How does social support affect public service motivation of healthcare workers in China: the mediating effect of job stress

In order to set apart the motivational bases of public service from the traditional rational motives of other sectors [1], Perry and Wise developed the concept of public service motivation (PSM) to understand behavior and staff management in public organizations, e.g., public hospitals [2], which has generated a lively research discourse and considerable interest in recent decades [3, 4]. PSM has been defined as “the idea of commitment to the public service, pursuit of the public interest, and the desire to perform work that is worthwhile to society” [5]. Witteloostuijn et al. described how research on PSM has involved two main perspectives. The first perspective focused on the PSM itself, including the definition, composition and measurement of PSM [6]. The second perspective was concerned with the impact of PSM at the individual and organizational level, such as volunteering and person-organization fit [7, 8]. Compared to existing research treating PSM as an independent variable, to our best knowledge, few studies have examined PSM as a dependent variable or have investigated the antecedents of PSM, although some investigations have been primarily conducted (e.g., individuals’ demographic information and job satisfaction) [6, 9].

Recent studies have investigated these limitations in the theoretical and practical treatment of PSM [2, 10]. Sex, education level, religious activities, volunteer work, family socialization, leadership style, hierarchical authority, and red tape are widely accepted antecedents of PSM [1, 11]. However, evidence and mediators regarding these antecedents are limited. Social support has a positive effect on individual motivation [12], and therefore affect PSM directly or through other variables, e.g., job stress, a common mediator in studies of social support [13]. Given the level of experienced stress was associated with specific stressors, job stress was divided into challenge stress (e.g., individuals felt high level of job overload, responsibility, and time stress) and hindrance stress (e.g., individuals suffered red tape, unclear tasks, and worry about job security) [14, 15], which would have positive or negative effects on their job satisfaction or voluntary turnover [14]. Therefore, it’s necessary and interesting to investigate how social support and job stress affect PSM.

Social support can affect PSM. Social support usually occurs when a person we can rely on shows that they care, value, and love us [16], which can be divided into supervisor/coworker support and non-work support (e.g., family support, friend support, and partner support) [17]. Supervisor support and coworker support may be the most important social support factors affecting workers’ PSM. With sufficient supervisor support, workers feel they are important members of the organization and realize that their goals fit organizational goals [18]. They will thus be more involved in their work and demonstrate more altruistic behavior, dedication, and organizational citizenship behavior—the concrete manifestations of PSM. With support from coworkers, employees can work better and provide better public service. More importantly, such employees are more likely to be happy with their work, which strengthens their PSM. These could satisfy the psychological needs of employees and increase the complementary fit between the individual and organization [19]. Therefore, we propose the following hypotheses for an empirical analysis.

Hypothesis 1: Supervisor support is positively related to PSM.

Hypothesis 2: Coworker support is positively related to PSM.

Job stress can be affected by social support. Job stress is generally regarded as a multidimensional concept, and the models proposed usually include various putative sources of job stress. A frequently used classification divides job stress into two factors: challenge stress and hindrance stress [14]. Challenge stress is defined as the job stress that people can overcome which is conducive to long - term career prospects (e.g., individuals felt high level of job overload, responsibility, and time stress), while hindrance stress is a kind of job stress that people cannot overcome which is harmful to long - term career prospects (e.g., individuals suffered red tape, unclear tasks, and worry about job security) [15]. In the workplace, supervisor support and coworker support are social support dimensions closed to job stress and contribute to supportive communication. Supervisor support may have both an informational and emotional effect on workers. Informational supervisor support could help reduce worker role conflict and organizational politics [20]. From an emotional perspective, supervisor support might help promote self-esteem and work security [21]. With the help and cooperation of coworkers, employees have a reduced job load and less time urgency and may thus better perform their job responsibilities. In turn, they likely obtain more personal fulfillment and less challenge to meet their job requirements. More importantly, workers are less likely to experience anxiety and can maintain a good state of mind by communicating with coworkers in the same work culture and environment [22]. This analysis suggests the following research hypotheses.

Hypothesis 3: Supervisor support is negatively related to hindrance stress.

Hypothesis 4: Coworker support is negatively related to challenge stress.

Job stress can affect PSM and mediate the effect of social support on PSM. Considering different types of job stress, job stress would affect PSM through two principal mechanisms. On the one hand, challenge stress, e.g., job load, job responsibility, and time urgency increase the psychological burden and prevalence of mental disorders among staff [23], as well as the possibility of burnout and turnover intention [24]. However, if workers have sufficient professional skills, vocational relations, and coworker support, they may be able to adapt and overcome such challenge stress. Challenge stress would then be less harmful and might even encourage employees to increase their degree of job control and act positively to finish their work [25, 26]. In this situation, workers would feel that they are fit for the job and organization and able to perform the work, act in the public interest, and provide public service to others [27].

On the other hand, a sense of “effort-reward imbalance at work” also produces hindrance stress [28], and weakens workers’ PSM. For many employees, especially new workers, reciprocal modulation of the relationship between them and their supervisors is very important. While working hard, they also want to be recognized and rewarded by their supervisors and organization [18]. If their efforts elicit a positive response from supervisors, PSM is strengthened and they will work harder. However, if workers feel that supervisors are more focused on their social relations and professional background rather than on their job performance, or if workers are confused about their role responsibility and work process, they might experience frustration and a lack of job security [29]. More importantly, workers might come to regard their work as stagnant because of the lack of rewards and supervisor support. In these situations, workers felt huge hindrance stress, their enthusiasm and service motivation will be diminished. This analysis suggests the following research hypotheses.

Hypothesis 5: Challenge stress is positively related to PSM.

Hypothesis 6: Hindrance stress is negatively related to PSM.

Hypothesis 7: Challenge stress mediates the effect of coworker support on PSM.

Hypothesis 8: Hindrance stress mediates the effect of supervisor support on PSM.

Additionally, JD-R theory that is proposed to describe how job stress appears and affects employees’ psychological outcomes, provides further explains of the relations between social support, job stress and PSM [30]. This theory proposes that job characteristics can be divided into two opposed categories: job demands and job resources. Job demands refer to factors that require the individuals to make efforts or costs to complete the work, such as physical, psychological, and social abilities. Job resources are defined as factors that can (a) promote the achievement of employment objective, (b) reduce job demands and associated psychological and physical costs, and (c) promote personal prospect [31]. On the one hand, job demands lead to constant overtaxing and job stress, resulting in negative psychological and emotional consequences (e.g., exhaustion) and ultimately reduce PSM, as levels of stress accumulate over time will cause psychological withdrawal [32]. On the other hand, job resources directly and indirectly incentivize individuals. An important job resource—supervisor and coworker support—helps workers overcome job stress and enhances their PSM since this resource can alleviate the negative effect of job demands [30, 33, 34].

In China, public hospitals are an important part of the public sector, providing most healthcare services. The job characteristics, responsibilities and requirements of healthcare workers have led to increasing research interest in PSM and job stress among this group [35]. In addition, healthcare workers need sufficient social support in order to deal with complex working environment (e.g., overwork and violence) and provide good healthcare service. Social support, job stress, and PSM may therefore be a crucial and topic concern.

Most of the previous studies did not explore the antecedents of PSM, although some investigations have been primarily conducted [6, 9]. They did not consider the influence of social support and the mediating role of job stress. Thus, in this study we examined the mediating effects of job stress on the association between social support and PSM (Fig. 1), with a sample of Chinese healthcare workers from the area of knowledge part of a hospital context (e.g., doctors, nurses, medical technicians, and administrators) [36].

Using a sample of 973 healthcare workers, we investigated the relationship between social support, job stress and PSM in Chinese public hospitals. Overall, we found comprehensive but mixed support for our initial hypotheses. Supervisor support and coworker support significantly increased PSM among healthcare workers. Challenge stress and hindrance stress were negatively associated with PSM. Supervisor support and coworker support diminished hindrance stress and challenge stress, respectively, among Chinese healthcare workers. Challenge stress and hindrance stress significantly mediated the indirect effects of coworker support and supervisor support, respectively, on PSM. The present findings should prove useful for academic researchers and practitioners.

Our first key finding was that social support and job stress were predictors of PSM of healthcare workers, which added to the evidence from antecedent research on PSM. Social support, especially supervisor support and coworker support, has been used to explain a wide range of individual values, attitudes and behaviors, such as affective commitment [58], presenteeism [15], However, limited studies have investigated the relationship between social support and PSM. Our study provided empirical evidence of the positive effects of supervisor and coworker support on PSM. However, multi-group analysis showed that the impact of coworker support on PSM was weaker than that of supervisor support. This result is likely attributable to the fact that public hospitals are the main provider of healthcare services in China. Healthcare workers in China are exposed to high workloads and health problem but get paid less compared with their counterparts in Europe and the US [15]. An imbalance between job demand and resources limits the PSM of healthcare workers and eliminates the effect of coworker support on PSM [30]. In the light of context above, administrators should encourage and assist supervisors in their leadership functions, e.g., by urging supervisors to care about the work and life of subordinates and assist them whenever possible, identify and acknowledge the strengths and accomplishments of workers and encourage and recognize their efforts, and make workers’ jobs as interesting as possible [59]. Besides, they should also emphasize coworker support and good employee relationships. For instance, a system of group activities in public hospitals could be developed in order to enhance coworker support. Such a system could include training activities and outward-bound activities and might prevent conflicts and improve career development.

Our findings showed that supervisor support and coworker support had significant negative effects on hindrance stress and challenge stress of healthcare workers, respectively, which supported our previous hypotheses. The relationship between social support and job stress is multipath [60]. Social support and job stress are both multidimensional concepts, with the development of research, scholars are not only concerned with the overall concept but also the relationship between different dimensions which is multipath. Some previous studies have proved that supervisor support can reduce job stress [61‐63], and coworker support can also play the same role [64, 65], which was consistent with our findings. Supervisor support and coworker support can be viewed as job resources that deals with job stress through reducing psychological costs and promoting personal development according to JD-R theory [66]. However, these studies regarded stress as a unidimensional conceptualization and ignored the possible positive effect of stress [67, 68]. Consequently, to complement these previous findings, stress was divided into challenge stress and hindrance stress in this study. We investigated separately the relationships between supervisor support and hindrance stress, and between coworker support and challenge stress. Our results suggested that supervisor support lessened the hindrance stress of healthcare workers, because they feel they are taken seriously by their supervisors which indicates that organizational decisions are affected by their performance rather than politics so that the work environment is fair. Besides that, supervisor will explain the job to employees to help them understand and perform job, and provide job security. All these factors consist of the antitheses of hindrance stress. In contrast, coworker support decreased challenge stress among healthcare workers, because when healthcare workers cooperate with others, they can complete their duties—such as diagnosis and treatment—faster and more effectively, which lightens their psychological burden and sense of urgency [22].

Challenge stress and hindrance stress had a significantly direct negative effect on PSM of healthcare workers. Since individuals under severe job stress are less sensitive to others, they are unwilling and impatient to help. Therefore, job stress increased aggressiveness and weakened PSM [69, 70]. Previous studies have claimed that PSM can reduce the job stress on employees in the public service sector [2]. However, Giauque et al. believe that the current research on work stressors and PSM is far from enough. The relationship explained at this stage is much simpler than the real mechanism. Therefore, more empirical articles are needed to explore this topic [71].. Nevertheless, there are currently few articles exploring the role of job stress on PSM. Our research eliminated this limitation and found the negative relationship between job stress and PSM. On the one hand, the present findings showed that challenge stress had a significant negative effect on PSM and that the effect was as strong as that of hindrance stress. This result differs from our hypothesis. Since challenge stress always has a positive effect on individuals, e.g., by encouraging workers to learn and to overcome obstacles, thus benefiting career development [14, 72], we proposed that challenge stress was positively related to PSM. This interesting finding might be due to the complex working environment for healthcare workers. To our knowledge, the workload of healthcare workers in China is heavy: many are pressured to work 10 or more hours almost every day and always with high efficiency and in a state of tension [72]. In addition, the duties of healthcare workers are taxing, such as the responsibility to improve and maintain patient health. Episodes of medical violence against healthcare workers have worsened both the psychological burden of healthcare workers and the healthcare environment [73]. In this context, challenge stress may exceed the threshold for benefit and is therefore unlikely to have positive effects on PSM.

On the other hand, hindrance stress showed a negative relationship with PSM, which prove our hypothesis. Although no studies have examined the relationship between hindrance stress and PSM, the adverse effects of job stress, especially hindrance stress, on the individual and organization have been widely discussed in many studies based on JD-R theory. These effects include burnout [74], increased presenteeism [72], and increased turnover intention [75]. Hindrance stress includes demands that are viewed by administrators as unnecessary impediments to personal growth and goal attainment, and by employees as insurmountable [14]. The present analysis of data from 973 healthcare workers employed in Chinese public hospitals provided direct evidence of the negative effect of hindrance stress on PSM. Nevertheless, administrators of public hospitals should still be mindful of the intense job stress of healthcare workers and undertake interventions targeting challenge stress and hindrance stress. For example, public hospitals should consider interventions that help relieve employee job stress, such as psychological counselling, physical exercise, recreational activities, and lectures on mental health.

Another important finding of this study is that while hindrance stress and challenge stress directly affected PSM, hindrance stress also mediated the effects of supervisor support, and challenge stress mediated the effects of coworker support, on PSM. In the subgroup analysis, the influences of social support on doctors’ PSM have been fully mediated by challenge stress and hindrance stress. This is mainly because doctors in China suffer from huge challenge stress (e.g., job load that can increase the psychological burden and prevalence of mental disorders) [76] and hindrance stress (e.g., job insecurity that cannot be solved and prevent career development) [77]. Severe stress makes individuals less sensitive and impatient to help others, which weakens PSM [69, 70]. Under such tremendous stress, doctors may first find job resources like supervisor support (e.g., supervisors reward doctors’ efforts to make them secured) [21] and coworker support (e.g., coworkers assist doctors’ job to reduce their job load) [22] to reduce stress according to JD-R theory. With less job stress, doctors are willing to help others and will demonstrate more PSM (e.g., altruistic behavior, dedication, and organizational citizenship behavior according to PSM theory [4]). Therefore, supervisor support and coworker support could significantly enhance PSM only through intervening challenge stress and hindrance stress among doctors. For nurses and other healthcare workers, the impact of coworker support on PSM was not significant, that is, the challenge stress played a completely intermediary role. This is because they generally play a supporting role in the team and need the help from other coworkers to reduce the challenge stress like job load [78]. With less job load, they can perform better and feel happy with their work to satisfy the psychological needs and increase the complementary fit between the individual and organization, which strengthens their motivational base for public service [19]. Therefore, like doctors, for nurses and other healthcare workers, coworker support can only increase PSM by reducing challenge stress. The mediating effect of the hindrance stress on nurses was not significant. This is mainly because nurses are always treated as support staffs, rather than formal members of the treatment team [79]. They are more eager to be treated as an important member of the team through the supervisor support rather than reducing role conflict or red tape of organizational politics. Then person-organization fit can be achieved, and they are willing to perform more altruistic behavior, dedication, and organizational citizenship behavior—the concrete manifestations of PSM [4, 19]. Hence supervisor support can increase PSM directly and the mediating effect of hindrance stress of nurses was not significant.

Because of the limited data on the antecedents of PSM, previous studies did not consider mediators between social support and PSM. Our results shed light on how supervisor and coworker support affect PSM through hindrance stress and challenge stress, as described in JD-R theory. Hindrance stress and challenge stress are the individual’s psychological reactions to job demands. Supervisor support and coworker support are important organizational resources provided to workers and help workers to meet their work demands, while reducing job stress and increasing PSM.

In conclusion, supervisor support and coworker support are significantly negatively associated with hindrance stress and challenge stress, respectively, and positively with PSM. Challenge stress and hindrance stress are directly negatively associated with PSM, and the significant indirect effects between supervisor support and coworker support and PSM are significantly mediated by hindrance stress and challenge stress. Thus, administrators of public hospitals should focus on the relationship between social support, job stress and PSM and on interventions targeting increased supervisor and coworker support. In addition, administrators should attempt to decrease challenge stress and hindrance stress by improving work conditions and by offering more opportunities for healthcare workers to improve their work relationships and relieve stress.