The moderating role of paternalistic leadership in the relationship between job satisfaction and job stress among health workers in Gaziantep, Turkey

Abstract

BACKGROUND:

Adopting an effective leadership style is of critical importance in increasing healthcare efficiency and therefore determining patient satisfaction. For example, although there are many new and effective leadership types today, the paternalistic leadership approach can still play an effective role in developing countries.

OBJECTIVE:

The aim of this study is to examine the moderating role of paternalistic leadership in the relationship between job satisfaction and job stress.

METHODS:

A total of 466 healthcare workers completed measures of perceived paternalistic leadership, job stress, and job satisfaction. The research was conducted in the center of Gaziantep, one of the largest cities in Turkey. Regression analysis was used to evaluate the moderate variable. Dawson slope were used to visualize the results.

RESULTS:

A negative relationship was found between job satisfaction and job stress. Additionally, it has been determined that the perception of paternalistic leadership has a moderating role. It has been observed that as the perception of paternalistic leadership increases, the negative relationship between job satisfaction and job stress decreases.

CONCLUSION:

It has been concluded that the paternalistic leadership approach can play a critical role in increasing the productivity of healthcare workers and reducing the negative effect of stress on satisfaction. It has been suggested that policies be developed to develop appropriate strategies for creating work environments that will increase employees’ perceptions of paternalistic leadership.

1. Introduction

Many factors such as aging, population growth and epidemics increase the need for health services. Health workers working in hospitals are the groups that make the most effort to meet this need. Employees, one of the most critical elements of health service delivery, can be affected by the working environment in the institution. The main factors that make this effect positive or negative are the leadership styles exhibited by the managers in the institution [1]. Especially in recent years, the adoption of an effective leadership style has become even more critical for managers who want to increase the quality of health institutions [2, 3].

Leaders have the ability to shape the behaviors, attitudes and values of their followers within the framework of a reciprocal relationship. When these people meet a common goal, they can achieve more successful results by getting the support of their employees [4]. Leadership is more critical in healthcare organizations, which are one of the larger organizations. The role of leadership becomes more important, especially in health institutions, where there are too many sub-disciplines and in determining common goals for individuals working in this discipline. At this point, many elements such as benefiting from diversity and better organizing management processes are expected behaviors from leaders [5].

One of the leadership approaches that is still valid and widely used today is paternalistic leadership [1, 6]. With this leadership approach, managers behave in a fatherly manner towards their employees and motivate them. Many studies have revealed that paternalistic leadership can affect employee behaviour at work [7, 8] and outside of work [9]. In this study, the effect of paternalistic leadership on job satisfaction and job stress was examined, taking into account healthcare workers. Additionally, the moderating role of paternalistic leadership in the relationship between job stress and job satisfaction was evaluated.

2. Job satisfaction and job stress

Today, job satisfaction is defined as any combination of environmental, psychological and physiological conditions that causes a person to say that he is truly satisfied with his job. This approach clearly emphasizes the impact of both internal and external factors on job satisfaction [10]. In particular, features such as equality in the workplace, meeting the needs of employees in the workplace and meeting positive working conditions play a critical role in creating job satisfaction [11]. In short, job satisfaction, which is seen as a mediator of commitment to both the employer and the job, can also be defined as a concept that emerges from the interaction of work environment values and worker commitment [12]. Since each sector has its own dynamics, the factors affecting job satisfaction may change. Mishra [13] grouped the factors related to job satisfaction under three headings as personal, work-related and factors that can be controlled by the management. Gender, age, work time and education are personal factors. Job-related factors are responsibility, worker status, required skills, and type of job. Factors that can be controlled by management are opportunity for promotion, security, benefits, working conditions and wages. Meier and Spector [14] expressed work-related factors and management-related factors as situational characteristics in their study. The same study stated that situational characteristics known as job stressors affect employee job satisfaction.

A high level of job satisfaction plays a critical role in the productivity of both employees and institutions. Many studies have shown that as job satisfaction increases, organizational commitment [15] and employee motivation [16] can increase. Likewise, studies have given a lot of evidence that as job satisfaction increases, turnover intention[17], depression and anxiety levels [18], job stress [19] and emotional exhaustion [17] may decrease.

Health is one of the sectors that have focused on the job satisfaction approach in recent years [20, 21]. Organizations that want to increase the performance levels of their employees try to increase job satisfaction. At this point, many factors such as the division of labour and being a stress-intensive industry have made the job satisfaction process even more critical [22]. For example, Shirali et al. (2021) stated in their study that one of the main factors that increases job stress is the working environment [23]. Similarly, in their systematic review, Van Ham, Verhoeven [24] revealed that the factors that reduce job satisfaction are lack of recognition, lack of time, heavy workload, administrative burden, overtime working hours and low income.

Selye was one of the first scientists to include the concept of stress in scientific research. Stress was originally defined as the body’s non-specific response to any harmful stimulus [25]. In the same period, Cannon defined stress as a result of homeostasis and tried to reveal the effect of the sympathetic system [26]. In short, stress is used to describe physiologically and emotionally challenging experiences [27]. In a broader definition, stress is known as the metabolic and physiological disruptions caused by various aggressive agents and the psycho-physiological response of the organism faced with a perception of threat/ challenge [26].

There are many stressors that increase the stress level of individuals. When we look at our lives in general, the most common stressors are death of wife, divorce, death of close relative, illness, marriage, job loss, marital reconciliation, retirement, birth, moving to a new house, and holidays [28]. When we look at the work environment, stressors such as career development, role conflicts, relationships at work, excessive workload and shift work are encountered [29]. Today, psychosocial work environments such as job stress have become more popular topics. Biological, chemical and physical hazards in institutions have been focused on, and ensuring the safety and health of employees has become the main task of organizations [30]. On the other hand, it has been proven by many studies that employee health is adversely affected when job stress is high [31]. The study by Backé, Seidler [32] revealed that job stress is one of the main factors in the increase of cardiovascular diseases. Kivimäki and Kawachi [30] stated in their study that job stress increases the risk of stroke.

Stress in the workplace affects the health of employees as well as the efficient working of employees and institutions. For example, a systematic review of nurses revealed that stress is effective in decreasing performance capacity, decreasing productivity, and lack of interest in colleagues/organization [33]. Likewise, in another study conducted on physicians, it was stated that job stress increases the level of burnout and decreases the quality of life [34]. In this study, it was aimed to examine the relationship between job stress and job satisfaction. Looking at previous research, many studies on nurses [12], midwives [35] and physicians [36] have provided evidence of low job satisfaction levels of employees experiencing stress. Similarly, the following hypothesis was developed based on these studies.

Hypothesis 1. There is a negative relationship between job satisfaction and job stress levels.

3. Paternalistic leadership, job satisfaction and job stress

There are many definitions of leadership. Peter Drucker has briefly defined leadership as “someone who has followers”. Warren Bennis, on the other hand, defined leadership as “the function of knowing oneself, having a well-transmitted vision, building trust among colleagues, and taking effective actions to realize one’s own leadership potential” [2]. Examination and definition of leadership is directly related to the leadership understanding of individuals and organizations [37].

Leadership theories are dynamic and change over time. The first known of these theories is the Great Man theory. With this theory, it is believed that leadership characteristics are innate. After the 1940 s, leadership styles such as democratic and authoritarian leadership emerged. In these processes, the focus is on probability and state theories. It was stated that employees should focus on their environment and duties. Afterwards, especially after the 1970 s, new approaches such as the interactional leadership style have been proposed. It is emphasized that the leader affects the environment he is in and that he should interact with the follower. These approaches, expressed as supportive leadership, underlined the need to empathize with and motivate employees [5].

Today, leaders should be able to analyse their environment and their competitors well and be proactive in their decisions. Likewise, leaders should be able to motivate employees well and direct them in line with the basic objectives of the institutions. At this point, one of the most effective methods is the paternalistic leadership style. Although there are many different conceptualizations of paternalistic leadership, researchers have argued that paternalistic leadership includes three important leadership styles: moral, benevolence and authoritarianism leadership. Paternalistic leaders are authoritarian and expect followers to follow their decisions. Paternalistic leaders are also benevolent and moral individuals. They show a personal interest in the well-being of their followers and exemplify a life of supreme personal virtues, dedication and honesty [38]. In short, a paternalistic leader is someone who combines strong discipline and authority with paternal affection and moral honesty expressed in a ‘personal’ atmosphere [39].

Although many factors such as the socio-cultural structure of the society and the level of development are effective, the paternalistic leadership style is still widely and effectively used in many countries. It can especially positively affect the work-related behavior and corporate performance of healthcare workers. For example, a study conducted on nurses in Pakistan by Zhijie, Gull [40] found that paternalistic leadership reduces work-family conflict and increases life satisfaction. Likewise, another study conducted in Turkey by Saygili, Özer [7] concluded that the performance of healthcare workers was positively affected by paternalistic leadership. Similarly, this study aimed to examine the effect of paternalistic leadership on job satisfaction and job stress. When looking at the literature, studies show that both job satisfaction and job stress may be related to paternalistic leadership. For example, Putra [41] stated in their study that the job satisfaction levels of bank employees are positively affected by paternalistic leadership. Likewise, Nassir and Benoliel [42] revealed in their study that teachers’ job stress levels were negatively affected by paternalistic leadership. Apart from this, when we look at the studies conducted in the field of health, the studies examining the relationship between job stress and job satisfaction and paternalistic leadership are quite limited. This study aims to fill this gap in the literature. It was evaluated whether paternalistic leadership perceptions of healthcare workers played a regulatory role in the relationship between job satisfaction and job stress. To our knowledge, there is no study examining a similar model in the literature.

Hypothesis 2. The perceived paternalistic leadership has a moderating role in the relationship between job satisfaction and job stress.

4. Method

4.1. Aim

The aim of this study is to examine the moderating role of paternalistic leadership perceptions of healthcare workers in the Gaziantep province of Turkey on the relationship between job satisfaction and job stress.

4.2. Study group

It is a cross-sectional study. The main reason for choosing this research methodology is to make inferences about the cause-effect relationships between the variables of our research (paternalistic leadership, job satisfaction and job stress) by taking into account a certain time period. The population of the research is healthcare workers working in Gaziantep, Turkey. Gaziantep is one of the important metropolitan cities of Turkey. In this city, where there are significant investments in trade and industry, investments in health are increasing day by day. However, when looking at studies comparing provinces in Turkey in terms of indicators, it is seen that Gaziantep receives lower scores in terms of health than other provinces. This situation reveals that health services in Gaziantep need to be examined from various aspects. In this study, the group of healthcare workers was taken into account and the antecedent factors that may affect the stress status of healthcare workers were examined [43, 44]. There are a total of 31 hospitals and 13328 healthcare workers in the city. Considering the 5% margin of error, it was determined that 374 healthcare workers should be reached. Data was collected between September 26 and October 21, 2022. A total of 466 surveys were returned from visits to hospitals that allowed the research. The health workers were informed that the data would be anonymized and used in the study, and verbal consent was obtained. Permission was obtained from the Social and Human Sciences Ethics Committee to conduct the research.

4.3. Data collecting tools

The first part of the questionnaire form consists of demographic variables. These; marital status, types of institutions, experience, age and gender. In the other parts, the Perceived Paternalistic Leadership, the Job Stress Scale and the Job Satisfaction Scale were used. Cronbach Alpha values were checked to evaluate the validity of the scales.

Job Satisfaction. The scale developed by Judge, Locke [45] was used to determine the job satisfaction levels of healthcare workers. The Turkish validity and reliability study of the scale was carried out by Keser and Bilir [46]. The scale consists of five expressions such as “I am quite satisfied with my current job,” “I find my job fun” and “Most days I go to work with enthusiasm” Participants’ answers were scored using a five-point Likert scale (ranging from one (strongly disagree) to five (strongly agree)). Apart from this, in our study, it was found that the Cronbach Alpha value of the scale was at a good level (α = .88).

Job Stress. The scale developed by Cohen, Kamarck [47] was used to determine the job stress levels of healthcare workers. The Turkish validity and reliability study of the scale was carried out by Eskin, Harlak [48]. The scale consists of 10 expressions such as “In the last month, how often did you feel like everything was going well?” and “In the past month, how often did you feel irritable and stressed?” Participants’ answers were scored using a five-point Likert scale (ranging from zero (never) to four (every time)). Apart from this, in our study, it was found that the Cronbach Alpha value of the scale was at a good level (α = .85).

Paternalistic Leadership. The scale developed by Aycan, Schyns [49] was used to determine the perceived paternalistic leadership levels of healthcare workers. The scale consists of 10 expressions such as “My manager attaches importance to creating a family atmosphere at work” and “My manager is ready to help employees with non-work matters whenever they need it” Participants’ answers were scored using a six-point Likert scale (ranging from one (strongly disagree) to six (strongly agree)). Apart from this, in our study, it was found that the Cronbach Alpha value of the scale was at a good level (α = .94).

4.4. Statistical analysis

SPSS (v.26) was evaluated for data analysis. The relationships between job satisfaction, job stress and paternalistic leadership were examined using Pearson analysis. Regression analysis was used to evaluate the moderate variable. Dawson [50] slope were used to visualize the results. The level of significance was.05.

5. Results

The personal characteristics of the participants are presented in Table 1. It was observed that 54.7% were married, 67.2% of the participants were female and 51.3% were worked in public institutions. Mean age of the respondents was 31.16 years. Apart from this, the job stress levels of the participants were moderate (1.67±0.74); paternalistic leadership (3.99±1.25) and job satisfaction (3.39±0.93) were found to be at a good level.

Table 1.

Descriptive statistics of paternalistic leadership, job stress, job satisfaction and personal characteristics

Personal characteristics	Frequency	%
Gender
Female	313	67.2
Male	153	32.8
Marital Status
Married	255	54.7
Single (Unmarried, Divorced/Widowed)	211	45.3
Types of Institutions
Public	239	51.3
Private	227	48.7
	Mean	Standard
Deviation
Age	31.16	6.79
Experience (year)	7.27	5.69
Paternalistic Leadership	3.99	1.25
Job Stress	1.67	0.74
Job Satisfaction	3.39	0.93

Pearson correlation test was used to determine the level and direction of the relationships between paternalistic leadership, job satisfaction and job stress. Correlation values vary between 0 and 1. A value close to 1 indicates the level of the relationship. Looking at the results (Table 2), there is a negative relationship between job stress and paternalistic leadership (r = –0.228; p < .01). Likewise, a negative relationship was found between job satisfaction and job stress (r = –0.370; p < .01). On the other hand, there was a positive relationship between paternalistic leadership and job satisfaction (r = 0.516; p < .01).

Table 2.

Pearson correlations of the variables

Variables		1	2	3
Paternalistic Leadership (1)	r	–
Job Stress (2)	r	–.228**	–
Job Satisfaction (3)	r	.516**	–.370**	–

^**Correlation is significant at the 0.01 level. r: correlation coefficient.

Regression analysis was used to reveal the effect of paternalistic leadership and job stress on job satisfaction. In the model developed in this context, job satisfaction was taken into account as the dependent variable. The independent variables were job stress, paternalistic leadership and interaction factors. The model shown in Table 3 was found to be significant (p < .05). Both job stress (β= –0.238; p < .05) and paternalistic leadership (β= –0.430; p < .05) affect job satisfaction. Likewise, it is seen that the interaction value has an effect on job satisfaction (β= –0.170; p < .05). This result shows that paternalistic leadership has a moderator role in the effect of job stress on job satisfaction.

Table 3.

Moderating test regression weights

Dependent variable	Independent variable	Estimates	Standard error	p	R2 = .365 F = 90.065 p = .000b
Job satisfaction	(Constant)	3.354	.035	0.000
	Job Stress	–.238	.036	0.000
	Paternalistic Leadership	.430	.035	0.000
	Interaction (Paternalistic Leadership*Job Stress)	–.170	.033	0.000

Dawson slopes were used to more clearly reveal the moderating role of paternalistic leadership in the relationship between job satisfaction and job stress. According to Fig. 1 obtained by this method, it is understood that the relationship between job stress and job satisfaction is shaped by perceived paternalistic leadership (moderator). As paternalistic leadership increases, the negative effect of job stress on job satisfaction decreases.

Fig. 1.

Moderating effect of high and low paternalistic leadership (PL).

6. Discussion

In this study conducted on healthcare workers in Gaziantep, Turkey, the relationships between paternalistic leadership, job satisfaction and job stress were examined. Paternalistic leadership played a moderating role in the negative relationship between job stress and job satisfaction. While paternalistic leadership negatively affected job stress, it also positively affected job satisfaction.

The main purpose of this study is to examine whether paternalistic leadership has a moderator role in the relationship between job satisfaction and job stress. We have determined that the model we have established in this direction is meaningful. Our study revealed that the negative effect of stress on satisfaction may decrease with the increase of perceived paternalistic leadership. As far as we know, there is no other study supporting this result in the field of health. Apart from this, a similar model was used in the study conducted by Putra [41] on bankers in Indonesia. The results obtained from this study were compatible with the results of our study.

Paternalistic leadership is one of the most common leadership styles in healthcare institutions in Turkey. Although there are many studies stating that this type of leadership is common [7, 8], research examining its effect on job satisfaction is limited. With this study, it is aimed to fill this gap in the literature. Our result revealed that paternalistic leadership can positively affect job satisfaction. A study conducted on social workers, but not on healthcare workers, was consistent with our results. The research conducted by Aruoren [51] in Nigeria states that job satisfaction levels are positively affected by paternalistic leadership.

A study conducted in Qatar revealed that public health workers with high stress levels have low job satisfaction levels [52]. Similarly, a study conducted in China found a negative relationship between stress and job satisfaction [53]. Our result was consistent with the literature. We found that job stress can have a significant impact on job satisfaction.

Paternalistic leadership plays a critical role in creating a positive work environment. In our study, a result supporting this result was obtained. Although the correlation results we obtained were not strong, they revealed that there is a negative relationship between paternalistic leadership and job stress. When the literature is examined, it has been determined that there is no similar research in the field of health. Apart from this, it has been seen that similar studies conducted in different sectors support our results [54, 55].

There are some limitations regarding the generalization of the findings of this study to all healthcare workers. First, the study only includes healthcare workers working in a city in Turkey. Secondly, convenience sampling method was used when collecting data. Third, it is a cross-sectional study. Longitudinal studies should be conducted to reveal cause-effect relationships more clearly. Fourth, the relationships between the variables used in the study are unclear due to the limited number of studies conducted. This situation prevented the creation of the theoretical framework. Finally, only academic studies written in English and Turkish were taken into account.

7. Conclusion

The importance of paternalistic leadership for the employees in the institution has been clearly demonstrated with this study. It has been observed that as the perception of paternalistic leadership increases, the negative relationship between job stress and job satisfaction may weaken. Some critical evidence has been obtained that paternalistic leadership may have a critical role in controlling both job satisfaction and job stress.

It is critical for managers in health institutions to act with a paternalistic leadership understanding. At this point, managers can pay close attention to the problems of their employees and guide them by giving encouragement. Likewise, employees can be more helpful about the problems they encounter outside of work. On the other hand, training on leadership styles can be given to the managers in the institution. In this process, support can be obtained from experienced managers or academicians working in this field.

In future research, a comprehensive study including different cities may increase the generalizability of the results. Likewise, the effect of paternalistic leadership on satisfaction and stress was examined in this study. Apart from this, the creation of comprehensive models that take into account different organizational and personal effects will contribute to the field of health management. On the other hand, a qualitative study can be designed to more clearly reveal and interpret the effects of paternalistic leadership.

Ethical approval

This study was approved by the Social Sciences and Humanities Ethics Committee of Kahramanmaraş Sütçü Imam University (ref. no. 159893).

Informed consent

Verbal informed consent was obtained from the health worker(s) for their anonymized information to be published in this article.

Conflict of interest

We declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

We received no financial support for the research, authorship and/or publication of this article.