Strengths and limitations
The study design precludes any inference on causal associations. Nevertheless, the purpose was to test the cross-cultural transferability and postulated dimensionality of the scale in a new language, setting and occupational group. A limitation is the fact that the study targeted only one occupational group (registered nurses). Nevertheless, it was expected that the nationwide coverage of several work settings would introduce enough variability for the purposes of assessing the dimensionality of the scale.
It should be noted that information on place of employment was not collected in order to preserve anonymity and encourage participation. As a result, only the individuals’ perception of workplace social capital was assessed. Exploring the aggregate workplace social capital of specific hospitals and units was not the focus of the current study. The sampling frame in this study was based on class groups, comprising of nurses from several settings (hospitals, clinics, rehabilitation units, community health care centres, mental health services etc), operating in the public and private sector. One of the most enduring debates in the social capital literature is whether social capital is the property and resource for the individual, or whether it is should be conceptualized as a contextual characteristic, and thus measured at the group (community, work unit) level, or both [
20]. Future studies should use sampling frames that allow the measurement of workplace social capital at the individual as well as the unit level. Interestingly, previous multilevel studies incorporating both an individual’s perception as well as group-level social capital (expressed as the aggregate responses of the members of the work unit) commonly report stronger associations with individual, rather than contextual, WSC [
8,
9,
19].
Furthermore, reverse causation cannot be excluded i.e. people may have a different experience of their work environment or at least perceive it as less cohesive as a result of psychological distress or poorer health. Also, while the response rate was high among class attendees, it is likely that people who systematically attended classes are a select sub-group. For instance, people who skipped classes might be those who could depend on colleagues to share the lecture notes. Even though, selection bias is possible, the intention was neither to provide an estimate for either perceived levels of social capital or prevalence of poor health or distress. Nevertheless, this self-selection bias might have also impacted the results due to restriction in the range of WSC scores. Even though, it seems that there was no floor or ceiling effects, and the participants’ responses were distributed across all the full range of responses for all eight items, in the absence of any other studies of workplace social capital in this, or any other occupational groups for this matter in Cyprus, the extent to which this represents the expected variability in WSC is not known.
Association of social capital in the workplace with the health of employees
This study set out to explore the metric properties of the Workplace Social Capital scale in a different socio-cultural setting among a well-defined occupational group. The FPSS WSC scale had so far been used only in select linguistic and socio-cultural contexts (Finland, Japan and China). Other than the construct validity of the scale, the study investigated the criterion validity according to the observed association with self-rated health and psychological distress, as measured by the GHQ scale. Previous studies of workplace social capital explored a wide range of different health outcomes. In the original Finnish Public Sector Study, associations were observed between low baseline levels of workplace social capital or a decline in social capital during follow-up with depression [
9], self-rated health [
7] and likelihood to quit smoking [
21], but not the co-occurrence of lifestyle risk factors e.g. smoking, drinking, overweight and physical activity [
22]. Studies from the same group also linked low workplace social capital with risk of hypertension at least among men [
10] and even increased risk of all-cause mortality [
23].
Beyond the FPSS, we are aware of only two studies that have used the same tool. Consistently with the findings of this study, in the cross-sectional study by Gao et al. [
19] a more than three-fold increase in the odds of poor mental health was reported among Chinese employees with the lowest levels of social capital. It should be noted, however, that the results of this study cannot be directly compared to previous studies since either different occupational groups were studied and/or different scales to measure workplace social capital were used and/or different health outcomes were considered or different measurement tools were used for the same study outcome. For instance, while in the current study, self-rated health was measured using a 0–100 VAS, previous studies commonly assessed self-rated health on a 5-point response scale from Poor to Excellent, which was then commonly dichotomised to “more” or “less than good” [
7,
8]. Similarly, even though the study by Gao et al. [
8], used the same WSC scale, it measured mental well-being using the WHO-Five Well-Being Index [
19].
The GHQ, used in this study, is a commonly used screening tool for depressive symptomatology. There is plenty of evidence to suggest that perceptions of psychosocial stressors in the workplace are related to an elevated risk of subsequent depression or depressive symptomatology [
24]. Traditionally studies in occupational settings examine job strain and effort-reward imbalance on mental health; however, they are not commonly set in a social capital framework. A recent exception is the prospective study of 8000 employees across 12 companies in Japan (the J-Hope study), which provided evidence to suggest that an increase in workplace social capital, measured using a 6-item scale of cognitive social capital was associated with an improvement in psychological distress, measured by the Kessler Psychological Distress scale, even after adjusting for work environment characteristics [
25,
26]. Even though the study used a different scale to measure workplace social capital, it is important to note that most of the questions resemble closely those of the FPSS WSC questionnaire used here.
It is currently not clear whether all aspects of social capital (e.g. structural vs cognitive, or bonding, bridging, linking) carry the same weight [
27]. In this study we explored the purported dimensionality of a workplace social capital scale and compared a unidimensional scale with a two dimension (structural-cognitive) and a three dimension model (bonding, bridging, and linking), which appeared to be a better fit. With some exceptions [
18,
28], most published studies use an overall score to represent workplace social capital, as in Tsuboya et al. [
25], rather than investigate these dimensions separately. The cross-sectional survey of Kobayashi et al. [
18] is one of these exception. Using the same scale as in this study, it showed beneficial effects of overall, bonding and linking WSC on the prevalence of overweight, at least among male employees. Interestingly, like in the case of this study, no association was observed with bridging social capital. The authors attributed this lack of association to the limited heterogeneity in social class differentials among the study sample. While the specific sector in that study is not named, it is likely that in the particular sector cooperation across different occupational (and social) groups is not as an integral part of the organization’s function as it is among an inter-disciplinary health team, often with power differentials.
Since the aim of the study was to assess the metric properties of the WSC for potential use in future studies, we did not explicitly explore the underlying mechanisms by which workplace social capital may affect health. It is generally hypothesized that WSC may serve as a moderator of job stresses and other adverse psychosocial work conditions on health [
11]. At the same time, it is also likely that WSC may act as a mediator. A study among 9350 Japanese employees found evidence of both processes [
29]. Individual perceptions of WSC mediated the association between adverse work characteristics (mainly with regards to lack of supportive resources) and psychological distress. At the same time, there was evidence of a moderation effect of social capital on the association between external pressures (such as high job demands, strain, effort, and effort-reward imbalance) and psychological distress, but only when levels of social capital were highest.
Workplace social capital among health sector employees
It is only natural that a number of studies have focused specifically on the healthcare sector since the literature on job satisfaction, burn-out, retention of staff, and quality of care from clinical settings is vast, and has long recognized the importance of contextual factors, such as organizational dimensions of the work environment, without however always directly addressing the social dynamics involved [
30].
Unlike studies in the general working force, studies from clinical settings tend to be smaller and, like the current study, cross-sectional in design. These studies have provided evidence to suggest that aspects of the social environment in health organization are associated with the well-being of the staff as well as the performance of the organization. Nevertheless, comparison of findings across studies in clinical settings is limited as studies do not follow a common unified framework. In fact, they tend to measure different and select aspects of social capital, some considered to be antecedents, such as communication and trust, and their association to a wide range of outcomes. For example, a series of cross-sectional studies from Germany has provided evidence that low “social capital” among clinicians and nurses, defined here as “common values” and “perceived trust”, was associated with emotional exhaustion [
31,
32], lower job satisfaction [
33] and lower clinical risk management [
34]. Similarly, a study among 239 workers in 11 nursing homes in Belgium measured social capital by six items referring to vertical trust, justice and social community at work (drawn from the Copenhagen Psychosocial Questionnaire) [
35]. Spence Laschinger and Read [
36] developed a theoretical model where structural empowerment (defined as access to opportunities, resources, information, support and formal and informal power measured by the Conditions of Work Effectiveness Questionnaire) and social capital at unit-level were associated with unit effectiveness (ability to provide timely care) as well as perceived patient care quality. They measured social capital using 9 items that relate to structural, relational and cognitive aspects of social capital.
Measurement of workplace social capital
The continuing ambiguity around measurement issues with regards to the concept of social capital is not a unique feature of studies in occupational settings. In fact, one may argue that due to the fact that the literature is still smaller, studies of workplace social capital have been more consistent than the respective literature in community settings. The WSC scale has been more often used as a unidimensional scale, with some exceptions. For example, in Oksanen et al., [
27] it was operationalized as horizontal (bonding and bridging combined) and vertical (corresponding to linking), confirmed using factor analysis such as in this study..In Kobayashi et al. [
18] the bonding, bridging and linking sub-scales were used, however without testing the dimensionality of the scale. The observed dimensionality of the WSC scale in the present study appears more consistent with a bonding, bridging and linking typology (rather than a structural-cognitive typology)..
Like in Kobayashi et al. [
18], the weakest associations in the current study were also observed with bridging social capital. We hypothesize that this may reflect a weakness of the measure to fully capture bridging social capital both in terms of the scale itself (only 2 items), or perhaps the setting or occupational group under investigation. Specifically, the scale may not adequately capture the social interaction with other health professional groups (e.g. physicians). The WSC in its original format refers to “people”, “members”, and “we”. Even though this is understandable, since in the original study various occupational groups were represented, in-group identification is not explicit as the same terms are used for both bonding and bridging social capital. These terms contain an ambiguity, especially since items pertaining to bonding and bridging refer to “people”. These issues need to be explored further, as it might be worth revisiting and strengthening this aspect of the scale, and even customizing the scale to the specific setting it will be used in. In retrospect, it might have been better in the context of this study if items that tap on bridging were instead phrased as “members of the healthcare team of doctors, nurses etc … build on each other’s ideas etc” and “In this hospital (or ward or unit), members of the healthcare team cooperate”.
Approaching this issue from within a nursing management framework, Sheingold et al. [
30] compared the 96-item Integrated Questionnaire for the Measurement of Social Capital (SCIQ) developed by the World Bank with eight instruments referring to social dimensions of the work environment, including the Essential of Magnetism (EOM) tool. They noted that several of the SCIQ items map to currently accepted dimensions in existing questionnaires of the nursing work environment (such as nurse-nurse and nurse-physician interaction, effective communication, empowerment, supportive leadership). However, none adequately measures the nature of social relationships. Hence, social relational aspects of the work environment, central to the concept of social capital, such as the sense of belonging and shared identity, are currently not adequately addressed. They called for work environment instruments that could be anchored within a social capital framework.
The potential role of shared identities in protecting health and well-being as well as the potential to cultivate shared identities as a “social cure” has been extensively described by Haslam et al. [
37] and Jetten et al. [
38]. It is interesting to draw parallels between the workplace social capital approach and the track of research from social and organizational psychology on social identification. Social identity theory postulates that people define their sense of self in terms of group membership, single or multiple, which may be centred on family, friends, community, religion, political affiliations and/or work. In-group identification is internalized, provides a sense of belonging and purpose and shapes many processes beneficial for health, including the provision of social support and accrual of social capital. Haslam et al. (2018) criticize the social capital approach for neglecting the underlying mechanisms of social pathways to health, since in-group identification, the cognitive component of belonging to a group, is often assumed and not measured [
39].
Indeed, “sense of belonging” is a central tenet of social capital. It is somewhat surprising that there are not many published concept analyses of social capital even though there has been such an interest in the concept for a number of years now. A concept analysis by Reed [
40], as it specifically relates to nurses’ work environment, identified the essential attributes of social capital as “social relationships”, “shared assets” and “shared ways of knowing and being”, while antecedents include several of the concepts that existing questionnaires measure, such as communication, trust, and even positive leadership practices (which arguably pertains to linking social capital). A comparison between the WSC questionnaire and the attributes identified in the aforementioned theoretical study reveals an interesting parallelism. In terms of “social relationships”, these include relationships with other nurses (i.e. what would normally be termed “bonding”), within the entire healthcare team (i.e. perceived as “bridging” social capital) and across different levels of the management hierarchy (“linking”). In terms of “shared assets”, while this does not feature as a distinct dimension in the WSC scale, most of the assets named are one way or another referred to in the scale’s items, i.e. support (“People feel understood and accepted by each other”), cooperation and teamwork (“People … cooperate in order to help develop and apply new ideas”), and information (“… keep each other informed”). Lastly, in terms of “shared ways of knowing and being”, also referred to as “a sense of collective consciousness or social connectedness” [
41], one of the items in the WSC taps onto the fundamental concept of sense of belonging (i.e. People have a “we are together” attitude).
However, in-group identification is not explicitly defined in any of the items of the WSC. The items may tap to some extent on perceived shared identity (social identity) but do not explicitly refer to the individual’s relationship to the group (social identification). For example, the WSC scale’s item “People feel understood and accepted by each other” may tap on cognitive aspects of attributes attached to the group as a group, rather than the extent to which the group is a source of positive emotions for the individual. Similarly, “We have a ‘we are together’ attitude” assumes that the responder sees themselves as part of “we” rather than “I identify with..” or “the [group] is an important part of my identity”,more common in social identification scales.
Unidimensional and multidimensional scales have been developed to measure social identification [
42]. Unidimensional scales commonly tap on cognitive and affective aspects of identification to measure the relationship of the individual to the group. They often include phrases such as “having a lot in common” and “liking” other members of the group. Multidimensional scales are more complex and tap on self-investment and its components of centrality (i.e. the group being important to one’s sense of self), satisfaction (i.e. group membership is the source of positive emotions) and solidarity (i.e. attachment and commitment) [
43]. Among nurses in particular, in-group identification has been previously measured by a 3-item scale, “I identify with nurses”, “I have a lot in common with nurses” and “Being a nurse is an important reflection of who I am”, all of which tap on centrality, rather than the other components [
44]. Nevertheless, Postmes et al. (2013) have shown that the construct is sufficiently homogeneous to be measured by a Single-Item Social Identification measure (SISI): “I identify with my [group]”, measured on a 7-point scale [
42] .Such measures could supplement workplace social capital studies in the future. It is often cited that there is much need for experimental studies to document the potential effectiveness of interventions which aim to produce, foster or strengthen social capital. Examples of such interventions in the literature include techniques such as team-building training [
45] and work-based group physical exercise [
46]. However, it is not clear how these interventions were designed, which type of social capital they are targeting and in what way. Thus, more formative and empirical research is needed in order to delineate the determinants of social capital in the workplace and the underlying mechanisms linking it to well-being in order to design potentially effective interventions. Equally importantly, using a unified framework and the availability of valid measures of workplace social capital, supplemented by social identification measures, should be considered a prerequisite.