| BackgroundHealth technical personnel in township health centers (THCs) are direct providers of rural health service which play an important role in promoting rural resident health status. The New Health System Reform emphasizes the construction of primary health institution and increase input to THCs. However, THCs still face many problems in human resource, such as inadequate amount, poor quality, low level of work enthusiasm and stability. To a great extent, these problems belong to the problem of work attitude and work performance. Therefore, a critical question faced with policy makers and administrators is how to promote work attitude and performance of Health technical personnel in THCs through effective incentive measures.To answer the question, the first step is concept definition. In this study, Incentive is defined as the factors which can promote work enthusiasm, stability and performance. Work attitude include job satisfaction, organizational commitment and job burnout. Job satisfaction is the subjective cognition of incentive factors which can reflect the degree of incentive effect. Organizational commitment and job burnout can reflect work stability and enthusiasm, respectively. Work performance is defined as the individual’s work outcome and behavior which can benefit the organization. Therefore, the above-mentioned critical question can be translated into:What is the relationship of work attitude and performance?Some studies analyze the incentive problem in THCs and investigate the health workers’preference and satisfaction of the incentive factors. The studies of work attitude are mainly focus on job satisfaction. Many studies analyze the relationship of work attitude and performance but have no unified conclusion due to the different research object and design. There are some limitations of the current studies:(1) No study is found which systematically analyzes and summarize the incentive factors in the context of THCs. (2) Most studies only focus on one aspect of work attitude and use only quantitative methods. Few studies are found which focus on organizational commitment and job burnout of health technical personnel in THCs. No study is found which focuses on work performance of health technical personnel in THCs. (3) Few study is found which analyze and examine the relationship of different dimension of work attitude and performance. No empirical study is found which take health technical personnel in THCs as research object.ObjectivesThe overall objective of this study is to analyze the incentive factors in the context of THCs, investigate work attitude and performance of the health technical personnel in THCs, reveal the relationship of work attitude and performance, and offer incentive suggestions to the policy makers and administrators. Specially, the objective of this study include:(1) to analyze the incentive factors in the context of THCs which can influence work attitude and performance; (2) to investigate work attitude which include job satisfaction, organizational commitment and job burnout, and job performance of the health technical personnel in THCs of three provinces. (3) to reveal the relationship of different dimensions of job satisfaction, organizational commitment, job burnout and work performance and construct the model of four integral concept.MethodsThe theoretical study discusses the relationship of work attitude and performance according to the incentive theory then proposes six hypotheses.The data of empirical study derives from the project "Appraisal of rural primary health institution. This study uses a multistage cluster sampling design.45 THCs in Shandong, Anhui and Shanxi are selected. All doctors, nurses, public health workers and medical technicians on duty are investigated, and choose three of them to take the in-depth interview. The final sample consists of 803 questionnaires and 138 interviews.The questionnaire consists of social demographic characteristics, job satisfaction questionnaire, organizational commitment scale, job burnout scale, work performance scale. The interview consists of three questions about work attitude and uses one-to-one semi-structured means.The quantitative analysis methods include descriptive analysis, univariate analysis, exploratory factor analysis, confirmatory factor analysis, reliability analysis, multivariate analysis and structural equation model. Spss17.0 and Amos17.0 are used to complete the quantitative analysis. The qualitative analysis method is theme framework method which is be performed by the software Maxqda10.0.Results(1) The study concludes 16 incentive factors in the context of THCs:income, welfare, distribution, living environment, working condition, training opportunity, career development opportunity, mental reward, working relationship, physician-patient relationship, performance appraisal, management, job autonomy, job challenge, and leader ability.(2) The score of job satisfaction is as follows. The overall satisfaction is 3.39±0.770. The three highest score of incentive factors are physician-patient relationship, working relationship and leader ability. The three lowest score of incentive factors are income, welfare and training opportunity. The satisfaction of Shandong personnel is highest in most factors and Anhui is lowest. Through factor analysis, the 16 incentive factors can be reduced to 6 dimensions named organizational system, job characteristics, individual development, economic incentive, physical environment and interpersonal relationship. In interview, the most satisfied aspects can be concluded to 5 aspects including recognition by patients, harmonious relationship with colleague, good management, job interest, and good working environment. On the contrary, the most unsatisfied aspects can be concluded to 7 aspects including bad physician-patient relationship, poor working condition, inconvenient living environment, heavy workload, poor income, lack of drug, and poor management.(3) The score of five dimensions of organizational commitment from high to low is as follows:normative commitment 14.92±2.958, affective commitment 14.08±2.923, ideal commitment 12.87±3.028, economic commitment 12.13±2.933, opportunity commitment 11.17±2.707. The younger and higher education, the lower score every dimension gets. In interview, the reason of having turnover intention can be conclude to 4 aspects including inconvenient life environment, poor income and welfare, lack of career development opportunity, and heavy workload. The factor of constrain turnover can be concluded to 3 aspects including lack of other work opportunity, poor working ability, and taking care of family. The reason of desire to remain can be concluded to 6 aspects including work stability, convenient life environment, enjoyment of the organization, work habit, enjoyment of the job, and older ages.(4) The score of three dimensions of job burnout is as follows:emotional exhaustion 19.13±10.432, depersonalization 4.30±3.920, diminished personal accomplishment 11.48±8.589. More than fifty percent personnel are detected moderate burnout in the two dimensions of emotional exhaustion and diminished personal accomplishment. Depersonalization is low burnout. Doctors, personnel under 30 years and having bachelor degree experience heavier burnout than others. In interview, the reasons of working with enthusiasm can be concluded to 8 aspects including professional ethics, satisfied income, performance-based distribution, job interest, harmonious relationship with college, good management, good physician-patient relationship, and heavy workload. The reasons of working without enthusiasm can be concluded to 5 aspects including poor income, poor welfare, unjust distribution, bad management, and bad physician-patient relationship.The suggestions of promoting enthusiasm can be concluded to 7 aspects including improving income and welfare, using performance-based distribution, improving working and living environment, decreasing workload, improving management, strengthening training, improving physician-patient relationship.(5) The score of three dimensions of work performance is as follows:task performance 24.35±3.650, contextual performance 29.17±4.591, learning performance 17.60±3.405. The percent of learning performance in low group is higher than other two dimensions. Nurses and personnel under 30 years get lowest score in all three dimensions.(6) The relationships of the dimensions of work attitudes and performance are as follows.Job satisfaction and organizational commitment:economic incentive has positive effect on economic commitment; all dimensions but individual development have positive effect on affective commitment; all dimensions have positive effect on ideal commitment and normative commitment; individual development and economic incentive have positive effect on opportunity commitment. The effects of internal satisfaction are not always stronger than that of exogenous satisfaction.Job satisfaction and job burnout:all dimensions have negative effect on emotional exhaustion; the four dimensions of organizational system, economic incentive, physical environment and interpersonal relationship have negative effect on depersonalization; work characteristic and interpersonal relationship have negative effect on diminished personal accomplishment. The effects of internal satisfaction are not always stronger than that of exogenous satisfaction.Organizational commitment and job burnout:economic commitment has positive effect on emotional exhaustion and ideal commitment has negative effect; economic commitment has positive effect on depersonalization; affective commitment and normative commitment have negative effect on diminished personal accomplishment. Job satisfaction and work performance:work characteristic and interpersonal relationship have positive effect on task performance; the three dimensions of organizational system, individual development and interpersonal relationship have positive effect on contextual performance; interpersonal relationship has positive effect on learning performance. The effects of internal satisfaction are not always stronger than that of exogenous satisfaction.Organizational commitment and work performance:affective commitment and normative commitment have positive effect on task performance and opportunity commitment has negative effect; affective commitment and normative commitment have positive effect on contextual performance; ideal commitment and normative commitment have positive effect on learning performance and opportunity commitment has negative effect.Job burnout and work performance:diminished personal accomplishment has negative effect on all three dimensions of work performance.(7) The relationships of the integral concept of work attitudes and performance are as follows. Job satisfaction has no significant effect on organizational commitment, job burnout and work performance. Organizational commitment has a 0.331 direct effect and a 0.074 indirect effect through burnout on work performance. Job burnout has a-0.192 direct effect on work performance.Conclusion and policy implication(1) Most health technique personnel in THCs have positive attitude towards their organization. Senses of responsibility and belongingness are main mental reasons that they choose to remain and lack of opportunity is secondary reason. Whether the life environment is convenient is the realistic reason. As for the attitude towards job, the degree of emotional exhaustion and diminished personal accomplishment are heavier. Heavy workload, lack of feedback and recognition are main risk factors of job burnout.(2) Most health technique personnel have a rather high assessment on their work performance in particular of task performance and contextual performance. The learning performance is relatively poor, which can reflect the deficiency of effective training opportunity. Improving physician-patient relationship and interpersonal relationship, and strengthening normative commitment and sense of achievement can improve all dimensions of work performance.(3) The physician-patient relationship and working relationship in organization play quite important role in incentive system in the context of THCs, and most people are satisfied with them so they can effectively promote work enthusiasm and stability. Economic incentive, career development opportunity, and organizational management system are also important incentive factors, but most people are not satisfied with them so they can deactivate the personnel. The effects of internal satisfaction are not always stronger than that of exogenous satisfaction, which depend on the situation and incentive purpose. In addition, the study confirms the path relationship of "organizational commitmentâ†'job burnoutâ†'work performance".Based on the above conclusion, the study gives five policy implications. First, improve income, welfare and distribution system. Second, increase training opportunity and career development opportunity. Third, strengthen the education of professional ethics. Fourth, use all kinds of incentive methods. Fifth, use different incentive methods to different personnel. |
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