Job satisfaction and emotional work tasks : dentists in Sweden and Denmark

LICENTIA TE DISSERT A TION IN ODONT OL OG Y KAMILL A BER GS TR ÖM MALMÖ UNIVERSIT MALMÖ UNIVERSITY

KAMILLA BERGSTRÖM

JOB SATISFACTION AND

EMOTIONAL WORK TASKS

Dentists in Sweden and Denmark

isbn 978-91-7104-613-0 (print) isbn 978-91-7104-614-7 (pdf) issn 1650-6065 JOB S A TISF A CTION AND EMO TION AL W ORK TASKS L I C E N T I A T U P P S A T S L I C

Kamilla Bergström 2014 Illustration Elsa Mathiasen ISBN 978-91-7104-613-0 (print) ISBN 978-91-7104-614-7 (pdf) ISSN 1650-6065

KAMILLA BERGSTRÖM

JOB SATISFACTION AND

EMOTIONAL WORK TASKS

Malmö högskola, 2014

Department of Oral Public Health

Faculty of Odontology

Dentists in Sweden and Denmark

This publication also available online see: www.mah.se/muep

CONTENTS

PREFACE ... 9

ABSTRACT ... 10

SAMMANFATTNING ... 12

INTRODUCTION ... 14

The dentist-patient relationship at the core of dentistry work ...15

Job satisfaction, ‘arbetsglädje’ and eudaimonia ...17

Emotion work ...19

The intertwined values and logics in dentistry ...20

AIMS ... 23

MATERIALS AND METHODS ... 24

Paper I ...24

Paper II ...25

Additional questions for empirical illustration ...25

RESULTS ... 27

Paper I ...27

Paper II ...27

Additional results for empirical illustration ...30

DISCUSSION ... 32

Emotion work in dentistry ...33

CONCLUSION ... 37 IMPLICATIONS ... 38 ACKNOWLEDGEMENTS ... 39 REFERENCES ... 42 PAPERS ... 45 APPENDIX ... 88

PREFACE

This thesis is based on two papers, which will be referred to in the text by their numerals. Additional results for empirical illustration are also presented:

Paper I: Bergström K, Söderfeldt B, Berthelsen H, Hjalmers K, Ordell S. 2010. Overall job satisfaction among dentists in Sweden and Denmark: a comparative study, measuring positive aspects of work. Acta Odontol Scand 68(6):pp.344–353.

Paper II: Bergström K, Hakanen JJ, Aspelin J, Söderfeldt S, Schou L Emotion work in dentistry – A theoretical overview of the key concepts, conditions and consequences. Resubmitted to Community Dentistry and Oral Epidemiology July 2014.

ABSTRACT

The thesis consists of two papers which are based on a research project called ‘Good Work’. The overall aim of the Good Work project was to use dentistry as an example of work which has close relations with patients at its core. This kind of work (also called human service work) has special psycho-social work environment considerations and emotional requirements, which need to be considered when organizing work.

The aims of the first study were to describe the background and development of the questionnaire ‘Swedish and Danish Dentists’ Perceptions of Good Work’ and to create a measure of overall job satisfaction, applying the measure in four organizational settings. The aim of the second study was to introduce the concept of emotion work in dentistry by giving a theoretical overview of the emotional aspects of work, the conditions under which it is performed and the potential effects on the dentist’s wellbeing. Additional results from the Good Work project have been included in the thesis with the purpose of giving an empirical illustration of how dentists experience the emotional factors related to patient interaction and their job satisfaction.

Data from 1226 Danish and Swedish practising dentists was collected in November 2008, with a 68% response rate. An additive index was created to measure overall job satisfaction showing statistical difference in the dentists’ experience according

The Danish public dentists had the highest degree of overall job satisfaction and the Swedish public dentists had the lowest. A reason for this difference might be that Danish public dentistry differs from the other three groups in the characteristics of both dentists and patients. However, the lower job satisfaction for the Swedish public dentists could be an effect of New Public Management thinking in organizing dentistry. The additional results showed that Swedish public dentists had substantially less energy left for their private lives compared with the other three groups and only half of them expected to continue working as they do now until retirement.

Working directly with or on people is very much about creating good interactions and relations between the health professional and the patient. Good patient relations can be a primary aim and/or a secondary aim, to make other things, e.g. the clinical treatment, easier. To many health professionals their relations with the patients is an arena in which to activate their human potentials and can be experienced as a lasting intrinsic joy from work, called eudaimonia. In the relation with the patient the dentist performs emotion work as an intervention toolkit to direct the patient in a specific direction. Dentists have extensive emotional work tasks in their patient interactions, however this emotional part of dentists’ work is, so far, a neglected research area of odontology. The emotion work tasks are conditioned because the dentists’ incentives are not one-dimensional and require a great deal of emotional flexibility, attentiveness and reflection by the dentist. The influence of the market and managerialism on the professional values of dentistry may challenge the conditions for these tasks in the patient interaction and the wellbeing of the dentist if they are experienced as contradictory.

This research aims to encourage and empower different levels of dentistry to further investigate, understand and support the dynamics of the emotional aspects of work with the aim to constitute a sustainable work environment where values and logics can be experienced as compatible with professional values.

SAMMANFATTNING

Avhandlingen består av två studier som utgår från projektet ”Det goda arbetet”. Det överordnade syftet med projektet Det Goda Arbetet var att använda tandvård som ett exempel på ett arbete där relationerna med patienterna utgör arbetets kärna. Denna typ av arbete (även kallat människovårdande arbete) har speciella psyko-sociala arbetsmiljövillkor och känslomässiga krav som måste tas hänsyn till vid organisering av arbetet.

Syftet med den första studien var att beskriva bakgrunden och utvecklingen av frågeformuläret ’Svenska och Danska tandläkares uppfattning av ’Det Goda Arbetet’ och att skapa ett mått för generell arbetstillfredsställelse, applicerat på fyra organisatoriska miljöer. Syftet med den andra studien var att introducera konceptet emotionellt arbete i tandvård genom att ge en teoretisk överblick av de emotionella aspekterna av arbetet, villkoren under vilka arbetet utförs och de potentiella effekterna på tandläkarnas välbefinnande. I kappan har kompletterande resultat från projektet Det Goda Arbetet inkluderats i syfte att ge en empirisk illustration av hur tandläkare upplever de emotionella faktorer som relaterar till patient-interaktionen och deras arbetsglädje.

Data från 1226 danska och svenska verksamma tandläkare samlades in i November 2008 med en svarsprocent på 68 %. Ett additivt index skapades för att mäta generell arbetstillfredsställelse, och resultaten visade statistiska skillnader i tandläkarnas uppfattning

och Danska offentliga/privata). De danska offentliga tandläkarna hade den högsta graden av generell arbetstillfredsställelse medan de svenska offentliga hade den lägsta graden. En möjlig förklaring till detta kan vara att danska offentliga tandläkare skiljer sig från de andra tre grupperna i karakteristika vad gäller både tandläkare och patienter. Den låga graden av generell arbetstillfredsställelse hos de offentliga svenska tandläkarna kan möjligtvis vara en effekt av New Public Management-tänkande i sättet att organisera tandvård. Tilläggsresultaten visade att de svenska offentliga tandläkarna hade mycket mindre energi till sina privatliv i jämförelse med de andra tre grupperna och bara hälften av dem förväntade sig att fortsätta arbeta som nu fram till pensionen.

Att arbeta med eller på människor handlar mycket om att skapa goda interaktioner och relationer mellan vårdgivaren och patienten. Goda patientrelationer kan vara ett primärt- och/eller sekundärt mål för att göra andra saker, som t.ex. den kliniska behandlingen, lättare. För många vårdgivare är relationerna med patienterna en arena där de kan leva ut sin potential som människor och kan upplevas som en bestående inre glädje av arbetet, kallat eudaimonia.

I patientrelationen utför tandläkaren emotionellt arbete som ett sätt att intervenera med patienten för att vägleda denne i en bestämd riktning. Tandläkare har uttalade emotionella arbetsuppgifter i sina interaktioner med patienterna, emellertid har dessa emotionella aspekter av arbetet hitintills varit ett försummat forskningsområde inom odontologin. De emotionella arbetsuppgifterna är betingade eftersom att tandläkarens incitament inte är endimensionella och därför kräver de en hel del emotionell flexibilitet, uppmärksamhet och reflektion av tandläkaren. Påverkan från marknadskrafter och managerialism på de professionella värdena inom tandvård kan av tandläkaren uppfattas som motstridande och utmana villkoren för emotionellt arbete och tandläkarnas välbefinnande.

Denna forskning syftar till att starka och uppmuntra olika nivåer av tandvård till att ytterligare undersöka, förstå och stötta dynamiken i de emotionella aspekterna av arbetet för att skapa en hållbar arbetsmiljö där värden och logik kan uppfattas som kompatibla med tandvårdens professionella värden.

INTRODUCTION

This thesis originates from a large-scale project investigating ‘good work’. The Good Work project emerged from a need to understand the factors that constitute good work and a good working life for dentists in Sweden and Denmark. We were interested to investigate if there were any differences in the experience of work according to nationality and affiliation (public vs. private dentistry). With the background of findings by Hjalmers and Berthelsen and colleagues, it was a hypothesis that an increasing influence of New Public Management (NPM)1 _{in the organization of dentistry might be correlated with a}

decrease in job satisfaction because of an increased gap between the ideal and the reality of practising dentistry (Hjalmers 2006, Berthelsen 2010). Among others, the conditions and terms evolving from NPM for practising dentistry seemed contrary to supporting the possibility for building good dentist-patient relationships. This, in turn could affect the positive aspects of the dentist-patient relationship, not only for the patient but also for the dentist’s experience of work.

Therefore, in 2008, a project group of two Danes and three Swedes from the field of dentistry developed an extensive psycho-social work environmental questionnaire. Distributed to dentists in Denmark and Sweden, there was a 68% response rate from the dentists (Bergström et al. 2010). A database of the answers was created containing different perspectives of the construct of good work in dentistry, e.g. organizational factors and leadership, collegial collaboration, dentist-patient interaction and demographic data (Questionnaire in

Appendix). The database was used in the theses of Hanne Berthelsen and Svens Ordell, respectively, to examine the influence of collegial and organizational factors on the dentists (Berthelsen 2010, Ordell 2011). This thesis focuses on the data collection process, dentists’ overall job satisfaction and, finally, the emotional aspects of the dentist-patient interaction, thus addressing different aspects of the construct of ‘good work’ in the Good Work project.

This thesis presents an analysis of dentists’ experience of overall job satisfaction according to affiliation and nationality, as well as a theoretical introduction to the concept of emotion work in the context of the dentist-patient relationship. The quality of the dentist-patient relationship is based on the dentist’s ability properly to recognize, manage and display their own emotions in a way which affects the patient’s emotions in a specific direction. However, the context of dentistry has complex circumstances under which the emotional part of work is performed and this can in turn affect the interaction, as well as dentists’ wellbeing, in both negative and positive ways. The effect of NPM and market thinking on the conditions for emotion work will be discussed, as a factor influential on work environments in recent decades. This thesis may be considered critical of the human consequences of NPM thinking; however, the ambition of this thesis is to increase dentists’ opportunities to be aware of their working conditions, interpersonal performance and reactions as professionals in a context of multifaceted demands. Hopefully that awareness can empower them to handle the specific conditions and complex psycho-social challenges in their work tasks in a sustainable way. An understanding of emotion work practice could be used explicitly, e.g. in dental education and in organizing dental health services, to attain compatibility of professional values and other logics.

The dentist-patient relationship at the core of dentistry work

It is in the interaction between dentist and patient that aid and care can take place. However, it is important to distinguish between (a) professional relationships, (b) pseudo-relationships and (c) encounters. According to Gutek, professional relationships are based on shared history and knowledge where mutual trust has evolved. There is also reciprocal identification and the interaction fosters emotional

involvement, which allows the dentist to give the patient special treatment (Gutek, Cherry et al. 2000). Pseudo-relationships are more typical of a dental clinic-patient relationship, where the patient does not have any knowledge about the dentist and all the dental professionals at the clinic have access to the same information about the patient. The patient may know and trust the common procedures, reputation and atmosphere at the clinic and relies on being treated as well as any other patient. Encounters are defined by Gutek as where there is no identification of the patient with the dentist, no previous personal history between them, no trust developed over time, nor any expectation to meet again (Gutek 1999, Gutek, Cherry et al. 2000). This kind of interaction makes standardized procedures possible because it focuses on the specific task with as little ‘interruption’ from human factors as possible. However, some health-promoting support for patients is difficult without mutual personal trust because it requires access to the patient’s personal life to succeed.

Pseudo-relationships are actually serial encounters at the same clinic

where several dentists within the clinic are regarded as interchangeable and functionally equivalent. From research in doctor-patient relationships, continuity in care is a factor which only has benefits for the patient’s satisfaction if the patient trusts the doctor; however, trust seemed to increase with increased continuity. Most often patients are unable properly to judge the technical competences of the doctor, however, they are better placed to judge the interpersonal competences and care of the doctor (Baker, Mainous III et al. 2003). These findings could easily be applicable to dentists as well, as the patient relationships have many similarities.

Among all professional relationships, dentists are reported as most common service provider with whom patients have a professional relationship (80%) (Gutek, Cherry et al. 2000). In a professional relationship, the success of a service/treatment is attributed to an internal cause in the dentist (e.g. ‘my dentist is skilled and competent’) and subsequently, when a service failure occurs it is due to an external cause in the situation (e.g. ‘waiting time is caused by some unavoidable situation that my dentist needs to take care of’) (Gutek 1999). The dentist-patient relationship is a human interaction with

an opportunity to actively live out human potential by evolving trustful and compassionate caring connections. Research shows that relations with their patients are an essential factor for dentists’ job satisfaction as well as a crucial factor for the overall human and clinical outcome (Harris, Ashcroft et al. 2008, Berthelsen, Hjalmers et al. 2010, Hakanen, Peeters et al. 2011). Besides the rewarding human aspects of a good dentist-patient relationship, mutual trustful relations make the clinical performance much easier. When trust is gained and the emotional effort in the interaction is minimized, it is much easier to concentrate energy on the specific treatment. Not only do patients in a vulnerable situation feel better about the practitioner’s efficiency, but dentists also enjoy being efficient and productive. There is a positive correlation between job satisfaction (arbetsglädje) and the feeling of getting things done. Data from the Good Work project support these findings (Bergström et al. 2010).

Job satisfaction, ‘arbetsglädje’ and eudaimonia

From a work environment perspective, it is important also to focus on the positive aspects of work which can serve as ways to cope with potentially deteriorating conditions of work. Focusing on promoting the positive aspects of work instead of just preventing the negative ones has increased through the last decades. Martin Seligman, who is one of the founders of positive psychology, has criticized academics for focusing too much on work issues that cause negative effects and pathology and not enough on positive effects. For example, in the last three decades of the twentieth century some 46,000 psychology papers on depression were published, but only 400 on joy (Seligman, Csikszentmihalyi 2000). Psycho-social work environmental researchers have often been accused of being uninterested in the good aspects of work though it is possible to describe variables that benefit health development in employees (Nilsson et al. 2005).

In positive psychology it is emphasized that joy or happiness is gained from discovering what is right for us instead of just avoiding what is wrong for us (Linley et al. 2009). The aim of the Good Work project was to find positive aspects of work, here especially the intrinsic and more enduring experiences from the dentists’ interaction with patients. To identify these intrinsically good factors of work it was reasonable to

investigate some global measures of the dentists’ experience of work. The variable we examined to cover this positive intrinsic experience from work was the Nordic term arbetsglädje /arbejdsglæde (Swedish/ Danish) which has no equivalent term in English. Work fulfilment was the term and concept which, after considerable consideration, we found most recognizable and suitable as the nearest term to ‘arbetsglädje’. ‘Arbetsglädje’ can be defined as an intrinsic feeling of happiness and fulfilment in the work you do, in the context you are in. The measure of overall job satisfaction can be defined as a more rational objective view on work, as being fulfilled and content with the properties and conditions of work and the reward you get from it. However, even though ‘job satisfaction’ does not capture the whole breadth of what is actually assessed in our data, it was considered the best scientific term to use because it is the term most commonly used in research within the field. It is also worth noting that job satisfaction is a more stable cognitive assessment of work, all in all, than ‘arbetsglädje’ which is an emotion and thereby cannot be understood or assessed fully by reason. However, it is not as ephemeral as having a good mood at work. ‘Arbetsglädje’ is an intrinsic reward and emotion which can be connected to a feeling that one’s human and professional potentials are being actively well used and that you and your work contribute to something meaningful. These potentials can often be characterized as highly interpersonal in the context of work. Establishing close union with others by showing concern, as well as guiding and directing others and putting own needs second, is according to Erikson a part of a universal generative adult development (Hoare 2001). Wellbeing at work is another term used within work environmental research which considers several dimensions at work. It relates to all aspects of working life, from how work is organized, the physical environment, job tasks and how the climate is at work (EU-OSHA 2013).Wellbeing measures often aim at ‘creating an environment to promote a state of contentment which allows an employee to flourish and achieve their full potential for the benefit of themselves and their organization’ (EU-OSHA 2013 p. 1), and the term is thereby also closely connected to the concept of eudaimonia.

Aristotle used the term eudaimonia to refer to activities which, through the flourishing of human potentials, can create an enduring

by doing good’, referring to the actions we do and not the potentials we have (Aristotle 2006). By activating one’s potential as a human being, it is possible to feel one is making a purposeful contribution in life (Ryan, Deci 2001). Cultivating good relationships is described as eudaimonic activity. Engaging and applying oneself authentically in a relationship can foster deep connection and trustworthiness (Seligman, Csikszentmihalyi 2000). Engaging in positive relations with others is a way to use personal talents and can also become a resource for sustainability for the organization and in life for oneself (Myers 2000, Linley 2009). For example, healthcare professional’s interaction with patients can create a sense of relatedness, contributive guidance and universal care. Ryff and Singer claim that interpersonal flourishing is a core feature of good quality of life across cultures and across time (Ryff, Singer 2000).

Positive professional relationships can be a source of deep inner meaningful experiences beyond the ‘hedonic treadmill’ which is continuous pleasure seeking, such as the pursuit of money, status and recognition (Ryan, Deci 2001). Eudaimonia, as an enduring state of fulfilment, can be gained when activity of the soul – in accordance with reason – learns to consciously choose to do good things (Aristotle 2006). When our emotions are in harmony with our thoughts and motives, we feel intrinsically aligned and in harmony.

Emotion work

Emotions govern our experiences and vice versa. Emotions also influence our thoughts and actions. Perceiving, interpreting and handling both one’s own and others’ emotions through daily life is a substantial part of interpersonal connection and relationship building – emotion work is thus a tool to connect. Compared with private life, other requirements, rules and expectations regarding behaviour and display govern interactions in the context of work. Depending on the complexity of the professional context and of the emotions emerging, more or less emotional effort is put in to the interaction. Work tasks that require the display of one’s own emotions to affect the patient’s emotions are called emotion work. The concept of emotion work is a new field of research within odontology, with no previous literature on the subject in spite of its obvious relevance within the profession. Hochschild introduced the concept of emotions as a part of work in

her seminal book from 1983 The managed heart – commercialization

of human feeling (Hochschild 1983). Since then conceptual and

empirical descriptions with illustrations from professions other than dentistry have appeared in the literature (Morris, Feldman 1996, Zapf 2002, Diefendorff, Croyle 2006). Emotion work is a fundamental part of the interaction toolkit in the dentist-patient relationship to guide and direct the patient in a desired direction. The norms and rules of performance of emotion work can be both implicit and explicit, and are mostly taught through socialization in dental school. For example, a dentist is expected to display a calm, friendly and sensitive attitude in the interaction with patients, and to accommodate the often unpleasant and vulnerable situation for the patient. However, other emotional displays can also be required, e.g. gravity over a diagnosis, a neutral perspective when advising and a cheerful demeanour towards children. All displays, whether truly felt or not, are part of the emotional toolkit of the dentist, with the aim of gaining trust and permission to access the personal life and oral cavity of the patient. Mutually trustful relationships with the patients built on continuity and history will also give a better insight in the patient’s life and oral health progress. This can enhance a well supported prognosis, trust in the dentist’s advice and support for a more systemic perspective on preventive and health promoting services. In addition, a mutually trustful relationship can make a concentrated clinical performance more comfortable, for both dentist and patient.

The intertwined values and logics in dentistry

A challenge for the dentist-patient relationship is the increase of incentives additional to the professional ones in work. The aim of oral healthcare provision is to prevent and treat oral diseases and promote oral health. The values which support this aim are learned through the dentistry education and actively take form in the dentist’s interaction with patients. In the core dentistry curriculum there are domains and competences aimed at the patient relationship, such as professional behaviours. These include, for example, communication skills, professionalism and expressed behaviours, such as honesty, confidentiality, personal and professional integrity and appropriate moral values (Cowpe et al. 2010). As oral health care providers, dentists are encouraged to undertake lifelong learning beyond

dentistry to understand their role in society better. As health care providers in Scandinavia, dentists are also a part of the extensive publicly provided and (partially) funded national welfare service. Through the last three decades, NPM has influenced the organization of most welfare services in the Nordic countries, including dentistry. The implementation of NPM reforms have differed nationally and have different expressions on the specific professions.

In Denmark, a combination of decentralization, managerialism and democratization is widespread as a variation of NPM in welfare services (Sehested 2002). Oral health care services are divided into public and private provision. The public oral health care includes care for children up to 18 years of age and persons with disabilities. Private oral health care primarily provides care for the adult population. Thus, there is very little competition for patients between the public and the private sector. Private oral health care is primarily paid for as a fee per item with public funded subsidies. The public oral health care is fully funded.

In Sweden the NPM tradition has a longer history and is more market orientated than in Denmark. The welfare is here based on a purchaser provider model with competition between health care providers which has made large dental cooperatives competitive due to rationalization and economies of scale (Ordell 2011). Among other effects on Swedish public dentistry, the terminology has shifted from patient to customer, which also has influenced the relation with the patient who has need for expertise and customer demands. Nordgren explains that a compromise has evolved in public dentistry; the patient is a customer until she is in the dental chair and afterwards. In the chair, she is a subordinate patient who leaves her body to experts (Nordgren 2003). For further reading, see Bergström (2010) and Ordell (2011).

One challenge with NPM in healthcare is that the logic, values and goals of NPM differ from the professional ones, which means that the NPM trend can undermine professionalism as the governing principle (Sehested 2002). One aspect for which NPM has been criticized is a tendency to focus on productive targets while setting aside the

human factor, thus making professionals interchangeable units with standardized work tasks in rationalized cooperatives (Sehested 2002, Hjalmers 2006, Ordell 2011, Hjort 2012). NPM values are governed by fiscal goals, measures of productivity and human resource management, which makes the aim of oral health care intertwined with management and market goals, with the risk of conflicting interests. In dentistry, this development has primarily happened in Swedish public dentistry, where dentists have been found to be less satisfied with work than their private and Danish counterparts partly because of conflict between the professional ideal and the reality of work influenced by NPM (Nordgren 2003, Hjalmers 2006, Bergström et al. 2010, Ordell 2011). As professionals become juridical and financially dependent on bureaucrats, their professional autonomy and governing human moral values become challenged. Gardner, Csikszentmihalyi and Damon point to this development as a potential threat: ‘we feel the need to sound an alarm when any valued human sphere threatens to be overwhelmed by the search for profit – when the bottom line becomes the only line that matters’ (Gardner 2001 p. 14). In this respect, the ‘bottom line’ can also be productive measures other than fiscal ones – treatment units, time per treatment, number of patients per dentist, waiting time etc. – imposed to satisfy political objectives for evaluation of the society’s investment in the citizens. A dental clinic is also a business with an interest in cost efficiency which by reflective interaction with different logics in the clinical situation should be experienced as compatible with professional values (Nash 2007, Harris 2013). However, there are factors which are essential for the success of oral health care but not easily measured by bottom lines, such as health promoting services, empowerment of patients, the quality of clinical work, the mutual trust in the patient relation, and the wellbeing of patients and dentists.

AIMS

The general aim of the Good Work project was to use dentistry as an example of work where close relations with patients were at the core of work. This kind of work (also called human service work) has special psycho-social work environmental considerations and emotional requirements, which need to be considered when organizing and supporting good work. It also has interpersonal aspects where it is possible to experience deep connections and a feeling of doing good. The three main aims of the project were to investigate: (a) What is good work?, (b) What contributes to an experience of good work? and (c) How can we obtain it? Subsequently we would compare the results across national and affiliation borders. A partial aim of the project was to investigate the emotional aspects of the dentist-patient relationship and how these aspects can affect the dentist’s experience of work.

The specific aims for this thesis were:

1. (a) Describe the background and development of the questionnaire Swedish and Danish Dentists’ Perceptions of Good Work, and (b) create a measure of overall job satisfaction, applying the measure in four organizational settings. This is accomplished in Paper I.

2. Introduce the concept of emotion work in dentistry by giving a theoretical overview of the emotional aspects of work, the conditions under which it is performed and the potential effects on the dentist’s wellbeing. This is accomplished in Paper II.

Additional results from the Good Work project have been included with the purpose of giving an empirical illustration of how dentists experience emotional factors related to the patient interaction and their job satisfaction.

MATERIALS AND METHODS

The thesis consists of two papers. The first is an empirical study based on the responses to a questionnaire by 1226 dentists in Denmark and Sweden. The second is a literature review and conceptual study as an introduction and theoretical foundation for further empirical analysis on the data from the Good Work questionnaire.

Paper I

As a part of the Good Work project, the paper was based on data from a questionnaire consisting of 39 question batteries on the multidimensional concept of ‘good work’. The questionnaire covers nine general constructs developed by the research group: drawn from or inspired by established questionnaires on the subject, based on previous empirical findings, and new items for the specific context. The questionnaire was language validated by bilingual researchers, and content validated in a pilot in both countries. The questionnaires were sent to a random sample of practising dentists in Denmark and Sweden in November 2008 with two subsequent reminders. The variable used for this paper was a measure of overall job satisfaction consisting of three items: (a) ‘arbetsglädje’, (b) job satisfaction and (c) a good working life. (See Appendix)

Statistical methods

A Mann-Whitney U-test (asymptotic significance, two-tailed) was used for the special non-response study to detect differences between respondents and non-respondents on eight selected items.

Principal component analysis (PCA) was used to reduce data to make an additive index. Stability was tested on gender and on the four subgroups: Swedish public/private practitioners and Danish public/ private practitioners. A Kruskal-Wallis test on the four subgroups was performed to detect differences. P < 0.05 was set as the significance level.

Paper II

One of the general aims of the Good Work project was to consider the emotional aspects of work when the raw material of work is another human being. There are special moral requirements and intrinsic rewards in that kind of work, which has to be considered a core task of dentist-patient relationship and an important aspect when organizing dentistry (Hasenfeld 2010). The emotional aspects of work are called emotion work and before analysing the data it was necessary to perform a literature review on this subject. In cooperation with a librarian at Malmö University in 2010 we searched for literature containing emotion work/emotional work/emotional labour, adding

dentist/dentistry/dental in the databases Pubmed and Psycinfo. No

references were found. Therefore we conducted a literature study on empirical findings from other similar professions as well as a review of literature by influential authors and the most referenced papers on the subject. The special context of dentistry was then theoretically applied, by literature from e.g. dental curricula and other descriptions shaping the dentist’s competences and conditions for emotion work. We simplified and reduced the definition and number of terms within the concept, to make the complex psycho-social mechanisms of human interaction more intelligible and make the theory more applicable for dentistry. We also discussed the conditions for performing emotion work and the potential consequences of emotion work in the complex context of dental practice. Finally examples are presented.

Additional questions for empirical illustration

Description of the material can be found in Paper I and the data are descriptive, splitting the respondents into four subgroups: Swedish private, Swedish public, Danish private and Danish public, and dividing the whole sample by gender.

The questions are listed below and response was set on a five-point Likert scale:

a) ‘Do you expect to continue working as you do now forward until retirement?’

b) ‘How often do you have energy left for your private life?’ c) ‘To what degree do you experience your work as meaningful?’ d) ‘How often do you consciously use your personal way of being

as a tool in the interaction with patients?’

e) ‘How often do you try to appear happy when the patient is in the chair?’

f) ‘At the clinic, are you expected to always appear smiling and obliging?’

RESULTS

Paper I

We sent out 1835 questionnaires and the net response rate was 68% (n = 1226). A special non-response study showed that there were differences in replies according to affiliation within each country (range = 60–75%). The non-response study of the Danish private practitioners who had the highest rate of non response, included more men, more employers, and more who worked more hours per week than their respondent counterparts. The general characteristics of the respondents showed statistical differences in all variables between the subgroups: Swedish public/Swedish private/Danish public/Danish private practitioners.

PCA showed a stable one-factor solution for the ‘Overall job satisfaction’ index on the three items. The additive index Overall job

satisfaction was created and tested on the four subgroups, showing

differences in mean rank, with Danish public ones as the highest ranked and the Swedish public ones as the lowest.

Paper II

Emotion work is an umbrella term for work tasks containing emotions, with some underlying assumptions describing emotion work as effortful, contextual and subjective and partly determined by rules of behaviour (Zapf 2002). In helping professions, emotional interactions with patients are usually not scripted, nor are display rules formalized or explicit (Hochschild 1983, Hasenfeld 2010). However, in these occupations there are often shared but hidden expectations and rules of display within the given professions and organizations.

The emotional effort and requirements are characterized by the frequency, attentiveness and intensity of emotion which the health care professional needs to accommodate. It also depends on the variety of emotions needing to be expressed, e.g. positive, negative, and neutral or a combination (Morris, Feldman 1996).

Emotion work will always demand some emotional effort of the dentist even when the expressed emotions are truly felt. In the professional context emotion work involves effort, planning, and control in expressing the emotion needed to ‘get the job done’. This expression can imply contradictory emotions because of influence from different values and rules in the professional context. When work directly implies another human being (the patient) it is thereby moral work and can have great implications for the patient (Hasenfeld 2010). However, as there are also external demands and conditions for work, the intentions, interests and goals of the dentists’ work can be incompatible. For example, the dental clinic can have specific fiscal goals or service motives besides the dentists’ professional values. Throughout the work day, dentists have frequent patient interactions with various expressions and intensity. In the patient relation a great deal of flexibility is required in engaging and managing one’s own emotions as well an ability to react in the most effective way in a given situation. In the many daily work tasks containing emotions, the dentist needs to act in an emotionally balanced way. Contradictory emotional demands can make this balance tip and influence the dentist’s wellbeing in negative ways, including causing him or her to feel emotionally dissonant from work.

The conditions for sustainable emotion work can be threatened by an increasing focus on productivity and market values which intertwine the values of the profession. However, in the dentist-patient relationship there are also possibilities for feeling relatedness and to guide and care for others, with the potential to experience eudaimonia; which is to use our human potential actively in the feeling of doing good. These positive factors of work could empower dentists to cope with the complex demands they face, and should be organizationally supported in oral health care practice.

Special conditions of clinical dentistry, affecting the dentist-patient interaction and emotion work tasks.

• Clinical dentistry is most often performed while the patient is in a horizontal position whereas the dentist is in an upright position leaning over the patient, creating an unequal position of power.

• Many patients are emotionally affected by the bright light, smells and sounds and are often anxious before and during the clinical performance.

• Afflicting physical discomfort and pain is an almost inevitable part of dental work with which both patient and dentist needs to cope.

• The clinical appearance of the dentist can create an interpersonal distance between patient and dentist. • In the dentist-patient relation, dissimilar roles of lay

person-expert and customer-provider are embedded. These roles can involve the power of, e.g. shame, authority, guilt, paternalism and care.

• The clinical performance is limited by the available time which is determined by an expectation and assumption of what is required.

• There are often disruptions in the contact with the patient while the dentist interacts with auxiliaries and handles equipment.

• The dentist’s workspace is the patient’s mouth which can create a limitation for dialogue during clinical work (which then often takes place before or after entering the patient’s mouth). The dentist can continue talking when the patient is limited in participating verbally as well as physically. Table 1. Special conditions of clinical dentistry, affecting the dentist-patient interaction and emotion work tasks

Additional results for empirical illustration

Data from the good work project showed that only half of the Swedish public dentists (53%) expected to continue working as they do now until retirement. For the other three groups the percentage was 63–75%. The same pattern could be found when they were asked how often they had energy left for their private life, where only 8% of the public Swedish dentists reported always/almost always having energy left. In the other three groups 19–31% reported always/

almost always having energy left for their private life. An average

of 87% of the dentists experienced a high and a very high degree of meaningfulness in their work, with small differences according to affiliation, nationality and gender.

In the interaction with patients, almost twice as many Danish public dentists used their personal way of being as a tool in the interaction with patients than the Swedish private dentists (68% vs. 35%). A mean of 64% of the dentists responded always/almost always trying to appear happy when the patient is in the chair, however, there were distinct differences in response according to nationality and gender. Females and Danish dentists were the ones most frequently trying to appear happy when the patient was in the chair. The same pattern of differences in nationality and gender could be recaptured when asked if they were expected to always appear smiling and obliging at the clinic. See Table 2. Missing values <1% for all questions.

Subg ro ups Sw ed is h P riv at e Sw edi sh P ubl ic Da ni sh P riv at e Da ni sh P ubl ic W ho le sa m pl e n V alid % n V alid % n V alid % n V alid % n V alid % M/ F D o y ou e xpe ct to c ont inu e wor ki ng a s y ou d o n ow f or wa rd u nt il r et ire m ent ? Ye s 185 63 150 53 290 72 113 75 738 66 68/ 63 H ow o fte n do y ou h av e e ne rg y le ft f or y ou r p riv at e l ife ? A lwa ys/ A lm os t a lwa ys 56 19 23 8 113 27 49 31 241 21 20/ 22 To w ha t de gr ee do y ou e xp er ien ce y ou r w or k a s m ea ni ng fu l? H ig h a nd v er y h ig h de gr ee 402 89 266 89 348 84 190 88 10 19 88 25/ 32 H ow of te n d o y ou c onsc iou sly u se y ou r pe rsona l wa y of be ing a s a tool in t he int er ac tion wi th t he pa tie nt s? A lwa ys/ A lm os t a lwa ys 105 35 136 46 206 50 106 68 751 50 38/ 54 H ow of te n d o y ou tr y t o a ppe ar ha ppy w he n t he pa tie nt si ts i n t he d ent al ch air? A lwa ys/ A lm os t a lwa ys 160 54 166 56 284 69 121 76 731 64 49/ 72 A t t he c lini c y ou a re e xpe ct ed to a lwa ys a ppe ar sm ili ng a nd obl ig ing ? To a hi gh a nd v er y hi gh d eg re e 165 55 158 53 327 79 117 75 767 66 58/ 71 Table 2.

Dentists’ response according to nationality

, affiliation and gender

DISCUSSION

The response rate for the study was 68% which can be considered acceptable (Cook et al. 2009). There was some variance in the characteristics within each affiliated subgroup, with an overrepresentation of female dentists in the Danish sample. The non-respondent group was not affected in experiencing job satisfaction compared to the rest of the sample. The statistical analysis of the three items within ‘Overall job satisfaction’ showed a stable one-factor solution with mean rank differences between the four subgroups. As hypothesized in previous studies by Bejerot, Hjalmers and Berthelsen, the way dentistry is organized might influence job satisfaction even though the core work is the same (Bejerot 1996, Hjalmers 2006, Berthelsen 2010).

The results showed that the dentists in general had a high degree of overall job satisfaction. A study by Det Nationale Forskningscenter for Arbejdsmiljø (NFA) (The National Research Centre for the Working Environment) in 2010 found that in Denmark dentists (together with general practitioners) had an average degree of overall job satisfaction compared with other professional groups (NFA 2010). From the same dataset, dentists and general practitioners were the professional group with the highest experience of meaningfulness (NFA 2010). The Good Work project found that 88% of the dentists experienced work as highly meaningful (Table 2 in thesis) which supports the findings from the NFA. One explanation for the high meaningfulness score could be that dentistry offers a good opportunity to realize universal human needs: to relate, to guide and help, to be creative and autonomous

besides the objective quality of a clinical treatment, have a subjective meaning and activate fundamental human emotions and actions which transcends any constructed measures of ‘good’ (Gardner et al. 2001). Deci and Ryan describe the general approach in research on eudaimonia as uncovering what can be ascribed as human nature and understanding the conditions that facilitate rather than diminish it (Ryan, Deci 2001). This is very much in line with the aim of the Good Work project; to uncover the emotional aspects of dentists’ work and what conditions in the dental context seem to facilitate or challenge them.

In this thesis, the Danish public dentists were the most satisfied and the Swedish public ones the least. As the mean differences between the other three subgroups were so small, the statistically significant lower rank of the Swedish public dentists might be a consequence of the differences in the way NPM has been implemented. The Swedish public dentistry have been subject to great changes towards competition and rationalization with greater units and decentralized management, in recent decades (Ordell 2011). This development has, through standardization, decreased autonomy at both clinic and dentist level and made dentists interchangeable units. The realization in daily practice might affect their overall experience of work as dissonant from their professional ideal of oral health care (Hjalmers 2006, Bergström et al. 2010, Ordell 2011). The additional results in this thesis illustrated that only half of Swedish public dentists expected to continue working as they do now until retirement and considerably fewer always had energy left for their private life, compared with the other three groups (Table 2 in thesis). From all levels, these results can be worth serious consideration for a further analysis.

Emotion work in dentistry

Emotion work was described as work tasks where the dentist aims at affecting the patient in a desired direction and implies managing and expressing specific emotions in the clinical situation (Zapf 2002). The concept of emotion work is not yet established in the context of dentistry, hence a simplification of perspectives and a reduction of terms was required for this introduction, from established theory and other professions, to create a manageable overview. Using emotion

work as an umbrella term and mostly keeping a broad perspective was considered necessary to reduce the complexity for the reader. For example, the term ‘emotional labor’ which Hochschild (1983) originally used for unauthentic emotional display was captured in the concept of emotion work and more individually based measures like ‘emotional intelligence’ were left out. Introducing established concepts in new contexts by adapting terms and re-viewing perspectives creates a risk of what is called ‘concept stretching’ (Sartori 1970). That means a risk of stretching the concept of emotion work more than it is sensible in order to adapt it to a context. However, most empirical comparisons were used within human service professions to accommodate the special emotional demands and conditions of these professions.

One characteristic of human service work like dentistry is that it implies a high degree of engagement of the dentist’s personal self and emotional demands (Hasenfeld 2010). Data shows that dentists (and general practitioners) along with teachers, nurses, social workers, childcare workers and police officers, as typical human service workers, have the highest emotional demands (NFA 2010). The emotional work tasks in dentistry are extensive, however; dentists’ engagement, suppression, adaptation and expression of emotions are so far considered an implicit skill and competence. Little attention is given to: the special clinical conditions in dentistry for the emotional performance (e.g. sensing other signals when the patient is verbally limited); which factors affects the dentists’ emotional direction (e.g. production targets); and the potential effect on the dentist (e.g. emotional dissonance).

The additional results in this thesis showed related differences in the frequency of the dentists’ conscious use of their personal way of being as a tool in the interaction with the patients. These findings can be a reflection of the differences in the composition of patients as well as dentists, where the Danish public dentists primarily see children and disabled people who need extra attention and care and 87% of the respondent dentists in that group were female. However, of more interest is that gender and nationality seemed to affect how often the dentists tried to appear happy when interacting with patients and

experienced that it was expected of them as an emotional display rule from the clinic. Female dentists tried to act positively in a way that was emotionally contagious in their patient interaction more frequently than their male counterparts and also to a higher degree experienced that it was expected as a display rule (Table 2 in thesis). One explanation for this gender difference could be the historical socialization of woman into affective roles as found in Hjort (2012). She critically describes how the affective aspects of work have been influenced by a general Nightingale-ish view of female virtues of love and ‘calling’, and argues that it is culturally constructed and will need change to adapt to the welfare system and the wellbeing of the human service worker (Hjort 2012). Because the mean age of the dentist respondents reflects a mature sample (reflected in mean years since graduation = 23 years) these historical virtues of care might be strongly incorporated. Even if two-thirds of human service work in Scandinavia is still carried out by women these gender differences in emotional display, might even out with increasing professionalization of the emotional aspects of human services (Hjort 2012). Considering the national differences in distribution, structural confounders (e.g. work hours and leadership) should be analysed further.

From a work environment perspective, the interaction with patients based on human values interacts with other logics, goals and interests as part of the dentists’ daily work. Professional human interaction is a moral praxis involving ‘rules’ to guide us in our relation to each other (Hasenfeld 2010). It also implies considerable tacit knowledge which makes standardized work tasks difficult. It is therefore debatable whether it makes sense to generalize specific rules, because in the interaction with patients, these rules as well as all the other logics, goals and interests will be subjectively interpreted by the dentist in the specific situation. However, philosophers such as Løgstrup point out that interacting with others always implies holding some of their lives in our hands (Birkelund 2002). The implication which comes along with this responsibility should be explicit in a professional context and also incorporate a dimension of ‘self-care’ in the professional role. Relational competence could be a way to grasp all dimensions; understood as an ability to recognize the influencing factors of the context, the patients’ conditions, attuning one’s own reactions for

these and self-preservation (Lis Møller in Hjort 2012). In dental curricula as well as in organizing dentistry there is a need to embrace that relational competence is complex and includes attentiveness, self-awareness, presence and reflection in daily practice; and that it is developmental, impermanent, and context dependent (Browning et al. 2007). The recognition of the impermanent character and to some extent unpredictable nature of daily dental practice is recognizing that humans, technologies and politics are dynamic and constantly evolving.

This research seeks to develop an increased consciousness among stakeholders and policymakers around the dental community about which factors affect the emotional part of dentists’ work and their wellbeing. It is of interest to find out which factors in the relations with patients constitute a good sustainable work life for dentists to empower them in the dentist-patient interaction, making dentists more resilient to changing and challenging circumstances in general dental practice. However, it is worth highlighting that in our additional results the group with the highest degree of overall satisfaction was the same group who most frequently had energy left for private life; most frequently smiled when the patient sits in the chair; and most expected to continue working as they do now further on. Therefore, without concluding any linearity or causality, it could seem worthwhile for dentists to keep calm and carry on smiling.

CONCLUSION

The background of the Good Work project was presented including characteristics of the respondents and the creation of a measure of overall job satisfaction, applying the measure in four organizational settings. Differences in overall job satisfaction according to affiliation were found. Furthermore the concept of emotion work in dentistry was introduced, giving a theoretical overview of the emotional aspects of work. Dentists have extensive emotional work tasks in the patient interaction which are conditioned and complex and require a great deal of emotional flexibility, attentiveness and reflection by the dentist. The influence of markets and managerialism on the professional values of dentistry could challenge the conditions for these tasks in the patient interaction and also the wellbeing of the dentist. Empirical examples of Danish and Swedish dentists’ experiences of emotional aspects of work showed differences in distribution according to nationality and gender, however, these findings need further analysis for any conclusive remarks.

IMPLICATIONS

The findings might imply that the emotional aspects of work need explicit attention in dental curricula and in organizing work in dentistry practice. We hope to encourage research in emotion work in this, so far, neglected field in dentistry to increase an understanding of emotion work so that it can be used, for example, in dental education and in organizing dental health services for the benefit of dental professionals as well as patients and dental practices.

ACKNOWLEDGEMENTS

In 2007 I was taking a class in theory of science in Malmö where Björn Söderfeldt was teaching. In a break I asked him what my options were in Sweden, if I wanted to learn more about science. He glanced seriously at me with an ‘Are you sure you want to go down that road?’-look, as only Björn could do, asked me a couple of questions (to which I must have replied to his contempt) and the week after I was sitting in his office and my journey into science began. Björn took me under his caring wings and gave me access to his philosophical wisdom, broad knowledge and well reflected critique. Together with Karin Hjalmers, Hanne Berthelsen and Sven Ordell we created a research group as a fine example of what ‘good work’ should be like; exploring, challenging, creative, engaging, developing and fun. Björn died in August 2013 leaving a huge gap in many of us. However, his imprints of exemplary wilfulness and transcendent faith lives on and have kept me engaged and empowered to continue. I am forever grateful for all we shared in our research group and for the competent feedback from my co-authors and the crucial emotional support from Jari Hakanen when times were difficult. Luckily Lone Schou willingly supervised me the last bit and her wholehearted expertise and inspirational person helped me get this thesis to shore. It is another shore than I initially aimed for, but the shore with the best perspectives, all considering.

This thesis would not be a reality without the support and assistance of the following: FAS (now FORTE) who funded our research project; the Faculty of Odontology for financing my postgraduate programme and the administrative personnel for flexibility and guidance; and Malmö Högskola centrally for providing opportunities to develop and co operate with colleagues at all levels of research, beyond my specific area.

I would also like to thank everyone who have been part of daily life at work, and especially Adam, Vera, Liv, Zdenka and Lisa for mutual understanding and caring support; Björn A for all the goodwill; Alborz for thorough expertise and irrepressible belief in human goodness and; Susan for friendship and engaging cooperation in the Doctoral Union.

My gratitude also goes to my colleagues and patients at Implantatklinik København for their flexibility and support with my multifaceted work-life puzzle.

In my personal life, I thank my children for daily reminding me of what really matters and that imprints lasts beyond presence – my son Oskar for keeping my eyes on the road and my daughter Liva, who was born during this project, for her ability to see right through me. My gratitude for the unconditional love and care from my mother goes beyond words, I would not be who I am and not have been able to go through this process without her lifelong support. I also thank Jan for support and adding luxury in our lives; my grandmother for showing me that engagement and love has no age; my ex-husband Kim for his tremendous patience and support in my personal and professional life; my dear friends and life-witnesses, especially Ann, Elsa, Jaron and Rikke for indulgently keeping up with my development and being there for me and; Jonas for bringing out the best in me through his encouragement, passion, love & aspiration.

My father, who died in 1992, said to me the same year when I graduated from high school: ‘Life is like the Olympics; it’s not about winning, it’s about having fully attended.’ I thank my father for many of my fundamental values and perspectives in life. My striving to make

Lastly I would like to acknowledge life for not always providing me with the opportunities and challenges I want, but the ones I need. My time as a doctoral student has been a life-affirming journey with wonderful and tough insights, as a privileged opportunity to gain a broader perspective and sensation of life. This thesis may just look like a summation of what I’ve learned; however, it is also an expression of great curiosity and depth, caring human connections, despairing realizations and universal trust.

REFERENCES

Aristotle. Nicomachean Ethics, Translated by W. D. Ross: eBooks@Adelaide 2006.

Baker R, Mainous III AG, Gray DP, Love MM. 2003. Exploration of the relationship between continuity, trust in regular doctors and patient satisfaction with consultations with family doctors. Scand J Prim Health 21(1):pp.27–32.

Bejerot E. 1998. Dentistry in Sweden – Healthy work or ruthless efficiency? Thesis. Stockholm: Arbete och hälsa. Vetenskaplig skriftserie.

Bergström K, Söderfeldt B, Berthelsen H, Hjalmers K, Ordell S. 2010. Overall job satisfaction among dentists in Sweden and Denmark: a comparative study, measuring positive aspects of work. Acta Odontol Scand 68(6):pp.344–353.

Berthelsen H, Hjalmers K, Pejtersen JH, Söderfeldt B. 2010. Good work for dentists – a qualitative analysis. Community Dent Oral (2):pp.159–170. Berthelsen H. 2010. Work-related support, community and trust – Dentistry in

Sweden and Denmark. Thesis. Malmö University.

Birkelund R. 2002. Ed. Eksistens og Livsfilosofi. (Existence and Philosophy of Life). Munksgaard.

Browning DM, Meyer EC, Truog RD, Solomon MZ. 2007. Difficult conversations in health care: cultivating relational learning to address the hidden curriculum. Acad Med 82(9):pp.905–913.

Cook JV, Dickinson HO, Eccles MP. 2009. Response rates in postal surveys of health care professionals between 1996 and 2005. BMC Health Serv Res 9. Cowpe J, Plasschaert A, Harzer W, Vinkka-Puhakka H, Walmsley AD. 2010.

Profile and competences for the graduating European dentist – update 2009. Eur J Dent Educ 14:pp.193–202.

Diefendorff JMR, Erin MR, Croyle MH. 2006. Are emotional display rules formal job requirements? Examination of employee and supervisor

EU-OSHA 2013. Wellbeing at work: creating a positive work environment. Literature review. European Agency for Safety and Health at Work. Luxembourg.

Gardner H, Csikszentmihalyi M, Damon W. 2001. Good Work: When excellence and ethics meet. New York: Basic Books.

Gutek BA. 1999. The social psychology of service interactions. J Soc Issues55(3):pp.603–617.

Gutek BA, Cherry B, Bhappu AD, Schneider S, Woolf L. 2000. Features of service relationships and encounters. Work Occup 27(139):pp.319–352. Hakanen JJ, Peeters MCW, Perhoniemi R. 2011. Enrichment processes and

gain spirals at work and at home: A 3-year cross-lagged panel study. J Occup Organ Psychol 84:pp.8–30.

Harris R, Holt R. 2013. Interacting institutional logics in general dental practice. Soc Sci Med 98:pp.63–70.

Harris RV, Ashcroft A, Burnside G, Dancer J, Smith D, Grieveson B. 2008. Facets of job satisfaction of dental practitioners working in different organisational settings in England. Br Dent J 204:pp.1–8.

Hasenfeld Y. 2010.. Human services as complex organizations. SAGE Publications Los Angeles.

Hjalmers K. 2006. Good work for dentists – ideal and reality for female unpromoted general practice dentists in a region of Sweden. Thesis. Malmö University.

Hjort K. 2012. Det affektive arbejde. (Affective work) 1st edn. Frederiksberg: Samfundslitteratur.

Hoare CH. 2001. Erikson on development in adulthood: New insights from the unpublished papers. Cary, NC: Oxford University Press.

Hochschild AR. 2003. The managed heart: Commercialization of human feeling: Twentieth anniversary edition with a new afterword: University of California Press.

Linley PA, Harrington S, Garcea N. 2009. Eds. Oxford handbook of positive psychology and work. Oxford University Press.

Morris A, Feldman DC. 1996. The dimensions, antecedents, and consequences of emotional labor. Acad Manage R 21(4):pp.986–1010.

Myers DG. 2000. The funds, friends, and faith of happy people. Am Psychol 55(1):pp.56–67.

Nash, DA. 2007. On ethics in the profession of dentistry and dental education. Eur J Dent Educ 11: pp.64–74.

NFA 2010. Det Nationale Forskningscenter for Arbejdsmiljø (National Research Centre for the Working Environment). Arbejdsmiljø og helbred fordelt på jobgrupper. http://www.arbejdsmiljoforskning.dk/da/arbejdsmiljoedata/flere-datasaet/arbejdsmiljo-og-helbred/sammenligning-af-jobgrupper.

Nilsson K., Hertting A., Petterson I, Theorell T. Pride and confidence at work: potential predictors of occupational health in a hospital setting. BMC Public Health 2005.5(1):p.92.

Nordgren L. Från patient till kund : intåget av marknadstänkande i sjukvården och förskjutningen av patientens position. (From Patient to Customer: The advent of market thinking in healthcare and the misalignment of the position of the patient). Lund Business Press 2003.

Ordell S. 2011. Organisation and management of public dentistry in Sweden: Past, present and future. Thesis. Malmö University.

Prescott-Clements L, Felix DH, Hurst Y, Jack K, Rennie JS. 2006. A

curriculum for UK dental foundation programme training. Department of Health (England).

Ryan RM, Deci EL. 2001. On happiness and human potentials: A review of research on hedonic and eudaimonic well-being. Annu Rev Psychol 52:pp.141–66.

Ryff CD, Singer B. 2000. Interpersonal flourishing: A positive health agenda for the new millennium. Pers Soc Psychol Rev 1(4):pp.30–44.

Sartori G. 1970. Concept misformation in comparative politics. Am Polit Sci Rev (4):pp.1033–1053.

Sehested K. 2002. How new public management reforms challenge the roles of professionals. Int J Public Admin 25(12):pp.1513–1537.

Seligman M, Csikszentmihalyi M. 2000. Positive psychology. An introduction. Am Psychol 55(1): pp.5–14.

Zapf D. 2002. Emotion work and psychological well-being: A review of the literature and some conceptual considerations. Hum Resour Manage R 12:pp.237–268.

Acta Odontologica Scandinavica, 2010; Early Online, 1–10

ORIGINAL ARTICLE

Overall job satisfaction among dentists in Sweden and Denmark: A comparative study, measuring positive aspects of work

KAMILLA BERGSTRÖM, BJÖRN SÖDERFELDT, HANNE BERTHELSEN, KARIN HJALMERS & SVEN ORDELL

Department of Oral Public Health, Faculty of Odontology, Malmö University, Malmö, Sweden

Abstract

Objective. Human service work differs from industrial work, which should be considered when organizing work. Previous research has shown organizational differences in the perceptions of work, often with a focus on negative aspects. The aim of this study was to analyse the overall job satisfaction among private- and public-practising dentists in Sweden and Denmark. This also implied a description of the questionnaire Swedish and Danish Dentists’ Perceptions of Good Work about opportunities and positive and rewarding aspects of work.Material and methods. A questionnaire covering the multidimensional concept of good work was developed. A total of 1835 dentists randomly sampled from the dental associations were sent a questionnaire in November 2008. A special non-response study was performed. Principal components analysis (PCA) was used to create a measure of overall job satisfaction, comparing four organizational subgroups.Results. The average net response rate was 68% (n= 1226). The special non-response study of the Danish private practitioners showed more males, managers and dentists with more working hours than the respondents. PCA of three satisfaction questions showed a stable one-factor solution. There were differences in job satisfaction, with Danish public dentists ranked highest in overall job satisfaction and Swedish public dentists lowest.Conclusions. There were organizational differences in the perception of job satisfaction. Further analysis of how the human service is organized in the different groups is needed.

Key Words: Eudaimonia, good work, human services, patient relation, rewards

Introduction

Organization and human services

In dentistry, as well as in other kinds of human service work, the patients are what Hasenfeld [1] calls the raw material of work. As such, the patients represent complex systems with attributes which interrelate but are yet unstable and vary from person to person. Lipsky [2] describes human service workers as“street level bureaucrats_{” with three characteristics of their} work: (1) a constant interaction with patients; (2) being independent and discrete where personal attri-butes and reactions of the human service worker affect their patients_{’ treatment; and (3) having a significant} impact on the lives of the patients. The core of human service work is the relation between the patient and the human service provider. The nature and quality of this relation is a critical determinant of the success or

failure of a people-changing organization, where the aim is to directly alter the personal attributes of patients to improve their well-being [1].

The focus on this social interaction between the provider and the patient has been lost in research; instead, there has been an increased emphasis on industrial/organizational theoretical frameworks [3]. However, even though the specific human service characteristics differ from work in industry, environ-mental models developed for industrial organizations are often transferred directly to human service orga-nizations without considering the contextual and organizational differences [4]. Examples are the two work environmental models: the Demand–Control (DC) model [5]; and the Effort–Reward Imbalance (ERI) model [6]. Even if they are industry-oriented, there are still relevant perspectives in the ideas of the positive counterbalances in the two models which are relevant when studying human services. From the DC

Correspondence: Kamilla Bergström, Department of Oral Public Health, Faculty of Odontology, Malmö University, SE-205 06 Malmö, Sweden. Tel: +45 29 72 52 79. E-mail: kamilla.bergstrom@mah.se

(Received 29 January 2010; accepted 3 June 2010)

ISSN 0001-6357 print/ISSN 1502-3850 online 2010 Informa Healthcare DOI: 10.3109/00016357.2010.514719

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