Impact of leadership communication on job satisfaction and well-being of physicians

Communication and leadership communication are key for an efficient performance of physicians. They hold a team together, help hospitals to develop and retain capable employees, and are directly related to physicians’ job satisfaction. We aim to test the impact of leadership models and various items of leadership communication on job satisfaction and well-being of physicians working in Swiss hospitals. We conducted a nationwide survey of physicians in Swiss hospitals in 2019 to assess the correlation between communication and leadership style with job satisfaction and well-being of physicians. The evaluation of the survey uses multivariate, statistical analysis (descriptive evaluations, regression model, factor analyses). The data reveal that leadership communication, e.g., the tone of communication, information quality and information behaviour and feedback have the most positive impact on job satisfaction and well-being. These items have a stronger influence on well-being when physicians belong to a younger generation, such as Generation Y (born after 1980). Leadership communication has the greatest impact on job satisfaction on residents and a lesser impact on physicians in higher hierarchical levels. To increase job satisfaction and well-being amongst physicians, hospitals superiors and supervisors are advised to invest in education and training on leadership communication and feedback with special focus on the younger generation as well as on female physicians as this will have the greatest impact.


Background
Communication and leadership communication are key for an efficient performance of empoyees and teams [1].Communication is the kit that holds a team together, helps companies to develop and retain capable employees, and is directly related to an employee's job satisfaction [2].Many leadership concepts are based on the assumption that leadership communication is pivotal [3].Leadership and leadership styles have been studied extensively in the past.Let us first consider the term leadership.There are numerous definitions of leadership.Hackman and Johnson [4] cite leadership as ''human symbolic communication that modifies the attitudes and behaviors of others in order to meet shared group goals and needs.'' This definition already shows that leadership and communication cannot be separated.This is because communication skills are needed to achieve leadership goals [5].Communication is therefore described as a tool of leaders [6].This tool aims to teach, plan, coordinate, and evaluate [7].Communication competence as a part of leadership competencies has been investigated in different studies and produces various definitions of leadership communication [8].However, recurring elements can be found as summarized by Hertzsch, Schneider [8] in their research.These include, for example, behavior, cognition, and motivation.Of special note is the situational and social appropriateness of the communication as described by Six and Gimmler [9].
Numerous studies highlighted the importance of communication for successful leadership of employees two decades ago [10][11][12].The findings are supported by a literature review in healthcare in particular by Martins, De Sousa [13], one of the systematic literature reviews on the relationship between communication and leadership specifically in the healthcare sector.The literature review demonstrates the link between communication and leadership in healthcare (emergency teams) as follows: Good leadership in healthcare relies on good leadership communication to guide and direct.For leadership, communication is not the only essential leadership skill, but it is one of the most important [14].Some studies suggest that the most important attribute for employee satisfaction is the communication skills of leaders [2,15,16].The effects of good leadership communication on organisation outcomes have been examined and demonstrated in previous studies, for example [1,8,[17][18][19].Litmanen [20] made a compilation of the effects of leadership styles on employees in her literature review.The results of the reviewed studies indicate that leadership and leadership styles have different influences on employee well-being.This is evident in the categories of performance, behavior and exchange.Positive influences in the healthcare setting have also been demonstrated on team motivation, patient care, and patient safety [21].On the other hand, the negative effects of insufficient communication in healthcare could also be demonstrated.This is especially true for underperformance in the emergency room [22,23], staff well-being [24,25], work efficiency [26] and loss of employer's self-confidence [27].
The aim of the current study is to test the impact of leadership models and various items of leadership communication on job satisfaction and well-being of physicians working in Swiss hospitals.The items of leadership communication include tone of communication, information quality and feedback.The questionnaire includes gender, generational affiliation, functional affiliation, language, type of hospital and medical specialty.While the multivariate variance analyses provided further insights on the correlation of these categories with leadership communication, this paper concentrates on generational and functional affiliation of physicians and the correlation with job satisfaction and well-being as the clearest differences were found between these categories.

Questionnaire
The questionnaire was created using the online survey tool ''Questback'' [28].In particular, the filter function allowed respondents to be presented with specifically formulated versions of the individual questions depending on their functional level, since a particular focus of the study was on the mutual perception of members of the four hierarchical levels: Residents, senior physician, attending physicians, head physicians.
The first version of the survey instrument was revised in a workshop with representatives of various Swiss medical associations regarding efficiency and practice-relevant issues.The members of the workshop were also consulted in the further course of the survey for validation, queries and interpretation of the results. 1  The revised version underwent a two-stage pre-test in July 2019.First, four cognitive interviews were conducted with physicians of different functional levels.This allowed the wording of individual questions to be optimized in terms of comprehensibility and sensitivity.The processing time and complexity of the questionnaire were also subjected to critical feedback from the participants.
For the subsequent test survey, a random sample (n = 100) was sent to German-speaking members of the Professional Association of Swiss Physicians (FMH).The response rate was 10%.The data obtained were subjected to initial analyses, which focused on possible shortenings and clarified the comprehensibility of the questions.The final version of the questionnaire was translated into French and Italian by a professional translation service.
The data collection took place in the period from 01.10.2019 to 30.11.2019.Our sample consists of physicians in Swiss hospitals in all parts of the country and language regions.With the completion of the survey phase, a data set with 1565 respondents were available.

Data preparation and analysis methods
The raw data were processed for further analysis.Using the filters, the same questions were asked depending on the respondents' functional level: residents, senior physicians, attending physicians and head physicians in relation to individuals in each of the other functional levels.To reduce complexity, only two groups were formed for supervisors: direct reports and head physicians as supervisors.The generations were defined as follows: Baby Boomers (born before 1965), Generation X (born between 1965 and 1980) and Generation Y (born between 1981 and 2000) [29,30].
A central element of the data preparation was the calculation of various indices.By means of principal component analysis and reliability tests, we examined to what extent individual items of the respective questionnaires could be combined into indices.We performed univariate group comparisons using the nonparametric Kruskal-Wallis H test due to the characteristics of our data (not normally distributed, many outliers, more than two characteristic values among the groups).This global test is suitable to identify differences between groups: the null hypothesis is that the medians of all groups are equal, while the alternative hypothesis is that at least one median of one group is different from the median of at least one other group.

Theoretical foundations and operationalization of the concepts
The concepts on which the questions in our survey were based are provided in (Fig. 1).This article concentrates on the generational and function affiliation of physicians and the correlation with job satisfaction and well-being.Therefore, the concepts of human value scale and parts of other concepts are not considered in this current article.

Job satisfaction
We use Agnes Bruggemann's model, the so-called Zurich model, to capture job satisfaction [31].The model has been operationalized in various settings and has produced a relevant approach of perceiving job satisfaction as a process and linking it to expectations by the employers.This results in five types of job satisfaction [32]: stabilized work satisfaction, constructive work satisfaction, constructive work dissatisfaction, resigned work satisfaction, resigned work dissatisfaction.

Well-being
Besides the level of job satisfaction, we added a questionnaire based on the Copenhagen Psychosocial Questionnaire (COPSOQ III) [33] in its third version [34].In this paper, we use only the part of "Well-being" and shorten it to fulfill the needs of the questionnaire.For well-being, specific questions were asked about time management, emotional state, and the ability to express one's opinion.

Feedback, tone of communication and quality of communication
One part of the survey asked about the quantity and type of feedback, the expectation around feedback and who physicians received feedback from.Parts of the feedback questions are based on the HR Barometer [35] and adapted to the needs of the survey.Another part asked about the tone of communication and the quality of communication content.The questions around tone of communication and the quality of communication content were developed within the scientific advisory council for this study, tested and evaluated as described in the section "Questionnaire" 2 1 3

Job satisfaction and well-being
The questions on job satisfaction reveal that physicians are rather satisfied in Swiss hospitals (close to 43% stabilized work satisfaction and around 61% constructive work satisfaction in (Fig. 2).Furthermore, the addition ''but would like my work situation to improve'' indicates that they have a constructive view of their work situation.Both types (constructive job satisfaction and stabilized job satisfaction) are desirable and have positive connotations for employers as well as employees.
The same holds for well-being.Regarding well-being, physicians indicate that their work is ''sometimes'' to ''often'' emotionally demanding and that they ''sometimes'' do not have enough time to complete these tasks carefully.Physicians appear rather confident about their own opinion.It is ''rarely'' withheld for fear of negative consequences or because it is not considered.

Impact of leadership items on job satisfaction
Based on these results, a multiple linear regression model is presented in Table 1 that allows us to estimate the strength and direction of the influencing variables.Table 1 shows that three important aspects of leadership communication have a strong influence on job satisfaction: the index of Leader-Member Exchange (LMX), which measures trust and respectful interaction, the self-assessment of leadership communication skills (Perceived Leadership Communication PLC self-assessment) and the tone of communication.The self-assessment of team and leadership communication skills shows how physicians assess themselves in sensitivity, handling mistakes and dealing with their own weaknesses.

Impact of leadership items on well-being
The regression analysis on well-being provides further interesting information.In contrast to job satisfaction, the effects are significantly less pronounced.The regression analysis in Table 2 provides more detailed information on the degree and direction of the effects.Table 2 confirms the influence of leadership communication such as the tone of communication, information quality and behavior, and mutual respect and trust (as queried in the Leader-Member Exchange LMX) for positive physician well-being.The degree to which expectations are met contributes positively to well-being.This item examined what expectations were fulfilled regarding participation in decision-making, working hours, work content and development potentialities.
The effect of a generation affiliation such as Generation X and even more so of Generation Y is negative, relative to Baby Boomers.Physicians from these generations show, on average, a lower well-being compared to Baby Boomers.

Job satisfaction, generation and communication
To clarify the figures from the five categories, the agreements ''agree completely'' and ''agree'' were combined for the respective items.This generates a clearer picture of which generation agrees more with which category.Since multiple answers were possible, the sum exceeds 100% in each case.
Figure 3 shows that the Baby Boomer generation is much more stabilized satisfied (close to 60%) than their colleagues in Generations X and Y, 45% and 34%, respectively.The younger generations are less frequently in the stabilized satisfaction and constructive satisfaction categories.It is also striking that Generation Y is much more often resigned dissatisfied.However, the largest grouping of resigned satisfied respondents is found among the Baby Boomers (''I am satisfied overall because I don't think you should expect too much from your work situation'').
The item stabilized job satisfaction was tested for correlations with leadership communication items to check the impact of communication items and job satisfaction (Table 3).We find the following: Generation Y shows a high and positive correlation with the index tone of communication and information quality which means that Generation Y is more satisfied when working in an environment with efficient and positive communication style.Generation X shows the same correlation with the item tone of communication, and the Baby Boomer generation shows this correlation with feedback they receive from head physicians.The same items show the same but negative correlation with resigned job dissatisfaction.

Job satisfaction, function and communication
The query of the five types of job satisfaction, respectively job dissatisfaction shows a significant difference between the two lower and the two higher function levels at the most extreme expressions of the scale (Fig. 4).The residents and senior physicians are both less often stabilized satisfied and more often resigned dissatisfied than their colleagues (attending and head physicians).
The generational comparison has already shown that Generation Y is significantly more satisfied in their job when they receive efficient leadership communication.This became even more evident in the comparison between functional affiliation, i.e. residents, senior physicians, attending physicians and head physicians.Again, good leadership communication with a positive tone of communication and proactive communication with a high quality of information leads to a higher job satisfaction.The lower the functional level, the stronger this effect and it is very pronounced among residents and senior physicians.The regression models show that the effect of the functional affiliation is more pronounced than the generational affiliation, i.e. job satisfaction is significantly shaped by the functional affiliation.The bivariate correlation regarding job satisfaction at the functional level clearly shows which items have an influence.These are Perceived Leadership Communication (PLC), tone of communication and quality of information.The concept of Perceived Leadership Communication (PLC) was a significant item for a positive job satisfaction within the functional affiliation of physicians.The PLC questionnaire grew out of the need for a sound research model on communication and leadership qualities, and for a questionnaire that could be used for this purpose [36].The underlying model by Hertzsch, Schneider, and Maier [8] examines interpersonal communication in organizations and provides a differentiated view of leadership behavior in a wide variety of communication situations.Besides the items of PLC, tone of communication and quality of information played an important role in the job satisfaction of physicians as seen in Table 4.

Well-being, generation, and communication
While job satisfaction is significantly shaped by the functional affiliation, well-being is significantly shaped by the generational affiliation.Members of the Baby Boomer generation achieve higher values for well-being than the younger generations as shown in the boxplot (see Fig. 5).Generation X and Generation Y scored significantly worse.Hence, wellbeing is shaped by generational affiliation and is not overridden by functions or gender.
The bivariate correlation coefficients regarding well-being (see Tables 5 , 6) show the impact of the following four items of leadership communication and job items: Leader-Member Exchange model, tone of communication, quality of communication and stabilized job satisfaction.

Well-being, function, and communication
The theory of Leader-Member Exchange (abbreviated as LMX) goes back to a study by George Graen, who defined the roles and tasks of employees far beyond the scope of duties described in the employment contract [37].Here, employees are offered new roles or tasks (role-taking), which employees can accept or reject (role-making).This can lead to a routine  (role routinization), which Graen and Scandura describe as a ''high-quality'' and stable collaboration between supervisors and employees [38].The Leader-Member Exchange Scale uses seven items to describe the quality of this dyadic process.The questionnaire was compiled by Graen and Uhl-Bien and adopted in the present study as translated by Schyns and Paul [39,40].The questions aim to clarify how well supervisors and employees know, respect, and trust each other.Table 5 demonstrates the impact of a trustful and respectful leadership model with Generation Y while this impact drops drastically with the Generation Baby Boomer with regard to well-being Table 6 shows the impact of quality of information, tone of communication and the Leader-Member Exchange with regard to well-being.The differences are less pronounced to functional affiliation even though residents show a stronger correlation than head physicians.

Feedback
Significant differences were found between generations regarding how much feedback was demanded as shown in Fig. 6.Feedback from superiors is clearly more important to the younger generations than to the older ones: Generation Y wants   more active feedback from direct superiors as well as from head physicians than Generation X.The differences are highly significant in generational comparison.
The lower the functional level, the more pronounced the desire for feedback.This corresponds to the expectations of the results, according to which younger generations and members of the resident level want more feedback at the beginning of their career.In Fig. 7, the importance of feedback from superiors can also be observed across the function levels.

Perception of communication in the team: tone of communication and information quality
In general, it can be stated that the tone of communication and the information quality and behavior within Swiss hospitals are rather positive.Doctors often assess them as ''friendly'' .The evaluation of the items ''transparent'' and ''helpful'' is more negative.The quality of information is generally rated as worse than the tone of communication.Physicians are most likely to rate the quality of information and the behavior of superiors as ''sincere'' and least likely as ''proactive".It is also shown that job satisfaction increases significantly with the tone of communication.
The perception of the tone of communication is primarily determined by generational affiliation and although there are significant differences between functional levels, gender and other categories, it remains a generational issue.
Generational differences in the assessment of the tone of communication are significant.Only members of Generation Y rate the tone of communication more negatively than other generations Fig. 8).

Discussion
Efficient leadership communication, which was surveyed and evaluated in terms of tone of communication, quality of information and information behavior, leadership style, trusting interaction and feedback, has a positive effect on the job satisfaction of all physicians, across all functions, generations, languages, genders, hospital types and specialties.The results are quite homogeneous when it comes to the influence of positive leadership communication on job satisfaction and well-being.In a first step, the models of leadership style and the trusting interaction between employees and superiors were evaluated.Transformational leadership was introduced in leadership communication as a concept that rests on the pillars of motivation and sharing a common vision.The better supervisors lead their employees to intrinsic motivation via a shared vision (as part of the transformational leadership model), the higher their job satisfaction.This leadership style, tone of communication, feedback, and quality of information have the greatest positive impact on job satisfaction as well as physicians' well-being.
An even more significant and stronger relationship is shown between the concept of Leader-Member Exchange (trusting interaction) and job satisfaction.This effect is equally pronounced as in the correlation between transformational leadership and job satisfaction.It proves that employees who experience trust and appreciation from their head physicians show significantly higher satisfaction with their work.The same effect is found for well-being, albeit less pronounced.In addition, it is primarily the tone of communication and the information quality and behavior of superiors and within the team that have a direct and positive influence on job satisfaction and well-being.
The well-being index is made up of the items on emotional stress, separation of private and professional life, and dealing with one's own opinion.Trusting interactions in the team, a good tone of communication and high information quality also lead to higher values in the well-being index.However, the effect size of these items is lower than for job satisfaction.This may indicate that although physicians are often stressed and emotionally charged in their work, many physicians still manage to let it have less of an impact on their private lives.Generational affiliation has a negative impact on the well-being index.Compared to Baby Boomers, physicians of generations X and Y show a lower well-being.Analogous to job satisfaction, it can be stated that a positive tone and good quality of information as well as trusting interaction between employees and superiors lead to higher well-being.
Nevertheless, a negative tone of communication has only a weak effect on well-being.The effects on job satisfaction, on the other hand, are significant.In particular, information quality and information behavior show this correlation, with the tone of interaction showing a weaker effect.The effect of good leadership communication on job satisfaction is most evident among Generation Y, residents, female physicians, German-speaking physicians, and internists.

Tone of communication
A detailed analysis of the various categories reveals considerable differences.Female physicians are significantly less satisfied with the tone of communication than male physicians.This especially applies to female residents, who rate it more negatively than their hierarchically higher colleagues.
How the tone of communication is evaluated and correlates with job satisfaction is clearly dependent on the generational affiliation.Generation Y is less satisfied with the quality of information and information behavior.The item that physicians miss most is proactive information.Generation Y is also critical of the tone of communication within the team.The most relevant item within the topic of tone is "appreciative".An appreciative tone is thus rated higher than a friendly, helpful or equal tone of communication.
Of course, the question arises as to why the relevance of the tone of interaction decreases within the older generations or has a lower influence on job satisfaction.Baby Boomers experience the conversational tone significantly more positively than Generation Y physicians.The correlation of good tone/quality of information and job satisfaction is evident with respect to function and with respect to generational affiliation.Possibly, being less sensitive to a somewhat harsher atmosphere in the team represents an opportunity for advancement for older generations.Or this robustness is established during the careers of Generation X and the Baby Boomers.Another conceivable interpretation could be that physicians of the older generations who prefer a different tone of voice, leave the hospital.The functional level does not determine the experience of the conversational tone.

Information quality and behavior
The quality of information also has a strong influence on job satisfaction.Across all generations and function levels, the better the quality of information, the higher the job satisfaction.Residents and senior physicians rate the quality of information more negatively than their more senior colleagues.The item most frequently mentioned by the physicians is the component ''sincere'' .

Feedback
The study demonstrates that the more feedback is given, the more satisfied physicians are.This is evident in all functional levels, generations, languages, genders, and hospital types.Looking at all respondents, it is evident that the desire for feedback exceeds the volume of feedback received.In other words: No physician receives as much feedback as he or she desires.
As might be expected, the desire for feedback is more pronounced at the beginning of a career.Younger physicians also desire and receive more than their older colleagues.Residents would also like more feedback from their head physicians.
Generation Y physicians are asking for more feedback, even if they are already in more senior roles.Feedback not only has a positive influence on job satisfaction, but there is also a correlation between positive feedback from direct supervisors and a positive assessment of the tone of interaction.
Female physicians desire more feedback than their male colleagues.The difference between the sexes is significant: women receive significantly less feedback from their head physicians than men.

Limitations
There are several well-known limitations to using a survey, and we list some of them here.Since our sample is a voluntary response sample, and not everyone who was sent the survey responded, there is a selection bias since respondents who choose to respond often have different characteristics than people who choose not to respond.Our sample does not contain individuals who did not respond, thus leading to nonresponse bias.There may also be response bias with respondents tailoring their responses to what the researchers expect.

Conclusions
The survey of physicians in Swiss hospitals has shown that trust-building leadership communication, a positive tone of communication and a high quality of information and a transparent information behavior have the greatest positive impact on job satisfaction.To increase this, supervisors and hospitals can invest in education and training on leadership communication to help improve job satisfaction among their physicians.This also includes the role of feedback.Most physicians would like to receive more feedback in general, with an accentuation on the younger generation as Generation Y. Supervisors should pay special attention to employees who are particularly self-critical.It is primarily younger physicians at the functional level of residents, especially women in the medical profession who rate themselves as more self-critical in terms of communication.This grouping attaches particular importance to a great deal of feedback from direct superiors, head physicians.Although female and male physicians feel they are sufficiently prepared by their training to give feedback and to master team communication, these topics could be addressed more in the classroom.Far too few female physicians still receive sufficient feedback in their opinion.

Fig. 2
Fig. 2 Job satisfaction of all physicians

Fig. 3
Fig. 3 Job satisfaction by generation

Fig. 4
Fig. 4 Job satisfaction by function

Fig. 6 Fig. 7
Fig. 6 Desire for active feedback from direct superiors across generations

Fig. 8
Fig. 8 Tone of communication by generation

Table 1
Regression model of

Table 3
Job satisfaction,

Table 4
Job satisfaction, function and communication