SlideShare a Scribd company logo
1 of 104
Download to read offline
LICENTIATEDISSERTATIONINODONTOLOGY
KAMILLABERGSTRÖMMALMÖUNIVERSITY2014
MALMÖ UNIVERSITY
205 06 MALMÖ, SWEDEN
WWW.MAH.SE
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
JOBSATISFACTIONANDEMOTIONALWORKTASKS
L I C E N T I AT U P P S AT SL I C
Kamilla Bergström MUEP (1)
J O B S A T I S F A C T I O N A N D E M O T I O N A L W O R K T A S K S
Kamilla Bergström 2014
Illustration Elsa Mathiasen
ISBN 978-91-7104-613-0 (print)
ISBN 978-91-7104-614-7 (pdf)
ISSN 1650-6065
Holmbergs, Malmö 2014
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
To Björn
Kamilla Bergström MUEP (1)
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
Kamilla Bergström MUEP (1)
9
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.
Reprint is made with permission from the publisher.
10
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
to affiliation (Swedish public/private, Danish public/private).
11
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.
12
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
mellan de olika organisatoriska miljöerna (Svenska offentliga/privata
13
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.
14
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
1 New Public Management is a management system which, in Scandinavia, was broadly implemented
in the public sector in the 1980s with the aim of modernization.
15
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
16
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
17
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
18
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
state of intrinsic meaningfulness. He claimed that ‘one becomes good
19
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
20
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
21
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
22
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.
23
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.
24
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
Data collection
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.
25
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.
26
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?’
27
RESULTS
Paper I
Data collection
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.
28
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.
29
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
30
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.
31
SubgroupsSwedishPrivateSwedishPublicDanishPrivateDanishPublicWholesample
nValid
%
nValid
%
nValid
%
nValid
%
nValid
%
M/F
Doyouexpecttocontinueworkingasyoudonowforwarduntilretirement?
Yes185631505329072113757386668/63
Howoftendoyouhaveenergyleftforyourprivatelife?
Always/Almostalways56192381132749312412120/22
Towhatdegreedoyouexperienceyourworkasmeaningful?
Highandveryhighdegree4028926689348841908810198825/32
Howoftendoyouconsciouslyuseyourpersonalwayofbeingasatoolinthe
interactionwiththepatients?
Always/Almostalways105351364620650106687515038/54
Howoftendoyoutrytoappearhappywhenthepatientsitsinthedental
chair?
Always/Almostalways160541665628469121767316449/72
Attheclinicyouareexpectedtoalwaysappearsmilingandobliging?
Toahighandveryhighdegree165551585332779117757676658/71
Table2.Dentists’responseaccordingtonationality,affiliationandgender.
32
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
and to do good to others. According to Damon, ‘doing good’ can,
33
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
34
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
35
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
36
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.
37
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.
38
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.
39
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.
40
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 co­operate 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
him proud will continue.
41
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.
42
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
perceptions. J Occup Organ Psychol 79:pp.273–298.
43
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.
Retrieved June 2014.
44
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.
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
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 Ó 2010 Informa Healthcare
DOI: 10.3109/00016357.2010.514719
ActaOdontolScandDownloadedfrominformahealthcare.comby188.177.16.241on09/07/10
Forpersonaluseonly.
model, the Activity diagonal is relevant, where the
demands as well as the control over the work are
simultaneously high [5]. From the ERI model, the
rewarding aspects of work are also relevant. A criti-
que of the DC model is that it should be adapted with
more specific demand and control measures relevant
for human services [4]. Examples of such specific job
demands in human service could be high moral exer-
tions, empathy and the necessity of hiding one’s own
feelings in the interaction [7]. For job control, an
example could be that skill discretion can be high
while decision authority can be low in the same job. In
the ERI model, rewards are primarily defined as
money, esteem and job security/career opportunities.
Neither model addresses the potential intrinsic lasting
rewards that may be specific for human services, e.g.
trustful relationships, the feeling of doing good or a
creative zest [8]. The potential dilemmas of the dif-
ferences between industry and human services form
the framework for the research project behind the
present study, where the overarching aim was to
find positive aspects of human service work in differ-
ent organizational settings.
The way human services are organized affects not
only the patients but also the human service provider.
During the last couple of decades, administrative
reforms and strategies in the public sector, also in
the Nordic countries, have been inspired by the ‘New
Public Management’ (NPM) idea. Hood [9] argued
that a “Swedish way” that included all Scandinavian
countries in the 1980s had both strong motives (fiscal
stress) and opportunity (central leverage over public
sector) for the development of NPM. In NPM, focus
is set on outputs and results and a public sector is split
into separate units with decentralized management.
This has also been the case in public dentistry, where
the organization of work has been affected by, for
example, outsourcing and increased competition by
market-oriented conditions [10].
The different ways of organizing human service
in dentistry have been shown to affect the human
service provider. The results of Bejerot [11], Moore
[12], Hjalmers [13], Berthelsen et al. [14,15] and
Harris et al. [16] point to organizational and national
differences between dentists’ perceptions of their
work. This has primarily been revealed in health
problems, stress and job dissatisfaction, but the
results have also pointed to positive and satisfactory
elements of work as well. As Maslach et al. [17] put
it: “Although a neutral work life has clear benefits
over burnout, it does not encompass the full range of
potential experiences at work. Work life provides
opportunities for exceptional performance, joyous
experiences, and deep fulfillment.” (p. 103).
In the present study, the human service pro-
vider, more particularly the dentist, was the object
of research. Both the special caregiver relationship
and the organizational framework of human services
were taken into account. The overarching aim was to
capture positive aspects of work in dentistry, what
may be called Good work.
Positive aspects of work
Research is limited on positive aspects of work as a
dentist. A pathogenic, problem-based paradigm has
dominated most occupational research [18]. Within
occupational health psychology, a paradigm shift from
a disease model towards a genuine health model is
necessary for the field to develop in a more balanced
way [19]. For example, in psychology, the ratio of
scientific publications on positive versus negative
states has been 1:14 until the year 2000 [20].
Although statements with positive wording are
included in many papers, most research has focused
on health problems, stress and demands. There is
though research touching on some positive aspects
such as engagement and dentist’s internal resources
as ways of coping with high demands [21–23]. These
results, as well as job satisfaction research [16], indi-
cate that dentists have a positive working attitude and
high job satisfaction.
Research on job satisfaction is the field closest to
the object of the present research. According to
Locke’s [24] classic definition, job satisfaction refers
to “a pleasurable or positive emotional state resulting
from the appraisal of one’s job or job experiences”
(p. 1300). Job satisfaction has empirically been
measured in dentistry in more than a dozen different
countries. For example, Harris et al. [16] measured
job satisfaction aspects among dentists with various
affiliations in the UK. The results showed dif-
ferent levels of job satisfaction between different
affiliations.
Aim
The purpose of this paper was to create an outcome
measure of overall job satisfaction, applying the mea-
sure in four organizational settings. Doing this also
implies a description of the background and devel-
opment of the questionnaire Swedish and Danish
Dentists’ Perceptions of Good Work.
Material and methods
Sample and questionnaire
The basis of this study comprised nationally repre-
sentative samples of Swedish and Danish dentists.
A proportionally stratified random sample was used
within each country, based on relative organizational
affiliations. The available sampling frames were the
membership registers of the Dental Associations in
2 K. Bergström et al.
ActaOdontolScandDownloadedfrominformahealthcare.comby188.177.16.241on09/07/10
Forpersonaluseonly.
the two countries. Around 21% of the Danish and
12% of the Swedish dentist populations were sam-
pled. The sample fractions differed since it was desir-
able to have similar sample sizes in the two countries.
The inclusion criterion was set as being a practising
general dentist in private or public practice in Sweden
or Denmark. In all, 1837 dentists were randomly
selected from the respective association registers.
Two were excluded, so that 898 Swedish dentists,
449 public and 449 private, and 937 Danish dentists,
201 public and 736 private, were sent a questionnaire,
marked with a code to identify non-respondents
with the purpose of sending reminders. The dentists
were informed that responses were confidential and
that, if participating, they would be sent an overview
of selected preliminary results from the study. The
Swedish versions were sent and received at Malmö
University and the Danish ones by the National
Research Centre for the Working Environment in
Denmark. One week after the first mailing of the
questionnaire in October 2008, the non-respondents
received a reminder and once again 2 weeks later, at
which point a new copy of the questionnaire and a
stamped return envelope were included. Data were
registered into the SPSS statistical program.
No non-response analysis of the whole sample
could be done, given a lack of appropriate data in
the sampling frame. A special non-response analysis
was carried out on 30 randomly selected Danish
private practitioners by telephone interview in June
2009. The interview consisted of eight core questions
taken from the questionnaire.
A brief description of the context of dentistry in
Sweden and Denmark can be found in the Appendix.
Construction of the questionnaire
The development of the questionnaire was inspired by
the recommendations of Wolfe and Smith [25] to
create variables based on theoretical constructs from
literature reviews with empirical, theoretical or
model-based focus. The questionnaire was also based
on the results from a study by Hjalmers [26] and on a
qualitative study by Berthelsen et al. [8]. The final
questionnaire contained 39 question batteries. Some
were tested in an on-line pilot study (defgo.net by
InterResearch A/S) on 66 Danish and 74 Swedish
practising dentists in spring 2008, where the dentists
were also asked to answer and comment on the degree
of intelligibility and readability of the questions.
About a quarter of the questions in the pilot were
retained after a critical revision. Translation was pri-
marily done by the research group, which contained
dentists and researchers from both countries. Content
was adjusted by reviews of dentistry and work envi-
ronmental research to ensure linguistic and content
accuracy, and that the questions could be applied to
all dentists within the sampling frame. Before finali-
zing the questionnaire, 20 dentists were asked to
discuss understanding, wording and overall impres-
sion. An English translation for descriptive purposes
was done in cooperation with a native English dentist
and researcher. A rhetorician verified the question-
naire for spelling and grammar. A graphics designer
produced the layout.
The multidimensional concept of good work in
the questionnaire was covered by nine general con-
structs: rewarding aspects of work, job satisfaction,
relations with patients, relations with colleagues and
management, work values, overall health, work–life
balance, organizational characteristics and personal
characteristics.
General characteristics
To describe some general characteristics of the
respondents, the questions and responses shown
in Table I were used.
Special non-response study
For the special non-response study, four questions
and four demographic questions were asked to show
tendencies in the perceptions of work in general. The
questions are shown in Table II.
Overall job satisfaction
An additive index consisting of three questions was
created after a dimensional analysis. The questions
are shown in Table III.
The questions were created by the research group
to measure the degree of fulfilment that work can
provide, satisfaction with general conditions at work
and satisfaction with work life in general. The ques-
tions were meant to cover a perceived fulfilment of
expectations of working life in the past and in the
future as well as the present emotional state of mind.
The Danish and Swedish word Arbejdsglæde/
Arbetsglädje was a translational challenge of this study.
The term has no direct translation into English but is
comparable to ‘eudaimonic work’. In this study it was
translated into ‘work fulfilment’. For the specific
perspective of ‘Overall job satisfaction’ being a lasting
intrinsic and ‘positive state of mind’, two classical
ideas can be applied from happiness and well-being
research: eudaimonia and hedonia. Eudaimonia has
mostly been used in well-being research and can be
defined as producing happiness and well-being for the
worker. This, by striving to actualize their potential,
doing work of meaning and seaking a purpose in their
lives, in line with their values, emanating from internal
Overall job satisfaction among dentists 3
ActaOdontolScandDownloadedfrominformahealthcare.comby188.177.16.241on09/07/10
Forpersonaluseonly.
and external sources [27,28]. However, the concepts
can be viewed as overlapping. The hedonic view can
be regarded as well-being achieved through the pur-
suit of pleasure, enjoyment and comfort, while the
eudaimonic view is more concerned with acting to the
best of one’s ability, developing one’s potential and
doing good. When experiencing a eudaimonic life, a
state of hedonia often follows [29].
Statistical methods
The material was analyzed using SPSS 16.0 for
Windows (SPSS Inc, Chicago, IL). The response
rate was calculated according to the recommenda-
tions of Locker [30] as the “number of completed
cases as a proportion of the number of eligible cases
in the sample” (p. 73). The general characteristics of
the respondents were analysed with the Kruskal–
Wallis non-parametric test (asymptotic significance)
between four groups: Danish public/private practi-
tioners and Swedish public/private practitioners.
When analysing these categories separately, no
weighting procedure due to the different sample
fractions was necessary. In the special non-response
study for the Danish private practitioners, a non-
parametric Mann–Whitney U-test (asymptotic signif-
icance, two-tailed) was used. Principal components
analysis (PCA) was performed on the three Overall job
satisfaction variables and tested for stability on gender
and on the four subgroups: Swedish public/private
practitioners and Danish public/private practitioners.
An unrotated initial factor solution, with pairwise
exclusion of missing values, was used. The Kaiser–
Meyer–Olkin measure of sampling adequacy, scree
plots, communalities and factor loadings were used
for the determination of the number of factors. The
overall job satisfaction index was analysed using
the Kruskal–Wallis test on the four subgroups.
P £ 0.05 was set as the significance level.
Results
Response
Of the 1835 questionnaires sent out, 1292 were
returned. Of the respondents, 31 were excluded as
Table I. Questions and statements used to describe some general characteristics of the respondents.
Question Response
Your gender? Male  Female 
I am:  Member of Praktikertjänst (The producer cooperative; only in Sweden)
 Practice owner in private practice
 Employed in private practice
 Manager in public dentistry
 Employed in public dentistry without management responsibility
 Something else
You are:  Born in Sweden/Denmark
 Born in another Nordic country
 Born in a country outside Scandinavia
Your family situation: Single  Married/Cohabiting  Something else 
Which year did you complete your dental education? Year_____
How many persons work in your daily workplace (including yourself)?
Number of dentists _____
Number of dental hygienists _____
Number of dental nurses _____
How many hours per week do you work as a dentist? Total ____ hours
To what degree do you experience the following in your work?: To a very
low degree
To a low
degree
To some
degree
To a high
degree
To a very
high degree
- Work fulfilment     
- Satisfaction with your work as a whole?     
Do you feel that you have a good working life? Not at all To a low
degree
To some
degree
To a high
degree
To a very
high degree
    
4 K. Bergström et al.
ActaOdontolScandDownloadedfrominformahealthcare.comby188.177.16.241on09/07/10
Forpersonaluseonly.
not belonging to the sampling frame (not general
practising dentists). The issued number of question-
naires was thus corrected to 1804. The net response
rate was 68% (n = 1226). Of the 449 Swedish public
practitioners who received a questionnaire, 75% par-
ticipated (n = 325), while for the private practitioners
68% of 449 (n = 302) participated. For the Danish
population, 201 public practitioners were sent a
questionnaire and 81% participated (n = 160), while
736 private practitioners received a questionnaire and
60% participated (n = 439).
Special non-response study of the Danish private
practitioners
Because of the low response rate in this group, a
special non-response analysis was performed. There
were significantly more men in the sample and also
more dentists with managerial responsibility and
dentists with longer working hours among the group
of non-respondents. No statistically significant
differences were found with regard to time since
graduation, workload or if they were satisfied and
felt fulfilled in their work. A statistically significant
difference was found with regard to perceived general
health, where the non-respondents rated their health
as better than that of the respondents (Table IV).
General characteristics of the respondents
The Swedish private practitioners had a much lower
proportion of female respondents, with only 33%
compared to the other three subgroups: of the Danish
private practitioners 65% were women, and for the
public-practising dentists there were 71% women in
Sweden and 87% in Denmark. In both private and
public dentistry in Sweden, 89% and 86%, respec-
tively were born in Sweden, compared to 96% and
94%, respectively in private and public dentistry born
in Denmark. Most private-practising dentists were
married or cohabiting (91% in Sweden and 88% in
Denmark), which was the case for 86% of the Swedish
and 85% of the Danish public-practising dentists. As
many as 91% of the private-practising dentists had
Table II. Questions used in the non-response study.
Question Response
Your gender? Male  Female 
I am:  Practice owner in private practice
 Employed in private practice
Which year did you complete your dental education? Year_____
How many hours per week do you work as a dentist? Total ____ hours
To what degree do you experience the following in your work: To a
very low
degree
To a
low
degree
To some
degree
To a
high
degree
To a
very high
degree
- Work fulfilment?     
- Satisfaction with your work as a whole?     
How do you assess the extent of your workload? Much too
small
Too small Appropriate Too great Much too
great
    
In general, would you say your health is: Poor Acceptable Good Very good Excellent
    
Table III. Questions used to create the additive index.
Question Response
To what degree do you experience the following in your work?: To a very
low degree
To a low
degree
To some
degree
To a high
degree
To a very
high degree
- Work fulfilment     
- Satisfaction with your work as a whole?     
Do you feel that you have a good working life? Not at all To a low
degree
To some
degree
To a high
degree
To a
very high
degree
    
Overall job satisfaction among dentists 5
ActaOdontolScandDownloadedfrominformahealthcare.comby188.177.16.241on09/07/10
Forpersonaluseonly.
managerial responsibility in Sweden, but only 15%
of the public ones. In Denmark, 76% of the private-
and 62% of the public-practising dentists had
managerial responsibility. All questions in Table V
showed significant differences between the subgroups
(P £ 0.001).
Overall job satisfaction
The items were negatively skewed for all four groups
(skewness –1.0 to –0.3). The average share of internal
non-response was 1%.
PCA showed a one-factor solution. Results were
stable with regard to gender and the four subgroups:
Swedish public/private and Danish public/private. An
additive index (range 3–15) was constructed as Over-
all job satisfaction. The distribution was normal
but slightly negatively skewed (–0.65). For the whole
sample as well as for the subgroups, both median and
mode were 12. The four subgroups Danish public/
private practitioners and Swedish public/private
practitioners showed some differences in the
overall job satisfaction means. Using the Kruskall–
Wallis test on the index between the four groups
(P £ 0.001) indicated that they did not have equal
means (Table VI).
Discussion
The results showed organizational differences in the
perception of overall job satisfaction. The Swedish
public dentists were the least satisfied, and the Danish
public dentists were the most satisfied. There were
differences between the subgroups in all general char-
acteristics analysed. Especially great differences were
found among women respondents. In the special non-
response study, greater proportions of dentists who
were males, had managerial responsibility, worked
longer hours and had better perceived general health
were found among the non-respondents. An average
response rate of 68% was achieved for the whole
study.
Table IV. Special non-response analysis for Danish private practitioners.
Sample respondents Non-respondents (n = 30)
% Mean SD n % Mean SD P for difference
Gender (male/female) 35/65 – – 413 67/23 – – 0.02
Managers 76 – – 413 87 – – 0.001
Year since graduation 20 4.8 412 20 3 0.092
Working hours per week 36 7.6 405 40 11 0.001
Self-perceived health 3.7 0.9 413 4.2 0.6 0.001
Workload 3.4 0.6 411 3.6 0.6 0.131
Degree of work fulfilment 4 0.7 409 4.1 0.6 0.085
Degree of satisfaction with work as a whole 3.9 0.7 407 4.1 0.7 0.106
Table V. General characteristics of the general practising dentists grouped by nationality and affiliationa
.
National and organizational affiliation
Swedish private Swedish public Danish private Danish public
Mean SD n Mean SD n Mean SD n Mean SD n
Years since graduation 26 10 300 21 12 297 20 5 412 26 9 159
Average practice size:
No. of dentists 2.2 1.5 197 6 3.2 292 2.8 1.5 401 3 2.3 155
No. of dental hygienists 1 1 301 3 2 291 0.8 1 411 1.3 1.7 156
No. of dental nurses 3 3 301 10 5.4 291 4.3 2.3 411 5.7 4.4 156
Average working hours 38 8.4 297 35 8 296 36 7.6 405 32 6.4 158
Satisfaction with work 3.9 0.9 295 3.6 0.8 292 3.9 0.7 407 3.9 0.7 158
Work fulfilment 3.9 0.9 297 3.7 0.8 292 4 0.7 409 4 0.7 158
A good working life 4 0.8 301 3.7 0.8 294 4 0.8 413 4 0.7 159
a
Statistically significant differences in mean rank between subgroups for all variables (P £ 0.001).
6 K. Bergström et al.
ActaOdontolScandDownloadedfrominformahealthcare.comby188.177.16.241on09/07/10
Forpersonaluseonly.
In a recently published review of response rates for
healthcare professionals, including dentists, average
response rates of 35–68% were found [31]. The
average response rate in this study may therefore be
considered acceptable. While previous research on
dentists in Sweden and Denmark has shown higher
response rates [15,26], a third reminder was consid-
ered for the Danish private-practising dentists.
Instead, a special non-response study was decided
on. Interviews revealed that the non-respondents
simply felt they had a lack of sufficient time to respond
to questionnaires in general. They also worked longer
hours than the respondents, which did not seem to
affect their job satisfaction in a negative way. The
Danish private practitioners also had greater propor-
tions of males and managers, the latter often having
increased responsibility and working longer hours.
This could be the simplest explanation for the higher
proportion of non-respondents in this group.
The proportions of public and private practitioners
in each country were reflected by the sample con-
struction. Except for the Swedish private practi-
tioners, the proportion of female respondents was
more than two-thirds. Several studies within dentistry
have shown a higher percentage of female respondents
[32–34]. The national share of female dentists in
Denmark was »55% in 2008 [35]. Therefore, there
was an overrepresentation of women among the
Danish public and private practitioners in the sample.
This does not seem to be the case for the Swedish
public and private practitioners, as the average share
of women in the two subgroups was close to the 49%
foundamongSwedishdentistsin2005[35].Thefemale
dentists in the sample worked on average four hours less
per week than the male ones. The gender differences
among respondents might be a confounder for working
hours, giving the female dentists more time to respond.
The overrepresentation of female respondents in the
sample might affect job satisfaction through organiza-
tional factors such as opportunities for practising fem-
inist values in human service work, as for example in
emotional and care work [7].
The Danish public practitioners comprised many
more dentists with managerial responsibility than the
Swedish public ones. Also, the Danish public clinics
had almost half as many employees as the Swedish
public clinics. This could be a reflection of a signif-
icant difference in how the ideas behind NPM are
implemented in the public sector in the two countries,
which in Denmark involves smaller units and decen-
tralized management.
Good work and job satisfaction as terms
As a scientific expression, Good work is mostly
used to describe a form of best practice in a cer-
tain job, unifying professional expertise and social
responsibility. A dual sense of the adjective ‘good’
is often used: (1) high-quality work objectively judged
by people knowledgeable about the domain; and (2)
work that goes beyond the worker and benefits a wider
good [36]. Good work and a good job can also differ,
by stating that a good job does not always provide the
possibility of doing good work [37]. Gardner [38]
acknowledges the individual requirements and
states: “It is always a challenge, requiring ethical
commitment and skill on the part of each individual
worker.” (p. 6).
It is hard to imagine what any ‘objective’ measure of
good work would imply. Good work is an individual
Table VI. Factor analysis on items concerning overall job satisfaction for dentists in Sweden and Denmark.
PCA No. of factors KMO Communalities Variance explained (%) Factor loadings a
Whole sample 1 0.708 0.695–0.826 78 0.834–0.909 0.86
Swedish private 1 0.671 0.617–0.839 76 0.785–0.916 0.84
Swedish public 1 0.715 0.717–0.835 79 0.847–0.914 0.87
Danish private 1 0.714 0.703–0.805 76 0.839–0.897 0.84
Danish public 1 0.733 0.769–0.853 82 0.877–0.924 0.89
Men 1 0.722 0.738–0.844 80 0.859–0.919 0.87
Women 1 0.693 0.662–0.826 76 0.814–0.909 0.84
Overall job satisfaction index (range 3–15) Mean SD n P between all subgroups
Swedish private 11.8 2.2 294
Swedish public 11.0 2.1 287
Danish private 11.8 1.9 405
Danish public 11.9 1.9 157
All subgroups 11.6 2.1 1197 £0.001
KMO = Kaiser–Meyer–Olkin.
Overall job satisfaction among dentists 7
ActaOdontolScandDownloadedfrominformahealthcare.comby188.177.16.241on09/07/10
Forpersonaluseonly.
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)
Kamilla Bergström MUEP (1)

More Related Content

Viewers also liked

AIDAHelp - Getting Started
AIDAHelp - Getting StartedAIDAHelp - Getting Started
AIDAHelp - Getting StartedAIDAIO
 
Demanda de inconstitucionalidad derecho constitucional iii semestre
Demanda de inconstitucionalidad  derecho constitucional iii semestreDemanda de inconstitucionalidad  derecho constitucional iii semestre
Demanda de inconstitucionalidad derecho constitucional iii semestrefabian chaparro
 
(SWOT) Understanding personal strengths and weaknesses
(SWOT) Understanding personal strengths and weaknesses(SWOT) Understanding personal strengths and weaknesses
(SWOT) Understanding personal strengths and weaknessesMcCare Extended-Diploma
 

Viewers also liked (7)

AIDAHelp - Getting Started
AIDAHelp - Getting StartedAIDAHelp - Getting Started
AIDAHelp - Getting Started
 
Antepastos[1]
Antepastos[1]Antepastos[1]
Antepastos[1]
 
Demanda de inconstitucionalidad derecho constitucional iii semestre
Demanda de inconstitucionalidad  derecho constitucional iii semestreDemanda de inconstitucionalidad  derecho constitucional iii semestre
Demanda de inconstitucionalidad derecho constitucional iii semestre
 
Skmbt c45014022514190
Skmbt c45014022514190Skmbt c45014022514190
Skmbt c45014022514190
 
fadl saleh CV
fadl saleh  CVfadl saleh  CV
fadl saleh CV
 
Recommendation-Dr-Qu
Recommendation-Dr-QuRecommendation-Dr-Qu
Recommendation-Dr-Qu
 
(SWOT) Understanding personal strengths and weaknesses
(SWOT) Understanding personal strengths and weaknesses(SWOT) Understanding personal strengths and weaknesses
(SWOT) Understanding personal strengths and weaknesses
 

Similar to Kamilla Bergström MUEP (1)

RESEARCH ARTICLE Open AccessExperiences of reduced work ho.docx
RESEARCH ARTICLE Open AccessExperiences of reduced work ho.docxRESEARCH ARTICLE Open AccessExperiences of reduced work ho.docx
RESEARCH ARTICLE Open AccessExperiences of reduced work ho.docxronak56
 
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...pateldrona
 
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...pateldrona
 
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...pateldrona
 
FINAL V3 Action Research Project
FINAL V3 Action Research ProjectFINAL V3 Action Research Project
FINAL V3 Action Research ProjectVictoria Wilson
 
Reflection On Shadowing A Dental Hygienist
Reflection On Shadowing A Dental HygienistReflection On Shadowing A Dental Hygienist
Reflection On Shadowing A Dental HygienistMaureen Nonweiler
 
APPROACH HIGHER EDUCATION TO SOCIAL NECESSITIES: IMPLEMENTATION OF NEW SUBJEC...
APPROACH HIGHER EDUCATION TO SOCIAL NECESSITIES: IMPLEMENTATION OF NEW SUBJEC...APPROACH HIGHER EDUCATION TO SOCIAL NECESSITIES: IMPLEMENTATION OF NEW SUBJEC...
APPROACH HIGHER EDUCATION TO SOCIAL NECESSITIES: IMPLEMENTATION OF NEW SUBJEC...University of Jaén-Psychology
 
A Qualitative Research Factors Affecting Patient Satisfaction and Loyalty A C...
A Qualitative Research Factors Affecting Patient Satisfaction and Loyalty A C...A Qualitative Research Factors Affecting Patient Satisfaction and Loyalty A C...
A Qualitative Research Factors Affecting Patient Satisfaction and Loyalty A C...YogeshIJTSRD
 
Research Paper Dental Hygienist
Research Paper Dental HygienistResearch Paper Dental Hygienist
Research Paper Dental HygienistJennifer Simmons
 
Bulletin kkm final 3
Bulletin kkm final 3Bulletin kkm final 3
Bulletin kkm final 3ohdmoh
 
What Are You Willing to Change to Promote Your Patients' Oral Health?
What Are You Willing to Change to Promote Your Patients' Oral Health?What Are You Willing to Change to Promote Your Patients' Oral Health?
What Are You Willing to Change to Promote Your Patients' Oral Health?Dr Marielle Pariseau
 
Predictors of sickness absence and presenteeism: Does the pattern differ by a...
Predictors of sickness absence and presenteeism: Does the pattern differ by a...Predictors of sickness absence and presenteeism: Does the pattern differ by a...
Predictors of sickness absence and presenteeism: Does the pattern differ by a...Palkansaajien tutkimuslaitos
 
Types Of Dentist Patient Interaction
Types Of Dentist Patient InteractionTypes Of Dentist Patient Interaction
Types Of Dentist Patient Interactionshabeel pn
 
POCF - Staff Care (web) - minimal referencing
POCF - Staff Care (web) - minimal referencingPOCF - Staff Care (web) - minimal referencing
POCF - Staff Care (web) - minimal referencingHilary Rowell
 
Dental Myth, Fallacies and Misconceptions and its Association with Socio-Dent...
Dental Myth, Fallacies and Misconceptions and its Association with Socio-Dent...Dental Myth, Fallacies and Misconceptions and its Association with Socio-Dent...
Dental Myth, Fallacies and Misconceptions and its Association with Socio-Dent...DrRipika Sharma
 

Similar to Kamilla Bergström MUEP (1) (20)

RESEARCH ARTICLE Open AccessExperiences of reduced work ho.docx
RESEARCH ARTICLE Open AccessExperiences of reduced work ho.docxRESEARCH ARTICLE Open AccessExperiences of reduced work ho.docx
RESEARCH ARTICLE Open AccessExperiences of reduced work ho.docx
 
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...
 
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...
 
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...
Sri Lankan Undergraduate Healthcare Student’s Perceptions of Interprofessiona...
 
FINAL V3 Action Research Project
FINAL V3 Action Research ProjectFINAL V3 Action Research Project
FINAL V3 Action Research Project
 
Reflection On Shadowing A Dental Hygienist
Reflection On Shadowing A Dental HygienistReflection On Shadowing A Dental Hygienist
Reflection On Shadowing A Dental Hygienist
 
APPROACH HIGHER EDUCATION TO SOCIAL NECESSITIES: IMPLEMENTATION OF NEW SUBJEC...
APPROACH HIGHER EDUCATION TO SOCIAL NECESSITIES: IMPLEMENTATION OF NEW SUBJEC...APPROACH HIGHER EDUCATION TO SOCIAL NECESSITIES: IMPLEMENTATION OF NEW SUBJEC...
APPROACH HIGHER EDUCATION TO SOCIAL NECESSITIES: IMPLEMENTATION OF NEW SUBJEC...
 
Physician-Dentist Teamwork Essential for Optimal Patient Care
Physician-Dentist Teamwork Essential for Optimal Patient CarePhysician-Dentist Teamwork Essential for Optimal Patient Care
Physician-Dentist Teamwork Essential for Optimal Patient Care
 
Leaflet_en_MIJC
Leaflet_en_MIJCLeaflet_en_MIJC
Leaflet_en_MIJC
 
International Journal of Gerontology & Geriatric Research
International Journal of Gerontology & Geriatric ResearchInternational Journal of Gerontology & Geriatric Research
International Journal of Gerontology & Geriatric Research
 
Thesis topic
Thesis topicThesis topic
Thesis topic
 
A Qualitative Research Factors Affecting Patient Satisfaction and Loyalty A C...
A Qualitative Research Factors Affecting Patient Satisfaction and Loyalty A C...A Qualitative Research Factors Affecting Patient Satisfaction and Loyalty A C...
A Qualitative Research Factors Affecting Patient Satisfaction and Loyalty A C...
 
Research Paper Dental Hygienist
Research Paper Dental HygienistResearch Paper Dental Hygienist
Research Paper Dental Hygienist
 
Bulletin kkm final 3
Bulletin kkm final 3Bulletin kkm final 3
Bulletin kkm final 3
 
What Are You Willing to Change to Promote Your Patients' Oral Health?
What Are You Willing to Change to Promote Your Patients' Oral Health?What Are You Willing to Change to Promote Your Patients' Oral Health?
What Are You Willing to Change to Promote Your Patients' Oral Health?
 
Predictors of sickness absence and presenteeism: Does the pattern differ by a...
Predictors of sickness absence and presenteeism: Does the pattern differ by a...Predictors of sickness absence and presenteeism: Does the pattern differ by a...
Predictors of sickness absence and presenteeism: Does the pattern differ by a...
 
Types Of Dentist Patient Interaction
Types Of Dentist Patient InteractionTypes Of Dentist Patient Interaction
Types Of Dentist Patient Interaction
 
Oral health education
Oral health educationOral health education
Oral health education
 
POCF - Staff Care (web) - minimal referencing
POCF - Staff Care (web) - minimal referencingPOCF - Staff Care (web) - minimal referencing
POCF - Staff Care (web) - minimal referencing
 
Dental Myth, Fallacies and Misconceptions and its Association with Socio-Dent...
Dental Myth, Fallacies and Misconceptions and its Association with Socio-Dent...Dental Myth, Fallacies and Misconceptions and its Association with Socio-Dent...
Dental Myth, Fallacies and Misconceptions and its Association with Socio-Dent...
 

Kamilla Bergström MUEP (1)

  • 1. LICENTIATEDISSERTATIONINODONTOLOGY KAMILLABERGSTRÖMMALMÖUNIVERSITY2014 MALMÖ UNIVERSITY 205 06 MALMÖ, SWEDEN WWW.MAH.SE 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 JOBSATISFACTIONANDEMOTIONALWORKTASKS L I C E N T I AT U P P S AT SL I C
  • 3. J O B S A T I S F A C T I O N A N D E M O T I O N A L W O R K T A S K S
  • 4. Kamilla Bergström 2014 Illustration Elsa Mathiasen ISBN 978-91-7104-613-0 (print) ISBN 978-91-7104-614-7 (pdf) ISSN 1650-6065 Holmbergs, Malmö 2014
  • 5. KAMILLA BERGSTRÖM JOB SATISFACTION AND EMOTIONAL WORK TASKS Malmö högskola, 2014 Department of Oral Public Health Faculty of Odontology Dentists in Sweden and Denmark
  • 6. This publication also available online see: www.mah.se/muep
  • 9. 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
  • 11. 9 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. Reprint is made with permission from the publisher.
  • 12. 10 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 to affiliation (Swedish public/private, Danish public/private).
  • 13. 11 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.
  • 14. 12 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 mellan de olika organisatoriska miljöerna (Svenska offentliga/privata
  • 15. 13 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.
  • 16. 14 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 1 New Public Management is a management system which, in Scandinavia, was broadly implemented in the public sector in the 1980s with the aim of modernization.
  • 17. 15 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
  • 18. 16 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
  • 19. 17 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
  • 20. 18 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 state of intrinsic meaningfulness. He claimed that ‘one becomes good
  • 21. 19 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
  • 22. 20 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
  • 23. 21 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
  • 24. 22 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.
  • 25. 23 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.
  • 26. 24 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 Data collection 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.
  • 27. 25 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.
  • 28. 26 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?’
  • 29. 27 RESULTS Paper I Data collection 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.
  • 30. 28 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.
  • 31. 29 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
  • 32. 30 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.
  • 33. 31 SubgroupsSwedishPrivateSwedishPublicDanishPrivateDanishPublicWholesample nValid % nValid % nValid % nValid % nValid % M/F Doyouexpecttocontinueworkingasyoudonowforwarduntilretirement? Yes185631505329072113757386668/63 Howoftendoyouhaveenergyleftforyourprivatelife? Always/Almostalways56192381132749312412120/22 Towhatdegreedoyouexperienceyourworkasmeaningful? Highandveryhighdegree4028926689348841908810198825/32 Howoftendoyouconsciouslyuseyourpersonalwayofbeingasatoolinthe interactionwiththepatients? Always/Almostalways105351364620650106687515038/54 Howoftendoyoutrytoappearhappywhenthepatientsitsinthedental chair? Always/Almostalways160541665628469121767316449/72 Attheclinicyouareexpectedtoalwaysappearsmilingandobliging? Toahighandveryhighdegree165551585332779117757676658/71 Table2.Dentists’responseaccordingtonationality,affiliationandgender.
  • 34. 32 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 and to do good to others. According to Damon, ‘doing good’ can,
  • 35. 33 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
  • 36. 34 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
  • 37. 35 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
  • 38. 36 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.
  • 39. 37 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.
  • 40. 38 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.
  • 41. 39 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.
  • 42. 40 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 co­operate 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 him proud will continue.
  • 43. 41 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.
  • 44. 42 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 perceptions. J Occup Organ Psychol 79:pp.273–298.
  • 45. 43 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. Retrieved June 2014.
  • 46. 44 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.
  • 49. 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 Ó 2010 Informa Healthcare DOI: 10.3109/00016357.2010.514719 ActaOdontolScandDownloadedfrominformahealthcare.comby188.177.16.241on09/07/10 Forpersonaluseonly.
  • 50. model, the Activity diagonal is relevant, where the demands as well as the control over the work are simultaneously high [5]. From the ERI model, the rewarding aspects of work are also relevant. A criti- que of the DC model is that it should be adapted with more specific demand and control measures relevant for human services [4]. Examples of such specific job demands in human service could be high moral exer- tions, empathy and the necessity of hiding one’s own feelings in the interaction [7]. For job control, an example could be that skill discretion can be high while decision authority can be low in the same job. In the ERI model, rewards are primarily defined as money, esteem and job security/career opportunities. Neither model addresses the potential intrinsic lasting rewards that may be specific for human services, e.g. trustful relationships, the feeling of doing good or a creative zest [8]. The potential dilemmas of the dif- ferences between industry and human services form the framework for the research project behind the present study, where the overarching aim was to find positive aspects of human service work in differ- ent organizational settings. The way human services are organized affects not only the patients but also the human service provider. During the last couple of decades, administrative reforms and strategies in the public sector, also in the Nordic countries, have been inspired by the ‘New Public Management’ (NPM) idea. Hood [9] argued that a “Swedish way” that included all Scandinavian countries in the 1980s had both strong motives (fiscal stress) and opportunity (central leverage over public sector) for the development of NPM. In NPM, focus is set on outputs and results and a public sector is split into separate units with decentralized management. This has also been the case in public dentistry, where the organization of work has been affected by, for example, outsourcing and increased competition by market-oriented conditions [10]. The different ways of organizing human service in dentistry have been shown to affect the human service provider. The results of Bejerot [11], Moore [12], Hjalmers [13], Berthelsen et al. [14,15] and Harris et al. [16] point to organizational and national differences between dentists’ perceptions of their work. This has primarily been revealed in health problems, stress and job dissatisfaction, but the results have also pointed to positive and satisfactory elements of work as well. As Maslach et al. [17] put it: “Although a neutral work life has clear benefits over burnout, it does not encompass the full range of potential experiences at work. Work life provides opportunities for exceptional performance, joyous experiences, and deep fulfillment.” (p. 103). In the present study, the human service pro- vider, more particularly the dentist, was the object of research. Both the special caregiver relationship and the organizational framework of human services were taken into account. The overarching aim was to capture positive aspects of work in dentistry, what may be called Good work. Positive aspects of work Research is limited on positive aspects of work as a dentist. A pathogenic, problem-based paradigm has dominated most occupational research [18]. Within occupational health psychology, a paradigm shift from a disease model towards a genuine health model is necessary for the field to develop in a more balanced way [19]. For example, in psychology, the ratio of scientific publications on positive versus negative states has been 1:14 until the year 2000 [20]. Although statements with positive wording are included in many papers, most research has focused on health problems, stress and demands. There is though research touching on some positive aspects such as engagement and dentist’s internal resources as ways of coping with high demands [21–23]. These results, as well as job satisfaction research [16], indi- cate that dentists have a positive working attitude and high job satisfaction. Research on job satisfaction is the field closest to the object of the present research. According to Locke’s [24] classic definition, job satisfaction refers to “a pleasurable or positive emotional state resulting from the appraisal of one’s job or job experiences” (p. 1300). Job satisfaction has empirically been measured in dentistry in more than a dozen different countries. For example, Harris et al. [16] measured job satisfaction aspects among dentists with various affiliations in the UK. The results showed dif- ferent levels of job satisfaction between different affiliations. Aim The purpose of this paper was to create an outcome measure of overall job satisfaction, applying the mea- sure in four organizational settings. Doing this also implies a description of the background and devel- opment of the questionnaire Swedish and Danish Dentists’ Perceptions of Good Work. Material and methods Sample and questionnaire The basis of this study comprised nationally repre- sentative samples of Swedish and Danish dentists. A proportionally stratified random sample was used within each country, based on relative organizational affiliations. The available sampling frames were the membership registers of the Dental Associations in 2 K. Bergström et al. ActaOdontolScandDownloadedfrominformahealthcare.comby188.177.16.241on09/07/10 Forpersonaluseonly.
  • 51. the two countries. Around 21% of the Danish and 12% of the Swedish dentist populations were sam- pled. The sample fractions differed since it was desir- able to have similar sample sizes in the two countries. The inclusion criterion was set as being a practising general dentist in private or public practice in Sweden or Denmark. In all, 1837 dentists were randomly selected from the respective association registers. Two were excluded, so that 898 Swedish dentists, 449 public and 449 private, and 937 Danish dentists, 201 public and 736 private, were sent a questionnaire, marked with a code to identify non-respondents with the purpose of sending reminders. The dentists were informed that responses were confidential and that, if participating, they would be sent an overview of selected preliminary results from the study. The Swedish versions were sent and received at Malmö University and the Danish ones by the National Research Centre for the Working Environment in Denmark. One week after the first mailing of the questionnaire in October 2008, the non-respondents received a reminder and once again 2 weeks later, at which point a new copy of the questionnaire and a stamped return envelope were included. Data were registered into the SPSS statistical program. No non-response analysis of the whole sample could be done, given a lack of appropriate data in the sampling frame. A special non-response analysis was carried out on 30 randomly selected Danish private practitioners by telephone interview in June 2009. The interview consisted of eight core questions taken from the questionnaire. A brief description of the context of dentistry in Sweden and Denmark can be found in the Appendix. Construction of the questionnaire The development of the questionnaire was inspired by the recommendations of Wolfe and Smith [25] to create variables based on theoretical constructs from literature reviews with empirical, theoretical or model-based focus. The questionnaire was also based on the results from a study by Hjalmers [26] and on a qualitative study by Berthelsen et al. [8]. The final questionnaire contained 39 question batteries. Some were tested in an on-line pilot study (defgo.net by InterResearch A/S) on 66 Danish and 74 Swedish practising dentists in spring 2008, where the dentists were also asked to answer and comment on the degree of intelligibility and readability of the questions. About a quarter of the questions in the pilot were retained after a critical revision. Translation was pri- marily done by the research group, which contained dentists and researchers from both countries. Content was adjusted by reviews of dentistry and work envi- ronmental research to ensure linguistic and content accuracy, and that the questions could be applied to all dentists within the sampling frame. Before finali- zing the questionnaire, 20 dentists were asked to discuss understanding, wording and overall impres- sion. An English translation for descriptive purposes was done in cooperation with a native English dentist and researcher. A rhetorician verified the question- naire for spelling and grammar. A graphics designer produced the layout. The multidimensional concept of good work in the questionnaire was covered by nine general con- structs: rewarding aspects of work, job satisfaction, relations with patients, relations with colleagues and management, work values, overall health, work–life balance, organizational characteristics and personal characteristics. General characteristics To describe some general characteristics of the respondents, the questions and responses shown in Table I were used. Special non-response study For the special non-response study, four questions and four demographic questions were asked to show tendencies in the perceptions of work in general. The questions are shown in Table II. Overall job satisfaction An additive index consisting of three questions was created after a dimensional analysis. The questions are shown in Table III. The questions were created by the research group to measure the degree of fulfilment that work can provide, satisfaction with general conditions at work and satisfaction with work life in general. The ques- tions were meant to cover a perceived fulfilment of expectations of working life in the past and in the future as well as the present emotional state of mind. The Danish and Swedish word Arbejdsglæde/ Arbetsglädje was a translational challenge of this study. The term has no direct translation into English but is comparable to ‘eudaimonic work’. In this study it was translated into ‘work fulfilment’. For the specific perspective of ‘Overall job satisfaction’ being a lasting intrinsic and ‘positive state of mind’, two classical ideas can be applied from happiness and well-being research: eudaimonia and hedonia. Eudaimonia has mostly been used in well-being research and can be defined as producing happiness and well-being for the worker. This, by striving to actualize their potential, doing work of meaning and seaking a purpose in their lives, in line with their values, emanating from internal Overall job satisfaction among dentists 3 ActaOdontolScandDownloadedfrominformahealthcare.comby188.177.16.241on09/07/10 Forpersonaluseonly.
  • 52. and external sources [27,28]. However, the concepts can be viewed as overlapping. The hedonic view can be regarded as well-being achieved through the pur- suit of pleasure, enjoyment and comfort, while the eudaimonic view is more concerned with acting to the best of one’s ability, developing one’s potential and doing good. When experiencing a eudaimonic life, a state of hedonia often follows [29]. Statistical methods The material was analyzed using SPSS 16.0 for Windows (SPSS Inc, Chicago, IL). The response rate was calculated according to the recommenda- tions of Locker [30] as the “number of completed cases as a proportion of the number of eligible cases in the sample” (p. 73). The general characteristics of the respondents were analysed with the Kruskal– Wallis non-parametric test (asymptotic significance) between four groups: Danish public/private practi- tioners and Swedish public/private practitioners. When analysing these categories separately, no weighting procedure due to the different sample fractions was necessary. In the special non-response study for the Danish private practitioners, a non- parametric Mann–Whitney U-test (asymptotic signif- icance, two-tailed) was used. Principal components analysis (PCA) was performed on the three Overall job satisfaction variables and tested for stability on gender and on the four subgroups: Swedish public/private practitioners and Danish public/private practitioners. An unrotated initial factor solution, with pairwise exclusion of missing values, was used. The Kaiser– Meyer–Olkin measure of sampling adequacy, scree plots, communalities and factor loadings were used for the determination of the number of factors. The overall job satisfaction index was analysed using the Kruskal–Wallis test on the four subgroups. P £ 0.05 was set as the significance level. Results Response Of the 1835 questionnaires sent out, 1292 were returned. Of the respondents, 31 were excluded as Table I. Questions and statements used to describe some general characteristics of the respondents. Question Response Your gender? Male Female I am: Member of Praktikertjänst (The producer cooperative; only in Sweden) Practice owner in private practice Employed in private practice Manager in public dentistry Employed in public dentistry without management responsibility Something else You are: Born in Sweden/Denmark Born in another Nordic country Born in a country outside Scandinavia Your family situation: Single Married/Cohabiting Something else Which year did you complete your dental education? Year_____ How many persons work in your daily workplace (including yourself)? Number of dentists _____ Number of dental hygienists _____ Number of dental nurses _____ How many hours per week do you work as a dentist? Total ____ hours To what degree do you experience the following in your work?: To a very low degree To a low degree To some degree To a high degree To a very high degree - Work fulfilment - Satisfaction with your work as a whole? Do you feel that you have a good working life? Not at all To a low degree To some degree To a high degree To a very high degree 4 K. Bergström et al. ActaOdontolScandDownloadedfrominformahealthcare.comby188.177.16.241on09/07/10 Forpersonaluseonly.
  • 53. not belonging to the sampling frame (not general practising dentists). The issued number of question- naires was thus corrected to 1804. The net response rate was 68% (n = 1226). Of the 449 Swedish public practitioners who received a questionnaire, 75% par- ticipated (n = 325), while for the private practitioners 68% of 449 (n = 302) participated. For the Danish population, 201 public practitioners were sent a questionnaire and 81% participated (n = 160), while 736 private practitioners received a questionnaire and 60% participated (n = 439). Special non-response study of the Danish private practitioners Because of the low response rate in this group, a special non-response analysis was performed. There were significantly more men in the sample and also more dentists with managerial responsibility and dentists with longer working hours among the group of non-respondents. No statistically significant differences were found with regard to time since graduation, workload or if they were satisfied and felt fulfilled in their work. A statistically significant difference was found with regard to perceived general health, where the non-respondents rated their health as better than that of the respondents (Table IV). General characteristics of the respondents The Swedish private practitioners had a much lower proportion of female respondents, with only 33% compared to the other three subgroups: of the Danish private practitioners 65% were women, and for the public-practising dentists there were 71% women in Sweden and 87% in Denmark. In both private and public dentistry in Sweden, 89% and 86%, respec- tively were born in Sweden, compared to 96% and 94%, respectively in private and public dentistry born in Denmark. Most private-practising dentists were married or cohabiting (91% in Sweden and 88% in Denmark), which was the case for 86% of the Swedish and 85% of the Danish public-practising dentists. As many as 91% of the private-practising dentists had Table II. Questions used in the non-response study. Question Response Your gender? Male Female I am: Practice owner in private practice Employed in private practice Which year did you complete your dental education? Year_____ How many hours per week do you work as a dentist? Total ____ hours To what degree do you experience the following in your work: To a very low degree To a low degree To some degree To a high degree To a very high degree - Work fulfilment? - Satisfaction with your work as a whole? How do you assess the extent of your workload? Much too small Too small Appropriate Too great Much too great In general, would you say your health is: Poor Acceptable Good Very good Excellent Table III. Questions used to create the additive index. Question Response To what degree do you experience the following in your work?: To a very low degree To a low degree To some degree To a high degree To a very high degree - Work fulfilment - Satisfaction with your work as a whole? Do you feel that you have a good working life? Not at all To a low degree To some degree To a high degree To a very high degree Overall job satisfaction among dentists 5 ActaOdontolScandDownloadedfrominformahealthcare.comby188.177.16.241on09/07/10 Forpersonaluseonly.
  • 54. managerial responsibility in Sweden, but only 15% of the public ones. In Denmark, 76% of the private- and 62% of the public-practising dentists had managerial responsibility. All questions in Table V showed significant differences between the subgroups (P £ 0.001). Overall job satisfaction The items were negatively skewed for all four groups (skewness –1.0 to –0.3). The average share of internal non-response was 1%. PCA showed a one-factor solution. Results were stable with regard to gender and the four subgroups: Swedish public/private and Danish public/private. An additive index (range 3–15) was constructed as Over- all job satisfaction. The distribution was normal but slightly negatively skewed (–0.65). For the whole sample as well as for the subgroups, both median and mode were 12. The four subgroups Danish public/ private practitioners and Swedish public/private practitioners showed some differences in the overall job satisfaction means. Using the Kruskall– Wallis test on the index between the four groups (P £ 0.001) indicated that they did not have equal means (Table VI). Discussion The results showed organizational differences in the perception of overall job satisfaction. The Swedish public dentists were the least satisfied, and the Danish public dentists were the most satisfied. There were differences between the subgroups in all general char- acteristics analysed. Especially great differences were found among women respondents. In the special non- response study, greater proportions of dentists who were males, had managerial responsibility, worked longer hours and had better perceived general health were found among the non-respondents. An average response rate of 68% was achieved for the whole study. Table IV. Special non-response analysis for Danish private practitioners. Sample respondents Non-respondents (n = 30) % Mean SD n % Mean SD P for difference Gender (male/female) 35/65 – – 413 67/23 – – 0.02 Managers 76 – – 413 87 – – 0.001 Year since graduation 20 4.8 412 20 3 0.092 Working hours per week 36 7.6 405 40 11 0.001 Self-perceived health 3.7 0.9 413 4.2 0.6 0.001 Workload 3.4 0.6 411 3.6 0.6 0.131 Degree of work fulfilment 4 0.7 409 4.1 0.6 0.085 Degree of satisfaction with work as a whole 3.9 0.7 407 4.1 0.7 0.106 Table V. General characteristics of the general practising dentists grouped by nationality and affiliationa . National and organizational affiliation Swedish private Swedish public Danish private Danish public Mean SD n Mean SD n Mean SD n Mean SD n Years since graduation 26 10 300 21 12 297 20 5 412 26 9 159 Average practice size: No. of dentists 2.2 1.5 197 6 3.2 292 2.8 1.5 401 3 2.3 155 No. of dental hygienists 1 1 301 3 2 291 0.8 1 411 1.3 1.7 156 No. of dental nurses 3 3 301 10 5.4 291 4.3 2.3 411 5.7 4.4 156 Average working hours 38 8.4 297 35 8 296 36 7.6 405 32 6.4 158 Satisfaction with work 3.9 0.9 295 3.6 0.8 292 3.9 0.7 407 3.9 0.7 158 Work fulfilment 3.9 0.9 297 3.7 0.8 292 4 0.7 409 4 0.7 158 A good working life 4 0.8 301 3.7 0.8 294 4 0.8 413 4 0.7 159 a Statistically significant differences in mean rank between subgroups for all variables (P £ 0.001). 6 K. Bergström et al. ActaOdontolScandDownloadedfrominformahealthcare.comby188.177.16.241on09/07/10 Forpersonaluseonly.
  • 55. In a recently published review of response rates for healthcare professionals, including dentists, average response rates of 35–68% were found [31]. The average response rate in this study may therefore be considered acceptable. While previous research on dentists in Sweden and Denmark has shown higher response rates [15,26], a third reminder was consid- ered for the Danish private-practising dentists. Instead, a special non-response study was decided on. Interviews revealed that the non-respondents simply felt they had a lack of sufficient time to respond to questionnaires in general. They also worked longer hours than the respondents, which did not seem to affect their job satisfaction in a negative way. The Danish private practitioners also had greater propor- tions of males and managers, the latter often having increased responsibility and working longer hours. This could be the simplest explanation for the higher proportion of non-respondents in this group. The proportions of public and private practitioners in each country were reflected by the sample con- struction. Except for the Swedish private practi- tioners, the proportion of female respondents was more than two-thirds. Several studies within dentistry have shown a higher percentage of female respondents [32–34]. The national share of female dentists in Denmark was »55% in 2008 [35]. Therefore, there was an overrepresentation of women among the Danish public and private practitioners in the sample. This does not seem to be the case for the Swedish public and private practitioners, as the average share of women in the two subgroups was close to the 49% foundamongSwedishdentistsin2005[35].Thefemale dentists in the sample worked on average four hours less per week than the male ones. The gender differences among respondents might be a confounder for working hours, giving the female dentists more time to respond. The overrepresentation of female respondents in the sample might affect job satisfaction through organiza- tional factors such as opportunities for practising fem- inist values in human service work, as for example in emotional and care work [7]. The Danish public practitioners comprised many more dentists with managerial responsibility than the Swedish public ones. Also, the Danish public clinics had almost half as many employees as the Swedish public clinics. This could be a reflection of a signif- icant difference in how the ideas behind NPM are implemented in the public sector in the two countries, which in Denmark involves smaller units and decen- tralized management. Good work and job satisfaction as terms As a scientific expression, Good work is mostly used to describe a form of best practice in a cer- tain job, unifying professional expertise and social responsibility. A dual sense of the adjective ‘good’ is often used: (1) high-quality work objectively judged by people knowledgeable about the domain; and (2) work that goes beyond the worker and benefits a wider good [36]. Good work and a good job can also differ, by stating that a good job does not always provide the possibility of doing good work [37]. Gardner [38] acknowledges the individual requirements and states: “It is always a challenge, requiring ethical commitment and skill on the part of each individual worker.” (p. 6). It is hard to imagine what any ‘objective’ measure of good work would imply. Good work is an individual Table VI. Factor analysis on items concerning overall job satisfaction for dentists in Sweden and Denmark. PCA No. of factors KMO Communalities Variance explained (%) Factor loadings a Whole sample 1 0.708 0.695–0.826 78 0.834–0.909 0.86 Swedish private 1 0.671 0.617–0.839 76 0.785–0.916 0.84 Swedish public 1 0.715 0.717–0.835 79 0.847–0.914 0.87 Danish private 1 0.714 0.703–0.805 76 0.839–0.897 0.84 Danish public 1 0.733 0.769–0.853 82 0.877–0.924 0.89 Men 1 0.722 0.738–0.844 80 0.859–0.919 0.87 Women 1 0.693 0.662–0.826 76 0.814–0.909 0.84 Overall job satisfaction index (range 3–15) Mean SD n P between all subgroups Swedish private 11.8 2.2 294 Swedish public 11.0 2.1 287 Danish private 11.8 1.9 405 Danish public 11.9 1.9 157 All subgroups 11.6 2.1 1197 £0.001 KMO = Kaiser–Meyer–Olkin. Overall job satisfaction among dentists 7 ActaOdontolScandDownloadedfrominformahealthcare.comby188.177.16.241on09/07/10 Forpersonaluseonly.