INTRODUCTION

The structure of most health care systems focuses on patient satisfaction and population wellness.¹ However, there is an ongoing shift in this trend to accommodate concerns for the psychological status of health care providers.¹

Early career doctors (ECDs) are a significant unique group of doctors globally and especially in Nigeria, constituting a significant proportion of the physician workforce.² In some other parts of the world the term Junior Doctor is used.^{2, 3} A good proportion of ECDs in Nigeria are enrolled in residency training programme.⁴

It is important to explore any factor that would contribute to their wellbeing, as this would invariably result in a win-win for everyone. For the ECDs, job satisfaction is associated with physical and mental health benefits, better motivation and enhanced productivity.^{3, 5} Patients tend to be satisfied with doctors who are satisfied; they also tend to be more motivated to follow through with their treatment (medication adherence, follow-up).⁶

Several types of research have explored the ECDs and other mental health and psychosocial issues such as burnout and job dissatisfaction.^7-9 However, it is essential to explore job satisfaction independently from these negative correlates. Several studies have suggested that their effects and influencing factors are not necessarily exact opposites of one another.^5,10

Job satisfaction in the context of ECDs

Job satisfaction is an independent indicator for judging an individual’s wellbeing that has been vastly explored.^6,11 Edwin A. Locke defined job satisfaction as ‘a pleasurable or positive emotional state’.¹⁰ Paul E. Spector defined it as ‘how people feel about their job and different aspects of their job’.¹² From the definitions, there is a strong emphasis on subjective emotional perception in defining job satisfaction. Job satisfaction in ECDs is the positive state attained from his/her job.

Two sets of factors impact on job satisfaction: intrinsic (autonomy, recognition gotten from the job, patients’ care, among others) and extrinsic factors (working conditions, company policies and salary). Intrinsic factors provide internal motivation from the resulting recognition, the tasks themselves and one’s responsibility on the job. Extrinsic factors are defined as those external benefits provided to the professional staff by the organisation.¹² Herzberg’s two-factor theory argues that only the former is a direct cause of satisfaction, while extrinsic factors predict dissatisfaction more. However, even though much of the empirical evidence available among ECDs agree to an extent the importance of intrinsic factors, their overall results deny that intrinsic factors have an exclusive effect on job satisfaction. In other words, contrary to Herzberg’s theory, available evidence suggests that extrinsic factors can contribute positively to job satisfaction. For example, a qualitative study was carried out amongst interns to determine predictors of job satisfaction and two extrinsic factors; supportive work environment and poorly organised teaching sessions were found to be significant predictors of job satisfaction.¹³

Most studies agree more with Locke’s contrary opinion that overall job satisfaction is a product of the total of the interaction between the worker, (in this case the ECD) and his/her work (intrinsic factors) and work environment (extrinsic factors).^{6, 10, 14}

Some of the other theories that have been applied to job satisfaction among ECDs are job demand-control model (JDC-model), Effort-reward Imbalance model(ERI-model), job characteristic model and Job Demand-Resource model (JDR-model).^{6, 14, 15} Solberg was able to demonstrate with his study that ERI model and JDC model are very applicable to ECDs given the high effort/demand involved in their work.

The job demand-resource model has also been employed in describing the epidemiology of job satisfaction among ECDs. For the ECDs, demands would include heavy patient load, long working/frequent call hours, emotional involvement in patient care etc. Resources would include inter-personnel communication, autonomy, participation, among others.

Assessment of Job satisfaction among ECDs

Most researchers employ questionnaire to conduct a cross-sectional or longitudinal survey in appraising job satisfaction among ECDs.¹⁵

Locke defined a job ‘not as an entity but an abstraction

referring to a combination of tasks performed by an individual in a certain physical and social context for financial (and other) remuneration’.¹⁰ Based on Locke’s definition, an appropriate assessment tool would not explore only intrinsic properties of the job but the interrelationship between the ECD and his work. Some of the popular validated tools globally are the Michigan Organisational Assessment Questionnaire Job Satisfaction Subscale (MOAQ JSS), Job Description Index (JDI), Job Satisfaction Survey (JSS)  and Job Diagnostic Survey (JDS).^{15, 16}

Many of these tools have been used/modified for use amongst ECDs, however hardly would one find a tool specifically validated for this population.

There is the 20-item Minnesota satisfaction questionnaire that has been used by various studies amongst doctors, including ECDs. The Job satisfaction survey (JSS) is a 5-point Likert scale with 36 items.¹² The 36 items span across nine dimensions of job satisfaction as classified by Spectre. These are pay, promotion, supervision, benefits, contingent rewards, operating procedures, co-workers, nature of work and communication.¹⁷

Batura et al studied the validity and reliability of the JSS in assessing job satisfaction among health workers in Nepal (a Low/middle-income country) and found it a reliable tool.⁶ He added the caveat that’ the work environment dimension of the tool be tailored to reflect the interests of the specific population being evaluated’.¹⁴ This same caveat was added by one of the validators of the 10-item Job Satisfaction Scale used to assess job satisfaction in the Medicine in Australia: Balancing Employment and Life (MABEL) study. The scale was initially constructed by Warr et al to consist of 15-item which was revised to 10 items because 5 of the questions did not apply to doctors. Solberg used it in his study on ECDs in Norway and Iceland.⁶

Professional Quality of Life (ProQOL) was used to assess job satisfaction among junior doctors in Australia, and, the results were consistent with other studies³.

Based on face validity, one can expect reasonable levels of reliability from their use amongst ECDs. All of these tools access various dimensions (both intrinsic and extrinsic factors) of job satisfaction using Likert scales.

Prevalence of Job Satisfaction among ECDs

The level of job satisfaction amongst doctors in Sub-Saharan Africa is generally thought to be low. Most studies focused on factors that influence job satisfaction with limited data on the exact prevalence in our locality. However, only 55.2% of a subset of ECDs in Ibadan, Nigeria, was said to have job satisfaction.¹⁸and about 62.7% of their counterparts in a similar study conducted in Egypt.¹⁹ In apparently more developed regions of the world, job satisfaction appears to be higher. For instance, over 70% of ECDs in Australia had high job satisfaction.³ This finding is similar to the 80-85% in a European study.⁶

The varying level of prevalence observed among ECDs in different regions of the world may be attributed to several factors, including the differences in the living conditions, technological advancement, and overall quality of life in these differing climes.

Several comparative studies of ECDs with older doctors consistently point to a significantly lower level of prevalence among ECDs.^{8, 20} Solberg studied the course of job satisfaction among doctors and found a higher satisfaction among mid- and later- career doctors compared to ECDs.⁶

Many works of literature agree that age in itself is not a statistically significant influencer of job satisfaction or maybe weakly significant.⁶ However, the highest job satisfaction has been found amongst older doctors or better still more experienced doctors.⁶ Certainly, age increase with the years of experience. Hence, it is possible that older doctors might get higher pay based on longer working experience and several promotions/recognitions, and may also have moved to areas of jobs they found more appealing to them – a fact that might not be true of younger doctors, who are still trying to find their footing on the job. Also, older people might be possibly more experienced on the job thus feel less stressed by it. These reasons may explain why they are more satisfied with it.

Theoretically, given the correlation between low level of satisfaction and migration; and the brain drain amongst ECDs in Africa- one may assume that ECDS have low satisfaction in Africa.²¹ Therefore there is the need to explore such interplay.

Factors affecting job satisfaction

Sociodemographic factors

1. Age- amongst ECDs, most studies show no significant difference with job satisfaction and age; however, a few studies show higher job satisfaction with lower age.^{18, 22-24} The latter finding is in keeping with the J-shaped curve that describes the relationship between age and job satisfaction generally.³ However, the high satisfaction within the younger age group may be attributed to excitement and anticipation of just starting a career.
2. Gender- the findings are variable. Many studies show no association between gender and job satisfaction, but few showed higher satisfaction among females.^{6, 23, 25} In these studies, females specifically had higher satisfaction with being a doctor (intrinsic value).

• Marital Status- ECDs who are married appeared to be more satisfied with their jobs than those who are not.⁶ Married persons might be expected to have better emotional support and companionship. These may contribute potentially to overall satisfaction.

Facets of job satisfaction

1. Autonomy

This is an intrinsic value that explores the extent to which one can control the content and schedule of his/her work.¹⁴ Being able to do this boosts self-confidence, sense of responsibility and morale which in turn would translate to professionalism and increased motivation.^{18, 26}

ECDs have high levels of satisfaction with many intrinsic factors with the notable exception of this facet-autonomy.^{6, 18, 26} This finding was consistent even among early-career general practitioners in the Netherlands, that many assume have a relatively more flexible work regimen.²⁶ The importance of autonomy among ECDs is reflected in the fact that a controllable lifestyle despite the job is considered very strongly in choosing their future specialities.¹⁸

1. Remuneration

Many studies show that pay is an important variable and many ECDs are not satisfied with their pay.^{23, 24} However, some studies have shown that the ECDs’ satisfaction goes beyond financial benefits. For example, more than 90% of ECDs reported satisfaction with pay but overall job satisfaction was much lower. In Egypt, although pay showed highest dissatisfaction among resident doctors, overall job satisfaction was generally acceptable.¹⁹ Comparatively, a study showed that ECDs are more satisfied with their pay compared to physicians in the end stage of their careers.²⁶

In considering financial benefits, the role of other factors such as specific discounts for health workers, special loan repayment schemes, pension schemes, as well as the overall purchasing power in the country may be explored rather than remuneration as a single factor.

1. Workload and working environment

Workload incorporates both the amount of work (patient/-load/clinical, administrative, academic) and the time put in to do the work. These are significant job demands. Junior doctors/ECDs generally work for very long hours, and this is a poor predictor of job satisfaction.²³ A  study showed that working for fewer hours was one of the reasons that ECDs in Norway had more job satisfaction than their counterparts in Iceland.⁶

1. Training and Skill Acquisition.

Training and skill acquisition are traditionally categorised as extrinsic factors; however, on the premise that they are core components of the job description of ECDs, one study suggested they may be better classified as intrinsic factors.^{2, 13}

Majority of ECDs are engaged in the residency training programme. Several studies found that a perception of suboptimal training is correlated with low satisfaction.^{14, 27} One study found only 12% of residents in a Nigerian hospital satisfied with the quality of their training.²⁸

In another study, the strongest influencer of satisfaction among a subset of ECDs was skill acquisition, and professional advancement and improved skill favours job satisfaction.^{6, 18}

This list exploring facets of job satisfaction is not exhaustive. However, different facets in all tools are designed based on the assumption that they all both independently and collectively contribute to overall job satisfaction.¹⁰

Measurable outcomes of Job Satisfaction among ECDs

Job satisfaction in ECDs is indeed a win for everyone. It may not directly translate to better performances, but studies show that in the very least may have an indirect effect.¹⁵ It improves commitment to the organisation by these group of workers. More so, its role in determining health and wellbeing cannot be overemphasised. Job satisfaction is associated with improved physical and mental health.^{3, 29} With these the likelihood of error is fewer.¹³ This also goes a long way in combating brain-drain to the advantage of the health sector.⁶ The satisfied ECDs also rubs off on his patients, motivating the patient to comply with the treatment plan leading to better health outcomes.⁶

While some studies have assessed job satisfaction among Nigeria physician cohorts, it is imperative to focus on ECDs which form the stock of future physician leaders. Furthermore, it is necessary to examine this in the background of the chronic inadequate physician workforce in Nigeria and continuous brain drain and the high burden of other mental health and psychosocial issues.^{17, 21, 30}

Conclusion

Enhancing job satisfaction among ECDs would go a long way in optimising the quality of health care provided and the health sector at large. Studies among sub-sets of ECDs imply they have low satisfaction. One cannot ascertain a national or general prevalence. Available literature supports the fact that low remuneration, unconducive work climate, perceived suboptimal training contribute strongly to this. There are available tools that can reliably assess job satisfaction. However, when used among ECDs, they need to be adapted to the context of their environment. There is a need for a large-scale study focused on ECDS to be able to make a categorical, general and evidence-based conclusion on job satisfaction among ECDs in this environment for policy formulation and beneficial decisions.

Funding

This study was supported by the Nigerian Association of Resident Doctors (NARD) via the Research & Statistics Committee of NARD.