Psychosocial work experiences related to health: A study of Lithuanian hospital employees

Abstract

BACKGROUND:

Research in the area of workplace health promotion from a salutogenic perspective is lacking in Eastern Europe.

OBJECTIVE:

To evaluate the relationship between psychosocial work environment and health from a salutogenic perspective among Lithuanian hospital workers.

METHODS:

Using a cross-sectional design a questionnaire was distributed to staff in a large hospital in Lithuania. Out of 811 employees, 714 completed the survey: 151 physicians, 449 nurses and 114 other staff members (e.g., psychologists, technicians, therapists). A response rate of 88.0% was achieved. The Work Experience Measurement Scale (WEMS) and the Salutogenic Health Indicator Scale (SHIS) were linguistically adapted and used for the first time in a Lithuanian context. Logistic and multiple linear regression models were used for the analyses.

RESULTS:

Supportive working conditions, positive internal work experiences and time experience contributed the most to good health, defined as a high SHIS index. Having an executive post was significantly related to good work experiences, i.e. a high WEMS score, while being at the age of 40–54 years was associated with a low WEMS score. Physicians had the highest score on supportive working conditions; while nurses had the lowest scores on autonomy.

CONCLUSIONS:

A salutogenic approach enables an organisation to identify how to improve working conditions for the employees by focusing on possibilities and resources. Individual activities for workplace health promotion among different work groups seem necessary.

Keywords

Salutogenic workplace health promotion evaluation Eastern Europe organisation

1 Background

Health and well-being are influenced by different factors, some of which are very close to an individual’s personal life: family relationships, leisure time and experiences at work. Seen from a salutogenic perspective, each of these areas could become an arena for health promotion. Salutogenesis and the Sense of Coherence Theory (SOC), proposed by Antonovsky provide guidance to developing health promotion interventions, enabling opportunities and identifying resources for promoting health [1, 2].

The workplace, where people spend a large part of their lives, has a major impact on health. Satisfaction with the workplace and one’s profession are important predictors for good health. Health outcomes can be predicted by the strength of the positive correlationbetween self-rated health and lower risk of future sickness and death [3]. Salutogenic research and appropriate measurements in workplace health promotion are highly desirable to increasing knowledge and practice strategies for developing workplace settings that enhance employee health [4].

When focus is on health promotion it is highly desirable to measure health from a salutogenic perspective [5]. However, workers’ health has usually been evaluated by measuring the incidence of ill-health. There is little research on workplace health from a salutogenic perspective reported in the literature and in Lithuania, as well as other Eastern European countries, it is sparse to non-existent. More commonly research has been focussed on negative work related experiences such as stress and burnout [6]. Stress at work is common among nurses and physicians working in Lithuanian hospitals [7]. Reviews of the scientific literature have consistently reported that the perception of adverse psychosocial factors in the workplace is related to an increased risk of depression, even if methodological limitations preclude any inference to causal relationships [8]. Different kinds of problems (e.g., sleep disturbance) related to the work situation have been reported [9 –11].

There has been a lack of instruments to measure work experiences from the salutogenic perspective [4]. However, the Work Experience Measurement Scale (WEMS) has recently been developed. When used in a dialogue process with shared decision making, this measure has proven useful in attempts to enhance the workplace [12]. Psychometric properties of WEMS support its applicability as a measure of work experience trends over time in health care settings. WEMS has also proven useful in measuring work-related experiences among people of different professions and ages in their everyday work life [4].

When analysing work experiences in relation to health, it is not appropriate to use a pathogenic health measure that focuses on health risks, when a salutogenic, resource-focused, model is what is needed. A recently developed instrument for studying health from a salutogenic perspective is The Salutogenic Health Indicator Scale (SHIS). SHIS is based on holistic health concepts. The psychometric properties of SHIS were considered satisfactory, and the authors suggested further research that explored the empirical relationship between the content of SHIS and health [13].

The aim of the present study was to evaluate therelationship between psychosocial work environment and health from a salutogenic perspective among Lithuanian hospital workers.

2 Methods

2.1 Sample

The survey was carried out in the autumn of 2010. A total of 811 questionnaires were distributed to all employees at one of the largest hospitals in Lithuania. The hospital is a secondary health care level facility, that provides both in-patient and out-patient services. It houses departments of internal medicine, obstetrics, paediatrics, diagnostics, surgery, and rehabilitation. As is typical in Lithuanian hospitals, it has a hierarchical administrative structure with a chain of middle level managers, heads of the departments, who are physicians. Nurses work under the supervision of these physicians and they also have their own middle level managers, e.g. head nurses, assistant heads etc.

Out of 811 employees, 714 completed the questionnaire. The response rate was 88.0% , with only small differences between the professions. The sample comprised of 151 physicians, 449 nurses, and 114 other staff members. The group of “other staff members” included laboratory assistants, psychologists, midwives, physiotherapists, massage specialists, and social workers. The study was approved by the local bioethics committee of the Klaipeda University.

2.2 Questionnaire

Each participant completed a three-part questionnaire: (1) Work Experience Measurement Scale, WEMS [4]; (2) The Salutogenic Health Indicator Scale, SHIS [13]; and (3) demographic data.

The Work Experience Measurement Scale (WEMS) consists of 32 statements in six dimensions or sub-indices: supportive working conditions (seven statements), internal work experiences (six statements), autonomy (four statements), time experience (three statements), leadership (six statements), and process of change (six statements). For responses, each item in WEMS uses a six-point Likert-type scale where 6 = “totally agree” and 1 = “totally disagree” (Table 1). A WEMS score may be used as a single index score and can range from 32 to 192 or the total score can be divided into the six sub-indices. Sub-index scores have different ranges but are standardised to range from0 to 100.

The Salutogenic Health Indicator Scale (SHIS) measures twelve aspects of health which include feeling alert, feeling calm/relaxed, and sleeping well. SHIS has one overall question: “How have you been feelingduring the past 4 weeks? The last 4 weeks I have...” with a response format going from for example “felt calm/relaxed” to “felt worried/tense”. A six-step semantic differential is used with one positive end and one negative end (Table 1). SHIS is used as one index; scores may range from a low of 12 to a high of 72.

The demographic data collected included sex,age (three groups: under 40, 40–54, 55 and older), position, years of employment in the hospital (three groups: less than 4, 4–10, more than 10), and other employment (work beyond the hospital such as private practice, consultancies). All these variables have been used in previous studies reported by Swedish researchers [12].

Prior to the study, translation and adaptation of the Swedish SHIS and WEMS questionnaires into Lithuanian was done, following published guidelines [14]. First, the questionnaires were translated from Swedish into Lithuanian with the aim of retaining original concepts while using culturally and linguistically appropriate expressions. The translator, who was not familiar with the questionnaires, had Lithuanian as her native tongue, but had good knowledge of Swedish as well. In a second step, the questionnaires were translated back to Swedish by another bilingual translator (also from Lithuania but living in Sweden), who was also unaware of the concepts being explored. The aim was to ensure that the Lithuanian version reflected the original meaning of the items and was conceptually equivalent. Thirdly, the translated version was discussed by the Swedish authors (IA and GE) together with the bilingual translators to identify anyinconsistencies and misunderstandings, and a parallel procedure was done including two of the Lithuanian researchers (JA and AJ) and the translators. Finally, a committee with the two translators and four authors agreed on the revisions to the final version.

2.3 Statistical analysis

Total indices of SHIS and WEMS, and the six sub-indices of WEMS, were standardised to make the score range from 0 to 100. This enabled a comparison of the index distributions. Internal consistency was explored using the Cronbach’s alpha (CA) coefficient. A high CA value is preferred, but it is possible to interpret even low values [15]. Means for numeric variables were tested with independent samples t-test when two groups were compared. If more than two groups were included, one-way ANOVA was used. A logistic regression model was used to mutually adjust for factors contributing to a high WEMS index. The dependent variable (WEMS index) was dichotomised by dividing WEMS according to the median value. Values above the median value were named high. All demographic variables were included as independent variables.

To study the relationship between SHIS and WEMS, a multiple linear regression model was adopted. SHIS was the dependent variable with the six sub-indices of WEMS as independent variables. The model was adjusted for age.

All analyses were made with SPSS ver. 19.0. The significance level was set at 0.05.

3 Results

3.1 Characteristics of the sample

A majority of the hospital workers (90.2%) were women. The age distribution is presented in Table 2 where it can be seen that only 15% of respondents were over 54 years of age. Although the majority of the nurses (80.5%) reported more than 10 years of employment at the hospital, 43.5% were younger than 40 years of age. Among the physicians, 11.9 % reported that they held an executive position at the time they were surveyed. Compared to the nurses and other staff members, physicians more often (36.4%) reported additional employment beyond the hospital.

3.2 Work experience

Total WEMS score, as a measure of work experience, showed no differences between the professional groups. However, a comparison of WEMS sub-indices demonstrated differences between physicians, nurses and other staff members in the domains of time experience, autonomy and supportive working conditions (Table 3). The domain of time experience was rated higher by other staff members, compared to physicians and nurses. Nurses had the lowest scores on autonomy, but physicians had higher scores on supportive working conditions when compared to nurses and other staff members. The reliability of the sub-indices of WEMS measured by Cronbach’s alpha varied between 0.64 and 0.94 (Table 1). For WEMS total and SHIS, the alpha values were 0.93 and 0.94, respectively.

A comparison of WEMS sub-indices by age, showed higher scores among older workers (≥55) for internal work experience, 78.6 vs. 74.8 (40–54 years) and 72.8 (≤39 years), respectively (p = 0.026), as well as autonomy, 68.0 vs. 61.9 (40–54 years) and 59.2 (≤39 years), respectively (p = 0.013), compared to younger respondents. Those who had more than 10 years of work experience reported higher scores for autonomy compared to those who had less than 4 years of experience, 63.1 vs. 52.3, (p = 0.003).

The comparison of WEMS sub-indices according to gender indicated that men reported higher scores on autonomy than women, 74.3 vs. 61.1, (p < 0.001), as well as supportive working conditions, 71.8 vs. 64.7, (p = 0.012).

A final logistic regression analysis was performed on the factors related to positive work experiences (high total WEMS score) (Table 4). After adjustment for interacting variables, having an executive post was significantly related to a higher WEMS score (OR = 2.58), while being between the age of 40–54 years was associated with a lower WEMS score (OR = 0.65).

3.3 Report of health indicators

The total SHIS score was 69.8 (95% CI 68.5–71.2). Those in the other staff member group obtained the highest average SHIS score (73.7), while physicians obtained 70.9 and nurses (68.5), p = 0.022. No significant difference in SHIS score was found in relation to executive position, years of employment or gender. There was a tendency towards age-related differences in SHIS (71.9 (>54 years), vs. 68.1 (40–54 years) and 70.8 (≤39 years), p = 0.08).

3.4 Relationship between work experience and health indicators

Results from four regression models among all employees and in different positions, with SHIS index as the dependent variable and WEMS sub-indices as the independent variables, are shown in Table 5. Contributing factors to a high SHIS index among all respondents were supportive working conditions (β= 0.22), internal work experience (β = 0.20) and time experience (β = 0.19). The explanatory power of the model was R² = 0.34.

When models for each professional group were created, some differences in explanatory factors were found. Among physicians, only time experience (β = 0.20) contributed significantly to the model. Two factors in the model were significant for the group of nurses: internal work experience (β = 0.23) and time experience (β = 0.22). Among other staff members, supportive working conditions (β = 0.42) and autonomy (β = 0.29) contributed significantly to the model.

4 Discussion

Lithuania, like many countries in Eastern Europe, has a tradition of top-down administrative structures where employees have limited influence on their work situations. Our results shed light on the relationship between the psychosocial work environment and health using the salutogenic perspective in a Lithuanian hospital setting. One of the largest hospitals of Lithuania was chosen for the investigation.

To compare findings with a similar Swedish setting, data from a study where the same measures were employed in a comparable Swedish hospital was used [12]. Even though Sweden is one of the countries in Europe where employed input influences the work environment, the overall differences between the most important health promoting work experiences were small. Still, some differences were apparent.

Nurses had the lowest score (57.1) on autonomy compared to staff in other professional groups. This is in line with Swedish results, where autonomy among registered nurses was 55.5 and among assistant nurses 49.5 [12]. Professional autonomy and control over nursing practice are known to be the primary causes of nurses’ job satisfaction; whereas factors like visibility and viability encourage nurses’ control over their practice [16]. A study on nurses who had decided to leave the nursing profession showed lack of professional opportunities as one reason for their decision [17]. As autonomy for the nurses in our study did not show a significant contribution to a higher SHIS index (i.e., better subjective health), autonomy may have other primary values for the personnel than just health. Low levels of autonomy among nurses can be seen as a warning sign concerning the willingness of the nurses to remain in their current job situations. Obviously, as the Lithuanian and Swedish figures on autonomy are similar, the problem with low autonomy may not be affected by the organisational situation.

The value of autonomy to physicians was evident given their higher score (68.4%) compared to nurses. Physicians were more likely to hold an executive post than nurses; giving them greater decision-making power. Our results demonstrated that holding an executive post was significantly associated with high WEMS (OR = 2.58), suggesting that factors related to management and decision-making may also be health promoting. On the other hand, high job demands among nurses and physician managers in Sweden were related to increased work stress from a pathogenic perspective [18]. A Swedish study on physicians, working in Swedish health care, pointed out the importance of maintaining a positive and supportive atmosphere for physicians in their work environment. Enhancing physicians’ influence over the decision-making processes was important to counteract work-related exhaustion and contributed to a more efficient organisation [19].

Compared to Swedish data [12], Lithuanian physicians had a much higher score on time experience (68.6 versus 38.5), while the difference for nurses were small. Even if many Lithuanian physicians have more than one job (in our study more than a third had at least one other job besides the one at the hospital) the ratio of physicians to patients was higher in Lithuania than in Sweden. A leaner organisation in Sweden has reduced the ratio of physicians to patients which may also account for the higher score on time. At the same time, the administrative burden has increased substantially in Sweden which would also affect time experiencescores [20].

In the current study the relationship between salutogenic health (measured as SHIS) and the sub-domains of WEMS differed between work positions. Physicians reported more supportive working conditions compared to the other professional groups, but in the regression models support contributed to explain health measured as SHIS only for nurses and other staff members. Support is a mediating factor of the demand-control theory. The lower impact of support on salutogenic health among physicians may be related to a relatively greater importance of demands and control compared those in other occupations with lower perceived support [21]. Results of a German study stressed the positive effect of supportive working conditions and work involvement on the possibility to preserve work ability among physicians [22]. Thus, the importance of supportive working conditions in relation to health promotion activitiesis evident.

Together with supportive working conditions, autonomy was a significant factor for SHIS in the group of other staff members. This group also reported a high score on autonomy, possibly reflected in the highest SHIS index score among the groups. The importance of autonomy and decision-making in relation to workplace health promotion has been evaluated in different settings, and a synergy between job control and support has been described [23, 24]. Such knowledge should influence health promotion in all groups. The domain of leadership showed high scores for all work positions, but nurses demonstrated the highest value (75.5) compared to other domains of WEMS. The role of nurses’ leadership in creating a healthy and sustainable work environment has been demonstrated by other researchers [25, 26]. In our study, the high scores indicate satisfaction with or acceptance of leadership, but without any impact on health. Several other studies [27, 28] have demonstrated the importance of leadership for workplace health; these have mostly been conducted from a pathogenic perspective, something which could account for the different findings. Among physicians, time experience was the only factor that was found explanatory to salutogenic health. Having additional employment, something which was specific for the Lithuanian situation, requires very good time management. While this may provide continuous time pressure, it may also be health-promoting due to variety and other incentives [29, 30].

4.1 Methodological considerations

Both limitations and strengths of the study should be considered. In this study, two previously developed instruments on health, SHIS [13], and work experiences, WEMS [4], were used. They are both in Swedish, and have both been psychometrically tested and described. To make them usable in a Lithuanian context, the two instruments were translated from Swedish into Lithuanian. This was made using a forward-backward translation approach following published guidelines [14]. It was of special importance to adapt the questions not only linguistically but also to insure that the meaning of the words and constructs were clear within a different culture. The internal consistency of the respective indices was measured and has been reported in our results. By following this procedure, the two instruments SHIS and WEMS were adapted for use in a Lithuanian hospital context.

In relation to work experience, SHIS in the Lithuanian hospital, just like in the Swedish hospital [31], demonstrated the ability to discriminate between different groups when analysing employment in the health sector. This characteristic improved the usefulness of SHIS as a salutogenic measure in different contexts such as health promotion. The WEMS instruments have been compared to other established measurements, including SHIS that are positively related to health and work [12]. WEMS was found to be both valid and reliable. In the Lithuanian context of this study, WEMS was also found to discriminate well between different groups. As in the Swedish study the construction of WEMS with sub-indices increased the comparability. Still, further research is needed to make more thorough psychometrical tests.

A comparison of WEMS sub-indices by age showed the highest scores among older workers (≥55) for internal work experience and autonomy. A tendency towards age-related differences in SHIS could also be seen, with the highest score in the oldest age group, which was similar to Swedish findings [31]. As in most work-related studies, some results in this study may be related to the healthy worker effect phenomenon. This suggests that an individual must be relatively healthy to be employable in any workforce. Both morbidity and mortality rates within the health sector workforce are usually lower than in the general population [32].

One limitation is that this study is cross-sectional. Therefore any reference to causal conclusions is not appropriate. However, as far as we can determine from the literature this is the first study in Lithuania of work experiences and health from a salutogenic perspective. It has been possible to make important conclusions about the relationship between different kinds of work experiences and health in different groups of employees, even if the causality remains unknown.

A strength of this study is the comparatively high response rate, 88% , which was evenly distributed across occupations and age groups thus making the results relevant to comparable hospital contexts in Lithuania.

Finally, the salutogenic approach of this study is also a strength. There are numerous studies worldwide about problems among employees in health care. But so far, there are only a few studies focusing on the positive outcomes, even if workplace health-promoting activities are increasingly more common also in hospitals [33]. Focusing on the workplace as a supporting environment creates possibilities to make the workplace a health resource and not a health problem. A lot more research needs to be done with a salutogenic focus.

5 Conclusions

Being the first study on the relationship between the psychosocial work environment and health from a salutogenic perspective among Lithuanian hospital workers, the findings may serve as a starting point for a new paradigm of workplace health promotion in Lithuania, as well as other Eastern European countries.

To increase autonomy among nurses will be an important challenge for the hospital sector. Enhancing nurses’ influence over the decision-making processes would increase job satisfaction and thereby the willingness for nurses to stay in their jobs.

Time experience was much more positive among Lithuanian physicians compared to their Swedish colleagues. This suggests that a move toward a leaner organisational structure in the Lithuanian health sector should be accompanied by efforts to maintain the positive time experience as it is related to good health.

As holding an executive post was the variable that had the strongest relationship to positive work experiences, it is important for health organisations to enhance the participation in decision-making for all groups of employees.

Studies like the present one, with a salutogenic approach, enable the organisation to strengthen the employees by focusing on possibilities and resources instead of the traditional emphasis on risks and failures.

The two measures of health and work experiences, SHIS and WEMS, which were developed in a Swedish context, discriminated well between different groups of participants in a Lithuanian hospital context. Individual activities for workplace health promotion for different work groups would be advisable given the findings of the present study.

Conflict of interest

The authors declare that they have no competing interests.

Authors’ contributions

JA was the main author of the manuscript and involved in all aspects of the study. AK contributed in the planning of the study and collected the data. AM performed the statistical analyses. AJ contributed in the planning of the study, the data interpretation and revision of the manuscript. GE and IA contributed in the conception, design and planning of the study as well as the data interpretation and writing of the manuscript. IA also contributed in performing the statistical analyses. All authors read and approved the final version of the manuscript.

Footnotes

Acknowledgments

We thank Česlovas Gutauskas, former head of Republic Panevežys Hospital in Lithuania, who gave permission to perform the questionnaire study.

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