Citizens’ Quality of Life: The Outcome of a Satisfied Health-Related Professional

: This paper argues that the quality of life of citizens of a nation can also be amplified by the quality of life of health-related professionals who provide myriad necessary services across a wide range of care pathways and in various settings. The approach was both theoretical and empirical – review of literature and statistical analysis of the collated data. Thus, the study utilized factor analysis to determine the factors that bring about job satisfaction amongst health-related professionals. The findings point to a number of important job satisfaction as well as organizational climate dimensions, which combine to generate high levels of job satisfaction amongst health-related professionals. The paper concludes by serving some important directives for management of health establishments.


Introduction
This study empirically associates quality of life with job satisfaction amongst health-related professionals in South Africa. Essentially the study argues that quality of life of citizens of a nation can also be achieved if health-related professionals in public hospitals in South Africa experience high levels of job satisfaction. The researcher uses the word also in recognition of the various perceptions of the concept of quality of life. The concept of quality of life has been used loosely to refer to aspects such as income, employment, housing, education, other living and environmental circumstances, as well as perceptions of overall quality of life, individualǯs experiences and values, and has included related, proxy indicators such as wellbeing, happiness and life satisfaction. In fact, the concept is both multi-level and amorphous. This is the contention of Brown et al. (2004) who utterly insist that there is no widely accepted or supported theory or measurement instrument of quality. What one gathers from this is that models of quality of life are not consistent; they range from needs-based approaches derived from Maslowǯs ȋͻ; ͻͺȌ hierarchy of human needs, to classic models based solely on psychological well-being, happiness, morale, life satisfaction (Andrews, 1986;Andrews & Withey, 1976;Larson, 1978), social expectations (Calman, 1983) and or the individualǯs unique perceptions ȋOǯBoyle, ͻͻȌ. Quality of life is thus a complex collection of interacting objectives and subjective dimensions (Lawton, 1991). Employee satisfaction is defined by Iwu et al. (2012) as the satisfaction derived by an employee from the positive presence of a combination of job satisfaction facets and certain dimensions of organisational climate. This definition invests employee satisfaction with a special kind of status and distinction that further clarifies the need not to identify the concept exclusively with any single facet of job satisfaction, as well as any single dimension of organizational climate. Health-related professionals comprise laboratory technicians, optometrists, radiographers, emergency medical services personnel (specifically paramedics), pharmacists and nurses who deliver high quality care to patients across a wide range of care pathways and in a variety of settings. They perform essential diagnostic and therapeutic roles. They work across a wide range of locations within acute, primary and community care, performing functions of assessment, diagnosis, emergency care, treatment and discharge throughout the care pathwayfrom primary prevention through to specialist disease management and rehabilitation. Essentially, healthrelated professionals also diagnose and treat patients. Given the nature of their jobs, these professionals should feel valued, appreciated and rewarded. The potential effects of not looking after them will not only result in lowered job performance, withdrawal, and increased absence from duty, counterproductive behaviour and health problems, but poor quality of life for innocent sick citizens. Health care organizations should therefore seek to improve the quality of life of health-related professionals so that citizens of a nation are able to enjoy quality health care.

Inspiration for the study:
The following constitute the main reasons behind the study:  High levels of health-related professional absenteeism in South Africa  High levels of health-related professional attrition in South Africa  Brain draindifficulty in retaining health-related professionals in South Africa  Brain gain from non-English speaking practitioners, prompting communication challenges  On the basis of the above, this paper presents the following propositions:  Quality of life of citizens will be greatly influenced by satisfied health-related professionals  Quality of professional life of practitioners will be greatly influenced by high levels of job satisfaction  The study therefore intended to determine which factors contribute to health-related professionalǯs job satisfaction in order for the above propositions to be successfully realised.

Methodology
A mixed research approach comprising qualitative, quantitative, exploratory and descritptive research was deployed, given the main objective of the study which was to identify the factors that contribute to health-related professionalǯs job satisfaction in South Africa. This approach was considered suitable for a number of reasons including ȋȌ qualitative studiesǯ help to achieve the objective of a study, which has two subjective variables. The conceptsquality of life and satisfactionare subjective and will, therefore, rely heavily on qualitative analysis; (2) qualitative research assists with careful and systematic collection, ordering, description and interpretation of data; (3) qualitative research explores the behaviour, processes of interaction, meanings, values and experiences of purposefully sampled individuals and groups in their natural context; ȋȌ quantitative studiesǯ help to obtain reliable frequency and descriptive statistics; (5) quantitative research methods aid in the collection of large volumes of data and in the elimination of factors that are irrelevant in a study; (6) exploratory studies help to uncover problems, opportunities, threats and salient variables or trends that are located within a research project; and (7) given that no study of this nature had been undertaken within health-related professions in South Africa, exploratory research was deemed suitable because it would assist with gaining greater understanding of the phenomenon under study. Statistical Package for Social Sciences (SPSS) was used to generate descriptive as well as other statistics. These are presented in this paper in the form of tables for ease of reading.
Research sample: Purposive sampling was used to select participants for the study in order to ensure that the researcher could access a particular subset of people (Trochim, 2006), who would participate meaningfully in the survey (focus) (Adler & Clark, 2007), so as to gain better control of the research process (Keegan, 2009). The researcher sent out close to a thousand questionnaires to public health institutions in a South African province, but received only 117 fully completed ones. The demographics of the participants (Table 1) as well as participantǯs representation by profession (Table 2) follow.

Data collection instrument:
Plus Delta Organisational Climate Questionnaire (Appendix A) was used for this study after two major reviews. The first review was necessitated after review of literature, while the second one was after diligent consultation with practitioners. De Cock (2006) found Plus Delta Organisational Climate helpful in a previous study because of its combination of job satisfaction facets and organisational climate dimensions. The categories in the questionnaire include organisational design; individual job characteristics; co-worker relations; culture/work environment, and senior management. The others are direct supervisor; work processes; communication; technology; customer satisfaction and remuneration. These eleven categories have 55 items in total. The overall reliability statistics of the instrument was .91.

Analysis:
To achieve high statistical reliability in this study, the researcher insisted on a reliability coefficient (Cronbach) of not less than 0.6, following the counsel of Zikmund et al. (2010). This means that this study was compelled to consider only those categories with very high factor loadings.   To achieve high factor loadings, it is evident from the above table, that certain items were deleted in order to arrive at an acceptable reliable coefficient α. According to Blaikie (2003) ǮBefore applying factor analysis, it is a good idea to inspect the matrix of correlation coefficients. The first thing to do is to see if any item has very low coefficients with all or most of the other items. Such items are not going to find their way into any factor and would be excluded.' For instance, to achieve a reliable Cronbach α in the category direct supervisor, the researcher needed to eliminate item 26. The same process was undertaken for the categories work process (item 32 were deleted) and communications (items 36 and 39 were deleted). A further interrogation of the category communications led to the exclusion of item 37, which then enabled the achievement of a Cronbach α of .ͺ. Thus, given the objective of the study, elimination of certain items (guided by factor analysis), was deemed necessary.

Analysis in terms of categories
Organizational design: In terms of clarity of organizational goals and objectives, there was a strong indication that organizational goals and objectives were clear to the health-related professionals who were sampled. This is evident from the almost 91 per cent of affirmative responses. The Cronbach coefficient was reliable (.75).

Individual job characteristics:
There seemed to be a sense of pride amongst the professions, which perhaps emanated from respective job responsibilities. However, the poor percentage response rates associated with items 7 and 9 was somewhat telling of a profession whose skills and abilities were yet to be fully utilised, and as a result, demands more given the responses to Ǯmy current role is challengingǯ. The Cronbach reliability coefficient for the items in this category was .82.

Co-worker relations:
There is a strong indication that mutual respect for each otherǯs work exists in the organizations that were sampled. However, one wonders why there seemed to be a higher percentage of respondents who indicated that they strongly disagreed, disagreed or were undecided with regard to identifying knowledge and information sharing as organizational norms. Most respondents however stated that they could consult their colleagues if they needed help. The low response rate obtained with regard to Ǯknowledge and information sharing are group norms…ǯ nonetheless seemed to suggest that coworker relations were strictly based on job responsibilities. The five items in this category obtained a reliability coefficient of .90. The results from the above category indicate that there is a good work culture in the organizations that were sampled. Sadly, a miserly 35 per cent of the participants agreed that there is a balance between work and personal life. This small figure no doubt suggests that the nature of the job itself does not allow for socialisation, hence, one can infer that the professionals work in a high-pressured work environment.
Senior management: There are five items in this category. The Cronbach coefficient was reliable (.67).
The main objectives of the category included (1) to assess the extent of collaboration between senior management and employees; and (2) to assess the extent to which management is supportive and shows concern for employees. The perception that senior management treats employees fairly is clearly indicated from the responses of the participants. A total of 84% of the population agreed, while 16% responded negatively.

Direct supervisor:
The responses from this category indicate that members of health-related professions have direct supervisors who appreciate their work; clarify objectives of the organization; and provide helpful feedback. However, poor responses were noted in favour of Ǯmy direct supervisor listens to my ideas and concernsǯ ȋ%Ȍ; and Ǯmy direct supervisor serves as a positive role modelǯ ȋͺ%Ȍ. This perhaps suggests that the members value interaction around creative ideas and personal feelings and if these are not allowed, then perceptions of the direct supervisor are negative. The items under this category achieved a Cronbach alpha reliability coefficient of .63.

Work processes:
Work processes refer to steps, which are required to produce an expected outcome. The objective of this 5-item category was to assess the extent to which employees were clear on what they should do; level of connectedness with their tasks; and how much collaboration exists among employees with relation to task execution. This category also hoped to examine the influence of task activities on an employeeǯs functioning within an organization. The five items in this category generated a Cronbach reliability coefficient of .65. There was a general positive feeling towards the work processes in use at the organizations that were sampled, and these work processes no doubt facilitated work, which enhanced the responsibility of members towards their tasks. They also helped members to operate effectively.

Communication:
It was evident in a category that fairly positive perceptions of organizational communication exist among the organizations that were sampled. Respondents affirmed that they received the information that they needed to perform their tasks efficiently; could ask for help from group members when they needed it; and were convinced that interpersonal communication and relationships contributed to organizational performance. The downside was that only 40% of participants were clear about how their jobs supported their departmentǯs overall objectives, thus hinting that the connection that their jobs had with the organization was not properly communicated.
Technology: Given the high percentage of positive responses, it was clear that a high level of appreciation of the significance of efficient technology in the organizations that were sampled existed. Technologies in use assist with the execution of tasks, which advance business processes. This is perhaps a source from which they derive satisfaction from their current job responsibilities. The five items in this category, sought to determine the quality of tools and technologies that were required to perform tasks and how these tools and technologies were perceived by employees. A high reliability coefficient of .88 was generated for the five items in this category.

Customer satisfaction:
The results from the category ǮTechnologyǯ indicated an appreciation of efficient technology in the execution of tasks. The category Ǯcustomer satisfaction, however, strengthens this result. The necessity to deliver high quality service is indicated in the % of the respondentsǯ affirmation that they are focused on delivering high quality service to their customers. This 4-item category explored employee perceptions of service quality. The Cronbach coefficient that was generated for the four items was a strong .65.
Remuneration: This 4-item category examined employeesǯ perceptions of remuneration. The results indicated that the respondents were generally dissatisfied with their income. This conclusion is drawn from the trend of responses, which seem to suggest that the income does not accommodate their basic needs. The Cronbach coefficient was .609.

Analysis using exploratory factor analysis (EFA):
To achieve the intention of this study, the researcher explored all the items in the categories to determine their level of correlation. The others include Self-efficacy (0.918); Family-friendly work environments ȋFFWEǯsȌ ȋ.ͺȌ, Leader credibility and innovation ȋ.ͺȌ and Excellent customer relations and technology (0.791). This paper therefore argues that these factors will improve the quality of life of health-related professionals in South Africa; consequently amplifying the quality of life of its citizens. The factors are described below.

Role clarification and job design:
The items in this factor were derived from a mix of categories, namely organizational design, culture/work environment, senior management and work processes. (See Plus Delta Organizational Climate Questionnaire in Appendix).   .745 0.96

Self-efficacy:
The items in this factor were derived from two major organizational climate dimensions (culture/work environment, and senior management and one job satisfaction facet, namely remuneration. They have been grouped together under the factor self-efficacy because of their high factor loadings. Together, these items achieved a Cronbach α of .ͻͺ. See table below.

Leader credibility and innovation:
The table below depicts the leader credibility and innovation factor. The current study identifies with the factor because of its high factor loadings. The items in this factor were derived from direct supervisor, technology, customer satisfaction and remuneration categories. Together, the items achieved a high Cronbach Alpha of 0.874.

Discussion
Customers are usually the reason for any organizationǯs existence; hence, organizations must have strategic relationships with them. As partners, they should maintain good relations with each other, gain experience with each other, develop a common language and perspective, which will reduce misunderstanding and enhance collaboration (Larson & Gray, 2011: 431), thereby improving the return on investment. Battisti et al. (2007) refer to a healthcare organization as a service organization. Service organizations are characterized mainly by the intangibility of their offerings with external customers as the main reason for their existence. Given the impact of customer satisfaction on organizational profit, it is important that organizations continue to satisfy their employees because satisfied employees are more likely to be friendly, upbeat, and positively responsive towards customers appreciate (Robbins et al., 2009). This paper posits that health-related professionals are happy when they provide quality service to their customers. Therefore performing to the high standards set by management requires the right kinds of tools. With the right kinds of tools, employees can deliver quality service. If external customers are satisfied, it improves the self worth of internal customers (in this case, employees) and gives them a feeling that they contribute to the growth of the organization. This also adds to their positive perception of the organization. Given the nature of the work of health-related professions, one can safely say that excellent customer relations are achievable through functional technology. Reference is made to Battisti, Iacovone, and Nicolini (2007) and Daviaud and Chopra (2008) in the argument that health-related professions are both technology intensive professions, as well as service-oriented. industries realize their objectives through effective customer services, which are supported by functional technology.
Role clarity is achieved when an organizationǯs goals and objectives are clear to an employee. Effective job design helps to assure the roles and responsibilities of members of an organization. If members of an organization understand what is expected of them, they will be able to perform their tasks with more clarity. Simplifying and clarifying guidelines are important determinants of performance in health care establishments (Rowe et al., 2005(Rowe et al., : 1026(Rowe et al., , 1032. Improving role clarity therefore will guarantee someone occupying a given position a clearer understanding of the set of expected behaviours (Robbins et al., 2009: 221), as well as goals, tasks and authority (Carpenter et al., 2003(Carpenter et al., : 1092 for that particular position. In fact, Albion et al. (2008: 279) found that the only organisational climate variable that emerged in their study as a unique contributor to the formation of intentions to leave the health profession was role clarity. This therefore backs the finding in this study that role clarity was a significant element in the quest for satisfactory service for citizens of a nation by health-related professionals. Poor job design can negatively affect an employeeǯs emotional and physical well-being, and general attitude to work and the organisation (Michie & West, 2004: 94). Work must therefore be designed to provide autonomy and a good degree of challenge. Work must also be designed to excite and generally make sense to the holder of the job (Nel et al., 2008;Robbins et al., 2009). A poorly managed performance system results in unhappiness within an organization, which decreases motivation. It also increases insecurity among members of that organization. To eradicate this, Webster and Omar (2003) suggest the institution of rights and equitable distribution of resources at all levels in an organization. Employees, who fear that they may lose their jobs, experience a loss of job significance. Stander and Rothmann (2010: 7) argue that this breeds a sense of incompetence (a situation that affects the skills and abilities of employees to do their work efficiently).
Self-efficacy refers to an employeeǯs conviction that he has the capability to organise and execute courses of action, which are required to manage situations (Robbins et al., 2009). In their study of employee engagement and manager self-efficacy, Luthans and Peterson (2002) found a close relationship between employee self-efficacy and organizational commitment. They believed that a strong psychological commitment emanated from employees whose work environment was both emotionally engaging (strong ties to work and co-workers) as well as cognitively engaging (provided with information and feedback). According to Strydom and Roodt (2006), the prestige attached to health-related professions offers an intrinsic satisfaction. They also found out that self-efficacy predicted job satisfaction when it interacted with internal climate dimensions such as specialist qualification. Low self-efficacy could result in high levels of burnout (Rothmann, 2003) while jobs that enhance situational and personal control have the potential to bring about higher self-management efficacy beliefs (Strydom & Roodt, 2006: 17). Xu and Thomas (2011) thus insist that psychological meaningfulness of work results in a much-improved output. A feeling of self-worth (feeling of being valued as an employee) is derivable from an organization that treats employees fairly; a management that interacts with employees (thus providing information to employees that can be trustedȌ, total respect for oneǯs professional abilities and an organization that offers competitive remuneration packages. As Liese et al. (2003) counsel, medical establishments must offer internally competitive wages and benefit packages in order to retain highly trained staff. They admonish further: Ǯhealth personnel must be offered a living wage so that they do not seek outside employment or under-the-table payments for services in order to survive'.
Health-related professionals work in highly pressured environments, and are often detached from their families and other social environments. Therefore, there is a high need for various support mechanisms for these professionals. These support mechanisms can include flexible work schedules, dependent care assistance, leave arrangements, counselling and referral services, which Ngo et al. (2009:667) refer to as components of family-friendly work environments. Family-friendly work environments ȋFFWEǯsȌ serve as positive symbols (Perry-Smith & Blum, 2000: 1114 that impact positively on both organizational and worker outcomes ȋGlass & Finley, : ͻȌ. It is important to have FFWEǯs so that health-related professionals can achieve a good balance between their work and personal lives. The benefits of a balanced work-personal life are unachievable if good supervisorial support is lacking ȋOǯNeill et al., 2009), and if there is no financial growth (Bailey, 2003;Kingma, 2001). Poor pay will provide reason to leave an organization (Slabbert, 2008;Oosthuizen, 2005) and significantly breeds a feeling of insecurity (Bailey, 2003;Kingma, 2001). Thus, Powers (2007) suggests a more fluid environment where a health-related professional encounters a sense of community, which perhaps begins from the first day of the new hire. This is to enable the new hire to escape the Ǯhoneymoon-hangoverǯ effect ȋBentein et al., 2005;Boswell et al., 2005). It has been revealed in this study that health-related professionals do not consider their immediate superiors as role models. They were also of the view that their immediate superiors do not seem to listen to their ideas and concerns. These findings suggest a great deal of leader credibility, innovative and integrated leadership is required to get health-related professionals working optimally and enjoying their jobs. It does help for employees to perceive their managers as possessing the right skills and attitudes, which will consequently enable an environment of trust in the feedback received by employees (Lesabe & Nkosi, 2007). Essentially, leader credibility is supported by the perception that the leader cares for and values the contribution of employees. The findings in this study suggest that healthrelated professionals value participation in the affairs of their establishments.

Conclusion
Increased competition has placed a premium on customer satisfaction (Larson & Gray, 2011: 11) because only successful organizations meet the needs and expectations of their customers more effectively than their competitors, while at the same time generating acceptable financial returns (Strydom & Roodt, 2006: 15). If service quality is poor, health establishments may not be competitive. To measure the competitiveness of a health service organization, it is necessary to analyse not only performance levels, but also the perceived quality of the services provided and the level of customer satisfaction (Battisti et al., 2007: 1). Vilares andCoehlo (2000, cited in Bulgarella, 2005: 2) found that perceived employee satisfaction, perceived employee loyalty, and perceived employee commitment had a sizeable impact on perceived product and service quality. According to Bulgarella (2005), empowered employees are those that have motivational resources to deliver adequate effort and care. These motivational resources can be training, meaningful remuneration, and adequate technology. A functional and supportive work environment is made up of quality equipment and technology (Castro & Martins, 2010). With quality equipment and technology, employees then perceive their organizations as superior to their competitors (Jacobs & Roodts, 2008), thus strengthening their confidence. In fact, Daviaud and Chopra (2008: 49) warn that poorly equipped facilities will negatively impact quality of service. A good work environment is supported by an organisational culture that allows for democratic functioning of the organisation, as well as full opportunities for participation, a sense of identity with and loyalty towards an organisation (Mullins, 2007). Thus managers must be able to show care, interest and empathy towards employees, be able to explain what is expected of them, as well as provide regular and positive feedback and recognition for work well done (Robinson, 2006).
The results of this study indicate that health-related professionals work in high-pressured environments. It might help for health establishments to consider family friendly work environments. Family friendly work environments can include flexible work arrangements, employer supported childcare policies, parental/maternity leave policies. These are expected to reduce absenteeism, stress, role conflict and intention to leave an establishment. In fact, this study argues that family friendly work environments can bring about increased levels of health-related professionalǯs work commitment. Therefore, to provide quality of life to citizens, health-related professionals require a good degree of psychological commitment, which consists of meaning, competence, impact and self-determination (Stander & Rothmann, 2010: 7). According to Michie and West (2004: 94), the three psychological consequences, which are key to predicting valuable functioning and performance at work, are knowledge, skills and motivation. This should represent a situation where health-related professionals are free to apply their skills, knowledge and expertise thus enjoying their jobs. A situation of this nature can spur a sense of pride in employees who will then feel that their work adds value to the organisation. In fact, the findings of Jeon and Choi (2012) are apt here: Employee self-efficacy, perceived fairness in supervisory support and reward allocation positively moderate the impact of employee satisfaction and customer satisfaction. Healthrelated professionals need to experience high levels of job satisfaction in order for citizens of a nation to be guaranteed quality of life. The following can serve important directives for management of healthrelated establishments:  It is critical that health-related professionals should be made aware of what is expected of them through organized communication systems. They produce better when they are clear on how best to meet perform their tasks especially when their tasks have high psychological meaningfulness.  Performance management systems should not only be fair, but should be seen to be so. This is in order to achieve high employee morale and satisfaction.
 Health-related personnel should be integrated in matters that affect them. Integrated leadership can be empowering. When employees are involved in matters that affect them, they feel valued, respected and consequently value their membership of the organization. Formal and informal face-to-face meetings and socialization opportunities can enhance trust and communication among units. Achieving trust requires an environment that acknowledges the informal organizationthe network of relationships that facilitate the accomplishment of responsibilities.  Flexible working hours, child-care utilities, as well recreational facilities can take the stress and strain from the long arduous schedule of the health-related professionals. Hence, they will be able to relax and also find time to spend with their families. Recreational facilities help with socialization at work.  It is important that health-related professionals be made to feel a sense of value both in them and in their jobs. The feeling of self worth comes with comparative remuneration, a sense of fair treatment from management and the perception that the efforts are significantly related to organizational goals. This will help to reduce stress and burnout.