Job Satisfaction Among Syrian Health Workers in Refugee Health Centres in Turkey

Job satisfaction among Syrian health workers in refugee health centres in Turkey

Achieving universal health coverage is subject to the availability, accessibility, acceptability and quality of health workers. A health workforce aligned to population needs is critical to making progress towards universal health coverage. Countries that host refugees and migrants strengthen the capacity of their health systems to increase access to services, including engaging refugees and migrants as health workers. The employment, integration, retention and performance of migrant health workers are key to their success in contributing to the health-care system. This report presents the results of an assessment of job satisfaction among Syrian physicians and nurses working in refugee health centres in Turkey and the factors that influence job satisfaction. The analysis of job satisfaction in this category of migrant health workers contributes to the wider evidence on human resources for health.

KEYWORDS

JOB SATISFACTION MIGRANT HEALTH WORKERS NURSES PHYSICIANS SYRIAN REFUGEE TURKEY

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Document number: WHO/EURO:2020-1576-41327-56246

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Art-direction and layout: www.freightdesign.co.uk Job satisfaction among Syrian health workers in refugee health centres in Turkey © WHO iii

Preface iv

Acknowledgements vi

Abbreviations vii

Executive summary ix

Introduction 1 Background 2 Methodology 5 Study questionnaires and variables 5

Results 7 Sociodemographic and occupational 7 characteristics of participants Work characteristics and work environment 10 Job satisfaction 10 Determinants of job satisfaction 14 Work environment 17 Profession, experience and income 17

Discussion 19 Conclusions 22 References 23 Annex 1. Five-point responses 26 to the 20-item MSQ

Preface

The conflict in the Syrian Arab Republic has caused one of the world’s largest and most dynamic displacement crises, affecting millions of lives. WHO is supporting the response to the crisis through its operations in Turkey, which comprise a cross-border response from the field office in Gaziantep and a health response to refugees in Turkey, coordinated from the WHO Country Office in Ankara.

In north-western Syria, WHO is implementing Activities of the programme are defined within interventions such as the delivery of vital medicines the scope of the Regional Refugee and Resilience and medical supplies and providing support for the Plan (3RP) 2018–2019, a broad partnership platform operational costs of health facilities and capacity- for over 270 development and humanitarian building of health staff. Through the Refugee partners to provide coordinated support in Health Programme in Turkey, efforts have been countries bordering Syria that are heavily impacted made to strengthen the national health system by the influx of refugees. This platform capitalizes through integrating Syrian health workers and on the knowledge, capacities and resources of translators, build capacity for mental health care, humanitarian and development actors to provide a provide linguistic and culturally sensitive health single strategic, multisectoral and resilience-based services, and support home care for older refugees response. Supported by several donors, WHO’s and those with disabilities. activities are complementary to the Ministry of Health's SIHHAT (Improving the health status of the Syrian population under temporary protection and related services provided by Turkish authorities) project, a joint initiative by the European Union and Ministry of Health of the Republic of Turkey that aims to improve health-care services for Syrian refugees in the country. This project operates under the European Union’s Facility for Refugees in Turkey and focuses on strengthening the provision of primary and secondary health-care services to Syrian refugees, building and supporting a network of refugee health centres across the country, and employing additional health personnel, including Syrian doctors and nurses.

In November 2018 the Refugee Health Programme conducted the Workshop on Refugee and Migrant Health in Turkey: Survey and Research Consultation to identify gaps in the information and evidence required for programme development and adaptation and for informing policies on migrant health in Turkey. The Workshop brought together more than 57 national and international experts from academia, Ministry of Health, United Nations agencies and WHO collaborating centres and led to the formulation of the programme’s research framework. Within this framework, a series of studies were implemented in the fields of mental health, health literacy, women and child health, health workforce and noncommunicable diseases. This study, Job satisfaction among Syrian health workers in refugee health centres in Turkey, is one of the studies implemented within the Refugee Health Programme research framework.

Acknowledgements

The WHO Health Emergencies team in Turkey would like to thank Kanuni Keklik and Habibe Özdemir of the Ministry of Health of the Republic of Turkey for their leadership and guidance in implementing the study.

The WHO Health Emergencies team in Turkey Authors would like to thank Kanuni Keklik and Habibe The principal authors of this report are Monica Özdemir of the Ministry of Health of the Republic Zikusooka and Omur Cinar Elci, WHO Regional of Turkey for their leadership and guidance in Office for Europe. implementing the study. Thanks also go to Pelin Cebeci, Çetin Doğan Dikmen, Elif Göksu, Nurtaç Peer reviewer Kavukcu, Melda Keçik, Kadriye Küçükbalci, Altin The report was peer-reviewed by Nazmi Bilir, Malaj and Mustafa Bahadir Sucakli of WHO formerly with the Department of Cancer Control, and Mehmet Balcılar, Alpaslan Girayalp, Burçin Ministry of Health, Ankara, Turkey; Founding Tahtacıoğlu and Sarp Üner of PGlobal Global Director of the National Committee on Smoking Advisory and Training Services for their valuable and Health, Turkey; and Director of the Institute contributions to data collection, data analysis and of Public Health, Hacettepe University, Ankara, the overall implementation of the study. Turkey.

This report was produced with financial assistance of the Government of Germany through KfW Development Bank.

Abbreviations

CI confidence interval

MSQ Minnesota Satisfaction Questionnaire

RHC refugee health centre

RHTC refugee health training centre

SD standard deviation

SIHHAT I mproving the health status of the Syrian population under temporary protection and related services provided by Turkish authorities (project)

Executive summary

Turkey hosts about 3.6 million Syrian refugees, who are given access to free primary health-care services through refugee health centres (RHCs). RHCs are supported through the Turkish Ministry of Health’s Improving the health status of the Syrian population under temporary protection and related services provided by Turkish authorities (SIHHAT) project, which is funded by the European Union.

The SIHHAT project is operational in 29 provinces Of the targeted 1577 health workers, 891 with a high population density of Syrian refugees. participated in the study, giving an overall response As of June 2020 712 Syrian physicians, 977 Syrian rate of 56.5%. Most participants were nurses/ nurses and 1148 patient guides were employed via midwives (62.3%), and 65.2% of the participants SIHHAT project resources to provide language and were male. The highest proportion of participants culturally appropriate services to Syrian refugees. were in the 30–39 years age group (37.8%). In all, This study aimed to assess job satisfaction and 47.3% of participants were Syrian with Turkish the factors that determine job satisfaction among citizenship. Almost half (41.2%) reported having refugee physicians and nurses working in RHCs five or fewer years of work experience in Syria, to generate evidence for actions to improve and while most (64.5%) reported having worked in the maintain the motivation, job satisfaction and job SIHHAT project for two years or less. The mean performance of health workers, with the ultimate (± standard deviation (SD)) score for general job aim of improving the quality of health care. satisfaction was 63.3 ± 14.6 for general physicians, 65.9 ± 13.2 for the specialist physicians and 74.9 The study was a quantitative cross-sectional ± 11.0 for nurses. Multivariate analyses revealed a survey targeting all Syrian physicians and nurses significant difference in general job satisfaction working in RHCs in Turkey. Job satisfaction between physicians and nurses (P < 0.001). Of all 20 was assessed using a short-form Minnesota items in the MSQ, participants reported having the Satisfaction Questionnaire (MSQ), which has been highest satisfaction level in security (26.5%). used to measure job satisfaction in health-care professionals in other studies. Additionally, data on the potential determinants of job satisfaction were collected using a questionnaire developed from literature reviews on the factors influencing job satisfaction in health workers. The two questionnaires were combined into a single online self-administered questionnaire in Arabic. x

The level of job satisfaction was higher among The study provides evidence of a need to health workers aged between 40 and 49 years and improve work engagement for physicians and for those without Turkish citizenship. Job satisfaction maintaining good teamwork and management in was also higher among those who reported having RHCs. The results also indicate a need to consider access to the resources needed for their work, those adjustment for the annual cost of living in the who worked in refugee health training centres salaries of health workers coupled with non- (RHTCs) and those who perceived teamwork and financial incentives to maintain high levels of job team management to be good in their RHC. Job satisfaction and motivation. Overall, managers of satisfaction was also higher among those who RHCs and the SIHHAT project can consider these had had less work experience in Syria and those issues in developing policies and strategies for who perceived their income from the RHC to be human resources in RHCs to improve and maintain good. The level of job satisfaction was shown to high levels of job satisfaction. decrease with increasing numbers of patients per day. However, multivariate analyses revealed that the only factors significantly influencing job satisfaction among health workers in RHCs were their profession in Turkey (i.e. general physician, specialist physician, or nurse or midwife), income, teamwork and team management.

Introduction

Turkey hosts the largest number Syrian refugees, with an estimated population of 3.6 million (1). In 2018 the Ministry of Health of the Republic of Turkey, through the SIHHAT project, established the RHC mechanism to provide culturally and linguistically sensitive primary health-care services for Syrian refugees.

The SIHHAT project is operational in 29 provinces with the highest population densities of Syrian refugees. In 2016 the Ministry of Health established the RHC mechanism to provide culturally and linguistically competent primary health-care services to Syrian refugees. The Ministry of Health further developed and extended this mechanism through the SIHHAT project. By December 2019 there were 178 active RHCs across Turkey. Since becoming operational, RHCs have provided more than 1 270 000 patient consultations. As of June 2020, the SIHHAT project employed 712 Syrian physicians, 977 Syrian nurses and 1148 patient guides. This study aimed to collect evidence on job satisfaction and the factors influencing job satisfaction among refugee physicians and nurses working in RHCs. This report presents the findings of the job satisfaction study among Syrian health workers in RHCs.

Background In Turkey, primary health care is provided through National health system and RHC mechanism community health centres and family health Health-sector partners of the 2019–2020 Regional centres; in addition, RHCs have been established as Refugee and Resilience Plan (3RP) framework for part of the network of community health centres Turkey have committed to supporting the Ministry by the Ministry of Health to meet the primary of Health in building health system resilience to health-care needs of the Syrian refugee population ensure that the needs of Syrians under temporary within the scope of the SIHHAT project. The RHC protection and host communities are met (2). mechanism was planned and implemented based Primary health care is the route to achieving on the organization of primary health-care services universal health coverage and the Sustainable in Turkey. RHCs comprise Refugee Health Units, Development Goals (3) but to make progress with each consisting of a physician and nurse pair. countries need a primary health workforce aligned The mechanism also has extended RHCs that to its population’s needs (4). The primary health- additionally provide internal medicine, paediatrics, care workforce includes health workers engaged obstetrics and gynaecology, oral and dental health, along the continuum of health promotion, disease and psychosocial support services, and simple prevention, treatment, rehabilitation and palliative imaging and laboratory services. In addition to care, and those engaged in addressing the social RHCs and extended RHCs, there are seven RHTCs determinants of health (4). that, in addition to providing all of the services of extended RHCs, have training facilities for health workers and are jointly managed by the Ministry of Health and WHO.

© WHO The RHC mechanism differs from the national health system in how it is financed and its health- worker profile and target population. In the Turkish health system, primary health-care services are financed through the general social security system’s general health insurance budget and all health services are provided by Turkish nationals or foreigners who have accreditation. In contrast, RHCs are financed through the SIHHAT project (with funding from the European Union and nurses move to their home towns or a nearby support from other external donors) and health- location to work in public or private hospitals, with care service providers are primarily Syrian nationals, no centralized Ministry of Health appointment who are authorized to work only in RHCs. Syrian system (as there is in Turkey). Working in their nurses, midwives and general physicians work at own communities allows them to receive social the same level as they did in Syria, but specialist support. In Syria, besides working in hospitals, physicians are mostly employed as general physicians could work in private clinics and physicians – only a small proportion continue employ nurses, enabling them to gain additional to work as specialists. Although RHCs primarily income. Compared with Turkey, health workers provide services to Syrian refugees, like all health- in Syria worked fewer hours, worked in their own care facilities in Turkey they provide services related communities and had access to additional income to communicable disease prevention (such as through private practice. As such, refugee health vaccination) and emergency health services to workers have to adapt to new working and living those in need, regardless of their nationality and environments in Turkey. registration status1. Before employment, Syrian health workers are trained and oriented to work in Physicians’ job satisfaction the Turkish health-care system through a tailored and patients’ satisfaction adaptation training programme implemented by Studies have shown that physicians’ satisfaction WHO in collaboration with the Ministry of Health. with their work and work environment may impact WHO and Ministry of Health joint adaptation the quality of patient care (5), patients’ satisfaction training is delivered in WHO-managed RHTCs with their health care (6), patients’ adherence located in seven provinces (Ankara, Gaziantep, to medical instructions (7) and physicians’ Hatay, Istanbul, Izmir, Mersin and Sanliurfa). commitment to staying in the job (5,8). The higher Through this action, WHO aims to fill a human turnover rates for physicians due to poor job resources gap in the primary health-care service satisfaction may disrupt care provision and access delivery to Syrian refugees in order to increase to health care, while recruitment and replacement access to quality and equitable health care for all. efforts may increase the overall health-care costs. As of March 2020, WHO and the Ministry of Health Jobs satisfaction among physicians is related to have trained 638 physicians, 806 nurses, 927 a range of factors. A systematic review of studies translators and 337 auxiliary staff providing on factors affecting job satisfaction of physicians services in 178 RHCs located in 29 provinces, and working in European countries showed that over 1 270 000 Syrian refugees have received some factors affecting job satisfaction relate to health-care services in RHCs. the individual, such as age, gender, marital status Syrian health workers who are employed in the and work experience, while others are intrinsic Turkish health system find contextual differences to the nature of the job, such as specialization, to which they have to adapt, as established in a patient interactions and work engagement (9). WHO field assessment on the employability of Yet other factors can relate to the job context, Syrian health workers in Turkey (Factors affecting such as workload, job security and income level, employability of trained Syrian health-care or to the work environment, such as type of health professionals in Turkey, WHO Regional Office for centre, management, professional development, Europe, unpublished data, 2020). In Syria, upon teamwork and access to resources. completion of their training, physicians and

1 That is, as a as a Syrian under temporary protection. 4 Job satisfaction among Syrian health workers in refugee health centres in Turkey

Patient satisfaction may be influenced by the values, attitudes and expectations of individual patients, but may also depend on the job satisfaction level of physicians. For instance, one study reported that patients of physicians with a high level of professional satisfaction were more satisfied with the health care they received compared with the patients of physicians with lower satisfaction levels (6). Another study found that job satisfaction among nurses correlated © WHO positively with patient satisfaction (8). Specific recruited nurses in the United Kingdom reported aspects of health workers’ experiences that some positive experiences but also reported that reduce patient satisfaction levels include having many nurses had negative experiences related to too little time to accomplish their tasks (10), not feeling valued or respected professionally (15). high work pressure for staff, staff perceptions of Overall, these studies indicated the value of migrant unequal treatment, discrimination and physical health workers in the health-care systems of host violence (11). However, another study did not find a countries – irrespective of the reason for migration. correlation between patient satisfaction and the job satisfaction of physicians working in primary health Existing evidence on migrant health workers largely care (12). Instead, they found a correlation between relates to migrants who are integrated into the host patient satisfaction and job satisfaction of non- country’s health system and provide services to the physician staff (practice nurses, practice managers host population. However, Syrian refugee health or secretaries/administrators), suggesting that workers working within the Turkish health system patients may be more concerned about the provide culturally and language-sensitive services overall service quality than the just the physician’s only to the Syrian refugee population through performance. the RHC mechanism. Although there might be similarities between the experiences of Syrian Several studies have investigated job satisfaction refugee health workers in Turkey and migrant in migrant health workers, with varying levels of health workers elsewhere, understanding job job satisfaction reported compared with national satisfaction in this unique context could contribute professionals (i.e. citizens of the host country). to human resource planning and providing A study in Spain showed that being foreign born universal health coverage in health systems in was a significant predictor of job satisfaction other countries with large refugee and migrant among physicians, with foreign physicians being populations. more satisfied than national physicians (11). Similarly, a study in Singapore reported high levels Study aim and objectives of satisfaction among 495 migrant nurses, which WHO field assessments indicate that, despite correlated negatively with the work environment their importance in scaling up human resource (13). However, other studies have reported the capacity and adherence to Turkish Labour difficulties experienced by migrant health workers: Regulations, which includes 45 working hours for example, a qualitative study among migrant per week, Syrian physicians and nurses complain physicians in Germany reported that the challenges that they face challenges such as high workload, experienced by foreign workers were related limited opportunities for specialization, challenging to the organization of health-care institutions, working environments and managing the cost such as regulation of licensure, legal norms of living. Such challenges may impact their and distribution of tasks, and difficulties with motivation, satisfaction and ability to effectively their own competencies, such as language and deliver quality health care and reduce their work understanding the organization of the health-care performance. However, no study has yet been system (14). The study also reported that physicians conducted to generate evidence on the level of job face difficulties related to their patients, colleagues satisfaction among physicians and nurses working and superiors, and said they felt discriminated in RHCs. The objectives of the study were to (i) against as foreigners. An integrative review of establish the level of job satisfaction and (ii) identify studies into the experiences of internationally the factors that determine job satisfaction in Syrian physicians and nurses working in RHCs in Turkey. Job satisfaction among Syrian health workers in refugee health centres in Turkey 5

Methodology Since most specialist physicians work as general Study design practitioners at the RHCs, the profession variable This study was a quantitative cross-sectional was especially important in this study. survey that targeted all Syrian physicians and nurses working in RHCs across Turkey. According The questionnaire on determinants of job to Ministry of Health figures, at the time of the satisfaction was developed following a literature survey 681 physicians and 896 nurses were review that included a systematic review on employed in RHCs across Turkey. Sample size quantitative research that assessed factors estimation using WinPepi (version 11.65) at a 95% influencing job satisfaction in health workers (9). confidence interval (CI), 0.01 error margin and In addition to these factors, the questionnaire 5% loss to follow-up yielded a sample size of 630 included factors identified in other WHO physicians and 783 nurses. assessments that might also affect job satisfaction in health-care professionals working in RHCs Study questionnaires and variables (Factors affecting employability of trained Syrian Job satisfaction questionnaire health care professionals in Turkey, WHO Regional Job satisfaction was assessed using the General Office for Europe, unpublished data, 2020). Prior to Job Satisfaction scale based on the short-form use, the questionnaire was translated from English MSQ (16) and included 20 items on job to Arabic and then re-translated to English by a satisfaction: ability utilization, achievement, different translator in line with the principles of activity, advancement, authority, company cultural adaptation (20). Discrepancies between the policies, compensation, co-workers, creativity, two English versions (original and translated from independence, moral values, recognition, Arabic) were resolved to finalize the Arabic version. responsibility, security, social status, social service, Prior to data collection, the questionnaire was supervision – human relations, supervision – pretested in 10 respondents to check the suitability technical, variety and working conditions. The of the Arabic dialect for the study population, version used in this study was translated into clarity of meaning, clarity and interpretation of Arabic. questions, and the questionnaire flow. Following the pretest, minor adjustments were made and The MSQ is a product of research on adjustment the final version was adapted into an online survey to work within the theory of work adjustment, tool using Kobo Toolbox. which postulates that work fit depends on a match between the individual skills and work Data collection environment (16). The short-form MSQ was used in Data were collected through the self-administered this study because it has been widely adapted to questionnaire between 9 October and 1 December other health-care settings (17–19) and can be self- 2019. A link to the online questionnaire was sent to administered within five to 10 minutes. all physicians and nurses working in RHCs by the Ministry of Health in an official letter to ensure the Determinants of job satisfaction questionnaire anonymity of participants. The questionnaire did Based on literature reviews (6,7,9,17) and not include any personal or other information that other assessments in RHCs (Factors affecting could be used to identify the study participants. To employability of trained Syrian health care improve the response rate, all study participants professionals in Turkey, WHO Regional Office for were sent weekly reminders by the Department of Europe, unpublished data, 2020), the following Migration, Ministry of Health, via the head physician potential determinants of job satisfaction were for each RHC. considered: sociodemographic factors (age, gender, education, marital status, nationality, residency in Turkey), characteristics of the work (working hours per day, workload/number of patients per day), work environment (type of health-care centre (RHC, extended RHC and RHTC), teamwork and team leadership/management), profession (general physician, specialist physician and nurse/midwife), length of experience (years of experience in Syria) and income. 6 Job satisfaction among Syrian health workers in refugee health centres in Turkey

Data cleaning and analysis Ethical approval Collected data was securely stored in a password- Ethical approval for this study was obtained encrypted server, checked against all entry errors from the WHO Ethical Review Committee, Gazi and discrepancies, and cleaned before data University Ethical Board and Ministry of Health analyses. A descriptive analysis was conducted to Ethical Board in Turkey. describe the distribution of study variables and determine the level of job satisfaction. Due to the non-parametric nature of the data, relationships between different variables and the job satisfaction score were assessed using the Mann–Whitney U test and the Kruskal–Wallis test. For variables that had three groups, Dunn’s pairwise tests with adjustment using Bonferroni correction was conducted after the Kruskal–Wallis test to identify groups with significantly different levels of job satisfaction. Linear regression analysis was also conducted to determine the factors that influenced job satisfaction. Data were analysed using IBM SPSS Statistics version 25. © WHO

Results

This study was conducted to determine the level of job satisfaction among refugee physicians and nurses working in RHCs and to identify which factors determine job satisfaction. Of the targeted 1577 health workers, 891 completed the questionnaires (555 nurse/midwives, 259 general physicians and 77 specialist physicians), giving an overall response rate of 56.5% (61.9% for nurses and 49.3% for physicians).

Sociodemographic and occupational characteristics of participants Most of the participants were nurses/midwives (62%). Approximately two thirds of respondents were men (65.2%), a similar proportion were younger than 40 years of age (56.7%) and 86.9% were married. In all, 47.3% of participants were Syrians with Turkish citizenship; the majority of those with Turkish citizenship were physicians (Table 1). Most health workers had an undergraduate degree or higher; however, for 28.8% of nurses, the highest education level was high school. Almost half (41.2%) of study participants had five or less years of work experience in Syria, and most (64.5%) had worked in the SIHHAT project for two years or less.

Table 1. Sociodemographic and occupational characteristics of respondents

General physician Specialist physician Nurse/midwife Total Characteristic (n = 259) (n = 77) (n = 555) (n = 891) n % n % n % n %

Sex

Male 209 80.7 58 75.3 314 56.6 581 65.2

Female 50 19.3 19 24.7 241 43.4 310 34.8

Age group (years)

20–29 41 15.8 0 0.0 127 22.9 168 18.9

30–39 100 38.6 24 31.2 213 38.4 337 37.8

40–49 56 21.6 34 44.2 159 28.6 249 27.9

≥ 50 62 23.9 19 24.7 56 10.1 137 15.4

Marital status

Not married 37 14.3 3 3.9 77 13.9 117 13.1

Married 222 85.7 74 96.1 478 86.1 774 86.9

Nationality

Syrian 111 42.9 31 40.3 328 59.1 470 52.7

Syrian with Turkish citizenship 148 57.1 46 59.7 227 40.9 421 47.3

Education

High school 0 0.0 0 0.0 160 28.8 160 18.0

Undergraduate degree 166 64.1 16 20.8 386 69.5 568 63.7

Masters/postgraduate degree 93 35.9 61 79.2 9 1.6 163 18.3

Profession in Syria

General physician 184 71.0 0 0.0 0 0.0 184 20.7

Specialist physician 75 29.0 77 100.0 0 0.0 152 17.1

Nurse/midwife 0 0.0 0 0.0 555 100.0 555 62.3

Years worked in Syria

0–5 134 51.7 20 26.0 213 38.4 367 41.2

6–10 53 20.5 21 27.3 123 22.2 197 22.1

> 10 72 27.8 36 46.8 219 39.5 327 36.7

Years worked in Turkey*

0–2 172 66.4 42 54.5 361 65.0 575 64.5

> 2 87 33.6 35 45.5 194 35.0 316 35.5

* In the SIHHAT project. Job satisfaction among Syrian health workers in refugee health centres in Turkey 9

Table 2. Work characteristics and work environment of respondents

General physician Specialist physician Nurse/midwife Total Characteristic (n = 259) (n = 77) (n = 555) (n = 891) n % n % n % n %

Type of health centre

RHTC 23 8.9 11 14.3 42 7.6 76 8.5

RHC 215 83.0 56 72.7 491 88.5 762 85.5

Extended RHC 21 8.1 10 13.0 22 4.0 53 5.9

Average number of patients/day

< 21 3 1.2 3 3.9 68 12.3 74 8.3

21–40 40 15.4 18 23.4 256 46.1 314 35.2

41–60 95 36.7 26 33.8 153 27.6 274 30.8

≥ 61 121 46.7 30 39.0 78 14.1 229 25.7

Access to resources needed for work

Yes 196 75.7 49 63.6 489 88.1 734 82.4

No 63 24.3 28 36.4 66 11.9 157 17.6

Know how to use equipment/other materials

Yes 256 98.8 77 100.0 551 99.3 884 99.2

No 3 1.2 0 0.0 4 0.7 7 0.8

Teamwork

Poor 11 4.2 2 2.6 8 1.4 21 2.4

Average 34 13.1 7 9.1 43 7.7 84 9.4

Good 214 82.6 68 88.3 504 90.8 786 88.2

Team management

Poor 34 13.1 8 10.4 27 4.9 69 7.7

Average 49 18.9 15 19.5 66 11.9 130 14.6

Good 176 68.0 54 70.1 462 83.2 692 77.7

Income

Poor 118 45.6 23 29.9 73 13.2 214 24.0

Average 111 42.9 43 55.8 257 46.3 411 46.1

Good 30 11.6 11 14.3 225 40.5 266 29.9 10 Job satisfaction among Syrian health workers in refugee health centres in Turkey

Work characteristics and work environment Job satisfaction Over 85% of study participants worked in RHCs Nurses/midwives reported the highest level of (Table 2). Almost half of the nurses/midwives (46.1%) general job satisfaction, followed by specialist reported seeing an average of 21–40 patients per physicians and then general physicians (Table 3). day; in comparison, the highest proportions of both Kruskal–Wallis testing provided a strong support general and specialist physicians reported seeing that job satisfaction levels differed between the more than 61 patients per day (46.7% and 39.0%, three professional groups (P < 0.001); a follow-up respectively). Most participants reported having Dunn’s pairwise test revealed that job satisfaction access to the resources required for their work and scores were significantly higher in nurses than in knowing how to use the equipment and materials physicians (both general and specialist; P < 0.001). at their disposal. Among all participants, 88.2% Further analysis revealed that physicians who had rated the level of teamwork as good. A slightly worked as specialists in Syria but were now working lower proportion of all participants (77.7%) rated as general physicians in Turkey had the lowest their team management as good, and the lowest satisfaction levels (Fig. 2). However, the difference proportion of participants giving this assessment in job satisfaction between groups of physicians were general physicians (68.0%). Of the three was not significant. professional groups, nurses were the most positive about their teamwork and team management. Overall, 46.1% of participants rated their income as average; this rating was reflected among the specialist physicians and nurses, while the highest proportion of general physicians assessed their income as poor.

Fig. 2. Job satisfaction level by profession and country of work

100

80 77

66 69 62 60

40 * * General Job Satisfaction score 20 *

0 General physician Specialist physician Specialist physician Nurse/midwife in Syria and Turkey in Syria and General in Syria and Turkey in Syria and Turkey physician in Turkey

Table 3. Job satisfaction by profession

Profession Participants (n) Mean SD 95% CI Range

General physician 259 63.3 14.6 61.5–65.1 20.0–100.0

Specialist physician 77 65.9 13.2 63.2–69.0 29.0–88.0

Nurse/midwife 555 74.9 11.0 74.0 –75.8 20.0–100.0

Total 891 70.8 13.4 69.9–71.7 20.0–100.0 Job satisfaction among Syrian health workers in refugee health centres in Turkey 13

Fig. 3. Satisfaction levels related to the 20 items of the MSQ: physicians

Co-workers Authority Social service Satisﬁed Achievement Neutral Dissatisﬁed Supervision – human relations Creativity Independence Supervision – technical Ability utilization Social status Recognition Responsibility Security Work conditions Variety Advancement Activity Moral values Company policy and practice Compensation

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Fig. 4. Satisfaction levels related to the 20 items of the MSQ: nurses

Social service Ability utilization Co-workers Satisﬁed Authority Neutral Dissatisﬁed Achievement Supervision – human relations Advancement Creativity Security Work conditions Supervision – technical Recognition Company policy and practice Variety Responsibility Social status Independence Compensation Activity Moral values

0% 20% 40% 60% 80% 100% 120% 14 Job satisfaction among Syrian health workers in refugee health centres in Turkey

As there was no significant difference in job Determinants of job satisfaction satisfaction between general and specialist Sociodemographic factors physicians, data for both groups were combined Sociodemographic factors included age, gender, in the analysis of satisfaction on the items of the education and nationality (Turkish citizenship). MSQ. Levels of satisfaction on the 20 items on Statistically significant variation was found in the the MSQ also varied among the different groups mean general job satisfaction score between age of participants (Figs 3 and 4). Responses for the groups (P < 0.003), education levels (P < 0.001) and five-point scale (Annex 1) were combined into citizenship categories (P = 0.002; Table 4). When three categories: satisfied (satisfied and very analysed by age group, the mean general job satisfied), neutral and dissatisfied (dissatisfied and satisfaction score was highest among those aged very dissatisfied). Physicians were most satisfied 40–49 years, and when analysed by education l with the co-workers, authority and social service evel, it was highest among those with high school items and least satisfied with the compensation, as the highest level of education. Job satisfaction workplace policy/practice and moral values scores were higher for health workers without items. Nurses were most satisfied with the Turkish citizenship than those with Turkish social services, professional ability utilization and citizenship (P = 0.002). co-workers items and least satisfied with the moral values, compensation and independence items. Physicians were more dissatisfied than nurses with compensation. Job satisfaction among Syrian health workers in refugee health centres in Turkey 15

Table 4. Relationship between general job satisfaction scores and sociodemographic factors

Sociodemographic General Job Participants (n) SD P value factor Satisfaction scale

Sexa

Male 581 70.29 13.6 0.135

Female 310 71.68 13.0

Age group (years)b

20–29 168 70.57 14.4 0.003*

30–39 337 68.69 14.2

40–49 249 73.15 12.1

≥ 50 137 71.77 11.7

Educationb

High school 160 76.87 10.5 < 0.001*

Undergraduate 568 70.76 13.1 degree

Masters/ postgraduate 163 64.83 14.3 degree

Marital statusa

Not married 117 68.79 16.7 0.449

Married 774 71.07 12.8

Citizenshipa

Syrian 470 72.00 13.2 0.002*

S yrian with Turkish 421 69.40 13.6 *: P < 0.05. citizenship a Differences were analysed using the Mann–Whitney U test. b Differences were analysed using the Kruskal–Wallis test.

Work characteristics The work characteristics assessed in this study were number of patient consultations per day, access to resources (e.g. equipment and supplies) needed for work and knowing how to use the available equipment and other materials (Table 5). Job satisfaction scores were significantly different according to the number of patients seen per day scores were highest among health workers who saw fewer than 21 patients per day (P < 0.001). There was a significant inverse relationship between the number of patients seen per day and job satisfaction scores (P < 0.001). Participants who reported having access to necessary resources also had significantly higher job satisfaction scores (P < 0.001).

Table 5. Relationship between general job satisfaction score and work characteristics

General Job Work characteristic Participants (n) SD P value Satisfaction scale

Patients/day (n)a

< 21 74 75.39 11.0 < 0.001*

21–40 314 73.33 10.9

41–60 274 70.89 13.3

≥ 61 229 65.64 15.8

Access to resourcesb

Yes 734 72.82 12.2 < 0.001*

No 157 61.22 14.9

Know how to use equipment/other materialsb

Yes 884 70.79 13.4 0.444

No 7 68.43 16.4 *: P < 0.05. a Differences were analysed using the Kruskal–Wallis test. b Differences were analysed using the Mann–Whitney U test.

Table 6. Relationship between general job satisfaction scores and the work environment

General Job Work environment Participants (n) SD P value Satisfaction scale

Type of health centre

RHTC 76 73.07 11.5 0.007*

RHC 762 70.90 13.4

Extended RHC 53 65.64 14.6

Teamwork

Poor 21 41.90 18.6 < 0.001*

Average 84 60.61 14.6

Good 786 72.63 11.7

Team management

Poor 69 49.59 15.6 < 0.001*

Average 130 60.61 11.6

Good 692 74.79 10.1 *: P < 0.05.

Note: differences were analysed using the Kruskal–Wallis test. Job satisfaction among Syrian health workers in refugee health centres in Turkey 17

Work environment The mean job satisfaction score was directly The factors used to assess the work environment associated with the perception of income earned of Syrian physicians and nurses were type of from working in the RHCs (from poor to good; health centre and the participants’ perceptions of P < 0.001). teamwork and team management. Job satisfaction scores were significantly influenced by all three Multiple regression analysis was used to determine factors (Table 6). The mean job satisfaction score which factors were associated with job satisfaction. was significantly lower for those working in Variables included in the analysis were age group, extended RTCs (P = 0.007) and significantly higher nationality, number of patients per day, type of among those who rated teamwork and team health centre, teamwork, team management, job management as good. in Turkey, number of working years in Syria and income. Out of these factors, only profession in Profession, experience and income Turkey and perception of income, teamwork and The mean job satisfaction scores were significantly team management were significantly associated higher in nurses than in the two groups of with job satisfaction (Table 8). physicians. (P < 0.001; Table 7). Job satisfaction scores also differed significantly different by the number of years worked in Syria (P < 0.001) but not by the number of years working in the SIHHAT project in Turkey (P = 0.19). Compared with the other categories for years worked in Syria, participants who had over 10 years of experience had the highest mean job satisfaction scores.

Table 7. Relationships between general job satisfaction scores and job type, work experience and income

Profession and General Job Participants (n) SD P value experience Satisfaction scale

Job in Turkeya

General physician 259 63.35 14.6 < 0.001*

Specialist physician 77 65.95 13.2

Nurse/midwife 555 74.91 11.0

Years worked in Syriaa

0–5 367 68.53 14.5 < 0.001*

6–10 197 70.57 13.9

> 10 327 73.40 11.2

Years worked in Turkeyb,c

0–2 575 71.01 13.5 0.19

> 2 316 70.34 13.2

Incomea

Poor 214 60.26 15.2 < 0.001*

Average 411 71.49 11.3

Good 266 78.12 8.6 *: P < 0.05. a Differences were analysed using the Kruskal–Wallis test. b Differences were analysed using the Mann–Whitney U test. c In the SIHHAT project. 18 Job satisfaction among Syrian health workers in refugee health centres in Turkey

Table 8. Multiple regression analysis of factors associated with the general job satisfaction score

Variable B 95% CI SE P value

Lower bound Upper bound

Age group (years) (ref. ≥ 50)

20–29 −4.32 −7.53 −1.12 1.634 0.008*

30–39 −4.61 −7.28 −1.94 1.361 0.001*

40–49 −0.48 −2.59 1.62 1.070 0.651

Nationality (ref. Syrian with Turkish 0.32 −0.97 1.61 0.655 0.626 citizenship)

Education (ref. High school)

Undergraduate degree −0.52 −2.45 1.42 0.984 0.600

Masters/postgraduate degree −0.31 −3.12 2.50 1.432 0.829

Number of patients/day (ref. < 20)

21–40 −0.81 −3.26 1.63 1.247 0.515

41–60 −0.45 −2.97 2.07 1.285 0.725

≥ 61 −1.52 −4.19 1.15 1.361 0.265

Type of health centre (ref. RHTC)

RHC −1.65 −3.93 0.63 1.161 0.156

Extended RHC −2.00 −5.38 1.38 1.721 0.245

Teamwork (ref. Good)

Poor −13.44 −18.11 −8.77 2.379 0.000*

Average −3.82 −6.13 −1.51 1.178 0.001*

Team management (ref. Good)

Poor −15.85 −18.63 −13.08 1.412 0.000*

Average −9.31 −11.27 −7.35 0.998 0.000*

Profession (ref. Nurse/midwife)

General physician −6.84 −8.81 −4.88 1.000 0.000*

Specialist physician −6.60 −9.59 −3.62 1.522 0.000*

Years worked in Syria (ref. > 10)

0–5 1.99 −0.37 4.35 1.202 0.099

6–10 2.26 0.05 4.48 1.130 0.045*

Income (ref. Good)

Poor −7.79 −9.77 −5.81 1.009 0.000*

Average −3.24 −4.77 −1.72 0.777 0.000*

B: unstandardized coefficient; Ref: reference category; SE: standard error; *:P < 0.05. Job satisfaction among Syrian health workers in refugee health centres in Turkey 19

Discussion

Syrian health workers in RHCs provide a critical human resource in response to the health needs of Syrian refugees in Turkey. Previous assessments among Syrian health workers showed that physicians and nurses valued the opportunity to work in Turkey because, as well as continuing to work in their profession, they can also earn a livelihood and serve their fellow nationals.

Most of the respondents were nurses/midwives The study found that levels of job satisfaction (62.0%), men (65.2%), younger than 40 years were higher in nurses than in physicians. Factors old (61.3%), married (86.9%) and had worked in that most contributed to job satisfaction in the SIHHAT project for two years or less (64.5%). nurses were service, ability to apply their skills Although only 56% of the target population and teamwork, while those for physicians were responded, the analysis revealed important results teamwork, having authority and the social status on job satisfaction and related factors among accorded by their job. Work characteristics for Syrian health professionals in Turkey. The level of nurses working in RHCs are similar to those in Syria, job satisfaction was highest among nurses, health but perhaps the more advanced health system in workers aged between 40 and 49 years, and those Turkey provides more opportunities to apply their without Turkish citizenship. Mean job satisfaction skills. In comparison, physicians working in RHCs was highest in respondents who reported having provide only primary health-care services, which access to the resources required to do their work, limits their ability to apply their skills, especially those working in RHTCs, and those who rated for specialists. Although the difference was not teamwork and team management as good in their statistically significant, physicians who had worked RHC. Multivariate analyses identified factors that as specialists in Syria but were working as general significantly influenced job satisfaction among physicians in Turkey had lower job satisfaction health workers in RHCs as their profession in Turkey than those who continued to work as specialists in (i.e. general physician, specialist physician or nurse), Turkey. Previous studies in health workers reported income, teamwork and team management. that work engagement is associated with job satisfaction (7,20). Indeed, profession in Turkey was a significant determinant of job satisfaction for health workers in RHCs. 20 Job satisfaction among Syrian health workers in refugee health centres in Turkey

The RHC mechanism and SIHHAT project provide but particularly by physicians. Income was a a time-bound response to health service provision significant predictor of job satisfaction: compared to Syrian refugees under temporary protection with those who rated their income as good, the job in Turkey. However, there is no mechanism for satisfaction score was 7.7 points lower among those professional advancement of Syrian health who rated it as poor and 3.4 points lower among for workers. In this context, it is unsurprising that those who rated it as average. A qualitative study physicians expressed dissatisfaction with the on factors affecting the employability of Syrian lack of opportunities for advancement. Other health workers revealed that the cost of living, studies have demonstrated that opportunities for not having other salary supplements, the costs of advancement influence staff motivation and job transportation, lunch and child care, and not being satisfaction among health workers (19). Improving allowed to supplement their work with private work engagement for physicians in RHCs could practice limited the adequacy of their income from improve their job satisfaction levels, motivation RHCs (Factors affecting employability of trained and intention to stay in the job, and have a Syrian health care professionals in Turkey, WHO positive impact on job performance in terms of Regional Office for Europe, unpublished data, effectiveness of care, quality of care and patient 2020). These factors may explain the importance satisfaction. of income in determining job satisfaction in health workers in RHCs. In addition, comparing their own The mean job satisfaction score increased with income with that of Turkish physicians working perception of income adequacy. Most study in hospitals and not those working in primary participants said their income was average. health care may influence their perception of Evidence of inadequate income from working at income adequacy. Studies conducted elsewhere all three types of health centres (RHCs, extended showed that remuneration influences job RHCs and RTHCs) was provided by the low rating satisfaction (21) and that non-monetary incentives for compensation by both nurses and physicians, increased levels of professional and performance

satisfaction among physicians (11,21). In fact, one Patient workload and citizenship were also study argued that non-monetary incentives could examined in Syrian health workers working in the be more important than monetary incentives in RHCs. A previous report found that the nursing supplementing physicians’ incomes (22). Annual workload and staffing correlate strongly with the cost of living adjustments to the salaries of health quality of outcomes for patients, nurses and the workers in RHCs coupled with non-financial organization (28). Other evidence indicated that incentives could improve job satisfaction, especially increased patient workload or work-related stress for those who are dissatisfied with their current could decrease job satisfaction for physicians (20). income level. Similarly, the mean job satisfaction score decreased with increasing patient load in the present study. Physicians and nurses considered that co-workers The dissatisfaction may be explained by the get along with each other to a satisfactory extent, difference in working hours between Syria and which is indicative of good teamwork at RHCs. The Turkey, with fewer working hours in Syria. However, study also found that the quality of teamwork is a when other factors were considered, the number significant determinant of job satisfaction: those of patients seen per day did not have a significant who rated teamwork as poor had job satisfaction effect on job satisfaction among Syrian health scores 13 points lower than those who rated it as workers in RHCs, suggesting that it may not be good and three points lower than those who rated an important factor. Job satisfaction was found to it as average (P < 0.001). Relationships between be higher in health workers who did not yet have co-workers shape the work environment and Turkish citizenship, but the association was not influence job satisfaction in general, and previous significant when other factors were considered. studies have reported this is also the case among Acquiring citizenship might be expected to lead health workers. One study demonstrated that to greater job satisfaction because it provides job satisfaction was predicted by organizational opportunities to work within the Turkish health culture and teamwork (23), and others found system. However, the higher satisfaction levels that collaboration between workers and collegial of participants without Turkish citizenship might relationships were associated with job satisfaction simply indicate a more positive response to the (23,24,25). Therefore, maintaining good teamwork in study by these participants; therefore, this result RHCs (as perceived by most participants) is critical should be interpreted cautiously. to maintaining a supportive working environment for the health workers. Both nurses and physicians expressed dissatisfaction on the professional moral values Management and leadership are important for item of the MSQ, but further examination is delivering health-care services. Poor management required to determine the explanation. However, of planning and coordination processes, care differences in the working context might present processes, human resources and information the health workers with issues that challenge the flow has a negative impact on the work values they hold as foreign health workers. environment and on job satisfaction in health workers. This study found that the quality of team This was the first study to examine job satisfaction management was significantly associated with job among Syrian health workers in RHCs in Turkey. satisfaction. Compared with those who rated team The response of rate of 56.5% was sufficiently high management as good, job satisfaction levels were to suggest that evidence obtained in the study can 15.9 points lower in health workers who rated team be used to improve and maintain job satisfaction management as poor (P < 0.001) and 9.3 points in RHCs and makes a useful addition to the body lower in those who rated it as average (P < 0.001). of knowledge on refugee health workers. Although One previous study also found that the quality of factors influencing job satisfaction were identified, leadership was positively associated with physician these can only explain some of the variation in the satisfaction (26) and another found an association job satisfaction score. Therefore, other important between the quality of nurse management at factors that determine job satisfaction among unit level and job satisfaction (27). Therefore, Syrian health workers need to be examined strengthening leadership and management in through further research. RHCs may have positive outcomes not only for health workers but also for health service delivery. 22 Job satisfaction among Syrian health workers in refugee health centres in Turkey

Conclusions

Among Syrian health workers in RHCs in Turkey, the study found that job satisfaction was significantly higher in nurses than in physicians. Significant determinants of job satisfaction were profession in Turkey, income, teamwork and team management.

The study identified a need to diversify work engagement for physicians, maintain good teamwork and management, and consider making cost of living adjustments to health workers’ salaries coupled to non-financial incentives to maintain high levels of job satisfaction, motivation and, subsequently, job performance. In general, managers of RHCs and the SIHHAT project should consider incorporating these issues into their policy and strategy for human resources in RHCs to improve job satisfaction in health workers and, consequently, performance levels in health care for refugees and migrants. Future studies into job satisfaction in Syrian health workers in Turkey could focus on professional development, social services, independence, social status and moral values items within the job satisfaction score because most variation in job satisfaction was linked to these factors.

References

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Annex 1. Five-point responses to the 20-item MSQ

Table A1 shows the distribution of five-point responses of the 891 participants to the 20 items of the MSQ (1).

Table A1. Participants’ responses to the 20 items of the MSQ

Very dissatisfied Dissatisfied Neutral Satisfied Very satisfied Item n % n % n % n % n %

Ability utilization: the chance to do something 40 4.5 98 11.0 84 9.4 460 51.6 209 23.5 that makes use of my abilities

Achievement: the feeling of accomplishment I get 54 6.1 79 8.9 86 9.7 463 52.0 209 23.5 from the job

Activity: being able to 38 4.3 127 14.3 279 31.3 408 45.8 39 4.4 keep busy all the time

Advancement: the chances for advancement 67 7.5 133 14.9 103 11.6 456 51.2 132 14.8 on this job

Authority: the chance to 29 3.3 73 8.2 97 10.9 565 63.4 127 14.3 tell people what to do

Company policy and practice: the way that 34 3.8 100 11.2 186 20.9 482 54.1 89 10.0 policies are put into practice

Compensation: my pay and the amount of work 110 12.3 235 26.4 131 14.7 372 41.8 43 4.8 I do

Co-workers: the way my co-workers get along with 25 2.8 62 7.0 70 7.9 523 58.7 211 23.7 each other

Creativity: the chance to try my own methods of 28 3.1 95 10.7 132 14.8 542 60.8 94 10.5 doing the job

Independence: the chance to work alone 45 5.1 172 19.3 131 14.7 480 53.9 63 7.1 on the job

Moral values: being able to do things that don’t go 231 25.9 171 19.2 153 17.2 247 27.7 89 10.0 against my conscience

Responsibility: the freedom to use my own 56 6.3 123 13.8 141 15.8 473 53.1 98 11.0 judgement Job satisfaction among Syrian health workers in refugee health centres in Turkey 27

Recognition: the praise I 75 8.4 127 14.3 98 11.0 445 49.9 146 16.4 get for doing a good job

Security: the way my job provides for steady 61 6.8 82 9.2 149 16.7 363 40.7 236 26.5 employment

Social service: the chance to do things for other 23 2.6 48 5.4 104 11.7 574 64.4 142 15.9 people

Social status: the chance to be “somebody” in the 39 4.4 76 8.5 207 23.2 474 53.2 95 10.7 community

Supervision – human relations: the way my 50 5.6 113 12.7 74 8.3 510 57.2 144 16.2 supervisor handles his/her workers

Supervision – technical: the competence of my 49 5.5 129 14.5 106 11.9 493 55.3 114 12.8 supervisor in making decisions

Variety: the chance to do different things from time 40 4.5 123 13.8 172 19.3 498 55.9 58 6.5 to time

Work conditions 48 5.4 111 12.5 147 16.5 513 57.6 72 8.1

Reference 1. Weiss DJ, Dawis RV, England GW, Lofquiist LH. Monograph XXII: manual for the MN Satisfaction Questionnaire. Minneapolis (MN): Industrial Relations Center, University of Minnesota; 1967.

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