlevel of satisfaction with your: (pay, supervisor, benefits).”
Perceived reward fairness. The rewards measure was a composite mea-sure across four specific items related to the hospital working environment.Items included “To what extent are you fairly rewarded . . . consideringthe responsibilities you have, for the amount of work you put forth, for thestresses and strains of the job, and for the work you have done well?” Thismeasure was also a 9-point measure anchored by “very little [1]” and“very much [9].” The coefficient alpha (�) for this measure was .94.
Turnover intentions. The turnover intentions construct was assessedon a four-item, 9-point Likert scale that was adapted from Harris andLee (2004). This measure included items such as “I plan to be with thishospital for a while,” “I plan to be with this hospital five years fromnow,” and “I would turn down an offer from another hospital if it cametomorrow.” The coefficient alpha (�), though again relatively low, wasan acceptable .73 (� = .73). Note that these items were reverse-scored sothat higher scores on the scale reflect stronger turnover intentions.
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Organizational commitment. The organizational commitment con-struct was also assessed on a four-item, 9-point Likert scale adapted fromHartline and Ferrell (1996). Items for this measure included “I would bewilling to change hospitals if the new job offered 25% pay increase,”“I would be willing to change hospitals if the new job offered more cre-ative freedom,” “I would be willing to change hospitals if the new joboffered more status,” and “I would be willing to change hospitals if thenew job was with people who were more friendly.” The coefficient alpha(�) for this measure was .89. Note that this scale is scored in such a waythat higher scores indicate lower levels of organizational commitment.
RESULTS
Where appropriate, the measures were initially subjected to an Ex-ploratory Factor Analysis (i.e., we excluded single-item measures). Allitems loaded significantly on their respective constructs using the criteriapresented by Hair et al. (1998). The relatively small sample size preclud-ed the use of confirmatory analysis, however, the reliability statisticssuggested that the measures were appropriate for further analysis. Thecorrelation matrix for the measures is shown in Table 1.
Hypotheses 1 and 2 were tested by utilizing regression analysis. Due tothe high collinearity between the independent variables (as shown by thesignificant correlations between the variables in the correlation matrix),the influence of each (external) independent variable relative to patient
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TABLE 1. Correlation Matrix
Pay Sat Sup Sat Ben Sat Re Sat OJS OC ITL PO
Pay Sat 1.00Sup Sat .35** 1.00Ben Sat .21 .10 1.00Re Sat .48** .46** .27* 1.00OJS .38* .62** .18 .49** 1.00OC �.22 �.45** �.22 �.50** �.49** 1.00ITL �.29* �.61** �.21 �.48** �.68** .57** 1.00PO .14 .09 �.01 .01 .27* .14 �.18 1.00
Note: Pay Sat = satisfaction with pay, Sup Sat = satisfaction with supervisor, Ben Sat = satisfaction withbenefits, Re Sat = satisfaction with rewards, OJS = overall job satisfaction, OC = organizational commit-ment, ITL = intentions to leave, PO = patient orientation (n = 54, *p � .10, **p � .05).
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orientation was assessed via a series of regression analyses. The resultsof this regression procedure are shown in Table 2.
Hypothesis 1 stated that patient orientation is positively related tonursing job satisfaction, controlling for the influence of satisfaction withpay, supervisors, benefits, and fairness of rewards. As shown in Table 1,this hypothesis is supported across all facets of satisfaction. Patient orien-tation is shown to be significantly (and positively) related to overall jobsatisfaction when controlling for satisfaction with pay (�pay = .35 [p <.05], �po = .22 [p < .10]), supervisor (�super = .61 [p < .05], �po = .22 [p <.05]), benefits (�benefits = .18 [p > .10], �po = .27 [p < .05]), and rewardfairness (�rewards = .49 [p < .05], �po = .27 [p < .05]). The beta coeffi-cients for the association of patient orientation with job satisfactionwere significant at p < .05 for all variables, with the exception of whencontrolling for satisfaction with pay, where the significance level wasp < .10 for the construct. We further note that the beta coefficient associ-ated with benefit satisfaction was not significant at p > .10.
Hypothesis 2 was tested using mediation analysis (Baron and Kenny,1986). In the first step, turnover intentions was regressed on job satis-
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TABLE 2. Regression Results: Hypothesis 1
Independent Variable H1 DV = Job Satisfaction
� p
Pay Sat .35 .01**PO .22 .09*
Adjusted r2 16%F-Statistic (Model) 6.03 .01**
Supervisor Sat .61 .00**PO .22 .04**
Adjusted r2 42%F-Statistic (Model) 19.47 .00**
Benefits Sat .18 .19PO .27 .05**
Adjusted r2 7%F-Statistic (Model) 2.96 .06*
Reward Fairness .49 .00**PO .27 .03**
Adjusted r2 28%F-Statistic (Model) 11.25 .00**
Note: n = 54, *p � .10, **p � .05.
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faction. This effect was significant (�job sat = �.69 [p < .05]. In the nextstep, organizational commitment was regressed on job satisfaction.Again, the effect was significant (�job sat = �.49 [p < .05]). Finally,turnover intentions were regressed on both job satisfaction and organi-zational commitment. The overall model was significant (F = 29.50, [p <.05]) and the effects of both job satisfaction (�job sat = �.53 [p < .05]) andorganizational commitment (�orgcom = .31 [p < .05]) were significant.Note that the influence of job satisfaction dropped in size (i.e., from�.69 to �.53) with the addition of organizational commitment to themodel, supporting the hypothesized mediational role of organizationalcommitment on the job satisfaction on turnover intentions relationship.The findings of Lum et al. (1998) were therefore corroborated and hy-pothesis two was supported.
DISCUSSION
In sum, both hypothesis one and two were supported. Patient orienta-tion has been identified as an important variable in healthcare marketing.Controlling for the effects of external influencers, patient orientation isassociated with overall job satisfaction. Furthermore, corroborating evi-dence of the mediating role of organizational commitment in the job sat-isfaction on turnover intentions relationship exists in this study.
As noted, patient orientation is a trait that should be expected to lead po-tential nursing candidates into the profession. The tendency to have empa-thy for patients and to enjoy responding to their needs is obviously important.For managers, it is noteworthy that internal factors, such as patient orienta-tion, play an important role in job satisfaction. As Cangelosi, Markham, andBounds (1998) note, “throwing more money” at nursing employees is notenough–nurses must derive satisfaction from their own internal motivationsand desires. When combined with previous findings pertaining to intrinsicand extrinsic aspects of nursing job satisfaction (e.g., Grieshaber, Parker,and Deering, 1995), these results are not surprising. Clearly, patient ori-entation, like customer orientation in the services marketing literature, isan important healthcare marketing construct.
For healthcare researchers, the results of the current study suggest thatthere is much to be gained from studying the patient orientation construct.While the customer orientation construct has received a great deal ofresearch attention in the sales and services marketing literatures, thereare several opportunities for inquiry into patient orientation in health care.
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Suggestions for future work are presented next along with limitations ofthe current study.
Limitations and Suggestions for Future Research
While the results of this study highlight the role of patient orientationin nursing job satisfaction, limitations of the research should be noted.First, the studies relied on self-administered surveys. Although this isappropriate given that the concepts central to the study were employee-related measures (i.e., personality, satisfaction, turnover intentions) theinclusion of measures from other sources (e.g., objective work perfor-mance, supervisor rated-performance) would strengthen future research.We also suggest that work is performed that examines the influenceof patient orientation on patient perceptions of service quality.
We also note that the sample size utilized in this study was relativelysmall (n = 54 nurses). Importantly, however, statistically significant find-ings were evident for all hypothesized patient orientation relationships,limiting concerns over lack of statistical power. Furthermore, the sam-ple size does meet guidelines for power given a two independent vari-able design (Hair et al., 1998). Nevertheless, future work that includeslarger sample sizes is encouraged. We also note that we focused on a sin-gle hospital. Although this practice is common, it may limit the generaliz-ability of our results.
Several of the measures in our study were single-item measures. Whilesingle-item measures are often criticized in survey research, we notethat evidence suggests that single-item measures may actually outper-form full-scale indicants (Nagy, 2002), especially in satisfaction re-search. Nevertheless, multi-item scales have clear advantages and futureresearch that includes multi-item measures is encouraged.
Additional work is needed that examines the validity of the patientorientation measure. Given that this measure was adapted from the ser-vices marketing literature, additional work is warranted. In particular,future work that explores additional dimensions of the construct wouldbe helpful. The measure utilized in this study included two dimensions–“needs” and “enjoyment.” Are there additional dimensions that wouldimprove the validity of this scale?
Finally, we note that our analysis focused on patient orientation effects con-trolling for only a handful of variables thought to influence job satisfaction(i.e., satisfaction with pay, rewards, benefits, and supervisor). Clearly, othervariables influence overall job satisfaction in the nursing profession. Futureresearch that expands our framework is therefore encouraged.
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