Effects of role variables on job satisfaction. (Physician Executive Role Variables).

EVERY HEALTH CARE MANAGER FACES THE DILEMMA of balancing quality versus cost of care on a daily basis. One stakeholder who is not used to dealing directly with these pressures is the physician. For years, the physician has assumed the primary role of the clinician in the organization. More recently, however, the role has shifted from clinician to executive/manager. In part, this transition is In response to economic constraints, advances in medical technology, rising health care costs, and other factors that are endemic to this rapidly changing environment. Physicians have been called upon to participate not only in clinical decision-making, but in managing the enterprise as well.

Physicians and role stress

Role stress, a component of role theory, evolved in the late 1920s and has been addressed extensively in the social science literature. Role stress is composed of at least two parts: Role conflict and role ambiguity. Within an organizational context, a role is defined as a set of expectations applied to a person in a particular position by others both within and beyond an organization's boundaries. (1) Since roles are an important part of a group's structure, these expectations are often rigidly enforced and they become difficult to change. Thus, roles can present problems for members of an organization, and may be magnified for physician executives.

When a physician moves from the clinical role into the world of management, administration, and leadership, it is common for him or her to continue to use learned clinical behaviors, and professional norms and values in managing. While clinical behaviors are critical for success as a practitioner, they tend to create conflict, resistance, and tension in the managerial role. (2) The effect on the individual physician moving into management may not be altogether positive.

Clearly, the major reason that the management role is so foreign to physicians has to do with their typical training. This training or socialization process as a medical expert is extremely different from the manager's socialization process. Historically, many factors have worked to divide administrators and physicians. They have been rained in different schools, used different theoretical frameworks, and employed different languages, They have been influenced by different professional literatures and organizations and traditionally have been licensed to perform different tasks. (3) Because of the nature of these differences, the role of management is certainly not a comfortable one for the majority of physicians.

In fact, most physicians have had little or no formal management training. Often, the functions they learn to perform result in very different approaches to problem-solving and decision-making. One of the significant issues for the physician and non-physician manager to resolve is the dilemma between the professional's need for autonomy and the manager's need for control. Both groups have their own ideas with regard to time horizons. expectations, and patience for results. (3) This new position requires a shift in thinking, philosophy, attitudes, and behavior if the physician executive Is to be seen as successful and an asset to the organization. (2)

The nature of the physician's work dramatically changes with the entry into management. Two factors that must be studied are role conflict and role ambiguity. as both can result in stress for the physician executive. Role conflict involves an incompatibility between job tasks, resources, and decision-making authority through the hierarchy. (4) Conversely, role ambiguity encompasses a lack of information about the job for the individual with regard to uncertainty between role requirements (usually defined directly by job descriptions or organizational rules and procedures). (4)

Research on role theory

Overall, there are studies that have found that role conflict and ambiguity are positively correlated with job dissatisfaction. Low organizational commitment. increased psychological and physiological stress, and lower performance. (5,6,7,8,9,10) However, there are very few studies that utilize these variables in samples particular to the health care industry.

Research by Rizzo et al (11) found that role conflict results from the dual hierarchy of hospitals and that those affected respond with hostility to physicians and passive resistance to formal rules. BenDavid (12) reported that physicians who became members of a government public health insurance system felt dissatisfied, exploited, and experienced a loss of professional independence because of conflict with the organization.

Blau and Scott (13) pointed out that two sources of authority exist when organizational discipline is based not only on position power, supported by formal sanctions, and derived from the legal contract governing employment of the organizational member, but also on professional expertise. which is enforced by collegial authority. Several studies have shown that multiple authority disrupts the individual's orientation to his or her organization or profession by requiring him or her to choose between the two. (11) Physician executives find themselves exactly at this crossroads.

Scalzi and Burke (1) were interested in the effects of role ambiguity and role conflict in senior executive nurses and health care executives. Their samples consisted of senior executive nurses randomly chosen from hospitals in Los Angeles County and 169 affiliates of the American College of Healthcare Executives in Houston and San Antonio. The researchers used the Rizzo, House and Lirtzman instrument. (11)

Role ambiguity scores for Burke and Scalzi's studies were significantly lower than the scores reported by Rizzo et al. The mean role conflict score of the hospital executives was lower, even though often the complaint is made that hospital management is a stressful field. The relationship between role conflict, role ambiguity, and job dissatisfaction corresponded to the Rizzo et al's research.

In 1986, Ellis conducted a study of role ambiguity in head nurses and found that there was a significant negative relationship between job satisfaction and role ambiguity. She found that the level of job satisfaction increased with leader initiated structure. (1)

Moorhead (14) tested the proposition that perceived stress at work is a function of certain aspects of organizational structure, job characteristics, and role dynamics. He used two different samples; resident physicians working in a large general hospital in the Southwestern United States and middle level managers from two manufacturing firms. The results were quite interesting as compared to previous research in this area. For example, as already outlined, Rizzo et al (11) found significant inverse relationships between perceived role conflict and ambiguity and job satisfaction, organizational commitment and psychological stress. Moorhead's results showed that role conflict inversely affected satisfaction in the hospital. whereas role ambiguity had inverse effects on satisfaction in the manufacturing firms.

To the extent that ambiguity is associated with personal control, the effect of ambiguity among physicians may be different. The two samples were similar with regard to work stress. Where managers and residents experienced role conflict and ambiguity. they reported high work stress, and more fatigue, irritability, headaches, and restlessness.

Given this important set of results found in Moorhead's research, and the transition that the physician is currently experiencing from clinician to executive, it is valuable to examine the relationship of these variables among physician executives as compared with non-physician executives.

Hypotheses

Physician executive and non-physician executive samples:

1. Role conflict and role ambiguity will lead to an increase in role stress and thus a decrease in job satisfaction and organizational commitment for the physician executive and the non-physician executive.

2. Unresolved conflict and ambiguity will lead to anger, frustration, and lack of motivation and satisfaction for the physician executive.

Research method

Physician executives

A geographically stratified random sample of physician executive names was obtained from the American College of Physician Executives, (ACPE) (N=160). All physicians were full-time executives employed by a private not-for-profit health care system in the U.S. Exclusion criteria were as follows: No dual roles (clinical and managerial) and no physician executives from other types of health systems were included, (such as managed care providers, federal systems. physician's offices, and consulting groups).

According to the American College of Physician Executives, approximately 55 percent of all physician executives are employed by not-for-profit health care systems, primarily hospitals. There was no better place to begin a study on role stress among physician executives than within this particular complex environment.

Non-physician executives

A geographically stratified random sample of non-physician executive names was obtained from the American College of Health Care Executives (ACHE) (N=l60). All executives were full time executives employed by a private not-for-profit health care system in the U.S., and were hospital-based. Exclusion criteria were as follows: No part time executives, and no executives from any other types of health systems were included.

Response rates averaged 50 percent for both groups. This response rate compares well to other surveys of top corporate executives (ACPE and ACHE, 1994). Also non-response analysis showed that both groups mirrored the total ACPE and ACHE population characteristics.

Measures

A mail survey was used to examine the effect that role conflict and ambiguity have on job satisfaction, organizational commitment, and level of stress for both executive groups in the hospital setting. Demographic data were also collected. The survey was conducted according to the Dillman method (15) for the design and administration of mail surveys. The standardized instruments used were as follows:

Role conflict and role ambiguity

These two variables were measured using the instrument developed by Rizzo, House, and Lirtzman (11) consisting of 30 items graded on a 1 to 7 Likert scale. This study followed the Price and Mueller (16) recommendation that only the 14 items with factor loadings above .30 should be used. Coefficient alpha reliabilites for role conflict were .71 and .81 and .82 and .75 for role ambiguity for the physician and non-physician executive samples respectively.

Job satisfaction

This variable was gauged using the Quinn and Stains measure for job satisfaction. (17) Coefficient alpha reliabilities were .80 and .70 for the physician and non-physician samples respectively.

Organizational commitment

Organizational commitment was assessed using the Organizational Commitment Questionnaire from Mowday and Steers. (18) Fifteen items are used to capture three factors: (1) A strong belief in and acceptance of the organizations goals and values; (2) a willingness to exert considerable effort on behalf of the organization; (3) and a strong desire to maintain membership in the organization. Coefficient alpha reliabilites were .91 and .86 for the physician and non-physician executive samples respectively.

Role-related stress

Role-related stress was assessed using the General Health Questionnaire (GHQ) short form, a 12-item scale that has been validated on a variety of samples and is useful in identifying people who are experiencing distress, particularly work samples. (19) Coefficient alpha reliabilities were .80 and .79 in the physician and non-physician executive samples respectively.

Demographics 

Questions related to demographic data were included at the end of the overall questionnaire. This data identifies the type of position that the executive occupies, years in present position, previous management experience, highest degree or type of education in management, age, number of FTEs reporting to the position, and type of hospital and number of beds.

Results

I. Descriptive analysis

Physician executive population and sample. The overall population comprised more than 12,000 physician executives nationwide who are members of the American College of Physician Executives. The average age of this population is 56 years old, and they have been in their current positions three to five years. Approximately 80 percent of this membership is employed in hospitals that have more than 250 beds. Approximately 25 percent have degrees beyond MD status, while 25 percent express interest in future management education. The sample used in this particular study is representative of the overall population.

Non-physician executive population and sample. According to the American College of Healthcare Executives (1994), there are approximately 30,000 members nationwide. The mean age for this population is 46, and these executives have been In their current positions six years on average. The majority of health care executives, particularly at the vice president level and beyond, are seeking educational opportunities on an ongoing basis. Eighty-eight percent of the overall membership has a master's degree. Similarly, the particular sample in this study matches the overall population in terms of age, tenure, and educational background.

The data show that there are significant differences between groups on the demographic variables of age [t(147)=5.22, p<.001], years of previous management experience [t(l12)=-3.73, p<.001], and the number of beds [t(144)=2.07, p<.05]. In other words, physician executives are older, supervise fewer FTEs, and work in larger hospitals than the non-physician executive group.

II. Comparison of groups on substantive variables

Potential differences between groups for the substantive variables used in this study were examined. The mean role conflict score was 4.29 in the physician executive group and 4.31 for the nonphysician executives, a nonsignificant difference. The average for role ambiguity was 4.95 in the physician executive group and 5.49 for the non-physicians [t(144)=3.96, p<.001]. Interestingly, the non-physician executive group showed a slightly higher level of role conflict and a significantly higher level of role ambiguity than the physician executives.

Role-related stress was measured on a scale from zero to three, with higher numbers denoting more stress. The mean stress score was 2.25 for the physician executive group and 2.34 for the non-physician executive group. The T Test between groups for role-related stress was nonsignificant. The mean job satisfaction score was 4.04 for the physician executive group and 4.13 for the non-physician executives, another nonsignificant difference.

Finally, with regard to organizational commitment, the difference between the two groups was statistically significant. The physician executive sample showed a mean commitment score of 5.22, whereas the value for the nonphysician executive group was 5.72. The physician executives, therefore, show a lower level of organizational commitment [t(195)= -3.05, p<.01].

Testing the predicted hypothesis

The predicted hypothesis for other professions has been widely discussed in the literature. This is now being applied to physician executives: "Role conflict and role ambiguity will lead to an increase in role stress and, thus, a decrease in job satisfaction and organizational commitment for the physician executive and non-physician executive groups." It is important to test this hypothesis in these two health care executive groups, as well as the generalizability of the findings to this health care sample.

Path analysis was used to study the direct effects of these variables. For the non-physician executive group, role conflict has a significant positive direct effect on role stress as predicted. The path coefficient in the non-physician executive group for this relationship is significant (+36, p<.00l) and for the physician group (+.15), non-significant.

For both groups, the relationship between role ambiguity and role stress is positive and significant. For the physician executive group, role ambiguity shows the predicted positive significant effect on role stress (+35, p<.00l). In the non-physician executive group, this relationship is also positive and significant (+.45, p<.00l). Only role conflict shows the predicted positive effects on role stress in the non-physician executive group. In the physician executive group, the path coefficient representing the causal relationship between role ambiguity and stress is larger than the coefficient between conflict and stress. This may be due to the high correlation between role conflict and role ambiguity; thus, role conflict may be suppressing a greater portion of the variance in role ambiguity.

With both groups, the predicted negative effects on job satisfaction were not seen. Although both physicians and non-physicians are experiencing role stress, it has not led to job dissatisfaction in either group. These results are not in keeping with the general literature on role stress and its effect on job satisfaction.

Discussion

The physician executives that participated in this study presented a somewhat, but not remarkably, different profile from the traditional, nonphysician executive. For example, physicians were older and had less management experience. One may conclude that this reflects the general industry failure to educate and socialize the physician into these types of positions earlier. It was also found that physician executives worked in hospitals that had more beds than traditional nonphysician health care executives.

Physician executives also supervised fewer FTEs. Perhaps this is the case because smaller institutions (with small medical staffs) cannot afford to have one of the physicians not practicing clinical medicine, while a larger, more complex organization can't afford not to have a full-time physician executive if it desires adequate and successful management. Another possibility may be because larger hospitals are much more open to the notion of the physician in this role and the overall environment within these organizations may be much more hospitable than in smaller institutions.

For both the physician and nonphysician executive groups, role conflict and role ambiguity were positively related with job satisfaction, which is contrary to the literature. One may conclude that both groups recognize there is a certain level of conflict and ambiguity within their roles as senior executives, however, this knowledge is not leading to job dissatisfaction. Based on the results of the mean score of the T-Test discussed earlier, this group of physician executives found the role as executive significantly more ambiguous than the nonphysician executive. Yet, they seem to be making a successful transition to management with regard to job satisfaction.

The majority of research on role conflict, role ambiguity, and the outcome measures of these variables has studied middle management in general industry, but not health care institutions. It is well known that the health care industry is unlike any other "business." Thus, not only is this population somewhat unique because the overall sample represents management at the executive level, but the samples are exclusively employed in health care institutions. However, even when these unique features are taken into consideration, the Burke and Scaizi study (13) still found inverse relationships between role variables and job satisfaction with nurse executives and health care executives, which is in keeping with the literature on role theory.

While few research studies have used physicians in the sample and virtually none have used physician executives, this study does in fact allow for an extension of the use of role theory. It is possible that situational factors for both the physicians and nonphysicians were modified by variables outside those studied here. For example, both groups may have been able to utilize effective coping strategies, such as stress management skills, which could have allowed a positive relationship to be identified with job satisfaction. (20) Also, according to research conducted by Schuler, there was a significant relationship between rank and role conflict.

There seemed to be a curvilinear relationship in which the maximum conflict occurred at what might be called the upper middle and upper levels of management. Again, this relationship did not result in job dissatisfaction. (21)

Fischer and Gittleson have commented that higher level, more complex or boundary spanning jobs carry more conflict. However, there is also great tolerance for conflict at this level. (22) Although the issue of boundary spanning was not specifically examined in this study, there is no question that executive positions are more complex and a greater tolerance for conflict was seen. Clark explains that although there is considerable discontent in roles, senior executives still draw general satisfaction from the intrinsic aspects of autonomy they have at this level in their jobs. (23)

Burke, Tompkins, Sommers and Jagman point out that successful physicians learn to deal with role stress routinely. (24) It is quite possible that this particular group of physicians is capable of handling conflict and ambiguity and may, in fact, gravitate to these positions deliberately. If this is the case, it would be usual to have this sample of physician executives mirror a group of traditional nonphysician health care executives.

Conclusion

Overall, the study results indicate that role variables have an effect on stress, job satisfaction, and organizational commitment in the physician and nonphysician executive. There is no question that these findings document an extended use of role theory. In these samples, role variables did not show the expected effect on job evaluations. While physicians and nonphysicians experience significant levels of role conflict and ambiguity, it apparently does not result in job dissatisfaction.

These two groups actually show many similar relationships found with these variables, but there are major differences that one can speculate with regard to the reasons behind the relationships. The development of a common language, clearer communication, joint problem-solving, and joint education and training must be given priority if this integration effort between physician and nonphysician executives is to be successful. While there seems to be an initial fit' into the role of the executive for the physician, there is a long way to go before completely understanding the complexity and nuances of this new role in this new breed of health care executives.

References

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(16.) Price, J. & Mueller, C. (1986). Handbook of organizational measurement. Marshfield: Pitman Publishing Inc.

(17.) Quinn, R.P. & Staines. G.L. (1979). The 1977 Quality of Employment Survey Ann Arbor: Survey Research Center, Institute for Social Research, University of Michigan.

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(19.) Banks, M., Clegg, C., Jackson, P., Kemp N., Stafford E., & Wall T. (1980). The use of the general health questionnaire as an indicator of mental health in occupational studies. Journal of Occupational Psychology 53, 187194.

(20.) Kemery, E., Bedeian, A., Mossholder, K., Touliastos, J. (1985). "Outcomes of role stress: a multisample contractive replication. Academy of Management Journal. 28:2, 363-375.

(21.) Schuler, R.S. (1980). Definition and conceptualization of stress of organizations. Organizational Behavior and Human Performance, 24, 115-130 and 104. (184-213).

(22.) Fisher, C.D. & Gitelson, R. (1983). A meta-analysis of the correlates of role conflict and ambiguity. Journal of Applied Psychology 68, 320-333.

(23.) Copur, H. (1990), Academic professionals: A study of conflict and satisfaction in professionals. Human Relations, 43:2, pp. 113-127.

(24.) Burke. G., Thompkins, L., Summers. J. & Jugmu, C. (1993). Role stress among physician executives. The Physician Executive, Sept-Oct. 19:5, 9-14.

Eileen C. Sherman, PhD, MBA, is an Assistant Professor and Program Director for the Health Services Administration Program, Department of Preventive Medicine, at the Medical College of Wisconsin in Milwaukee. She also consults and delivers seminars to diverse groups of health care professionals on topics in organizational behavior and management. She can be reached by calling 414/456-4505 or via email at [e-mail].