Job satisfaction of medical interns: a qualitative study using Herzberg’s hygiene motivation theory

Background: Human resource management policies and practices are not well understood and implemented in some health care settings. Besides affecting client outcomes, poor management practices can adversely affect the health and wellbeing of healthcare professionals such as nurses and doctors. The junior most doctors in the medical hierarchy of a hospital are interns. Owing to long working hours and heavy workloads, internship can be quite a stressful experience resulting in unprofessional and unethical behaviours as well as increased number of medical errors. Although there is an abundance of research on the difficulties faced by interns, there is a paucity of research highlighting their job satisfaction. Identifying factors that influence interns’ job satisfaction could inform better working conditions for interns as well as improve client outcomes and overall hospital performance. Methods: Job satisfaction was explored by one-to-one semi-structured interviews with 12 senior interns within the theoretical framework of Herzberg’s ‘hygiene-motivation’ or ‘two factor theory’. Data were analysed thematically. Results: Reasons for job satisfaction included feeling supported in the work place as well as getting quality supervision, teaching and clinical exposure. Reasons for job dissatisfaction included poor access to administration, unduly stressful working situations, lack of support for mental health and wellbeing and poorly organised teaching sessions. The results of this study closely align with Herzberg’s motivation hygiene theory showing that reasons for job satisfaction are mostly different from reasons for job dissatisfaction. Conclusion: The internship experience, together with the people they are influenced by, can determine a doctor’s future career pathway. It is therefore vital for internship coordinators and hospital managers to facilitate a positive internship experience. The findings have implications for human resource management policy and practice in


Background
Human resource management [HRM] policies and practices have been known to be linked to the performance of healthcare organisations for some time [1]. However, they are not well understood and implemented in some health care settings [2,3]. Besides affecting client outcomes, poor HRM practices can adversely affect the health and wellbeing of healthcare professionals such as nurses and doctors. There are reports of poor management practices resulting in decreased job satisfaction [2], emotional exhaustion resulting in low motivation and turnover intentions [4], as well as psychological distress and depression [5]. Nurses, allied health workers and junior doctors appear to be most affected [3].
The junior most doctors in the medical hierarchy of a hospital are interns. Internship, also referred to as prevocational training is a one year mandatory apprenticeship that medical students need to undertake in order to successfully complete their degree, [6].
Whilst medical students who have completed their five years of medical studies have preferences for hospitals to undertake their internship, hospitals also need interns on whom they depend on for much of the basic clinical work. However, research suggests that hospitals do not often invest in junior doctors [3].
Internship is the first year of transition for junior doctors from student to doctor. This transition has been described as a big cultural leap [7,8] and can be quite a stressful experience [9]. Stressors experienced by junior doctors include long working hours and heavy workloads [10], managing one's newly gained responsibility particularly during uncertain situations, encountering death, feeling unsupported [9], role ambiguity and conflict as well as work relationships [11,12].
Interns have reported emotional exhaustion, cynicism, low professional effectiveness and 4 burnout [13] as well as sleep deprivation, emotional distress [14] and depression [15]. The consequences of stress can result in unprofessional and unethical behaviours, [16] increased number of medical errors [17] and can adversely affect young physicians' empathy and attitudes towards their patients [14,18]. Despite the stress they are under, interns are not expected to talk about it but rather present themselves as being professional and competent at all times [19].
Although there is an abundance of research on the difficulties faced by interns, there is a paucity of research highlighting job satisfaction of interns. Identifying aspects of internship that influence interns' job satisfaction could help hospital managements understand what changes to make in working conditions for interns. After all, interns are at the coalface of patient care in hospitals and a happy intern can contribute to a happy patient. On the contrary, poor wellbeing among healthcare professionals has shown to adversely impact patient safety [20].

Theoretical Framework
Fredrick Herzberg's 'hygiene-motivation' or 'two factor theory' published in 1959 is a popular, albeit sometimes controversial theory has been used to explore job satisfaction [21]. According to Herzberg, factors affecting job satisfaction can be divided into two categories -hygiene factors and motivation factors. Hygiene factors are related to working conditions, interpersonal relations, supervision, company policy and administration, salary, and job security. Motivation factors relate to achievement, recognition, responsibility, and advancement and align with the self-actualisation needs of Abraham Maslow [22].
Herzberg borrowed the term hygiene from epidemiology where good hygiene prevents disease but does not make people healthy. Similarly, when hygiene factors are met, people will not be dissatisfied [23]. However, in order to increase satisfaction, motivation 5 factors must be met [21,24]. Therefore, according to Herzberg, there are two types of satisfaction: satisfaction with motivating factors and satisfaction with hygiene factors, both of which operate on a different continuum. There are also two types of dissatisfaction -dissatisfaction with motivating factors and dissatisfaction with hygiene factors which again operated on different continuums [23].
Herzberg's research showed no association between job satisfaction and mental health.
Nonetheless, it is now known that very high levels of job dissatisfaction can cause distress, and affect one's health [25]. Herzberg also discussed the importance of job enrichment in order to increase job satisfaction [26]. However, this is relevant only when job monotony is the problem [26]. This study had two objectives. 1. To ascertain the aspects of internship that interns were happy with and those that they were unhappy with.
2. To assess if the results from this study held true to Herzberg's hygiene motivation theory.

Study design
Using a qualitative methodology one-to-one interviews were conducted with interns.

Setting
The study was located in a region approximately 92-143kms from a major Australian capital city and is classified as a District of Workforce Shortage (DWS) for GPs [27]. The Rural Intern Training program was established as part of an endeavour to attract doctors to work in the region. It was set up as a partnership between three regional hospitals and an independent rural GP training company and employs up to 25 interns a year through Intern Match coordinated through the Post Graduate Medical Council of Victoria. During the program, interns spend 12 months moving through 5 of 10 possible rotations spread 6 over the three hospitals and general practice in the region. The program commences with a three-day orientation consisting of practical skills, simulation, and education sessions, which provide an opportunity for new interns to 'shadow' a current intern and help support transition to practice [28,29]. The program is aimed at maintaining safety and governance in prevocational training for interns. There is also a weekly protected teaching time throughout the training year.

Data collection
Semi-structured interviews [30] were conducted by the lead researcher via telephone except for one which was held face-to-face in a private office space that was approved by the participant. The interview commenced with two questions: 1.
Which aspects of your internship were you happy with and why?

2.
Which aspects of your internship do you think needed improvement and why?

Data analysis
Data from transcripts were analysed thematically [31]. After reading each transcript, chunks of data were inductively assigned codes [32]. Once all data were coded, the researchers stepped back from the data to look for similarities and connections between codes. Codes that were aligned to a similar topic were separated into groups. These groups, which were further refined by modifying or combining them developed into the basic construct of a theme [31]. Researchers worked together to review data within each code to ensure that the content and meaning represented each theme accurately. At each step of data analysis and after discussion, codes and themes were finalised. Hospital and rotation names have been removed to ensure confidentiality. Once thematic analysis was complete, attempts were made to align themes related to positive and negative experiences with Herzberg's hygiene and motivation factors.

Results
A total of 12 interns participated in this research project of who 7 were female. All were aged over 20 with one intern aged over 30 years. Two interns were from another country and one was from interstate. While one intern was a local resident, eight were resident over 100 kms from the region. Demographic characteristics are given in Table 1. On the topic of positive experiences of internship, four themes emerged from the data. They were: Supportive work environment, quality supervision, good teaching and advantages of rural internship. See Table 2 for themes, codes and representative quotes on positive 8 experiences. Four themes also emerged from the data on negative experiences of internship. They were: Poor access to administration, unduly stressful working conditions, lack of support for mental health and wellbeing and poorly organized teaching sessions.
See Table 3 for themes, codes and representative quotes on negative experiences. Positive experiences of internship

Supportive work environment
A comprehensive orientation at the start as well as a friendly and welcoming attitude of administrative staff made interns feel supported. They stated that a good work culture more than made up for the lack of resources in a health service and that supportive colleagues such as consultants and registrars who treated junior doctors well were key to maintaining a supportive workplace. In addition, interns also felt that it was important to feel safe and not have to make difficult decisions on their own. 14 Quality supervision This theme encompasses some of the aspects of good supervision. In more proceduredriven rotations, interns describe how they moved from being initially hand-held to doing on their own, under supervision. In other rotations, where the focus was on arriving at a diagnosis and planning treatment, they were able to discuss their findings and management plan with a supervisor before proceeding to treatment. The freedom to discuss their work with and ask questions to registrars and consultants was greatly valued by interns, particularly during their first rotations.

Good teaching
In this theme, interns speak about their experience of good teaching received during their internship. Regular hours dedicated to formal teaching of junior doctors that was conducted in some rotations was acknowledged by interns. Informal teaching such as those conducted on rounds or afterwards was also valued. Interns indicated that relevant teaching that was conducted one on one was more effective, even if it was not detailed.

Advantages of rural internship
This theme pertains to factors that make a rural internship more useful from that in the city. Interns suggested that there was generally better clinical exposure in a rural setting.
They also indicated that rural general practitioners tended to manage a wider variety of clinical conditions.

Negative experiences of internship Poor access to administration
This theme relates to the difficulties faced by interns in finding the right people to approach for their administrative issues.
Unduly stressful work situations 15 Interns described their experiences of stressful situations. A major cause of concern for interns was when they were alone with serious patients and no senior doctor was available to ask for guidance. Situations such as these made them feel alone and unsupported.
Lack of support for mental health and wellbeing Interns described a general dearth of available formal support systems for those experiencing a crisis although the participating hospital services did provide written resources for support. Participants also noted that when the cause of their stress was their supervisor, it was very difficult to get appropriate help. Peers were considered an important group from whom interns obtained support when they were in a crisis.

Poorly organized teaching sessions
Hospitals generally organise regular teaching sessions for junior doctors. However, sometimes, these sessions were poorly organised making it either irrelevant or difficult for interns to attend. Table 4 Comparison of themes from interviews and Herzberg's hygiene and motivator factors. Three themes related to negative experiences of internship aligned closely with hygiene factors. They were unduly stressful working conditions, poor access to administration and lack of support for mental health and wellbeing. One theme (Supportive work environment) related to positive experiences was also aligned with hygiene factors. Three themes, namely quality supervision, good teaching, and advantages of rural internship from positive experiences were closely aligned with motivator factors although one theme from negative experiences (Poorly organized teaching sessions) was also aligned with motivator factors. Hence three out of four themes from the results of this study held true for Herzberg's theory.

Discussion
This study explored the positive and negative experiences of interns. This is important for those involved in delivering training for junior doctors [33]. Having senior doctors and other work colleagues who treat them well was considered imperative for a supportive workplace. Previous studies have also shown that when they feel supported, junior doctors are likely to enjoy their work and learn more [33,34].
Stressful situations are commonplace in medical practice and junior doctors are more than likely to encounter them [9,10,35,36]. Our findings add to previous literature on the causes of stress among junior doctors such as heavy workloads and conflict in the workplace, [10,11]. What this study adds is a general lack of support systems in the workplace resulting in interns feeling unsupported. Easily accessible support in a time of crisis and stress management strategies are not commonly available for interns in hospitals [37]. Even when support systems are in place, they are often not very useful.
It is well known that workplace bullying is consistently associated with reduced mental health [38] and bullying of junior doctors is ubiquitous in the workplace. It is also recognised that very few junior doctors report on bullying due to factors such as fear of reprisals and impact on one's career [39][40][41][42]. However, even in the absence of bullying, the work environment can still be unsupportive. The findings of this study suggest that senior doctors need to go a step further and ensure that junior doctors are treated wellthat they can feel free to ask questions. Interns are particularly vulnerable in their first rotations. However, this inexperience does not appear to be considered when they are rostered [43]. Hence a new intern who gets posted to a busy department that has little in the form of supervision and mentoring might feel a considerable amount of stress.
Interns also described the different types of quality supervision. Previous studies have indicated that good supervision determined the ability of junior doctors to recognise and respond to patient deterioration [44] and resulted in them undertaking an increased number of activities [45]. However, types of supervision vary widely and there are no clear standards for supervisors or on what is expected of those who are supervised [46].
Nonetheless, some suggest that supervision must include creating pleasant learning environments and stimulating junior doctors to learn and function independently [47].
The Australian Curriculum Framework for Junior Doctors states that interns need to be provided with effective supervision, which means supervisors being available, offering learning opportunities and supervision according to the learner's competence and confidence as well as being a role model [48]. These aspects were highlighted by interns in this study. Hospital consultants routinely supervise registrars and junior doctors but rarely receive training in supervision [46].
Interns also described different types of good teaching. This included the regular routine teaching sessions conducted by the hospital, teaching on rounds and after hours teaching.
The emphasis however, was more on teaching that was relevant even if not very detailed.
A good clinical teacher is knowledgeable, competent, caring, professional, and motivating [49] and although most clinical teachers are interested in teaching, only a small fraction have actually received any teacher training [50,51]. Our findings concur with previous studies in that those teachers who were interested in teaching junior doctors found ways to do so.
Previous studies have indicated that a rural placement is an excellent way to learn medicine, [52][53][54] and develop a disposition to practice in rural areas [55]. Our findings concur with previous reports [55] in that there tends to be better clinical exposure in rural areas [54] making it a good place to start one's career.
Herzberg's theory and job satisfaction of interns According to Herzberg, themes about satisfaction (motivating factors) are not the same as themes about dissatisfaction (hygiene factors) [23]. For instance, themes such as good teaching and advantages of rural internship which related to advancement and achievement (motivating factors) were different from themes such as unduly stressful working conditions and poor access to administration which related to working conditions and administration (hygiene factors). Except for two themes, namely supportive work environment and poorly organised teaching sessions, the results of this study held true for Herzberg's theory. Nonetheless, it is important to note that during their internship, junior doctors are still learning their role and building their competencies. They are also learning the subtle hierarchies in the workplace. The work environment is therefore inextricably linked to learning [33] which is perhaps the essence of internship and could be considered a motivating factor. Furthermore, although supervision is traditionally a hygiene factor, in this study it was considered a motivation factor because the role of the supervisor in internship relates more to that of a teacher. Hence the responses such as 'being spoon-fed', having autonomy, being able to ask questions and being taught. Although internship might not be considered a part of traditional education, it essentially teaches interns how to translate their theoretical knowledge into practice and work in a team environment. More often than not, the internship experience together with the people they are influenced by, determines a doctor's future career pathway. It is therefore vital for internship coordinators to facilitate a positive internship experience.
Herzberg's motivation hygiene theory is not without criticisms [23,26]. Nonetheless, it makes a valuable contribution to human resource development by identifying factors that impact upon employee satisfaction [26]. A limitation of this study is that the number of interns was small and the study was restricted to one region. Geography, setting and culture might play a role in determining motivating and hygiene factors. However, the findings of this study can provide a starting point for health care managers when considering ways to improve experiences of interns.

Conclusion
This is perhaps the first study to explore factors that influence job satisfaction among interns. The results of this study closely align with Herzberg's motivation hygiene theory showing that reasons for job satisfaction are mostly different from reasons for job dissatisfaction. The findings have implications for health managers and internship coordinators.

Ethics approval
Ethics approval was obtained from Latrobe Regional Hospital Human Research Ethics Committee (Project no: 2018-12 LNR) Consent for publication Written informed consent for publication was obtained from all participants.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
AR, AJ and PH are part of the executive of one of the hospitals where this research was conducted. AI declares no conflict of interest.

Funding
This study was partly funded by the Postgraduate Medical Council of Victoria. 20 Author contributions AR conceived the idea for the study, and contributed to data analysis and writing of the manuscript. AI planned the study, undertook data collection and analysis and wrote the first draft. AJ and PH contributed to data analysis. All authors read and approved the final manuscript.