Background
There is increasing evidence to suggest a positive relationship between physician job satisfaction and patient satisfaction as well as health outcomes, i.e. continuity of care, lower no-show rates, and enhanced adherence to treatment [
1‐
4]. Interestingly, the “affective revolution”, taking place in organizational context the last decades, has pointed out the importance of psychological constructs implicated in the process of job satisfaction (JS), such as Emotional Intelligence (EI) and Emotional Labor (EL) [
5].
Although emotions constitute a common characteristic of human beings, each individual differs widely in “the ability to monitor one’s own and others’ feelings and emotions, to discriminate among them and to use this information to guide one’s thinking and actions” (i.e. EI) [
6], p. 189]. Mayer and Salovey [
7] conceptualized four facets in EI: appraisal of emotion in self, recognition of emotion in others, regulation of emotion, and use of emotion to promote performance. Theoretical approaches were followed by the design of measures to assess the construct of EI. On the basis of the measurement method used to operationalize them, EI constructs can be categorized into trait EI (emotion-related self-perceived abilities and behavioral tendencies measured through self-report tests) and ability EI (emotion-related cognitive abilities that should be assessed via maximum-performance tests) [
8]. Most scientific research in various fields is conducted within the framework of trait EI [
9]. Irrespective of the theoretical framework used for empirical data interpretation, self-report measures remain important as well as widely used tools in different scientific fields [
9,
10].
EI has emerged as an interesting topic in social and organizational psychology [
11] and appears to play a critical role in key organizational outcomes, such as job performance and JS, especially when the focus is on human interaction [
12‐
15]. Importantly, in the health care setting, physicians who are more competent in recognizing emotions, concerns and needs of patients are more successful in treating them [
15,
16]. Therefore, the interpersonal communication between the patient and the physician plays a major role in patient outcomes, and emotionally intelligent physicians consist of a valuable resource for hospitals. In the organizational psychology literature, much attention has been drawn to the positive association between EI and JS (the latter being defined as “a pleasurable or positive emotional state resulting from the appraisal of one's job or job experiences”) [
17], p.1304]. As supported by a wide range of studies in varied work environments, employees with higher EI are more satisfied with their job [
13,
14,
18‐
21]. Furthermore, research findings from the limited number of empirical studies examining the moderating role of gender in the EI-JS relationship are controversial. According to Petrides and Furnham [
22] and Salim et al. [
23], gender does not moderate the path from EI to JS, whereas Afolabi et al. [
24] argue that EI and gender may interact to influence JS.
H1a: EI is positively related to JS
H1b: Gender may moderate the positive effect of EI on JS
During interpersonal transactions, service employees are frequently involved in the process of emotional labor, i.e. amplifying, suppressing or faking emotions to comply with organizationally desired rules and complex role demands [
25‐
28]. Two types of EL acting mechanisms have been proposed: surface acting (SA) and deep acting [
29,
30]. In SA, employees alter the outward appearance of an emotion, i.e. put on a fake smile towards an annoying customer, thereby masking true feelings. In deep acting, employees modify internal feelings in order to comply with the appropriate organizational display rules, by making an effort to understand and sympathize with other people [
30]. EL is associated with emotional exhaustion and job burnout [
29,
31], higher levels of work stress and psychological distress, and job dissatisfaction [
29,
32,
33]. Typically, research indicates a negative correlation between EL and JS for employees who engage in the process of SA [
25,
29,
34‐
36]. According to a meta-analysis underlying the importance of each type of EL, SA, as an “arduous” process entailing both emotional suppression and production of the appropriate emotion [
37], is negatively related to JS, whereas deep acting does not display any significant relationship with JS [
38]. Interestingly, Johnson and Spector [
39] indicated gender as a significant moderator in the relationship between SA and JS, with females being more likely to experience job dissatisfaction when engaged in SA. Furthermore, to the authors’ best knowledge, it has not been clarified whether SA is uniquely associated with JS beyond other influential factors including EI.
H2a: SA is negatively related to JS
H2b: Gender moderates the negative effect of SA on JS
H2c: SA may predict JS above and beyond EI
EI is a critical factor in performing EL; attributes of EI, such as perception and regulation of emotion, may modify employee’s EL behaviors [
40,
41]. Although emotionally intelligent people are assumed to be more adaptive in regulating emotions according to situational demands [
7], results of studies exploring the association between EI and EL have been contradictory. Austin et al. [
42] and Mikolajczak et al. [
40] showed a negative correlation between EI and surface-acting EL, whereas Brotheridge [
43] demonstrated no significant correlation between EI levels and SA, assuming that sample characteristics might have weakened the strength of the relation between EI and EL.
H3: EI is negatively associated with the SA component of EL.
Apart from a direct relationship between EI and JS, research has also established the mediating role of different variables, such as positive and negative affect, as well as personal accomplishment, in the EI-JS relationship [
13,
41]. According to Wong and Law [
44], a significant positive correlation exists between EI and JS; yet, the relationship is not moderated by EL. Lee and Ok [
41] recently suggested that SA played no mediating role in the EI-JS relationship in hotel employees. Given the limited evidence, any possible mediating or moderating role of SA in the EI-JS relationship remains to be elucidated.
H4a: SA may mediate the EI-JS relationship
H4b: SA may moderate the EI-JS relationship
Research has primarily focused on direct associations among organizational psychology variables, while empirical studies integrating the constructs of EI, JS and EL in healthcare occupational setting and particularly among physicians are very limited; thus no safe conclusions can be drawn. The present study investigated the possible direct and/or indirect links between EI, SA component of EL, and JS as well as any possible moderating role of SA and demographic variables in medical staff working in tertiary health care in Greece. Apart from the primary research hypotheses, reliability and validity of constructs were also tested.
Discussion
The results of this study indicate that physicians with higher EI (i.e., higher UOE) have higher levels of JS. This finding is in accordance with a growing number of studies, showing a positive correlation between EI and JS [
13,
14,
19,
41]. EI may promote the building of interpersonal relationships in the work environment [
13] and contribute to an employee’s success and competence in an organization [
20]. Furthermore, awareness of the factors that elicit particular emotions, positive or negative, permits employees to act in the most appropriate way to enhance job satisfaction [
14]. Physicians receiving collegial support and maintaining long-term relationships with patients are more satisfied [
58]. Therefore, physicians who use the practical skills underlying EI (i.e. self-confidence, empathy, adaptability, conflict management) [
15] to successfully interact with patients and coworkers may feel more competent and satisfied with their job.
Additionally, a negative correlation between SA of EL and JS was observed, i.e. the more physicians displayed an appropriate but not felt emotion in their interpersonal relationships with colleagues and patients, the less satisfied with their job they were. It has been supported that EL can undermine JS by increasing emotional demands, thereby contributing to increased levels of stress and psychological distress as well as symptoms of depression of the employee [
30‐
32]. The present study focused on the SA component of EL, as there is increasing evidence that the negative effects of EL, such as stress and job dissatisfaction, are mediated by SA (as opposed to deep acting) [
29,
35,
38].
Our findings confirm the mediating role of SA in the relation between SEA dimension of EI and JS. In the present study, the supported model of partial mediation, i.e. only a part of the total effect of EI on JS is due to SA, is not surprising as EI is also considered to have a direct effect on JS. On the other hand, other variables such as positive and negative affect [
13], and self-esteem [
59] have been reported to function as mediators in the EI-JS relationship.
SA was also found to moderate EI-JS relation. With increased SA, physicians with low SEA scores had relatively higher JS compared with those with high SEA scores. As far as OEA dimension of EI is concerned, with decreased SA scores, physicians with low OEA scores had relatively low JS compared with those with high OEA scores. Hochschild [
30] supported that the extent of EL may differ across occupations. Based on that, Wong and Law [
44] hypothesized, although did not prove, that the EI-JS relationship was moderated by the extent of EL; EI is expected to have greater effect on JS for employees who engage more frequently and extensively in the process of EL. EI constitutes a key asset to performing effectively a job requiring high levels of discrepancy between expressed and experienced emotions (e.g. social worker, nurse, physician); yet its significance may be less important for jobs involving little EL.
Although moderation and mediation are distinct processes, a variable may function both as a moderator and a mediator in a single functional relation [
60]. However, to the best of our knowledge, a possible moderating and/or mediating role of SA has not been sufficiently tested in the EI-JS relation in medicine. In addition to both the moderating and mediating roles, SA was found to be a predictor of JS variable, above and beyond EI dimensions. This finding can be explained in the context of the high EL inherent in clinical practice [
61] and point out SA as a source of strain undermining physicians’ professional satisfaction and well-being.
Gender was not found to moderate the direct effect of SA on JS. However, the indirect effect of SEA on JS, via SA, was moderated by gender, with this positive effect being larger for male physicians than their female counterparts. According to previous studies, females are more likely to experience job dissatisfaction when engaged in SA [
39]; on the other hand, the effect of EI on JS may be fully mediated by positive and negative affect for men but partially for women [
13]. Gender’s moderating role may be interpreted in the context of gender differences in the hospital workplace, such as responsibilities, family- and work-related stressors experienced by female physicians, who simultaneously take on the roles of mothers and professionals, and gender-specific resistance to females’ effort to ascend organizational hierarchies [
22].
Research has revealed a negative relationship between EI and SA [
40,
42]. In the present study, physicians with high SEA were less likely to mask their true emotions in order to comply with organizational display rules. This finding could be related to the superior abilities attributed to high-EI individuals, such as understanding their true emotions and expressing emotions naturally [
7,
44,
62].
The use of self-report measures, which may result in response bias (e.g. social desirability, mood state) and in overstatement of the relationships between the examined constructs [
47], does serve as limitations of the study. Furthermore, the adopted cross-sectional research design of our study renders difficult any interference about the causative nature of the examined relationships. Additionally, the power to detect moderators might have been decreased by the relatively small sample size, unequal sample sizes across groups (e.g. male vs. female), and possibly heterogeneous error variance [
51]. Other limitations of our study concern the collection of data from one hospital center and the relative brevity of the measures used.
Elucidating interactions between emotion-related constructs and job satisfaction is critical to developing support programs and communication-skill training courses that may facilitate emotional appraisal and emotional regulation, reduce the related individual and organizational costs, and contribute to the improvement of health care quality. In addition, personality constructs (i.e. EI) might be used as predictive variables for health care managers in order to recruit physicians who would be most effective in the emotionally “charged” hospital environment [
63]. Emotion management workshops and interpersonal skill training could be incorporated in medical schools’ curriculum with a view to preparing more competent doctors.
Despite the extensive literature on EI and JS, scant research has integrated EI with SA and JS, particularly in the hospital workplace. Most empirical studies, in health care environment, have examined the role of emotion-related constructs in the “nursing framework” [
64], although a strong emotional component is interwoven with medical profession, as well [
65]. Doctors interact with people at one of the most important or difficult circumstances of their lifetime and are often required to take on complex, albeit not always harmonized with their true experienced emotions, roles. This study provides evidence on the interactions between emotion-related constructs, presenting an integrative EI-SA-JS model. Further research based on longitudinal design, larger sample sizes across different health care settings and encompassing methods based on physiology (e.g. monitoring heart rate during the performance of emotional labor) is needed to examine in more depth the influence of emotions in the workplace, the causal associations, and the effect of emotion-related parameters on physicians’ wellbeing, on delivered patient care and on organizational management.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
The present study was carried out by all authors working collaboratively. AP conceived the study, collected data, performed statistical analysis, and wrote the first draft of the paper. FA performed advanced statistical analyses, participated in data interpretation, and revised the paper. EM contributed to the design and analysis of the data. DN participated in data interpretation and was involved in revising the manuscript critically. All authors have contributed to, seen and approved the manuscript.