Prevalence and Factors Affecting Employee Satisfaction: The Case of King Abdullah University Hospital in Jordan

Purpose: To discover some factors and their prevalence affecting employee satisfaction in a large modern hospital using Maslow’s five-level hierarchy of human needs, to help with the aim of improving both professional productivity and employee satisfaction. Methodology: A case study questionnaire was administered to 150 participants in a large modern regional hospital over a month in 2013, with results from Likert scales analysed using descriptive analysis, means and SDs and One way ANOVA to tabulate and analyse satisfaction measures. Employee satisfaction, or how employees respond emotionally to work, is a significant factor for organizational success and profit in improving employee performance and motivation. Satisfaction was measured on 18 Likert subscales of items based on responses to Maslow’s hierarchy of need fulfillment concerning working environment, payment and promotion, fairness and relations with supervisors. Results: Analysis of 121 suitable responses among roughly two thirds males and one third females showed 40.5% males of the total with bachelor degrees and 24% had master degrees; 22.3% females had bachelor with 13.2% masters’ degrees. Overall employee dissatisfaction was 88.4% (satisfaction 11.6%) with the highest item score for “Hospital’s influence on raising the Jordanian standard of living” and lowest for “priorities and performance reporting system”. Conclusions: Quality work environment was significant for achieving Maslow’s Safety and Belongingness, contributing to Esteem needs and fairness in working hours. Improved salaries and treatment could satisfy Esteem needs and help some achieve Self-actualization. Supervisoremployee relationships were a significant factor with Belongingness and Esteem needs requiring significant improvement. For increased motivation and productivity personal growth and fulfillment possibilities must be improved to encourage and release the profitable potential of Self actualization. Recommendations: (1) Improve psychological and interpersonal work environment by efficient communication among employees and change to a more collaborative managerial style. (2) Improved remuneration to recognize performance and service quality. (3) Fairness requires an efficient, collaboratively developed means to reward employee quality performance, to answer needs for Esteem and Self-actualization.


Introduction
Large institutions invariably have internal problems associated with their high number and variety of employees, a hospital being a prime example.There appeared to be considerable dissatisfaction among employees at King Abdullah University Hospital in Irbid, north Jordan, so it was determined to see if Maslow's Hierarchy of Needs (1943, 1954) might be used as an appropriate tool to discover the type and extent of this and to provide management with clear indications of how this problem might be addressed or alleviated.

King Abdullah University Hospital
The late King Hussain of Jordan inaugurated the King Abdullah University Hospital (KAUH) in 1994 to cope with a critical lack of advanced hospital and medical facilities in the north of his kingdom.It was named on its completion after King Abdullah I, the founder of Transjordan and grandfather of King Hussain.As a non-profit hospital, it started out with departments of internal medicine, obstetrics, gynecology, pediatrics, general and special surgery and an emergency facility including a medivac heliport.KAUH supplies facilities providing medical, dental and nursing students with internships, laboratories, practicals and residency (www.just.edu.jo.).This hospital employed a total staff of 1186 in 2013 at the time of the study.

Maslow
In 1943 Abraham Maslow, an American psychologist focusing on positive qualities in people, wrote a paper and subsequent book suggesting a new "Theory of Human Motivation".For psychological health he postulated five levels of innate motivational needs in hierarchical priority order with human beings ultimately seeking personal growth and fulfillment (Self-actualisation), after deficiency or "lower order needs" were met.In this brief outline, the needs relevant to employee satisfaction on the job are bolded.These needs range in ascending order from the basic lower order needs of survival with physical and emotional well-being to a culminating peak of Self-actualisation as the peak of "higher order needs".In his Needs pyramidal description diagram the base consists of Physiological (breath, food, water, sex, sleep, warmth etc.) which must be satisfied first; after that is taken care of Safety (protection, security, order, stability etc.) must be achieved; following this is Love and Belonging (family, affection, sexual intimacy, relationships, workgroup etc.) needs which comprise basic needs'.When these needs are satisfied then the first level of higher order needs is made up of Esteem (achievement, status, responsibility, reputation etc.).At the top of the pyramid is Self-actualisation (morality, creativity, acceptance of facts, personal growth and self-fulfillment) which means achieving individual potential.All elements referred to in the paper are bolded here and later capitalized, although all Need apply for everyone always.

Employee Satisfaction
For employee satisfaction in the workplace, some scholars have adopted Maslow's theory and used his notion of need fulfillment to measure this factor (Naseem, Sadia & Malik, 2011).Both employee satisfaction and dissatisfaction are affected by the job environment and by how much job satisfaction is possible within it (Hussami, 2008).Perceived fairness is one key factor affecting employee satisfaction and improved performance (Parvin & Kabir, 2011).Nonfinancial measures also have a significant direct effect on procedural fairness (Sharon, L. C. et. al., 2012).
Job satisfaction is a complex factor encompassing different facets (Naseem et al., 2011) and subject to factors like wages or salary, working environment, management style and friendly staff relationships (Lane, Esser, Holte & McCusker, 2010).As a result, the success of an organization can be significantly determined and affected, together with performance and profit (Chen, Yan, Shiau & Yang, 2006).The significance of studies of employee is significant for human relations and management concerning both people in companies and for the scholars seeking and analyzing relationships as well as directors and shareholders (Greasley, Bryman, Dainty, Price, & King, 2005).

Managers
Managerial factors including leadership, motivation and attitude are important, so researchers have tried to be specific in identifying the managerial components closely involved with providing overall employee satisfaction.In this way, the importance of each factor for managers to consider in relation to effects on the efficiency of employees.Parvin and Kabir, (2011) agree that how workers regard their jobs and their resulting feelings.Supervisor support, though not critical to measuring satisfaction, impacts positively on both the perception of job satisfaction and actual employee satisfaction at work.How a supervisor acts as a role model by personal demonstration, in the view of Chakrabarty, Oubre and Brown (2008) of the correct techniques so the employee can perform the job appropriately from the model.This notion is supported by Ellickson and Logsdon (2002) who defined the extent employees like their work as job satisfaction and later Naseem et al. (2011) agreed with this definition: his addition was to "like" as worker's "emotional response" towards the different elements of the work.Parvin and Kabir (2011) revealed that salary was the paramount motivational factor for job satisfaction for employees on salary when he reviewed this aspect in a car company.His aim was to judge job characteristics in order to assess how employees ranked the motivators and satisfiers.Primacy was accorded to compensation for both job satisfaction and motivation, salary increase according to performance ranked at the top, while administrator support had a positive impact on satisfaction (Griffin, Patterson & West, 2001).On other hand the causes of dissatisfaction and demotivation stem from a number of factors which are outside of the control of the employees such as salary (Pauline Ghenghesh, 2013).

Maslow and Employee Satisfaction
According to J. D. Politis (2001) the results produced demonstrated a positive relationship between styles of leadership and how to acquire knowledge, which associated human interaction and the method of participative decision making.Naseem, et al. (2011) confirmed that where management and staff were friendly, job satisfaction increased and this remains true today (Naseem et al., 2011).Employees naturally desire physical comfort at work are concerned with their work environment and such comfort influence job satisfaction first (Robbins, 2001).Physical factors including noise, temperature, hygiene, lighting and working hours, representing Maslow's lower order Physiological and Safety needs were an important part of the working environment.Employees, to be content and productive desire working conditions resulting in sufficient or preferably better than sufficient physical comfort (Naseem et al., 2011).The absence of a comfortable working environment satisfying basic needs can impact badly on the employees' psychological health in addition to physical well-being thereby leading to negative performance ( Naseem et al., 2011;Greenburg & Baron, 2003) and show the necessity of having improved work surroundings.Knowing the attributes that contribute to job satisfaction can help hospitals to better manage their areas concerning employee attendance, effectiveness, turnover and productivity.Moreover, a comfortable and well-managed good work condition helps to increase positive thinking, innovative contributions to the job, and willingness and ability to work well (Kolawole, et al., 2013).
In line with Maslovian, theories companies must understand how to generate a supportive work environment which will enhance customer satisfaction and company profit by persuading employees their management is concerned with satisfying employee needs thereby enabling quality responses to customer needs (Parvin & Kabir, 2011).This case study aims to ascertain prevalence and variables involved with employee satisfaction in Irbid's King Abdullah University Hospital as a means of improving other large hospitals and to look generally at the fit between Maslow's theories of a hierarchy of human needs and staff satisfaction in a large institution.

Methodology
The population to be studied consisted of 1186 employees, a sample of whom was studied over one month from April 2013 until May 2013, composed of doctors and surgeons, nurses, ancillary-secretarial and maintenance.

Criteria for Sample
The 150 employees were selected randomly (By what criterion?Eg.Every 10 th person on a total employee list?People whose names began with B? Those whose birth date contained an 8 etc) considering the gender and the education level for the seven areas listed roughly 13% were randomly chosen from each area reducing the total number from 1186 to 150.

Hypotheses
The notion that Maslow's theory of a hierarchy of human needs, which must be satisfied in order to allow employees to progress to their productive potential among these dissatisfied employees, might give the key to managers for unlocking the problem of appropriate management particularly in human relations by attitudes of supervisors to employees.Thus the first hypothesis generated was (1) that Application of Maslow's Hierarchy of Needs (H O N) will help determine the sources of employee dissatisfaction at KAUH and the second following from that was merely assumed ( 2) is Revealed needs and their cause will give managers the tools to address these needs.
The questionnaire instrument used to determine dissatisfaction sources was developed after reviewing the literature on employee satisfaction; the variables measuring employee satisfaction were drawn from previous studies in the literature referenced following.

Questions
This questionnaire consists of two sections.The first section includes demographics: questions about background of the participants including level of education and gender when the study was conducted.The second section is a scale totaling 18 questions measuring employee satisfaction.It contains four subscales: working environment, payment and promotion, fairness, relations with supervisor.The eight item measurement questions selected for employee satisfaction have been developed and used in employee satisfaction literature (Naseem et al., 2011;Lane, et al., 2010).

Measuring Variables
The measurements for the independent variable of employee satisfaction were also developed from the literature (Parvin & Kabir, 2011;Chakrabarty, Oubre and Brown, 2008;Politis, 2001) The first independent variable contains items applying to the working environment of the hospital: job location, present working hours, physical working conditions (4 items).The second independent variable, payment and promotion, includes questions about employee satisfaction with the existing salary structure of the hospital, compensation, other professional workers who left the job owing to unreasonable salary, level of salary, long term benefit and insurance policies (5 items).The third independent variable, fairness, included questions about balance between work and family life, work responsibilities (4 items) and the last independent variable, relations with supervisor, asked questions workplace managers acting as positive role models, attitude of managers towards relationships, right to put forward opinions, esteem and prestige between colleagues, and harmony between employees (5 items).Employee satisfaction had questions about influence on raising the Jordanian standard of living, complaints department, management treatment of its employees, management responsiveness to employees' needs, reputation as a good employer, sharing a vision that is known and corroborated by most people in the hospital workplace, training received, priorities and performance reporting system: eight items provided for answers about employee satisfaction.Participants were asked to locate their responses on a Likert-type five point scale ranging from negative (1 = strong disagreement ) to positive (5 = strong agreement).To calculate a cut-off score on the satisfaction scale, the total mean score plus one standard deviation (SD) was used as shown in Table 1 following.

Content Validity
To ensure content validity and semantic factual soundness: each original English questionnaire item was transcribed into Arabic then translated back again to English using four Jordanian bi-lingual scholars who had done postgraduate work in countries speaking English as an official language.To further check content and face validity, a marketing and business panel of 12 experts further reviewed items for how relevant, clear, comprehensive, understandable they were, as well as how easy the whole question set was to administer.

Data Collection
Data in the form of responses were collected from KAUH located in Irbid city, North Jordan from April to May 2013.Personal opinions and preferences were requested in the 150 questionnaires which were distributed among professional and across the range including ancillary employees.A total of 134 questionnaires were collected afterwards from employees.Incomplete answers reduced the number of usable responses to 121 suitable for analysis.

Validity of Data Collected
A pilot study was initially conducted with 12 expert employees working in the health area to test the instrument's content and face validity and the writers asked to make suggestions and comments which were used for improvement where pertinent

Reliability of Collected Data
Gronbach Alpha statistical was used as a base to test each question's reliability.Each independent factor was tested to a reliability coefficient of: payment (79%), working conditions (74%), relations (71%), fairness (81%).The reliability coefficient of the all factors was 93%, while satisfaction showed a reliability coefficient of 82%.The inter-item correlation for each factor contained in the questionnaire was tested by a reliability test with a result that "exceeded the satisfactory limit" (Sekaran, 2003).Given that the alphas approach 1, these results indicate that the data collected are reliable.

Data Analysis
The tools utilized to test and assess the study items and their individual impacts concerning payment, working conditions, fairness, and relationship with supervisors on employee satisfaction were: analysis by description, looking at means (averages) and standard deviations, measuring the difference between groups using One way ANOVA, stepwise regression analysis and checking with Pearson Correlation.

Demographic Profile
Table 1 below shows the questionnaires were given to 64.5% male and 35.5% female employees: and according to collected data, the respondents had different educational levels, the male respondents numbered 78, with 49 having bachelor degrees (40.5% of the total respondents) and 29 having master degrees, or 24% of the total of the respondents.Among 43 female respondents, 27 had bachelor degrees (or 22.3% of the total) and 16 had master degrees (13.2% of total respondents).

Overall Employee Satisfaction
The total mean score of the employee satisfaction was 22.40 (SD ± 3.31).See Table 2 below.Satisfaction scores of ≥ 26 are considered positive towards increased satisfaction.Only 11.6% (n = 14) of the participants scored ≥ 26.The remaining 88.4% (n = 107) were dissatisfied in questionnaire items."Hospital's influence on raising the Jordanian standard of living" ranked first in satisfaction score at a mean of 3.02 and "priorities and performance reporting system" was the lowest scored satisfaction item at a mean of 2.69, while "reputation as a good employer" and "share a vision among most of the people in the hospital", got the same mean scored items of satisfaction of 2.71 as demonstrated in Table 2 following: A significant effect is demonstrated for payment, relationship, working environment, and fairness on employee satisfaction as well as the relationship with supervisors in KAUH.Karl Pearson's Correlation coefficient, the most commonly used, was applied in testing the relationship between the dependent variable and independent variables to measure both direction and strength of the linear relationships between pairs of statistical variables (Cohen, Cohen, West & Aitken, 2002).Additionally, to test the possible effect of all variables, the study made use of Enter regression.Table 3 shows the model results.Using the Pearson Correlation statistical output, the result found a strong positive correlation between employee satisfaction and independent variables of (0.759).
Enter regression was used in testing the effect of the independent variable of employee satisfaction on four dependent variables as demonstrated in Tables 4 and 5   Tables 3, 4 & 5. Table 3 tabulates correlation of independent variables; Table 4 shows the model study of four independent variables and the dependent variable: satisfaction to demonstrate change statistics.Table 5 summarises ANOVA analysis results.

Environment
Work environment was also confirmed to have significant influence in KAUH.The modern design of the hospital (built 1994-2002) impacts positively on satisfaction of basic needs in accordance with Maslow's three lower levels and these are prerequisite for aspirations for higher pay, also consistent with findings by Naseem et al., 2011).A high-quality work environment, answering lower order needs first of all, guarantees security and stability (Safety) followed by relationships in work groups (Love and Belongingness).Fulfilling these needs increases employee satisfaction and inspires the employees, thereby further motivating their performance toward Maslow's higher order Esteem needs of responsibility and the urge for greater achievement and Self-actualisation.This finding is also consistent with work by Robbins (2001).
These results above may suggest that management and policy makers should seriously consider providing their employees with varied or new types of facilities as in order to give them more job satisfaction in accordance with Maslow's HON: Physiological and Safety to give both a physically comfortable and a supportive psychological environment.In this study variables affecting employee satisfaction in KAUH, the findings indicated that 11.6% or most employees were dissatisfied with the majority of factors tested in this study: "working environment, pay, fairness, relationship with supervisor"; that good remuneration was the primary motivator for employee satisfaction, this related to the HON factor of Esteem needs related to achievement and status, which agrees with the previous findings coefficient of Parvin and Kabir (2011).

Fairness
Another major factor affecting employees' satisfaction in KAUH was fairness.If hospital management designed fair working hours, fair salaries, fair employee treatment where Esteem needs could to be satisfied and employees perceived themselves to be valued; management could increase employee satisfaction and motivate employees to be more diligent as they strive toward Self actualization through personal fulfillment in work as shown by Parvin and Kabir (2011).The relationship between the supervisors and employees was a very significant factor requiring improvement for KAUH employee satisfaction to achieve needs of both Belongingness and Esteem shown in a previous study by Chakrabarty et al., (2008).

Satisfaction
For overall employee satisfaction in this study, 88.4% of participants (an overwhelming majority) expressed their dissatisfaction about the four factors tested: only 11.6% were satisfied also confirmed by Hussami, (2008).Both dissatisfaction and satisfaction for employees not only depends not only on the job environment, but also on possible future achievement, personal growth and fulfillment possibilities provided in order to motivate employees with resulting increased productivity.Fairness testing revealed lack of satisfaction in Belongingness and Esteem leading to this general atmosphere of dissatisfaction.

The Hypotheses Conclusions
Hypothesis (1) Application of Maslow's Hierarchy of Needs (H O N) will help determine the sources of employee dissatisfaction at KAUH was proven according to the results shown; and following (2) Managers may respond to needs revealed to increase employee satisfaction and resultant productivity is interpreted in implications below.

Implications for Managers
Employee satisfaction is a major key to productivity and paying close attention to satisfying the needs revealed by Maslow's hierarchy is an excellent tool to help.Asking questions about needs satisfaction can be a useful guide to management in dealing with dissatisfaction in the labor force from least to most qualified employees.
Here it was interesting that the higher need related to Esteem was identified as paramount through the need for greater remuneration.Environmental satisfaction answers basic lower needs for Safety, Love and Belongingness in the workplace, arguing for managers to check on this first priority as it forms a basis for satisfying higher needs (as Maslow states) through motivation towards Self-Actualization and resultant higher productivity.
Fairness perceptions are a check for managers in supervisor-employee relationships.Valuing workers can be demonstrated by introducing a more inclusive and collaborative managerial style is indicated as required by high (88.4%)levels of dissatisfaction.High Priorities and Performance Reporting System dissatisfaction indicates acceptable supervision was lacking.This indicated basic Belongingness and Esteem needs were not met; and it should tell managers that career paths for all levels of employees need attention and should be worked out in collaboration and publicized so that this factor contributes to a happy productive work environment with promotion possible on the horizon.This method should be part of an improved and thus more efficient communication system within the workplace as part of a collaborative managerial style.The study also points out that management should closely monitor the workplace's psychological and interpersonal work atmosphere to discover sources of such solvable problems to help in greater employee motivation.

Limitations of the Study
Participant bias prevents a high percentage of accuracy in figures Generalization of data to all Jordanian health sector employees is not possible from a single hospital

Future Research
Opportunities for future study exist in investigate other factors affecting professional employees' satisfaction, such as the relationship between co-workers and job security.The possibility of conducting observational and/or interview studies might further research employee satisfaction at KAUH and other large hospitals for confirmation of results.These different methods may provide a different perspective on factors for managers to improve employee satisfaction, productivity for public hospitals and profit for private hospitals.Other bases for examination of the problem than Maslovian theory might be explored to give a new and different perspective on employee satisfaction.

Recommendations
On basis of the above analysis of four selected factors which affected KAUH employee satisfaction and with reference to Maslow's HON, the results suggest the following recommendations to managers of the King Abdullah University public hospital to further fulfill both basic and higher personal needs of employees and thus to increase productivity: 1) Ensure a good psychological working environment within the hospital by improving efficient communication between employees and building a good interpersonal environment within the hospital by changed managerial style, in order to create better work conditions to satisfy Belongingness.
2) Improve employee remuneration with the overall salary packages for employees which is based on productivity rewards, because recognition of achievement and responsibility by a fair and collaboratively agreed system creates Esteem; for example, consider the implementation of three eight hour shifts as a means to reduce employee workload and increase comfort thus providing Safety with stability and Security).
3) To improve fairness in KAUH devise an efficient means collaboratively to evaluate and reward the work performance of the best best employees, marking out clear career paths to encourage workers and demonstrate that rewards exist for better productivity, that service quality will be evaluated, all contributing towards Esteem and Self -actualization.

Figure 1 .
Figure 1.Flowchart of research model (a, b, c, d).The statistical models represent the following independent variables respectively: a. Pay, b. pay, relation, c. pay, relation, fairness, d. pay, relation, fairness, working, e. dependent variable: satisfaction.The results revealed in

Table 2 .
Degree of acceptance based on respondent's satisfaction

Table 3 .
Correlation of independent variables