Leadership in Health Services

A study of relationship between managers' leadership style and employees' job

satisfaction
Ali Mohammad Mosadegh Rad, Mohammad Hossein Yarmohammadian,
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Leadership and
A study of relationship between job satisfaction
managers leadership style and
employees job satisfaction
xi
Ali Mohammad Mosadegh Rad
School of Management, Royal Holloway University of London, Egham, UK, and
Mohammad Hossein Yarmohammadian
Isfahan University of Medical Science, Isfahan, Iran
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Abstract
Purpose The purpose of this descriptive and cross-sectional study is to explore the relationships
between managers leadership styles and employees job satisfaction in Isfahan University Hospitals,
Isfahan, Iran, 2004.
Design/methodology/approach The data were collected through the distribution of two
questionnaires among the 814 employees, first line, middle and senior managers of these hospitals
through a stratified random sampling.
Findings The dominant leadership style of managers was participative. The mean score of
employee-oriented dimension of leadership style in first line, middle and senior managers were 52, 54,
and 54 (from 75 credit) respectively. The mean score of task-oriented dimension of leadership style in
first line, middle and senior managers were 68, 69, and 70 (from 100 credit) respectively. The mean
score of employees job satisfaction was 3:26 ^ 0:56 on a 6 scale (moderate satisfaction), 1.9, 26.1, 64.7,
and 7.3 percent of hospital employees had respectively very low, low, moderate, and high satisfaction
with their job. Employees demonstrated less satisfaction with salaries, benefits, work conditions,
promotion and communication as satisfier factors and more satisfaction with factors such as the
nature of the job, co-workers and supervision type factors. There was significant correlation
(p , 0:001) between the use of leadership behaviors and employees and job satisfaction.
Research limitations/implications Employee job satisfaction depends upon the leadership style
of managers. Nevertheless, participative management is not always a good management style.
Managers should select the best leadership style according to the organizational culture and
employees organizational maturity.
Originality/value Although this study conducted in Iran, it is anticipated that the findings may
have relevance on a broader scale. By replicating this study in different countries and contexts the
results of could be very helpful for developing a new model of leadership with new implementation
techniques that can be implemented easily and successfully in a cross cultural context.
Keywords Leadership, Employees, Job satisfaction, Hospitals, Iran
Paper type Research paper

Introduction and background

Organizations are social systems where human resources are the most important
factors for effectiveness and efficiency. Organizations need effective managers and
employees to achieve their objectives. Organizations cannot succeed without their
personnel efforts and commitment. Job satisfaction is critical to retaining and Leadership in Health Services
Vol. 19 No. 2, 2006
pp. xi-xxviii
q Emerald Group Publishing Limited
This study was funded by Isfahan University of Medical Sciences. The authors gratefully 1366-0756
acknowledge the IUHs managers and employees for their assistance in performing this research. DOI 10.1108/13660750610665008
 LHS attracting well-qualified personnel. This is especially an issue in medical
19,2 institutions such as hospitals where specialist training and retention are highly
important
Employee job satisfaction is an attitude that people have about their jobs and the
organizations in which they perform these jobs. Methodologically, we can define job
satisfaction as an employees affective reaction to a job, based on a comparison between
xii actual outcomes and desired outcomes (Mosadeghrad, 2003b). Job satisfaction is generally
recognized as a multifaceted construct that includes employee feelings about a variety of
both intrinsic and extrinsic job elements. It encompasses specific aspects of satisfaction
related to pay, benefits, promotion, work conditions, supervision, organizational practices
and relationships with co-workers (Misener et al., 1996).
Concerns about employee job satisfaction are just as critical in the health care
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industry as they are in other business sectors. Similarly, the motivation to

investigate job satisfaction among health care employees is similar to the interest
of research concerning job satisfaction in industrial settings (McBride, 2002).
Numerous factors influence employee job satisfaction, including: salaries, fringe
benefits, achievement, autonomy, recognition, communication, working conditions, job
importance, co workers, degree of professionalism, organizational climate, interpersonal
relationships, working for a reputable agency, supervisory support, positive affectivity,
job security, workplace flexibility, working within a team environment and genetic
factors. Sources of low satisfaction are associated with working with unskilled or
inappropriately trained staff, laborious tasks such as documentation, repetition of duties,
tensions within role expectations, role ambiguity, role conflict, job/patient care, feeling
overloaded, the increasing need to be available for overtime, relations with co-workers,
personal factors and organizational factors (Navaie-Waliser et al., 2004; Koustelios et al.,
2003; De Loach, 2003; Ilies and Judg, 2003; Gigantesco et al., 2003; Blegen, 1993; Chu et al.,
2003; McNeese-Smith, 1999; Thyer, 2003).
Irvine and Evans (1995) have also underlined the importance of work characteristics
(routine, autonomy and feedback), characteristics of how the work role is defined (role
conflict and role ambiguity) and characteristics of the work environment (leadership,
stress, advancement opportunities and participation) in relation to job satisfaction.
Justification for the need to investigate job satisfaction is exemplified in the
seemingly observed relationship between the levels of job dissatisfaction, absenteeism,
grievance expression, tardiness, low morale and high turnover. Job satisfaction is an
immediate antecedent of intention to leave the workplace and turnover. Unsatisfied
workers will leave their jobs more than their satisfied colleagues (Padilla-Vellez, 1993;
Gangadhraiah et al., 1990; Martin, 1990). Retention and turnover of staff, particularly
highly skilled personnel, are important issues for managers in the current health care
environment (McBride, 2002). Employees who experience job satisfaction are more
likely to be productive and stay on the job (McNeese-Smith 1997; Irvine and Evans,
1995). Furthermore, more satisfied employees have more innovative activities in
continuous quality improvement and more participation in decision-making in
organizations (Kivimaki and Kalimo, 1994). Job satisfaction is also found to be
positively-related to patient satisfaction (Morana, 1987; Kivimaki and Kalimo, 1994).
Among determinants of job satisfaction, leadership is viewed as an important
predictor and plays a central role. Leadership is a management function, which is
mostly directed towards people and social interaction, as well as the process of
 influencing people so that they will achieve the goals of the organization (Skansi, 2000). Leadership and
Numerous studies carried out in several countries showed that there is a positive job satisfaction
correlation between leadership and the job satisfaction of health care providers (Seo
et al., 2004; Vance and Larson, 2002; Chiok Foong Loke, 2001; Martin, 1990;
Dunham-Taylor, 2000; Stordeur et al., 2000; Hespanhol et al., 1999; Lowe et al., 1996;
Berson and Linton, 2005; Morrison et al., 1997; Mosadeghrad, 2003a).
Organizational success in obtaining its goals and objectives depends on managers xiii
and their leadership style. By using appropriate leadership styles, managers can affect
employee job satisfaction, commitment and productivity. Leadership style can be
viewed as a series of managerial attitudes, behaviors, characteristics and skills based
on individual and organizational values, leadership interests and reliability of
employees in different situations (Mosadeghrad, 2003b). It is the ability of a leader to
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influence subordinates to performing at their highest capability. This factor captures

the extent to which management respects workers, operates with honesty and
integrity, promotes efficiency, and has open lines of communication with employees
(Aronson et al., 2003).
The subject of leadership is interesting for many researchers. The continued search
for good leaders has resulted in the development of many leadership theories. Studies
have been carried out to determine how leadership behaviors can be used to influence
employees for improved organizational outcomes (Kreitner, 1995). In the past several
decades, management experts have undergone a revolution in how they define
leadership and their attitudes toward it. They have gone from a very classical
autocratic approach to a very creative and participative approach. Ideas about
management and leadership have changed considerably in recent years. People today
are better-educated and more articulate. They can no longer be commanded in the same
way as before. There needs to be much more involvement and participation at work
(Stewart, 1994).
There are several styles of leadership such as: autocratic, bureaucratic, laissez-faire,
charismatic, democratic, participative, situational, transactional, and transformational
leadership (Mosadeghrad 2003b, 2004). Not everyone agrees that a particular style of
leadership will result in the most effective form of organizational behavior. Different
styles were needed for different situations and each leader needed to know when to
exhibit a particular approach. No one leadership style is ideal for every situation, since
a leader may have knowledge and skills to act effectively in one situation but may not
emerge as effectively in a different situation.
Irans health system is passing though a period of transformation. Since the early
2000s, the Ministry of Health has been working on a comprehensive health care reform
programme especially in hospitals. One of the aims of this reform programme is to
strengthen health care management. However, human resource management is still not
what it should be, and the human aspects relating to employee satisfaction and quality
of work life, which affect productivity, are inevitably neglected. As well, in the Iranian
health care profession, leadership is still in its infancy. There has been little research
related to this subject particularly in the health care service organization and service
delivery in this country. Therefore, this research with its aim of investigating the
relationship between managers leadership style and employees job satisfaction in
Isfahan University Hospitals (IUHs) is an important step toward hospital effectiveness
and increased efficiency. The results of this research will allow a better understanding
 LHS of the relationship between leadership styles and employee job satisfaction. It is
19,2 anticipated that a better understanding of these issues and their relationships can aid
further research, pinpoint better strategies for recruiting, promotion, and training of
future hospital managers and employees, particularly in Iran but perhaps in other
societies as well.

xiv Methodology
The study utilized descriptive correlation design and cross sectional survey methodology.

Setting
The health care settings for this study included 12 university hospitals (IUHs) within
Isfahan, Iran. At the time of the study (2004), these hospitals employed 6,405 full time
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employees.

Instruments
Two questionnaires were used for data collection and were sent out in two packages to
two different populations:
(1) An employee questionnaire package containing a cover letter, and a questionnaire
related to their job satisfaction and the leadership style of hospital manager.
(2) A managers questionnaire package containing a cover letter, and a leadership
questionnaire related to style and job satisfaction.

The cover letter briefly explained the purpose of the study and the mechanisms to
maintain confidentiality. A demographic questionnaire was intended to furnish the
researcher with the respondents biographical, educational information and working
experience in the hospital. Further explanations of the variables were given when
requested. The respondents received and answered the questionnaires at their work
place. Data were collected for approximately one month. Participation was voluntary.

Leadership survey questionnaire

The conceptual framework for this study derives from Rensis Likerts model of leadership
styles. According to Likert, the four distinct practices, which outstanding leaders use to
affect employee and organizational performance include: exploitive authoritative,
benevolent authoritative, consultative and participative (Likert, 1967). This questionnaire
has 35 items of which 15 items determine a managers employee oriented dimension and
20 items determine the task-oriented dimension of leadership style. Each statement
includes a five-point Likert scale (from very rarely 1 to often 5).

Job satisfaction survey questionnaire

A standard job satisfaction questionnaire (Spector, 1997) (job satisfaction
questionnaire), was used to assess the level of job satisfaction among employees in
IUHs according to nine sub-scales (salaries, fringe benefits, recognition, promotion,
communication, working conditions, nature of the job, supervision and co workers).
This questionnaire has 36 items (four items in each domain). It was decided to use
six-point Likert scales to measure the responses to each item (from strongly
disagree 1 to strongly agree 6).
 Part II of the questionnaire provided ten important job motivators. Employees were Leadership and
asked to prioritize these motivators according to their personal interests. Managers job satisfaction
asked to prioritize these motivators one time according to their personal interests and
another time according to their employees interests to find out more about managers
knowledge about employees perception of their most important motivators. Those
motivators were listed as: good pay, job security, good working conditions,
involvement, recognition, promotion, interesting work, loyalty to employees, tactful xv
discipline, and help with personal problems.

Validity estimates
Content and face validity, were established by a panel of experts consisting of
management experts.
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Reliability estimates
Cronbachs alpha coefficient has been preferred for estimating the reliability of multi-
item scales. An alpha value of 0.70 or higher was considered as acceptable reliability
for group. To determine the reliability of questionnaires, these questionnaires were
surveyed in two time intervals and an alpha coefficient was determined (leadership
style questionnaire from the view point of employees, 0.8767; leadership style
questionnaire from the view point of managers, 0.8139; and job satisfaction
questionnaire, 0.8749). The instrument was pilot tested with a group of hospital
employees (40 persons) who were not included in the sample.

Acceptability estimates
It is essential that instruments are acceptable to participants in order to obtain the
maximum response rate, thus making trial results easier to interpret, more generalized
and less prone to bias from non-response (Fitzpatrick et al., 1998). Acceptability was
assessed in terms of refusal rates, and rates of missing responses. A total of 814
hospital employees filled out the questionnaires (85.68 percent). Organization specific
response rates varied from 91 to 100 percent. Missing data analysis showed that 88
percent respondents had no missing values for the entire set of 71 items.

Data collection
The sampling method was stratified random sampling. From 6,405 employees of
hospitals, 950 persons were selected for this research after a pilot study by using the
following formula (n 6405, d 0:03, z 1:96 and s 0:51). Employees who had
less than six months working experience were excluded from this study. From the 950
distributed questionnaires, 832 questionnaires were returned and from those, 814
questionnaires were completely filled in showing a return rate of 85.68 percent.

NZ 2 S 2
n
Nd 2 Z 2 S 2

Analysis of data
All data were analyzed using the statistical package for the Social Sciences (SPSS 11).
Appropriate statistical procedures for description and inference were used. The
 LHS missing values were checked prior to further statistical analysis. In order to normalize
19,2 the likert scale on 1-6 scales for each domain of job satisfaction, the sum of raw scores
of items in each domain was divided by the numbers of items in each domain (four) and
for overall job satisfaction, sum of raw scores of items was divided by 36. Higher scores
indicate better job satisfaction. The scores of employee oriented and task oriented
dimensions of leadership were varied between 15-75 and 20-100. Higher scores in the
xvi domains indicate more employee-oriented or more task oriented managers.
The differences between groups were tested with the chi-square, Mann-Whitney
and Kruskal Wallis tests. The correlation coefficients were calculated to evaluate the
relationship between variables. Forward conditional logistic regression analysis was
used to identify the most important predictor domains in global satisfaction. Data were
presented as the mean ^ standard deviation (SD) and percentage (p values less than
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0.05 were considered as significant).

Result
In this survey the results are as follows.
A total of 814 employees participated in this study. These included 665 employees,
127 first line managers or departments heads, 11 middle managers or hospital
managers and 11 senior managers or hospital presidents. Respectively 51.5, 87.4, 90.9
and 90.9 percent of employees, first line, middle and senior managers had permanent
employment. There was no relationship between educational background and current
organizational positions of employees, first line, middle and senior managers in
respectively 19.54, 11.02, 90.9 and 9.1 percent cases.
The mean age for employees, first line, middle and senior managers were 34.2, 41.8,
46.4 and 45.2 years respectively. The ages ranged from 18 to 58 year. Male employees
were significantly older than female employees. Employees, first line, middle and
senior managers on the average, had 10.6, 18.7, 20.2 and 17.7 years of working
experiences respectively. Male employees, on the average, had 12.28 years of working
experience while females averaged 9.30 years. Males had significantly more years of
working experience than females. First line, middle and senior managers on the
average had 8.7, 11.8 and 8.7 years of managerial experiences respectively. The
majority of employees of IUHs had attained a bachelors degree (Table I).
Total job satisfaction of the respondents was measured on a six-point scale, where 6
stood for highly satisfied and 1 for highly dissatisfied. Total job satisfaction of the
respondents was 3:26 ^ 0:56 point (moderate satisfaction). The mean score of job
satisfaction of employees, first line, middle and senior managers was 3.21, 3.40, 3.97
and 3.73 from six credits respectively. Then 1.9, 26.1, 64.7, and 7.3 percent of hospital
employees had respectively very low, low, medium, and high satisfaction with their
job. Also, 23.9, 63.2, 12, and 0.9 percent of departments heads had respectively low,
medium, high and very high satisfaction with their job. A total of 27.2, 45.5, 18.2, and
9.1 percent of hospital managers had respectively low, medium, high and very high
satisfaction with their job. A total of 9.1, 63.6, 18.2, and 9.1 percent of hospital
presidents had respectively low, medium, high and very high satisfaction with their
job.
Participant scored were lowest in the benefits, 1.93; recognition, 2.44;
communication, 2.53; salaries, 2.67; working conditions, 2.76 and promotion 2.91
 Leadership and
Frequency and percent Job satisfaction
Demographic parameters Frequency Percent Mean SD job satisfaction
Sex
Male 394 48.4 3.28 0.50
Female 420 51.6 3.23 0.56
Marital status xvii
Single 147 18 3.21 0.59
Married 667 82 3.27 0.52
Graduation degree
Illiterate 23 2.8 3.58 0.54
Under diploma 97 11.9 3.23 0.65
Diploma 62 7.6 3.28 0.59
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Post diploma 202 24.8 3.21 0.58

Bachelor of science 325 39.9 3.24 0.62
Master of science or doctor of medicine 58 7.2 3.15 0.50
Doctor of philosophy 47 5.8 3.37 0.43
Area of work
Managerial and clerical 156 19.1 3.32 0.59
Ancillary or logistic 108 13.3 3.44 0.43
Therapeutic 448 55.1 3.20 0.56
Diagnostic 102 12.5 3.24 0.47
Age group
Under 20 years 3 0.4 4.04 0.33
Between 20-30 years 234 28.7 3.25 0.53
Between 31-40 years 340 41.8 3.21 0.54
Between 41-50 years 217 26.6 3.30 0.48
Between 51-60 years 20 2.5 3.50 0.69
Work experience years group
Under one year (six months to one year) 26 3.2 3.34 0.43
Between one and five years 202 24.8 3.29 0.48
Between six and ten years 169 20.7 3.20 0.53
Between 11-15 years 147 18.1 3.15 0.53
Between 16-20 years 112 13.8 3.32 0.51 Table I.
Between 21-25 years 104 12.8 3.33 0.46 Frequency and
Between 26-30 years 54 6.6 3.34 0.65 percentage of
Received wages participants and the
, 1,500,000 RLS 667 81.9 3.22 0.53 mean score of their job
. 1,500,000 RLS 147 18.1 3.44 0.54 satisfaction

(achievement) areas but scores were highest in the supervision, 4.69; nature of the job,
4.39 and co-worker, 4.36 domains (Table II).
The mean score of employees job satisfaction in the Central Storage Department
(4.21), Secretarial Unit (4.05), Public Relations Office (3.91), Social Worker Office (3.90)
and Material Supply Department (3.66) were high. In the Psychiatry Ward (2.55),
Pediatrics Ward (2.63), Dialysis Ward (2.75), Urology Ward (2.85) and Medical Records
Department, (2.88) they were low. The employees job satisfaction in therapeutic and
diagnostic departments was lower than administrative and ancillary departments. A
statistical significant association was seen between employees job satisfaction and
their area of work or specialty (p , 0:01).
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19,2
LHS

xviii

Table II.
The mean score of

to job satisfier factors

employees and managers
job satisfaction according
The mean score of job satisfaction Senior managers (hospital Middle managers (hospital First line managers All of the
Job satisfier factors presidents) managers) (departments head) Employees employees

Salaries 3.04 3.63 2.75 2.64 2.67

Promotion 3.95 3.59 3.09 2.85 2.91
Supervision 4.29 3.36 4.77 4.71 4.69
Fringe benefits 2.75 2.34 1.91 1.92 1.93
Recognition 2.72 3.29 2.76 2.37 2.44
Working conditions 2.65 3.06 2.64 2.78 2.76
Co workers 4.77 4.98 4.54 4.32 4.36
Nature of the job 5.06 4.88 4.60 4.34 4.39
Communication 3.54 3.72 3.14 2.38 2.53
 As Table III shows motivators such as loyalty to employees, job security, good pay, Leadership and
good working conditions, tactful discipline, and involvement were more important job satisfaction
respectively for employees. From the viewpoint of first line managers, motivators such
as tactful discipline, involvement, good working conditions, recognition, loyalty to
employees, and good pay were more important respectively. From the viewpoint of
middle managers, motivators such as involvement, loyalty to employees, recognition,
and tactful discipline were more important respectively. From the viewpoint of senior xix
managers, motivators such as good working conditions, good pay, loyalty to
employees, involvement and tactful discipline were important respectively. When
managers were asked to prioritize their employees job motivators from the viewpoint
of their employees, first line and senior managers chose sufficient salaries and
recognition and middle managers listed job security, promotion and involvement as
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important.
The satisfaction scores for men were found to be significantly higher than those of
women (p , 0:001). The mean score of married employees job satisfaction was 3.27
and the single employees job satisfaction was 3.21. The differences between values
were statistically significant (p , 0:05). There was no statistically significant
correlation between job satisfaction of employees and their graduation levels and type
of employment (p . 0:05). There was strong correlation (p , 0:01) between the job
satisfaction of employees and their age, years of work experiences, organizational
position and received salaries.
In order to determine the main factors that cause satisfaction and/or dissatisfaction
with work, the relationship between total job satisfaction and job satisfier factors was
analyzed. Calculations of Spearmens ratios revealed the strongest correlation between
total job satisfaction and such characteristics as salaries, 0.68; fringe benefits, 0.68;
promotion, 0.67 and communications, 0.63. Work conditions, 0.46; nature of the job,
0.50; supervision, 0.53 and co-workers, 0.55 had less effect on employees job
satisfaction respectively. This relationship was statistically significant in all of cases
(p 0:00).
The mean score of employee-oriented dimension of leadership style in first line,
middle and senior managers were 52 ^ 6:35, 54 ^ 3:89, and 54 ^ 50 (from 75 credit)
respectively. The mean score of task-oriented dimension of leadership style in first line,
middle and senior managers were 68 ^ 9:25, 69 ^ 6:70, and 70 ^ 7:20 (from 100 credit)
respectively. A total of 0.78, 4.74 and 94.48 percent of first line managers had
Exploitive-Authoritative, Benevolent-Authoritative and Participative leadership
styles. A total of 100 percent of middle and senior managers had a participative
leadership style (Figure 1).
From the viewpoint of employees the mean score of hospital managers
employee-oriented and task-oriented credits were 46 and 65. From the viewpoint of
hospital managers the mean score of their employee-oriented and task-oriented credits
were 54 and 69. The differences between values were statistically significant
(p 0:00). In other words, from the viewpoint of employees, hospital managers were
more task-oriented and from the viewpoint of the hospital managers themselves, they
were more employee-oriented.
There was no correlation between leadership style of managers and their
demographic variables except managerial experience years. Pearson correlation
coefficients indicate a significant statistically relationship between hospital managers
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xx
19,2
LHS

Table III.

the viewpoint of
the most important
motivators ranking from

employees and managers

Employees Employees
Motivators Motivators Employees motivators motivators
Motivators ranking from the ranking from the Motivators motivators ranking from the ranking from the
ranking from the view point of view point of ranking from the ranking from the view point of view point of
Priorities view point of middle first line view point of view point of middle first line
Motivators senior managers managers managers employees senior managers managers managers

Good working 1 8 3 4 8 10 6
conditions
Involvement 4 1 2 7 6 3 4
Tactful discipline 5 4 1 6 9 7 8
Recognition 6 3 4 8 2 6 2
Loyalty to 3 2 5 1 7 4 3
employees
Good pay 2 10 6 3 1 8 1
Promotion/growth 9 9 8 9 3 2 9
Help with personal 8 6 10 10 5 5 5
problems
Job security 7 7 7 2 4 1 7
Interesting work 10 5 9 5 10 9 10
 Leadership and
job satisfaction

xxi

Figure 1.
The percentage frequency
of leadership style of IUHs
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managers

management experience years and their employee oriented (p 0:024 and r 0:736)
and task oriented (p 0:023 and r 0:706) dimensions of leadership style.
There was a statistically significant correlation between the job satisfaction of
employees and the leadership style of managers. This correlation between employees
job satisfaction and employee-oriented and task-oriented dimensions of leadership
style of hospital managers was at p 0:00 and p 0:01 levels.
The correlation co efficient between employee oriented and task orient dimensions
of leadership style and employees satisfaction factors showed that the most positive
co-efficiency was between supervision and employee oriented dimension and the most
negative co-efficiency was between fringe benefits and task oriented dimension of
leadership style of managers.
IUHs had 2,342 active beds in 2003. Bed occupancy rate (BO), patient average length
of stay (ALS), bed turnover rate (BT) and bed interval turnover rate (BIT) indicators of
IUHs in this year were 57.3 percent, 4.07 days, 51.4 times and 3.03 days respectively.
There was no statistically significant correlation between leadership style of managers
and hospital efficiency indicators (p . 0:05). A significant statistically relationship
was between employee job satisfaction and hospitals BT rate (p 0:029 and
r 0:655) and BIT rate (p 0:039 and r 0:627).

Discussion
In Iran 6 percent of GDP is allocated to health care sector and significant portion of
government employees work in this sector (7.6 percent), so health care managers
should be more concerned with the effectiveness, efficiency and productivity principles
in these organizations (Mosadeghrad, 2004).
In this study, both global job satisfaction and different dimensions of satisfaction
were evaluated. The results of this study have shown that employees were moderately
satisfied with their jobs. Employee job satisfaction in relation to salaries and fringe
benefits and working conditions was low. It is recommended that particular attention
be given to improving employees job satisfaction. Motivators such as loyalty to
employees, job security, good pay, good working conditions, discipline, involvement,
recognition, promotion, and help with personal problems were important respectively
for employees. Managers do not have enough authority to affect job security and
 LHS salaries in public hospitals; however, they could make effective efforts in other areas of
19,2 motivation to improve employee morale.
Several researchers have concluded that employee job satisfaction in health care
organizations is shown to be correlated with age, gender, marital status, number of
children, graduation level and work experience years (Al-Ahmadi, 2002; Aronson et al.,
2003; Blegen, 1993; Bodur, 2002; Chu et al., 2003; Gangadhraiah et al., 1990; Gigantesco
xxii et al., 2003; Hespanhol et al., 1999; Lyons et al., 2003; Hallock et al., 2004). In this current
study, variables such as employees age, gender, work experience years, marital status
and organizational position were seen as having significant effects on their job
satisfaction. But graduation levels had no significant correlation with job satisfaction.
It seems that job satisfier factors such as salaries, benefits and working conditions
were more important in neutralizing the effect of graduation level on job satisfaction. A
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higher level of job satisfaction in illiterate employees may be due to the fact that most
of these individuals are old and have been working in the hospitals for many years.
Therefore, they are receiving higher pay because of their length of service. Also, they
do not do the difficult jobs in hospitals. The higher level of job satisfaction for
employees with diplomas is because of the nature of the jobs they perform. In Iran,
such individuals do the paper work in organizations. However, those employees who
fail to finished high school and do not have a diploma, have to do the hard and non
professional jobs in hospitals such as working in the laundry, or cleaning patients
rooms and so on.
Numerous studies have shown that salary and working conditions were the most
important factors for dissatisfaction of health care providers (Bodur, 2002; Seo et al.,
2004; Fitzpatrick et al., 1998; Sur et al., 2004). The finding, which indicated that there
was a significant association between employees job satisfaction and their received
salary, nature of the job and work conditions is consistent with the findings of these
previous studies.
The current study showed that promotion opportunities were another significant
predictor of job satisfaction among study participants. This finding is consistent with
other studies, which have shown the opportunities for personal and professional
growth and achievement is one of the best predictors of job satisfaction (Lyons et al.,
2003; Al-Ahmadi, 2002; Freeborn and Hooker, 1995; Wittig et al., 2003).
The u-formed relationship between age, seniority and job satisfaction requires two
interpretations. Among younger employees, a higher level of satisfaction may be due to
the fact that inexperienced employees have fewer duties and responsibilities, less
pressure, and fewer demands from colleagues. They may also be less exposed to
work-to-family conflicts. Among older employees, higher satisfaction could be
explained by a better knowledge of hospital working, by benefits linked to seniority
(schedules, salary), and by fewer external demands. It is also possible that older
employees refocus their priorities to factors outside of the work setting, such as family
and or planning for retirement.
As expected, satisfaction was higher among employees with higher occupational
positions. This can be attributed to having more control over the job, more
decision-making latitude, along with a more central position between healthcare
professionals, a valued position within the hospital hierarchy, higher salaries and
benefits linked to seniority and more social recognition.
 This study also demonstrates that those employees who work with patients have Leadership and
less job satisfaction. Employees working in psychiatry, haemodialysis and pediatrics job satisfaction
have less satisfaction. Job rotation could possibly be a good strategy for improving job
satisfaction of these employees. The lower level of job satisfaction for employees
working in the medical record department is likely also because of the specific nature
of the jobs they perform. Automation is not used in these hospitals, and these
employees have to perform their duties manually. Documentation, repetition of duties xxiii
and low salaries are the most important sources of dissatisfaction of employees in this
department.
The results of this study also show that nature of the job is not an important
motivator for either employees or managers. This has important implications for the
universities, which educate people in health care professions. A higher importance
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should be placed on the interest people need to have in working with patients before
they choose such people oriented careers in the first place.
Another major finding as the cause of employee job dissatisfaction is the lack of
respect and recognition they receive from hospital management. Recognition and
respect are highly important especially for employees who are in direct contact with
patients, families, peers and other health care team members. Recognition from
managers for good performance is vital in increasing job satisfaction and is central to
boosting morale. A supportive management style, demonstrated through open
communication, respect and recognition could greatly improve the satisfaction of
employees on the job.
Possessing knowledge and information about employee motivation helps managers
understand how employees can be involved to achieve process improvement. While
management thinks that good pay is the number one desire of the employees, the
results of this survey show that this factor is usually in the middle of the ranking. It is
interesting to note that the perceptions of managers of the importance of motivators for
employees vary considerably from how employees view what motivates them. More
understanding of the needs and wants of their employees, as well as a better
understanding of the impact of their own managerial behavior on others would help
them in terms of improving performance in the workplace.
It has been noted in this study that leadership is positively correlated with hospital
employee job satisfaction. Nevertheless, participative management did not improve the
hospital effectiveness and efficiency. The efficiency of hospital managers can be
assessed by indicators such as bed occupancy (BO), average length of stay (ALS), bed
turnover (BT) and bed interval turnover (BIT) rates. Increases in BO and BT rates and
decreases in of ALS and BIT rates indicate more efficiency of hospital. There is an
inefficiency rating for about 43 percent of active beds in IUHs. On the other hand,
employee job satisfaction is one of the most important effectiveness indicators and the
findings showed that hospital employees were moderately satisfied with their jobs.
Therefore, it can be concluded that participative management was not successful in
these hospitals
It seems that managers have insufficient information about leadership theories and
principles. Therefore, Mosadeghrad and Tahery (2004), tested this hypothesis by
administering a research questionnaire to investigate the level of IUHs managers
knowledge about Likerts leadership styles (Mosadeghrad and Tahery, 2004). The
results showed that the mean score of managers knowledge about leadership styles
 LHS was 14:15 ^ 4:77 on a 36 scale (low knowledge). The mean score of their knowledge
19,2 about Exploitive authoritative, Benevolent authoritative, Consultative and
Participative styles were respectively 4.52, 2.73, 3.20 and 3.69 on a nine scale. One
can conclude therefore that more information about participative management might
help managers understand more the impact of their managerial style on their
employees.
xxiv Managers should choose the best style of leadership according to organizational
culture of hospitals and employees organizational maturity. According to
Mosadeghrad and Malek pour (2005), from 12 Isfahan university hospitals, nine
hospitals (75 percent) had bureaucratic structure versus three hospitals (25 percent)
organic structure; and five hospitals (41.6 percent) had weak organizational culture
versus seven hospitals (58.4 percent) medium culture. Furthermore, according to
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Maslows theory of hierarchy of needs, each individual has basic, physiological needs
and as needs are met, the individual seeks to satisfy other needs. Once individuals have
satisfied one need in the hierarchy, it ceases to motivate their behavior and they are
motivated by the need at the next level up the hierarchy. He categorizes needs into
physiological, safety, love, esteem, and self-actualization. Based upon Maslows theory
of human motivation, employees will seek to fulfill self-actualization needs whenever
their other low level needs have met (cited in Mosadeghrad, 2003b). In this study
employees job satisfaction in relation to their salaries and fringe benefits and working
conditions was low. In other words, they are in the primary needs level. These needs
should be met in order to they think about participating in their organizations
management process. Therefore, at this time participative management is not a good
leadership style for these hospitals, unless hospital managers try to improve
organizational culture of hospitals and employees organizational maturity.
Generally speaking, participative management is not always a good management
style; managers should be first educated and trained in choosing the proper scientific
methods and techniques of participative management, as well its goals, objectives,
weaknesses, strengths and application in the organization. Then, they should
determine the organizational maturity level of their employees. After that, they should
improve their employees organizational maturity and use this leadership style
conservatively.

Implications
Employees are the most important resource in organizations. Nevertheless, managers
spend a minimal amount of time learning more about human behavior, communication,
and how their attitudes and behavior impact employee performance. Management
requires a keen understanding of human nature, the basic needs, wants and abilities of
people. Managers at all levels cannot cause an employee to become motivated; they can
however, through their actions and more participative attitudes help to create the
environment for individuals to motivate themselves.
The results of this study suggest that management might be able to increase the
level of commitment in the organization by increasing satisfaction with compensation,
policies, and work conditions. One way of addressing this could be by increasing the
interactions with employees in staff meetings and hospital committees. Changes in
organizational variables, such as benefit scales, employee input in policy development,
 and work environment could then be made in an effort to increase employees job Leadership and
satisfaction. job satisfaction
Conclusion
This study was undertaken because of the researchers interest in determining the
aspects of a leadership style of hospitals managers that affect employees job
satisfaction. Employees job satisfaction was significantly correlated and was affected xxv
by leadership style of managers especially employee-oriented dimension. It was also
believed that hospital managers need a more in-depth understanding of the
relationships these variables have with one another.
Also, this study provides information about the status of global and
dimension-specific job satisfaction among a group of hospital employees who work
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in IUHs, Iran. The findings show that hospital employees were only moderately
satisfied with their jobs. Specific job satisfaction dimensions indicate that highest
dissatisfaction levels occur in the area of salary, benefits and working conditions.
Areas of dissatisfaction are signals for change.

Limitations
In this study, employees participation was voluntary and was conducted at twelve
university hospitals in Isfahan City, Iran. These factors limit the possibility of
generalizing from the study findings. The results of the study can only be generalized
to all employees employed in IUHs. So, the findings should be interpreted with caution
since the participants were hospital employees from a particular province of Iran and
do not represent all hospital employees in this country.
This study may serve as a foundation for future studies in different countries. It is
recommended therefore that this study be repeated in different countries and contexts.
This study may serve as a foundation for future studies, in different hospitals, on a
larger scale. The results of such studies can be very helpful for developing a new model
of leadership with new implementation techniques that can be implemented easily and
successfully in a cross cultural context.

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Corresponding author
Ali Mohammad Mosadegh Rad can be contacted at: m.mosadeghrad@rhul.ac.uk

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