Leadership and Job satisfaction among Physicians in the Public Health Sector of Cyprus

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Economidou, Demetris Avraam, Elpidoforos S. Soteriades, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4293854/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Healthcare leadership and job satisfaction constitute important characteristics of health professionals’ employment status. Our study aim was to examine the relationship between managers’ leadership styles and physicians’ job satisfaction in the public health sector of Cyprus. Methods A cross-sectional survey was conducted using self-administered questionnaires among all physicians working in the public health sector of Cyprus (Ministry of Health, administration offices, public hospitals and healthcare centers). In this context we used two standardized internationally validated instruments: the Multifactor Leadership Questionnaire (MLQ-5X), and the Job Satisfaction Survey (JSS). Results Out of 690 physicians working in the public health sector who received an invitation to participate, 511 completed the survey and 9 were excluded. Therefore, a total of 502 physicians (262 male and 235 female) were included in the final analysis (response rate 73%). Transactional and transformational leaderships had strong positive effects on six out of the nine job satisfaction subscales, as well as on the total job satisfaction scale, whereas passive leadership had a negative effect on job satisfaction. Overall, total leadership had a strong statistically significant positive effect on total job satisfaction [odds ratio = 3.88, 95% CI (2.27, 6.63)]. Conclusions We found strong and statistically significant associations between the transactional and transformational leadership styles and health professionals’ job satisfaction in most of the job satisfaction subscales. Establishing a causal relationship between the above requires further investigations with appropriate study design. Physicians’ leadership Job Satisfaction public health sector Cyprus Figures Figure 1 Background The word leadership derives from an old English word “laedere” – the one who leads, its noun “laedan” – to guide or to bring forth. The meaning of leadership has occupied human mind since ancient times, as it is found in the works of Plato, Plutarch and other ancient historians and philosophers [ 1 , 2 ]. It is also one of the most studied social science phenomena. The word leadership (in Greek “ηγεσία”) comes from the ancient Greek verb “ηγέοµαι”, which means to advance, precede, lead, direct, show the way to someone [ 3 ]. The concept of leadership has a multidimensional character, while it is further broadened by the various different characteristics that define a leader. Therefore, the multidimensional leadership and its characteristics combined with the various modes of leadership recorded in the international literature add even more complexity to its construct. Leadership in the healthcare sector in particular, constitutes one of the most vital factors within the realm of human resource management concerning health professionals. Thus, effective leadership and adoption of an appropriate tool to assess leadership in an organization becomes a crucial scientific inquiry. Health professionals in general and physicians in particular are one of the cornerstones of healthcare systems. In parallel employees’ job satisfaction is seen as one of the most defining factors of organizational effectiveness [ 4 ]. Employees in healthcare institutions confront many challenges on a daily basis, resulting in job dissatisfaction, which has been linked to stress [ 5 , 6 , 7 ], medical errors, intention to leave [ 8 , 9 ], reduction in quality of care, increased medical care costs, reduced patient compliance with medical advice, and professional burnout [ 10 , 11 , 12 ]. Considering the importance of healthcare quality, it is crucial for doctors to be able to “have a voice” regarding their professional duties and experience, a feeling of being respected and valued within an organization that is part of a leadership agenda and could improve job satisfaction [ 13 ]. In our effort to interpret and investigate the meaning of job satisfaction, as well as the way it functions among healthcare employees and how it affects their behavior and attitude towards their job, copious theories are reviewed [ 14 ]. The definition of job satisfaction adopted in our study is the one specified by Spector, who associates job satisfaction with the positive affective orientation towards employment by an organization, while job dissatisfaction is associated with corresponding negative feelings [ 15 ]. This same definition considers job satisfaction as the overall emotional reaction of people to their job. By better understanding the above relationships, public health policy makers could intervene with appropriate incentives that could positively affect employees’ job satisfaction among health professionals [ 16 ]. In the past couple of years, Cyprus government implemented a general healthcare system (GHS) under the Law of 2001 (Ν.89 (Ι)/2001)[ 17 ]. The aim of the new healthcare plan was to offer citizens a comprehensive access to healthcare services through a functional, efficient and financially sustainable system, and at the same time solve chronic problems in the delivery of health care in Cyprus. One of the main reformations of the system was the transformation of public hospitals into autonomous organizations in order to operate according to their own budget and organizational planning. The aim of this study was to evaluate the association between managers’ leadership style and job satisfaction among physicians in the public health sector of Cyprus, as well as to explore the potential association of job satisfaction with physicians’ demographics and other characteristics in the context of the above described healthcare reform. Materials and Methods Study design and Setting Based on the above study objective, a cross-sectional study using a quantitative survey with self-administered questionnaires was adopted concerning leadership and job satisfaction among physicians in the public health sector of Cyprus. The study involved all physicians from the five main public hospitals one from each geographical district (Nicosia, Limassol, Larnaca, Paphos and Famagusta General Hospital), the main paediatric hospital of the island (Makarios III Hospital which is located in Nicosia), two rural hospitals (Polis Chrysochous and Kyperounta Hospital), forty-three public healthcare centers (urban and rural), Nicosia, Limassol and Larnaca Old Hospital Healthcare Center, the headquarters of the medical and public health services, as well as the administration offices of the Ministry of Health in Cyprus. The self-administered questionnaires were distributed and collected between October 2016 and January 2017. The study approach was based on two standardized instruments: the Multifactor Leadership Questionnaire (MLQ-5X) and the Job Satisfaction Survey (JSS). Ethical consideration The study was approved by the Cyprus National Bioethics Committee (07/04/2016, Protocol number ΕΕΒΚ ΕΠ 2016.02.57) and relevant permissions to conduct the survey were also obtained from the office of the Commissioner for the Protection of Personal Data and the Ministry of Health. Sample rectruitment Study participants included all physicians who worked in the public healthcare sector of Cyprus (census) in September 2016. The number of all physicians who worked in the public healthcare sector of Cyprus was calculated based on the number of physicians reported by the directors of public hospitals and healthcare centers. These included all physicians from the public healthcare sector of Cyprus as described above. Certain inclusion criteria were applied for the final study sample, namely: being a physician, working in public healthcare sector of Cyprus for more than six months, having a permanent job position or working based on a written contract. Out of 690 physicians working in the public sector in September 2016 who received an invitation to participate, 511 completed the survey and 9 were excluded (incomplete questionnaires). Therefore, a total of 502 physicians were included in our study. Questionnaires The self-administered questionnaires consisted of three sections. The first section was used to collect physicians’ demographic characteristics such as age, gender, job position, educational level, work tenure etc. The second section consisted of the Multifactor Leadership Questionnaire (MLQ-5X). Initially known as the MLQ-5X, its strength depends on its ability to capture several leadership styles in a single measurement instrument [ 14 , 18 ]. MLQ-5X comprises of 45 items; the first 36 items measure the type of leadership style and the next 9 items the leadership outcomes [ 15 ]. The first 36 items are used to estimate nine subscales which then determine three leadership styles: (a) transformational leadership is defined as the average of five subscales: idealized influence (attributed), idealized influence (behavior), inspirational motivation, intellectual stimulation, and individualized consideration; (b) transactional leadership is defined as the average of two subscales: contingent reward, and management-by-exception (active); and (c) passive leadership is defined as the average of two subscales: management-by-exception (passive) and laissez-faire. The last 9 items of the questionnaire are used to estimate three subscales which consider leadership outcomes: extra effort, effectiveness, and satisfaction. Each of the 45 items is rated using a 5-point Likert scale including not at all, once in a while, sometimes, fairly often, and frequently if not always. The score for every item ranges from 0 (not at all) to 4 (frequently if not always) [ 15 ]. A double reverse translation was used as well as an adaptation from a specialized health professionals’ team for the Cypriot population was applied in order to adjust the questionnaire to the cultural context. The third section consisted of the Job Satisfaction Survey (JSS) questionnaire developed by Spector (1985) [ 19 ]. JSS is a 36-item, nine-facet scale to assess employee attitudes about the several aspects of their job. The nine facets include payment, promotion opportunities, fringe benefits, contingent rewards, recognition, operating procedures, relationships with co-workers, interest in the nature of work, and communication within the organisation. Each facet is assessed with four items, and a total score is computed from all items. A summated rating scale format is used, with six choices per item ranging from 1 “strongly disagree” to 6 “strongly agree”. Some of the questions are negatively marked, therefore after reversing the score, the result of each questionnaire is calculated based on the average of all answers, which are subsequently added and divided by the number of equivalent questions (as well as the availability of non-missing responses). The JSS scale was translated into Greek with a double reverse translation method and was adapted from a specialised health professionals’ team for the Cypriot population. The questionnaire was used following permission from the author, which was kindly provided. Pilot study Α pilot study to assess the survey tools was conducted in July 2016, where 15 questionnaires were distributed to corresponding physicians of the public health sector of Cyprus. All physicians were members of the Cyprus Medical Association and came from all hierarchical ranks of medical officers in the public sector of the Ministry of Health. During this process, we were able to modify the questionnaires according to the responders’ feedback. Specifically, we removed a question on the medical specialization of health professionals in order to avoid concerns of potential identification of respondents. Data collection and management The data collection was completed between October 2016 and January 2017. The questionnaires were distributed to physicians working in health centers by post. In addition, each physician was informed via phone by the main researcher regarding the survey. An envelope was included so that participants could seal the questionnaires to strictly protect anonymity and confidentiality. An informational leaflet was also included describing who was performing the study, the title and purpose of the study and the required completion time of the questionnaires. Participation was voluntary. A consent form was also enclosed. A healthcare professional from each center was assigned to collect the consent forms along with the questionnaires in sealed envelopes. The questionnaires in the hospitals were given by the main researcher to all physicians. Responses were collected by a health professional in each particular hospital who was assigned to collect both the questionnaires and the consent forms in a separate sealed box. The questionnaires were kept locked and only the main researcher had access to the questionnaires. Statistical analysis For the statistical analysis, we dichotomised each satisfaction subscale where values equal or above 3.5 (i.e. the middle value of the continuous range 1–6) were considered as “job satisfaction” and values below 3.5 as “not being satisfied”. Number of cases with percentages and Pearson's Chi-squared tests with Yates' continuity correction were used for each pair between a categorical demographic characteristic of physicians and the total job satisfaction indicator, while means with standard deviations and Mann-Whitney (i.e. two-sample Wilcoxon rank-sum) tests were used for each pair between a continuous demographic and the total job satisfaction indicator. Welch two sample t-tests were used to indicate if there is a statistically significant difference on the average scores of leadership styles between the physicians who were not satisfied by their job and those who were satisfied. Furthermore, univariate logistic regressions were performed between each leadership subscale (independent variable) and binary indicator for each job satisfaction subscale (dependent variable) to investigate their associations. Statistical significance was assessed at the level of 0.05 for both sides. Results Out of 690 physicians working in the public sector who received an invitation to participate, 511 completed the survey and 9 were excluded. Therefore 502 physicians were included in our study (response rate 73%). About half of the 502 physicians were females (n = 262, 52.2%). The mean age of the participants was 47.7 years (SD = 9.2), whilst the mean year of experience in the public sector was 12.4 years (SD = 8.4) and in private was 4.4 years (SD = 5.9), respectively. From the 502 physicians, that were included in the current study, 69.7% were working in public hospitals and 30.3% in health care centers. In Table 1 we present the demographic characteristics of physicians in association with job satisfaction. One chi-squared test from all pairs between the dichotomous demographic variables and the dichotomous total job satisfaction indicator, had a p-value lower than the significance level of 0.05, indicating the statistically significant relationship between the variable representing physicians’ educational level and job satisfaction. In addition, all Mann-Whitney tests had a p-value greater than 0.05 indicating that there was no statistically significant difference in the means of age, years of experience in public health and years of experience in the private sector with respect to job satisfaction. Table 1 Demographic characteristics of physicians relative to job satisfaction Physicians’ demographics Total Total Job Satisfaction p-value a n (%) not Satisfied n (%) Satisfied n (%) Gender Female 262 (52.2) 206 (51.4) 56 (55.4) 0.533 Male 235 (46.8) 191 (47.6) 44 (43.6) Missing 5 (1.0) 4 (1.0) 1 (1.0) Family status Live alone 76 (15.1) 58 (14.5) 18 (17.8) 0.618 I do not live alone 393 (78.3) 313 (78.1) 80 (79.2) Missing 33 (6.6) 30 (7.5) 3 (3.0) Children Yes 391 (77.9) 313 (78.1) 78 (77.2) 0.519 No 84 (16.7) 64 (16.0) 20 (19.8) Missing 27 (5.4) 24 (6.0) 3 (3.0) Workplace Public Hospitals 350 (69.7) 276 (68.8) 74 (73.3) 0.455 Health Centers 152 (30.3) 125 (31.2) 27 (26.7) Missing 0 (0) 0 (0) 0 (0) Job position Internal medicine 345 (68.7) 274 (68.3) 71 (70.3) 1 Surgical 80 (15.9) 64 (16.0) 16 (15.8) Missing 77 (15.3) 63 (15.7) 14 (13.9) Master degree Yes 205 (40.8) 177 (44.1) 28 (27.7) 0.002 No 240 (47.8) 178 (44.4) 62 (61.4) Missing 57 (11.4) 46 (11.5) 11 (10.9) PhD Yes 83 (16.5) 72 (18.0) 11 (10.9) 0.113 No 359 (71.5) 281 (70.1) 78 (77.2) Missing 60 (12.0) 48 (12.0) 12 (11.9) Tenure Yes 273 (54.4) 223 (55.6) 50 (49.5) 0.284 No 193 (38.4) 149 (37.2) 44 (43.6) Missing 36 (7.2) 29 (7.2) 7 (6.9) Contract Yes 193 (38.4) 148 (36.9) 45 (44.6) 0.192 No 273 (54.4) 224 (55.9) 49 (48.5) Missing 36 (7.2) 29 (7.2) 7 (6.9) N Mean (SD) n Mean (SD) n Mean (SD) p-value b Age 471 47.7 (9.2) 372 47.7 (8.8) 99 47.7 (10.3) 0.983 Years of experience in public health 462 12.4 (8.4) 365 12.6 (8.2) 97 11.7 (9.3) 0.140 Years of experience in private 408 4.4 (5.9) 322 4.2 (5.6) 86 5.2 (7.1) 0.905 a Chi-squared test; b Mann-Whitney test Leadership as evaluated by the Multifactor Leadership Questionnaire (MLQ-5X) relative to job satisfaction is presented in Table 2 . All two-sample t-tests had a p-value less than 0.05 indicating that there was a statistically significant difference in the means of all leadership subscales between the physicians who were not satisfied by their job and those who were satisfied. Furthermore, in Table 2 we show that the means of transformational, transactional, passive and total leaderships are statistically significantly different between the physicians who were not satisfied by their job and those who were satisfied. Table 2 Association of Leadership with total Job satisfaction MLQ Scale Total Job Satisfaction p-value not Satisfied mean (SD) Satisfied mean (SD) idealized influence (attributed) 1.7 (0.9) 2.4 (0.8) < 0.001 idealized influence (behavior) 1.7 (0.9) 2.3 (0.7) < 0.001 inspirational motivation 1.7 (0.9) 2.4 (0.9) < 0.001 intellectual stimulation 1.5 (0.8) 2.1 (0.7) < 0.001 individual consideration 1.5 (0.8) 1.9 (0.7) < 0.001 contingent reward 1.3 (0.8) 2.0 (0.9) < 0.001 management by exception (active) 1.9 (0.8) 2.2 (0.7) 0.005 management by exception (passive) 2.5 (0.9) 1.9 (0.9) < 0.001 laissez-faire leadership 2.3 (1.0) 1.6 (0.9) < 0.001 extra effort 1.3 (1.0) 2.1 (1.0) < 0.001 Effectiveness 1.5 (1.0) 2.4 (1.0) < 0.001 Satisfaction 1.6 (1.0) 2.4 (1.0) < 0.001 Factor transformational leadership 1.6 (0.7) 2.2 (0.7) < 0.001 transactional leadership 1.6 (0.7) 2.1 (0.7) < 0.001 non-leadership 2.4 (0.9) 1.7 (0.8) < 0.001 Total 1.8 (0.4) 2.1 (0.5) < 0.001 In Fig. 1 we present the results (odds ratios with 95% Confidence Intervals (CI)) of different logistic regression models examining the association between leadership styles (independent variable) and job satisfaction subscales (dependent variables) among physicians. We found that transactional and transformational leaderships have positive effects on the nine subscales and the total scale of job satisfaction (i.e. odds ratios greater than 1), while passive leadership has negative effects on job satisfaction. The total leadership has positive effects on job satisfaction subscales being statistically significant for six out of nine subscales. Total leadership has also a statistically significant positive effect on total job satisfaction [odds ratio = 3.88, 95% CI (2.27, 6.63)]. Discussion In summary, we evaluated the association between physician managers’ leadership styles and job satisfaction among physicians in the public health sector of Cyprus. The results of our study demonstrated that transformational and transactional leaderships have a strong positive effect on job satisfaction while passive leadership has a negative effect. However, as an overall result of the above findings, the measure of total leadership has a positive effect on the job satisfaction of health professionals in the public health sector of Cyprus. It is also worth highlighting that both leadership styles (transformational and transactional) show similar strong associations with health professionals’ job satisfaction in the same subscales, namely, pay, promotion, supervision, fringe benefits, contingent rewards, communication and total satisfaction. Several studies have described the positive contribution of physician managers using transformational leadership practices [ 20 , 21 ]. Weberg emphasized that a transformational leader can extend and elevate the interests of staff, who can facilitate employee commitment to the mission and values of the organization and who can lead staff to rise above their personal interests [ 21 ]. Lavoie-Tremblay et al. indicated that transformational leadership potentially lead to high quality care and weak intention to quit the healthcare facilities and conversely, abusive leadership potentially lead to poorer quality care and to strong intention to quit the healthcare facilities having lower job satisfaction [ 22 ]. To this day, transformational leadership remains the better-known leadership approach [ 23 ], and our study findings are strongly compatible with the existing scientific literature on this topic. Limitations Some limitations of our study are worth mentioning. Although the response rate in our study was high, we had to exclude a sizable number of responders due to missing values. Moreover, data were collected from physicians and no other healthcare workers. The relatively small sample size does not allow for a more detailed statistical analysis between the different subscales. Finally, in this particular study we have examined the association of leadership with job satisfaction, although there are several other aspects of health professionals’ resource management styles that are also involved in this complex interconnection network that were not addressed in the current study. Conclusions We have found that transactional and transformational leadership styles were strongly and positively associated with health professionals’ job satisfaction in most subscales of the job satisfaction questionnaire used in this study. On the contrary, passive leadership style was associated with a negative impact on job satisfaction. Our study findings provide a strong insight regarding the association of leadership with several job satisfaction attributes. Provided that our reported associations are based on underlying causal associations, our study findings could support relevant policies and educational programs to promote transactional and transformational leadership styles in the healthcare sector in order to promote health professional job satisfaction and associated additional positive outcomes including healthcare quality. Our findings also support the important role of associated training to promote transactional and transformational leadership in the healthcare sector in preparing new leaders that could facilitate organization-wide changes during this highly demanding period of innovative technology and digital transformations in the healthcare sector. Declarations Acknowledgments: We acknowledge the contribution and help of Dr. Stavros Chatzopoulos in statistical analyses. Author Contributions: IG conceptualized the project and was the PI of the study. IG, AS and AC planned the study and implemented its methodology. AM and EP contributed to the study’s design. IG, AS and AC performed data collection. DA performed the statistical analysis of the data. IG, ECE, AS and ESS wrote the first draft of the manuscript. ECE and DA prepared the tables and figures. All authors were involved in data interpretation and writing of subsequent manuscript iterations. All authors conducted critical review of the manuscript and approved of the final version of the manuscript. Funding: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Data Availability Statement: Data are available upon request. Competing Interests: The authors declare no competing interests. Ethics approval and consent to participate: Approved by the National Bioethics Committee of Cyprus (07/04/2016, Protocol number ΕΕΒΚ ΕΠ 2016.02.57). An informed consent was signed by all physicians’ participants prior to questionnaire completion. References Bass BM. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4293854","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":293394330,"identity":"a13991d1-64f3-4c7e-b2ea-39b6fbc60b27","order_by":0,"name":"Ioanna Gregoriou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYDCCAzAGM4gwsAESjI0HcCjGqiUNpKWBSC0QcBibICrgu32A+XVFRa2ceTvzMQmGgvN2a9sPA22psYnGpUXyXAKb5Zkzx41lDrOlSTAY3E7ediYRqOVYWm4DDi0GZxjYDBvbjiXOYOYxA2sxOwDUwthwmICWf3At55LNzj8kqIX5YWNDDUzLATuzGwRskTzD2MbYcOyAsQQzW7JFgkFygtkNoC0JePzCd4b58MeGmjo5Cf7DB298+GNnb3Y+/eGDDzU2OLUAI65NAhYdDAkMDIkNUAY+wPyBgaEOzrPHr3gUjIJRMApGIgAAooRetg+Sh9UAAAAASUVORK5CYII=","orcid":"","institution":"Technological University of Cyprus","correspondingAuthor":true,"prefix":"","firstName":"Ioanna","middleName":"","lastName":"Gregoriou","suffix":""},{"id":293394331,"identity":"96916d1c-d3e8-43ab-bd42-ed6ce2d41f7c","order_by":1,"name":"Eleftheria C. Economidou","email":"","orcid":"","institution":"Larnaca General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Eleftheria","middleName":"C.","lastName":"Economidou","suffix":""},{"id":293394332,"identity":"9b789d84-ff9e-4467-8050-52cd16bfac13","order_by":2,"name":"Demetris Avraam","email":"","orcid":"","institution":"University of Liverpool","correspondingAuthor":false,"prefix":"","firstName":"Demetris","middleName":"","lastName":"Avraam","suffix":""},{"id":293394333,"identity":"9e3f4726-848a-4766-9945-f286fb52742d","order_by":3,"name":"Elpidoforos S. Soteriades","email":"","orcid":"","institution":"Open University of Cyprus","correspondingAuthor":false,"prefix":"","firstName":"Elpidoforos","middleName":"S.","lastName":"Soteriades","suffix":""},{"id":293394334,"identity":"16def037-bbaf-4348-8f5b-fc8f753f99b8","order_by":4,"name":"Evridiki Papastavrou","email":"","orcid":"","institution":"Technological University of Cyprus","correspondingAuthor":false,"prefix":"","firstName":"Evridiki","middleName":"","lastName":"Papastavrou","suffix":""},{"id":293394342,"identity":"cccb78b1-2a11-4264-a52f-61670db18d16","order_by":5,"name":"Andreas Charalambous","email":"","orcid":"","institution":"Technological University of Cyprus","correspondingAuthor":false,"prefix":"","firstName":"Andreas","middleName":"","lastName":"Charalambous","suffix":""},{"id":293394343,"identity":"761efe52-2f5b-4be7-9ecc-5c8d9f3b3839","order_by":6,"name":"Antonis Stylianides","email":"","orcid":"","institution":"Technological University of Cyprus","correspondingAuthor":false,"prefix":"","firstName":"Antonis","middleName":"","lastName":"Stylianides","suffix":""},{"id":293394345,"identity":"e9975eab-a798-4493-8c77-dc25a7ba2ffa","order_by":7,"name":"Anastasios Merkourios","email":"","orcid":"","institution":"Technological University of Cyprus","correspondingAuthor":false,"prefix":"","firstName":"Anastasios","middleName":"","lastName":"Merkourios","suffix":""}],"badges":[],"createdAt":"2024-04-19 14:48:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4293854/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4293854/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55222016,"identity":"1bb860a9-35a9-4c12-a52b-fa423893847a","added_by":"auto","created_at":"2024-04-24 09:23:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":63909,"visible":true,"origin":"","legend":"\u003cp\u003eOdds ratios with 95% confidence intervals from logistic regression models for each pair between a leadership style (independent variable) and a job satisfaction subscale (dependent variable).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4293854/v1/8de7ae417acb3125e4aef463.png"},{"id":62000859,"identity":"37a5ffd3-e3bd-4dc0-b0e6-c5a17551592f","added_by":"auto","created_at":"2024-08-08 05:47:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":678852,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4293854/v1/24920baf-a60f-44b2-8ef4-1d2093b7328c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Leadership and Job satisfaction among Physicians in the Public Health Sector of Cyprus","fulltext":[{"header":"Background","content":"\u003cp\u003eThe word leadership derives from an old English word \u0026ldquo;laedere\u0026rdquo; \u0026ndash; the one who leads, its noun \u0026ldquo;laedan\u0026rdquo; \u0026ndash; to guide or to bring forth. The meaning of leadership has occupied human mind since ancient times, as it is found in the works of Plato, Plutarch and other ancient historians and philosophers [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It is also one of the most studied social science phenomena. The word leadership (in Greek \u0026ldquo;ηγεσία\u0026rdquo;) comes from the ancient Greek verb \u0026ldquo;ηγέο\u0026micro;αι\u0026rdquo;, which means to advance, precede, lead, direct, show the way to someone [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The concept of leadership has a multidimensional character, while it is further broadened by the various different characteristics that define a leader. Therefore, the multidimensional leadership and its characteristics combined with the various modes of leadership recorded in the international literature add even more complexity to its construct. Leadership in the healthcare sector in particular, constitutes one of the most vital factors within the realm of human resource management concerning health professionals.\u003c/p\u003e \u003cp\u003eThus, effective leadership and adoption of an appropriate tool to assess leadership in an organization becomes a crucial scientific inquiry. Health professionals in general and physicians in particular are one of the cornerstones of healthcare systems. In parallel employees\u0026rsquo; job satisfaction is seen as one of the most defining factors of organizational effectiveness [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Employees in healthcare institutions confront many challenges on a daily basis, resulting in job dissatisfaction, which has been linked to stress [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], medical errors, intention to leave [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], reduction in quality of care, increased medical care costs, reduced patient compliance with medical advice, and professional burnout [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Considering the importance of healthcare quality, it is crucial for doctors to be able to \u0026ldquo;have a voice\u0026rdquo; regarding their professional duties and experience, a feeling of being respected and valued within an organization that is part of a leadership agenda and could improve job satisfaction [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our effort to interpret and investigate the meaning of job satisfaction, as well as the way it functions among healthcare employees and how it affects their behavior and attitude towards their job, copious theories are reviewed [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The definition of job satisfaction adopted in our study is the one specified by Spector, who associates job satisfaction with the positive affective orientation towards employment by an organization, while job dissatisfaction is associated with corresponding negative feelings [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This same definition considers job satisfaction as the overall emotional reaction of people to their job. By better understanding the above relationships, public health policy makers could intervene with appropriate incentives that could positively affect employees\u0026rsquo; job satisfaction among health professionals [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the past couple of years, Cyprus government implemented a general healthcare system (GHS) under the Law of 2001 (Ν.89 (Ι)/2001)[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The aim of the new healthcare plan was to offer citizens a comprehensive access to healthcare services through a functional, efficient and financially sustainable system, and at the same time solve chronic problems in the delivery of health care in Cyprus. One of the main reformations of the system was the transformation of public hospitals into autonomous organizations in order to operate according to their own budget and organizational planning.\u003c/p\u003e \u003cp\u003eThe aim of this study was to evaluate the association between managers\u0026rsquo; leadership style and job satisfaction among physicians in the public health sector of Cyprus, as well as to explore the potential association of job satisfaction with physicians\u0026rsquo; demographics and other characteristics in the context of the above described healthcare reform.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and Setting\u003c/h2\u003e \u003cp\u003eBased on the above study objective, a cross-sectional study using a quantitative survey with self-administered questionnaires was adopted concerning leadership and job satisfaction among physicians in the public health sector of Cyprus. The study involved all physicians from the five main public hospitals one from each geographical district (Nicosia, Limassol, Larnaca, Paphos and Famagusta General Hospital), the main paediatric hospital of the island (Makarios III Hospital which is located in Nicosia), two rural hospitals (Polis Chrysochous and Kyperounta Hospital), forty-three public healthcare centers (urban and rural), Nicosia, Limassol and Larnaca Old Hospital Healthcare Center, the headquarters of the medical and public health services, as well as the administration offices of the Ministry of Health in Cyprus. The self-administered questionnaires were distributed and collected between October 2016 and January 2017. The study approach was based on two standardized instruments: the Multifactor Leadership Questionnaire (MLQ-5X) and the Job Satisfaction Survey (JSS).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eEthical consideration\u003c/h2\u003e \u003cp\u003e The study was approved by the Cyprus National Bioethics Committee (07/04/2016, Protocol number ΕΕΒΚ ΕΠ 2016.02.57) and relevant permissions to conduct the survey were also obtained from the office of the Commissioner for the Protection of Personal Data and the Ministry of Health.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSample rectruitment\u003c/h2\u003e \u003cp\u003e Study participants included all physicians who worked in the public healthcare sector of Cyprus (census) in September 2016. The number of all physicians who worked in the public healthcare sector of Cyprus was calculated based on the number of physicians reported by the directors of public hospitals and healthcare centers. These included all physicians from the public healthcare sector of Cyprus as described above. Certain inclusion criteria were applied for the final study sample, namely: being a physician, working in public healthcare sector of Cyprus for more than six months, having a permanent job position or working based on a written contract. Out of 690 physicians working in the public sector in September 2016 who received an invitation to participate, 511 completed the survey and 9 were excluded (incomplete questionnaires). Therefore, a total of 502 physicians were included in our study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eQuestionnaires\u003c/h2\u003e \u003cp\u003eThe self-administered questionnaires consisted of three sections. The first section was used to collect physicians\u0026rsquo; demographic characteristics such as age, gender, job position, educational level, work tenure etc. The second section consisted of the Multifactor Leadership Questionnaire (MLQ-5X). Initially known as the MLQ-5X, its strength depends on its ability to capture several leadership styles in a single measurement instrument [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. MLQ-5X comprises of 45 items; the first 36 items measure the type of leadership style and the next 9 items the leadership outcomes [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The first 36 items are used to estimate nine subscales which then determine three leadership styles: (a) transformational leadership is defined as the average of five subscales: idealized influence (attributed), idealized influence (behavior), inspirational motivation, intellectual stimulation, and individualized consideration; (b) transactional leadership is defined as the average of two subscales: contingent reward, and management-by-exception (active); and (c) passive leadership is defined as the average of two subscales: management-by-exception (passive) and laissez-faire. The last 9 items of the questionnaire are used to estimate three subscales which consider leadership outcomes: extra effort, effectiveness, and satisfaction. Each of the 45 items is rated using a 5-point Likert scale including not at all, once in a while, sometimes, fairly often, and frequently if not always. The score for every item ranges from 0 (not at all) to 4 (frequently if not always) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A double reverse translation was used as well as an adaptation from a specialized health professionals\u0026rsquo; team for the Cypriot population was applied in order to adjust the questionnaire to the cultural context.\u003c/p\u003e \u003cp\u003eThe third section consisted of the Job Satisfaction Survey (JSS) questionnaire developed by Spector (1985) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. JSS is a 36-item, nine-facet scale to assess employee attitudes about the several aspects of their job. The nine facets include payment, promotion opportunities, fringe benefits, contingent rewards, recognition, operating procedures, relationships with co-workers, interest in the nature of work, and communication within the organisation. Each facet is assessed with four items, and a total score is computed from all items. A summated rating scale format is used, with six choices per item ranging from 1 \u0026ldquo;strongly disagree\u0026rdquo; to 6 \u0026ldquo;strongly agree\u0026rdquo;. Some of the questions are negatively marked, therefore after reversing the score, the result of each questionnaire is calculated based on the average of all answers, which are subsequently added and divided by the number of equivalent questions (as well as the availability of non-missing responses). The JSS scale was translated into Greek with a double reverse translation method and was adapted from a specialised health professionals\u0026rsquo; team for the Cypriot population. The questionnaire was used following permission from the author, which was kindly provided.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePilot study\u003c/h2\u003e \u003cp\u003eΑ pilot study to assess the survey tools was conducted in July 2016, where 15 questionnaires were distributed to corresponding physicians of the public health sector of Cyprus. All physicians were members of the Cyprus Medical Association and came from all hierarchical ranks of medical officers in the public sector of the Ministry of Health. During this process, we were able to modify the questionnaires according to the responders\u0026rsquo; feedback. Specifically, we removed a question on the medical specialization of health professionals in order to avoid concerns of potential identification of respondents.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData collection and management\u003c/h2\u003e \u003cp\u003eThe data collection was completed between October 2016 and January 2017. The questionnaires were distributed to physicians working in health centers by post. In addition, each physician was informed via phone by the main researcher regarding the survey. An envelope was included so that participants could seal the questionnaires to strictly protect anonymity and confidentiality. An informational leaflet was also included describing who was performing the study, the title and purpose of the study and the required completion time of the questionnaires. Participation was voluntary. A consent form was also enclosed. A healthcare professional from each center was assigned to collect the consent forms along with the questionnaires in sealed envelopes. The questionnaires in the hospitals were given by the main researcher to all physicians. Responses were collected by a health professional in each particular hospital who was assigned to collect both the questionnaires and the consent forms in a separate sealed box. The questionnaires were kept locked and only the main researcher had access to the questionnaires.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eFor the statistical analysis, we dichotomised each satisfaction subscale where values equal or above 3.5 (i.e. the middle value of the continuous range 1\u0026ndash;6) were considered as \u0026ldquo;job satisfaction\u0026rdquo; and values below 3.5 as \u0026ldquo;not being satisfied\u0026rdquo;. Number of cases with percentages and Pearson's Chi-squared tests with Yates' continuity correction were used for each pair between a categorical demographic characteristic of physicians and the total job satisfaction indicator, while means with standard deviations and Mann-Whitney (i.e. two-sample Wilcoxon rank-sum) tests were used for each pair between a continuous demographic and the total job satisfaction indicator. Welch two sample t-tests were used to indicate if there is a statistically significant difference on the average scores of leadership styles between the physicians who were not satisfied by their job and those who were satisfied. Furthermore, univariate logistic regressions were performed between each leadership subscale (independent variable) and binary indicator for each job satisfaction subscale (dependent variable) to investigate their associations. Statistical significance was assessed at the level of 0.05 for both sides.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOut of 690 physicians working in the public sector who received an invitation to participate, 511 completed the survey and 9 were excluded. Therefore 502 physicians were included in our study (response rate 73%). About half of the 502 physicians were females (n\u0026thinsp;=\u0026thinsp;262, 52.2%). The mean age of the participants was 47.7 years (SD\u0026thinsp;=\u0026thinsp;9.2), whilst the mean year of experience in the public sector was 12.4 years (SD\u0026thinsp;=\u0026thinsp;8.4) and in private was 4.4 years (SD\u0026thinsp;=\u0026thinsp;5.9), respectively. From the 502 physicians, that were included in the current study, 69.7% were working in public hospitals and 30.3% in health care centers.\u003c/p\u003e \u003cp\u003eIn Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e we present the demographic characteristics of physicians in association with job satisfaction. One chi-squared test from all pairs between the dichotomous demographic variables and the dichotomous total job satisfaction indicator, had a p-value lower than the significance level of 0.05, indicating the statistically significant relationship between the variable representing physicians\u0026rsquo; educational level and job satisfaction. In addition, all Mann-Whitney tests had a p-value greater than 0.05 indicating that there was no statistically significant difference in the means of age, years of experience in public health and years of experience in the private sector with respect to job satisfaction.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of physicians relative to job satisfaction\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePhysicians\u0026rsquo; demographics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c9\" namest=\"c5\"\u003e \u003cp\u003eTotal Job Satisfaction\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003ep-value \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003enot Satisfied\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003eSatisfied\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e262 (52.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e206 (51.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e56 (55.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.533\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e235 (46.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e191 (47.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e44 (43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e5 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e4 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e1 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLive alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e76 (15.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e58 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e18 (17.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.618\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI do not live alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e393 (78.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e313 (78.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e80 (79.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e33 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e30 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e3 (3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChildren\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e391 (77.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e313 (78.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e78 (77.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.519\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e84 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e64 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e20 (19.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e27 (5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e24 (6.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e3 (3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorkplace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic Hospitals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e350 (69.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e276 (68.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e74 (73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.455\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth Centers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e152 (30.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e125 (31.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e27 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJob position\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInternal medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e345 (68.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e274 (68.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e71 (70.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e80 (15.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e64 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e16 (15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e77 (15.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e63 (15.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e14 (13.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaster degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e205 (40.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e177 (44.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e28 (27.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e240 (47.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e178 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e62 (61.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e57 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e46 (11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e11 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e83 (16.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e72 (18.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e11 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e359 (71.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e281 (70.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e78 (77.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e60 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e48 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e12 (11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTenure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e273 (54.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e223 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e50 (49.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.284\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e193 (38.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e149 (37.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e44 (43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e36 (7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e29 (7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e7 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContract\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e193 (38.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e148 (36.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e45 (44.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.192\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e273 (54.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e224 (55.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e49 (48.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e36 (7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e29 (7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e7 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003eMean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003eMean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e \u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e471\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.7 (9.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e372\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e47.7 (8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e47.7 (10.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.983\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eYears of experience in public health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e462\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.4 (8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e365\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e12.6 (8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e11.7 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.140\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eYears of experience in private\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e408\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.4 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e322\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e4.2 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5.2 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.905\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003e\u003csup\u003ea\u003c/sup\u003e Chi-squared test; \u003csup\u003eb\u003c/sup\u003e Mann-Whitney test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eLeadership as evaluated by the Multifactor Leadership Questionnaire (MLQ-5X) relative to job satisfaction is presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. All two-sample t-tests had a p-value less than 0.05 indicating that there was a statistically significant difference in the means of all leadership subscales between the physicians who were not satisfied by their job and those who were satisfied. Furthermore, in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e we show that the means of transformational, transactional, passive and total leaderships are statistically significantly different between the physicians who were not satisfied by their job and those who were satisfied.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation of Leadership with total Job satisfaction\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMLQ Scale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eTotal Job Satisfaction\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003enot Satisfied\u003c/p\u003e \u003cp\u003emean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSatisfied\u003c/p\u003e \u003cp\u003emean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eidealized influence (attributed)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.7 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.4 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eidealized influence (behavior)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.7 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.3 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003einspirational motivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.7 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.4 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eintellectual stimulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eindividual consideration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.9 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003econtingent reward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.3 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.0 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emanagement by exception (active)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.9 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.2 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emanagement by exception (passive)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.9 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003elaissez-faire leadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.3 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.6 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eextra effort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.3 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.1 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEffectiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.4 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.6 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.4 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFactor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etransformational leadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.6 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.2 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etransactional leadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.6 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enon-leadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.4 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.7 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.8 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.1 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e we present the results (odds ratios with 95% Confidence Intervals (CI)) of different logistic regression models examining the association between leadership styles (independent variable) and job satisfaction subscales (dependent variables) among physicians. We found that transactional and transformational leaderships have positive effects on the nine subscales and the total scale of job satisfaction (i.e. odds ratios greater than 1), while passive leadership has negative effects on job satisfaction. The total leadership has positive effects on job satisfaction subscales being statistically significant for six out of nine subscales. Total leadership has also a statistically significant positive effect on total job satisfaction [odds ratio\u0026thinsp;=\u0026thinsp;3.88, 95% CI (2.27, 6.63)].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn summary, we evaluated the association between physician managers\u0026rsquo; leadership styles and job satisfaction among physicians in the public health sector of Cyprus. The results of our study demonstrated that transformational and transactional leaderships have a strong positive effect on job satisfaction while passive leadership has a negative effect. However, as an overall result of the above findings, the measure of total leadership has a positive effect on the job satisfaction of health professionals in the public health sector of Cyprus. It is also worth highlighting that both leadership styles (transformational and transactional) show similar strong associations with health professionals\u0026rsquo; job satisfaction in the same subscales, namely, pay, promotion, supervision, fringe benefits, contingent rewards, communication and total satisfaction.\u003c/p\u003e \u003cp\u003eSeveral studies have described the positive contribution of physician managers using transformational leadership practices [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Weberg emphasized that a transformational leader can extend and elevate the interests of staff, who can facilitate employee commitment to the mission and values of the organization and who can lead staff to rise above their personal interests [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Lavoie-Tremblay et al. indicated that transformational leadership potentially lead to high quality care and weak intention to quit the healthcare facilities and conversely, abusive leadership potentially lead to poorer quality care and to strong intention to quit the healthcare facilities having lower job satisfaction [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. To this day, transformational leadership remains the better-known leadership approach [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and our study findings are strongly compatible with the existing scientific literature on this topic.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eSome limitations of our study are worth mentioning. Although the response rate in our study was high, we had to exclude a sizable number of responders due to missing values. Moreover, data were collected from physicians and no other healthcare workers. The relatively small sample size does not allow for a more detailed statistical analysis between the different subscales. Finally, in this particular study we have examined the association of leadership with job satisfaction, although there are several other aspects of health professionals\u0026rsquo; resource management styles that are also involved in this complex interconnection network that were not addressed in the current study.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWe have found that transactional and transformational leadership styles were strongly and positively associated with health professionals\u0026rsquo; job satisfaction in most subscales of the job satisfaction questionnaire used in this study. On the contrary, passive leadership style was associated with a negative impact on job satisfaction. Our study findings provide a strong insight regarding the association of leadership with several job satisfaction attributes.\u003c/p\u003e \u003cp\u003e Provided that our reported associations are based on underlying causal associations, our study findings could support relevant policies and educational programs to promote transactional and transformational leadership styles in the healthcare sector in order to promote health professional job satisfaction and associated additional positive outcomes including healthcare quality.\u003c/p\u003e \u003cp\u003eOur findings also support the important role of associated training to promote transactional and transformational leadership in the healthcare sector in preparing new leaders that could facilitate organization-wide changes during this highly demanding period of innovative technology and digital transformations in the healthcare sector.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e We acknowledge the contribution and help of Dr. Stavros Chatzopoulos in statistical analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003eIG conceptualized the project and was the PI of the study. IG,\u0026nbsp;AS\u0026nbsp;and AC planned the study and implemented its methodology. AM and EP contributed to the study\u0026rsquo;s design. IG, AS and AC performed data collection. DA performed the statistical analysis of the data. IG, ECE, AS and ESS wrote the first draft of the manuscript. ECE and DA prepared the tables and figures. All authors were involved in data interpretation and writing of subsequent manuscript iterations.\u0026nbsp;All authors\u0026nbsp;conducted critical review of the manuscript and approved of the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u0026nbsp;\u003c/strong\u003eData are available upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eApproved by the National Bioethics Committee of Cyprus (07/04/2016, Protocol number \u0026Epsilon;\u0026Epsilon;\u0026Beta;\u0026Kappa; \u0026Epsilon;\u0026Pi; 2016.02.57). 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Transformational and abusive leadership practices: impacts on novice nurses, quality of care and intention to leave. J Adv Nurs. 2016;72(3):582\u0026ndash;92. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jan.12860\u003c/span\u003e\u003cspan address=\"10.1111/jan.12860\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2015 Nov 25. PMID: 26602068.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDay DV, Antonakis J. Leadership: past, present and future. In: Day DVAntonakis J., editor. The Nature of Leadership. 2nd ed. Los Angeles, CA: Sage; 2012. pp. 3\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Physicians’ leadership, Job Satisfaction, public health sector, Cyprus","lastPublishedDoi":"10.21203/rs.3.rs-4293854/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4293854/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHealthcare leadership and job satisfaction constitute important characteristics of health professionals\u0026rsquo; employment status. Our study aim was to examine the relationship between managers\u0026rsquo; leadership styles and physicians\u0026rsquo; job satisfaction in the public health sector of Cyprus.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional survey was conducted using self-administered questionnaires among all physicians working in the public health sector of Cyprus (Ministry of Health, administration offices, public hospitals and healthcare centers). In this context we used two standardized internationally validated instruments: the Multifactor Leadership Questionnaire (MLQ-5X), and the Job Satisfaction Survey (JSS).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOut of 690 physicians working in the public health sector who received an invitation to participate, 511 completed the survey and 9 were excluded. Therefore, a total of 502 physicians (262 male and 235 female) were included in the final analysis (response rate 73%). Transactional and transformational leaderships had strong positive effects on six out of the nine job satisfaction subscales, as well as on the total job satisfaction scale, whereas passive leadership had a negative effect on job satisfaction. Overall, total leadership had a strong statistically significant positive effect on total job satisfaction [odds ratio\u0026thinsp;=\u0026thinsp;3.88, 95% CI (2.27, 6.63)].\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe found strong and statistically significant associations between the transactional and transformational leadership styles and health professionals\u0026rsquo; job satisfaction in most of the job satisfaction subscales. Establishing a causal relationship between the above requires further investigations with appropriate study design.\u003c/p\u003e","manuscriptTitle":"Leadership and Job satisfaction among Physicians in the Public Health Sector of Cyprus","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-24 09:23:06","doi":"10.21203/rs.3.rs-4293854/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"78045b08-621c-4cfb-8b7a-95b40460528d","owner":[],"postedDate":"April 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-08T05:39:43+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-24 09:23:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4293854","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4293854","identity":"rs-4293854","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}