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Journal of Social Work in End-of-Life & Palliative Care
ISSN: 1552-4256 (Print) 1552-4264 (Online) Journal homepage: https://www.tandfonline.com/loi/wswe20
Social Workers’ Perceptions of Job Satisfaction,
Interdisciplinary Collaboration, and Organizational
Leadership
Suzanne Marmo & Cathy Berkman
To cite this article: Suzanne Marmo & Cathy Berkman (2018) Social Workers’ Perceptions of Job
Satisfaction, Interdisciplinary Collaboration, and Organizational Leadership, Journal of Social Work
in End-of-Life & Palliative Care, 14:1, 8-27, DOI: 10.1080/15524256.2018.1437590
To link to this article: https://doi.org/10.1080/15524256.2018.1437590
Published online: 28 Feb 2018.
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JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE
2018, VOL. 14, NO. 1, 8–27
https://doi.org/10.1080/15524256.2018.1437590
REGULAR ARTICLES
Social Workers’ Perceptions of Job Satisfaction,
Interdisciplinary Collaboration, and Organizational
Leadership
Suzanne Marmoa and Cathy Berkmanb
aDepartment of Social Work, Sacred Heart University, Fairfield, Connecticut, USA; bGraduate School of
Social Service, Fordham University, New York, New York, USA
ABSTRACT
To address job satisfaction, and therefore employment
retention, of hospice social workers, this study examined how
relationships with other members of the interdisciplinary
hospice team and perceptions of hospice leadership may be
associated with job satisfaction of hospice social workers. The
sample of 203 hospice social workers was recruited by e-mailing
invitations to hospice social workers identified by hospice
directors in three states, use of online social media sites
accessed by hospice social workers, and snowball sampling.
Study measures included professional experience, hospice
characteristics, interdisciplinary collaboration, perception of
servant leadership, and intrinsic and extrinsic job satisfaction.
Variables significant in the model for intrinsic satisfaction were
perception of servant leadership, interdisciplinary collaboration,
and feeling valued by the hospice physician. Variables
significant in the model for extrinsic satisfaction were perception of servant leadership, interdisciplinary collaboration,
feeling valued by the hospice physician, and number of social
workers at the hospice. Interdisciplinary collaboration was more
important for intrinsic job satisfaction and leadership style was
more important for extrinsic job satisfaction. Profit status of the
hospice, experience of the social worker, caseload size, and
other variables were not significant in either model. These
results support previous findings that leadership style of the
hospice director and relationships with hospice colleagues are
important for hospice social workers’ job satisfaction. Such lowcost modifications to the hospice work environment, albeit not
simple, may improve job satisfaction of hospice social workers.
KEYWORDS
Hospice; interdisciplinary
collaboration; job
satisfaction; leadership style;
profit status; social work
Introduction
Job satisfaction of health-care employees contributes to the retention or
tenure of qualified and experienced employees (Fritzsche & Parrish, 2005;
Head, Washington, & Myers, 2013; Kobayashi & McAllister, 2013; Miller,
2008). High turnover is associated with decreased job satisfaction among
direct care hospice workers and compromises quality of care for hospice
none defined
CONTACT Suzanne Marmo [email protected] College of Arts and Sciences, Social Work
Department, Angelo Roncalli Hall, RH-212, 5151 Park Avenue, Fairfield, CT 06825-1000, USA.
© 2018 Taylor & Francis Group, LLC
patients (Dill & Cagle, 2010; Miller, 2008), higher job satisfaction among
health-care workers also contributes to reduced cost of training new
employees, improved patient satisfaction, and better adherence to treatment
for hospice patients (Miller, 2008; Weisman & Nathanson, 1985). The
majority of hospices in the United States are listed as for-profit status
(Stevenson, Dalton, Grabowski, & Huskamp, 2015; Thompson, Carlson, &
Bradley, 2012). Evidence suggests that there are differences with nonprofit
hospices regarding service provision, but little research has been conducted
comparing job satisfaction by profit status.
To better understand job satisfaction of hospice social workers, the goal of
this study was to examine how relationships with coworkers and perceptions
of leadership were related to job satisfaction of hospice social workers. The
specific aims were to examine whether: (1) job satisfaction was associated with
either interdisciplinary collaboration or with workers’ perceptions of hospice
leaders and (2) whether these associations differed by the hospice profit status.
Background
Job satisfaction
Job satisfaction of health-care workers has been defined as pleasant emotions
that flow from the realization of value in work and also as a more complex
understanding that incorporates person-and-environment fit (Dawis, 2005;
Dawis & Lofquist, 1984; Farr & Ringseis, 2002; Locke & Henne, 1986). The
conceptualization of job satisfaction for the present study is how well the
hospice social worker fits the environment of the hospice organization. This
process-oriented definition reflects an ongoing mutual and reciprocal
relationship or correspondence of the worker’s personality and the work
environment (Dawis & Lofquist, 1984; Farr & Ringseis, 2002). The Theory
of Work Adjustment posits that job satisfaction is a result of a worker’s
subjective assessment of how this reciprocal relationship or fit meets the
individual’s requirement for continued employment (Dawis, 2005; Farr &
Ringseis, 2002). This theory also proposes two different kinds of job satisfaction: intrinsic and extrinsic job satisfaction (Dawis & Lofquist, 1984; Fritzsche
& Parrish, 2005). Intrinsic job satisfaction includes recognition, feelings of
accomplishment, responsibility, perception of value, perceptions of shared
values with coworkers and leaders. Extrinsic job satisfaction includes job
security, salary, working conditions, and work relationships.
As in other workplace environments, job satisfaction in health-care settings
is negatively correlated with intention to leave an organization (Bright, 2008;
Dawis, 2005; Head et al., 2013) and a positive correlation with perception of
the degree to which social work is valuable to the organization (Fritzsche &
Parrish, 2005; Gellis, 2002; Parker-Oliver, Bronstein, & Kurzejeski, 2005; Price
& Mueller, 1986; Shier & Graham, 2013). Job satisfaction is positively
JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 9
correlated with productivity, communication, and cooperation with
coworkers and leaders, strength and stability of the organization, and life
satisfaction and other indicators of well-being outside of the workplace
(Dawis, 2005; Fritzsche & Parrish, 2005).
Interdisciplinary collaboration
The interdisciplinary approach to patient care is an essential component in
effective end-of-life care. Due to the complexity of caring for terminally ill
patients and their caregivers, effective hospice care depends on incorporating
the unique perspective of each discipline in a collaborative and professional
relationship (Kobayashi & McAllister, 2013). The Medicare Hospice Benefit
mandates inclusion of social work on the hospice interdisciplinary team
(Medicare and HHS, 2008) and increased social work involvement is associated
with cost containment and higher family satisfaction (Reese & Raymer, 2004;
Robinson, Hoyer, & Blackford, 2007). Yet, despite the recognition of the positive
role of social work in hospice, this is sometimes devalued as an ancillary service,
secondary to medicine (Blacker & Deveau, 2010; Casarett, Spence, Haskins, &
Teno, 2011; James, 2012; Reese & Raymer, 2004; Reese & Sontag, 2001).
Hospice social workers strongly agreed that teamwork with professionals
from other disciplines and their combined expertise was important to achieving best outcomes for their clients (Parker-Oliver et al., 2005). They were less
likely to agree that they talked with nonsocial work colleagues about role
responsibilities and improving their working relationship. Social workers were
less likely than nurses and physicians to perceive collaborative communication
on the team (Wittenberg-Lyles, Parker Oliver, Demiris, & Regehr, 2010), felt
the least connected and the least interdependent with other members of the
team (Kobayashi & McAllister, 2013), and scored the lowest on job satisfaction
compared with other members of the interdisciplinary team (Casarett et al.,
2011; Monroe & DeLoach, 2004). This may be partially explained by lack of
recognition of social work expertise on the hospice team (Weisenfluh & Csikai,
2013) or the view of hospice executive directors that nursing leadership has
often considered nurses to be as qualified as social workers in providing
psychosocial care (Kulys & Davis, 1986). Given that the interdisciplinary team
is the accepted model of providing hospice care, the degree to which other
members of the team value social work expertise, and its contribution to providing effective care may contribute to job satisfaction of hospice social workers.
This may, in turn, impact patient care outcomes (Monroe & DeLoach, 2004).
Perceptions of social work by hospice leadership
An early study found that hospice executive directors reported that nurses
provided more psychosocial care to patients than social workers and were
10 S. MARMO AND C. BERKMAN
as qualified as social workers, or better qualified, to provide crisis intervention, advocacy, and case coordination (Kulys & Davis, 1986). Only in
the areas of using community resources, making referrals to community
resources, and providing financial information, did hospice directors consider
social workers to be more qualified than nurses (Kulys & Davis, 1986). A
more recent replication of this study (Reese, 2011) found a more positive
perception of the social work contribution to the hospice interdisciplinary
team by hospice directors, although nursing was considered more qualified
to perform over half of the activities that social workers typically claim as their
own (Reese, 2011). It is relevant to note that traditionally and currently the
large majority of hospice executive directors are nurses (Longenecker, 2006;
Reese, 2013). To date, no studies have examined hospice social workers’
perception of support from hospice directors and how this is related to their
job satisfaction.
Servant leadership style
The servant leader is perceived as motivating and mentoring individuals to
become self-actualizing by working for the greater good of the organization
(Winston & Fields, 2015). Servant leadership theory predicts that organizational leaders who use this set of leadership behaviors will impact
employee perceptions and behaviors through forming reciprocal relationships that create a good fit between leader and employee, which then will
promote organizational stability (Peterlin, Pearse, & Dimovski, 2015; Van
Dierendonck, 2010; Winston & Fields, 2015). Hospice executive directors
perceive themselves as transformational leaders (Longenecker, 2006, 2008).
Servant leadership has been compared to transformational leadership, but
extends the theory of transformational leadership with an added dimension
of service, sometimes referred to as stewardship, for the overall good of the
people who work for the organization and the community it serves (Brown,
Treviño, & Harrison, 2005; Greenleaf & Spears, 2002; Peterlin et al., 2015).
The theory of servant leadership was introduced by Greenleaf and Spears
(2002) as a theoretical framework that describes a leader’s primary motivation
and role as service to others. Due to the shared service-oriented nature of
hospice and the social work profession, servant leadership theory was selected
to evaluate the social work perception of hospice leadership support and how
this is associated with job satisfaction.
Growth of the for-profit hospice market
Recent studies have examined changes in the hospice industry in the current
competitive health-care market (Carlson, Gallo, & Bradley, 2004; Doherty,
2009; Miller, 2008; Thompson et al., 2012; Wachterman, Marcantonio, Davis,
JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 11
& McCarthy, 2011). This has led to a critique of market-driven medicine at the
end of life and an examination of differences in patient care between for-profit
and nonprofit hospices (Perry & Stone, 2011; Wachterman et al., 2011;
Whoriskey & Keating, 2014). Between 1989 and 2009, one in five hospices
closed, with smaller hospices being more likely to close or merge with a larger
hospice agency to remain in business (Carlson et al., 2004; Stevenson et al.,
2015). During this time period, over 40% of hospices changed from a nonprofit
to a for-profit organization (Thompson et al., 2012), with 62.8% of hospices in
the United States having for-profit status in 2016 (National Hospice and
Palliative Care Organization, 2016). The growth of for-profit hospices has
raised concerns about patient care outcomes and adherence to the original
philosophy of the hospice movement (Iglehart, 2009; Perry & Stone, 2011; Unal,
2011; Wachterman et al., 2011). For-profit hospices employ fewer social workers then nonprofit hospices and social workers at for-profit hospices make
fewer visits per patient than social workers at nonprofit hospices (Cherlin
et al., 2010). There are no studies that have examined whether profit status of
the hospice organization affects social workers’ job satisfaction or perceptions
of relationships with hospice coworkers and executive directors.
Relevance for hospice social work
Reese (2011, 2013) has noted the trend of lowering costs by reducing social
work services. She has called for research to provide evidence for the positive
outcomes for patients and families as well as for the organization, due to the
services provided by hospice social workers. Greater social work involvement
in patient care is positively correlated with cost containment and family
satisfaction (Cherin, 1997; Mahar, Eickman, & Bushfield, 1997; Paquette,
1997; Reese & Raymer, 2004).
The reduction in social work services and larger caseloads for hospice social
workers in both for-profit and nonprofit hospices may explain why hospice
social workers have lower job satisfaction compared with other members of
the interdisciplinary team (Casarett et al., 2011). One of the aims of this study
was to examine whether relationships with other members of the interdisciplinary team and with hospice leadership are associated with job satisfaction and to
determine whether these relationships differ by profit status of the hospice.
Methods
Study design
This study used a cross-sectional design. Data were collected with an online
questionnaire using Qualtrics (Qualtrics, Provo, UT) that was accessed
through a link in the e-mail invitation sent to potential respondents.
Data were collected between September, 2015 and November, 2015. The study
12 S. MARMO AND C. BERKMAN
was approved by the Fordham University Institutional Review Board.
Information necessary for informed consent was included in the invitation
e-mail and the landing page of the survey.
Sample
Four methods were used to recruit the sample of 203 social workers. The first
method involved contacting 213 hospices in three states by telephone and
asking hospice directors for permission to send e-mail study invitations to
social workers at that hospice. A sampling frame of all hospices in New York,
Connecticut and New Jersey was created using the National Hospice Locator
compiled by Hospice Analytics, Inc. and available online: http://www.
hospiceanalytics.com/. The second method involved posting an announcement about the study on SW-PALL-EOL, a palliative and end-of-life social
work listserv, and by searching Linkedin and Facebook for potentially eligible
participants and posting an announcement on the National Hospice and
Palliative Care Organization (NHPCO) and national association of home care
and hospice Linkedin sites. The third method involved the first author sending
an e-mail invitation to hospice social workers known to her or identified by one
of her colleagues. The fourth method used snowball sampling, asking social
workers recruited from the other sampling methods, or who had completed
the survey to send the e-mail address of potential respondents. An e-mail invitation was sent to these individuals stating how they were identified and inviting
them to participate. Inclusion criteria were: (1) at least 18 years of age; (2) on the
payroll of the hospice for over 30 days; and (3) self-identification as a hospice
social worker. The identity of study participants was anonymous. Participants
were entered into a raffle for three $40 gift cards.
Measures
Interdisciplinary collaboration
Perceptions of interdependence in interdisciplinary collaboration were measured
using the interdependence subscale in the index for interdisciplinary collaboration (IIC) (Bronstein, 2002). The 13-item scale had a Cronbach’s alpha of .78
in a sample of members of the National Association of Social Workers (NASW)
who routinely worked with other professionals (Bronstein, 2002) and .87 in a
sample of hospice social workers (Parker-Oliver et al., 2005). The scale has a
score range of 13–65, with a higher score indicating higher perception of
interdependence in interdisciplinary collaboration.
Servant leadership
Perception of servant leadership was measured using the essential servant
leadership survey (Winston & Fields, 2015). This scale measures the extent
to which an employee perceives their leader, the executive director of the hospice
JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 13
in this case, to be a servant leader, defined as someone whose primary purpose
for leading is to promote the common good (Liden, Wayne, Zhao, & Henderson,
2008; Winston & Fields, 2015). Each of the 10 items represents essential servant
leadership behaviors. The score range is 10–50, with a higher score indicating
higher perception of servant leadership. Cronbach’s alpha was .96 in a sample
of 433 employees in a wide range of jobs (Winston & Fields, 2015).
Job satisfaction
Job satisfaction was measured using the Minnesota satisfaction questionnaire
(MSQ) (Fields, 2002). In addition to using the MSQ to measure overall job
satisfaction as a composite score of the 20 items, two subscales were used:
intrinsic satisfaction scale (12 items) that measures feelings about job tasks
and the extrinsic satisfaction scale (six items) that measures conditions of
the job environment, such as company policies, pay, and opportunities for
advancement. Cronbach’s alpha was .87 for the intrinsic satisfaction scale
and .78 for the extrinsic satisfaction scale in a sample of hospital workers
(Martins & Proença, 2012). Each item has five-point response categories ranging from extremely satisfied (=5) to not satisfied (=1). The score ranges of
the scales are 12–60 for the intrinsic satisfaction scale, 6–30 for the extrinsic
satisfaction scale, and 20–100 for the total scale (Schriesheim, Powers,
Scandura, Gardiner, & Lankau, 1993; Weiss, Dawis, & England, 1967). A
higher score on each scale indicates higher satisfaction.
The Michigan organizational assessment questionnaire job satisfaction
subscale, although a weaker measure than the MSQ (Cammann, Fichman,
Jenkins, & Klesh, 1979) was also included to allow comparison with previous
studies. This is a three-item scale that assesses affective response to the job
using seven-point Likert response categories ranging from strongly disagree
to strongly agree. The score range is 3–21, with a higher score indicating
higher satisfaction. Cronbach’s alpha ranges from .77 to .87 in different
samples (Cammann et al., 1979; Jex & Gudanowski, 1992).
Profit status
The profit status of the hospice was measured by asking participants if the
hospice where they were currently employed was for-profit or nonprofit. This
information was confirmed through the Hospice Analytics, Inc. database if
the participant provided the name of the hospice. The following measures
were also completed by participants: (1) number of social workers employed
at the hospice; (2) estimated average daily caseload; and (3) roles performed
by the study respondents at the hospice.
Perception of value
Perception of being valued by other members of interdisciplinary team was
measured by asking the extent to which the respondent agreed or disagreed
14 S. MARMO AND C. BERKMAN
with each of four statements: “I feel valued by the hospice ______ I work
with,” substituting “nurses,” “doctors,” “chaplains” and “other hospice social
workers” in the statement. The four-point Likert response categories ranged
from strongly disagree to strongly agree. A higher score indicated stronger
agreement.
Professional characteristics
Professional characteristics were assessed by self-report, including:
(1) Number of years in social work practice; (2) highest social work or other
degree; and (3) number of years in social work practice; (4) whether salaried
or per diem employee. Personal characteristics that were assessed include age,
gender, and ethnicity.
Data analysis
Data analysis was conducted using the Statistical Package for the Social
Sciences (SPSS) (IBM Corp, Released 2016). Univariate statistics were
obtained to assess missing data and deviations from normality. Chi-square,
t-test, ANOVA, and correlation were used in bivariate analyses conducted
to determine the association or correlation between the independent and
dependent variables and with the hypothesized moderating variable.
Hierarchical multiple linear regression analyses were conducted by
regressing each of the job satisfaction scales on the other study variables.
The independent variables were entered in the first step. The final model
was estimated by entering the main effects of the independent variables.
Variables that were significant at alpha =.05 were kept in the model, as was
profit status of the hospice.
Results
The sociodemographic and professional characteristics of the sample are
shown in Table 1. Most participants were female and were non-Hispanic
white. Almost all had a Master of Social Work (MSW) degree. On average,
participants were employed at their current hospice for 5.6 years (SD = 5.4)
and most were salaried. The mean number of social workers employed at
the hospice was 10.5 (SD = 11.1) with an average caseload of 28.8 patients
(SD = 14.1). The majority were employed at a nonprofit hospice (70.4%).
More than half of the reported work activity was in direct practice.
The percentage dissatisfied on each item in the MSQ is shown in Table 2.
All of the items in the extrinsic satisfaction scale had higher percentages of
dissatisfied ratings than all of the items in the intrinsic satisfaction scale.
Respondents were most dissatisfied with salary and workload, followed closely
by chance for advancement.
JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 15
Participants at nonprofit hospices had worked at their current hospice
almost 3 years longer, on average, than those at a for-profit hospice (p = .001)
(Table 3). The number of social workers employed at nonprofit hospices was
almost 2.5 times as many as compared with for-profit hospices (p < .001).
Caseload size in for-profit hospices was almost 10 patients more than in nonprofit hospices (p < .001). Despite the higher caseload at for-profit hospices,
none of the job satisfaction scales were associated with profit status.
The regression models for each of the job satisfaction scales are shown in
Table 4.
Servant leadership had a greater effect in the model for extrinsic satisfaction
scale than for intrinsic job satisfaction, while the reverse was seen for
Table 1. Sample characteristics.
Characteristics N Mean (SD) or %
Age
18–24 years 1 .5
18–34 years 36 18.9
35–44 years 42 21.5
45–54 years 46 23.6
55–64 years 61 31.3
65 + years 10 5.1
Gender
Female 177 92.2
Male 15 7.8
Ethnicity
White 167 87.0
Hispanic 10 5.2
Black (non-Hispanic) 5 2.6
Other 5 2.6
Asian 4 2.1
Native Hawaiian, Pacific Islander 1 .5
Years at current hospice 195 5.6 (5.4)
Degree
BSW 2 1.0
MSW 189 96.9
PhD or DSW 3 1.5
Does not have a SW degree 1 .5
Payment Type
Salary 166 85.6
Per diem 28 14.4
Number of social workers at hospice 186 10.5 (11.1)
Work at more than one hospice
Yes 4 2.1
No 191 97.9
Caseload size 177 28.8 (14.1)
Profit status of hospice
Nonprofit 133 72.3
For-Profit 51 27.7
Percent of time spent in:
Direct practice 189 54.1 (26.6)
Administration 187 16.5 (17.6)
Bereavement 189 8.9 (13.9)
Supervision 186 6.3 (11.0)
Marketing 189 2.3 (7.0)
16 S. MARMO AND C. BERKMAN
Table 2. Dissatisfaction with aspects of the job as measured by the MSQ.
Job satisfaction item n % Dissatisfied
Job satisfaction
scale
My pay and the amount of work I do. 90 46.2 Extrinsic
The chance for advancement on this job 85 43.6 Extrinsic
The way company policies are put into practice 71 36.4 Extrinsic
The way my boss handles his/her workers 49 25.1 Extrinsic
The competence of my supervisor in making decisions 37 19.0 Extrinsic
The praise I get for doing a good job 37 19.0 Extrinsic
The working conditions 30 15.5 General
The chance to tell people what to do 30 15.4 Intrinsic
The way my coworkers get along with each other 24 12.3 General
Being able to do things that do not go against my conscience 21 10.8 Intrinsic
The way my job provides for steady employment. 8 4.1 Intrinsic
The chance to use my own methods of doing the job 8 4.1 Intrinsic
The freedom to use my own judgment 8 4.1 Intrinsic
The chance to be “somebody in the community” 6 3.1 Intrinsic
The chance to work alone on the job. 5 2.6 Intrinsic
Being able to keep busy all the time 4 2.1 Intrinsic
The feeling of accomplishment I get from the job 3 1.5 Intrinsic
The chance to do something that makes use of my abilities 3 1.5 Intrinsic
The chance to do different things from time to time 1 .5 Intrinsic
The chance to do things for other people 1 .5 Intrinsic
MSQ, Minnesota satisfaction questionnaire.
Table 3. Hospice employment characteristics by profit status.
Hospice characteristics
Profit status
p Value
on t-test
Nonprofit For-profit
n M SD n M SD
Years at current hospice 131 6.42 5.67 54 3.82 4.19 .001
Number of social workers at hospice 131 12.73 12.09 54 5.09 5.34 <.001
Caseload size 124 26.00 12.31 52 35.46 15.93 <.001
Perception of servant leadership 131 37.26 8.23 51 36.08 9.63 .41
Interdependence in interdisciplinary collaboration 133 54.81 5.80 51 55.47 5.95 .49
Job satisfaction
General 134 76.24 10.34 54 74.32 11.09 .26
Intrinsic 134 49.46 5.34 54 48.54 5.25 .28
Extrinsic 134 19.17 5.02 54 18.41 5.57 .36
Table 4. Linear regression models for job satisfaction scales (n = 182).
Characteristics
General Intrinsic Extrinsic
job satisfaction job satisfaction job satisfaction
β p β p β p
Servant leadership scale .58 <.001 .15 <.001 .34 <.001
Interdependence in interdisciplinary
collaboration scale
.63 <.001 .42 <.001 .13 .02
Strongly agree valued by doctors (compared
with not strongly agree)

Number of social workers at hospice Adjusted R2 .48 .49
p value on model .001 .02
JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 17
interdependence in interdisciplinary collaboration. Those who strongly
agreed that they were valued by hospice doctors had higher scores on all of
the job satisfaction scales as compared with those who did not agree strongly.
Number of social workers at the hospice was significant in the extrinsic satisfaction scale model, but not for intrinsic job satisfaction, although the magnitude of the effect was very small. Neither profit status of the hospice nor
interactions with profit status were significant in any of the regression models.
Discussion
The mean level of job satisfaction on the Michigan satisfaction questionnaire
was only slightly higher than that found in a previous study of hospice social
workers (Coopman, 2001). Social workers in the present study had higher
mean scores on intrinsic job satisfaction than hospice nurses and dialysis
health-care professionals (Miller, 2008; Ross, Jones, Callaghan, Eales, &
Ashman, 2009), and lower mean scores than dialysis professionals on extrinsic
satisfaction (Ross et al., 2009). Several studies have found that hospice social
workers have lower levels of job satisfaction when compared with nurses
(Casarett et al., 2011; Miller, 2008; Monroe & DeLoach, 2004). Further
research is needed to understand these inconsistent findings.
Individual item analysis of job satisfaction scale
The item on the MSQ scale with the lowest degree of dissatisfaction was “the
chance to do things for other people.” Finding satisfaction in work that is
meaningful and serves others is congruent with social work values. Feelings
of accomplishment gained through work that advances a social cause may
therefore be positively linked to job satisfaction. In the case of hospice social
workers, this includes providing high-quality service to patients and their
family members at the end of life. The concept of meaningful work and public
service motivation has received some attention and support in studies on
nonprofit organizations, but this has not been examined in hospice settings
(Bright, 2008; Haley-Lock, 2008).
The higher levels of dissatisfaction on the extrinsic satisfaction scale as
compared with the intrinsic job satisfaction scale indicate lower satisfaction
with conditions of employment, such as salary, job security, and opportunities
for advancement as compared with professional rewards of the job, such as
having autonomy, feelings of accomplishment in helping clients, and making
good use of professional skills. The perception of relationships with interdisciplinary team members was more strongly associated with intrinsic factors of
job satisfaction than with extrinsic factors, a finding that was supported by a
previous study of hospice social workers (Kobayashi & McAllister, 2013) and
is consistent with the World Health Organization recommendation of
18 S. MARMO AND C. BERKMAN
interdisciplinary team collaboration for better patient outcomes and higher
job satisfaction for hospice workers (World Health Organization, 2002).
The stronger association of team member interrelationships with intrinsic
satisfaction suggests that improving relationships with team members may
be a relatively low-cost way to improve job satisfaction. This is not to suggest
that improving team collaboration is easily achieved, nor that advocating for
better employment conditions is less important for job satisfaction.
Servant leadership, with its focus on the leader serving the needs of team
members and the community, has been suggested as an effective leadership
approach in complex service-based organizations, faith-based organizations,
and health-care organizations (Schwartz & Tumblin, 2002). The hallmark of
servant leadership is to empower employees to share in the success or failure
of the organization, while also serving the interests of the community (Russell
& Gregory Stone, 2002). Higher perception of servant leadership in the
present study was most strongly correlated with improving external aspects
of the work environment and promoting a better fit between the hospice
social worker and the work environment. Servant leadership contributed to
both extrinsic an intrinsic job satisfaction, but the correlation was stronger
with the former. Service-oriented professionals, such as hospice social workers, may respond better to this leadership style that promotes values that are
congruent with the ethics and values of the social work profession. Leaders in
human service agencies need to recognize the importance of meaningful work
and service to the community, and not being motivated to simply “help
people” (Cole, Panchanadeswaran, & Daining, 2004; Fisher, 2009). Traditional
methods of leadership in social work organizations have relied on wisdom
and experience to guide leadership and this may not be effective in complex
organizations (Fisher, 2009; Peterlin et al., 2015; Sullivan, 2016).
Profit status
The shorter duration of employment at for-profit as compared with nonprofit
hospices could be due to lower retention of hospice social workers at forprofit organizations or to for-profit hospices being a more recent phenomenon (Aldridge et al., 2014). The smaller number of social workers employed
at for-profit hospices may reflect a greater emphasis on the biomedical model,
which places primacy on physical symptoms over psychosocial needs, and
therefore nursing over social work (Buck, 2009; Reese, 2013). Lower staff to
patient ratios at for-profit as compared with nonprofit hospices (Cherlin
et al., 2010) is consistent with the findings of caseload reported here.
Despite the finding of higher caseloads and fewer social workers at
for-profit hospices compared with nonprofit hospices, job satisfaction did
not differ based on the profit status of the hospice, nor did profit status moderate any of the associations between perception of servant leadership or
JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 19
interdependence in interdisciplinary collaboration and job satisfaction. There
is no prior research on this, but it has been suggested that working conditions
at for-profit hospices, which have higher caseload sizes and fewer social
workers employed as compared with nonprofit hospices, may contribute to
lower job satisfaction of hospice social workers (Cherlin et al., 2010). The
findings reported here do not support this.
Caseload size
The caseload sizes of hospice social workers reported in the few previous
studies that have examined this are consistent with the present study (NASW,
2006; Weisenfluh & Csikai, 2013). A study of caseload size of hospice and
palliative social workers combined found that half reported a caseload size
between 21–50 patients and one-third reported caseloads of 20 or fewer
patients (Weisenfluh & Csikai, 2013). A national study found that 12% of
hospice social workers had caseloads of 50 or more as compared with 34%
of hospital social workers who had caseloads of this size (NASW, 2006)
Studies of social workers in health-care, mental health, and other human
service settings have found a negative correlation between perceived workload
and job satisfaction and a positive correlation between caseload size and
degree of burnout (Cole et al., 2004; Thomas, Kohli, & Choi, 2014). The lack
of correlation between caseload size and job satisfaction in the present study
may be due to organizational support that ameliorated the stress associated
with high caseloads as has been suggested in previous research (Thomas
et al., 2014). It may also be due to a lower mean caseload size in the present
study compared with previous studies or to variables not measured in this
study, including perceived workload, service to community or social justice
orientation, that may be more closely related to job satisfaction.
Study limitations and strengths
This study had several limitations. The cross-sectional study design does not
allow for establishing causality. It is not possible to determine the temporal
relationship between perception of servant leadership or interdependence in
interdisciplinary collaboration and job satisfaction. The sampling plan
undoubtedly led to selection bias due to disproportionate representation of
personal or professional characteristics of respondents. Participants who
responded to social media and listserv invitations may be more connected to
social work hospice networks and differ from other hospice social workers.
The sampling strategy in which the researcher contacted every hospice in three
northeastern states to invite hospice social workers who do not access the listserv
or social networking sites of relevant professional organizations may have mitigated this bias, although hospices in these states are most likely not representative
20 S. MARMO AND C. BERKMAN
of hospices in other regions. The sample was predominantly Caucasian (87%)
and female (92%). While the gender distribution is consistent with a prior study
of hospice and palliative social workers (Weisenfluh & Csikai, 2013), there were
no prior reports of ethnicity of hospice social workers.
This study also had some strengths, it is the only study of hospice social
workers to examine the association between perception of the executive
director and relationships with coworkers with job satisfaction. Job satisfaction was measured as a multidimensional and process-oriented concept with
three subscales, which strengthened assessment of this concept. Including a
measure of the profit status of the hospice allowed for examining an issue that
is of increasing importance as more patients and families are served by forprofit hospices, particularly under the auspices of large providers of hospice
care. The sample had a wide geographical distribution, drawing participants
from at least 32 states. Four different sampling strategies were used, mitigating
the weakness of any single strategy.
Future research
The purpose of this study was to examine the perspective of hospice social
workers. Research on the relative contribution of intrinsic and extrinsic job
satisfaction to patient outcomes and job longevity are needed. Studies should
also examine in more depth how workload is associated with different types of
job satisfaction and how both of these are associated with patient outcomes,
including patient and family satisfaction, stress level, feeling supported by
staff, and bereavement outcomes. Skilled psychosocial support provided
by social workers during the patient’s dying process has been shown to
have a positive effect on bereavement outcomes (Kissane et al., 2016) as well
as improving cost effectiveness and satisfaction with the hospice (Reese &
Raymer, 2004). Longitudinal studies are needed to examine the causal
relationship between workload, tenure of social work, and others on the
interdisciplinary team, job satisfaction, and patient outcomes.
Leadership style should be measured not only based on the perception of
employee, as was measured in this study, but also by the leader, to determine
whether there is congruence in these descriptions, and whether degree of
congruency in perception of leadership style is associated with social worker
job satisfaction.
Future research should include more sensitive measures of workload,
including objective and subjective measures, to identify risk and protective
factors for job satisfaction and burnout (Cole et al., 2004). Scheduling and
compensation, professional development opportunities, and role of the social
worker on the interdisciplinary team should be assessed. Intention to stay
employed at the hospice should also be included in future studies to further
assess whether job satisfaction of hospice social workers foster tenure of
JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 21
hospice social workers. There should also be additional measures on the
hospice setting, including total patient size and the corporate and management structure of the hospice.
Implications for social work practice
Not surprisingly, hospice social workers in the present study were most
dissatisfied with salary. The remedy for this is one that is difficult to achieve
but is important to continue working toward. Hospice social workers deserve
a salary that is commensurate with this challenging and often stressful work.
There was also very high dissatisfaction with the chance for advancement.
Hospice leadership should consider reorganization of administrative roles
to include more opportunities for social workers to advance in the
organization.
Understanding hospice social workers’ job satisfaction can promote a better
fit with the hospice work environment, which may result in better care for
patients. Cabin (2008) suggested that there is a match between the values of
hospice and the values of social work, thereby creating in an opportunity to
“actualize altruism” (p. 474) that contributes to job satisfaction and better
service to patients. The present study found that “providing service to others,”
which reflects altruism, was the highest ranked job satisfaction item on the
MSQ (Brown et al., 2005). Future research should examine whether hospice
organizations that promote providing service to others have higher job
satisfaction than those who do not (Dawis, 2005; Dawis & Lofquist, 1984).
As suggested in the present study, perceptions of altruism in the director,
which is characteristic of a servant leader, may be associated with job
satisfaction of hospice social workers.
The NHPCO has not endorsed a specific leadership style nor recommended
a type of leadership training for hospice executive directors, although it has
offered servant leadership education for hospice physicians(National Hospice
and Palliative Care Organization, 2016). Servant leadership emphasizes
service and healing (Peterlin et al., 2015). Given that hospice workers are
dealing with loss and transitions in life with the patients and families whom
they serve, a servant leader who recognizes shared vision of service and
healing is well suited to the philosophy of hospice and the ethics of the social
work profession. As suggested in the present study, perception of the hospice
director as a servant leader was positively correlated with job satisfaction.
Research on the ways in which hospice leadership and hospice social workers
share the mission of healing and service, and how this affects job satisfaction,
tenure in the position, and patient care, would be useful.
Study respondents were less likely to agree that they felt valued by hospice
doctors as compared with nurses, chaplains, and other social workers. Perception of value by hospice doctors was the only measure of feeling valued by
22 S. MARMO AND C. BERKMAN
coworkers who was significant in the regression models. This is possibly due
to the leadership role of doctors and their greater influence on the hospice
interdisciplinary team (Abramson & Mizrahi, 2003; Casarett et al., 2011;
Gordon & Daugherty, 2003; Marmo, 2014). The full integration of social work
in hospice care requires an egalitarian and integrative interdisciplinary team
model (Parker-Oliver et al., 2005; World Health Organization, 2002). The
mutual understanding and respect of the interdisciplinary team and leadership was suggested to be associated with job satisfaction in this study. Future
studies should identify any weaknesses in these relationships to promote the
maximum efficiency of interdisciplinary collaboration and the best possible
service to hospice patients and families.
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