Ronald J. Burke
York University
Mustafa Koyuncu
Nevsehir University
Lisa Fiksenbaum
York University
Abstract
This study examined potential antecedents and consequences of workaholism types among 431 male and female physicians in Turkey. Three workaholism types (Work Enthusiasts, Work Addicts, Enthusiastic Addicts) and one non-workaholic type (Unengaged workers) previously identified by Spence and Robbins (1992) were compared. Antecedents included personal and work situation characteristics and personality factors; consequences included work experiences, work outcomes and indicators of psychological well-being. Unengaged workers were significantly different from the three workaholism types reporting less positive work experiences, work outcomes and psychological well-being. There were fewer differences among the three workaholism types than have been reported in previous research, but when type differences were present, Work Addicts were disadvantaged, consistent with earlier work. These findings highlight a need to further study the work and health consequences of disengagement from work among professionals. Unengaged workers may be in greater distress than workers that are more heavily invested in their workplaces.
Individuals’ rate health care as an important priority in most countries and it is likely to become even more important as populations age. In response to this need, governments devote significant amounts of their budgets to funding the heath care system, this allocation typically being the largest budget item in almost all countries. Increases in funding for health care have also generally risen faster than inflation rates highlighting both the importance and costs of health care.
Doctors, while not the largest group of employees in the health care system, occupy a central role in the delivery of health care in all countries, though countries may have different health care systems and methods of payment options for their services. Some countries report an increasing shortage of doctors, often compounded by the fact that richer nations lure doctors away from poorer ones.
The health care system has also undergone significant changes of the past decade stemming from the greater use of new technologies, off-shoring some services to developing countries, advances in medical knowledge, an aging population, more informed and critical users of the health care system, efforts by governments to control health care expenditures, and the entrance of more female physicians into the profession.
It is not surprising then that considerable research has been undertaken in several countries to understand the work experiences of doctors, particularly as these relate to physician satisfaction and patient care (Schaufeli, Taris & Bakker, 2008). Doctors are well paid, hold prestigious positions, work long hours, experience various work stressors, and report varying degrees of satisfaction, burnout and psychological distress.
This study examines potential antecedents and consequences of workaholism types among male and female physicians in Turkey. Although some research has examined work experiences and health among Turkish physicians (Ozyurt, Hayran & Sur, 2006), the relationship of workaholism types to the experiences of physicians in Turkey has not been examined previously to our knowledge. We will set the stage for our research by providing a selective review of literature relating to (1) physicians and health care in Turkey, and (2) work and health of physicians in general.
Physicians and health care in Turkey
According to the Organization for Economic Development (OECD), based on 2007 data, Turkey ranks low on health spending falling below the average across all OECD countries based on share of Gross Domestic Product expenditures per capita; the US spending the most, followed by Switzerland, France and Germany. Most of the funding for health care in Turkey comes from the government or public sector. Turkey is now, however, increasing health care spending above the OECD average. Turkey has fewer doctors and nurses per capita than other OECD countries. Life expectancy in Turkey is still below the OECD average. Infant mortality rates are higher in Turkey, as are rates of smoking, but rates of obesity are lower.
Work and health of physicians
Physician well-being has received considerable research attention over the past twenty years. Burnout among physicians, its antecedents and consequences, has been the subject of increasing interest and concern in several countries such as Canada (Boudreau, Grieco, Cahoon, et al, 2000; Elit, Trim, Maud-Bains, et al, 2004; Grunfeld, Whelan, Zitzelsberger, et al, 2000; Lloyd, Streiner & Shannon,1994), Turkey (Ozyurt, Hayran & Sur, 2006), South Africa (Schweitzer, 1999), and the US (Keeton, Fenner, Johnson & Hayward, 2007).
Other stressors and strains among physicians have also been the focus of research. For example, Rout and Rout (1994) considered workload and work-family conflict and job stress among physicians in the UK; and Williams, et al, (2002) examined time pressure, workplace control, administrative responsibilities and co-worker support and job stress among physicians in the US.
Much of the research examining physicians has considered the relationship of work experiences, job stress and psychological well-being (Burke, 1990; 1996). Cooper, Rout and Faragher, (1989), in a sample of 1817 general practitioners in the UK, found that four job stressors were predictive of high levels of job satisfaction and lack of psychological well-being: demands of the job and patient’s expectations, interference with family life, constant interruptions at work and home, and administrative duties.
A number of other researchers have examined work experiences, stress and well-being among physicians. Chambers, Wall and Campbell, (1996) considered stresses, coping and job satisfaction in general practitioner registrars; Golub, Weiss, Ramesh, Ossoff and Johns (2007) studied burnout in US residents in otolaryngology-head and neck surgery; Garza, Schneider, Promecene and Monga (2004) considered burnout of residents in obstetrics and gynecology; and Burbeck, Coomber, Robinson and Todd (2002) considered occupational stress in consultants in accident and emergency medicine.
Richardsen and Burke (1991), in a large sample of Canadian female and male physicians, reported that for both female and male physicians, high levels of occupational stress were associated with less job satisfaction and satisfaction with medical practice, and more negative attitudes about the Canadian medicare system and health care in general, and high job satisfaction was related to fewer specific work stressors and more positive attitudes about the health care system.
Rout and Rout (1994) compared measures of job satisfaction, psychological well-being and job stress among general practitioners in the UK before and after the introduction of a new government-physician contract. Data were collected in 1987 and again in 1993 from 380 physicians. Physicians reported higher levels of job dissatisfaction, psychological distress, and more stress in 1993 than in 1987. The new contract heightened stress, dissatisfaction, and distress. Sutherland and Cooper (1992) reported similar increases in dissatisfaction, psychological distress and job stressors following the introduction of the new contract in the UK in 1990 in a sample of 917 general practitioners. Appleton, House and Dowell (1998) reported significant increases in mental distress following the new contract in a study of 285 general practitioners, along with decreases in job satisfaction. Their respondents also believed that their work had a negative effect on their physical health. Job stress and dissatisfaction seems to be increasing among general practitioners in the UK (Bailit, Weisberger & Knotek, 2005), and elsewhere (e.g., for Canada, see Burke, 1996; for Germany, see Janus, Amelung, Gaitanides & Schwartz, 2007; for the US, see Murray, Montgomery, Chang, Rogers, Innu & Safran, 2001).
In summary, much of the research on physicians has utilized a stressor-strain paradigm (Simpson & Grant, 1991). Physicians work long hours (Defoe, Power, Holzman, Carpentieri & Schulkin, 2001) and experience high levels of work-family conflict. They are concerned abut patient expectations, litigation from malpractice, and increasing amounts of paperwork. There is also accumulating evidence that physician dissatisfaction with their work and their profession has increased overt the past 20 years in several developed countries. But physicians tend to be generally satisfied with their relationships with their patients and their commitment to improving patient well-being.
Workaholism among physicians
The term workaholic was coined by Oates (1971), who equated work addiction or workaholism with other addictions such as alcoholism. Oates depicted workaholics as unhappy, obsessive, tragic figures who were not performing their jobs well and were creating difficulties for their co-workers (see Porter, 1996, Naughton, 1987; Killinger, 1991, for a similar viewpoint). Machlowitz (1980), however, conducted a qualitative study of 100 workaholics and found them to be very satisfied and productive. It is possible though to reconcile these divergent viewpoints. Some researchers have proposed the existence of different types of workaholics, each having potentially different antecedents and associations with job performance, work and health outcomes (Naughton, 1987; Scott, Moore & Miceli, 1997; Spence & Robbins, 1992).There has been considerable support for the notion of different types of workaholics, with type differences being observed on potential antecedents and work and health outcomes (see Burke, 2007, for a review).
Naughton (1987) presents a typology of workaholics based on dimensions of career commitments and obsession-compulsion, identify four types of workaholics. Scott, Moore and Miceli (1997) propose three types of workaholic behavior patterns: compulsive-dependent, perfectionist and achievement-oriented. Spence and Robbins (1992) identify three workaholic patterns based on their “workaholic triad” notion. The workaholic triad consists of three concepts, work involvement, feeling driven to work because of inner pressures and work enjoyment. Work Addicts score high on work involvement and feeling driven and low on work enjoyment; Work Enthusiasts score high on work involvement and work enjoyment and low on feeling driven to work; and Enthusiastic Addicts score high on all three components.
Schaufeli, Taris and Bakker (2008) have reported the only published study of workaholic types among physicians to our knowledge. They collected data from 2115 Dutch medical residents using questionnaires. They used two scales to measure workaholism types: Working excessively and Working compulsively. Four types were created based on high or low scores on the two scales: Workaholics, Hard workers, Compulsive workers, and Relaxed Workers. There groups were then compared on 22 dependent variables (e.g., job demands, job resources, burnout, recovery after work, happiness, absenteeism, and self-rated medical performance). They predicted, and found, that Workaholic medical residents would have more unfavorable scores on these measures. Workaholic medical residents had the least favorable scores on 16 of the 21 measures that had a significant workaholic type effect. Workaholic medical residents scored less favorably than the Relaxed worker group on all 21 measures.
The present study examined antecedents and outcomes of workaholic types among Turkish physicians. Three workaholic types, and one non-workaholic type, were considered using measures developed by Spence and Robbins (1992). Based on previous research findings (Burke 2000; 2007: Schaufeli, Taris and Bakker, 2008) it was expected that Work Addicts would report less favorable work and well-being outcomes when compared with the two other workaholic types (Work Enthusiasts, Enthusiastic Addicts) with the non-workaholic type also being disadvantaged, but for different reasons.
Method
Respondents
Table 1 presents the demographic characteristics of the sample. The sample had slightly more males than females (55%), were forty years of age or younger (68%), slightly more than half were married (56%), most married respondents had one or two children (62%), most worked in large cites (greater than 500,000, 49%), worked in medium-sized hospitals (125-400 beds, 65%), worked in group practices (70%), earned between US$12,000 to US $26,000 (65%), had less than 10 years of profession, job and hospital tenure (63%, 85%, and 87%, respectively), and worked between 41-60 hours per week (79%).
Procedure
Data were collected from 431 physicians using anonymously completed questionnaires. Questionnaires were sent to about 1800 physicians working in three Turkish cities (Nevsehir, Nigde and Kayseri). Thirty-nine were returned incomplete giving a response rate of twenty-six percent. The names of physicians were obtained from the Directorate of Health and excluded Residents. This response rate is typical of studies of physicians, an occupation characterized by heavy workloads and paper-work.
Measures
All measures were translated from English to Turkish using the back translation method
Personal Characteristics
Individual demographic characteristics were measured by single items and included: age, sex, marital status, number of children, and income.
Work Situation Characteristics
Several work situation characteristics, also measured by single items were included. These were: size of community in which they worked, years in present position, years in present hospital, years in profession, size of hospital, main form of payment, and hours worked per week.
Workaholism Components
Spence and Robbins (1992) derived three workaholism components based on an extensive review of relevant literature: Work Involvement, Feeling Driven to work because inner pressures and Work Enjoyment. Their scales were used in this study.
Work Involvement (α = .36) had eight items (e.g., “I get bored and restless and vacations when I haven’t anything productive to do”). This scale was dropped from further consideration based its low reliability.
Feeling Driven to Work (α = .91) had seven items (e.g., “I often feel that there’s something inside me that drives me to work hard”).
Work Enjoyment (α = .90) had ten items (e.g., “My job is more like fun than work”).
Stable Individual Difference Factors
Type A Behavior
Two aspects of Type A behavior, Achievement Striving (AS) and Impatience-Irritation (II) were assed using the Revised Jenkins Activity Survey (Pred, Helmreich & Spence, 1987; Spence, Helmreich & Pred, 1987). Both scales consisted of six items. Respondents indicated the alternative that best described them of their opinion on a five point Likert scale. AN item on the AS scale (α = .90) was “How seriously do you take your work.”; an item on the II scale (α = .86) was “Do you usually get irritated”.
Beliefs and Fears
Three measures of beliefs and fears developed by Lee, Jamieson and Early (1996) were used. One, Striving against others had six items (e.g., “There can only be one winner in any situation”). A second, No moral principles had six items (e.g., “I think that nice guys finish last”). The third, Prove yourself had nine items (e.g., “I worry a great deal about what others think of me”). A total score was obtained by combining these three scales (α = .93) as they were all significantly and positively inter-correlated.
Proactive personality was measured by a seventeen items scale (α = .93) developed by Bateman and Crant (1993). Respondents indicated their agreement with each item on a seven-point Likert scale (1 = Strongly disagree, 4 = Neither agree nor disagree 7 = Strongly agree).An item was “I am good at turning problems into opportunities.”
Optimism was measured by an eight item scale (α = .81) developed by Scheier and Carver (1985, 1987). One item was “In uncertain times, I usually expect the best”. Respondents indicated their agreement with each item on a five point scale.
Gratefulness was assessed by a six items scale (α = .71) developed by McCullough, Emmons and Tsang (2002) and Emmons and McCullough (2003). One item was “I have so much in my life to be thankful for.” Respondents indicated their agreement with each item on a seven-point Likert scale ( 1 = strongly disagree, 4 = neutral, 7 = strongly disagree).
Job Behaviors
Perfectionism (α = .93) was measured by eight items (e.g., “I can’t let go of projects until I’m sure they are exactly right.”) developed by Spence and Robbins (1992).
Non-delegation (α = .87) was assessed by seven items (e.g., “I feel that if you want something done correctly you should do it yourself.” developed by Spence and Robbins (1992).
Job Stress (α = .74) was measured by nine items (e.g., “Sometimes I feel like my work is going to overwhelm me”) developed by Spence and Robbins (1992).
Extra Hours Worked (α = .66) was measured by six items. Respondents indicated how frequently they did each item (e.g., “go to work early”) on a four-point scale.
Hours worked was measured by a single item: “How many hours do you work in the typical week?”
Work outcomes
Job satisfaction (α = .92) was measured by a seven item scale developed by Kofodimos (1993). An item was “I feel challenged by my work”.
Career satisfaction was measured by a four item scale (α = .89) developed by Greenhaus, Parasuraman and Wormley (1990). One item was “I am satisfied with the success I have achieved in my career.
Intent to Quit ( = .69) was measured by two items (e.g., “Are you currently looking for a different job in a different
organization?”). This scale had been used previously by Burke (1991).
Absenteeism was measured by a two item scale (( = .75). One item was “How many days of scheduled work have you missed in the past month?”
Work engagement
Three aspects of work engagement were measured using scales developed by Schaufeli et. al. (2002) and Schaufeli and Bakker (2004). Respondents indicated their agreement with each item on a five-point Likert scale (1 = strongly disagree, 3 = neither agree nor disagree, 5 = strongly agree)
Vigor was measured by six times (α = .94). “At my work I feel bursting with energy”.
Dedication was assessed by five items (α =.92). “I am proud of the work that I do.”
Absorption was measured by six items (α =.81) “I am immersed in my work”.
Organizational Life Experiences
Six aspects of work life were measured by scales developed by Maslach and Leiter (1997).
Workload was measured by six items (α = .33). This scale was dropped from further consideration given its low reliability.
Control was measured by three items (α= .76). “I am my own boss when it comes to pursuing the tasks that I am assigned”.
Reward and Recognition was assessed by four items (α= .87). “The recognition and reward people receive reflect their contribution to the organization”.
Support and Community was assessed by five items (α = .85). “This organization does a good job of responding to the distinct cultural perspectives of its client population”.
Fairness was assessed by six items (α = .83). “Respect is evident in relationships within the organization”.
Value-fit was measured by five items (α = .55). “This job provides me with the opportunities to do work that I feel is important”. This scale was also dropped from further consideration given its modest level of reliability.
Quality of Life and Psychological Well-Being
Three aspects of psychological well-being were included: work-family and family-work conflict, psychosomatic symptoms and life satisfaction.
Work-family and Family-work conflict
Work-family and Family-work conflict were each measured by five item scales developed by Carlson, Kacmar and Williams (2000). One item for the Work-family conflict scale (α = .94) was “The demands of my work interfere with my home and family life”, an item on the Family-work conflict scale (α = .92) was “I have to put off doing things at work because of demands on my time at home”.
Extra-Work Satisfaction
Three aspects of life or extra-work satisfaction were included.
Family satisfaction was measured by a seven item scale (α = .64) developed by Kofodimos (1993). One item was “I have a good relationship with my family members”.
Friends satisfaction was measured by three items (α = .69) developed by Kofodimos (1993). An item was “My friends and I do enjoyable things together”.
Community satisfaction was measured by four items (α = .69) again developed by Kofodimos (1993). A sample item was “I contribute and give back to my community”.
Psychosomatic Symptoms was measured by nineteen items ( = .88) developed by Quinn and Shepard (1974). Respondents indicated how often they experienced each physical condition (e.g., “headaches”) in the past year
Life Satisfaction was measured by five items (α = .93) developed by Diener, Emmons, Larsen and Griffin (1985). One item was “In most ways, my life is closer to ideal”. Respondents indicated their agreement with each item on a five point Likert scale.
Results
Workaholism Types
Spence and Robbins (1992) derive workaholism types on the basis if either high or low scores on their scales. Four workaholism types were examined here based on high and low scores on Feeling driven to work because of inner pressures and Joy in work.: Work Enthusiasts (WEs), Work Addicts (WAs), Enthusiastic Addicts (EAs), and Unengaged Workers (UWEs). The sample sizes were 54, 48, 169 and 160, respectively.
Analysis Plan
The four workaholism types were compared on a number of potential antecedents and consequences using one-way ANOVA. When a significant type effect was present (p<.05), all pair-wise comparisons were undertaken and significant differences reported (p<.05)..
Personal Demographic and Work Situation Characteristics
Table 2 presents the comparisons of the four workaholism types on a number of personal demographic and work situation characteristics. Significant type effects were present on eight of the eleven items (73%). The following comments are offered in summary. First, UWs were significantly different from one or more of the three workaholism types (WAs, WEs, EAs) in all eight instances. They were older than the other three types, worked in smaller hospitals than did WAs, had longer professional, job and hospital tenure, earned more income and income from different sources, than did the other three workaholism types, and worked in larger cities. Second, there were relatively few differences among the three workaholism types (WEs, WAs, EAs) . the latter findings is consistent with previous comparisons of these three types on personal demographic and work situation characteristics (Burke, 2000, 2007; Spence & Robbins, 1992).
Stable Individual Difference Characteristics
Table 3 shows the comparisons of the four workaholism types on various measures of stable personality and individual difference measures. Significant differences among the four types were present on each measure. The pattern of difference among the types was similar to that observed on personal demographic and work situation characteristics. First, UWs were significantly different from the three workaholism types on each measure: UWs scored lower on achievement striving, impatience-irritation, proactive personality, optimism, gratitude) and higher on the measure of beliefs and fears. Second, relatively few differences were observed among the three other workaholism types (WAs, WEs, EAs). But WAs scored higher on the beliefs and fears than did EAs, consistent with previous findings (Burke, 2000; Burke 2007); WAs were less optimistic than EAs, and WAs scored lower on Achievement Striving that did EAs.
A comparison of the four types on four measures of organizational life experiences is shown in Table 4. First, UWs scored lower than the three workaholic types on all four. Second, EAs scored lower than WEs on two of the four organizational experiences
(support, rewards and recognition).
Job Behaviors, Work Outcomes and Engagement
Table 5 shows the comparisons of the four types on various job behaviors, work outcomes and work engagement. Once again, the pattern of differences here was similar to that noted earlier. First, significant type effects were present on all but one measure (hours worked). Second, UWs were significantly different from one or more of the workaholism types, but the direction of the differences varied. UWs were less job and career satisfied, absent more, more likely to intend to quit, less work engaged, and worked fewer extra hours, and indicated lower levels of job stress, perfectionism and non-delegation. Third, there were significant differences among the three workaholism types on about half the measures showing type effects (5 of 11, 45%). WAs has higher levels of job stress, perfectionism, non-delegation, less career satisfaction but worked more extra-hours than one of the two other workaholism types. Again, this pattern has been noted previously (Burke, 2000, Burke 2007).
Quality of Life and Psychological Well-Being
Table 6 presents the comparisons of the four types on measures of quality of life and psychological well-being. Significant type effects were observed on five of the seven measures (not work-family or family-work conflict). First, UWs were significantly different from the three workaholism types. UWs indicated lower family and community satisfaction, more psychosomatic symptoms (but not when compared to WAs), a lower life satisfaction, but more friends satisfaction than EAs. Second, there were few differences between the three workaholism types; WAs indicated more psychosomatic symptoms than did both WEs and EAs, and WEs reported more friends satisfaction than did EAs.
Discussion
This research examined potential antecedents and consequences of workaholism types among physicians in Turkey. It is possible to position the results of this study in both the larger body of workaholism research and the single study of workaholism among Dutch resident physicians undertaken by Schaufeli, Taris and Bakker (2008). Our findings were consistent with previously reported conclusions on some fronts but only partially replicated other results in other areas.
Let us first consider areas in which our results replicated previous work. First, although most of the published work has focused on the three workaholism types, some research has also undertaken comparisons of workaholic and non-workaholic types (Buelens & Poelmans, 2004; Burke, 2000;, 2007; Spence & Robbins, 1992). This research has shown that Unengaged Workers (UWs)-low on work involvement, feeling driven to work, and joy in work-indicated low levels of job stress, perfectionism, hours worked, extra hours worked, job and career satisfaction and more psychosomatic symptoms. This group has unfortunately received little emphasis since the research addressed workaholism and not non-workaholism types. Individuals who “go through the motions” at work also may be paying a price.
Schaufeli, Taris and Bakker (2008) found that their Relaxed resident physicians were generally more satisfied and psychologically healthier than were Work Addict resident physicians. Their Relaxed resident physicians scored low on their two workaholism scales but no data on other aspects of their “work” involvement were addressed. It was not possible to compare their Relaxed resident physicians with our Unengaged physicians; these two are likely to be very different.
Our findings were only partly consistent with previous studies comparing the three workaholic types (Burke, 2000, 2007). First, the three workaholism types were similar on personal and work setting characteristics, including hours worked (see Table 2). Second, we found relatively few differences between the three workaholism types on work and well-being outcomes, much fewer than others have reported. But when differences were found in the present study, WAs tended to be disadvantaged, findings commonly reported by others.
Phoning it in
Our results involving Unengaged physicians (UWs) were somewhat surprising. We had not expected the consistent pattern of findings that emerged. Unengaged physicians were dissatisfied with their job, careers and lives and in moderate psychological distress.
Unengaged physicians were older, had longer job, hospital and professional tenure and earned more income, likely reflecting their longer careers. These physicians, rather than being leaders exemplifying enthusiasm and career success seemed to be “phoning it in”. It is not clear the effect being “unengaged” has in relationship with hospital staff and colleagues and the patient-physician relationship however. Low engagement is likely to be associated with less satisfying work and well-being outcomes in most occupations. The consequences of low work engagement are likely to be more worrisome in some occupations (e.g., physicians, air traffic controllers) than in others (e.g., servers in restaurants).
Practical implications
Our findings indicate that particularly organizational experiences were more common among UWs (see Table 4). Organizations might find it useful to first assess the levels of these and then make efforts to increase them. In addition, it is likely that providing these work experiences to physicians when they begin their careers with their hospitals might also lessen their becoming UWs.
Limitations of the study
Some limitations of this study should be acknowledged to put the findings in a broader context. First, though the sample was large and the response fairly high, it was not possible to determine the representativeness of the sample. Second, all measures were based on respondent self-reports raising the possibility of common method variance. Third, a few of the measures had internal consistency reliabilities below the typically accepted level of .70. Fourth, many of the work and extra-work outcomes were themselves moderately correlated. Fifth, it is not clear the extent to which our findings generalize to physicians working under different fee arrangements or in other cultures or countries.
Future research directions
Our understanding of the relationship of workaholism types and work experiences, satisfactions and health of female and male physicians would be increased by incorporating additional measures in future research. First, the use of objective indicators of both absenteeism and psychological and physical health obtained from hospital records or independent sources would complement self-report questionnaire data. Second, the antecedents of becoming unengaged warrant attention to better understand this condition. What are the processes or mechanisms through which over time a physician becomes unengaged? Third, what are the effects of unengaged physicians on hospital staff, colleagues and their contribution to hospital functioning and patient care? Fourth, interventions designed to build continuous work engagement need to be identified and evaluated.
Footnotes
1. This research was supported in part by Nevsehir University and York University. We acknowledge the cooperation of our respondents.
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