The Determinant Factors Effecting the Job Satisfaction and Performance in Libyan Government Hospital

Job satisfaction and Job performance are two variables that affect the efficiency and service quality in organizations. This study shows that the performance of medical staff and medical service quality in hospitals could be enhanced when employees are satisfied and are well treated by their managers in addition to good salaries and effective incentive system. The study attempts to understand the nature of job satisfaction in hospitals and its relationship to job performance. Therefore, it aims to evaluate the factors that affect job satisfaction and improve the performance of human resources in government hospitals in Libya. Two approaches were applied (descriptive and quantitative) because they complement each other and also because using both approaches will help to make more accurate conclusions about the study variables. This paper identified four factors; work comfort, work treatment, salary, incentives, and evaluated their impact on job satisfaction of the medical staff working in government hospitals in Libya.


Introduction
Job satisfaction is a psychological sense of confidence and satisfaction to fulfill personal needs, desires and expectations with the work itself and the work environment, and loyalty to work (Schultz, 2010;Thompson et al., 2012).
Job Performance is a degree of achievement and the completion of tasks required by the organization.Job performance reflects how employees and workers achieve or fulfill the requirements of the job (Dalal, 2008).
An incentive is something that motivates an individual to perform an action, and it is a set of influences that is used to raise the motivation of the individual, and thus to determine the level and form of behavior by providing opportunity for the individual to satisfy the needs that drive motives (Roberts, 2006).
The human resources in organizations in general and hospitals in particular is the most important success factors that is responsible to provide high-quality medical services which is the basis of health care and the scale of the success of any hospital in the delivery of excellent services to its customers (patients) in order to achieve satisfaction by them (Hassan & Fuadah, 2014).
The performance of employees in organization is similar to behavior.It is something done by the employee and reflects on the organization's outcome (Campbell, 1990).Outcomes are the result of an individual's performance, but they are also the result of other influences (Karriker, 2009).There are many factors that affect the performance of employees in any organization such as job satisfaction and organization behavior.Campbell (1990) allows for exceptions when defining performance as behavior.For instance, he clarifies that performance does not have to be directly observable actions of an individual.It can consist of mental productions such as answers or decisions.However, performance needs to be under the individual's control, regardless of whether the performance of interest is mental or behavioral (Marina, 2006).
The attempt to understand the nature of job satisfaction and its relationship to job performance is not an easy task.For at least 50 years scholars in the social science and business management have been trying to answer the questions associated with the relationship between job satisfaction and job performance.This study assumes that the factors that affect job satisfaction will reflect on job performance positively or negatively.Factors such as incentives, work treatment, salaries, and work comfort will raise job satisfaction and then job performance as well.
Researchers have taken a lot of effort to demonstrate that a happy worker is a good worker that can produce good performance to the organization (Borman, 1993;Sackett, 2001;Schmidt, 1998).Although this sounds like a very reasonable conclusion, the results of empirical literature are too mixed with regard to the prediction that better job satisfaction leads to better performance and vice versa, or even that there is a strong positive correlation between these two variables (Kacmar, 2009;Erez, 2001).This paper endeavors to discuss the impact and relationship of job satisfaction on job performance in Libyan hospitals.This paper emphasizes on the importance of the value of this relationship to health organizations.

The Background of the Study
The human factor in organizations in general and hospitals in particular, is the main success factors for medical and health institutes to provide high-quality medical services, which are the basis of healthcare and the scale of the success of any hospital in the delivery an excellent medical service to its customers (patients) in order to achieve patients and staff satisfaction (Harem, 1997).
Many studies and government reports have pointed out the apparent negligence in managing personnel and medical staff in public hospitals, this situation leads to poor performance by the hospital staff, and this was the main causes of the weakening of the level of human resources management in these hospitals (Spector, 2002;Edwards & Fisher, 2007;Kacmar et al., 2009).
The government hospitals in Libya suffered from low performance due to low job satisfaction, which was a realistic result of low salaries and absence of incentives and training programs to the medical staff as well as the management employees.Most of the medical staff and employees felt they were neglected by the senior management in government hospitals.This situation led to low job satisfaction and low job performance by most the medical staff and employees.This study will discuss the low job satisfaction levels and weak job performance due to lack of training programs and plans to improve the medical skills and job satisfaction of the medical staff in government hospitals, which was reflected by their performance and the vast difference with regard to job performance in private hospitals or hospitals in neighboring countries.

Literature Review
The relationship between people and work and their performance, including work and job satisfaction, has been intensively researched since the beginning of the previous century.Job satisfaction is found to be significantly linked to absenteeism (53) and turnover (Hackett, 1999).There is evidence that job satisfaction positively influences loyalty towards organizations (Organ, 2006).The direct link between job satisfaction and performance is found to be unequivocal (Vroom, 2008) despite the fact that the direction of causal relationship between individual's performance and job satisfaction is disputable.This means whether happy workers are productive workers or vice versa.
However, in recent years, managers and industrial/organizational psychologists tend to define satisfaction as a job attitude, along with other attitudinal concepts, such as morale, job involvement, and organizational commitment.Spector (2002), for example, refined job satisfaction as an attitudinal variable that measures how a person feels about his or her job in general, and also how he or she feels about different facets of the job.In their definitions Lofquist and Davies (1996), and Price (2001) focused on these affective components of attitudes.They described job satisfaction as the affective orientation that an employee has towards his or her work.
Taking into account that customer satisfaction is a top priority outcome of ISO 9001 based quality systems and patient satisfaction forms one of the main outcomes for quality for patients in healthcare and job satisfaction in healthcare settings has been found to have a strong direct correlation with patient satisfaction.Job satisfaction is an important organizational variable in all settings and especially in healthcare settings.Hence it has become an integral part of the theories of motivation and dedication to work and serves as an important object of study for various organizations and professions.
Job satisfaction is a multidimensional, enduring, important and much researched concept in the field of organizational behavior (Bassett, 1994).The concept is an outgrowth of the human relations movement that began with the classic Hawthorne studies in the late 1920s.There is a lack of consensus as to what job satisfaction is (Hall, 1986), and how the job satisfaction of employees should be assessed.Buss (1988), for example, described job satisfaction as an employee's perception that his or her job allows the fulfillment of important values and needs according to Siegel and Lane (1982).Locke's (2006) discrepancy theory, on the other hand, explains job satisfaction in terms of needs.It focuses on satisfaction and dissatisfaction with a job, and states that satisfaction, or dissatisfaction, with some aspect of a job depends on the perceived congruence or discrepancy between desires (needs) and outcomes (what is received), and the importance of what is wanted.Overall job satisfaction is the sum of each of the aspects of the job multiplied by the importance of the aspect for a person.
Marina Kaarna (2007) found that executives and HR managers in a health care institution that are informed about the expectations and daily work-related problems of their employees are better able to understand the needs of their employees.Executives and managers in hospitals should build effective relationships between with staff; and identify negative working conditions which affect staff; and appropriately delegate authority to personnel, and hold them accountable for work done in their organizational units; and finally keep staff informed about changes that will affect them and express appreciation and recognition for the efforts of staff members in accomplishing the work of the health care organization.In doing this, executives and HR managers will create a favorable working environment for the hospital staff.
Job satisfaction is a complicated concept that is affected by many factors within the organization (Wicker, 2011).Additionally, it can mean different things with different impacts on different people.Job satisfaction is usually linked to salaries, incentives and work treatment (Borman, 1993).The nature of this relationship is not clear to many scholars and there does not seem to be a common agreement among them.Although satisfaction is not the same as motivation, they are closely related and could be clear when employees receive incentives which are one of the elements of motivation.Job satisfaction is an internal state of personality and closely related to personal attitude (Herzberg, 1963).It could, for example, be associated with employee's feeling when he or she achieves something from his/her organization.In recent years the attention to job satisfaction has increased and become more associated with improving job environment and the quality of working life as well as comfort in work and increasing the salary.Edwards (2007) found that the work environment also matters and it affects job satisfaction and job performance directly.Contrary to some commonly held practitioner beliefs, the most notable situational influence on job satisfaction is the nature of the work itself.
The relationship between job performance and job satisfaction is a continuous debate and argument between scholars.One of the opinions, associated with the early human relationship, is that better satisfaction leads to better performance (Lise, 2004).An alternative view is that job performance leads to job satisfaction (Saari, 2002).This study will examine the main factors that affect job satisfaction in hospitals and examine why job performance is improved if employees were satisfied.

The Problem Statement
Libyan hospitals suffered for decades from a distinct lack of medical expertise and medical staff with good performance, and lack of professionals in medical care and weak training for most employees lead a situation of very poor medical services, however, this situation let the management of many hospitals in Libya to bring professional staff in medical care from outside Libya to cover the lack of expertise and improve the overall performance of Libyan government hospitals.This led to high amounts of money paid to foreign employees and medical staff.The same money could be used to pay for training programs to develop the performance local staff.
One of the main problems that will be discussed in this study is the poor job satisfaction among medical staff and employees working in government hospitals in Libya due to many reasons such as bureaucratic obstacles and low salaries and incentives that have caused an increasing number of Libyan patients to seek better medical treatment and healthcare outside Libya.It has also attracted foreign expertise demanding high salaries that use up funds which could be better spent on improving performance of local medical staff and employees.

The Research Objectives
1) To evaluate the factors that affect job satisfaction and job performance of human resources in Libyan government hospitals 2) To examine the relationship between job satisfaction and job performance in Libyan government hospitals 3) To make recommendations to improve the current job satisfaction and job performance in government hospitals in Libya.

The Contribution of This Research
The importance of job satisfaction on the performance of employees and medical staff in hospitals is essential for all healthcare institutes and hospitals where job satisfaction is one of the important factors in influencing the quality of the health service provided to patients.This study contributes to enhance the quality of medical service and improving the job performance of medical staff and employees in government hospitals through improving the current low job satisfaction.Human resources in any modern organization reflects the wealth of humanity or service productivity, which is the main component of outcome of personnel and most importantly understanding the importance of specific factors that influence employees' satisfaction and this is reflected on their performance.
This study contribute to the literature in the field of human resources in medical institutes and shows the impact of specific factors on the overall performance and improving the medical services of hospitals and medical institutes.According there are few studies that cover this topic in Libya and this study will provide important conclusions and results that contribute to future studies on this subject.

The Study Hypothesis
1) There is a statistical direct relationship between job satisfaction and job performance 2) Incentives, salaries, and work treatment are positively correlated to job satisfaction

The Research Methodology
In this study we used a mix of descriptive and quantitative approaches because the two complement each other and also using the two approaches will help to make accurate conclusions about the study variables which are job satisfaction and job performance.
The descriptive research will be used in this study in the earlier phases of the research.This approach relies on books, journals and reports, and previous studies associated with each configuration of job satisfaction and job performance for the purpose of the research.The next part of the research is where quantitative approach will be applied.The descriptive methodology is used in order to explore and understand the impact of incentives and salaries on job satisfaction.
The reason why quantitative approach in the next stage of this research is to help the researcher to have a better understanding depending on statistical tools in order to predict the impact of job performance on job satisfaction on the medical service quality in government hospitals in Libya.The quantitative approach can provide more accurate results that cannot be predicted using the descriptive approach only, therefore using quantitative analysis which will provide high reliability to the final conclusion of the study.The population in this study includes all managers, medical staff, and employees working in a government hospital.The number of participants of the survey is 179, and the researcher chose a Tripoli government hospital where a random sample will be selected.

Results and Discussion
The study included the main factors that affect job satisfaction of human resources in a Tripoli hospital.These factors are work comfort, work treatment, salary and incentives.The study assumes these factors play an important role in improving and raising the level of job satisfaction and improve job performance of employees and medical staff.Therefore the study has focused on these factors and measures each factor separately in order to reach a precise conclusion about the reality of job satisfaction among employees and medical staff in a Tripoli hospital.The questions submitted to the consumers and the results obtained are discussed in the following sections.

Work Comfort
The study measured the impact of work comfort on the employees and medical staff in their work environment.The result showed that among the 179 participants; (6 employees strongly agree, 16 employees tend to agree, 60 employees undecided, 65 employees tend to disagree, 32 employee strongly disagree), The overall percentage of employees as follow; (2.80% strongly agree, 9.50% tend to agree, 33% undecided, 36.30%tend to disagree, 18.40% strongly disagree) as shown in Figure 1 below.

Figure 1. Work comfort in Tripoli hospital
The chart above in Figure 1 indicate that more than 36.31% of employees are relatively unsatisfied and do not feel comfortable at work and the standard deviation from this point is very low (0.98749).The unsatisfied were strongly supported by 18.40%, which indicate to strongly disagree and 33.51% undecided about their work environment.The mean value of job satisfaction equals 3.581>3, which indicates that work comfort is below the minimum standard required at a work environment as shown in the chart below (Figure 2).

Figure 2. Variation of work comfort between the participants
It is significant to know that only of 2.8% are comfortable with their work.This result shows the need for immediate reactions from the HR managers and managers of the Tripoli hospital to raise the job satisfaction to optimum levels.The result in this survey is identical with the study's hypothesis H1 because the majority of employees tends to unhappy with the current working environment and generally feels uncomfortable.

Work Treatment
The study measured the treatment that employees and all working individuals in the hospitals receive from their human resources managers; the level of work treatment is highly affecting job satisfaction of employees and medical staff.This in turn affects their ability to fulfill the commitment in doing their medical service to the patients in the hospital.
The results showed that among the 179 participants; (0 employees strongly agree, 24 employees tend to agree, 56 employees undecided, 75 employees tend to disagree, 24 employee strongly disagree), The overall percentage of employees as follow; (0% strongly agree, 13.4% tend to agree, 31.3%undecided, 41.9% tend to disagree, 13.4% strongly disagree) as shown in Figure 3   We include a question in our survey to measure this treatment inside Tripoli hospital locations.The result showed that 41.89% stated they receive bad treatment and 13.40% indicate they are strongly unhappy with the treatment they receive from their managers in the hospital and the total percentage of those respondents who were not happy and satisfied with treatment at job site equals 55.30% which is more than acceptable to ensure standard health business environment inside the Tripoli hospital that push the performance of human resources to peak.
As shown in Figure 3 above, a percentage of 31.3% of employees indicated their uncertainty about the treatment and the standard deviation was also low at 0.8876 and which make this group more close to the mean (3.5531) and more likely to disagree with the treatment they receive at work from HR managers and managers.None of the participants indicate receiving any good treatment from their HR managers and managers.
There researcher sees that if employees are loyal to their Tripoli hospital and provide outstanding performance at Tripoli hospital sites, they must receive reasonable good treatment and respect from their HR managers.The loyalty improves employee performance and, as a consequence, increases revenues to the Tripoli hospital health organization.The subject of job treatment should be of high interest because of its influence on job related behaviors like productivity, personnel turnover.

Incentives
The incentive factor (which is called satisfier) is said to sustain job satisfaction and make employees more pleased about their job.The researcher believes the satisfaction coming from incentives will positively reflect on individual's performance in Tripoli hospital according to psychological theories and then increase the annual revenue of these hospitals and improve its medical services.
The obtained results in our survey showed that incentive system was ineffective in Tripoli hospital, and this situation led to many complains by employees and medical staff.
The study measured the incentives that employees have received in the past.The result showed that among the 179 participants; (0 employees strongly agree, 6 employees tend to agree, 53 employees undecided, 67 employees tend to disagree, and 53 employees strongly disagree).The overall percentage of employees a ras follow; (0% strongly agree, 3.40% tend to agree, 29.60% undecided, 37.40% tend to disagree, 29.60% strongly disagree) as shown in Figure 4   The mean value (3.9330 ≈ 4) means that most of the employees in Tripoli hospital tend to disagree with the current incentive systems and other opinion near cluster to the mean and share the opinion because the standard deviation is small (0.85195<1).
Incentives are one of the main factors that increase and improve performance at any health organization.The senior management of Tripoli hospital neglected the impact of this factor, which is reflected negatively on the poor medical services given to the patients.The result obtained is shown above in (Figure 4) illustrating that the incentive systems in Tripoli hospital was nearly non-existent and the major percentage of employees revealed no incentives have been given to them in the past with increase the reliability of study hypothesis regarding the impact of specific factors such incentives on job satisfaction and the performance of medical staff.Therefore, the senior management in Tripoli hospital should give the medical staff and all employees the needed motivation without discrimination to work better through effective incentive system, doing this will push all individuals in the hospital to work better and give their best output to their health organization in order to get more rewards from the management of the hospital.
The chart in Figure 4 below showed that 37% of employees tend to disagree with the current incentives, and 30% strongly disagree with the current incentives, if we consider both percentages which will be equal 67% those employees who are not receiving any considerable incentives in the past and they showed their opinion about the incentive system clearly in this survey.
Only 3% tend to agree with the current incentive system and this small percentage represent interpersonal relations action according to Herzberg theory (1959).Few people get the advantage of incentives due to strong relations with HR managers and top management in Tripoli hospitals.This action produce work discrimination and it is negatively affecting the relations between employees badly.Some employees complained the small percentage employees benefitted from these systems are not doing the job well and they received these incentives because of their interpersonal relations.
Figure 5 below shows the deviation factor equal to (0.851) which is very small and the slope is not sharp from the mean value (3.93).The chart shows that most of employees tend to have common opinion in respect to the incentives and they were not happy to be treated in this way without encouraging incentives for their work during the past years.

Salaries
The study measured the salaries paid for employees and medical staff during their past period working in Tripoli hospital.
The result showed that among the 179 participants; (0 employees strongly agree, 0 employees tend to agree, 36 employees undecided, 89 employees tend to disagree, and 52 employees strongly disagree).The overall percentages of employees are as follow: (0% strongly agree, 5.60% tend to agree, 22.90% undecided, 43.60% tend to disagree, 27.90% strongly disagree) as shown in Figure 6 below.The mean value (4.0894) and the standard deviation (0.69739), we conclude from this result that the majority of employees (total number = 128 employees) either disagree or strongly disagree about the current salaries given to them.This is a clear indication that in order to improve job satisfaction, the management in the Tripoli hospital hospitals should consider increasing the salaries as the first step towards improving employee's conditions.
The impact of salary on job satisfaction is higher than other factors.The survey indicated two questions to measure the salary impact on employee's satisfaction.The result showed that about half of participants (49.72) were not satisfied with their salary, and 29% are strongly not happy with their salary.Employee attitude was very low because of low salaries they received during the past years without any bonus and paid incentives.Odugbesan (1995) & Gregson (1986) indicated that reward and salary is the key factor that dictates man's attitude to work while a good wage is the most significant element that motivates them to work well.When asked if the employees agree that the salary is enough, none of the participants were satisfied with the current salaries.
As we can see from the chart in Figure 6 above, the employees stated clearly that salary was not enough to cover their living expenses which highly affect their attitude during time of work and in some case cause distraction to their concentration on doing their job perfectly.This is one of the main factors that affect job satisfaction in the researcher opinion.
The senior managers in Tripoli hospital should consider the result of this question in considering better salaries for the employees in the future.
The mean value is high and the standard deviation is very low, which shows that low salaries have been paid to employees which are reflected in their job satisfaction.None of the employees were satisfied with the payment system in Tripoli hospital.It is interesting to note that the percentage of those employees who were not satisfied with the salary amount is so close to 0%.The final statistics of job satisfaction survey is shown in Table 1 below As Shown in Table 1, the highest mean are focus on two main statements in which near to disagree and strongly disagree.The two statements are on the disagreement on "the value of salary" and "obtained the incentives in the past".The highest Standard Deviation is focus on the statement of "feel of comfortable at work", and the lowest is on the "agree that the salary is enough".

Recommendations
The study set the following recommendations that contribute to improve the current job satisfaction and the overall performance of employees and medical staff in government hospitals in Libya.
1) The managers of human resources departments should take further steps toward improving the relationship with their employees and facilitate a highly productive and pleasant working environment; 2) The management of government hospitals should pay higher attention to improving the incentives and salaries, and therefore they should consider increasing the salaries as the first step towards improving employee's conditions and encourage them to perform better; 3) The senior management should encourage the managers of all departments in the government hospital to remove all differences between employees to allow them sharing their opinions and give them the right opportunities to put their suggestions for the benefit of patients and the reputation of the hospital; 4) Appointing qualified managers to manage human resources in the hospital, and place stress on removing any kind of bureaucratic behaviour by the managers; 5) Initiate a feedback system between the employees and their managers in order to send suggestions that contribute to the work and improve the performance of human resources department.

Conclusion
The results of this study show that employees and medical staff are generally not satisfied with all factors affecting job satisfaction (work comfort, work treatment, salary, incentives) which lead to low job performance in the Tripoli hospital.This is not an encouraging result since any incentives and no good salaries are given but bad treatment to employees.All these negative results show why medical service quality in Tripoli hospital is very poor and why patients look for other hospitals outside Libya.
The results is identical with the second hypothesis of the study which states that; "Salaries, Incentives, and work treatment are positively correlated to job satisfaction", and this indicates that job satisfaction is correlated with job performance because the overall performance of Tripoli hospitals is no encouraging and very low because of very low job satisfaction, which concurs with the first hypothesis of the study.
This study concluded that the overall performance of the hospitals could be boosted when employees feel better and receive good treatment from their HR managers, in addition to increasing the current low salaries and initiate effective incentive system that can raise job satisfaction.It is clear that when the job performance is low, the performance of employees and medical staff is also low. below.

Figure 3 .
Figure 3. Participants' response towards received treatment from managers below.

Figure 4 .
Figure 4. Chart illustrating the incentives distribution to employees in Tripoli hospitals

Figure 5 .
Figure 5. Illustration deviation from the mean value related to incentives

Figure 6 .
Figure 6.Illustration chart on salary satisfaction in Tripoli hospital

Table 1 .
. Descriptive statistics of job satisfaction