Background
‘Job morale’ is a widely used concept both in healthcare and in wider contexts [
1]. Although job morale does not have a universally adopted definition, in healthcare research is seen as an umbrella term for various job-related concepts, including job motivation, job satisfaction, burnout and job-related well-being [
1]. It was defined that employee needs to be pleased, enthusiastic and comfortable with their job in order to have positive job morale. In contrast, negative job morale was claimed to be present if feelings of displeasure, anxiety and depression prevailed [
2]. Current literature suggests that healthcare staff with positive job morale are more likely to provide higher quality care to patients [
3], and it has been suggested that improving job morale can improve job performance and/or address inadequate job performance in areas with fewer/inadequate resources [
4]. Furthermore, positive job morale is associated with greater retention and higher recruitment of healthcare staff [
5]. It has also been suggested that positive job morale is linked with better experiences for patients, contributing to patient-centred care [
6,
7]. Negative job morale among healthcare staff, in turn, is linked to poorer patient safety [
3], higher levels of self-reported errors [
3], poor career engagement [
8] and increased healthcare expenditure on staff turnover and sickness absence [
9].
Despite that job morale has been reported to differ by professional group [
10] and training status [
11‐
13], most studies on job morale in healthcare have targeted either medical residents [
14,
15], nurses [
16‐
19] or healthcare staff in general [
10,
20‐
22]. Recent reviews have begun to explore levels of indicators associated with job morale physicians and dentists in Low-and-Middle-Income Countries (LMICs), as well as factors and experiences influencing job morale [
23,
24]. This research has showed that job morale in LMICs varied by country and speciality to some extent, but was generally positive, with around 60% of physicians and dentists reporting satisfaction with their job [
24]. One of the main factors influencing job morale, is negative experiences such as poor salary or a poor physical or social working environment [
23].
Kazakhstan is a country located in Central Asia which became independent in 1991 after the dissolution of the Soviet Union. Since gaining its independence, Kazakhstan has demonstrated strong economic growth, allowing the country to move from the lower-middle-income to upper-middle-income group, according to the World Bank classification [
25]. However, economic progress has not been reflected in accompanying improvements in the healthcare system and health-related outcomes. Despite several waves of reforms, reliance on hospital care is still prevailing, and governance remains centralised [
26]. Healthcare service delivery is fragmented, and quality of care is impaired by the insufficient staffing levels and limited infrastructure of healthcare facilities [
26]. Public healthcare settings in Kazakhstan are funded depending on their level. Financing of outpatient service providers is achieved via a two-level capitation payment system which reflects the number and features of the allocated population, and includes an additional pay-for-performance component [
26]. Financing of hospitals is based on diagnoses-related groups, where each diagnosis-related group/ service has a fixed price called a tariff [
26]. Per these tariffs, hospitals are reimbursed by the state. Tariff prices for healthcare services are low in Kazakhstan, which results in low salaries for healthcare workers as tariffs are included in the salary costs. In general, physicians’ salaries are formed from a guaranteed basic salary and differential payments allocated depending on state budgetary savings and in accordance with qualification category and exposure to stress [
27]. A review by the Organisation for Economic Co-operation and Development (OECD) reported that job morale among healthcare providers in Kazakhstan is low. However, there are limited data supporting this finding or exploring the factors behind the low morale [
26].
Considering the previous literature, this study aimed to further explore experiences underpinning positive and negative job morale, and to generate potential strategies for improving job morale of physicians and dentists working in public healthcare settings in Kazakhstan prior to the COVID-19 pandemic.
Methods
This study report follows the Consolidated Criteria for Reporting Qualitative Studies (COREQ) [
28].
Design
A subtle realist approach was employed in this qualitative study, which stresses that there is ultimately a reality but that human knowledge of this reality is shaped by subjective perceptions [
29]. It was appropriate for the context of this study because views about job morale are based on and influenced by participants’ personal experiences and perceptions of these experiences.
It was pragmatically assumed that participants’ personal experiences underpinning job morale and views on what could be done to its improvement will be closely linked and largely overlapped. Therefore, the current study adopted a combination of two methods of data collection—individual, semi-structured, face-to-face interviews and focus group discussions. Specifically, interviews were conducted to collect in-depth personal experiences of job morale, and focus groups to gain a group perspective on what could be done to improve job morale.
Sampling and recruitment
A multistage stratified purposive sampling method was adopted for the individual interviews. It allowed to ensure the incorporation of a range of experiences via selecting participants groups that "display variation on a particular phenomenon, but each of which is fairly homogeneous” [
30]. To begin with, Astana has been chosen as a study site because, as the capital, it allocates all types of state healthcare settings, including polyclinics (primary healthcare settings), regional, city, specialised and national hospitals, which differ in their capacity, infrastructure, financing, and payment schemes. Further, out of physician specialities, psychiatrists have been chosen as representatives of specialised hospitals, surgeons as representatives of regional, city, and national hospitals, and dentists were selected as polyclinics’ representatives. Based on the systematic review and meta-analysis findings that years of experience are likely to be correlated with job morale [
24], stratification was advanced by the inclusion of years of practice (0–9 years or 10 + years) as a further stratification category. Thus, physicians could take part if they had qualified with a specialisation in psychiatry, surgery, or dentistry, and were currently employed in public healthcare settings in Astana. Medical students and residents were excluded for this study. Theoretical saturation was achieved by conducting thirty interviews, or in other words “gathering fresh data no longer sparks new theoretical insights” [
2]. Although theoretical saturation is conceptually controversial and uncertain [
31], it was possible to claim that it had, in fact, been achieved because transcription and familiarisation with data were performed concurrently with the interviews.
To ensure a range of opinions and to identify central themes, maximum variation sampling was adopted for focus group discussions, with the sampling frame designed to increase the variation in healthcare physician specialities, years of practice and employment settings across public healthcare. Thus, physicians and dentists could take part if they were qualified and employed in public healthcare settings in Astana. Furthermore, participants from the individual interviews were invited to attend focus group discussions. It allowed the emerging thematic framework from the interviews’ analysis to be tested with the focus group participants. Three focus groups were planned based on the recommendation that the overwhelming majority of themes would be discoverable within the dataset obtained from three focus groups [
32]. The aim was to recruit six to eight participants for each focus group (including physicians who were recruited from the interviews), which is the optimal number of participants to create an adequate group dynamic, giving each participant enough time to discuss their own views [
30].
Participants were recruited for interviews and focus groups via adverts disseminated on online social media and WhatsApp. Moreover, participants who had taken part in the individual interviews were invited to participate in the focus group discussions.
Procedure
At the start of each interview and focus group discussion, participants were provided with the information sheet, introducing study aims and procedures. It was highlighted that participation is voluntarily and anonymous and participants can withdraw from the study at any time. Further, participants were asked to sign an informed consent form, and a short socio-demographic form detailing participants’ specialities, gender, and years of practice was filled out.
AS conducted each offline face-to-face interview in a private office at the participants’ workplaces in the presence of the interviewer and interviewee only between April and July 2019. The interviews were conducted in Russian (n = 27), and Kazakh (n = 3) and whose duration ranged between 35 and 60 min. Participants received 10,000 KZT (£20) remuneration for their participation. The interview topic guide was developed in English and covered the following areas: 1) general views on job morale in participants’ specialities and professions; 2) specific views on experiences influencing job morale (physical and social work environment, financial and non-financial rewards, work content, and managerial context); 3) general views about the potential impact of job morale on the care provided; and 4) specific views on factors which could potentially worsen or improve job morale. Consistent with the semi-structured interviews, participant leads were pursued by asking follow-up questions to clarify their responses.
All focus groups were conducted by two facilitators (AS and MT) at Astana Medical University during October 2019. The focus groups were conducted in Russian and lasted between 90 and 120 min. AS acted as the main group facilitator and asked the majority of questions. A co-facilitator (MT) assisted the main facilitator by prompting the group during the discussion. Participants received 5000 KZT (£10) remuneration for their participation. The topic guide for the focus groups was also developed in English and consisted of two main parts. Firstly, it included an introduction to the main negative influences on job morale as identified in the individual interviews. Secondly, it provided the framing question and potential probes on what could be done to improve the job morale of physicians and dentists working in Kazakhstan. To ensure the accuracy of the data collected, all interviews and focus groups were audiotaped and field notes were taken.
Transcription and translation
The transparency and reliability of the study were enhanced by following the recommendations for cross-language qualitative research [
33].
AS translated the interview topic guides for individual interviews and focus group discussions into Russian and Kazakh, and MT carried out the backtranslations, ensuring the consistency and validity of the translations.
Interviews and focus groups were transcribed verbatim, and a random subsample were proofread by MT for accuracy. Transcripts of three randomly selected interviews and one focus group were fully were translated into English by the lead author and a translation agency in Astana (agreement 75%). Disagreements were resolved by involving another reviewer (MT), and iterative backtranslation was conducted to ensure reliability and transparency. Further, only quotes used in the study were translated by the candidate and backtranslated by the translation agency in Astana.
Research governance and ethics
The study received positive opinions by ethics committees at Astana Medical University and Queen Mary, University of London.
Data analysis
Data analysis was performed in two stages. The analysis of data obtained from individual interviews was followed by the analysis of information gathered from focus group discussions. Thematic analysis was chosen as the analytic strategy in both stages and performed following six recursive phases: familiarisation with data, generating initial codes, searching for themes, reviewing for themes, defining and naming themes and producing the report [
34]. A multicultural research team was assembled, spanning a variety of different disciplines. Firstly, AS and MT familiarised themselves with the transcripts and used NVivo (Version 12) to initially code the transcripts. An open inductive or “data-driven” coding approach was utilised, which is highly dependent on and is linked with the data. Furthermore, the inclusivity principle was employed in order to detect as many potential codes as possible [
34]. For both individual interviews and focus groups, a random selection of transcripts were selected, and coding frames were created, compared and merged into one by AS and SP. Transcripts were then recoded in accordance with the agreed coding frame by AS. Analysis then moved into more in-depth interpretation of the coded data via collating and merging of codes into themes and sub-themes. During this process, a sufficient level of internal and external homogeneity was reached, ensuring that quotes assigned to the same theme were related, and that quotes assigned to different sub-themes were different, respectively. Themes and subthemes were then arranged and named by AS and SP. Study team members challenged the coherence of developed themes, checked whether they had enough data to support them and ensured the distinctiveness of themes by advising conceptually similar ones be collapsed.
Creating a shared responsibility for health
This theme encompassed the need for revised ethical guidelines for healthcare providers in Kazakhstan. It was suggested by participants that these guidelines should clarify ethical principles and how to raise concerns in medical practice.
“Perhaps our ethical standards are outdated. We are still living by the principles that were developed for the Soviet healthcare system, which was free and for all. (…) I got used to delivering care for everyone and for free, so I am not sure how to say to a patient that he does not have health insurance and he will not get treatment, for example.” (Focus group 1, male, cardiologist)
Additionally, it was suggested that there should be a shared responsibility for the health of patients, achieved by educating patients about their health and simple first aid and prevention. It was suggested that guidance should be given to patients about how to navigate medical information in the media, in the climate of irresponsible and hostile journalism.
“I do not believe that we can do anything about our media and their hostile attitude towards us. (…) In this situation, I think we need to explain that not everything being published is true. (…) We can provide something like guidance on how to read health-related articles or something like that.” (Focus group 2, female, ophthalmologist)
Furthermore, participants noted the urgent need to revisit health promotion approaches as the overall impact of current methods is somewhat limited. It was stressed that health promotion should correspond to the technologically changing environment and demands integrated action by the health sector and the media.
“I think it is important to understand and promote the fact that we cannot rely purely on the health sector. For example, health promotion programmes should be supported by industries or other stakeholders.” (Focus group 2, female, dentist)
Discussion
Main findings
This study aimed to explore the job morale of health professionals working in public settings in Kazakhstan, and potential strategies for improving it. Participant accounts were largely consistent, regardless of speciality, gender, years of practice and type of state healthcare setting. However, the female participants spoke explicitly about their additional pressures relating to marital status and prioritising of work-life balance.
The findings suggest that where job morale is positive, this is largely due to a high value-based motivation to work in their vocation, and help patients. However, various external pressure threatens the ability of professionals to deliver high-quality care. Participants described being unfairly rewarded for the excessive workload due to meagre income levels and existing problems accessing professional development. Poor financial remuneration often led to participants taking on extra responsibilities, which influenced a poor work-life balance and increased intentions to leave the profession. The perception of medical professions by society and media was also found to lead to poor job morale, as well as poor working cultures and practices. A number of suggestions were made to improve or at least sustain job morale, such as ensuring higher salaries through raised healthcare costs, improving malpractice systems and improving working practices in workplaces.
Comparison with the literature
Previous research has shown that excessive workloads and a lack of financial reward have been important factors contributing to low job morale of physicians in LMICs [
35,
36]. This was predictable, given prior knowledge of the relatively low incomes in the healthcare sector and considering that any increase in income does not correspond to an increase in real income amongst LMICs [
37]. Healthcare providers’ remuneration increases with country income group [
37], therefore, this issue has only rarely been mentioned in studies of HICs. Multiple employment, while common in healthcare across LMICs, has been suggested to lead to a poor work-life balance, especially in cultures where family (and starting a family) is an important part of a country’s culture [
36,
38,
39]. The importance of cultural expectations of family raising, and the pressure of participants to take on multiple jobs and responsibilities was also observed in the present study. Further to this, the findings of the current study reflect the factors found to predict burnout in the context of the COVID-19 pandemic [
40]. A recent systematic review aimed to summarise COVID-19 pandemic-specific factors and influences on burn-out and job morale [
40]. Similar to the findings of the current study, an increased workload and being unmarried were linked to burn-out [
40]. Furthermore, in the context of the COVID-19 pandemic, a wide range of physicians and healthcare professionals were found to be at a higher risk of burnout [
41,
42], with a number of different variables predictive of this, such as financial problems, facing violence when caring, being single [
41], and facing COVID-19 infection [
43], which were also mentioned in the present study.
Increases in income were often dependent on revalidation and appraisals which affected morale. This resembles findings of research among General Practitioners in England, in which General Practitioners claimed that these procedures had a negative impact on job morale and influenced their intentions to leave clinical practice [
44]. As in the present study, a sense of feeling undervalued and/or vulnerable to aggressive behaviour was found to contribute to poor job morale in Hispanic nurses working in the USA, which is a High Income Country (HIC) [
45]. A further factor linked with poor job morale in this current study was the concern of being sued for malpractice, leading to a sense of vulnerability. A study in Japan found that an increasing number of medical malpractice disputes are being handled through the criminal justice system, although Japan is not widely regarded as a particularly litigious society [
46]. This suggests that this factor may be felt by many medical professionals around the world.
Previous research has shown that the interactions and relationships between staff members in healthcare settings were seen as a positive aspect of work in those working in both LMICs [
35,
47] and HICs [
3,
48,
49], which links to the finding of relationships and interaction positively influencing job morale in the present study. Participants voiced a strong desire to help patients, and whilst altruism is important, it is important to highlight that the medical profession is not purely altruistic, as altruism often creates standards that are un-obtainable [
50].
Strengths and limitations
The current study has the following main strengths. Firstly, to our knowledge, this is the first qualitative study exploring the experiences underpinning positive and negative job morale, and the potential strategies to improve job morale in physicians and dentists working in public healthcare settings in Kazakhstan. Thus, this study allows us to further understand the processes underlying job morale and generate strategies at the local level which should be capable of shaping and driving potential policies and interventions. A second strength relates to its methodological rigorousness and sampling methods, ensuring that the sample included participants from across all types of state healthcare settings, multiple clinical specialities and ranging a vast number of years of clinical experience. A third strength was related to the methodological and participant triangulation, increasing the depth, breadth, and validity of the findings. Methodological triangulation was achieved by adopting two methods of data collection, namely individual semi-structured interviews and focus group discussions. Participant triangulation, in turn, was achieved by inviting participants from the individual interviews to attend focus group discussions. Additionally, the research team included researchers from the culture in which the study was conducted, thereby increasing cultural sensitivity, which is thought to be critical when conducting focus groups with culturally and linguistically diverse samples [
51].
A key limitation of the study is the recruitment of participants via social media, which may not be representative of the target population. However, this limitation is somewhat mitigated by the use of a sampling frame, recruiting a range of experiences and specialties. Another limitation was related to translation bias, which is common in cross-language qualitative research. This limitation was mitigated by involving another native speaker reviewer (MT) and a translation agency in Astana, who performed iterative backtranslations to ensure the transparency and reliability of the translation process. Furthermore, the findings may not be generalisable to other cities/regions within Kazakhstan, although training of professionals, societal context and overall health care system are similar, or other LMIC’s with different economic, legislative and healthcare contexts. Finally, in line with a subtle realist epistemology, it should be noted that the present study may be influenced by the first author, who was the interviewer, main facilitator of focus group discussions, and lead analyst.
Implications
Future studies should systematically assess and understand job morale of health professionals in the Central Asian region in particular and in LMICs in general, beyond Kazakhstan. Such research should also study how health promotion can be utilised and updated to provide patient education and share the responsibility of healthcare with self-management. Due to the cross-sectional nature of this research, future studies may need to examine longitudinal changes in job morale. However, even more important than assessing job morale are initiatives for improving. Our findings, which are largely consistent with other research, have suggested some strategies for achieving this. Such strategies should be implemented, tested and evaluated in different health care settings. The required research may take time and is unlikely to use strictly controlled experimental designs. In order to progress, international co-operation seems essential so that countries can learn from experiences elsewhere, even if contexts may differ.
Conclusions
The present study found that despite a number of significant threats, job morale of physicians and dentists working in public healthcare settings in Kazakhstan have been prevented from becoming negative by their strong sense of calling to medicine and the satisfaction of helping patients recover. Emphasising this rather traditional understanding of the role of health care professionals may be a way to improve morale throughout training and practice. Ensuring adequate and equitable financial income, improving the current malpractice system, eliminating poor working styles and practices, and creating a shared responsibility for health and care would help physicians and dentists feel fairly treated, heard and appreciated, and would thus sustain or improve job morale. It was noted that job morale is a key indicator of healthcare system inefficiencies, and significantly influences care quality.
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