Job autonomy, its predispositions and its relation to work outcomes in community health centers in Taiwan

Health Promotion International, Jun 2013

It has been debated that employees in a government or public ownership agency may perceive less need for growth opportunities or high-powered incentives than is the case for employees in private organizations. This study examined employees’ job autonomy in government-run community health centers, its predispositions and its relation to their work outcomes. A cross-sectional study was conducted in Taiwan. From 230 responding community health centers, 1380 staff members responded to the self-completed, structured questionnaire. Structural equation modeling revealed that employees’ job autonomy has positive work outcomes: greater work satisfaction, and less intent to transfer and intentions to leave. In addition, job autonomy was related to employees’ higher education levels, medical profession, permanent employment and serving smaller populations. Moreover, employees’ age, educational levels, medical profession and employment status were found to be related to their work satisfaction, intent to transfer and intent to leave.

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Job autonomy, its predispositions and its relation to work outcomes in community health centers in Taiwan

Health Promotion International Job autonomy, its predispositions and its relation to work outcomes in community health centers in Taiwan BLOSSOM YEN-JU LIN 2 YUNG-KAI LIN 0 1 CHENG-CHIEH LIN 2 4 5 6 TIEN-TSE LIN 3 0 Department of Business Administration, National Chung Hsing University , Taichung, Taiwan, ROC 1 Division of Cardiovascular Surgery, Taichung Veterans General Hospital , Taichung, Taiwan, ROC 2 School and Graduate Institute of Health Services Administration, College of Public Health, China Medical University , 91 Hsueh Shih Rd., Taichung 404, Taiwan, ROC 3 Sioushuei Township Health Station , Changhua County, Taiwan, ROC 4 Institute of Health Care Administration, College of Health Science, Asia University , Taichung, Taiwan, ROC 5 Department of Family Medicine, China Medical University Hospital , Taichung, Taiwan, ROC 6 College of Medicine, China Medical University , Taichung, Taiwan, ROC job autonomy; community health center; public health-care organization; permanent employee - SUMMARY It has been debated that employees in a government or public ownership agency may perceive less need for growth opportunities or high-powered incentives than is the case for employees in private organizations. This study examined employees’ job autonomy in governmentrun community health centers, its predispositions and its relation to their work outcomes. A cross-sectional study was conducted in Taiwan. From 230 responding community health centers, 1380 staff members responded to the self-completed, structured questionnaire. Structural equation modeling revealed that employees’ job autonomy has positive work outcomes: greater work satisfaction, and less intent to transfer and intentions to leave. In addition, job autonomy was related to employees’ higher education levels, medical profession, permanent employment and serving smaller populations. Moreover, employees’ age, educational levels, medical profession and employment status were found to be related to their work satisfaction, intent to transfer and intent to leave. INTRODUCTION Autonomy refers to a context of accountability, authority and responsibility (Mrayyan, 2006) . Job autonomy can be defined as ‘a practice, or set of practices involving the delegation of responsibility down the hierarchy so as to give employees increased decision-making authority in respect to the execution of their primary work tasks’ [ (Leach et al., 2003) , p. 28]. This perspective views job autonomy as structural empowerment (Kanter, 1993, 1997) through access to information, support, resources and growth opportunities that directly affect workers’ level of control. According to Herzberg’s motivation-hygiene theory, job autonomy is a factor that motivates employees (Herzberg et al., 1969) . In the Job Characteristics Model, job autonomy is viewed as one of the core task characteristics (i.e. task variety, task identity, task significance, autonomy and feedback), the elements that positively affect employees’ psychological states and thus lead to better work consequences including higher intrinsic work motivation, quality of performance and work satisfaction and lower absenteeism and turnover (Hackman and Oldman, 1975) . In addition to the theoretical arguments, previous empirical studies have shown that job autonomy is positively related to job involvement, satisfaction, general health and well-being and employees’ motivational and metacognitive learning processes (Probst et al., 1998; Demerouti et al., 2000; Spence Laschinger et al., 2001; Barling et al., 2002; Thompson and Prottas, 2006; Wielenga-Meijer et al., 2010) . Job autonomy also is viewed as a protection against negative outcomes for those individuals who use emotional work strategies (Johnson and Spector, 2007) to counter the stress of high job demands (Spoor et al., 2010) , and it is related to less turnover (Parsons et al., 2003) . Moreover, increased job autonomy is related to increased task variability and more customized care for patients (Streit and Brannon, 1994) . It has been debated that employees in a government or public ownership agency may perceive less need for growth opportunities or high-powered incentives than is the case for employees in private organizations (Dixit, 1997) . On the other hand, it was argued that in pubic organizations, more participation in decision-making, less political penetration, more respectful and supportive supervision and more opportunities for advancement are factors in employees’ commitment to their organizations (Balfour and Wechsler, 1996) . As public health-care organizations, Veterans Health Administration centers have appreciated the value of high-involvement work systems, characterized as a holistic work design of these interrelated core features: involvement, empowerment, development, trust, openness, teamwork and performance-based rewards. These features were found to be associated with both greater employee satisfaction and lower costs for patient services (Harmon et al., 2003) . Also, the attempt in the primary care trust (PCT), part of the National Health Services (NHS) in England, which is the publicly funded healthcare system, to make employees more autonomous was seen as a strategy to increase organizational control. However, it was also argued that tensions can arise between the promotion of a discourse of autonomy versus the need to control employees to achieve centrally determined objectives efficiently, or by creating expectations that are not fulfilled. The introduction of a discourse of autonomy in this case left staff feeling undervalued and demoralized (McDonald and Harrison, 2004) . Community health centers in Taiwan are government-run. They are the first line of primary care providers, responsible for national disease prevention and providing primary care services in their communities. This study recruited employees at government-run community health centers as a study sample to explore how the extent of employees’ job autonomy might be related to their work outcomes (Figure 1). Hypothesis 1: In the community health centers, the extent of staff members’ job autonomy is related to their job satisfaction, intent to transfer and intent to leave, controlling for the staff members’ personal and working status. Moreover, it has been argued that government-run health-care organizations may be relatively bureaucratic and hierarchical and thus may obstruct participatory decision-making (Rainey, 2009) . However, lower-level members of public organizations can have substantial power, i.e. autonomy, through their own efforts, interests or informal coalitions (Rainey, 2009) . Studies have shown that employees’ personal and job-related characteristics influence employee autonomy (Alexander et al., 1982) . Among such influences are gender (Schulz and Schulz, 1988) , age (Stuart et al., 2000) , professionalism (Allgood et al., 2000) , permanent employment (Han et al., 2009) and working in rural areas (Ulmer and Harris, 2002; Bigbee et al., 2009) . Therefore, the study sample was recruited also to explore how the extent of employees’ job autonomy might be related to their predispositions, that is, their personal characteristics and working status (Figure 1). Hypothesis 2: In the community health centers, staff members’ predispositions (i.e. personal characteristics and working status) are related to the extent of job autonomy. METHODS This was a cross-sectional study with individual staff members in community health centers as the unit of analysis, conducted in 2005. The staff members in the recruited community health centers were surveyed using a selfcompleted questionnaire about the extent of their job autonomy and their work outcomes, personal characteristics and working status. The subjects, measurements and analytical techniques are described as follows. Subjects For this study, the researchers first asked the executive directors of the community health centers whether they were willing to join the study. Two hundred and thirty community health centers, in the study population of 348 community health centers voluntarily participated in this study, for a facility response rate of 66%. The personnel in community health centers can be categorized as of two types: medical staff including medical/dental doctors, public health nurses, medical technologists and pharmacists, all with medicine-related professional licenses; and non-medical staff including public health inspectors and administrative staff. An executive director is the top authority at each community health center. The numbers of personnel vary among the centers, depending on the budgets of city and county governments, rural or urban location, population demographics, economics and medical resources (Bureau of Health Promotion, Department of Health, Taiwan). A 2006 report indicates that on average there were 13 staff members per community health center in 2005 (Annual Report for County and City Community Health Centers published in 2006) . The centers’ executive directors distributed the survey questionnaires to their staff members. Six members of each center, around half the average number of staff in the population of centers studied, were sampled. To avoid selection bias, the rule set for the executive directors of the community health centers in choosing the surveyed staff members was to choose from among the medical staff and from among the non-medical staff, those with the next three birthdays. If a selected staff member declined to participate, the replacement was the staff member with the next birthday. If the medical staff recruited were too few, the vacancy could be filled by non-medical staff, and vice versa. To preserve respondent confidentiality, the surveyed staff returned the completed questionnaires in sealed envelopes to the executive directors, and the researchers then collected them. It deserves mention that the executive directors’ assistance in administering the survey might suggest some process bias as a study limitation. All the research processes were monitored by the Bureau of Health Promotion, Department of Health, ROC for ethics and legal data use. With 230 responding community health centers, a total of 1380 staff members responded to our survey. That sample total is 31% of the 4392 personnel (of the 348 community health centers as study population) in Taiwan community health centers in the surveyed year, 2005. Measurement Employee job autonomy To examine the task dimensions of job autonomy and to capture their roles in community health centers, six executive directors from a range of professions: medical, dental, nursing, pharmacy, medical technology and administration were interviewed to identify the tasks that employees at community health centers might perform. The interviews sought to capture practical and actual scenarios in the dynamics of the community health centers. These interviews helped us to check the validity of the study measures and to assess the practical measures of employee job autonomy. The drafted questionnaire was corrected by employees in the community health centers for their suggestions before its final version was released. The criteria of employee job autonomy were developed separately for the individual and organizational levels. The six items for the individual employee level were (i) scheduling one’s own activities, (ii) exercising autonomy over one’s own money resources, (iii) serving the intended customers, (iv) having opportunities for self-rated performance appraisal, (v) providing opinions about one’s own disciplines and rewards and (vi) arranging and designing one’s own job contents. The eight items at the organizational level were (i) planning and using the government-funded budgets for the community health center, (ii) planning and using the community health center’s revenue from medical services, (iii) scheduling the community health center’s activities, (vi) distributing the community health center’s money resources, (v) planning which customers the community health center would serve, (vi) making decisions about the community health center’s employee performance appraisal, (vii) making decisions about the community health center’s employee rewards and disciplines and (viii) arranging and planning the community health center’s employees’ tasks. All the survey items were answered a five-point Likert scale as never, seldom, sometimes, often or always authorized. Factor analyses were performed for the measured indicators for job autonomy, with factor loading 0.774 – 0.870 at the individual level and 0.769 – 0.898 at the organizational level. The Cronbach’s a values are 0.919 for job autonomy at the individual level and 0.930 for job autonomy at the organizational level. Employee predispositions: personal characteristics and working status Several personal characteristics of employees and aspects of their working status were measured as possible determinants of employee job autonomy or confounders of work outcomes (Lu et al., 2007; Li et al., 2008; Han et al., 2009; Ning et al., 2009) . These characteristics were: a staff member’s age, gender, education, professional occupation (medical staff versus non-medical staff), working experience in years and employed status ( permanent versus fixed-term employment) and the population of the served areas. Employee work outcomes Employee work outcomes: work satisfaction, intent to transfer and intent to leave the employment of community health centers were included in this study. Work satisfaction of a community health center’s employees was measured by one question item about employees’ work satisfaction in overall (Stone et al., 2005; Lin et al., 2008) . It was measured on a score of 0 – 100 with higher score higher work satisfaction and with 50 as the mid-point. One question item was used to measure employee intent to transfer (Ma et al., 2009) to another community health center, measured as 0 – 100 scores with higher score higher intent to transfer and with the score 50 as the mid-point. One question item was used to measure employee intent to leave the employment (Lin et al., 2008; Ma et al., 2009; Nakanishi and Imai, 2011) at the community health centers, measured as 0 – 100 scores with higher score higher intent to leave and with the score 50 as the mid-point. The detailed definitions of the studied variables mentioned in this section are summarized in Table 1. Analytical techniques The data were analyzed using the descriptive statistics of means, standard deviations, frequency and percentages. Missing data in the job autonomy measures for individual respondents were filled by the method of linear regression interpolations. Then structural equation modeling (SEM), also known as Linear Structural Relationships (LISREL) or the covariance structural model, was employed. SEM has two parts: the validation of the measurement model and the causal confirmation of the SEM. The measurement model assesses how well the observed indicators can work as measurements of the latent variables; the SEM seeks to identify any causal relationships between the exogenous and the endogenous variables, that is, testing the proposed hypotheses. The maximum likelihood estimation procedure used in the SEM assumes that the data have a multivariate normal distribution. The violation of the assumption of normality may bias the statistics and the standard errors of the parameter estimates, yet not affect the parameter estimates themselves because a correlation matrix is used (Long, 1983; Sharma, 1996) . The skewness statistic, kurtosis statistic and one-sample Kolmogorov – Smirnov test for all study continuous variables were used to examine whether a variable has a normal distribution. These statistics revealed that all the study’s continuous variables had the problem of normality. Since there is no one standard for handling normality, and the most important thing is to determine whether the standard deviation or variance is too large, the continuous variables were transformed (divided by 100 to minimize standard deviation). The SEM analysis comprises model construction, parameter estimation of the model, test of the fit of the model and model modification (Bollen, 1989; Jo¨ reskog and S o¨rbom, 1989) . The hypotheses were empirically examined using a two-tailed test for statistical significance at the 0.05 level or lower. Satisfactory model fit includes the following: (i) a non-significant Chi-square test ( p . 0.05); (ii) mean square error of approximation (RMSEA) values ,0.08; (iii) P_CLOSE (close fit) values .0.05; (iv) Hoelter’s critical n values .200 and (v) normed fit index (NFI) and comparative fit index (CFI) for model goodness-of-fit .0.90 (AMOS 6.0 User’s Guide). Two measurement models were formed: the constructs of employee job autonomy at the organizational level, and of employee job autonomy at the individual level. The SEM specifies the causal relationships, which here were the relationships of staff members’ personal characteristics and working status with the extent of their job autonomy and the relationships of staff members’ extent of job autonomy with their work outcomes, adjusting for their personal characteristics and working status. It deserves mention that the data in this study could be analyzed by multilevel analysis if there were variations in community health centers such as cluster effects. However, a check of the intraclass correlation coefficient (ICC) index for the individual endogenous variables: each item of employee job autonomy, work satisfaction, intent to transfer and intent to leave (all ICCs ,0.001) found that all the ICC values are ,0.05, which is the minimum cut-off point for performing multilevel analysis. Given that circumstance, it is suggested that the multilevel effects in this data set could be ignored (Bliese, 2000; Cohen, 1988) . The statistical analyses in this study were performed using SPSS 12.0 software and AMOS 6.0. RESULTS Of the 1380 staff members, from 230 community health centers who responded to the survey, 80% were female; the average of age of the staff members was 40. Of the staff respondents, the percentage of medical staff (52%) was slightly higher than that of the non-medical staff (48%). Seventy percent of staff had technical college degrees. On average, the respondents had worked for 10 years in their community health centers. Eighty percent of staff were permanent employees. Fifty percent served in community health centers with community populations of ten thousand to fifty thousand. With 0 – 100 scoring for work outcomes, on average respondents scored work satisfaction at 70 points, intent to transfer to other community health centers at 29 points and intent to leave at 30 points. Other details are listed in Table 2. Measurement models of employee job autonomy In this study, two measurement models were validated for employee job autonomy: one at the organizational level and the other at the individual level. The measurement model for employee job autonomy at the organizational level was measured by eight indicators and that at the employee level by six indicators. All the factor loadings, or standardized regression coefficients, between the models’ observed variables and their corresponding latent constructs were significant at the 0.001 level (Table 3). Overall both models showed good model fit, with Chi-square/df of 5.283 ( p ¼ 0.000), RMSEA value ,0.08 (0.058 in this study), PCLOSE value .0.05 (0.248), Hoelter’s critical n values .200 (491) and NFI and CFI for evaluating the goodness-of-fit .0.90 (0.995 and 0.996, respectively) for employee job autonomy at the organizational level. For employee job autonomy at the individual level, those values were: Chi-square/df of 0.087 ( p ¼ 0.967), RMSEA value ,0.08 (,0.001), PCLOSE value .0.05 (1.000), Hoelter’s critical n values .200 (41 435), NFI and CFI for evaluating the goodness-of-fit .0.90 (both 1.000). The two validated measurement models: job autonomy at the organizational level and job autonomy at the individual level were retained for the testing of the causal model. Causal model of job autonomy: its predispositions and work outcomes (hypotheses testing) After the two measurement models were validated, SEM was performed to test the causal relationships. Employee job autonomy both at the organizational level and at the individual level is related to higher employee work satisfaction, lower intent to transfer to other community health centers and lower intent to leave (Hypothesis 1, p , 0.05). Moreover, the results revealed that higher educational level, medical professions and permanent staff are positively related to job autonomy for both organizational tasks and individual tasks. In addition, it was showed that at the organizational level of job autonomy, community health centers’ staff who work in communities with greater populations have less job autonomy (Hypothesis 2, p , 0.05). Also, certain personal characteristics and working status were shown to influence work outcomes to some extent (statistical significance at a 0.05 level). That is, older employees and those with longer work experience have less intent to transfer and/or leave; however, those with more education have more intent to transfer and intent to leave. Medical staff reported less work satisfaction than other staff did as well as more intent to transfer from their community health centers and intent to leave. Permanent employees have less work satisfaction and more intent to transfer to other community health centers than fixedterm employees do. Overall model fit in this causal model was shown to be good, with Chi-square/df of 4.878 ( p ¼ 0.000), RMSEA value ,0.08 (0.053 in this study), PCLOSE value .0.05 (0.069), Hoelter’s critical n values .200 (332), and NFI and CFI for evaluating goodness-of-fit .0.90 (0.950 and 0.960, respectively). Detailed information is shown in Table 4. Indicators Regression estimation lambda Critical ratio (CR) Squared multiple correlation DISCUSSION With the individual employee of a community health center as the unit of analysis, this study sought to determine how job autonomy is related to these work outcomes: work satisfaction and intent to transfer from or intent to leave the present work setting; and also what factors are related to employee job autonomy. For the 1380 staff members at community health centers responding, employees with autonomy in both organizational and individual tasks were found to have positive work outcomes: more work satisfaction and less intent to transfer and intent to leave (Hypothesis 1). Moreover, greater employee job autonomy is related to higher education level, medical profession, permanent employment and serving smaller populations (Hypothesis 2). In addition, it was found that employees’ age, educational level, medical profession, working experience and employment status also were related to their work outcomes: work satisfaction, intent to transfer and intent to leave. This study found that in the community health centers the extent of staff job autonomy is positively related to work satisfaction. Like previous research that has verified theories of job autonomy in the health-care industry with regard to other health professionals, this study has verified that among the staff of community health centers, the benefits of employee job autonomy are better work satisfaction and less intent to leave. Campbell et al.’s survey found that public health nurses’ work environments where supervisors and subordinates consult together about job tasks and decisions and where individuals are involved with peers in making decisions and defining tasks are positively related to job satisfaction (Campbell et al., 2004) . Executive directors of public community health centers should take note that their employees value job autonomy, which is also strongly emphasized in motivation theories. In this study, employees’ job autonomy in individual tasks has a higher standardized coefficient (g ¼ 0.17, p , 0.001) than that for their organizational job autonomy (g ¼ 0.08, p , 0.05) on their work satisfaction. Bateson argued that in business, boundary-spanning employees are more able to satisfy their customers when they have control over their service encounters (Bateson, 1985) . It could be argued that, similarly, granting employees in community health centers autonomy for their individual tasks may increase their ability to respond effectively in the public health environment, and especially in community health centers, where they have face-to-face interactions to provide their served population with primary care and to promote heath. Moreover, there is a need for professional development to support public health workers to engage with empowerment and self-efficacy in their practical works (Cawley and McNamara, 2011) , given the organizational structure of community health centers. This study found that employees, who have higher education levels, are medical staff (versus non-medical staff ), and are permanent staff (versus fixed-term staff ), have somewhat more autonomy for both organizational and individual tasks. It might be that executive directors trust employees with formal education more for performing organizational tasks because of their professional currency. Also, strategic contingency theory argues that a department with abilities to deal with uncertainty, work centrality and lower skill substitutability has more power than others do (Hickson et al., 1971) . Since medical professionals have more control over the community health centers’ primary care and health promotion, it may be rational for community health centers’ medical professionals to be given more discretion and participation in decision-making. In addition, medical staff members in the community health centers were found to have more job autonomy, especially in individual tasks (g ¼ 0.27, p , 0.001) when compared with organizational tasks (g ¼ 0.08, p , 0.05), though both levels of job autonomy were higher than those for the nonmedical staff. The study found that permanent staff in the community health centers have more job autonomy than the fixed-term staff have. This result is similar to that of Han et al.’s study of nurse empowerment, which found a higher level of autonomy for permanent nurses than for temporary nurses (Han et al., 2009) . Kuokkanen and Katajisto found that short work periods deter employee empowerment, and that career consciousness increases empowerment (Kuokkanen and Katajisto, 2003) . It has also been pointed out that temporary workers may have little voice or little room for negotiation in specific assignments (De Cuyper et al., 2009) , and that employees with more tenure in an organization feel more empowered (Koberg et al., 1999) . It seems likely that employees with more tenure would be more experienced and so more trusted, and also would better understand the organizational culture and leaders; thus they would be likely to have more job autonomy. Another explanation would be that since permanent employees have more job security and work period stability (De Cuyper et al., 2009), executive directors in the community health centers give them more authority and responsibilities. This study found that the staff members in centers with larger community populations have less job autonomy. The reason may be that serving a larger community distracts staff members from organizational tasks because of their greater burdens in providing health services. Also, the community health centers serving larger populations have more formalized structures, which could reduce the opportunities for staff participation in organizational tasks. Furthermore, the community health centers serving smaller populations, usually categorized as rural, may have limited human resources to draw on for health and medical services, and so need to compensate by empowering staff in order to gain more efficiency. It is worth noticing, however, that those staff members with more education, medical professions and permanent employment reported more negative work outcomes: less work satisfaction, more intent to transfer to other community health centers or more intent to leave. Studies have explored permanent employees’ organizational behaviors in terms of work satisfaction, productivity and health, with varying results. For example, Liukkonen et al. prospective cohort study of 6028 public sector employees in Finland found that fixed-term employment predicted better self-rated health and less psychological distress, when compared with permanent employment (Liukkonen et al., 2004) . On the other hand, Han et al. study found that permanent nurses reported higher levels of job satisfaction (Han et al., 2009) . We might argue that fixed-term employees may simply have lower workloads (Virtanen et al., 2003) , or they may expect less of their careers in community health centers than permanent employees do (De Cuyper et al., 2009) , and thus have better work satisfaction. Further studies could examine what lies behind the influence on employees’ psychology of higher education levels, medical profession and permanent employment, in order to guide the creation of friendlier working environments in the public community health centers. Job autonomy can be measured in several ways. Traditionally, a ‘job’ is usually viewed as a whole without tasks being specified (Bakker et al., 2004; Morgeson et al., 2005) . Because of the unique characteristics of community health centers in Taiwan, this study focused on task-oriented or specified ways to describe employee job autonomy. Task-oriented job autonomy descriptions can be useful as practical guidance for top managers/executives. Further studies, however, might focus more on the psychological perspective (Manojlovich, 2007) of the staff members of community health centers, given the prevalence of formal hierarchies in public primary care organizations. 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Lin, Blossom Yen-Ju, Lin, Yung-Kai, Lin, Cheng-Chieh, Lin, Tien-Tse. Job autonomy, its predispositions and its relation to work outcomes in community health centers in Taiwan, Health Promotion International, 2013, 166-177, DOI: 10.1093/heapro/dar091