LIC

EN

TIA

TE

DIS

SE

RTA

TIO

N IN

OD

ON

TO

LOG

Y

KA

MIL

LA

BE

RG

ST

RÖ

M

MA

LM

Ö U

NIV

ER

SIT

Y 2

01

4

MALMÖ UNIVERSITY

205 06 MALMÖ, SWEDEN

WWW.MAH.SE

KAMILLA BERGSTRÖMJOB 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

JOB

SA

TIS

FA

CT

ION

AN

D E

MO

TIO

NA

L W

OR

K TA

SK

S

L I C E N T I A T U P P S A T SL I C

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, 2014Department of Oral Public Health

Faculty of Odontology

Dentists in Sweden and Denmark

This publication also available online see: www.mah.se/muep

To Björn

CONTENTS

PREFACE ....................................................................... 9

ABSTRACT .................................................................. 10

SAMMANFATTNING ..................................................... 12

INTRODUCTION .......................................................... 14The dentist-patient relationship at the core of dentistry work .......15Job satisfaction, ‘arbetsglädje’ and eudaimonia .......................17Emotion work ......................................................................19The intertwined values and logics in dentistry ...........................20

AIMS ......................................................................... 23

MATERIALS AND METHODS ........................................... 24Paper I ...............................................................................24Paper II ...............................................................................25Additional questions for empirical illustration ..........................25

RESULTS ..................................................................... 27Paper I ................................................................................27Paper II ...............................................................................27Additional results for empirical illustration ................................30

DISCUSSION ............................................................... 32Emotion work in dentistry ......................................................33

CONCLUSION ............................................................ 37

IMPLICATIONS ............................................................. 38

ACKNOWLEDGEMENTS ............................................... 39

REFERENCES ............................................................... 42

PAPERS ....................................................................... 45

APPENDIX ................................................................... 88

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 workIt 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 eudaimoniaFrom 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 dentistryA 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 collectionAs 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 methodsA 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 IIOne 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 IData collectionWe 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 IIEmotion 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 illustrationData 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

Subg

roup

s Sw

edis

h Pr

ivat

e Sw

edis

h Pu

blic

D

anis

h Pr

ivat

e D

anis

h Pu

blic

W

hole

sam

ple

n V

alid

%

n

Val

id

%

n V

alid

%

n

Val

id

%

n V

alid

%

M

/F

Do

you

expe

ct to

con

tinue

wor

king

as y

ou d

o no

w fo

rwar

d un

til re

tirem

ent?

Y

es

185

63

150

53

290

72

113

75

738

66

68/6

3 H

ow o

ften

do y

ou h

ave

ener

gy le

ft fo

r you

r priv

ate

life?

A

lway

s/A

lmos

t alw

ays

56

19

23

8 11

3 27

49

31

24

1 21

20

/22

To w

hat d

egre

e do

you

exp

erie

nce

your

wor

k as

mea

ning

ful?

H

igh

and

very

hig

h de

gree

40

2 89

26

6 89

34

8 84

19

0 88

10

19

88

25/3

2 H

ow o

ften

do y

ou c

onsc

ious

ly u

se y

our p

erso

nal w

ay o

f bei

ng a

s a to

ol in

the

inte

ract

ion

with

the

patie

nts?

A

lway

s/A

lmos

t alw

ays

105

35

136

46

206

50

106

68

751

50

38/5

4 H

ow o

ften

do y

ou tr

y to

app

ear h

appy

whe

n th

e pa

tient

sits

in th

e de

ntal

ch

air?

A

lway

s/A

lmos

t alw

ays

160

54

166

56

284

69

121

76

731

64

49/7

2 A

t the

clin

ic y

ou a

re e

xpec

ted

to a

lway

s app

ear s

mili

ng a

nd o

blig

ing?

To

a h

igh

and

very

hig

h de

gree

16

5 55

15

8 53

32

7 79

11

7 75

76

7 66

58

/71

Tabl

e 2.

Den

tists’

resp

onse

acc

ordi

ng to

nat

iona

lity,

affi

liatio

n an

d ge

nder

.

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 dentistryEmotion 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 co operate 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.

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

AbstractObjective. Human service work differs from industrial work, which should be considered when organizing work. Previousresearch has shown organizational differences in the perceptions of work, often with a focus on negative aspects. The aim of thisstudy was to analyse the overall job satisfaction among private- and public-practising dentists in Sweden and Denmark. Thisalso implied a description of the questionnaire Swedish and Danish Dentists’ Perceptions of Good Work about opportunities andpositive and rewarding aspects of work. Material and methods. A questionnaire covering the multidimensional concept ofgood work was developed. A total of 1835 dentists randomly sampled from the dental associations were sent a questionnaire inNovember 2008. A special non-response study was performed. Principal components analysis (PCA) was used to create ameasure 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 withmore working hours than the respondents. PCA of three satisfaction questions showed a stable one-factor solution. There weredifferences in job satisfaction, with Danish public dentists ranked highest in overall job satisfaction and Swedish public dentistslowest. Conclusions. There were organizational differences in the perception of job satisfaction. Further analysis of how thehuman 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 servicework, the patients are what Hasenfeld [1] calls theraw material of work. As such, the patients representcomplex systems with attributes which interrelate butare yet unstable and vary from person to person.Lipsky [2] describes human service workers as “streetlevel bureaucrats” with three characteristics of theirwork: (1) a constant interaction with patients; (2)being independent and discrete where personal attri-butes and reactions of the human service worker affecttheir patients’ treatment; and (3) having a significantimpact on the lives of the patients. The core of humanservice work is the relation between the patient andthe human service provider. The nature and quality ofthis relation is a critical determinant of the success or

failure of a people-changing organization, where theaim is to directly alter the personal attributes ofpatients 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 onindustrial/organizational theoretical frameworks [3].However, even though the specific human servicecharacteristics differ from work in industry, environ-mental models developed for industrial organizationsare often transferred directly to human service orga-nizations without considering the contextual andorganizational differences [4]. Examples are the twowork 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 thepositive counterbalances in the two models which arerelevant 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 � 2010 Informa HealthcareDOI: 10.3109/00016357.2010.514719

Act

a O

dont

ol S

cand

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

188.

177.

16.2

41 o

n 09

/07/

10Fo

r pe

rson

al u

se o

nly.

model, the Activity diagonal is relevant, where thedemands as well as the control over the work aresimultaneously high [5]. From the ERI model, therewarding aspects of work are also relevant. A criti-que of the DC model is that it should be adapted withmore specific demand and control measures relevantfor human services [4]. Examples of such specific jobdemands in human service could be high moral exer-tions, empathy and the necessity of hiding one’s ownfeelings in the interaction [7]. For job control, anexample could be that skill discretion can be highwhile decision authority can be low in the same job. Inthe ERI model, rewards are primarily defined asmoney, esteem and job security/career opportunities.Neither model addresses the potential intrinsic lastingrewards that may be specific for human services, e.g.trustful relationships, the feeling of doing good or acreative zest [8]. The potential dilemmas of the dif-ferences between industry and human services formthe framework for the research project behind thepresent study, where the overarching aim was tofind 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, administrativereforms and strategies in the public sector, also inthe Nordic countries, have been inspired by the ‘NewPublic Management’ (NPM) idea. Hood [9] arguedthat a “Swedish way” that included all Scandinaviancountries in the 1980s had both strong motives (fiscalstress) and opportunity (central leverage over publicsector) for the development of NPM. In NPM, focusis set on outputs and results and a public sector is splitinto separate units with decentralized management.This has also been the case in public dentistry, wherethe organization of work has been affected by, forexample, outsourcing and increased competition bymarket-oriented conditions [10].The different ways of organizing human service

in dentistry have been shown to affect the humanservice provider. The results of Bejerot [11], Moore[12], Hjalmers [13], Berthelsen et al. [14,15] andHarris et al. [16] point to organizational and nationaldifferences between dentists’ perceptions of theirwork. This has primarily been revealed in healthproblems, stress and job dissatisfaction, but theresults have also pointed to positive and satisfactoryelements of work as well. As Maslach et al. [17] putit: “Although a neutral work life has clear benefitsover burnout, it does not encompass the full range ofpotential experiences at work. Work life providesopportunities for exceptional performance, joyousexperiences, and deep fulfillment.” (p. 103).In the present study, the human service pro-

vider, more particularly the dentist, was the objectof research. Both the special caregiver relationshipand the organizational framework of human services

were taken into account. The overarching aim was tocapture positive aspects of work in dentistry, whatmay be called Good work.

Positive aspects of work

Research is limited on positive aspects of work as adentist. A pathogenic, problem-based paradigm hasdominated most occupational research [18]. Withinoccupational health psychology, a paradigm shift froma disease model towards a genuine health model isnecessary for the field to develop in a more balancedway [19]. For example, in psychology, the ratio ofscientific publications on positive versus negativestates has been 1:14 until the year 2000 [20].Although statements with positive wording are

included in many papers, most research has focusedon health problems, stress and demands. There isthough research touching on some positive aspectssuch as engagement and dentist’s internal resourcesas ways of coping with high demands [21–23]. Theseresults, as well as job satisfaction research [16], indi-cate that dentists have a positive working attitude andhigh job satisfaction.Research on job satisfaction is the field closest to

the object of the present research. According toLocke’s [24] classic definition, job satisfaction refersto “a pleasurable or positive emotional state resultingfrom the appraisal of one’s job or job experiences”(p. 1300). Job satisfaction has empirically beenmeasured in dentistry in more than a dozen differentcountries. For example, Harris et al. [16] measuredjob satisfaction aspects among dentists with variousaffiliations in the UK. The results showed dif-ferent levels of job satisfaction between differentaffiliations.

Aim

The purpose of this paper was to create an outcomemeasure of overall job satisfaction, applying the mea-sure in four organizational settings. Doing this alsoimplies a description of the background and devel-opment of the questionnaire Swedish and DanishDentists’ 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 usedwithin each country, based on relative organizationalaffiliations. The available sampling frames were themembership registers of the Dental Associations in

2 K. Bergström et al.

Act

a O

dont

ol S

cand

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

188.

177.

16.2

41 o

n 09

/07/

10Fo

r pe

rson

al u

se o

nly.

the two countries. Around 21% of the Danish and12% 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 practisinggeneral dentist in private or public practice in Swedenor Denmark. In all, 1837 dentists were randomlyselected 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-respondentswith the purpose of sending reminders. The dentistswere informed that responses were confidential andthat, if participating, they would be sent an overviewof selected preliminary results from the study. TheSwedish versions were sent and received at MalmöUniversity and the Danish ones by the NationalResearch Centre for the Working Environment inDenmark. One week after the first mailing of thequestionnaire in October 2008, the non-respondentsreceived a reminder and once again 2 weeks later, atwhich point a new copy of the questionnaire and astamped return envelope were included. Data wereregistered into the SPSS statistical program.No non-response analysis of the whole sample

could be done, given a lack of appropriate data inthe sampling frame. A special non-response analysiswas carried out on 30 randomly selected Danishprivate practitioners by telephone interview in June2009. The interview consisted of eight core questionstaken 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 bythe recommendations of Wolfe and Smith [25] tocreate variables based on theoretical constructs fromliterature reviews with empirical, theoretical ormodel-based focus. The questionnaire was also basedon the results from a study by Hjalmers [26] and on aqualitative study by Berthelsen et al. [8]. The finalquestionnaire contained 39 question batteries. Somewere tested in an on-line pilot study (defgo.net byInterResearch A/S) on 66 Danish and 74 Swedishpractising dentists in spring 2008, where the dentistswere also asked to answer and comment on the degreeof intelligibility and readability of the questions.About a quarter of the questions in the pilot wereretained after a critical revision. Translation was pri-marily done by the research group, which containeddentists and researchers from both countries. Contentwas adjusted by reviews of dentistry and work envi-ronmental research to ensure linguistic and contentaccuracy, and that the questions could be applied to

all dentists within the sampling frame. Before finali-zing the questionnaire, 20 dentists were asked todiscuss understanding, wording and overall impres-sion. An English translation for descriptive purposeswas done in cooperation with a native English dentistand researcher. A rhetorician verified the question-naire for spelling and grammar. A graphics designerproduced 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 andmanagement, work values, overall health, work–lifebalance, organizational characteristics and personalcharacteristics.

General characteristics

To describe some general characteristics of therespondents, the questions and responses shownin Table I were used.

Special non-response study

For the special non-response study, four questionsand four demographic questions were asked to showtendencies in the perceptions of work in general. Thequestions are shown in Table II.

Overall job satisfaction

An additive index consisting of three questions wascreated after a dimensional analysis. The questionsare shown in Table III.The questions were created by the research group

to measure the degree of fulfilment that work canprovide, satisfaction with general conditions at workand satisfaction with work life in general. The ques-tions were meant to cover a perceived fulfilment ofexpectations of working life in the past and in thefuture 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 iscomparable to ‘eudaimonic work’. In this study it wastranslated into ‘work fulfilment’. For the specificperspective of ‘Overall job satisfaction’ being a lastingintrinsic and ‘positive state of mind’, two classicalideas can be applied from happiness and well-beingresearch: eudaimonia and hedonia. Eudaimonia hasmostly been used in well-being research and can bedefined as producing happiness and well-being for theworker. This, by striving to actualize their potential,doing work of meaning and seaking a purpose in theirlives, in line with their values, emanating from internal

Overall job satisfaction among dentists 3

Act

a O

dont

ol S

cand

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

188.

177.

16.2

41 o

n 09

/07/

10Fo

r pe

rson

al u

se o

nly.

and external sources [27,28]. However, the conceptscan be viewed as overlapping. The hedonic view canbe regarded as well-being achieved through the pur-suit of pleasure, enjoyment and comfort, while theeudaimonic view is more concerned with acting to thebest of one’s ability, developing one’s potential anddoing good. When experiencing a eudaimonic life, astate of hedonia often follows [29].

Statistical methods

The material was analyzed using SPSS 16.0 forWindows (SPSS Inc, Chicago, IL). The responserate was calculated according to the recommenda-tions of Locker [30] as the “number of completedcases as a proportion of the number of eligible casesin the sample” (p. 73). The general characteristics ofthe 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, noweighting procedure due to the different sample

fractions was necessary. In the special non-responsestudy for the Danish private practitioners, a non-parametric Mann–Whitney U-test (asymptotic signif-icance, two-tailed) was used. Principal componentsanalysis (PCA) was performed on the threeOverall jobsatisfaction variables and tested for stability on genderand on the four subgroups: Swedish public/privatepractitioners and Danish public/private practitioners.An unrotated initial factor solution, with pairwiseexclusion of missing values, was used. The Kaiser–Meyer–Olkin measure of sampling adequacy, screeplots, communalities and factor loadings were usedfor the determination of the number of factors. Theoverall job satisfaction index was analysed usingthe 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 werereturned. 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 verylow degree

To a lowdegree

To somedegree

To a highdegree

To a veryhigh 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 lowdegree

To somedegree

To a highdegree

To a veryhigh degree

& & & & &

4 K. Bergström et al.

Act

a O

dont

ol S

cand

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

188.

177.

16.2

41 o

n 09

/07/

10Fo

r pe

rson

al u

se o

nly.

not belonging to the sampling frame (not generalpractising dentists). The issued number of question-naires was thus corrected to 1804. The net responserate was 68% (n = 1226). Of the 449 Swedish publicpractitioners who received a questionnaire, 75% par-ticipated (n = 325), while for the private practitioners68% of 449 (n = 302) participated. For the Danishpopulation, 201 public practitioners were sent aquestionnaire and 81% participated (n = 160), while736 private practitioners received a questionnaire and60% participated (n = 439).

Special non-response study of the Danish privatepractitioners

Because of the low response rate in this group, aspecial non-response analysis was performed. Therewere significantly more men in the sample and alsomore dentists with managerial responsibility anddentists with longer working hours among the groupof non-respondents. No statistically significantdifferences were found with regard to time since

graduation, workload or if they were satisfied andfelt fulfilled in their work. A statistically significantdifference was found with regard to perceived generalhealth, where the non-respondents rated their healthas better than that of the respondents (Table IV).

General characteristics of the respondents

The Swedish private practitioners had a much lowerproportion of female respondents, with only 33%compared to the other three subgroups: of the Danishprivate practitioners 65% were women, and for thepublic-practising dentists there were 71% women inSweden and 87% in Denmark. In both private andpublic dentistry in Sweden, 89% and 86%, respec-tively were born in Sweden, compared to 96% and94%, respectively in private and public dentistry bornin Denmark. Most private-practising dentists weremarried or cohabiting (91% in Sweden and 88% inDenmark), which was the case for 86% of the Swedishand 85% of the Danish public-practising dentists. Asmany 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 avery lowdegree

To alowdegree

To somedegree

To ahighdegree

To avery highdegree

- Work fulfilment? & & & & &

- Satisfaction with your work as a whole? & & & & &

How do you assess the extent of your workload? Much toosmall

Too small Appropriate Too great Much toogreat

& & & & &

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 verylow degree

To a lowdegree

To somedegree

To a highdegree

To a veryhigh 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 lowdegree

To somedegree

To a highdegree

To avery highdegree

& & & & &

Overall job satisfaction among dentists 5

Act

a O

dont

ol S

cand

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

188.

177.

16.2

41 o

n 09

/07/

10Fo

r pe

rson

al u

se o

nly.

managerial responsibility in Sweden, but only 15%of the public ones. In Denmark, 76% of the private-and 62% of the public-practising dentists hadmanagerial responsibility. All questions in Table Vshowed 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 internalnon-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. Anadditive index (range 3–15) was constructed as Over-all job satisfaction. The distribution was normalbut slightly negatively skewed (–0.65). For the wholesample as well as for the subgroups, both median andmode were 12. The four subgroups Danish public/private practitioners and Swedish public/private

practitioners showed some differences in theoverall job satisfaction means. Using the Kruskall–Wallis test on the index between the four groups(P £ 0.001) indicated that they did not have equalmeans (Table VI).

Discussion

The results showed organizational differences in theperception of overall job satisfaction. The Swedishpublic dentists were the least satisfied, and the Danishpublic dentists were the most satisfied. There weredifferences between the subgroups in all general char-acteristics analysed. Especially great differences werefound among women respondents. In the special non-response study, greater proportions of dentists whowere males, had managerial responsibility, workedlonger hours and had better perceived general healthwere found among the non-respondents. An averageresponse rate of 68% was achieved for the wholestudy.

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

aStatistically significant differences in mean rank between subgroups for all variables (P £ 0.001).

6 K. Bergström et al.

Act

a O

dont

ol S

cand

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

188.

177.

16.2

41 o

n 09

/07/

10Fo

r pe

rson

al u

se o

nly.

In a recently published review of response rates forhealthcare professionals, including dentists, averageresponse rates of 35–68% were found [31]. Theaverage response rate in this study may therefore beconsidered acceptable. While previous research ondentists in Sweden and Denmark has shown higherresponse rates [15,26], a third reminder was consid-ered for the Danish private-practising dentists.Instead, a special non-response study was decidedon. Interviews revealed that the non-respondentssimply felt they had a lack of sufficient time to respondto questionnaires in general. They also worked longerhours than the respondents, which did not seem toaffect their job satisfaction in a negative way. TheDanish private practitioners also had greater propor-tions of males and managers, the latter often havingincreased responsibility and working longer hours.This could be the simplest explanation for the higherproportion 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 wasmore than two-thirds. Several studies within dentistryhave shown a higher percentage of female respondents[32–34]. The national share of female dentists inDenmark was »55% in 2008 [35]. Therefore, therewas an overrepresentation of women among theDanish public and private practitioners in the sample.This does not seem to be the case for the Swedishpublic and private practitioners, as the average shareof women in the two subgroups was close to the 49%foundamongSwedishdentists in2005[35].The femaledentists in the sampleworked on average four hours lessper week than the male ones. The gender differences

among respondents might be a confounder for workinghours, giving the female dentists more time to respond.The overrepresentation of female respondents in thesample might affect job satisfaction through organiza-tional factors such as opportunities for practising fem-inist values in human service work, as for example inemotional and care work [7].The Danish public practitioners comprised many

more dentists with managerial responsibility than theSwedish public ones. Also, the Danish public clinicshad almost half as many employees as the Swedishpublic clinics. This could be a reflection of a signif-icant difference in how the ideas behind NPM areimplemented 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 mostlyused to describe a form of best practice in a cer-tain job, unifying professional expertise and socialresponsibility. A dual sense of the adjective ‘good’is often used: (1) high-quality work objectively judgedby people knowledgeable about the domain; and (2)work that goes beyond the worker and benefits a widergood [36]. Good work and a good job can also differ,by stating that a good job does not always provide thepossibility of doing good work [37]. Gardner [38]acknowledges the individual requirements andstates: “It is always a challenge, requiring ethicalcommitment and skill on the part of each individualworker.” (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

Act

a O

dont

ol S

cand

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

188.

177.

16.2

41 o

n 09

/07/

10Fo

r pe

rson

al u

se o

nly.

matter which can only be grasped by asking thepersons in question. The good work perspectiveinvolves a feeling of fulfilment, well-being or happi-ness, i.e. work with hedonic and eudaimonic proper-ties. Job satisfaction can be regarded as similar to goodwork, although maybe lacking a specific state of mind.One can be satisfied with the conditions of work, suchas the surroundings, relations, salary or tasks, withouthaving a feeling of well-being, fulfilment or a state ofhappiness. Questions with factors which can beregarded as an intrinsic feeling closely related tofulfilment can also be found in The Dentists’ Satis-faction Survey [16].As an outcome of experiencing good work, three

items concerning overall job satisfaction were ana-lysed. The obtained single factor can be interpreted todescribe overall satisfactory and eudaemonic percep-tions of work, also covering satisfaction with andexpectations of the conditions at work over time.On the basis of the content of the questions andon the fact that the factor was statistically one-dimensional and stable, there were grounds to createan index of overall job satisfaction (Table VI).

Organizational differences in overall job satisfaction

When analysing the index of overall job satisfactionfor organizational differences, there were clear indica-tions of such. The Swedish sample in particularshowed differences between the two organizationalaffiliations. Similar results concerning differences injob satisfaction between public and private practi-tioners were found in a UK study, where the privatepractitioners were also the most satisfied [16]. Withinpublic dentistry, the Danish dentists in the samplewere the most satisfied, and the publicly organizeddentists in Sweden were found to be the least satisfied.Corresponding to previous results about public den-tists in Sweden, this subgroup appears to face work-environment challenges.The way that public dentistry is organized differs in

the two countries. The Swedish public dentists treat asimilar patient group as private dentists, whereas themajority of Danish public dentists are limited totreating children and the elderly and disabled. TheNPM idea also has a much longer tradition in Swedenand is implemented differently compared to the sit-uation in Denmark. Management and productivityare focal points in Swedish public dentistry, whereclinics are transformed into profit centres on budget-ary grounds and have specific financial goals. Forsome dentists, this may conflict with their moralvalues and ideals of providing good care for the public[8,10,11,13]. This may lead to the implication that agood job can have different possibilities for doinggood work in public dentistry in the two countries.The perception of high job satisfaction is not only

an individual matter for the dentists but also a positive

external outcome for patients and organizations.Studies have shown that positive experiences ofwork, as for example work engagement, are predictiveof job performance and client satisfaction [39,40].Engaged workers with high job demands are found tobe more creative, more productive and more willingto go “the extra mile” [40].

Conclusions

This study has indicated organizational differences inthe overall job satisfaction among publicly and pri-vately organized dentists in Sweden and Denmark.The results confirm previous results within dentistry.Further research will be of interest to grasp the spe-cific differences in the organization of work as well asindividual factors which seem to have a positive influ-ence on the perception of work.

Acknowledgements

We thank The Swedish Council for Working Life andSocial Research study for funding the study, TheDanish Dental Association for funding of postagein Denmark and sampling and The Association ofPublic Health Dentists in Denmark, The SwedishDental Association, the Association of Public HealthDentists in Sweden and the Swedish Association forPrivate Dental Practitioners for sampling. The DanishNational Research Centre for the Working Environ-ment is thanked for assistance with sending andreceiving the Danish questionnaires and Inter-Research A/S (defgo.net) for the assistance and pro-vision of software for the pilot study.

Declaration of interest: The authors report noconflicts of interest. The authors alone are responsiblefor the content and writing of the paper.

References

[1] Hasenfeld Y. Human service organizations. Englewood Cliffs,NJ: Prentice-Hall Inc.; 1983.

[2] Lipsky M. Street-level bureaucracy. Dilemmas of the individ-ual in public services. New York: Russel Sage Foundations;1980.

[3] Schaufeli WB, Maslach C, Marek T. Professional burnout.Recent developments in theory and research. Philadelphia,PA: Taylor & Francis; 1993.

[4] van Vegchel N. Two models at work: A study of interactionsand specificity in relation to the Demand-Control Model andthe Effort-Reward Imbalance Model [Thesis]. Utrecht, TheNetherlands: Utrecht University; 2005.

[5] Karasek RA, Theorell T. Healthy work. Stress, productivityand the reconstruction of working life. New York: BasicBooks; 1990.

[6] Siegrist J, Peter R. Measuring Effort-Reward Imbalance atwork: Guidelines. Düsseldorf, Germany: Heinrich HeineUniversity; 1996.

8 K. Bergström et al.

Act

a O

dont

ol S

cand

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

188.

177.

16.2

41 o

n 09

/07/

10Fo

r pe

rson

al u

se o

nly.

[7] Hasenfeld Y. Human services as complex organizations,2nd ed. Los Angeles, CA: SAGE Publications, Inc.; 2010.

[8] Berthelsen H, Hjalmers K, Pejtersen JH, Söderfeldt B. Goodwork for dentists—a qualitative analysis. Commun Dent OralEpidemiol 2010;38:159–70.

[9] Hood C. The “New public management” in the 1980s:Variations on a theme. Organizations and Society 1995;29:93–109.

[10] Franzén C. Att vara en tandläkare i Folktandvården [Thesis].Malmö, Sweden: Malmö Högskola; 2009 (To be a dentist inthe Public Dental Health Service. In Swedish, with an EnglishSummary).

[11] Bejerot E. Dentistry in Sweden—Healthy work or ruthlessefficiency? [Thesis]. Stockholm: Arbete och hälsa. Vetenska-plig skriftserie; 1998. p. 14.

[12] Moore R. Danish dentists’ career satisfaction in relation toperceived occupational stress and public image. Tandlæge-bladet 2000;2000:1020–4.

[13] Hjalmers K, Söderfeldt B, Axtelius B. Moral valuesand career: Factors shaping the image of healthy workfor female dentists. Acta Odontol Scand 2006;64:255–61.

[14] Berthelsen H. Stress, health and social support at theworkplace in view of changes in the demands made ondentists—A cross-sectional survey of Danish general dentalpractitioners [Thesis]. Copenhagen: Copenhagen University;2003. p. 96 (in Danish, with an English abstract).

[15] Berthelsen H, Hjalmers K, Söderfeldt B. Perceived socialsupport in relation to work among Danish general dentalpractitioners in private practices. Eur J Oral Sci 2008;116:157–63.

[16] Harris RV, Ashcroft A, Burnside G, Dancer J, Smith D,Grieveson B. Facets of job satisfaction of dental practitionersworking in different organisational settings in England.Br Dent J 2008;204:1–8.

[17] Maslach C, Leiter M, Schaufeli WB. Measuring burnout. In:Cooper CL, Cartwright S, editors. The Oxford handbookof organizational well-being, 2nd ed. Oxford, UK: OxfordUniversity Press; 2009. p. 86–108.

[18] Christensen M, Lindström K, Vivoll Strume L,Kopperud KH, Borg V, Clausen T, et al. Positive factors atwork. Copenhagen: Nordic Council of Ministers; 2008.Report No. 1.

[19] Schaufeli WB. The future of occupational health psychology.Applied Psychology: An International Review 2004;53:502–17.

[20] Myers DG. The funds, friends, and faith of happy people. AmPsychol 2000;55:56–67.

[21] Hakanen JJ, Bakker AB, Demerouti E. How dentists cope withtheir job demands and stay engaged: The moderating role ofjob resources. Eur J Oral Sci 2005;113:479–87.

[22] Te Brake HJ, Bouman AM, Gorter RC, Hoogstraten J,Eijkman MA. Professional burnout and work engagementamong dentists. Eur J Oral Sci 2007;115:180–5.

[23] Gorter RC, Te Brake HJ, Hoogstraten J, Eijkman MA. Pos-itive engagement and job resources in dental practice. Com-mun Dent Oral Epidemiol 2008;36:47–54.

[24] Locke EA. The nature and causes of job satisfaction. In:Dunette MD, editor. Handbook of industrial and organiza-tional psychology. Chicago, IL: Rand McNally; 1976.p. 1297–349.

[25] Wolfe EW, Smith Jr. EV. Instrument development tools andactivities for measure validation using Rasch models: Part I—Instrument development tools. J Appl Measure 2007;8:1–27.

[26] Hjalmers K. Good work for dentists—ideal and reality forfemale unpromoted general practice dentists in a region ofSweden. [Thesis]. Swed Dent J Suppl 2006;182.

[27] Lent RW, Brown SD. Social cognitive career theory andsubjective well-being in the context of work. J Career Assess2008;16:6–21.

[28] Ryan RM, Deci EL. On happiness and human potentials:A review of research on hedonic and eudaimonic well-being.Annu Rev Psychol 2001;52:141–66.

[29] Huta V, Ryan RM. Pursuing pleasure or virtue: The differ-ential and overlapping well-being benefits of hedonic andeudaimonic motives [Digital version]. J Happiness Stud2009;1–28 doi:10.1007/s10902-009-9171-4.

[30] Locker D. Response and nonresponse bias in Oral HealthSurveys. J Publ Health Dent 2000;60:72–81.

[31] Cook JV, Dickinson HO, Eccles MP. Response rates in postalsurveys of health care professionals between 1996 and 2005.BMC Health Serv Res 2009;9.

[32] Ayers KMS, Thomson WM, Rich AM, Newton JT. Genderdifferences in dentists’ working practices and job satisfaction.J Dent 2008;36:343–50.

[33] Johansson V, Axtelius B, Söderfeldt B, Sampogna F,Paulander J, Sondell K. Patients’ health in contract andfee-for-service care. A descriptive comparison. Swed Dent J2007;31:27–34.

[34] Pilgård G, Rosenquist J, Söderfeldt B. Quality managementsand work environment in oral and maxillofacial surgery inSweden. Swed Dent J 2006;30:117–22.

[35] Kravitz AS, Treasure ET.Manual of dental practice 2008, 4thed. Bruxelles Council of European Dentists; 2008.

[36] Gardner H, Csikszentmihalyi M, Damon W. Good Work:Whenexcellenceand ethicsmeet.NewYork:BasicBooks; 2001.

[37] Landy FJ, Conte JM. Work in the 21st century.An introduction to industrial and organizational psychology,3rd ed. Somerset, NJ: Wiley-Blackwell; 2010.

[38] Good Work project team. The Good Work Project: Anoverview. The Good Work Project 2006. Available from:http://www.goodworkproject.org.

[39] Bakker AB, Schaufeli WB, Leiter MP, Taris T. Work engage-ment: An emerging concept in occupational health psychol-ogy. Work Stress 2008;22:187–200.

[40] Bakker AB, Demerouti E. Towards a model of work engage-ment. Career Dev Int 2008;13:209–23.

[41] Holst D. Varieties of oral health care systems. In: Pine C,Harris R, editors. Community oral health, 2nd ed. Chicago,IL: Quintessence Publishers; 2007.

[42] Widström E, Eaton KA. Oral healthcare systems in theextended European Union. Oral Health Prev Dent 2004;2:155–94.

[43] Strandberg-Larsen M, Nielsen MB, Vallgårda S, Krasnik A,Vrangbæk K. Health systems in transition. Denmark—Healthsystem review. WHO, on behalf of the European Observatoryon Health Systems and Policies; Copenhagen 2007. ReportVol. 9, No. 6.

[44] Glenngård AH, Hjalte F, Svensson M, Anell A,Baukauskaite V. Health systems in transition. Sweden.WHO, on behalf of the European Observatory on HealthSystems and Policies; Copenhagen 2005.

Overall job satisfaction among dentists 9

Act

a O

dont

ol S

cand

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

188.

177.

16.2

41 o

n 09

/07/

10Fo

r pe

rson

al u

se o

nly.

Appendix. Danish and Swedish organizationalcontexts of dentistry

The Nordic countries are often regarded as a singleentity because they share a common cultural basis,even though dentistry is organized differently [41].A Nordic model of oral healthcare is characterized by alarge public dental service, financed by local or gen-eral taxation [42]. Dental care is free for citizens until18 years of age in Denmark and 20 years of age inSweden. For those who are institutionalized, hospi-talized or mentally or physically disabled, dental careis charged up to a maximum yearly fee in Sweden, andin Denmark it has a percentage user’s fee. The privatesector is partly financed through subsidized services.The dentist/population ratio in Denmark as well asin Sweden was around 1:1200 in 2008, beingamongst the highest rates of dentist per citizen inthe EU [35]. Both countries have a team-basedhealthcare service where some aspects of oral health-care can be provided by dental nurses, dental hygie-nists and, in Denmark, clinical dental technicians. In2007, a new law removed limitations to the use ofassistance and delegation of all tasks in Denmark, aslong as it was done with solicitousness andconscientiousness.

Dentistry in Denmark

The state has a supervisory, regulatory and fiscal role.There are five geographical regions which have themain responsibility, but the 98 local municipalitiesare accountable for the healthcare services, preven-tion and health promotion, including dental care forchildren and the disabled [43]. Adults get a pro-portion of their dental healthcare costs covered bypublic insurance, depending on the kind of treatment.A private health insurance, ‘Health InsuranceDenmark’, can give subsidies for dental care; »30%of the adult population are members. The activeworkforce in 2008 was »4500 dentists; the proportion

of private practitioners was 70%, 45% were men and55% women. Full-time working hours are 37 hoursper week and the normal age of retirement is 67 yearsin 2010. There is no real competition between publicand private dental providers, because they mostlytreat different patient groups (however in somemunicipalities, private providers care for children).Children aged 16 and 17 years can choose betweenpublic and private free dental care. Around 95% of alldentists in Denmark are members of the DanishDental Associations [35,43].

Dentistry in Sweden

Healthcare is provided and financed publicly, where21 county councils have the overall responsibility forfinancing and provision of health, including dentistry.Management systems with specific purchaser func-tions separated from the provider functions have beenestablished in a number of county councils. Countycouncils can impose taxes to finance their activities.For adults, dental care is partly covered by NationalSocial Insurance, a system funded at national level.Subsidies are the same for the two sectors, private andpublic, amounting to 80% of the cost for extensivedental work but with lower limits for routine dentistry.Patient fees are set by each private practitioner and atthe political level in county councils for the publicdental health service. The two sectors in principletreat the same types of patients, and the patient has afree choice of provider. Private healthcare providersare remunerated through a fee-for-service, and publichealthcare providers are employed on a salary basis.The workforce in Sweden amounted to 7414 activedentists in 2005, 49% of whom were women. Thefull-time working week is 40 hours and the Swedishretirement age is 65 years. In 2007, »56% of dentistswere publicly organized, and 44% were privatelyorganized [35]. Of the Swedish dentists, 95% aremembers of the Swedish Dental Associations [35,44].

10 K. Bergström et al.

Act

a O

dont

ol S

cand

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

188.

177.

16.2

41 o

n 09

/07/

10Fo

r pe

rson

al u

se o

nly.

1

Emotion work in dentistry

– A theoretical overview of the key concepts, conditions and consequences

Authors:

KAMILLA BERGSTRÖM¹

JARI JUHANI HAKANEN2

JONAS ASPELIN3

BJÖRN SÖDERFELDT¹ †

LONE SCHOU4

¹Malmö University

Department of Oral Public Health

Faculty of Odontology

205 06 Malmö

Sweden

2 Finnish Institute of Occupational Health

Development of Work and Organizations

FI-00250 Helsinki

Finland

3 Kristianstad University

School of Education and Environment

291 08 Kristianstad

Sweden

4 Section for Global Oral Health Promotion

Department of Odontology

University of Copenhagen

2200 København N

Denmark

Correspondence: Kamilla Bergström, mobile nr. +45 29 72 52 79. Mail: kamilla.bergstrom@mah.se

2

Abstract

Objective: Emotion work is a concept rarely used in dentistry. It is defined as an umbrella term for many

different types of work tasks that aim to affect the emotions of the patient in a desired direction. The

inner emotional process to perform the work task is a rather complex interaction between the dentist

and the patient in a context with professional norms and values at a specific dental clinic. Emotion

work is a key work task of dentists in the dentist–patient relationship, and how it is performed can have

great implications for the outcomes of the dental clinic, patients and dentist. Not much is known about

what is emotionally required of dentists, how they manage and perform the emotional part of their

work and how dentists’ well-being is affected by it. This study provides a theoretical overview of the

emotional aspects of work as a dentist to introduce the concept of emotion work, the conditions under

which it is performed and its potential effects.

Methods: A conceptualization of emotion work in dentistry is presented by first describing emotion

work in a general context; the conditions of emotion work in a human service context; the terms and

conditions of emotion work in human service; and the effects of emotion work on human service

employees. Thereafter, emotion work in the dentist–patient relationship and in the era of New Public

Management and the dilemmas of emotion work in dentistry are introduced. Finally, we reflect on the

specific conditions and requirements in dentistry to summarize the findings.

Results & conclusion: In the dentist–patient relationship, many work tasks contain emotions and the

dentist is required to be emotionally balanced under these various conditions and demands. The

performance and effect of emotion work can influence the dentist’s well-being in different ways. It is,

however, of interest to investigate which factors support the core practice of emotion work and its

rewards in patient interactions. These reflections might be used as recommendations to support the

dentist–patient relationship as well as improve sustainable work life for dental professionals.

3

Keywords: Work environment, emotion work, dentist–patient relationship, human service, positive

factors

4

Introduction

Dentists, like many other healthcare professionals, face various job demands beyond the actual clinical

skills in their everyday work (e.g. the handling of their and patients’ emotions, also called emotion work).

Emotion work can be defined as a purposeful or unplanned approach to influencing the actions and

responses of patients that requires the use of the dentists’ emotional attention, effort and display. In

other words, it is the engagement, suppression or evocation of a dentist’s emotions necessary to get the

job done (1). However, besides patient needs, the emotional requirements and demands are also

determined by professional norms and values, the goals and conditions at work and the dentist’s

perception of the situation. These various requirements and demands seem to have increased

concurrently with the rise in patient’s needs, demands and requests.

In the interaction between dentist and patient, these various demands form a part of the

dentist’s considerations and decisions on how to act. The dentist needs to deal with this variety of

demands and influencing factors in a harmonic way to emotionally guide the patient in a specific

direction. Often, handling these different demands and emotional expressions throughout the day

requires a great deal of emotional effort as well as the compromise, or even suppression, of some of the

dentists’ own emotions. The requirement to relate to different demands simultaneously in praxis is

hypothesized to affect a dentist’s well-being, where emotion work can be demanding as well as

rewarding to dentists. However, very little is known about emotion work in dentistry and its

consequences for dentists, patients and treatment outcomes. There is thus a need to gain understanding

about emotion work, how it is constituted and performed as well as the factors that may affect both the

performance and the dentists’ self in positive and negative ways. In turn, that could help empower

dentists to recognize and navigate among these complex demands in a rewarding and sustainable way.

The background for this theoretical paper was a study based on a questionnaire on good

work for dentists in Denmark and Sweden, including the emotional aspects of the dentist–patient

5

relationship (2). A search of the odontological literature on PubMed and PsycInfo with the keywords

‘emotional work’/ ‘emotion work’/’emotional labor’ adding ‘dentists’ or ‘dentistry’ showed no hits.

However, one study on dental hygienists was found and for other healthcare professions (e.g. nurses

and physicians), around 30 hits came up. This conceptual paper describes and develops the concept of

emotion work in a dental context by reviewing scientific literature on the topic in general. The aim of

this theoretical overview is therefore to present a conceptual framework, the key concepts and

requirements of emotion work, first in a general and then in a dental context followed by a description

of the possible effects on dentists’ well-being. Furthermore, we hope to encourage research in this

under-researched field in dentistry and to increase an understanding of emotion work so that it can be

used in dental education and in organizing dental health services to benefit dental professionals as well

as patients.

The concept of emotion work in a human service context

Emotions have historically been regarded from mainly two perspectives: 1) an organismic biological one

where they generally are regarded as impulses or instincts that are stimulated and expressed rather

universally, independent of the social requirements and 2) a socially constructed one where expression

and emotions are internally managed by adapting to social rules and the requirements of specific

interactions (3). Hochschild suggests a third interactionist perspective where emotions are considered to

be aspects of social exchange between individuals who are aware of the emotional requirements of the

situation. She claims that people bond emotionally by either fulfilling or openly setting aside the

traditional requirements of the situation (4). In this paper, we focus on this third vantage point of

emotions.

Generally, emotion work is used as an umbrella term for work tasks where emotions are a

substantial part. According to Zapf’s broad definition, emotion work is both part of an overall task and

a contributing factor to increasing task effectiveness (5). He characterizes emotion work as follows: a)

6

emotion work occurs in face-to-face or voice-to-voice interactions with clients; (b) emotions are

displayed to influence other people’s emotions, attitudes and behaviours; and (c) the display of

emotions has to follow certain contextual rules (5). Emotion work is a way in which to interact with the

patients you service, genuinely or as part of the work you sell for a wage. It is interpreted and displayed

according to the individual perception of the situation and the interplay between the professional and

the patient. In other words, emotion work can be the primary aim of work as well as include a

secondary aim of simplifying other work tasks.

Several factors such as occupational, organizational and cultural norms, the specific

context and situation as well the characteristics of the patient and the employee determine the

emotional requirements of the job (6). According to Morris and Feldman, the concept of emotion work

includes four underlying assumptions: 1) emotion work is at least partly socially constructed.

Individuals tend to make sense of emotions in the context in which they take place; 2) in work settings

where people in some way are in need of help, some emotional effort will always be needed. Even

when the externally defined rules for showing specific emotions are genuinely felt, the employee will

still put more or less effort into translating the appropriate emotions in the given context; 3) the

employee’s emotions are part of the service itself and they have become a requested product of service;

and 4) the standards or rules in the various professions and at workplaces dictate how and when

emotions should be expressed (7). These assumptions reflect the importance of not just focusing on

the skills and abilities of the employee. From an interactionist perspective, they clearly elaborate that

emotion work is not only an interaction between the patient and the dentist. In the professional

context, employees’ own emotional states and strategies also affect how the specific situation,

interaction and context are perceived and interpreted. Thus, employees’ own emotions influence how

impressions from the patient (e.g. a feeling of stress) may make the employee less sensitive to the

signals of the patient. In this paper, the complexity of the influencing factors in emotion work is the

focus, as this influences job performances and affects how employees experience their work.

7

Employees with emotion work tasks are expected to manage their own and their patients’

emotions in line with a specific organizationally defined strategic direction. Thus, personal emotional

management has an exchange value for the organization as an emotional commodity. According to

Morris and Feldman, emotion work is defined as “the effort, planning, and control needed to express

organizationally desired emotion during interpersonal transactions” (7). Here, the interactionist perspective

emphasizes the importance of different social factors that affect both the experience and the expression

of emotions (1). Emotional display rules are the explicit or implicit organizational expectations for the

employee to show emotions in a certain way. It is stressed that the display should be in focus in

emotion work and not the feeling itself, because there are learned norms regarding what kinds of

emotions can be expressed at work to create certain impressions for patients (7). For example, dentists

should show positive emotions as part of certain tasks as an emotional contagion of the patient.

Hochschild also calls these rules ‘the underside of ideology’ and refers to emotion management as the

type of work necessary to cope with display rules (2).

In addition to the specific organizational display rules for emotions, the emotional

requirements and effort in a job are also dependent on the characteristics of the job (e.g. how

frequently the employee needs to accommodate all kinds of patients and situations and thereby manage

and express emotions, and how much attentiveness (duration and intensity) the emotional display

requires). A long duration is more emotionally straining. The intensity of the emotional display refers to

the magnitude and strength of the emotions that are felt and expressed. Moreover, the job

characteristics may define the variety of emotions (positive, neutral or negative, or all of them

combined) that are required to be displayed in different situations. If emotional displays have to be

altered throughout the day, it takes more effort to consciously manage one’s expressions in different

situations (4).

Emotion work research has aimed to identify a connection between the emotional

requirements of a job and the individual employee’s emotional strategy to perform it (5). More and

8

more occupations are based on patient interactions and service orientations with increasing emotional

demands (8,9). Therefore, a fundamental research challenge is to understand how these emotional

requirements and strategies affect emotional performance in practice and how, in turn, this

performance affects employees (10). This complexity of emotional performance was also shown in a

study of emotional display rules in a global service economy, in which some display rules in customer

interactions seemed to be global, although there were cultural differences in terms of emotional norms

(11). Integrating contextual knowledge, practice, ideals, goals and patients and employees’ emotions

into a coherent and meaningful emotional patient interaction is therefore required when interacting

with patients.

The terms and conditions of emotion work in human service

Human service work is mainly determined by the level of emotional characteristics and the degree of

emotional requirements in a job (10,12). A unique factor in human service work is that its delivery in

the relationship with the client or the patient requires the use of the employee’s self (1,13). In addition,

the frequency of face-to-face interactions, display rules and intensity of the interactions define a job as

human service work (1,5,14). In human service work, employees are expected to embody the values of

caring, commitment, trust and responsiveness to human needs. Even though it is often invisibly

embedded into the routines of the employee, human service work is moral work, guided by moral

values to enter the private lives of patients. However, these values and moral actions are often

compromised and adapted to a bureaucratic set of rules, regulations and conditions within

organizational or professional legislation (1). Organizations that provide human service work are called

human service organizations. Typical human service professions can be found in education and in

social and healthcare settings. Emotional demands in human service work have among others been

found to be positively related to burnout and psychosomatic symptoms, which are worsened by strong

identification with the work role (15,16). Hasenfeld categorizes human service organizations into three

9

kinds of service providers with normal or malfunctioning clients or patients: 1) people-processing,

often labelling citizens (e.g. for social welfare services), 2) people-sustaining, to keep them in present

shape and condition (e.g. home care) and 3) people-changing, to alter and change people’s attributes or

enhance their well-being (e.g. schools and hospitals) (1). Dentistry most often offering people-

sustaining and people-changing services, and, according to Hasenfeld, human service employees who

work in a people-changing organization with malfunctioning patients have the highest emotional

workload.

Expectations about the expression and behaviour of human service employees often

evolve: a flight attendant is expected to be friendly and cheerful, a nurse caring and empathic and a

psychologist trustworthy and objective. In helping professions, emotional interactions with patients are

usually not scripted, nor are display rules formalized or explicit. However, in these occupations there

are often shared but hidden expectations and rules of display within the given professions and

organizations. The societal norms and expectations of professional behaviour can also be morally

determined by jurisdiction (5,6). In healthcare, there are extensive studies of nurses requiring emotion

work with both positive emotional display and negative emotional suppression. Nurses are described as

‘emotional jugglers’ and they often deal with the subsequent emotions of patients after doctors’

diagnoses or treatments (17). Conversely, doctors who deal with the same patients as nurses do have

not been subject to much research on emotion work. One explanation could be that emotional aspects

are regarded as interrupting or disturbing technical and diagnostic processes. Doctors have traditionally

been regarded as more professional by upholding an objective distance and neutral appearance (17).

Previously, this was also a sign of authority, expertise and paternalism. Today, this objectivity is

primarily due to increased demand for evidence-based medicine focusing on quantitative knowledge

and general guidelines. However, objectivity can be just as effortful as showing positive or negative

emotions. Objectivity is also challenged by the ideals of patient-centred practice where patients’

qualitative and subjective understanding of disease and health has to be included in the decision–

10

making process. The emotional skills of health professionals have further been challenged by the

current focus on service orientation and patient satisfaction as important factors for the overall

outcome (18).

The effects of emotion work on human service workers

The emotional aspects of work can be a source of positive as well as negative work experiences and

outcomes. Previous research findings suggest that emotional requirements and efforts can have

negative (e.g. burnout) as well as positive (e.g. job satisfaction) effects on employees (14,19).

Hochschild considers three negative consequences of emotion work, namely burnout, personal

unauthenticity and work role detachment (3). So-called emotional dissonance can occur if the various

requirements are emotionally contradictory or differ from an inner emotional state (7). Depending on

the ability to navigate these requirements consciously, this mismatch can result in a compromise of the

employees’ own emotions to display the emotions expected by the organization. Consequently, non-felt

emotional display, dissonance acting, is then sold as an act of service, and so-called ‘true’ emotional labour

evolves (7). Although this is sometimes considered to be a negative consequence of displaying non-felt

emotions at work, dissonance acting can also be an emotion work requirement of human service work

because of the inevitably complex emotional demands (20). Emotional processes may also result in

negative consequences such as a decrease in task effectiveness, declining service delivery and a feeling

of decreased personal accomplishment.

The frequency of emotional display has been the most examined component of emotion

work aspects. It has been found to be associated with, for example, burnout. For flight attendants,

Hochschild notes that as the number of passengers increases, the more likely flight attendants are to

routinize, shorten and limit the magnitude of expressed emotions (3). A consequence of contact

overload can be emotional exhaustion, which can lead to burnout (i.e., depersonalization), meaning that

11

employees become emotionally detached and robotic in order to cope with work demands. Thus,

emotion work may have human as well as financial consequences for the whole organization (5,21).

However, the effects of emotional requirements in the patient interaction can also be

positive. Although emotion work may be a stressful part of human service work, it has been found to

be positively related to job satisfaction because of the opportunity to work with and help people (8,22).

Thus, emotion work can also be useful for coping with high workload as well as a source of positive

and meaningful experiences at work (22–25). Specifically, social support, a variety of skills and high

control over work have been found to buffer the negative effects of emotional demands (9,23,26,27).

With an ongoing interaction between the inner and outer emotional states, norms and rules, the

employee interprets and adapts a suitable emotional expression for the situation, which in turn also

affects the patient. Thus, emotion work will always demand some emotional effort and may influence

the employee, which in a professional context represents a commodity of work.

Next, we focus on the specific context of dentistry. We describe the emotional

requirements and emotion work in dentistry, the conditions that affect dentists’ emotional requirements

as well as management and consequences of emotion work.

Emotion work in the dental context

Dentistry is a good example of professional human service work where people are the ‘raw material’ and

the services take place in the dentist–patient relationship (1,28). Emotion work is a key factor in the

quality of the interaction between the dentist and the patient. When working directly with or on people,

the emotional aspects of work are often comprehensive and always require some emotional effort to

succeed. Display rules to perform certain emotions (and not others) in dentistry have roots in the

professional ethics and norms taught in the curriculum and these are thereby internalized in the

professional role as ‘emotional socialization’. Emotional socialization processes are parts of a ‘hidden

curriculum’ that often take place in both dental education and subsequently at a dental clinic. There,

12

accepting, adapting and aligning the norms and culture of the profession and clinic take place (21). As a

profession, the distinction between cure and care is important. Cure requires knowledge, experience and

communicative skills, whereas care requires affective and interpersonal work, namely emotion work.

For the interpersonal aspects of dentistry, a guideline for proper behaviour and emotional

performance at work was proposed, for example, by the Association of Dental Education in America

(ADEA) in 2008 and in the European update of profile and competences for the graduating dentist (2009) where

parts of the emotional content in the dental education are described (29). The ADEA document

describes six domains within the skills of a new graduate: critical thinking, professionalism,

communication and interpersonal skills, health promotion, practice management and informatics, and

patient care (30). From the European Update, Professionalism and Interpersonal, Communication and Social

skills are two domains described as competences that are characteristic of healthcare professions. These

include providing humane and compassionate care to all patients, practicing with personal and

professional integrity, honesty and trustworthiness, focusing on the patient’s best interests, striving to

provide the highest possible quality of patient care in a variety of circumstances and establishing a

dentist–patient relationship that allows the effective delivery of dental treatment (29). Thus, good

interpersonal skills, care and a good patient relationship are described as central to the overall outcome.

However, the emotional part of work is described as a secondary task to making treatments easier, and

there are no guidelines on how to manage ‘the variety of circumstances’ in a sustainable way for the

dentist. Thus far, the emotional and interpersonal dimensions of the dentist–patient relationship have

mainly been investigated with a focus on the outcomes for the patient. For example, studies have

examined dental anxiety using verbal communicative models which concludes that for prosthetic care

in dentistry, the emotional exchange factor captures the largest share of the variance in treatment

outcomes (30-32). These researchers suggest that the relationship between dentists and patients is a

human one with a strong emotional content affecting the overall outcome (32).

13

In dentistry, the demands on how to express and display emotions in the clinic are rarely

explicit. However, emotional demands do exist in dentistry as standards concerning which emotions are

appropriate to be felt or expressed in a given situation (3). The standards can be a combination of

professional norms and specific work demands, where expressions most often are positive regardless of

the felt emotions (19). Because of dentists’ great autonomy in the patient relation, the effectiveness of a

dental clinic is dependent on the skills and abilities of the dentist to adapt and provide ‘the right’

organizational service as emotion work in the dentist–patient interaction. In addition, the dental clinic

also consists of colleagues, caregivers, reference specialists, financing authorities and other

collaborators, with whom it is required and important for the dentist to have good relationships and

common denominators.

In other words, the dentist must be able to manage many demands in the dental clinic in

a way that influences patients in an organizationally desired direction. The intention of managing these

processes and trajectories is to direct patients and employees towards a given emotional state and

thereby a better outcome for the clinic. The management of patient and employee compliance and

handling of contingencies are also features that must be addressed to encompass the complexity

interacting of factors for a good outcome. For example, dentists are expected to appear cheerful and

happy at any time when at work, while there are demands to use specific communicative methods to

persuade the patient to choose a specific treatment. Similarly, dentists need to profile a specific image

of the dental clinic through outer appearance or written standards. If there is no dissonance between

the expectations from the clinic and dentists’ perceptions of the situation, the emotional effort will

mostly be an interpersonal exchange between patient and dentist. If the dentist disagrees or does not

have the resources or motivation required for the situation, the dentist’s emotional display will be an

exchange between him/her and the clinic. The dentist will, for a wage, disregard authentic emotions

and display those necessary in the situation. Conflicting emotional demands can be even more complex

if the patient feels this emotional dissonance. Failure to display the appropriate emotions (e.g. empathy

14

and ease) or displaying an inappropriate emotion (e.g. indifference or frustration) in an often sensitive

situation can have an irreversible effect on the patient and damage the relationship with the dentist and

the dental clinic for good (34).

Even though there are implicit expectations on the behaviour of the dentist, dentists are

experts and ‘privileged emotion managers’ with great autonomy and considerable power in interpreting

and reacting to the emotional requirements at work (10). However, having the main responsibility for

the quality of the work and the necessary constant interpretation and accommodation to different

patients, situations, tasks and displays will always make emotion work demanding for the dentist.

Dentistry requires a great deal of flexibility in engaging and managing one’s own emotions as well as the

ability to react in the most effective way in a given situation (1). For example, being able to perceive,

understand and react to patients’ needs and expressions (e.g. anxiety, expectations or lack of

confidence) are often required skills. This interaction further requires emotive sensing, perceptiveness,

care, active listening, developing rapport and empathizing. Emotion work can therefore be defined as a

performance art to engage in one’s and others’ affective states and the craft of one’s emotions to elicit a

desired response of the patient (1). The requirements needed to comply with these different demands

are high and the internal strategies that guide the actions of the dentist are performed live, with little

time to reflect. In summary, these interactions can be based on conscious, constrained or strategically

governed reflections for a specific intention. They can also be spontaneously unconscious, natural or

authentic and governed by the development of the situational relationship, all within the same 30-

minute appointment.

Thus, a dentist’s dissonance acting may be a requisite to manage different needs and

expectations. Therefore, this ability should be considered to be an explicit requirement of most quality

human service work in healthcare, and not only a consequence as often proposed. This human service

paradox needs much more attention in work environmental practice as well as research.

15

Emotion work in the dentist–patient relationship

A good relationship with patients is regarded as a core job dimension in dentistry and an integral

element of quality care (24,35,36). In a qualitative analysis on good work for Swedish and Danish

dentists, a dentist exemplifies the importance of the dentist–patient relationship: “Meeting the patients over

and over again is exceptionally stimulating, important and precious. The patients’ impression of being known to the

dentist, and the fact that you don’t need to read the medical journal in detail, is of great value for the patient as well as for

the dentist” (24). This statement illustrates the use and meaningfulness of building trustful relationships

through continuity as well as the fact that the parties of the interaction are not easily interchangeable.

As regards the nature of interactions between the dentist and patient, Gutek make a useful distinction

between encounters and relationships (37). They define encounters as single, short interactions between

strangers, whereas relationships define partners who have a shared history and know each other. In this

context, partners are presumed to show authentic feelings and trust (37). When a patient and a dentist

expect to interact again in the future and become interdependent, it is defined as a relationship. Over

time, the patient and dentist may develop a sense of trust, common history and knowledge of each

other as individuals and role occupants in the relation. When such a relationship and interdependency

develop, an element of servitude to please the patient and a sense of belongingness to the dentist can

evolve (37). As the interaction between dentists and patients most often can be defined as a

relationship, dental patients can often identify a particular dentist; indeed, verbally, they do not go to a

dentist, but rather the dentist or my dentist. Intense emotions are more likely to be felt when participants

have some shared history (25). The unscripted display of more sincere emotions may thus be involved

when the relationship is built on personal trust and understanding.

A good relationship is also a key determinant of the outcome and success of the

organization in satisfying patients’ needs, wishes and demands (5). In addition, not only patients’ oral

health needs require attentiveness and possibly dissonance acting by the dentist. Patients are also

customers with expectations and demands to the service they buy. Examples of emotion work tasks in

16

dentistry can include the first impression of facing and greeting a new patient and thus making the

patient feel welcome and seen; calming an anxious patient through a relaxed and professional attitude

(sometimes also with a physical touch); and showing an attentive and positive display when the patient

is in the chair through eye contact, listening and reflecting upon his/her words. There are specific

conditions of dentistry which are illustrated in table 1.

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 as is an almost inevitable part of dental work which both patient

and dentist need to incorporate and cope with.

The clinical appearance of the dentist can create an interpersonal distance to patient.

In the dentist-patient relation a dissimilar role as lay person & expert/customer & provider is embedded.

These roles can involve the power of e.g. shame, authority, guilt, paternalism and care.

The available time for the clinical performance is limited and 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.

Dentist´s workspace is the patient´s mouth which can create a limitation for dialog 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 the emotion

work tasks.

In dentistry, daily human contacts are numerous and not strictly scripted; indeed, the dentist has to be

constantly sensitive of the emotions of the patient. As the patient’s emotions are a prerequisite for the

dentist’s emotional reaction, sensitivity requirements are high (19). Because of the special conditions in

the clinical situation (as illustrated in table 1) the dentist needs to also sense other kinds of signals from

17

the patient, such as: tensions, sounds, mental awareness, smell etc. Perceiving and recognizing these

signals involve: Unconscious human awareness of the well being of others; acquired routine in

recognizing the most common emotional expressions of the patients and; balancing the patient´s

reactions with what is common for (the specific) patients and what is possible and required for the

specific treatment. This limitation in dialog can also create an opportunity for dentists’ to relax their

emotional display while concentrating on the clinical performance.

Emotion work is thus part of the dentist’s intervention toolkit, and it can be used to

create trust and to motivate and influence the patient in the desired direction through emotional

contagion (5). The dentist can use her/his own emotions as a tool to ease or comfort a patient or to

carry out a given treatment or task (5,14,38). In this sense, emotion work can be used to make other

things easier (e.g. a complicated treatment), and is thereby a secondary and parallel task to the primary

one. However, emotion work can also be a primary task. It can aim to create a specific sensation in the

patient such as ‘strategic friendliness’, or provide an experience of feeling welcome or of being taken

seriously (21). Emotion work can thus be performed to increase the effectiveness of a treatment or to

fulfil an ultimate goal in the dentist–patient relationship (5,39,40).

For caring professions such as dentistry and other healthcare professions, interpersonal

dimensions are obviously more prominent than for other types of professions. Personal involvement

between the dentist and patients, discretionary authority, tacit knowledge as well as an extent of

altruism are regarded as professionalism (41,42). Dentistry contains many emotion work tasks involving

different interpersonal and personal skills as well as personality. Additionally, a desire for self-

improvement and professional development with an awareness of what constitutes acceptable

performance under changing circumstances is required of a dentist today (43).

18

Emotion work and relationships in the era of New Public Management (NPM)

A considerable challenge for the dentist–patient relationship and requirement in emotion work is the

increasing influence of NPM thinking in the organization of dentistry (28). This thinking has evolved

over the past 30 years to mean rationalization, effectiveness of recourses, decentralization and focus on

economy and production, often compromising professional values. NPM has especially been applied to

large public dental services, with Swedish public dentistry a prime example (44). In particular, female

dentists have been found to be affected by the employer’s demand for productivity with a high

workload, as a result potentially affecting emotional display and management towards patients (44,45).

Bergström and colleagues show that the lowest job satisfaction is found among Swedish public dentists,

which may be correlated to NPM thinking, particularly in dental organizations in the public sector (2).

Market or business-like principles can, through the influence of NPM, affect professional

values and thus the provision of care. For example, Nash describes the values of dentistry as care and

concern for all people and for their oral health (46). Oral health is thereby the primary good and an end

in itself. With an increasing business culture in dentistry, patients become the means to another end:

building a successful organization or clinic and gaining profit. Nash emphasizes that “the practice of

dentistry is, or should be, the practice of a profession. Dentistry is only a business in the sense that good business practices

must exist in support of professional practice” (46). The tendency towards market-driven values in dentistry

can create a gap between the professional ideals taught at dental schools and the reality in dental clinics,

and these may demand more of the dentists’ skills in managing emotion work (28,44,45). As relations

with patients is a core factor influencing the positive aspects of work as a dentist, the influence of

NPM, undermining the possibilities for such relationships, can have great implications for both patients

and dentists’ well-being (28,44,45,47). Competition, patient centeredness and goals of productivity may

make emotion work increasingly explicit in the future. The combination of public service and private

business in dentistry together with increased scientific practices have made production in dentistry a

mixture of rational intelligence, skills and emotions. The consequence in e.g. Sweden and Finland is

19

that dentists become interchangeable units in organizations, making relationships with patients, as

Gutek defines them, impossible. Instead, pseudo-relationships, where patients trust what dental

organizations stand for and not the single dentist, might evolve (37).

Dilemmas of emotion work in dentistry

Emotion work can be both good and bad for dentists, as many factors of emotion work can constitute

each other’s opposites. These opposites may create dilemmas through which dentists have to navigate

on an everyday basis. As a dentist, there are daily work situations containing moral dilemmas,

conditional limitations and challenging human relations. In these situations, it is crucial that the dentist

is capable of acting upon the inner decisions in a trustworthy manner, with authority and conviction in

the interaction with the patient. For example, a dentist must have the ability to put on a happy face

even when frustrated; be empathic and caring while causing pain and discomfort; appear understanding

and obliging even if not understanding the patient; manage time and production pressure and

challenging patient situations with a display of ease; and control emotions such as anger,

disappointment, confusion or injustice.

When performing emotion work, authentic personal emotions can be compromised. The

display of positive emotions may have positive effects on the dentist, but the state of constant

compromise with one’s own emotions to meet emotional conditions and external demands can also

cause stress and burnout (19). Displaying certain emotions (often positive ones) and restraining from

displaying other maybe authentic ones are crucial. Burnout, or rather its core dimension, emotional

exhaustion, has been found to be combined with the initial expectations to do a good job and no longer

being able to manage the emotional responses required to do that (5). However, in daily praxis dentists

not only interact with patients. For a dentist, a series of parallel interactions or considerations also takes

place, forming the content and direction of the relation with the patient. In a recent qualitative study by

Harris and Holt, four dominant institutional logics in UK general dental practice were found, in which

20

the dentist interacts on a daily basis. These were: Ownership responsibilities; professionalism,;

population health managerialism and; entrepreneurial commercialism (48). The findings showed that

dilemmas could occur when the dentists experienced pressure from targets given by commissioners

creating a tension between professional values and a need for remuneration to keep up business. The

researchers suggest that the logics are compatible as long as autonomy is not too affected and that

dentists’ configures logics by reflexivity in care and constant interaction and contingency (48).

However, even if the logics are woven and well reflected in daily practice a great deal of emotional

flexibility and overview is required, in order to create a successful outcome for patient, organization and

dentist.

Relationships with patients may be demanding for the dentist, but they may also be key

factors to meaning in work and job satisfaction (23,24,49,50). It is in the relationship with the patient

that dentists can experience eudaimonic1 rewards such as helping and making a difference, doing good

to others and feeling that work is purposeful and meaningful (24). From an Aristotelian view, it is virtue

(e.g. doing good) that leads to well-being or human flourishing (51). A study of the influence of

intrinsic and extrinsic factors on dentists’ job satisfaction shows that the most positive impact is the

intrinsic experience of having an opportunity to use one’s abilities (52), which concurs with the concept

of eudaimonia, namely being able to actively live out one’s human potential by utilizing and sharing

one’s capacities. Eudaimonia is gained when the activity of the soul in accordance with reason learns to

consciously choose to do good things, as an optimal function of human being. Thus, doing good to

others and actively helping patients in need might affect dentists’ work fulfilment or job satisfaction.

Gorter finds that the strongest correlations of job resources for dentists’ work engagement are ‘patient

care’ and ‘idealism/pride’, such as gratitude from patients and being a good caregiver (53). Similarly,

Hakanen et al. show that job resources such as professional pride and seeing the direct and long-term

1 Eudaimonia: Translated from Greek as “A good guardian spirit”. Aristotle (Nicomachain Ethics) regards it as connected

with living and doing well.

21

results of one’s job in patients predict dentists’ work engagement and work–family enrichment (23,54).

A positive correlation between autonomy in the patient interaction and job satisfaction for human

service work similar to dentistry has also been found (5,25). Further, a dentist’s personal resources

(behaviour regulation and coping strategies as stress resilience) have been found to be related to job

satisfaction (55). These findings show that intrinsic aspirations increase the likelihood of positive

emotions, which might increase job satisfaction.

Dentists often identify themselves as ‘dentists’ – they do not work as dentists, they are

dentists. Employees who identify themselves with their work role have a greater risk of burnout

because the feelings expressed at work are somewhat inseparable from the self (22). On the contrary,

one could easily argue that non-separation between the personal self and the professional role could

make it easier to be authentic and emotionally balanced. In general, emotional harmony is attained if

there is concordance between the emotion that the clinic, profession or patient requires, the felt

emotions and the displayed emotions. Then, emotion work is experienced as more effortless where no

conscious attention is needed to regulate the display of emotions and the dentist can fully concentrate

on the work task (5). The emotion work performance can also become more and more automatic with

experience as a part of the socialization process in the professional role as a dentist, as a form of

professional detachment, and it can also be seen as a healthy reaction to emotional job requirements

that are not truly experienced.

Emotion work performed under complex conditions has become a commodity requested

by dental clinics as well as patients. Recognizing the emotional requirements that come with interacting

with patients and the conditions of human service work that has emerged from NPM might be a step

towards managing situations more consciously and harmoniously with the resources in hand. The

ability to manage and display one’s own emotions in a healthy way can determine the outcome for the

organization, patient and dentist. Therefore, emotion work in dentistry is a question of the awareness,

skills and ability to manoeuvre between requirements, strategies and expressions in a way that most

22

benefits all involved parties. This capability can create a sense of emotional resonance between the

affecting factors and be crucial for the dentist’s well-being. Recognizing and complying with the

requirements in a way that involves as few inner (personal or professional) compromises as possible

may make different logics and demands compatible and enhance the feeling of eudaimonia. Overall,

managing, regulating and displaying emotions should be considered to be an in-role requirement and

vital skill in healthcare (34,56) as well as an opportunity to access the deep intrinsic rewards from the

relationship with the patient.

In future environmental research, it would be interesting to focus on what promotes the

positive effect of working with people parallel to the prevention of negative effects. Positive access to

work environmental aspects in healthcare has been paid more and more attention in the past decade

(23,47,57). From this perspective, there are significant issues to consider: emotion work should become

explicitly focused when educating dentists at dental schools and continuing training at their workplaces.

In dental curriculums as well as at work places, there is a need to embrace that relational competence is

complex. Browning and colleagues argue that relational competence in health care depends on: habits

of mind, including attentiveness, critical curiosity, self-awareness, and presence; that it includes the

cultivation of emotions, values, and reflection in daily practice; and that it is developmental,

impermanent, and context dependent (58). Specifically important is developing and maintaining

relational and emotional competences, empowering the dentist to recognize, cope with and manoeuvre

in the specific demands of dentistry. This would create a consciousness about the consequences for the

dentist, which in turn would benefit the dentist, clinic and patient. Moreover, the conditions and

demands by the organizers of dentistry should support professional values and harmonious emotion

work to ensure a sustainable work life for dentists.

23

Conclusion

This study provided a theoretical overview of the emotional aspects of human service work, specifically

dentistry. This was carried out as a starting point to acknowledge emotion work as a core work task and

requirement in dentistry and introduce the possible effects of the increasing demands in the specific

context, with an overall aim to empower dentists to navigate the various emotional situations with the

patient to benefit both patients and themselves. Despite research on emotion work in other human

service professions, there is scarce research on the conditions and emotional requirements of the

dentist–patient relationship and on how dentists manage/are affected by these requirements. We hope

that this theoretical study will encourage future empirical research on dentists and emotion work.

Understanding the emotional requirements of the job and being able to act accordingly when working

with patients are likely to lead to positive outcomes both for patients and for dentists.

Acknowledgements

We thank the Swedish Council for Social Research, Swedish Council for Work Life Research (FORTE)

and Faculty of Odontology at Malmö University for financing the Ph.d. program of Kamilla Bergström.

I also want to acknowledge my main supervisor, Björn Söderfeldt, who died during the project. He

made it all possible and was my most caring critic as well as supporter. A sincere thank to Lone Schou

who took over the final supervision and helped me keep ambitions and engagement high.

24

References

(1) Hasenfeld Y. Human services as complex organizations.: SAGE Publications, Inc; 2010

(2) Bergström K, Söderfeldt B, Berthelsen H, Hjalmers K, Ordell S. Overall job satisfaction among dentists in Sweden and Denmark: a comparative study, measuring positive aspects of work. Acta Odontol Scand 2010;68(6):344–353.

(3) Hochschild AR. Emotion work, feeling rules, and social structure. Am J Sociol 1979:551–575.

(4) Hochschild AR. The managed heart: Commercialization of human feeling. Berkeley: University of California Press; 1983.

(5) Zapf D. Emotion work and psychological well-being: A review of the literature and some conceptual considerations. Hum Resour Manage R 2002;12:237–268.

(6) Rafaeli A, Sutton RI. Expression of emotion as part of the work role. Acad Manage R 1987;12:23–37.

(7) Morris A, Feldman DC. The dimensions, antecedents, and consequences of emotional labor. Acad Manage R 1996;21(4):986–1010.

(8) Natasja Van Vegchel. Two models at work: A study of interactions and specificity in relation to the Demand-Control Model and the Effort-Reward Imbalance Model. Universiteit Utrecht; 2005.

(9) Vegchel Nv, Jonge Jd, Söderfeldt M, Dormann C, Schaufeli W. Quantitative versus emotional demands among Swedish human service employees: Moderating effects of job control and social support. Int J Stress Manage 2004;11(1):21–40.

(10) Wharton AS. The sociology of emotional labor. Annual Review of Sociology 2009;35:147–165.

(11) Grandey A, Rafaeli A, Shy Ravid, Wirtz J, Steiner DD. Emotion display rules at work in the global service economy: the special case of the customer. J Serv Manage 2010;21(3):388–412.

(12) Hochschild AR. The managed heart: Commercialization of human feeling: Twentieth anniversary edition with a new afterword: University of California press; 2003.

(13) Brill N. Working With People: The Helping Process. Allyn & Bacon Inc; 2004.

(14) Brotheridge CM, Grandey AA. Emotional labor and burnout: Comparing two perspectives of ‘people work’. J Vocat Behav 2002;60:17–39.

(15) Borritz M, Rugulies R, Bjørner JB, et al. Burnout among employees in human service work: design and baseline findings of the PUMA study. Scand J Public Health 2006;34:49–58.

(16) Priorities for occupational safety and health research in the EU-25. 2005.

25

(17) Mann S. A health-care model of emotional labour: An evaluation of the literature and development of a model. J Health Org Manage 2005;19(4/5):304–317.

(18) May C. The clinical encounter and the problem of context. Sociology 2007;41(1):29–45.

(19) Zapf D, Holz M. On the positive and negative effects of emotion work in organizations. Work Org Psy 2006;15(1):1–28.

(20) Zapf D, Vogt C, Seifert C, Mertini H, Isic A. Emotion work as a source of stress: The concept and development of an instrument. Eur J Work Organ Psy 1999;8:371–400.

(21) Lively KJ. Emotions in the Workplace. In: Stets JE, Turner JH, editors.; 2001.

(22) Wharton AS. The affective consequences of service work: Managing emotions on the job. Work Occup 1993;20(2):205–232.

(23) Hakanen JJ, Bakker AB, Demerouti E. How dentists cope with their job demands and stay engaged: The moderating role of job resources. Eur J Oral Sci 2005;113(6):479–487.

(24) Berthelsen H, Hjalmers K, Pejtersen JH, Söderfeldt B. Good work for dentists - a qualitative analysis. Community Dent Oral 2010(2):159–170.

(25) Morris JA, Feldman DC. Managing emotions in the workplace. J Manage Issues 1997;9:257–274.

(26) Söderfeldt B, Söderfeldt M, Muntaner C, O'Campo P, Warg L, Ohlson C. Psychosocial work environment in human service organizations: a conceptual analysis and development of the demand-control model. Soc Sci Med 1996;42(9):1217–1226.

(27) Wharton AS. The psychosocial consequences of emotional labor. Ann Am Acad Pol Soc Sci 1999;561(1):158–176.

(28) Ordell S. Organisation and management of Public Dentistry in Sweden: Past, present and future. Thesis. Malmö University; 2011.

(29) Cowpe J, Plasschaert A, Harzer W, Vinkka-Puhakka H, Walmsley A. D. Profile and competences for the graduating European dentist - update 2009. Eur J Dent Educ 2010;14:193–202.

(30) Gilmour ASM, Jones RJ, Cowpe JG, Bullock AD. Communication and professionalism skills of a new graduate: the expectations and experiences of dental foundation trainers. Eur J Dent Educ 2014: online.

(31) Sondell K, Palmqvist RMS., Söderfeldt B. Dentist-patient communication and patient satisfaction in prosthetic dentistry. Int J Prosthodont 2002;15:28–37.

(32) Sondell K, Söderfeldt B. Dentist-patient communication: a review of relevant models. Acta Odontol Scand 1997;55(2):116–126.

(34) Mann S. People-work: Emotion management, Stress and Coping. Brit J Guid Couns 2004;32:205–221.

26

(35) Berthelsen H. Work-related support, community and trust - Dentistry in Sweden and Denmark. Thesis. Malmö University; 2010.

(36) Yamalik N. Dentist-patient relationship and quality care 3. Communication. Int Dent J 2005;55:254–256.

(37) Gutek BA, Cherry B, Bhappu AD, Schneider S, Woolf L. Features of service relationships and encounters. Work Occup 2000;27(139):319-352.

(38) Hasenfeld Y. Human Service Organizations. Prentice-Hall inc; 1983.

(39) Strazdins LM. Integrating Emotions: Multiple role measurement of emotional work. Aust J Psychol 2000;52(1):41–50.

(40) Ashforth BE, Humphrey RH. Emotional labor in service roles: The influence of identity. Acad Manage Rev 1993;18:88–115.

(41) Abbott P, Meerabeau L. The Sociology of the Caring Professions. London: UCL Press; 2005.

(42) Macdonald KM. The sociology of the professions.: SAGE; 1995.

(43) Chambers DW. The role of dentists in dentistry. J Dent Educ 2001;65(12):1430–1431.

(44) Bejerot E. Dentistry in Sweden - Healthy work or ruthless efficiency. Thesis. Stockholm: National Institute for Working Life; 1998.

(45) Hjalmers K. Good work for dentists - ideal and reality for female unpromoted general practice dentists in a region of Sweden; Thesis. Malmö University; 2006.

(46) Nash DA. On ethics in the profession of dentistry and dental education. Eur J Dent Educ 2007;11:64–74.

(47) 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):92.

(48) Harris R, Holt R. Interacting institutional logics in general dental practice. Soc Sci Med 2013;98:63-70.

(49) Gorter RC, Eijkman MA, Hoogstraten J. Burnout and health among Dutch dentists. Eur J Oral Sci 2000;108:261–267.

(50) Harris RV, Ashcroft A, Burnside G, Dancer J, Smith D, Grieveson B. Facets of job satisfaction of dental practitioners working in different organisational settings in England. Br Dent J 2008;204:1–8.

(51) Aristotle, Translated BW. Nicomachean Ethics.: eBooks@Adelaide; 2006.

(52) Goetz K, Campbell SM, Broge B, Dörfer CE, Brodowski M, Szecsenyi J. The impact of intrinsic and extrinsic factors on the job satisfaction of dentists. Community Dent Oral 2012;40(5):474–480.

27

(53) Gorter RC, Te Brake HJ, Eijkman MAJ, Hoogstraten J. Job resources in Dutch dental practice. Int Dent J 2006;56(1):22–28.

(54) Hakanen JJ, Peeters MCW, Perhoniemi R. Enrichment processes and gain spirals at work and at home: A 3-year cross-lagged panel study. J Occup Organ Psychol 2011;84:8–30.

(55) Montasem A, Brown SL, Harris R. Subjective well‐being in dentists: the role of intrinsic aspirations. Community Dent Oral. Online. 2013.

(56) Diefendorff JMR, Erin MR, Croyle MH. Are emotional display rules formal job requirements? Examination of employee and supervisor perceptions. J Occup Organ Psychol 2006;79:273–298.

(57) Christensen M, Lindstrøm K, Vivoll Strume L, Kopperud KH., Borg V, Clausen T, et al. Positive Factors at Work. TemaNord 2008:501.

(58) Browning DM, Meyer EC, Truog RD, Solomon MZ. Difficult Conversations in Health Care: Cultivating Relational Learning to Address the Hidden Curriculum. Acad Med 2007;82, 9,905-913.

AppendixQuestionnaire in Swedish

Svenska och danska tandläkares uppfattning av

Det Goda Arbetet

Vi har i dag stor kunskap om stressande och nedslitande förhållanden i tandläkares arbete. Däremot har vi långt mindre insikt i faktorer som har positivt inflytande på tandläkares synsätt på sitt arbete. Syftet med denna undersökning är därför att studera tandläkare i Sverige och Danmark, deras arbetsvillkor och deras uppfattning om sitt arbete. Undersökningen utgår från den Samhällsodontologiska avdelningen vid Malmö Högskola. Både svenska och danska forskare är engagerade i projektet. Genom under-sökningsresultaten kan vi uppnå större kunskap om vilka förhållanden som särskilt bidrar till arbetsglädje och upplevelsen av att ha ett gott arbetsliv.

Tandläkare från både privat och offentlig sektor i Sverige och Danmark har utvalts slumpmässigt från respektive organisationers medlemsregister. Alla personuppgifter kommer att behandlas konfidentiellt och förvaras efter gällande föreskrifter. Deltagande är givetvis friviligt. Resultaten kommer att presenteras i statistisk form utan att kunna hänföras till enskilda personer eller kliniker.

Projektet stöds av Forskningsrådet för Arbetsliv och Socialvetenskap, den Odontolo-giska Fakulteten vid Malmö Högskola samt av Fonden til Fremme af Videnskabelig og Praktisk Odontologi. Undersökningen är godkänd av etisk prövningsnämnd.

Undersökningens resultat kommer att publiceras såväl nationellt som internationellt. De tandläkare som deltar kommer att få en särskild sammanfattning av de första resultaten så snart som möjligt efter att undersökningen avslutats.

För att få god kvalitet på undersökningen är det viktigt att så många som möjligt svarar. Vi vill därför be dig att fylla i frågeformuläret och sända tillbaka det i bifogat portofritt svarskuvert inom en vecka. Det tar cirka 15 minuter att fylla i formuläret. Om du har frågor eller synpunkter om undersökningen är du naturligtvis välkommen att kontakta oss.

Svenska och danska tandläkares uppfattning av ett gott arbetsliv

Sven Ordell Karin HjalmersÖvertandläkare, MPH, Tandläkare,doktorand Odont. Dr.

Hanne Berthelsen Kamilla Bergström Björn SöderfeldtTandläkare, MPH, Tandhygienist, MSU, Professor i samhällsodontologi doktorand doktorand Projektansvarig

0

Postadress Besöksadress Tel E-post

Malmö Högskola Carl Gustafs väg 34 0046 40 665 8582 bjorn.soderfeldt@mah.seOdontologiska fakulteten sven.ordell@lio.seSamhällsodontologisk avd. karin.hjalmers@mah.se205 06 Malmö

Det Goda Arbetet �

I de första frågorna vill vi veta något om den arbetsglädje du upplever.

1. I vilken grad upplever du följande:

I mycket I liten Till viss I hög I mycket liten grad grad grad grad hög grad

Arbetsglädje? ® ® ® ® ®

 Tillfredsställelse med arbetet som helhet? ® ® ® ® ®

2. Vilken betydelse har följande förhållanden för din arbetsglädje? Ingen Liten Viss Stor Avgörande betydelse betydelse betydelse betydelse betydelse

Stämningen på kliniken ® ® ® ® ®

Arbetskamraterna ® ® ® ® ®

Tandläkarnas anseende hos allmänheten ® ® ® ® ®

Inkomsten ® ® ® ® ®

Patientrelationerna ® ® ® ® ®

Själva hantverket ® ® ® ® ®

Något annat: _________________________ ® ® ® ® ®

3. Hur viktigt är det för din arbetsglädje att:

Oviktigt Mindre viktigt Viktigt Mycket viktigt

Ta dig an andra människor? ® ® ® ®

Kunna ge patienten full uppmärksamhet? ® ® ® ®

Kunna följa patienterna genom åren? ® ® ® ®

Patienterna följer dina råd? ® ® ® ®

Patienterna visar att de har tillit till dig? ® ® ® ®

Patienterna helst vill behandlas av just dig? ® ® ® ®

� Det Goda Arbetet

Nu följer ett antal frågor om hur du uppfattar olika aspekter av arbetet med patienter.

4. I vilken grad ger dig arbetet med patienter följande?

I liten Till viss I hög I mycket Inte alls grad grad grad hög grad

Känslan av att göra något meningsfullt ® ® ® ® ®

Känslan av att göra en skillnad för patienterna ® ® ® ® ®

Känslan av att ha fått något ur händerna ® ® ® ® ®

Att patienterna visar sin direkta uppskattning av arbetet ® ® ® ® ®

Ömsesidigt förtroendefulla relationer till patienterna ® ® ® ® ®

Hantverksmässig glädje av ditt arbete ® ® ® ® ®

5. Här följer några frågor om samspelet med patienterna.

Aldrig/ Alltid/ nästan aldrig Sällan Ibland Ofta nästan alltid

Är samspelet med patienten delvis rutinartat? ® ® ® ® ®

Händer det att du känner att en patient- behandling borde ha gått bättre? ® ® ® ® ®

Försöker du att verka glad när patienten sitter i stolen? ® ® ® ® ®

Använder du medvetet ditt sätt att vara som ett redskap i patientbehandlingen? ® ® ® ® ®

Känner du dig rustad att hantera patienterna? ® ® ® ® ®

Blir du på bättre humör av att arbeta med patienter? ® ® ® ® ®

Det Goda Arbetet 5

6. Hur bra stämmer följande påståenden in på dig?

Stämmer i Stämmer Stämmer i Stämmer i Stämmer i mycket inte alls liten grad viss mån hög grad hög grad

Jag håller medvetet en distans till patienten ® ® ® ® ®

Jag tycker att patientrelationerna är givande ® ® ® ® ®

I mitt arbete måste jag ofta lägga band på mina känslor ® ® ® ® ® Jag betraktar mig själv som omsorgsgivare ® ® ® ® ®

Jag känner mig ibland mer som maskin än som människa ® ® ® ® ® Jag tycker att patientrelationerna är krävande ® ® ® ® ®

Jag sätter värde på att arbetsdagarna är förutsägbara ® ® ® ® ® Jag känner mig ofta uttråkad under arbetsdagen ® ® ® ® ®

Oavsett vad som sker i mitt arbete kan jag som regel lösa det ® ® ® ® ® Jag arbetar huvudsakligen för inkomsten ® ® ® ® ®

När jag kommer till arbetet och ser att dagens tidbok är full blir jag upplivad ® ® ® ® ®

Jag blir ofta uppslukad av mitt arbete ® ® ® ® ®

På kliniken förväntas man att alltid vara leende och tillmötesgående ® ® ® ® ®

Nu följer några frågor om kollegor och ledningen på kliniken. Vi ber dig svara på frågorna även om du är chef eller om du arbetar ensam.

7. Hur ofta har du träffat andra tandläkare, utanför arbetsplatsen, det senaste året?

Aldrig/ Varje vecka Varje månad Sällan nästan aldrig

På kurser och konferenser ® ® ® ® På kvalitetscirklar, fackliga möten eller liknande ® ® ® ® På fritiden ® ® ® ®

� Det Goda Arbetet

8. I vilken grad instämmer du i följande påståenden?

Instämmer Instämmer Instämmer Instämmer Instämmer i mycket inte alls i liten grad till viss grad i hög grad hög grad

Jag diskuterar knepiga behandlingar med en kollega ® ® ® ® ®

Jag har möjlighet att få praktiskt stöd från en kollega, om jag skulle behöva ® ® ® ® ®

Jag har möjlighet att rådgöra om arbetet med klinikens dagliga ledning ® ® ® ® ®

Klinikens övriga personal och jag har förtroende för varandra ® ® ® ® ®

Jag låter ibland patienter där kemin inte stämmer gå till en kollega i stället ® ® ® ® ®

Jag tar upp problem med missnöjda patienter med mina kollegor ® ® ® ® ®

Om jag skulle få en anmälan har jag en kollega som jag kan ta upp det med ® ® ® ® ®

Jag pratar med kollegor om hur jag trivs ® ® ® ® ®

9. I vilken grad:

I mycket I liten Till viss I hög I mycket liten grad grad grad grad hög grad

Litar ledningen på att medarbetarna gör ett bra jobb? ® ® ® ® ®

Litar de anställda på vad som sägs från ledningen? ® ® ® ® ®

Döljer ledningen viktig information för de anställda? ® ® ® ® ®

Döljer de anställda viktig information för ledningen? ® ® ® ® ®

Döljer de anställda viktig information för varandra? ® ® ® ® ® Litar de anställda i allmänhet på varandra? ® ® ® ® ®

Finns det utrymme för anställda att uttrycka sina åsikter och känslor? ® ® ® ® ®

Det Goda Arbetet �

10. Ange vänligen hur ofta följande förekommer:

Aldrig/ Alltid/ nästan aldrig Sällan Ibland Ofta nästan alltid

Är stämningen bra mellan dig och dina arbetskamrater? ® ® ® ® ®

Känner du dig delaktig i gemenskapen på din arbetsplats? ® ® ® ® ®

Har ni det kul på kliniken? ® ® ® ® ®

Har ni gemensamma raster på kliniken? ® ® ® ® ®

Känner du dig ensam i arbetet? ® ® ® ® ®

11. Har du det senaste året varit involverad i trakasserier eller konflikter på kliniken?

® Ja, ofta ® Ja, någon gång ® Nej

12. Hur många personer ingår i den dagliga ledningen av kliniken?

® En person ® Två personer ® Tre eller flera personer

13. Hur många kliniker har den dagliga ledningen ansvaret för?

® En klinik ® Två klinikker ® Tre eller flera klinikker

14. Vilken grundutbildning har klinikens dagliga ledning? (Det är möjligt att sätta flera kryss)

  ® Tandläkare ® Tandhygienist ® Tandsköterska ® Något annat: _________________________

15. Har klinikens dagliga ledning formell ledarskapsutbildning?(Det är möjligt att sätta flera kryss)

  ® Ja ® Nej ® Vet inte

16. Vilket kön har klinikens dagliga ledning?

  Antal män: ________

  Antal kvinnor: ________

� Det Goda Arbetet

Här frågar vi om hur du värderar olika aspekter på ditt arbetsinnehåll och ditt inflytande på arbetet.

17. Hur bedömer du omfattningen av:

Alldeles för För För Alltför litet/liten liten/litet Lagom stor/stort stor/stort

Tid för patientrelationen? ® ® ® ® ®

Ditt inflytande? ® ® ® ® ®

Ditt ansvarsområde? ® ® ® ® ®

Variationen i arbetsuppgifter? ® ® ® ® ®

Delegeringen av kliniska uppgifter till tandhygienister/tandsköterskor? ® ® ® ® ®

Alltför Alltför låg För låg Lagom För hög hög

Omgivningens förväntningar? ® ® ® ® ®

De krav som ställs på dig? ® ® ® ® ®

Din arbetsbelastning? ® ® ® ® ®

Din inkomst? ® ® ® ® ®

18. Vilket inflytande har du på följande förhållanden?

Inget inflytande Visst inflytande Bestämmer själv

Vilket märke på fyllningsmaterial som används på kliniken ® ®  ®

Val av tandtekniker ® ®  ®

Vilken sköterska som assisterar ® ®  ®

Nyanställning av klinikpersonal ® ®  ®

Tidsbokning ® ®  ®

Bokning av akutpatienter ® ®  ®

Val av egna kurser ® ®  ®

Klinikens målformuleringar ® ®  ®

Det Goda Arbetet �

Här ber vi om din uppfattning om klinikens värderingar och mål

19. I vilken grad anser du att följande faktorer kännetecknar din klinik?

I mycket I liten Till viss I hög I mycket liten grad grad grad grad hög grad

Initiativ ® ® ® ® ®

Hantverksmässig kvalitet ® ® ® ® ®

Produktivitet ® ® ® ® ®

Effektivitet ® ® ® ® ®

Engagemang ® ® ® ® ®

God samarbetsförmåga ® ® ® ® ®

Intäktsorienterat ® ® ® ® ®

Flexibilitet ® ® ® ® ®

Serviceorienterat ® ® ® ® ®

Kreativitet ® ® ® ® ®

Professionell utveckling ® ® ® ® ®

20. I vilken grad används följande metoder för uppföljning på kliniken?

I liten grad Till viss grad I hög grad

Informell dialog ® ® ®

Utvecklingssamtal ® ® ®

Klinikmöten ® ® ®

Skriftlig uppföljning ® ® ®

10 Det Goda Arbetet

Följande frågor handlar om hur arbetet påverkar ditt privatliv.

21. I allmänhet, skulle du vilja säga att din hälsa är:

® Dålig ® Någorlunda ® God ® Mycket god ® Utmärkt

22. Hur ofta:

Aldrig/ Alltid/ nästan aldrig Sällan Ibland Ofta nästan alltid

Har du energi över till ditt privatliv? ® ® ® ® ®

Kan du släppa arbetet när du kommer hem ? ® ® ® ® ®

Säger din familj eller dina vänner till dig att du arbeter för mycket? ® ® ® ® ®

Påverkar arbetet din hälsa negativt? ® ® ® ® ®

Påverkar arbetet din hälsa positivt? ® ® ® ® ®

Det finns många saker som kan påverka din arbetsglädje och din uppfattning om ett gott arbetsliv. Därför kommer nu några frågor om dig själv och din arbetssituation.

23. Ditt kön:

® Man ® Kvinna

24. Vilket år avslutade du din tandläkarutbildning:

År ________

25. Du är:

® Född i Sverige ® Född i annat nordiskt land ® Född i ett land utanför norden

26. Din familjesituation:

® Ensamstående ® Gift/Lever i fast parförhållande ® Något annat: ________________________

Det Goda Arbetet 11

27. Hur många barn under 7 år bor hos dig?

___________ barn

28. Jag är:

  ® Ansluten till Praktikertjänst

  ® Klinikägare i privatpraktik

  ® Anställd i privatpraktik

  ® Klinikchef i offentlig tandvård

  ® Anställd i offentlig tandvård

  ® Något annat: _____________________________________________

29. Hur många personer arbetar på din dagliga arbetsplats (inkl dig själv) (Om du arbetar i en större organisation avser vi bara den klinik där du normalt arbetar)

Antal tandläkare: ___________

Antal tandhygienister: ___________

Antal tandsköterskor: ___________

Antal andra anställda: ___________

30. Hur många timmar i veckan arbetar du som tandläkare?

Totalt ___________ timmar. Därav cirka ___________ timmar med direkt patientkontakt

31. Hur många patienter följer du regelbundet? Ca. ___________ patienter

32. Ungefär hur många patienter har du en vanlig vecka? Ca. ___________ patienter

33. Fördelning av din arbetstid på olika patientgrupper:

Ca. ___________ % barn

Ca. ___________ % vuxna

Ca. ___________ % patienter med nödvändig tandvård

12 Det Goda Arbetet

34. Hur avlönas du?

  ® Provisionslön/omsättningsbaserad inkomst

  ® Fast lön/timlön

  ® Något annat: ____________________________________________________________________________

35. Hur länge har du arbetat på din nuvarande arbetsplats?

Antal år: ______

36. Upplever du, att du har ett gott arbetsliv?

® Inte alls ® I liten grad ® Till viss grad ® I hög grad ® I mycket hög grad

37. Har du under det senaste året övervägt att sluta som tandläkare?

® Ja ® Nej

Om ja, av vilken primär orsak? __________________________________________________________________

38. Har du under det senaste året övervägt att byta till annan arbetsplats? ® Ja ® Nej

Om ja, av vilken primär orsak? ________________________________________________________________

39. Förväntar du dig att fortsätta arbeta som du gör nu fram till normal pensionsålder?

® Ja ® Nej

Om nej, beskriv gärna orsaken: _________________________________________________________________

Här får du gärna skriva egna kommentarer:

LIC

EN

TIA

TE

DIS

SE

RTA

TIO

N IN

OD

ON

TO

LOG

Y

KA

MIL

LA

BE

RG

ST

RÖ

M

MA

LM

Ö U

NIV

ER

SIT

Y 2

01

4

MALMÖ UNIVERSITY

205 06 MALMÖ, SWEDEN

WWW.MAH.SE

KAMILLA BERGSTRÖMJOB 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

JOB

SA

TIS

FA

CT

ION

AN

D E

MO

TIO

NA

L W

OR

K TA

SK

S

L I C E N T I A T U P P S A T SL I C