Job Satisfaction

The Safety Attitudes Questionnaire (SAQ) is a refinement of the Intensive Care Unit Management Attitudes Questionnaire, [14 (link),15 ] which was derived from a questionnaire widely used in commercial aviation, the Flight Management Attitudes Questionnaire (FMAQ). [16 ,17 ] The FMAQ was created after researchers found that most airline accidents were due to breakdowns in interpersonal aspects of crew performance such as teamwork, speaking up, leadership, communication, and collaborative decision making. The FMAQ measures crew member attitudes about these topics.
Because 25% of the FMAQ items demonstrated utility in medical settings in terms of the subject covered and factor loadings, they were retained on the SAQ, The new SAQ items were generated by discussions with healthcare providers and subject matter experts. In addition, we relied upon two conceptual models to decide which items to include: Vincent's framework for analyzing risk and safety [8 (link)] and Donabedian's conceptual model for assessing quality [18 (link)] This generated a pool of over 100 new items covering four themes: safety climate, teamwork climate, stress recognition, and organizational climate. Items were evaluated through pilot testing and exploratory factor analyses. This phase of survey development consistently yielded 6 factor-analytically derived attitudinal domains containing 40 items from the survey (two, three, four, and five factor structures were less robust). Three of the targeted themes, safety climate, teamwork climate, and stress recognition, emerged as factors. In particular, safety climate and stress recognition are conceptually quite similar to their counterparts in aviation. [19 ] The fourth targeted theme, organizational climate, consistently emerged as three distinct but related factors, perceptions of management, working conditions, and job satisfaction. Organizational climate plays a decisive role in setting the preconditions for success or failure in managing risks [3 ,4 (link),20 (link)] , and we therefore retained these three factors as part of safety attitude assessment. An additional 20 items were retained because they were deemed interesting and valuable to the unit managers and senior hospital leadership to whom we reported the results of our pilot studies.
The SAQ has been adapted for use in intensive care units (ICU) [15 ,21 ] , operating rooms (OR), general inpatient settings (medical ward, surgical ward, etc.), and ambulatory clinics. For each version of the SAQ, item content is the same, with minor modifications to reflect the clinical area. For example, "In this ICU, it is difficult to discuss mistakes," vs. "In the ORs here, it is difficult to discuss mistakes." The SAQ elicits caregiver attitudes through the 6 factor analytically derived climate scales: teamwork climate; safety climate; job satisfaction; perceptions of management; working conditions; and stress recognition (Figure 1).
The SAQ is a single page (double sided) questionnaire with 60 items and demographics information (age, sex, experience, and nationality). The questionnaire takes approximately 10 to 15 minutes to complete. Each of the 60 items is answered using a five-point Likert scale (Disagree Strongly, Disagree Slightly, Neutral, Agree Slightly, Agree Strongly). Some items are negatively worded. There is also an open-ended section for comments: "What are your top three recommendations for improving patient safety in this clinical area?" Each version of the SAQ in the current study includes a "Collaboration and Communication" section, where respondents are asked to indicate the quality of collaboration and communication they have experienced with each of the types of providers in their clinical area (e.g., Staff Surgeons, Surgical Residents, Staff Anesthesiologists, OR Nurses, etc.) using a five-point Likert scale (Very Low, Low, Adequate, High, Very High).

The answers of the 231 insurance physicians were used to determine which concepts from the questionnaire were suitable for further analysis. The responses given by the insurance physicians were inspected. For some items it was necessary to recode the original items in fewer categories as some categories were empty or almost empty. Negatively formulated items were recoded positively.
Scales were formed for the following already validated scales: job satisfaction, self-efficacy, work pressure, emotional workload, decision-making authority, emotional exhaustion and engagement. Cronbach's alpha was computed for each of these scales. For the remaining items, factor analyses with principal components analysis and varimax or oblique rotation per block of items, were performed to extract factors for each theoretical concept. Oblique rotation was chosen only if there was a significant correlation between the extracted factors. Where this was not the case, we decided to use varimax rotation. Bartlett's test of sphericity was used to test whether the correlation matrix was an identity matrix. The sampling adequacy was inspected by means of the Kaiser-Meyer-Oikin measure (KMO) and found to be greater than 0.6. The number of extracted factors was decided on the basis of the scree test, the Eigenvalue and, most of all, the interpretability of the extracted factors. For each extracted factor, reliability analysis, including item analysis, was performed to construct additive scales from the items of the factors. An additive scale is constructed of numerical categories of items that can be meaningfully added. In the item analysis, the contribution of each item to the reliability of an additive scale can be estimated. If an item did not contribute to an additive scale, this item was deleted from this scale. When Cronbach's alpha was equal to or larger than 0.6, additive scales of the selected items were calculated. We nonetheless also decided to use additive scales in three cases where Cronbach's alpha was less than 0.6 (0.560, 0.566 and 0.594, respectively). These three scales were considered to be theoretically important. For each additive scale we also calculated the percentage of respondents who, on average, scored above the theoretical mean of the additive scale. This means that in case of an additive scale consisting of four Likert scale items ranging from 1 to 5, we report the percentage of respondents with a scale average above 3*4 = 12.0. In the remaining text when we refer to scales, we mean 'additive scales'.
For some blocks of items and for some individual items it was not possible to construct a scale for several reasons: the correlation matrix was not an identity matrix, and/or the sampling adequacy was not good, or Cronbach's alpha was too small. We grouped these 'lost' items on a theoretical basis, recoded them, if necessary, into two or three categories and used HOMALS (homogeneity analysis by means of alternating least squares) to analyse the dimensions behind these grouped items [89 ]. The number of dimensions was decided on basis of the sum of the Eigenvalues of the dimensions. We estimated for each dimension the discrimination measures of the items, the category quantifications of categories of items, and the object scores of the cases. We used the discrimination measures and the category quantifications to interpret both poles (negative and positive) of the dimensions. The object scores of the dimensions that were meaningful and gave additional information were selected as variables. Because object scores of multiple Homals dimensions are constructed with non-linear transformations [90 ], they are not scales, and reliability analysis cannot be performed. Therefore, we call these variables 'dimensions', contrary to the variables which we constructed as additive scales, which we call 'scales'. We used the SPSS 15.0 program [86 ] for the factor analyses, reliability analyses and the HOMALS analyses.

For this survey, an institutional review board exemption (Charité – University Medicine Berlin, EA1/174/20) was obtained. All analyses were conducted in compliance with the revised Declaration of Helsinki.
A questionnaire was distributed via the German Roentgen Society’s (DRG) conference of university professors (KLR) and German Young Radiology Forum, the European Society of Radiology (ESR) and its Radiology Trainee Forum, and the Radiological Society of North America’s (RSNA) Resident and Fellow Committee and manually sent to 4500 radiologists of the biggest German hospitals between December 2020 and April 2021. It consisted of 66 items about (a) professional background, (b) current professional situation, (c) job satisfaction, (d) career aims, and (e) personal information. To enable quantitative analyses of the participants’ responses, besides open questions, Likert scales, e.g., to assess the agreement to different work expectations, were employed. The complete questionnaire is provided as Supplement 1 to this article.
As most respondents worked in Germany and the number of participants from other countries was not representative, this article only employs data from participants with German affiliations.

Characteristics of study participants are presented as mean with standard deviation (SD) for continuous data or proportions for categorical data. The responsibilities of study participants in the medical working area are shown in proportions.
For the evaluation of the information on job satisfaction, the percentage of study participants per item answer was calculated.
For the analysis of DASS-21 subscale scores, the respective items for each subscale were summed up and multiplied by 2, to receive values equivalent to the full version of the DASS-21 (44 (link), 45 ). To identify differences in DASS-21 subscale scores by gender, region, working unit, responsibilities, how often these responsibilities were carried out, net income per month, and overall job satisfaction, mean values and corresponding SD were calculated and analyzed using t-test and ANOVA. If the requirements for ANOVA were not fulfilled, the Kruskal–Wallis test was used. Statistical analysis was performed using the JASP software package (47 ), and a p-value of ≤ 0.05 was considered statistically significant.

The survey consisted of questions assessing sociodemographic (age, gender, family status, and region) and work-related items (net income per month, medical working area, and responsibilities), items from the short questionnaire of general and facet-specific job satisfaction (KAFA, Kurzfragebogen zur Erfassung von Allgemeiner und Facettenspezifischer Arbeitszufriedenheit) by Haarhaus (7 (link)), and items from the German version of the Depression, Anxiety, and Stress Scale (DASS-21) (44 (link), 45 ).
The KAFA was used to evaluate the job satisfaction of study participants. It is based on the Job Descriptive Index (46 ) and validated for a German sample with satisfactory psychometric properties (7 (link)). It included both general and facet-specific job satisfaction in six items with a total of 30 questions related to the work itself, coworkers, promotions, pay, and supervision. In the actual version of the KAFA, each question had to be rated with a 5-point Likert scale. To shorten the questionnaire, items of the KAFA were reduced without changing the original items. Only one answer per item could be selected.
The DASS-21 was used to monitor depression, anxiety, and stress of study participants. It is a 21-item questionnaire with three 7-item subscales. Each item is scored on a 4-point scale [ranging from never (0) to always (3 (link))]. Subscale scores were calculated as the sum of the responses to the seven items from each subscale multiplied by 2 to get scores equivalent to the 42-item full DASS. The cutoff scores for DASS-21 were taken from Lovibond and Lovibond (44 (link)): depression (normal 0–9, mild 10–13, moderate 14–20, severe 21–27, extremely severe 28+), anxiety (normal 0–7, mild 8–9, moderate 10–14, severe 15–19, extremely severe 20+), and stress (normal 0–14, mild 15–18, moderate 19–25, severe 26–33, extremely severe 34). For the cutoff values of 10 for depression, 8 for anxiety, or 15 for stress, an increased expression of these characteristics can be assumed.