Community Dent Oral Epidemiol 2012; 40: 474480 All rights reserved

2012 John Wiley & Sons A/S

The impact of intrinsic and extrinsic factors on the job satisfaction of dentists
Goetz K, Campbell SM, Broge B, Do rfer CE, Brodowski M, Szecsenyi J. The impact of intrinsic and extrinsic factors on the job satisfaction of dentists. Community Dent Oral Epidemiol 2012; 40: 474580. 2012 John Wiley & Sons A/S Abstract The Two-Factor Theory of job satisfaction distinguishes between intrinsic-motivation (i.e. recognition, responsibility) and extrinsic-hygiene (i. e. job security, salary, working conditions) factors. The presence of intrinsicmotivation facilitates higher satisfaction and performance, whereas the absences of extrinsic factors help mitigate against dissatisfaction. The consideration of these factors and their impact on dentists job satisfaction is essential for the recruitment and retention of dentists. Objectives: The objective of the study is to assess the level of job satisfaction of German dentists and the factors that are associated with it. Methods: This cross-sectional study was based on a job satisfaction survey. Data were collected from 147 dentists working in 106 dental practices. Job satisfaction was measured with the 10-item Warr-Cook-Wall job satisfaction scale. Organizational characteristics were measured with two items. Linear regression analyses were performed in which each of the nine items of the job satisfaction scale (excluding overall satisfaction) were handled as dependent variables. A stepwise linear regression analysis was performed with overall job satisfaction as the dependent outcome variable, the nine items of job satisfaction and the two items of organizational characteristics controlled for age and gender as predictors. Results: The response rate was 95.0%. Dentists were satised with freedom of working method and mostly dissatised with their income. Both variables are extrinsic factors. The regression analyses identied ve items that were signicantly associated with each item of the job satisfaction scale: age, mean weekly working time, period in the practice, number of dentists assistant and working atmosphere. Within the stepwise linear regression analysis the intrinsic factor opportunity to use abilities (b = 0.687) showed the highest score of explained variance (R2 = 0.468) regarding overall job satisfaction. Conclusions: With respect to the Two-Factor Theory of job satisfaction both components, intrinsic and extrinsic, are essential for dentists but the presence of intrinsic motivating factors like the opportunity to use abilities has most positive impact on job satisfaction. The ndings of this study will be helpful for further activities to improve the working conditions of dentists and to ensure quality of care.

K. Goetz1, S.M. Campbell1,2, B. Broge3, rfer4, M. Brodowski3 and J. C.E. Do Szecsenyi1,3

1 Department of General Practice and Health Services Research, University of Heidelberg Heidelberg, Germany, 2Primary Care Research Group - Health Sciences, University of Manchester Manchester, UK, 3 AQUA-Institute for Applied Quality Improvement and Research in Health Care Goettingen, Germany, 4Clinic for Conservative Dentistry and Periodontology, University of Kiel Kiel, Germany

Key words: dentists; job satisfaction; primary dental care Katja Goetz, Department of General Practice and Health Services Research, University Hospital Heidelberg, Vosstr. 2, Building 37, D-69115 Heidelberg, Germany Tel.: +49 6221 56 8129 Fax: +49 6221 56 1972 e-mail: katja.goetz@med.uni-heidelberg.de Submitted 22 June 2011; accepted 7 March 2012

The self-evaluation of job satisfaction is associated with various dimensions of work-related activity (1). Job satisfaction has been dened as the feeling an individual person has about his/ her job (2). Herzberg and colleagues developed a Two-Factor Theory of job satisfaction by distinguishing between intrinsic-motivational
doi: 10.1111/j.1600-0528.2012.00693.x

factors such as recognition, work tasks and responsibility, and extrinsic-hygiene factors like job security, working conditions or salary (2). Importantly, the presence of intrinsic motivators can generate positive job satisfaction, whereas the absence of extrinsic-hygiene factors can create dissatisfaction.

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Different studies from different countries have shown that the overall job satisfaction of dentists is good to very good (35). However, specic aspects related to intrinsic and extrinsic factors have been found to inuence job satisfaction. For example, productivity, the level of stress and burnout (6, 7) as well as income, working time and the perceived quality of staff affect the reported job satisfaction of dentists (5, 8, 9). A nationwide oral health survey published in 2006 showed that over 70% of the German population visit their dentist regularly (10). This shows that dentists are an important professional group for health care. The well-being of physicians as of dentists has been shown to be an essential modier of quality of care (11, 12). Therefore, this well-being should be of concern for further research. Different studies showed that medical personnel especially dentists suffer from occupational stress and have a high risk to develop a burnout (13, 14). Both aspects, occupational stress and burnout, are strongly related to job satisfaction. However, there are no current data regarding the levels of job satisfaction of German dentists, who work mostly in ambulatory care and are self-employed in singlehanded practices, factors that have been found to be associated with high stress and lower job satisfaction (6, 15). According to the German Dental Association, 67 808 dentists were registered in 2010 and about 1700 dentists newly qualify each year in Germany (16). Most dentists (n = 54 683, 80.6%) work in a solo practice (16). By the year 2030 a decrease of dentists by 10% (from 67 808 to 61 282 dentists) is predicted (16). Therefore, the consideration of working conditions and their impact on dentists job satisfaction are essential for recruitment and retention of dentists. The aim of the study was to assess the level of job satisfaction of German dentists in ambulatory care and to explore the impact of extrinsic-hygiene and intrinsic motivating factors on and their association with job satisfaction.

Procedure
To measure job satisfaction, organizational characteristics and other individual characteristics all participants completed a written questionnaire, which was returned in a prepaid envelope by mail to the Institute for Applied Quality Improvement and Research in Health Care (AQUA-Institute) domiciled in Goettingen, Germany (18). The application of the EPA in Germany is coordinated by the AQUA-Institute. The quality management programme EPA-Dentist was piloted in the year 2005 (19). The questionnaire included the following items: questions about gender and age, how many hours a week the dentists contractually worked at their practice and how many years they had worked in the practice. The mean weekly work time included chairside, administration and other ofce management. Job satisfaction was measured with the German validated version of the Warr-Cook-Wall (WCW) job satisfaction scale developed by Warr et al. (20) which original consists of 15 items. To allow international comparison we used the widespread 10-item version (17, 21). The WCW-instrument measures overall job satisfaction and satisfaction with nine aspects of work that can be aligned to the theoretical background of the TwoFactor Theory found in Herzberg and colleagues and which have face validity of intrinsic and extrinsic factors (2). Four WCW items were designated as intrinsic motivators: amount of variety in job, opportunity to use abilities, amount of responsibility and recognition for work. Five items were treated as extrinsic factors: freedom of working method, physical working condition, hours of work, income and colleagues. Each item was rated on a 7-point Likert scale (1 = extreme dissatisfaction to 7 = extreme satisfaction). A higher overall mean WCW score indicates higher job satisfaction. Organizational characteristics were measured by two items, the responsibilities within the practice team are clear and the work atmosphere in the team is good. Rating options ranged from 1 (fully disagree) to 5 (fully agree). A higher overall mean score indicates higher organizational structure.

Methods
Design and participants
This exploratory study was based on a job satisfaction survey. Data were collected from dentists working in 106 dental practices, which had used the European Practice Assessment (EPA) methodology (17) between June 2006 and January 2011.

Inclusion criteria
Since 2006 a quality management programme must be undertaken in every general dental practice in Germany. Regulations for the programme are outlined in the guideline of the Federal Joint Committee positioned in the Social Code Book V and the

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directives on quality management of the Federal Joint Committee (22). Different quality management programmes are available for dentists to choose from (23). The evaluation of job satisfaction is an essential component of any programme. One of the quality management programmes is the EPA (17). This study used data from the routine implementation of quality management in ambulatory care in Germany in dental practices that undertook EPA. The assessment of job satisfaction among dentists is one component of the EPA (19).

Table 1. Characteristics of participating practices and dentists Ofce-based dentists in Germany (n = 54 683)a 59.6% ~71.0% Data not available 6.13

Practices (n = 106) Mode of practice: single handed Location: urban Number of dentists [mean (SD)] Number of dentists assistants [mean (SD)] Age [mean (SD)] Sex (male) Mean weekly work time [mean (SD)] Period in the practice [mean (SD)] 66.0% 60.0% 1.46 (0.57) 6.54 (3.34) Dentists (n = 147) 46.1 (9.5) 65.3% 39.9 (10.7) 17.9 (9.9)

Data analysis
The analyses were performed using SPSS version 18.0 (SPSS Inc., Chicago, IL, USA). Continuous data were summarized using means and standard deviations. Categorical data were presented as frequency counts and percentages. Gender differences in job satisfaction and organizational characteristics were compared with the nonparametric, MannWhitney U-test. Furthermore, linear regression analyses were performed with each of the job satisfaction items as dependent outcomes; individual characteristics as well as organizational aspects were handled as potential predictors. Finally, a stepwise linear regression analysis was performed with overall job satisfaction as the dependent outcome variable and the nine aspects of satisfaction with work and individual characteristics as the potential predictors. An alpha level of P < 0.05 was used for tests of statistical signicance.

47.4 61.9% Data not available Data not available

SD, standard deviation. a Total sample of ofce-based dentists in Germany for 2010; Source: German Dental Association and Institute of German Dentists (16, 33).

Table 2. Descriptive statistics of job satisfaction items and organizational aspects Items Abbreviation Mean (SD) 6.18 (0.97) 5.93 (1.26) 6.46 (0.82) 5.97 (1.28) 5.46 (1.22) 5.18 (1.55) 4.99 (1.56) 5.96 (0.93) 5.96 (0.93) 5.97 (0.89) 4.13 (0.79) 4.29 (0.80) CI (95%) 6.016.34 5.726.15 6.326.60 5.756.19 5.255.66 4.915.44 4.725.25 5.816.12 5.816.12 5.826.12 3.994.26 4.154.42

Results
In 106 participating dental practices 155 questionnaires were handed out to dentists and 147 dentists completed and returned the job satisfaction survey. The response rate was 95%. Table 1 shows the characteristics of the participating practices and dentists. Most practices were single handed (66.0%) and urban (60%). Over 65% of the dentists were men. The mean age was 46 years (SD = 9.5), and the mean weekly work time was 39.9 h (SD = 10.7). The evaluation of job satisfaction and organizational aspects for the 147 dentists is presented in Table 2. Cronbachs a was 0.86 for the job satisfaction scale and 0.80 for organizational characteristics in our study. Dentists were highly satised with freedom of working method (mean = 6.46) and amount of variety in job (mean = 6.18) and

Amount of WCW 1 variety in joba WCW 2 Opportunity to use abilitiesa WCW 3 Freedom of working methoda WCW 4 Amount of responsibilitya WCW 5 Physical working conditiona WCW 6 Hours of worka WCW 7 Incomea Recognition WCW 8 for worka WCW 9 Colleagues and fellow workersa WCW 10 Overall job satisfactiona Responsibilities within the practice team are clearb Working atmosphere in the practice team is goodb

SD, standard deviation; CI, condence interval. a Range from 1 extreme dissatisfaction to 7 extreme satisfaction. b Range from 1 fully disagree to 5 fully agree.

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mostly dissatised with income (mean = 4.99). Furthermore, dentists highly agreed with the item working atmosphere in the practice team is good (mean = 4.29) and agreed less with responsibilities within the practice team are clear (mean = 4.13). Additionally, no differences for gender were found regarding job satisfaction and organizational aspects. The impact of individual characteristics and organizational aspects on each aspect of job satisfaction is presented in Table 3. Five of the nine regression models explained more than 20% (R2 > 0.20) of the variance of the dependent variables. These ve variables were amount of variety in job, opportunity to use abilities, physical working condition, hours of work and colleagues and fellow workers. The two items of the job satisfaction scale with the highest explained variance of the independent variables were colleagues and fellow workers (R2 = 0.541) and hours of work (R2 = 0.430). Thus, as an example, the independent variables that were signicantly associated with hours of work were gender (b = 0.193), age (b = 0.433), mean weekly work time (b = 0.589), period in the practice (b = 0.293) and working atmosphere in the practice team is good (b = 0.178). Of the 10 independent variables that were entered into the regression models, age, mean weekly working time, period in the practice, number of dentists assistant and working atmosphere in the practice is good were signicantly associated with items of job satisfaction. Table 4 shows the stepwise regression analysis of the individual characteristics, organizational

aspects and satisfaction with aspects of work on overall satisfaction for dentists in this study. A model with nine steps was carried out and explained more than 76% (R2 ~ 0.76) of the variance on the dependent variable overall job satisfaction. These were seven variables of satisfaction with aspects of work, the item working atmosphere in the practice team is good and the number of dentists assistants. In the rst step of the stepwise regression analysis the item opportunity to use abilities showed the highest score (R2 = 0.468) of explained variance. No associations were found regarding other individual (i.e. age and sex) and practice characteristics (i.e. mode and location of practice).

Discussion
The aim of our study was to assess the level of job satisfaction of German dentists in ambulatory care and the factors associated with job satisfaction. Our results showed that dentists in Germany have an overall high level of satisfaction, for example, in relation to job variation and their colleagues. However, they are dissatised with their hours of work and income. These results are comparable to studies among dentists in other countries (3, 5, 9, 24). The positive association between satisfaction and both job variety and satisfaction with work colleagues is related to available resources at work and has been found to reduce burnout (25, 26). These results show that both intrinsic and extrinsic factors are important in determining the perception of job satisfaction. Regarding the Two-Factor

Table 3. Impact of individual characteristics and organizational factors on each aspect of job satisfaction (results of linear regression analysis, under specication of standardized beta coefcient, a = 5%) WCW 1 WCW 2 WCW 3 WCW 4 WCW 5 WCW 6 WCW 7 WCW 8 WCW 9 Characteristic of participants Gender Age Mean weekly work time Period in the practice Mode of practice Location of practice Number of dentists Number of dentists assistant Organizational aspects Working atmosphere in the practice team is good Responsibilities within the practice team are clear Pseudo R2 0.015 0.653* 0.102 0.722* 0.091 0.080 0.149 0.375* 0.072 0.211* 0.205 0.040 0.579* 0.231* 0.625* 0.015 0.013 0.137 0.251* 0.218* 0.126 0.222 0.139 0.306 0.110 0.282 0.264 0.042 0.236 0.094 0.179 0.051 0.041 0.288* 0.241 0.246* 0.157 0.020 0.075 0.035 0.243* 0.267* 0.016 0.188 0.065 0.359* 0.378* 0.335* 0.010 0.070 0.106 0.054 0.107 0.161 0.218 0.193* 0.433* 0.589* 0.293* 0.130 0.016 0.020 0.010 0.178* 0.065 0.430 0.039 0.401* 0.143 0.493* 0.237 0.190* 0.408* 0.452* 0.104 0.019 0.158 0.040 0.130 0.112 0.110 0.133 0.005 0.055 0.131 0.217* 0.033 0.186 0.105 0.072 0.061 0.068 0.019 0.009 0.058 0.048 0.536* 0.286* 0.541

*Statistical signicances of difference: P < 0.05; meaning of abbreviation see Table 2.

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Goetz et al. Table 4. Associations of individual characteristics and satisfaction with aspects of work on overall job satisfaction (results of stepwise linear regression analysis, under specication of standardized beta coefcient, a = 5%) Step 1 Opportunity to use abilities Working atmosphere in the practice team is good Hours of work Number of dentists assistant Recognition for work Colleagues and fellow workers Income Amount of variety in job Freedom of working method Pseudo R2 0.687 Step 2 0.568 0.369 Step 3 0.446 0.334 0.319 Step 4 0.417 0.328 0.310 0.208 Step 5 0.376 0.293 0.274 0.182 0.173 Step 6 0.349 0.196 0.277 0.188 0.165 0.150 Step 7 0.253 0.185 0.271 0.163 0.139 0.188 0.160 0.750 Step 8 0.185 0.179 0.249 0.146 0.146 0.192 0.167 0.126 0.758 Step 9 0.142 0.173 0.236 0.151 0.124 0.200 0.162 0.134 0.107 0.764

0.468

0.587

0.669

0.710

0.730

0.738

All coefcients are statistically signicantly at the P < 0.05 level.

Theory of job satisfaction, the external-hygiene factors such as income or working hours are contributed to negative feelings at work. This conrms that their absence can create dissatisfaction. Alternatively, the presence of internal-motivational factors such as recognition contribute added value and act as a catalyst for positive feelings about being a dentist (27). Our results demonstrate that dentists are more likely to be satised with their job if they are younger, work fewer hours per week or have worked for many years at their own practice. However, these results are potentially contradictory and need some explanation. Dentists, who had worked for a long time at their own practice, are likely to have already paid off the debt associated with owning the practice thus reducing the nancial pressure which younger dentists are still exposed to. It has been shown that the number of years in practice positively inuences self-reported job satisfaction (28). Moreover, younger dentists had a higher level of stress (11). Additionally, it was shown that there is a negative correlation between work engagement, that is, more working hours and increasing age (29). One study showed that younger dentists (up to 29 years) and older dentists (aged 50 59 years) feel burn out (29). They also showed that female dentists at a younger age reported a higher risk for burnout than male dentists (29). Others have shown that the relationship between satisfaction and different aspects of jobs has a strongly signicant U-shape in age because of various expectations on the job or modied work values during the different stages of a dentists career (30). Overall, it may be that the aspects of the role that create high and low job satisfaction for dentists are differential and age dependent.

Remarkably, we found no gender differences compared to other studies. It has been observed that male dentists had higher mean career satisfaction scores than female dentists (3, 5, 31). Enhanced job satisfaction of dentists has been found to be associated with the presence of dentists assistants (5, 8), an external-hygiene factor. This study showed that increasing numbers of dentists assistants are positively associated with dentists satisfaction concerning variety in job, opportunity to use abilities, amount of responsibility and income. This result also supports the assumption that dentists assistants are an important resource for reducing the job demands on dentists. Finally, the intrinsic motivating item opportunity to use abilities showed the strongest association with job satisfaction with more than 47% of explained variance of dentists overall job satisfaction. Moreover, the performance of dentists not only depends on using their own skills and capabilities, it also requires sufcient time to deliver patient care and support from dentists assistants (8). The pre-eminence of this internal-motivational factor highlights the need to ensure that dentists and dental assistants are up-to-date with the latest evidence and best practice to give the dentist the support of a primary dental team enabling them to use their skills without restrictions. Overall, our results compare favourably with a study about job satisfaction of physicians in primary care which also used the WCW-instrument to measure job satisfaction (32). Like in our study about dentists job satisfaction a lower score about satisfaction with income was shown and the intrinsic factor the opportunity to use their ability showed the strongest association to overall job satisfaction of physicians in primary care (32).

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Study limitations
Most dentists in our study are self-employed and work in a single-handed practice in ambulatory care settings, and this reects the national situation as shown by the German Dental Association and Institute of German Dentists (16, 33). We used internationally validated measures for the evaluation of job satisfaction by dentists. Moreover, we only involved practices that had participated in the EPA quality management system. However, this was a cross-sectional study and thus, we must be cautious to derive causal links from these ndings and P-values should be interpreted carefully.

Acknowledgements
The authors would like to thank the EPA team, the participating dental practices and their staff for giving permission to use EPA data for scientic purposes.

References
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Conclusion
With respect to the Two-Factor Theory of job satisfaction both components, intrinsic and extrinsic, are essential for dentists but the presence of intrinsic motivating factors has most positive impact on job satisfaction. In conclusion, the study shows that dentists in Germany evaluate their job satisfaction positively with the exception of two extrinsic aspects: hours of work and income. Furthermore, the signicant factors that affect overall job satisfaction are the opportunity to use abilities, a good working atmosphere in the practice team, hours of work, number of dentists assistants, recognition for work, colleagues, income, amount of variety in job and freedom of working method. Of these factors, the opportunity to use abilities was the strongest predictor of overall job satisfaction. The ndings of this study will be helpful for further activities to improve the working conditions of dentists and to ensure quality of care. Dentists need support through Continuing Professional Development and a supportive team to enable them to use their abilities.

Conict of interest
BB and MB are employed by the AQUA-Institute which disseminates EPA in Germany. JS is its director and stockholder. Other authors: No conict of interest declared.

Funding
This study was funded by the Department of General Practice and Health Services Research, University Hospital of Heidelberg.

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