Journal of Work and Organizational Psychology 31 (2015) 207–213

Journal of Work and Organizational Psychology

www.elsevier.es/rpto

Original

Work stress and turnover intentions among hospital physicians:

The mediating role of burnout and work satisfaction
Aharon Tziner ∗ , Edna Rabenu, Ruth Radomski, Alexander Belkin
Netanya Academic College, Israel

a r t i c l e i n f o a b s t r a c t

Article history: Work stress has extremely significant consequences to the individual and to the organization (Barling,
Received 21 August 2014 Kelloway, & Frone, 2005). This study examined the relationship between perceived work stress, burnout,
Accepted 7 May 2015 satisfaction at work, and turnover intentions. We hypothesized that a positive relationship would be
Available online 26 September 2015
found between work stress and burnout, and negative relationships would be found between burnout
and satisfaction, and between satisfaction and turnover intentions. The sample included 124 hospital
Keywords: physicians. As expected, all our hypotheses were corroborated. Structural Equation Modeling (SEM) found
Work stress
that beyond the assumed direct relationships, burnout partially mediated between work stress and work
Burnout
Work satisfaction
satisfaction, and work satisfaction partially mediated the relationship between burnout and turnover
Turnover intentions intentions. The paper reviews the theoretical consequences and suggests ideas for future research.
Structural equation model © 2015 Colegio Oficial de Psicólogos de Madrid. Published by Elsevier España, S.L.U. This is an open
Mediation access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Estrés laboral e intención de abandono en médicos hospitalarios: el papel

mediador del agotamiento y la satisfacción laboral

r e s u m e n

Palabras clave: El estrés laboral tiene consecuencias muy importantes para la persona y para la organización (Barling,
Estrés laboral Kelloway y Frone, 2005). Este estudio analiza la relación entre estrés laboral percibido, agotamiento
Agotamiento (burnout), satisfacción laboral e intención de abandono. Planteamos las hipótesis de que habría una
Satisfacción laboral
relación positiva entre estrés laboral y agotamiento y negativa entre este último y satisfacción y entre
Intención de abandono
esta y la intención de abandono. La muestra estaba compuesta por 124 médicos de hospital. Según lo
Modelo de ecuaciones estructurales
Mediación esperado, se corroboraron todas las hipótesis. El modelo de ecuaciones estructurales demostró que más
allá de las supuestas relaciones directas, el agotamiento mediaba parcialmente entre el estrés laboral y la
satisfacción laboral y esta mediaba parcialmente la relación entre agotamiento e intención de abandono.
El trabajo revisa las consecuencias teóricas y propone ideas para la futura investigación.
© 2015 Colegio Oficial de Psicólogos de Madrid. Publicado por Elsevier España, S.L.U. Este es un
artículo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/licenses/
by-nc-nd/4.0/).

Work stress from work as taxing or exceeding his or her resources (Lazarus,
1999). Once employees perceive any work situation as presenting
Job stress has received extensive theoretical and research atten- demands that threaten to exceed their capabilities and resources
tion. Work stress occurs when a person appraises external demands for meeting them – or as being too costly if not met – they are
expected to assess the situation as stressful. These perceptions are,
of course, very subjective; stress is in “the eye of the beholder”.
∗ Corresponding author: Netanya Academic College, 1 University St. Netanya
Physicians, specifically, deal with numerous and varied stress-
42365 Israel.
ors: long work hours, unreasonable work conditions, and work
E-mail addresses: atziner@netanya.ac.il (A. Tziner), edna.rabenu@gmail.com
(E. Rabenu), ruth.radomsky@perrigo.co.il (R. Radomski), sashab@polygal.co.il environment (many patients and too little time for each patient),
(A. Belkin). sleep disorders because of night shifts, loss of autonomy (the

http://dx.doi.org/10.1016/j.rpto.2015.05.001
1576-5962/© 2015 Colegio Oficial de Psicólogos de Madrid. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
208 A. Tziner et al. / Journal of Work and Organizational Psychology 31 (2015) 207–213

physician is forced to cope with the economic, social, and legal burnout compared to 23% of the general population. Furthermore,
implications of his/her decisions; patients are better informed due physicians in specialties at the front line of care access (family
to exposure to the internet), lack of balance between work and medicine, general internal medicine, and emergency medicine)
personal life, isolation (a physician cannot discuss patients with seem to be at the greatest risk. Lower levels of burnout were found
colleagues because of confidentiality issues), relatively low pay among dermatologists, pediatricians, and pathologists1 . Burnout,
in comparison to what is expected in return for the long years as it increases, has been shown to result in lower work satis-
of training and long work hours, low promotion options, profes- faction and subsequently increased levels of turnover intentions
sional responsibility, dealing with illness and death on a daily basis, (Cropanzano, Rupp, & Byrne, 2003; Moreno-Jiménez, Hernández,
a sense of failure (when a patient is not cured), fear of lawsuits Carvajal, Gamarra, Ramón, 2009; Smith & Tziner, 1998; Urien
for medical malpractice, and more (Burbeck, Coomber, Robinson, Angulo, & Osca, 2012). Job satisfaction refers to one’s cognitive
& Todd, 2002; Klein, Frie, Blum, & Von dem Knesebeck, 2011). (evaluative), affective (or emotional), and behavioral responses to
It is, therefore, not surprising that physicians experience work one’s job, as assessed by one’s evaluation of job features or char-
stress. acteristics, emotional responses to events that occur on the job,
and job-related behavioral intentions (Locke, 1976). Individuals
suffering from unrelenting depletion of resources perceive little
Work stress, burnout, work dissatisfaction, and turnover or no chances to change this reality. Thus, understandably, they
intentions experience dissatisfaction with their work, a state that is psycho-
logically taxing. Moreover, the avenue to extract themselves from
Stress at the workplace has become an important issue because this unpleasant situation is by considering leaving their present
its consequences can take a heavy toll on organizations and their work, the source of their pain (i.e., they develop turnover inten-
employees (Barling, Kelloway, & Frone, 2005). High levels of stress tions) (Moreno-Jiménez et al., 2009).
can impair workers’ performance and result in negative behav- The following hypotheses are based on the above literature
ioral and attitudinal work outcomes (Barling et al., 2005; Gilboa, review and derived from it.
Shirom, Fried, & Cooper, 2008). Of interest, recent studies have Hypothesis 1: Work stress will positively relate to burnout.
shown that chronic work pressure conduces a feeling of overcon- Hypothesis 2: Burnout will negatively associate with work sat-
sumption of energy that undermines wellbeing. It occurs when isfaction.
job-relevant personal resources are constantly exceeded by work Hypothesis 3: Work satisfaction will negatively relate to turnover
demands (Urien Angulo, & Osca, 2012). intentions.
The Conservation of Resources Theory (COR) is a general In the present study, we intended to examine so-far insuf-
stress theory that is based on the premise that individuals seek ficiently investigated links between work stress, burnout, work
to preserve, renew, and enhance their resources – and when satisfaction, and turnover intentions of physicians, whose work is
they cannot do so, they experience stress. In other words, stress allegedly strenuous. Although previous studies have examined the
occurs when resources are perceived as unstable, threatened, or stress-burnout-turnover relationship, we believe that replication
lost, or when individuals are unable to attain or preserve resources of these studies in a different culture (Israel) and among doctors
with available means (Hobfoll, 2001). Resources are defined as employed in a specific framework (hospitals) can contribute to bet-
objective personal characteristics, conditions, or energies that are ter understanding physicians’ burnout and turnover processes. The
valued in themselves or because they contribute to achieving or literature certainly indicates a need to continue research in this
preserving valued resources. COR theory has been suggested as an area (Zhang & Feng, 2011). This recommendation is consistent with
integrative stress theory, which includes both the worker’s subjec- the contention of eminent scholars that the ultimate test for valid-
tive processes (i.e., personality attributes such as locus of control ity of findings is their recurrence in numerous replications (James,
and flexibility, which might exert influence on the perception of Mulaik, & Brett, 1982).
stress at work) and objective or external environmental sources
of stress (e.g., inherent extreme or noxious stimuli such as risk of Method
physical harm or extreme temperature work conditions). Based on
this theory, it may be claimed that as work demands exceed the Participants
bounds of the official job, they rob the worker of many resources
that are required to fulfill the formal job, thus leaving the worker The data were collected from 124 hospital-employed physicians
with fewer resources to devote to regular tasks, which, in turn, as respondents, of whom 50% were men and 50% women. Their
increases the sense of stress. This depletion of resources leads mean age was 39.86 years. Their tenure in the present organiza-
over time to burnout (Crawford, LePine, & Rich, 2010). Employee tion was 53.22% in the range of 1-10 years, 24.19% in the range of
burnout is a progressive psychological response to chronic work 11-20 years, 15.32% in the range of 21-30 years and 7.25% in the
stress involving emotional exhaustion, depersonalization, and feel- range of 30 years and above; 68.3% were married, 22% were sin-
ings of reduced personal accomplishment (Maslach & Jackson, gle, 8.9% were divorced, and 0.8% widowed; 32.8% of the physicians
1981). For doctors, burnout is an occupational disease that impairs that participated in the study were dermatologists, 32.8% internists,
both quality of healthcare and physicians’ health. It is associated 33.6% pediatricians, and 0.8% interns. About half of the respon-
with medical malpractice (Chen et al., 2013), emotional distress, dents (47.5%) were senior physicians, 42.5% were interns, 9.2% were
absenteeism, reduction in personal effectiveness, and increased chief physicians, and 0.8% were deputy chief physicians. Most of
risk of health problems (Kushnir & Cohen, 2006). A comprehensive the respondents (58.5%) were specialists, 33% were level-one resi-
study examining burnout among physicians in Israel (in the years dents, and 8.5% were level-two residents. The study was conducted
1994-2001) indicated that many suffered high levels of burnout, in six hospitals in Israel. One-hundred seventy questionnaires were
with burnout levels rising significantly throughout the years of the handed out, of which 124 were filled out and returned. The return
study (Kushnir, Levhar, & Cohen, 2004). These findings coincide rate was 72.94%.
with a study that examined burnout among American doctors in
various specialties (Shanafelt et al., 2012), and found that burnout
is more common among physicians than among other US work- 1
Respectively, this study examined doctors from both ends of the burnout scale:
ers. Of the physicians, 45.8% reported at least one symptom of internists on one hand and pediatricians and dermatologists on the other hand.
 A. Tziner et al. / Journal of Work and Organizational Psychology 31 (2015) 207–213 209

Measures directly and negatively connected to turnover intentions (␤ = −.53),

as hypothesized. Furthermore, however, we found a negative direct
Work Stress was gauged using a 14-item scale developed by relationship between work stress and work satisfaction (␤ = −.45) as
Cohen, Kamarck, and Mermelstein (1983). Sample items included: well as a direct positive link between burnout and turnover inten-
“I experienced a low mood during the last year”, “I felt tense and tions (␤ = .19), thereby lending support to the conclusion that the
under pressure during the last year”. Participants indicated the fre- relationships between work stress and work satisfaction as well as
quency with which they experienced the situation described by between burnout and turnover intentions are not fully and solely
each item using a 6-point Likert scale ranging from 1 (never) to 6 directly mediated but rather partially mediated.
(all the time). Cronbach’s alpha was .85 (M = 3.09, SD = 0.71).
Burnout was tapped with the Burnout Measure (BM; Pines &
Further analyses
Aronson, 1988) containing 21 items evaluated on 7-point frequency
scales, assessing the level of an individual’s physical, emotional, and
We used two statistical methods in order to test the validity and
mental exhaustion. Sample items included “feeling weak/sickly and
stability of our findings: (1) Spearman’s (1904, 1910) disattenuated
having sleep problems” (physical exhaustion), “Feeling depressed
correlation coefficient in order to control for measurement errors;
and hopeless” (emotional exhaustion), “Feeling worthless/like a
and (2) Browne’s (1975) cross-validation coefficient to control
failure and disappointed with people” (mental exhaustion). In a
for possible artifactual effects of the sample size. The disattenu-
dimensionality and validity research of the BM, Enzmann, Schaufeli,
ated correlation coefficients have been presented in Table 1 (in
Janssen, and Rozeman (1998) found that in contrast to the pre-
parenthesis). We can conclude that there were not substantial mea-
sumed dimensions ‘physical exhaustion’, ‘emotional exhaustion’,
surement errors in our data, because the disattenuated correlations
and ‘mental exhaustion’, the factors of the BM are ‘demoralization’
were in accordance with the predicted values, in regard to the
(D), ‘exhaustion’ (E), and ‘loss of motive’ (L). Cronbach’s alpha was
reliabilities and correlations of our study (see Muchinsky, 1996;
.90 (M = 3.10, SD = 0.80).
Zimmerman & Williams, 1997). Nevertheless, there are two corre-
Work satisfaction was measured by the 20-item Minnesota Sat-
lations which reached .99 (burnout E and total burnout) and .98
isfaction Questionnaire (MSQ) – short form. Responses were given
(burnout D and total burnout) after disattenuation, and thus can be
on a Likert scale ranging from 1 (totally dissatisfied) to 6 (extremely
considered measuring the same construct.
satisfied). A satisfaction score was calculated for each participant
In order to view more precise results in predicting the different
by averaging the responses to all items. Measure reliability (Cron-
variables (see Figure 1), we calculated Browne’s (1975) cross-
bach’s alpha) for the questionnaire was .91 (M = 4.2, SD = 0.81).
validation coefficient (P̂c2 ). For the R2 of burnout (.30), Browne’s
Turnover Intentions were measured using Rusbult and Lowery’s
cross-validation coefficient was .29, meaning there is a 1% dis-
(1985) questionnaire. This scale consisted of seven items. The ques-
crepancy between the original R2 and Browne’s cross-validation
tionnaire requires respondents to evaluate the degree to which they
coefficient. For the R2 of work satisfaction (.53), Browne’s cross-
agree with statements describing their intentions to remain in the
validation coefficient was .51, meaning there is a 2% discrepancy
organization on a 6-point scale. Cronbach’s alpha for this measure
between the original R2 and Browne’s cross-validation coefficient.
in the study was .73 (M = 1.84, SD = 0.72).
For the R2 of work satisfaction (.44), Browne’s cross-validation coef-
ficient was .41, meaning there is a 3% discrepancy between the
original R2 and Browne’s cross-validation coefficient. In sum, these
Results
discrepancies do not prove to be problematic for the current study
due to their low (although progressively increasing) values.
Table 1 shows correlations among the study variables. As can
be seen, a strong positive relationship between work stress and
burnout was found (.55, p < .0001), and a strong negative association Discussion
emerged between burnout and work satisfaction (−.63, p < .0001)
as well as between work satisfaction and turnover intentions (−.65, In the present study, we sought to extend the investigation of
p < .0001). the relationships between work stress, burnout, work satisfaction,
Evidently, all three hypotheses were corroborated. A structural and turnover intentions among hospital physicians.
equation model (by AMOS 7) was computed to simultaneously test The hypothesis (H1) – that a positive relationship would be
all the relationships as predicted by the three hypotheses (Figure 1). found between work stress and burnout – was upheld. Medi-
However, a direct path from work stress to work satisfaction and cal personnel face enormous mental pressures that could result
another from burnout to turnover intentions were also incorporated in burnout (Pines, 2011). In their work, physicians are required
into the model, because previous publications have borne out these to cope with numerous demands: clinical demands of the job
links (Moreno-Jiménez et al., 2009). (for instance, decisions about patients), academic demands (for
Since there is no single statistical test that best describes the instance, learning new technologies), and administrative demands
strength of a model’s predictions (Hair, Anderson, Tatham, & Black, (for instance, the need to consider financial considerations when
1992), several measures of approximation were employed. In the treating patients). These demands could easily result in various
Normed Fit Index (NFI), the Goodness-of-Fit Index (GFI), and the pressures, from clinical responsibility to an overload of tasks under
Comparative Fit Index (CFI) a degree of fit above .9 is consid- time constraints, emotionally fraught contact with patients and
ered sufficient (Bentler, 1990). The approximation measures found staff, and self-confidence in the ability to do their job properly
here were above .95, and therefore meet the approximation crite- (Agius, Blenkin, Deary, Zealley, & Wood, 1996; Bruke & Richardson,
ria (NFI = .991, CFI = .995). In addition, lack-of-fit was measured by 1990). Burnout is caused by ongoing mental stress or by other
means of RMSEA (root mean square error of approximation), where chronic work-related pressures (Hobfoll & Shirom, 2000; Maslach,
the value of a suitable fit should be lower than .1 (Jöreskog & Schaufeli, & Leiter, 2001). A recent study of IT specialists (Jung,
Sörbom, 1989). In the current study, the results for lack-of-fit were 2013) found respectively that each work burnout factor (i.e., emo-
sufficient (RMSEA = .088). In addition, ␹2 (1) was 1.95, p > .05. tional exhaustion and cynicism) was predicted by job stressors (i.e.,
Specifically, Figure 1 indicates that work stress relates directly role overload, role insufficiency, and role boundary).
and positively to burnout (␤ = .55), burnout relates directly and Our second hypothesis (H2) – that burnout would nega-
negatively to work satisfaction (␤ = −.37), and work satisfaction is tively associate with work satisfaction – was also confirmed. This
210 A. Tziner et al. / Journal of Work and Organizational Psychology 31 (2015) 207–213

Table 1
Correlations among study variables.

M SD ␣ 1 2 3 4 5 6

1. Work stress 3.09 0.71 .85 -

2. Burnout 3.10 0.80 .90 .55** (.63) -
3. Burnout E 3.93 1.13 .90 .45** (.51) .89** (.99) -
4. Burnout D 2.47 0.81 .81 .49** (.59) .84** (.98) .52** (.64) -
5. Burnout L 2.45 0.74 .74 .50** (.63) .68** (.83) .50** (.65) .55** (.71) -
6. Work satisfaction 4.20 0.81 .91 −.66** (−.75) −.63** (−.70) −.48** (−.56) −.57** (−.69) −.61** (−.74) -
7. Turnover intentions 1.84 0.72 .73 .52** (.66) .52** (.64) .37** (.48) .54** (.73) .46** (.63) −.65** (−.80)

Note. The disattenuated correlation coefficients (Spearman, 1904, 1910) are shown in parenthesis, and discussed in further analyses.
N = 124; * p < .05, ** p < .01.

Burnout Work Turnover

Work –.37** (–.63**) –.53** (–.65**)
.55** (.55**) satisfaction intentions
stress
R 2 = .30 R 2 = .53 R 2 = .44

–.45** (–.66**)
.19* (.52**)

N.S. (.52**)

Figure 1. Research Model.

Note. The stantardized regression coefficients are depicted on the paths, while the correlations coefficients are shown in parenthesis.
N = 124.
*p < .05, **p < .01.

connection was reported in previous studies (i.e., Hombrados- surgeons who provide services in hospitals) work for more than
Mendieta & Cosano-Rivas, 2013; Wolpin, Burke, & Greenglass, one organization (Nirel et al., 2003). That is to say, knowing medi-
1991). The intensity of the relationship depends on satisfaction cal organizations well, physicians are aware that moving from one
measures (for instance pay, promotion, the work itself, super- setting to another is not lucrative. As a result, physicians do not
visor, and the organization as a whole) and the sector (private engage in pipedreams that another hospital would be better and,
or public) (Tsigilis, Zachopoulou, & Grammatikopoulos, 2006). A consequently, their turnver intentions are lower despite their dis-
study conducted in Israel on 890 doctors in six areas of special- satisfaction.
ization revealed similar findings: physicians employed in hospitals Physicians who are fed up with the difficult work conditions
are more burned-out (the physical tiredness aspect) and express in hospitals could abandon the profession entirely, moving on
less satisfaction than independent HMO doctors (Nirel, Shirom, & to biotechnology, pharmaceutical companies, medical research,
Ismail, 2003). teaching, etc. (Dyke, Holtzman-Schweid, Bin-Nun, & Kushnir,
Finally, the third hypothesis (H3) – that work satisfaction 2011), but this obviously means intending to leave the profession
would negatively relate to turnover intentions – was corroborated. rather than to leave the organization.
Dissatisfaction and turnover intentions are types of employee Also, the mediation of work satisfaction between perceived
withdrawal. The withdrawal is intended to protect the individ- work stress and turnover intentions is known in the literature (for
ual from stress and its consequences (Keaveney & Nelson, 1993). example, Fried, Shirom, Gilboa, & Cooper, 2008 – partially; Paillé,
The results of the present study concur with other studies that see 2011 – fully). Our findings that work stress does not directly affect
the worker’s dissatisfaction or ‘psychological withdrawal’ as the turnover intentions could be explained by stress creating nega-
first stage that motivates the withdrawal behavior that eventually tive feelings manifested in reduction of the worker’s satisfaction.
results in turnover (Hom & Griffeth, 1991; Krausz, Koslowsky, & Turover intentions reflect the individual’s attempt to cope with
Eiser, 1998). these negative feelings (that deplete his/her resources) by means
Beyond the direct relationships, the results indicate that of psychological withdrawal. Support of this explanation can be
satisfaction mediates the relationship between stress and found in Lazarus’ (1999) process approach to coping with stress,
turnover intentions, whereas the direct link between turnover namely that an individual that is exposed to stress performs: (a)
intentions and stress is not significant. Some studies have primary appraisal – the individual perceives and interprets the
found weak correlation between work stress and turnover significance of the encounter with the stressor as damaging, threat-
intentions (i.e., Bedeian & Armenakis, 1981), but most of the ening, or challenging; (b) secondary appraisal – the individual
results show a significant relationship between the variables evaluates possible response options to the damage, threat, or chal-
(Goodman & Boss, 2002; Moreno-Jiménez, Gálvez-Herrer, lenge. Subsequent emotions are rooted in the secondary appraisal
Rodríguez-Carvajal, & Sanz-Vergel, 2012). (for instance, anger, anxiety, hope, etc.) (Lazarus, 1999, pp. 94-96).
The main explanation for not finding a significant link between As stated, individuals that suffer from constant depletion of their
stress and turnover intentions, in our opinion, could be the char- resources perceive the chance for change as slim. Evaluation of
acteristics of Israeli physicians’ work environment. The number of response options becomes limited (the employee is burned-out
hospitals in Israel is limited, and doctors realize that employment and depleted) and raises negative feelings that are the ingredi-
conditions in all hospitals are similar. Furthermore, a considerable ents of dissatisfaction. Thus, the individual concludes that action
number of hospital physicians in Israel work in a number of employ- must be taken on oneself (rather than changing the stressor), while
ment settings. Research has shown that most physicians (84%) adjusting and accepting the stress situation or, alternatively, with-
in the examined specialties (including cardiologists and general drawing from it, as is suggested in this model. Following Locke’s
 A. Tziner et al. / Journal of Work and Organizational Psychology 31 (2015) 207–213 211

(1976) widely-accepted definition of work satisfaction, and apply- discomfort and view their life as a series of stressors even in the
ing it to the present study’s variables, it can be said that after the absence of overt stress (Watson, 1988; Watson & Clark, 1984).
work is evaluated as stressful (due to demands from the doctors), Therefore, it seems quite possible that negative affectivity may be
an emotional reaction to work events is formed (probably neg- driving the obtained relationships among the variables.
ative, expressed as dissatisfaction) as are work-related behavior The research variables in this study were collected from single-
intentions (turnover). source data, namely self-report questionnaires filled out by the
We also found that burnout is a factor that partially mediates the respondents. We believed that, due to the nature of the variables
relationship between work stress and dissatisfaction. The expla- (subjective stress, burnout, work satisfaction, and turnover inten-
nation is in the fact that work stress often, although not always, tions), subjective reports would be the most appropriate. However,
directly causes dissatisfaction. Hindrance stressors (Cavanaugh, there is a risk that the correlations do not reflect a relationship
Boswell, Roehling, & Boudreau, 2000) are perceived as disrup- between the theoretic structures that we examined, but rather
tive to the individual (prevent him/her from achieving desired stem from the fact that a joint rules sytem, or schematic structure,
goals) such as organizational politics, bureaucracy, or concerns over was used to evaluate items or measures that represent separate
employment security (Gilboa, Shirom, Fried, & Cooper, 2008). When structures (Avolio, Yammarino, & Bass, 1991), so that the observed
faced with hindrance stressors, people believe that they do not relationships among variables were artificially ‘inflated’ (Lim &
have the required resources and coping mechanisms to face these Yuen, 1998). As regards our study, it is possible that the respondents
demands no matter how much effort they invest (LePine, Podsakoff, ‘colored’ their answers in gloomier shades because of negative feel-
& LePine, 2005). Podsakoff, LePine, and LePine (2007) reported that ings rooted in stress. Hence, correlations between variables could
while hindrance stressors decrease job satisfaction and increase suggest the emotional state in which the answers were given rather
turnover intentions, challenge stressors increase job satisfaction than a link between the variables themselves.
and decrease turnover intentions. In a study that examined stress Finally, the study sampled only 124 interviewees, a relatively
and burnout of police officers, Pines and Keinan (2005) found that small sample. This is in accordance with Salgado’s (1998) research,
despite the heightened stress and potential burnout, the police offi- in which he reviews and compares sample sizes across three peer-
cers reported satisfaction with their work. In their study, burnout reviewed journals. In his paper, he documents an increase in sample
was found to relate more to satisfaction and turnover intentions size over the years. This may possibly point to a weakness of the
than to work stress. Despite the stress, burnout can be low if work- current research, that is the sample size. Clearly, similar studies on
ers feel that their job is important and useful (Pines & Keinan, a larger scale would help to support both the reliability and valid-
2005), or if their sense of self-efficay is intact (Friedman, 2000). ity of the current findings, and better serve the goals of reaching
Challenge stress, which creates a sense of meaningfulness, reduces an all-encompassing model about the relationships between the
burnout and allows people to feel satisfied with their stressful investigated variables.
work (the interest, the challenge, etc.). As a result, there are fewer However, it is imperative to note that although the sample size
turnover intentions. Respectively, hindrance stress that disrupts might seem insufficiently large, we have used two methods in
the worker’s ability to achieve significant goals enhances burnout, order to test the stability of the findings and control for the pos-
which in turn leads directly to turnover intentions in order to stem sibility of artifactual sample size effect on them. Based both on
depletion of resources (Moreno-Jiménez et al., 2009), but also is cross-validation coefficients (Browne, 1975) and on disattenuated
indirectly mediated by dissatisfaction due to the presence of nega- correlation coefficients (Spearman, 1904, 1910), we conclude that
tive feelings. the sample size of the current research does not prove to have sig-
nificantly impacted on the results in terms of measurement errors
and strength of the findings.
Limitations

The present research has a number of limitations. Recommendations for future research
First, all of the study variables were examined concurrently.
Long-term investigation (longitudinal study), which is important Medicine is a draining profession in itself (Kushnir & Cohen,
when examining dynamic variables, is missing. This is especially 2006; Pines, 2011). Additionally, doctors’ satisfaction with inter-
true for burnout studies, because burnout changes over one’s nal factors (meaningfulness, interest, challenge, self-fulfillment) is
employment period (Dunford, Shipp, Boss, Angemeier, & Boss, much higher than their satisfaction with external factors (unre-
2012). warding work environment, hard physical conditions, inability
It is also possible that situation variables affected the to lead a normal family life) (Cooke & Chitty, 2004; Landon,
study. The data were collected around the time of the big doctors’ Reschovsk, Pham, & Blumenthal, 2006; Van Dyke, Holtzman-
strike. The strike was inundated with large media campaigns about Schweid, Bin-Nun, & Kushnir, 2011; Zuger, 2004). We suggest
doctors’ inferior wages and employment conditions. This could expanding the scope of the study and adding the variable ‘satisfac-
make generalization of the results to periods of stability and quiet tion with profession’. It could be interesting to investigate whether
difficult. burnout and stress affect various types of satisfaction. It is possible
Another possible drawback is that many specialists and physi- that among doctors, satisfaction with their profession medi-
cians work in more than one setting (Nirel et al., 2003). This has ates the relationship between stress and dissatisfaction with the
implications for the doctors’ sense of overload, burnout – physical organization.
fatigue and cognitive exhaustion, low satisfaction, and less commit- Additionally, turnover intentions are a form of psychological
ment to the primary place of work. Stress and burnout accumulate withdrawal. It should be examined whether, as a result of burnout
from numerous workplaces (more work hours per day). This study and dissatisfaction, more serious withdrawal behaviors occur (such
did not examine the respondents’ number of various work settings, as tardiness and absenteeism), as was found in many models (Hom
which could affect their burnout and dissatisfaction at the hospital. & Griffeth, 1991; Krausz et al., 1998), or whether among doctors –
This should be done in future studies. due to their complex and important profession – a different with-
In addition, the study did not control for individual differences drawal model occurs.
that might affect the level of subjective stress. For example, individ- Doctors may experience challenge stress in major parts of their
uals high in NA (negative affectivity) are more likely to experience work. We therefore recommend an in-depth examination of the
212 A. Tziner et al. / Journal of Work and Organizational Psychology 31 (2015) 207–213

research model that differentiates between hindrance and chal- resources, and enable recovery from stress. For instance, opening
lenge stressors. We believe that challenge stressors (as opposed a gym for doctors in the hospital, setting time for yoga/meditation,
to hindrance stressors) reduce burnout, and thus reduce turnover providing effective tools for coping with stress, augmenting psy-
intentions, both directly (Podsakoff et al., 2007) and mediated by chological resources (optimism, hope, resilience, etc.) that are
satisfaction. the basis of quality coping. A recent meta-analysis has substanti-
The present research was conducted among hospital physicians. ated the claim that cognitive, behavioral, and mindfulness-based
Hospitals are bureaucratic organizations, which include numerous approaches are effective in reducing stress in medical students
stressors that negatively affect employees: overload, lack of inde- and practicing physicians, and may also contribute to lower levels
pendence and rewards, and stressors that stem from the service of burnout in physicians (Regehr, Glancy, Pitts, & LeBlanc, 2014).
receivers (Pines, 2011). We have seen that there are differences Indeed, a controlled experiment concerning primary healthcare
rooted in the doctors’ employment base (hospital or HMO) (Nirel professionals has significantly shown that the use of mindfulness-
et al., 2003). We recommend examining the research model on based programs as part of continuing professional education to
physicians in less bureaucratic organizations, and comparing the reduce and prevent burnout promote positive attitudes among
results. health professionals, strengthen patient-provider relationships,
and enhance well-being (Asuero et al., 2014). Optimal coping with
stress at work to a certain degree reduces future stress, because it
Organizational and managerial implications is a cycle that feeds itself. Proper coping with stress at work will
enable the physician to be less impatient with the patient, which
Observing the research model and its results empasizes the in turn improves the level of service and prevents possible prob-
importance of treating physicians’ stressors and burnout in order lems from a patient who is dissatisfied with the service that he/she
to prevent their dissatisfaction and turnover intentions. Subjective received.
perception of stress and the burnout closely related to it precede the
rest of the unwanted organizational results, and should therefore be Conflict of Interest
addressed first. We recommend that heads of health systems treat
the physicians’ objective stressors, which affect subjective percep- The authors of this article declare no conflict of interest.
tions of stress, which is, in turn, related to burnout. We propose two
levels of treatment to reduce stress: structural and organizational. Acknowledgements
The structural aspect should involve reduction of objective
stress on physicians by changing the actual structure of health The authors are grateful to Mr.Or Shkoler for his assistance with
services. Hospital doctors suffer from an overload of tasks, great data analyses.
responsibility, and they work long hours. We believe that a consid-
erable number of tasks that are at present performed by hospital References
doctors should be transferred to other medical branches. Hospital
physicians would deal with life-threatening emergencies, inten- Agius, R. M., Blenkin, H., Deary, I. J., Zealley, H. E., & Wood, R. A. (1996). Survey
sive care, and complex medical procedures. Other cases, not related of perceived stress and work demands of consultant doctors. Occupational and
Environmental Medicine, 53, 217–224.
to infective diseases (which could cause epidemics), can be sup- Asuero, A. M., Queraltó, J. M., Pujol-Ribera, E., Berenguera, A., Rodriguez-Blanco,
ported by community clinics and home care. This would result in T., & Epstein, R. M. (2014). Effectiveness of a mindfulness education program
the development of new professions such as nurse’s assistant, who in primary health care professionals: A pragmatic controlled trial. Journal of
Continuing Education in Health Professions, 34, 4–12.
would actively perform simple, routine medical procedures that Avolio, B. J., Yammarino, F. J., & Bass, B. M. (1991). Identifying common methods
were so far performed by hospital doctors and nurses, thus free- variance with data collected from single source: An unresolved sticky issue.
ing them for the core roles of their profession. First examples of Journal of Management, 17, 571–587.
Barling, J., Kelloway, E. K., & Frone, M. (Eds.). (2005). Handbook of Work Stress. CA:
such steps already exist and are successful. We suggest expand- Sage Publications.
ing them to form a general rather than specific perception change, Bedeian, A. G., & Armenakis, A. A. (1981). A path analytic study of the consequences
primarily due to developing medical technologies that enable it. of role conflict and ambiguity. Academy of Management Journal, 24, 417–424.
Bentler, P. M. (1990). Comparative fit indexes in structural models. Psychological
For instance, in the past, treatment of diabetes was performed in
Bulletin, 107, 238–246.
hospitals, whereas today family members inject sick children with Browne, M. W. (1975). Predictive validity of a linear regression equation. British
insulin and supervise sugar levels by simple technological means. Journal of Mathematical and Statistical Psychology, 28, 79–87.
Other medical procedures, such as changing bandages of bedsores, Bruke, R. J., & Richardson, A. M. (1990). Sources of satisfaction and stress among
Canadian physicians. Psychological Reports, 67, 1335-1334.
could be performed by family members or caretakers after short Burbeck, R., Coomber, S., Robinson, S. M., & Todd, C. (2002). Occupational stress in
training. The benefits of the suggested structural change could have consultants in accident and emergency medicine: A national survey of levels of
far-reaching consequences. It could reduce hospital costs, while stress at work. Emergency Medicine Journal, 19, 234–238.
Cavanaugh, M. A., Boswell, W. R., Roehling, M. V., & Boudreau, J. W. (2000). An empir-
decreasing overload and improving service to the patients. Further- ical examination of self-reported work stress among U.S. managers. Journal of
more, it could reduce physicians’ overload by eliminating routine Applied Psychology, 85, 65–74.
tasks and grinding bureaucracy, which would enable a meaningful Chen, K. Y., Yang, C. M., Lien, C. H., Chiou, H. Y., Lin, M. R., Chang, H. R., & Chiu, W.
T. (2013). Burnout, Job Satisfaction, and Medical Malpractice among Physicians.
relationship with the patient, a sense of satisfaction and signifi- International Journal of Medical Sciences, 10, 1471–1478.
cance among doctors, spare time for updating, research, and rest, Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived
less mistakes, etc. Another benefit would be opening new employ- stress. Journal of Health and Social Behavior, 24, 385–396.
Cooke, L., & Chitty, A. (2004). Why do doctors leave the profession? A report issued
ment avenues and creating jobs that would relieve doctors and by the Health Policy & Economic Research Unit, British Medical Association,
nurses of routine procedures. Moreover, patients would be pro- Tavistock House.
tected from hospital-related infections, their autonomy would be Crawford, E. R., LePine, J. A., & Rich, B. L. (2010). Linking job demands and resources to
employee engagement and burnout: A theoretical extension and meta-analytic
preserved (home care), and their connection to the social networks
test. Journal of Applied Psychology, 95, 834–848.
that provide them with emotional support would not be severed. Cropanzano, R., Rupp, D. E., & Byrne, Z. S. (2003). The relationship of emotional
The organizational facet relates to the long work hours and exhaustion to work attitudes, job performance, and organizational citizenship
chronic stress that deplete the physician’s resources and increase behaviors. Journal of Applied Psychology, 88, 160–169.
Dunford, B. B., Shipp, A. J., Boss, R. W., Angemeier, I., & Boss, A. D. (2012). Is burnout
burnout. We propose that organizations increase physicians’ static or dynamic? A career transition perspective of employee burnout trajec-
resources wherever possible, so as to maintain a resonable level of tories. Journal of Applied Psychology, 97, 637–650.
 A. Tziner et al. / Journal of Work and Organizational Psychology 31 (2015) 207–213 213

Enzmann, D., Schaufeli, W. B., Janssen, P., & Rozeman, A. (1998). Dimensionality Moreno-Jiménez, B., Gálvez-Herrer, M., Rodríguez-Carvajal, R., & Sanz Vergel, A. I.
and validity of the Burnout Measure. Journal of Occupational and Organizational (2012). A study of physicians’ intention to quit: The role of burnout, commitment
Psychology, 71, 331–351. and difficult doctor-patient interactions. Psicothema, 24, 263–270.
Fried, Y., Shirom, A., Gilboa, S., & Cooper, G. (2008). The Mediating Effects of Job Sat- Moreno-Jiménez, B., Hernández, E. G., Carvajal, R. R., Gamarra, M. M., & Ramón, F. P.
isfaction and Propensity to Leave on Role Stress-Job Performance Relationships: (2009). El burnout del profesorado universitario y las intenciones de abandono:
Combining Meta-Analysis and Structural Equation Modeling. International Jour- Un estudio multi-muestra. Revista De Psicología Del Trabajo y De Las Organiza-
nal of Stress Management, 15, 305–328. ciones, 25, 149–163.
Friedman, I. A. (2000). Burnout in teachers: Shattered dreams of impeccable profes- Muchinsky, P. M. (1996). The correction for attenuation. Educational & Psychological
sional performance. Journal of Clinical Psychology, 56, 595–606. Measurement, 56, 63–75.
Gilboa, S., Shirom, A., Fried, Y., & Cooper, C. (2008). A meta-analysis of work demand Nirel, N., Shirom, A., & Ismail, S. (2003). Consultant doctors in Israel: Employment
stressors and job performance: Examining main and moderating effects. Person- characteristics and implications to their work life (Hebrew). Joint Israel: Brookdale
nel Psychology, 61, 227–271. Institute.
Goodman, E. A., & Boss, R. W. (2002). The phase model of burnout and employee Paillé, P. (2011). Perceived stressful work, citizenship behavior and intention to leave
turnover. Journal of Health and Human Services Administration, 25(1), 33–47. the organization in a high turnover environment: Examining the mediating role
Hair, J. F., Anderson, R. E., Tatham, R. L., & Black, W. C. (1992). Multiple Discriminant of job satisfaction. Journal of Management Research, 3, 1–16.
Analysis. In Mulivariate Data Analysis with Readings (Chapter 3, pp. 87-152). New Pines, A. M. (2011). Work burnout: Causes, results and ways of coping (Hebrew). Ben-
York: Macmillan Publishing Company. Shemen: Modan Publishers.
Hobfoll, S. E. (2001). The influence of culture community and the nested-self in the Pines, A. M., & Aronson, E. (1988). Career burnout. New York: Free Press.
stress process: Advancing conservation of resources theory. Applied Psychology: Pines, A. M., & Keinan, G. (2005). Stress and Burnout: The significant difference.
An International Journal, 50, 337–421. Personality and Individual Differences, 39, 625–635.
Hobfoll, S. E., & Shirom, A. (2000). Conservation of resources theory: Applications to Podsakoff, N. P., LePine, J. A., & LePine, M. A. (2007). Differential challenge
stress and management in workplace. In R. T. Golembiewski (Ed.), Handbook of stressor-hindrance stressor relationships with Job attitudes, turnover inten-
Organizational Behavior (2nd revised edition, pp. 57–81). New York: Dekker. tions, turnover, and withdrawal behavior: A meta-analysis. Journal of Applied
Hom, P. W., & Griffeth, R. W. (1991). Structural equations modeling test of a turnover Psychology, 92, 438–454.
theory: cross-sectional and longitudinal analyses. Journal of Applied Psychology, Regehr, C., Glancy, D., Pitts, A., & LeBlanc, V. R. (2014). Interventions to reduce the
76, 350–366. consequences of stress in physicians: A review and meta-analysis. Journal of
Hombrados-Mendieta, I., & Cosano-Rivas, F. (2013). Burnout, workplace support, Nervous and Mental Diseases, 202, 353–359.
job satisfaction, and life satisfaction among social workers in Spain: A structural Rusbult, C., & Lowery, D. (1985). When bureaucrats get the blues: Responses to
equation model. International Social Work, 56, 228–246. dissatisfaction among federal employees. Journal of Applied Social Psychology,
James, L. R., Mulaik, S. A., & Brett, J. M. (1982). Conditions for confirmatory analysis 15, 80–103.
and causal inference. San Francisco: Sage. Salgado, J. F. (1998). Sample size in validity studies of personnel selection.Journal of
Jöreskog, K. G., & Sörbom, D. (1989). LISREL 7: A guide to the program and applications Occupational and Organizational Psychology, 71, 161–164.
(2nd edition). Chicago: SPSS Inc. Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D., & . . . Oreskovich,
Jung, E. (2013). Work stress and burnout: The mediating role of mood regulation M. R. (2012). Burnout and Satisfaction With Work-Life Balance Among US Physi-
among information technology professionals. Journal of Workplace Behavioral cians Relative to the General US Population. Archives of Internal Medicine, 172,
Health, 28, 94–106. 1377–1385.
Keaveney, S. M., & Nelson, J. E. (1993). Coping with organizational role stress: Smith, D., & Tziner, A. (1998). Moderating effects of affective disposition and social
intrinsic motivational orientation, perceived role benefits, and psychological support on the relationship between person - environment fit and strain. Psy-
withdrawal. Journal of the Academy of Marketing Science, 21, 113–124. chological Reports, 82, 963–983.
Klein, J., Frie, K. G., Blum, K., & Von dem Knesebeck, O. (2011). Psychosocial stress Spearman, C. (1904). The proof and measurement of association between two things.
at work and perceived quality of care among clinicans in surgery. BMC Health American Journal of Psychology, 15, 72–101.
services research, 11, 109–117. Spearman, C. (1910). Correlation calculated from faulty data. British Journal of Psy-
Krausz, M., Koslowsky, M., & Eiser, A. (1998). Distal and proximal influences on chology, 3, 271–295.
turnover intentions and satisfaction: Support for a withdrawal progression the- Tsigilis, N., Zachopoulou, E., & Grammatikopoulos, V. (2006). Job satisfaction and
ory. Journal of Vocational Behavior, 52, 59–71. burnout among Greek early educators: A comparison between public and pri-
Kushnir, T., & Cohen, A. H. (2006). Job structure and burnout among primary care vate sector employees. Educational Research and Review, 1, 255–261.
pediatricians. Work: A Journal of Prevention, Assessment and Rehabilitation, 27, Urien Angulo, B., & Osca, A. (2012). Role stressors, task-oriented norm, and job
67–74. satisfaction: A longitudinal study. Revista De Psicología Del Trabajo y De Las
Kushnir, T., Levhar, C., & Cohen, A. H. (2004). Are burnout levels increasing? The Organizaciones, 28, 171–181.
experience of Israeli primary care physicians. Israel Medical Association Journal, Van Dyke, D., Holtzman-Schweid, K., Bin-Nun, G., & Kushnir, T. (2011). Work satisfac-
6, 451–455. tion, turnover intentions and leaving the medical profession among physicians
Landon, B. E., Reschovsk, J. D., Pham, H. H., & Blumenthal, D. (2006). Leaving in Israel: Survey of licensees in 2000, 2002, 2004, and 2006 (Hebrew). Harefua,
medicine: The consequences of physician dissatisfaction. Medical Care, 44, 150, 310–313.
234–242. Watson, D. (1988). Intraindividual and Interindividual Analyses of Positive and Neg-
Lazarus, R. S. (1999). Stress and emotion: A new synthesis. New York: Springer. ative Affect: Their relation to health complaints, perceived stress, and daily
LePine, J. A., Podsakoff, N. P., & LePine, M. A. (2005). A meta-analytic test of the activities. Journal of Personality and Social Psychology, 54, 1020–1030.
challenge stressor hindrance/stressor framework: An explanation for inconsis- Watson, D., & Clark, L. A. (1984). Negative Affectivity: The disposition to experience
tent relationships among Stressors and performance. Academy of Management aversive emotional states. Psychological Bulletin, 96, 465–490.
Journal, 48, 764–775. Wolpin, J., Burke, R. J., & Greenglass, E. R. (1991). Is job satisfaction an antecedent or
Lim, V. K. G., & Yuen, E. C. (1998). Doctors, patients and perceived job image: An a consequence of psychological burnout? Human Relations, 44, 193–209.
empirical study of stress and nurses in Singapore. Journal of Behavioral Medicine, Zhang, Y., & Feng, X. (2011). The relationship between job satisfaction, burnout, and
21, 269–282. turnover intention among physicians from urban state-owned medical institu-
Locke, E. A. (1976). The nature and causes of job satisfaction. In M. D. Dunnette (Ed.), tions in Hubei, China: A cross-sectional study. BMC Health Services Research, 24,
Handbook of Industrial and Organizational Psychology (pp. 1297–1349). Chicago: 235–248.
Rand McNally. Zimmerman, D. W., & Williams, R. H. (1997). Properties of the Spearman correc-
Maslach, C. A., & Jackson, S. E. (1981). The measurement of experienced burnout. tion for attenuation for normal and realistic non-normal distributions. Applied
Journal of Occupational Behavior, 2, 99–113. Psychological Measurement, 21, 253–270.
Maslach, C. A., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual Review of Zuger, A. (2004). Dissatisfaction with medical practice. New England Journal of
Psychology, 52, 397–422. Medicine, 350, 69–75.