The Moderating Effects of Job Satisfaction on the Relationship between Personality Traits and Customer-oriented Behavior in the Malaysian Health Tourism Industry

This paper aims to analyze the relationship between personality traits, customer-oriented behavior and job satisfaction. Focusing on the moderating role of job satisfaction in enhancing customer oriented behavior, the research was set in the context of Malaysian health tourism industry. The respondents consisted of nurses in health tourism hospitals in Malaysia. A quantitative cross sectional survey method was adopted, coupled with factor analysis and hierarchical regression analysis to analyze the collected data. The findings of this study revealed that extraversion and agreeableness were positively and significantly related to customer-oriented behaviour. Further, job satisfaction was found to be a quasi-moderator that interacted with extraversion to predict customer-oriented behavior. The findings of this research facilitate health tourism organizations to identify, recruit and train nurses who possess the right personality traits, structure the values of the organization and nurture a conducive work environment in order to maximize nurses’ job satisfaction that effectively improves their behavior towards customers and ultimately the performance of the firms.


Background of the Study
Health tourism is a growing offshoot business of the traditional healthcare and tourism industries. The niche market found its place mainly in Latin America and Asian countries, which offer both medical and travel services at a competitive price. In this regard, Malaysia is well-positioned as a strong market player in the Asian health tourism industry, considering the lower cost of labor, large pool of skilled workforce and high level of English proficiency. However, despite being reported by Patients Beyond Borders (2014) as to provide up to 80 percent of cost savings (cf. India 90 percent, Thailand 75 percent, Singapore 40 percent), the growth of health tourism industry in Malaysia has not been plausible in the recent years. According to Malaysia Healthcare Travel Council, the number of healthcare travelers in 2014 marginally grew to 882,000, merely a 0.1 percent increase from 2013. This development is not in line with the global growth projected by Patients Beyond Borders for the same year, whereby the number of cross-border healthcare patients was expected to grow at a minimum rate of 15 percent, with the highest rates projected for North, Southeast and South Asia. The data is evident that Malaysia is falling behind other health tourism countries despite its comparative advantage in offering cost effective medical treatments. In 2014, the National Consumer Complaints Centre of Malaysia reported that a total of 504 complaints were lodged in relation to healthcare services, whereby 71.8 percent of the complaints were on private healthcare institutions such as medical centers, private clinics, specialist clinics, dentists and nursing homes. In order to tackle the complaints and improve the quality of the services in health tourism hospitals, an effective transformation is required through participation across all levels of the organizations, particularly nurses as they act as the main contact employees in providing services to the patients. In this regard, this study aims to investigate the factors that lead to nurses' customer oriented behavior, specifically in relation to their personality traits and job satisfaction. Nurses' positive customer-oriented behavior will reflect the increased organizational commitment, which in turn enhances patients' satisfaction.

Customer-oriented Behavior and Personality Traits
Employees of a service-based firm demonstrate customer-oriented behavior by promoting and delivering the promises of the business, which effectively forms a brand image of the firm. While the term 'customer oriented behavior' is vastly used in marketing literatures, the concept of personality differences is also utilized in determining the desired behavior. Farrell, Souchon, & Durden (2001) defined customer oriented behavior as a service quality implementation behavior that represents the behavior policy implemented by an organization on the provision of the service quality. While there are various internal and external factors that influence customer oriented behavior beyond an organization's policy, employees' personality trait is commonly associated as the key determinant of customer oriented behavior. The theory of trait introduced by Allport (1937) defines personality as the dynamic organization within an individual of those psychophysical systems that determines his unique adjustments to the environment. Norman (1963) popularized the Big Five personality traits labelled as extraversion, neuroticism, agreeableness, conscientiousness and openness to experience. Since this taxonomy can serve as a meaningful classification of personality traits and has been used widely in the literatures, the present study has selected Big Five traits as the antecedent variable in the investigation of customer oriented behavior.
The relationship between employees' behavior and personality traits has been studied and supported by numerous scholars in the past in various service sectors viz. retail (O'Connell et al., 2001;Agnihotri et al., 2012), financial institution (George & Purva, 2004) and hospitality (Lee et. al, 2006). However, there is minimal discussion conducted on health tourism sector (Ong & Johari, 2014), which is a frightful gap as the industry is profoundly service centric, whereby customers' and providers' satisfaction are key in sustaining the business. Molinari & Monserud (2008) found that identifying nurse candidates with suitable personality traits and preference on work environment are particularly important to ensure their retention within the same firm. While nurses in all types of healthcare firms generally have similar job scope, Molinari & Monserud (2008) indicated that their environments differ significantly e.g. location of hospital, demographic profile of patients, type of treatment, patients' social profile, thus requiring different recruitment characteristics. Understanding the differences on nurses' personality and their work environment are critical as nurses are the primary contact point and the way their behaviors are perceived by patients is a critical determinant of overall patient satisfaction (Lanjananda & Patterson, 2009). Therefore, based on the above explanation, it is hypothesized that, H1: There is a significant relationship between nurses' personality traits and customer-oriented behavior.

Job Satisfaction
The concept of job satisfaction was first proposed by Hoppock (1935) who defined job satisfaction as an overall psychological, physiological, and environmental state measured by direct enquiry to employees on their self-assessed integral satisfaction level on the job. Herzberg (1959) identified different factors that lead to job satisfaction and job dissatisfaction in his two-factor theory, stating that motivators e.g. challenging work, recognition and responsibility contribute towards positive satisfaction, whereas hygiene factors e.g. salary, security, work environment determine one's job dissatisfaction. Subsequent studies narrowed the concept of job satisfaction as the feeling generated upon comparing rewards earned from the job with one's own contribution as described in Adam's Equity Theory (1963), expected performance and outcome as described in Vroom's Expectancy Theory (1964) and when certain needs or desires are fulfilled upon completing the job (Lawler & Porter, 1968).
In regards to the relationship between job satisfaction and behavior, fairness of job supervision, pay and promotion rules, as well as supervisor administration of these rules emerge as the key predictors of contact employee prosocial service behaviors and job satisfaction (Bettencourt & Brown, 1997). Aiken & Hage (1971) found that when employees feel satisfied with their jobs, they will be more committed to the organization and their work performance, thus engaging in more positive behaviors. Employees reciprocate their higher job satisfaction by demonstrating more organizational citizenship behavior (Lapierre & Hackett, 2007). According to Armstrong (2006) the satisfied feeling that employees have about their work is reflected in their attitude towards the job, whereby positive attitude indicates satisfaction and vice versa. This suggests that there is a correlation between job satisfaction and behavior. Niu (2014) found in his study on 626 employees of service companies in Taiwan that job satisfaction can enhance innovative behavior, and simultaneously be stimulated by job satisfaction.
Within the healthcare sector, personality traits factor has been recognized in various research in the past as the determinant of job satisfaction and service behaviors. Chang, Li, Wu, & Wang (2010) in a study on 314 nurses in Taiwan confirmed the importance of taking personality variables into account in order to measure job satisfaction, which is in line with past studies of similar setting. While past studies on job satisfaction categorized individual differences that shape an individual's level of job satisfaction from the perspective of demographic characteristics i. categorize individual differences in accordance with the personality traits as theorized by Allport (1937). In addition, this study attempts to introduce job satisfaction as a moderating variable in enhancing the relationship between personality traits and customer-oriented behavior. Based on the above rational explanation, it is hypothesized that, H2: Job satisfaction moderates the relationship between nurses' personality traits and customer-oriented behavior.

Participants
This study was conducted in the selected health tourism hospitals in Malaysia. A total of 268 nurses participated in the study, which is composed of 190 females (70.9%) and 78 males (29.1%). Majority of the participants were staff nurse (189 respondents or 70.5%), followed by assistant / enrolled nurse (43 respondents or 16%), senior staff nurse (20 respondents or 7.5%). The least number of respondents were head nurse / ward sister (16 respondents or 6%). The respondents represented 51.1% nurses from the medical department and 48.9% nurses from the surgical department.

Method and Instruments
This study employed quantitative cross sectional survey method. The samples were generated through stratified random sampling technique. The measures of customer-oriented behavior were adapted from Selling Orientation Customer Orientation Scale (SOCO Scale) developed by Saxe and Weitz (1982). Measures for personality traits were adapted from Five Inventory (BFI) developed by John, Donabue and Kentle (1991). On the other hand, measures for job satisfaction were adapted from the study of Warr, Cook and Wall (1979). Likert scale was used to measure the level of agreement for personality traits, job satisfaction and customer-oriented behavior. The scale was anchored by 1 (Strongly disagree), 2 (Disagree), 3 (Neither agree nor disagree), 4 (Agree) and 5 (Strongly agree).

Data Analysis
Data analysis in the present study was conducted using Statistical Package for Social Science (SPSS). Factor analysis was selected to test the validity of the constructs and to assess how well the results obtained from the use of the measures represent the concept being measured (Sekaran and Bougie, 2010). Separately, hierarchical regression analysis was used to examine the moderating effects of job satisfaction on the relationship between personality traits and customer-oriented behaviour.

Factor Analysis
The independent, moderating and dependent variables were validated using factor analysis.  (Hair, Black, Babin, and Anderson, 2010;Pallant, 2007). The Bartlett's Test of Sphericity was statistically significant at the 0.001 level, thus supported the factorability of the correlation matrix.

Personality Traits
The principal component analysis (PCA) with varimax rotation extracted five (5) components from personality traits after cross loadings were deleted and factor loading of 0.35 and below were discarded. The rotated factors captured a total of 62.786% of the variance in which component 1 contributes 16.360%, followed by component 2 at 12.599%, component 3 at 12.055%, component 4 at 11.055% and component 5 at 10.717%. Drawing on the factor analysis results (see Table 2), items that loaded on component 1 (4 items) were labeled as agreeableness, component 2 (4 items) were categorized as extraversion, component 3 (4 items) were named as conscientiousness, component 4 (3 items) were labeled as openness to experience and component 5 (3 items) were categorized as neuroticism.

Customer-oriented Behavior
The principal component analysis (PCA) extracted 9 items that captured a total variance of 51.153% with an Eigenvalue of 4.604. The values of factor loading for customer-oriented behavior were in the range of 0.545 to 0.773, whereas those factor loadings below 0.35 were discarded and cross loadings were deleted during the factor analysis. All the 9 items were loaded on a single factor and labelled as customer-oriented behavior. The results of the factor analysis were displayed in Table 3.

Job Satisfaction
The principal component analysis (PCA) extracted 11 items that captured a total variance of 56.800% with an Eigenvalue of 6.248. The factor loadings for job satisfaction were in the range of 0.618 to 0.820. All the 11 items were loaded on a single factor and named as job satisfaction. The results of the factor analysis were shown in Table 4.

Hierarchical Regression Analysis
Hierarchical regression analysis was performed to examine the moderating effects of job satisfaction on the relationship between personality traits and customer-oriented behavior. Table 5 displays the results of hierarchical multiple regression analysis. Model 1 indicates the results on the relationship between personality traits and customer-oriented behavior. Meanwhile, Model 2 and Model 3 show the results of the moderating effects of job satisfaction. Based on the results displayed in Table 5, Model 1 was significant with F value of 10.630, p<0.001. The R square value of the model was 0.169, which explains the 16.9% variance in the nurses' customer-oriented behavior. Two out of five dimensions of personality traits were found to be positively and significantly related to customer-oriented behavior. The two dimensions were extraversion (β=0.252, p<0.001) and agreeableness (β=0.312, p<0.001) (see Table 6).
Model 2 and Model 3 of the analysis were significant with F values of 31.871 and 19.095, p<0.001. The R square value for Model 2 was 0.423, which explains the 42.3% variance in the customer-oriented behavior. On the other hand, the R square value for Model 3 was 0.451, which explains the 45.1% variance in the dependent variable. The result shows that upon inclusion of job satisfaction as a moderator, the R square value had increased from 16.9% in Model 1 to 42.3% in Model 2. Further, this indicates that job satisfaction was a predictor for customer-oriented behavior. In Model 3, the R square value was further increased to 45.1%, which indicates that job satisfaction interacted with personality traits to enhance customer-oriented behavior. However, job satisfaction does not moderate each of the interaction items uniformly. The regression coefficient represented by the standardized coefficients (β) in Table 6 denotes that job satisfaction was significantly interacted with extraversion (β=0.120, p<0.05) to predict customer-oriented behavior. The results revealed that the relationship between extraversion and customer-oriented behavior was contingent upon the inclusion of job satisfaction as the moderator. To better understand the moderating effects of job satisfaction on the relationship between extraversion and customer-oriented behavior, a graphical illustration was used as depicted in Figure 1. Figure 1 demonstrates the interaction of extraversion and job satisfaction in predicting customer-oriented behaviour. The graph explains that the effect of extraversion on customer-oriented behavior is positive regardless of the level of job satisfaction whether it is low or high. The graph also illustrates that extraverted nurses exhibit higher level of customer-oriented behavior when they possess high level of job satisfaction. From the graph, it was understood that job satisfaction is demonstrating the role of a predictor and moderator. Hence, it is a quasi-moderator.

Discussions
The study provides greater understanding on the determinants of customer oriented behavior among nurses, which can help health tourism firms to effectively allocate their limited resources towards enhancing customer service. The management of tourism hospitals would benefit from the findings of this research in multiple ways. Firstly, recruitment efforts can be streamlined to focus on identifying nurses with positive personality traits that suit the job specification i.e. extraversion and agreeableness, as these traits positively influence customer oriented behavior. Nurses who possess agreeableness are loyal and able to perform their duties by nature. On the other hand, extraverted nurses are more sociable, cheerful and friendly. They interact proactively with the patients to solve problems. Secondly, health tourism firms would be able to justify the reward scheme for nurses, which ideally be based on their customer-oriented behavior, as the expected reward is likely to positively moderate their behavior towards patients. The finding on moderating role of job satisfaction allows management to provide the required attention on factors that contribute towards nurses' job satisfaction, which includes structuring core values of the organization, creating positive work environment among staff members of the hospital and providing fair rewards to nurses. Particularly for Malaysian nurses, team cohesion, benefit www.ccsenet.org/ibr International Business Research Vol. 9, No. 6;2016 and reward and working conditions play important roles in shaping nurses' job satisfaction (Atefi, Abdullah, & Li, 2014). Thirdly, the results of the study on job satisfaction will facilitate health tourism organizations in its efforts to retain the workforce and grow as a competitive health tourism employer in the region. A research by Molinari & Monserud (2008) on job satisfaction in hospitals indicated that poor job satisfaction may increase nurse shortage, while job dissatisfaction can actually threaten a hospital's existence.

Limitations
This research was conducted under certain limitations that have to be taken into consideration. Employees of health tourism organizations were represented by a single group of employee i.e. nurses, who generally makes up a significant ratio of a hospital workforce. Other employees who are of smaller number, but may be of similar or greater significance in serving patients e.g. doctors, health tourism facilitators, administrators were not considered in this study. As such, it is suggested that future research may expand the study samples to include other employees who directly or indirectly contribute towards patients' satisfaction in the hospitals.

Conclusion
The primary focus of this research aims to discuss the impact of job satisfaction in moderating the relationship between personality traits and customer oriented behavior in the context of health tourism organizations, which has yet to be discussed extensively in current literatures. In furtherance to earlier researches on personality traits and customer oriented behavior, this research found that extraversion and agreeableness among nurses in health tourism hospitals were positively and significantly related to customer-oriented behaviour. Additionally, job satisfaction was found to be a quasi-moderator that interacted with extraversion to predict customer-oriented behavior. The outcome of this research is expected to facilitate business and human capital managers of health tourism hospitals in planning, designing and implementing relevant recruitment, training and retention strategies on employees, while aligning organization goals and values with that of employees. Nurse candidates with strong personality trait of extraversion and agreeableness can be prioritized in the recruitment process, whereas hired nurses who are less extraverted and agreeable can be further motivated towards customer-oriented behavior by structuring strategic performance reward scheme. Further, intrinsic job satisfaction can be nurtured by providing nurses with relevant work opportunities that create challenges drive accomplishments, which are complemented by extrinsic rewards via tangible and intangible means of appreciation. These initiatives will contribute towards improving employees and patients' satisfaction in the health tourism hospitals, effectively strengthening firms' competitiveness in the industry.