Determinants of Job Satisfaction in Different Podiatric Clinical Settings

Aim. The podiatry profession has evolved over the past few decades and new specializations have been introduced in this field bringing with them new services and different work settings. The aim of this study is to explore the level of job satisfaction amongst Podiatrists working in two different clinical settings within the NHS. It also seeks to determine the factors influencing job satisfaction among public health professionals working in two different settings. Methods. A comparative non experimental design was employed. Twenty three Maltese State Registered Podiatrists working on a full time basis within the NHS were recruited. Twelve podiatrists were recruited from a hospital setting and 11 podiatrists were recruited from a Primary Care Setting. All consenting participants were asked to fill in the short form of the Minnesota Satisfaction Questionnaire. This questionnaire is composed of 20 statements and is used to explore levels of job satisfaction. Results. No statistical difference was found when comparing levels of job satisfaction between the study group [P=0.609]. The participants however reported a low mean satisfaction score for their work compensation and chances of advancements in their work place. Conclusion. This study has concluded that Podiatrists working within different settings in the NHS overall experience satisfactory levels of job satisfaction. However, it was also reported that participants felt that they were not well compensated for their work and that they are limited to advancement in their workplace – two factors which are known to be related to turnover rates and work retention. Results of this study need to be considered by the professional bodies and health care authorities for change in health and educational policies to be brought about. This paper will conclude by offering recommendations which offer proper action steps to be visited when looking to increase job satisfaction among health care professionals.


BACKGROuND Job satisfaction within health professionals
Job satisfaction has been of great interest worldwide in every work sector; however it is particularly beneficial in the healthcare setting due to the fact that it is known to have a great impact on work quality, work efficiency, and health related expenses.The allied healthcare professionals are an essential part of the workforce within the healthcare system and it is very important to attract such individuals and retain them within the workforce 1 .Job satisfaction is said to be linked with the employee's work environment, job responsibilities and powers and time pressure; the determinants which affect employee's organizational commitment and consequently the quality of services 2 .Due to the nature of their work, health care workers are more susceptible to occupational stress and work discontent 3 , and job dissatisfaction has been found to be a direct predictor of burnout syndrome 4 .In order to prevent such occurrence it is important to explore the different facets of job satisfaction, because this will enable researchers to highlight those factors that decrease job satisfaction and give out relevant recommendations.If left unaddressed, these factors could lead to job dissatisfaction and give rise to future challenges such as absenteeism and high turnover rates.
In clinical sciences, job satisfaction levels are reported to be of high importance since they are known to affect turnover rates, employee performance and overall patient care 1 .Although the majority of current literature focuses on job satisfaction amongst the nursing profession, the podiatry profession should not be left unaddressed since similar challenges could also be a reality amongst this profession.The podiatry profession is a growing profession and as a result, the perception of the public regarding podiatry as a profession has shifted from the 'traditional' core practice that was limited to corn and nail management to a highly specialized fields such as that of lower limb biomechanics 5 , podopaediatrics, podogeriatrics, sports medicine and specialization in the high risk foot 6 .As a consequence of these new services, new work environments have been created to address the expansion of this profession.

Contribution of work environment and setting
The physical working environment has a considerable impact on job satisfaction levels 7 .It has been reported that different clinical settings could affect levels of job satisfaction 8 .Various studies have been conducted amongst the nursing profession were the authors compared job satisfaction between different working settings such as nurses working in public health setting and home health nurses amongst other work settings.All studies support the possibility that job satisfaction levels could be affected according to the clinical setting.It has also been concluded that by improving the work environment, job dissatisfaction levels have decreased 9 .This in turn influences productivity together with better quality of work within any organization 2 .

Advances in Podiatry Practice
In this article the authors sought to explore the level of job satisfaction amongst Maltese podiatrists working in two different clinical settings within the NHS.The work environment of podiatry practices in Malta has been changing since podiatry services have expanded and are now being offered at primary care level, in public and private hospitals and in private practice.This expansion has brought about other changes such as working within a specialized team as healthcare professionals and in different clinical environments.Retention of these skilled healthcare professionals is of paramount importance and thus job satisfaction is such an important subject in management since they are both highly linked to each other 1 .Although there are several studies that attempted to explore job satisfaction levels amongst health care workers 10,11,12 , there is a dearth in the literature where podiatrists are concerned.This study explores level of job satisfaction amongst Maltese podiatrists working within the governmental services and seeks to determine whether there is a difference in job satisfaction between podiatrists working within the primary care setting and those working in a hospital setting.It also seeks to determine the factors influencing job satisfaction among public health professionals working in two different settings.To date no studies have been conducted to evaluate job sa-tisfaction amongst Maltese podiatrists although changes have occurred within this profession during the past years with the introduction of more sub specialties and more focused work.

MetHODS
A non experimental comparative quantitative study was conducted.This report includes data from a cohort of 23 podiatrists working on full time basis within the governmental sector in Malta.Although this might look like a small number, this figure accounts for 92% representation from the whole eligible population of podiatrists.Included participants were all State Registered Podiatrists, working on a full time basis in a state hospital setting [n=12] or in governmental primary care podiatry clinics [n=11] and had been working for more than one year in that particular setting.This study was approved by the University of Malta Ethics Research Committee.All participants had provided consent to participate in the study.The study was carried out in accordance with the principles of the Declaration of Helsinki as revised in 2008.All participants were assured of confidentiality and anonymity.

Outcome Measure
The outcome variable measured in this study was job satisfaction, assessed by the short form of the Minnesota Questionnaire 13 .This questionnaire was bought from the Vocational Psychology Research, University of Minnesota and permission was also granted to use this tool.The short form of the Minnesota Questionnaire is composed of 20 statements that need to be answered by marking the level of satisfaction using a scale from 1 to 5. The 20 statements include different intrinsic and extrinsic factors affecting job satisfaction.These include: Ability Utilization, Co-workers, Moral Values, Achievement, Creativity, Recognition, Activity, Independence, Responsibility, Advancement, Security, Supervision (Human Relations), Authority, Social Service, Supervision (Technical), Company Policies, Social Status, Variety, Compensation and Working Conditions.Each one is answered using a likert scale from 1 to 5 representing the following state-ments; Very satisfied, Dissatisfied, Neither, Satisfied and Very Satisfied.In order to safeguard the identity of the participants no names were recorded and each participant was coded with a number known only by the researchers.This questionnaire takes approximately five minutes to be completed.The questionnaire is simple to use and it has gone through different reliability and validity testing 14 .The questionnaire was sent out to each participant who fulfilled the inclusion criteria and who had consented to participate in the study.The Statistical Package for Social Sciences (SPSS) was used to analyze the data collected which included both descriptive and inferential statistics.

ReSuLtS
The respondents consisted of 43% males (n=10) and 57% females (n=13).The Independent One-way ANOVA was used to compare general satisfaction scores between the two groups.A p value of 0.609 was reported [primary care setting mean 77.07 vs. 75.25 in the hospital setting], concluding that there was no statistical difference in overall job satisfaction between podiatrists working in different clinical settings within the NHS.The Friedman Test was used to compare mean rating scores, between the 20 items included in the Minnesota Satisfaction Questionnaire as illustrated in Table 1.When comparing satisfaction scores between the 20 items of the questionnaire Social Service [4.43]  had the highest mean rating score, indicating that the satisfaction of carrying out a service of care to others achieved the greatest value, however Advancement in job [2.96] and Compensation [2.26] scored low.A p-value of .000was reported implying that mean satisfaction rating score for each item of the questionnaire differed significantly.

DISCuSSION
The podiatry profession has evolved over the past few decades and new specializations have been introduced in this field bringing with them new services and different work settings in bought primary and secondary settings.The results of this study indicate that Maltese podiatrists are overall satisfied with their occupation in both the primary care setting and in the hospital setting implying that different clinical settings did not affect levels of job satisfaction amongst Maltese podiatrists working within the podiatry department at the National Health Service.This finding was not congruent to other similar studies were the authors reported that different clinical settings could affect job satisfaction 2,7 , however since the questionnaire used in this study to evaluate job satisfaction was self-administered, it is possible that the respondents might have over-reported their level of satisfaction in their work place.However, although no statistical difference was found in job satisfaction amongst Maltese State Registered podiatrists working in different settings specific factors including compensation and chances of advancements were identified in both groups as the leading determinants to dissatisfaction among the study group.This result was similar to studies carried out in other countries amongst other healthcare professionals 15 .Employee's needs vary, so it is crucial to understand what improves job satisfaction and what motivates people to perform better in their work place 2 .
There is little doubt that within any healthcare system constraints exists.A system constraint is defined as 'anything that limits a system from achieving higher performance versus its goal'.The challenge for any system lies in identifying ways that will transform the system to one that is more viable and which can translate into 'state-of-the-art' care.In this study the work environment of local podiatrists was explored in order to determine its effect on job satisfaction.The literature identifies the concept of work environment as a possible barrier to job satisfaction leading to absenteeism, however a series of randomized controlled trials and controlled clinical trials did not provide enough evidence to link physical working environment to outcomes such as job satisfaction 16 .These findings are congruent with the findings of this present study.Further research is needed to explore the impact of different work environments on both health care providers and service users in both public and private sectors.However, as shown in previous studies two factors that act as predictors of job satisfaction and job involvement are compensations and chances of advancement in the profession 1,2,10 .Results of this study have confirmed these findings.According to the literature 17 , opportunity for advancement does not only involve the promotion with regards to an occupational level but it involves also the chances of continuing professional development by means of education and improving skills.Research has clearly shown that in the health care environment, care givers that demonstrate high levels of participation in continuing education and chances of advancement exhibit higher levels of job satisfaction than their colleagues 18 .Similar to chances of advancement, low financial compensation has been linked with reduced turnover intention and quality of care 19 .Higher income is related to higher satisfaction and reduces the chances of being dissatisfied, hence supporting the argument that compensation is one of the important factors in the overall job satisfaction 20 .
Although results of this study are positive to the local health care setting, it is very important for stakeholders to identify and understand the possible outcomes of job satisfaction.Organisational commitment is a very important concept in retention of healthcare professionals within the organization 1 .According to the literature organizational commitment has a positive effect on job satisfaction 21 and job satisfaction and organizational commitment are both strong predictors of turnover intention 22 .Results of this study need to be considered by the professional bodies, policy makers and health care authorities, and some of the issues raised by this study must be considered and possibly addressed.High levels of job satisfaction are beneficial to the organization, the care provider and the patient 1 .The message is that in order to ensure job satisfaction amongst health care professionals which in turn will result in a better health care service improved working conditions and revision of compensation scales need to be addressed.The continual monitoring of job satisfaction amongst healthcare professionals is also recommended.A workforce operating on cooperative lines is more likely to be innovative and productive than one where individuals and groups are in constant conflict with each other 23 .Good communication is the basis for effective cooperation 24 which is mandatory for effective multidisciplinary communication.Effective communication amongst healthcare providers is crucial for ensuring that patients receive safe and high quality care 25 .In an 'ideal' world communication would involve spontaneous, unlimited discussion among free and equal people 26 .Placed within the health context, ideal communication would result in much more open interaction between all potential stakeholders including government, health professional and patient/client.Communication will fail if stakeholders cannot agree about the facts, do not respect each others' values or mistrust or try covertly to manipulate each other 27 .Improved care could mean better quality of life, improved health outcomes, lesser health-related complications and less expenditure from healthcare budgets 28 .

CONCLuSION
The results of this study add to the limited literature considering podiatrists' job satisfaction.The results of the Minnesota Satisfaction Questionnaire suggest that the Maltese podiatrists studied exhibited overall good levels of job satisfaction in both the primary care setting and hospital setting.However, the themes of lack of level of advancement in the profession and compensation for work are troubling.It would be interesting to replicate this study amongst podiatrists working in the private setting to explore their level of job satisfaction.More important, the results need to be considered by the professional bodies and potential stakeholders in order to maintain a healthy workforce.Involving health care professionals and listening to their voices and concerns is likely to have a positive impact on job satisfaction and conse-

table 1 .
The Friedman Test results when comparing mean rating scores between the items in the Minnesota Satisfaction Questionnaire.