Introduction

During the last decade, an increased effort has been made to evaluate quality of medical treatment in Surgery hospital departments [1–3]. In addition, an increasing amount of research studies on surgical patient satisfaction with medical care and treatment have been performed [4–7]. Central dimensions in evaluation are fulfillment of patients’ health care needs and requests in Surgery hospital departments. Patient satisfaction is described as a combination of patients’ expectations regarding medical treatment, care, and their former experiences [8].

Previous studies investigated aspects of medical treatment and care in various medical fields which might have a great influence on patients’ evaluation and satisfaction [9–11].

In particular, a study by Schönfelder et al. [7] found factors which are associated with patient satisfaction in Surgery. The strongest predictors for patient satisfaction found in this study were interpersonal manners of medical practitioners and nurses, organization of operations, admittance, and discharge, as well as perceived length of stay [7].

Further studies mentioned perceptions of quality of medical treatment, clinic-organization of medical procedures and care, medical staffs’ kindness and professionalism, etc. as factors which have been shown to influence patient satisfaction in various medical fields [12, 13].

A study by Grol et al. [14] has demonstrated that general practitioners’ job satisfaction is also associated with patient satisfaction. Moreover, a study by Szecsenyi et al. [15] found also significant correlations between patient satisfaction and health care professionals.

Few published studies also focused on associations between hospital working environments and patient satisfaction in special medical fields (e.g., psychiatric wards). These previously published studies illustrated that patients being treated in hospital departments with high standards of work organization, social and cooperative support and low levels of conflicts or aggression were more satisfied [16, 17].

In addition, several studies have focused on relations between working environment and medical staffs’ satisfaction [18–21]. Attention has been drawn to this research field because associations have been found to turnovers, performance and treatment outcomes (e.g., medical errors), hospital financial outcomes (cost-effectiveness). In consequence, these factors are of great importance not only for each hospital management but also for health services in general [22–25].

Previous studies carried out in German hospitals analyzed doctors’ working conditions and job satisfaction in various hospitals [26–37]. A number of studies focused on German emergency departments using surveys on the quality of medical treatment to evaluate hospital performance and working environments [38–40]. These studies all demonstrated that working conditions such as excessive workloads can have a negative influence on general practice performance, treatment outcomes and medical errors [41–44]. In contrast, only few studies researched on the influence of positive working conditions (job resources) on treatment outcomes or patient satisfaction.

It is reasonable to assume that surgeons’ job satisfaction may influence the work environment and thus the quality of medical treatment in Surgery departments in total. Also, working conditions may influence surgeons’ satisfaction and patient satisfaction with treatment and care.

With regard to this, relations between surgeons’ assessment of their working conditions, job satisfaction and patients’ satisfaction with medical care are of great interest for health services. However, to our knowledge, in Germany, no study exists focusing on patients’ satisfaction with medical treatment in Surgery departments in relation to assessments of surgeons’ job satisfaction.

Results can give a first impression on how important satisfied surgeons are in relation to satisfactory medical treatment. In consequence, measures of patients’ and surgeons’ satisfaction can be used to redesign and optimize work schedules and organization of medical treatment in Surgery departments. All in all, information on this can be useful to improve the overall quality of care in Surgery.

Aims

The present research study aimed at focusing on interrelationships between working conditions, surgeons’ job satisfaction and patient satisfaction.

Regarding this, the aims of this study are (a) to investigate levels of surgeons’ job satisfaction, patients’ satisfaction with medical care in Surgery departments and (b) to analyze correlations between perceived working conditions and these two outcome parameters.

The following research questions are answered in our study:

  1. 1.

    How do (a) patients evaluate their satisfaction with medical treatment and care in Surgery departments and (b) surgeons their job satisfaction?

  2. 2.

    How do physicians evaluate their working conditions in Surgery departments?

  3. 3.

    Is there a correlation between surgeons’ job satisfaction and patients’ satisfaction with medical treatment and care?

  4. 4.

    Is there correlation between surgeons perceived working conditions and patients’ satisfaction with medical treatment and care?

Methods

Study design and setting

This study was conducted as a cross-sectional study conducted between 2009 and 2010 in seven General and Visceral Surgery hospital departments in Germany.

The hospital departments were comparable in number of patients/beds and size as far as employed doctors and other medical staff (e.g., nurses). The participating hospitals were all run by non-profit organizations. We did not include university hospitals in order to ensure comparability between the hospitals. Surgical procedures performed by the participating hospitals are illustrated in Table 1.

Table 1 Surgical procedures performed in the participating units
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Participants

All participating surgeons were full-time employed junior doctors or residents specializing in Surgery (general and visceral surgery). Inclusion criterion in this study was: having at least 1 year of work experience in Surgery. One hundred fifty surgeons were requested to fill in an anonymous questionnaire. Participants in our study population were patients receiving Surgery services in hospital. 250 patients were asked to take part in our study.

Data collection

First we presented our study design to surgeons during clinical conferences/meetings. In addition, we informed patients by handing information hand-outs about the purposes and procedures of this study. After this procedure we scheduled dates for administering the survey. In addition, we got a list of patients being at the department at this time and their attending physician. Afterwards potential candidates for our study were recruited by asking patients and their attending doctors of each Surgery department if they are interested to participate in our study. Patients were given a questionnaire and a consent form at the end of their hospital stay. In addition, surgeons were given a questionnaire as well as the consent form.

All questionnaires and consent forms were then collected by our researchers or if participants needed more time they were returned to boxes at the hospitals.

Variables

We included several independent variables in our study: working demands and working resources, etc. (see Tables 2 and 3). Independent variables are the variables that were varied by us as presumed predictors. In our study patient satisfaction and job satisfaction are dependent variables (response that is measured as presumed effects).

Table 2 Patient satisfaction scores: means and standard deviations
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Table 3 Surgeons’ working conditions and job satisfaction: means and standard deviations
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Patients’ socio-demographic characteristics might affect their ratings on satisfaction with treatment and care. To control for these mediating variables, we used patients’ data regarding for example, their age, race, gender, length of stay, number of surgical treatments performed. In addition, we also controlled physicians’ age, gender, years of experience, marital status and having children status.

Questionnaires

Working conditions and job satisfaction was evaluated by using the Copenhagen Psychosocial Questionnaire (COPSOQ) [45]. In addition, patients’ perceptions of medical quality, evaluation of the clinical stay etc. were asked by using a self-assessment questionnaire.

Patient satisfaction questionnaire

The survey used in this study is a general self-assessment questionnaire including a number of questions about perception of medical treatment and care, overall satisfaction with the hospital stay. In addition, the questionnaire included information regarding admission, effects of length of hospital stay, service aspects and motivation to return to this hospital department in case of a readmission (Table 1).

Patients’ evaluation was reported by individual scale items. Each item was scored as an adjectival Likert scale (five categories: 1 = poor, 2 = average, 3 = good, 4 = very good, and 5 = excellent).

We also validated the questionnaire: our results demonstrated that the patient questionnaire is reliable, valid, and practicable.

Cronbach's alpha coefficients for the items ranged from α = 0.70 to α = 0.85. The Intraclass correlation (ICC) values for the subscales varied between 0.82 and 0.90. The ICC values for the items ranged between 0.73 and 0.88.

To evaluate the convergent validity we related the patient satisfaction variables to what it should theoretically be related to. To show the convergent validity of the patient satisfaction questionnaire, the scores on the test were correlated with scores on other tests that are also designed to measure patient satisfaction. High correlations between the test scores would be evidence of a convergent validity.

We performed a pre-study with a sample of 100 surgery patients in hospital and correlated the sum score of our questionnaire with the sum score of the Zurich Questionnaire [46]. Correlation scores were r > 0.70 pointing to an acceptable convergent validity of the questionnaire.

To assess construct validity, two pairs of items were chosen from two different subscales [47]. The items of each pair had to be related to and dependent on each other (r > 0.30), while the items of the different pairs were not related (r < 0.30) [48].

Factor analysis with varimax rotation showed a two-dimensional structure. The first factor grouped ten items containing aspects about medical treatment (surgery procedures), satisfaction with outcome (after surgery), and organizational aspects (approx. 43 % of the variance). The second factor contained aspects on medical care and service (approx. 21 % of the variance).

Copenhagen Psychosocial Questionnaire

The COPSOQ (German version) was used to evaluate surgeons working conditions (job demands and job resources). Table 3 presents the scales used in this study.

We also checked and validated the COPSOQ although researchers have done this previously [49, 50]. Our results confirm reliability, validity and applicability of the COPSOQ, scores were satisfactory. Cronbach's alpha coefficients for the items ranged between α = 0.73 and 0.84 and all intercorrelations were measured between r = 0.40 and 0.72.

All items relating to working conditions and their outcomes (e.g., working demands, working resources, and job satisfaction) were transformed to a scale ranging from 0 (“do not agree at all”) to 100 (“fully agree”) [37]. The category “does not apply” and item non-response were coded as missing data.

Statistical methods

We analyzed descriptive statistics (frequencies, percentages, means and standard deviations). In addition, we analyzed the data with regard to their distribution. We consequently used parametric and non-parametric tests (T tests, Mann–Whitney U tests, Pearson and Spearman correlation analyses). All differences or correlations were considered to be statistically significant at p < 0.05-level.

Confounders (mediating variables) were controlled by using Sobel's test statistic; additional logistic regression analyses were carried out. In addition, we constructed regression models.

In general, we used the PASW® software package for statistical analyses.

Results

Of the 400 administered questionnaires, 55 % valid questionnaires were returned (n = 220). Return rates varied by group: 98 of the surgeons and 122 of the patients returned the questionnaires.

Patients’ characteristics

The majority of the patients were male (62 %); 55 % were married, 51 % had children. Patients’ age ranged between 28 and 82 years (mean = 43; SD = 6.4).

About 89 % of all participating patients were admitted by a specialist or by their general practitioner, 1 % was transferred from another clinic, and about 1 % reported self-admission. Nine percent of the patients did not answer this question.

A percentage of 74 of the patient sample evaluated the length of stay to be appropriate, 11 % reported their length to be inappropriate (too long or too short), and 15 % did not answer this question. Sixteen percent considered their hospital stay to be too short, 3 % to be too long, 8 % did not answer this question.

Medical complications after surgery were reported by 19 % of the patients. A percentage of 72 of all patients would use this specific surgery hospital department again.

Physicians’ characteristics

The study sample included 41 % female physicians and 59 % male physicians. 30 % were single and 41 % had no children. Age ranged from 27 to 54 years (M = 33; SD = 5.12). The mean number of physicians’ experience in the current job was M = 4.15 years, SD = 2.26 years.

Patient satisfaction

The results showed that about 70 % of the patients were satisfied with performed medical treatments and services in their Surgery department; that means they evaluated with good scores. Mean for overall satisfaction was M = 3.1 (SD = 0.91; Table 2).

Patients’ satisfaction with various dimensions of medical treatment (e.g., satisfaction with staff, treatment, organizational procedures) ranges between 2.67 and 3.23. Mean scores and standard deviations for the subscales are presented in Table 2.

Correlations between patient demographics, satisfaction and visit characteristics

We found that gender was not significantly correlated with patient satisfaction: significant differences between male and female patients’ satisfaction ratings were found.

We also analyzed age differences and found that the patients' age was related to assessments of satisfaction (p < 0.05). A positive correlation between increase of age and patient satisfaction was found. Figure 1 illustrates groups of patients differentiated with regard to their age. Correlation tests showed that the association between age and patient satisfaction is not linear. Significant differences did not occur between all included age groups. Younger patients in particular (<25) differed the most compared to older patients >60 years (p < 0.05).

Fig. 1
figure 1

Mean distribution of patient satisfaction in different age groups

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Our results also showed a significant difference in reported satisfaction between patients complaining about medical complications and patients without medical difficulties. The first group evaluated their overall satisfaction as less satisfied (M = 2.6) in comparison to patients without complications (M = 3.6; p < 0.01). In addition, those patients with complications also reported a significant lower motivation to return to this hospital department in case of a further readmission than patients without medical difficulties (p < 0.05). Patients who were satisfied with the length of their hospital stay also showed more overall satisfaction (M = 3.8) than patients who evaluated their hospital stay with being too short (3.1), or too long (3.2, p < 0.05).

Surgeons’ satisfaction ratings and working conditions

Evaluations of working demands and working resources are illustrated in Table 3. Working demands such as working under pressure have been validated as high in all seven hospital departments (M = 70.38, SD = 13.12). Emotional demands were evaluated as stressful (M = 67.52, SD = 13.56). Job resources were rated with scores between M = 34.68 and 67.59. The highest scores were reported for “possibilities for development” (M = 67.59, SD = 13.10) and “social support from colleagues” (M = 65.67, SD = 14.38). Receiving “feedback at work” was scored lowest with M = 34.68, SD = 16.62.

Surgeons rated their job satisfaction with moderate scores (M = 59.34; SD = 13.81; see Table 3). In addition, we analyzed associations between surgeons’ working conditions and their perceived job satisfaction. Table 4 illustrates these associations: job demands (quantitative job demands; working under pressure) correlated significantly negative to surgeons’ job satisfaction. That means surgeons who scored their job demands as high valued their job satisfaction low. In addition, our findings illustrated positive correlations between perceived job resources and job satisfaction. Surgeons who scored high at items such as “having influence at work”, “possibilities for development”, “social support” etc. valued their job satisfaction high (see Table 4).

Table 4 Correlations between all included variables concerning surgeons’ working conditions and job satisfaction
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Bivariate analyses

Bivariate analyses showed correlations between patients’ overall satisfaction and surgeons’ job satisfaction (r = 0.49, p < 0.01). The higher surgeons rated their job satisfaction the higher patients rated their overall satisfaction.

Moreover, our results showed that the better surgeons have rated their working conditions the better patients evaluated their satisfaction. In detail, analyses showed significant negative correlations between physicians’ assessments of their working demands and patient satisfaction (r = −0.38; p < 0.01). In contrast, positive correlations were analyzed between working resources (social support, feedback, etc.) and patient satisfaction (r = 0.42, p < 0.01).

Confounder analyses

Confounder analyses showed that the included independent variables were not significantly related to the mediating variables (p > 0.05). In addition, the mediating variables were not significantly related to the dependent variables (job and patient satisfaction; p > 0.05).

Discussion

As far as we know, this is the first German study investigating associations between physicians’ job satisfaction, working conditions and patient satisfaction with hospital care.

Study limitations

Some limitations of this study should be mentioned. First, the sample may not be representative for all Surgery departments in Germany. Additional investigations with a greater number of participants in various territories should be done. Second, study design was cross-sectional which limits the generalizability of our results. In general, cross-sectional analyses are of limited value in supporting causal effects [48]. Factors such as working conditions can change over time and might influence findings. Further studies including longitudinal analyses are advised to present supplementary information for the associations between job satisfaction, hospital working environment and patient satisfaction.

In addition, some questions of the patient satisfaction questionnaire might be too general and need to be adapted to give (1) specific details for medical care/treatment in Surgery and (2) more specialized information about patient needs. A supplementary qualitative study should be conducted. In doing so, more specific personal aspects which might influence patient satisfaction could be investigated.

Patient satisfaction

Regarding patient satisfaction our findings are concordant to prior performed studies. These findings were similar in particular for age differences [51–54]. Older patients tended to be more satisfied than younger patients. In contrast to our results, previous research also found significant gender differences [55–58].

In line with other previous studies, our results indicate that professional medical treatment has highly positive effects on patient satisfaction [59–61]. In contrast, different studies also showed that medical complications are strong predictors for patient dissatisfaction [62, 63]. Post-discharge complications can be seen as a generalizable factor for dissatisfaction.

Our results also revealed that patients with shorter lengths of hospital stay were more satisfied than patients who reported that their hospital stay was “too long”. This result is also consistent with previously performed studies in various medical fields [58, 64, 65].

Kindness of health care professionals and communication between patient and attending physician were mentioned in several studies as important factors for satisfied patients [66–69]. Unfortunately, as shown in our previously performed time and motion studies, little time has been used for doctor–patient interaction [28, 29, 31–34]. Work overload, pressures associated with numerous working demands can lead to less time spent on doctors’ patient talk [70]. A study performed by Argentero et al. [71] gave evidence of significant associations between kindness in medical practice (e.g., towards patients and their relatives) and physicians’ workload and emotional exhaustion.

Physicians working conditions and job satisfaction

Our assessments of working demands and resources are comparable to research previously investigated in other related medical fields (e.g. Internal Medicine, Pediatrics and Radiotherapy) [37, 72–74]. Evaluations of job satisfaction are also concordant with other studies having investigated this job outcome [37, 73, 75].

As discussed in prior publications, current working conditions and work environment in health services (e.g., financial restrictions, reductions in hospital staff members) reduce doctors’ job satisfaction in general [25, 76] and particularly with regard to Germany [37, 73].

Associations between physicians’ working conditions, job satisfaction, and patient satisfaction

One of our research questions referred to whether there are associations between surgeons working conditions/job satisfaction and patient satisfaction. The findings showed that surgical patient satisfaction is related to physicians’ perception of their work environment and their job satisfaction. Results have demonstrated that surgical patients are less satisfied in hospitals where surgeons reported unsatisfactory, unacceptable working conditions and reduced job satisfaction. Former studies performed by several researchers, as mentioned above, showed that satisfied medical staff has a strong influence on patients’ satisfaction [77–79].

With regard to the results of the present study, reorganization of schedules and hospital department structures might have the potential to improve the workplace for physicians and at the same time improve patient satisfaction with clinical care. More and regular job resources such as social support and constructive/helpful feedback should be guaranteed in every hospital department. In addition, a continuous supervision (expert consultations) and mentoring programs can support medical staff [80–82].

Remarkably, associations between surgeons’ job satisfaction and patients’ satisfaction can also indicate that satisfied patients can make doctors happier and more satisfied with their jobs. Patients’ satisfaction might also reflect having performed high-quality care.

Our findings also indicate that kindness of medical staff is highly correlated with the overall satisfaction of patients. Additional studies also demonstrated that patient satisfaction is mainly influenced by “communication with doctors and kindness of medical staff” [83]. Unfortunately, surgeons working under constant time pressure and handling more than one medical task at the same time have less time for individual contact with patients.

Prior studies demonstrated that on average only 10 % of the time during an average working day were spent on direct patient care [28, 30, 34]. It is well known that work overload, working under pressure, and multitasking, reduce the time for direct patient communication [84, 85]. Moreover, such a working environment can also decrease kindness of medical staff, a fact that has been illustrated by several studies [86–88].

However, it is important to note the fact that the present study did not investigate the direction of causality. On the basis of our investigation it is not clear, whether (1) satisfied surgeons have a positive influence on patients’ satisfaction or (2) whether satisfied patients make surgeons more satisfied with their jobs, or (3) also possible, both samples have an influence on each others’ satisfaction.

Conclusion

This study gives valuable information on relations between perceived working conditions and perceptions of patients’ satisfaction with clinical practice. Results revealed that physicians’ working conditions are related to both physicians’ job satisfaction and patient satisfaction.

In addition, our results demonstrated that healthcare professionals need to be attentive to the needs of each individual patient. This study illustrates the need for health care administrators to focus more on hospital management practices of their organization and efforts to improve the quality of medical care by changing employee working conditions, and satisfaction.