Employee satisfaction is one of the most studied areas in organisational psychology. Aziri (2001) defines employee satisfaction as the attitudes and feelings of people about their job and its numerous aspects, and the degree to which the job is liked or disliked by the worker. Heathfield (2016) uses the term ‘employee satisfaction’ to describe whether employees are contented, happy and fulfilling their work needs. For the purpose of this research, we define employee satisfaction as a multi-dimensional construct that consists of job satisfaction and general work satisfaction.

A great deal of research has been devoted towards understanding the predictors of job satisfaction in the healthcare industry. A study by Gormley (2003) showed that factors such as professional independence, leadership styles and behaviour, organisational climate, perceived role conflict and ambiguity and organisational characteristics had a significant impact on the job satisfaction of nurses. Parvin and Kabir (2011) found that remuneration, job efficiency, supervisions and collegial relationships are the most critical factors that enhance the job satisfaction of workers in pharmaceutical industry.

A comparative study by Campbell and Ebuehi (2011) showed that healthcare workers in rural and urban areas had different sources of job satisfaction. The study pointed out that urban workers derived their satisfaction from the availability of career development opportunities and the availability of materials and equipment. Job satisfaction for rural workers was dependent on community recognition for their work and improved staff relations. Both sample groups were dissatisfied with a lack of management support, client relationships and a lack of in-service training.

Coward, Hogan, Duncan and Felsen (2017) found no significant differences in job satisfaction between hospital nurses in urban and rural areas. The study however pointed out that factors such as race and personal income of nurses, perception of nurses about supervisor interest in their career aspirations, the length of time that nurses intended to stay at the time of their hiring and their current intentions to leave were significant predictors of the job satisfaction of nurses.

Grujicic, Jovovic-Bata, Radjen and Sipetic-Grujicic (2016) found that urban health professionals were significantly more satisfied with their jobs than their rural counterparts. Grujicic et al. (2016) further maintained that job satisfaction of health workers can be improved by providing better income, more supervisor support, awards for good performance, promotion and advancement opportunities, employment security and interpersonal relationships. Thus, this study proposes the following hypothesis:

This research followed a sequential approach whereby the quantitative data were first collected by using a survey, followed by the collection of qualitative data using focus groups. Johnson, Onwuegbuzie and Turner (2007) define a quantitative-dominant mixed-methods approach as:

Two important research paradigms for this mixed-methods approach were functionalism (quantitative phase) and interpretivism (qualitative phase). The functionalist paradigm is appropriate for replication in theory-testing and refinement. Data are gathered in such a way that a different researcher could replicate the same process under similar conditions and obtain the same results (Shah & Coley, 2006). Shah and Coley (2006) further stated that in the interpretive paradigm, the goal is to ensure representativeness of the data and interpretation thereof. A cross-sectional research design was followed whereby data were collected from the respondents at one point in time. Cross-sectional research is ideally suited to test for cause and effect relationships between variables (Field, 2018).

Ethical clearance was obtained prior to commencement of the study from North-West University (clearance number NWU-00224-14-A9).

The descriptive statistics and reliabilities of the measurements are presented in Table 1.

From Table 1, it is evident that about 75% of the respondents were satisfied with their work and believed that they delivered a good-quality service. The respondents reported moderate levels of job satisfaction, turnover intentions, satisfaction with supervision and career development. The results further showed low levels of satisfaction with compensation. The measurements showed usable reliabilities of α ≥ 0.60 (see Cortina, 1993).

The next section reports on the testing of the hypotheses for this study. The results of the gap analyses between the mean scores of the urban and rural sample groups are reported in Table 2.

The results in Table 2 show significant differences between all the measurements, except for supervision. The effects for work activities, compensation, development, work satisfaction, employee retention and service quality were medium. The participants employed in urban areas reported significantly higher levels on all the measurements, except development.

The results in Table 2 partially confirm hypothesis 1 that significant differences exist between urban and rural healthcare workers in terms of the antecedents of employee satisfaction.

Next the results of the hypothesised relationship between the antecedents and employee satisfaction are reported. Pearson correlation analyses were applied. The results are reported in Table 3.

The results in Table 3 show that all the dimensions of Work environment were significantly positively related to General work satisfaction, except for the Supervision dimension for the urban sample group. The effect of Work duties for the urban sample group was large, while the effects of Compensation and Development were medium. All the effects for the rural group were medium. The results in Table 3 show that Work duties, Supervision and Compensation were significantly positively related to Employee satisfaction for the urban sample group. Work duties (medium effect) and Compensation were significantly positively related to Employee satisfaction for the rural sample group.

Based on the above results, Hypotheses 2, namely, that the antecedents of employee satisfaction are significantly positively related to employee satisfaction, is partially accepted for both the urban sample group and the rural group.

Next, the results of the hypothesised relationship between employee satisfaction and outcome variables (i.e. employee retention and service quality) for urban and rural groups are presented in Table 4. Pearson correlations analyses were applied.

The results in Table 4 show a significant negative relationship between Work satisfaction and Employee retention for both sample groups (medium effects), and a significant positive relationship with Service quality for both sample groups (medium effect for the rural sample group). The results show a significant negative relationship between Employee satisfaction and Employee retention for the urban sample group and a significant positive relationship with Service quality for both sample groups.

The results confirm hypothesis 2 for the urban group that employee satisfaction is significantly negatively related to employee retention. The results further confirm hypothesis 3 for both the urban and rural groups that employee satisfaction is significantly positively related to service quality.

Focus group analyses and findings with proof of evidence quotes from participants are reported in the following tables of thematic coding. Table 5 presents the participants’ responses to lack of medicine, facilities and work environment.

The thematic codes for the responses regarding lack of recognition and appreciation for their work are presented in Table 6.

The thematic codes showing participants’ frustration with their remuneration, salaries and personal development are shown in Table 7.

One participant revealed that she had thoughts of going overseas, Australia or Saudi Arabia, but that the thought of being separated from her family was preventing her from doing so. In all focus group sessions, participants knew former friends in the health sector who had left their employment in South Africa for better opportunities in developed countries. They believed that the opportunities in such countries were better because there was evidence of the improvement in the lives of health workers who worked abroad. It was reported that, within a short period after securing employment overseas, their friends had managed to build houses in South Africa, buy cars and live a lavish lifestyle.

However, most of the qualitative findings above indicate dissatisfaction and frustration in the healthcare environment; an interesting counter-finding from the rural female participants was that they valued their rural workplace and environment as they could stay near to their children and serve their community and their people, as is clear from the following quote: ‘Our people are happy with the services we provide; Asithembeni uguthi bazoshintsha ngoba be’abantu bagithi [let’s hope they do not change]’. This referred to being part of a communal system as is upheld in rural communities within KwaZulu-Natal.

The implications of the results for management are that the stakeholders in the healthcare industry need to capacitate the administration of public health institutions to be able to motivate their employees by providing incentives that improve employee satisfaction. A clear policy framework for all the healthcare personnel may help them to realise their full potential. The plan may also need to focus on providing incentives for employees in rural settings. These incentives should cater for both the clinical and non-clinical staff.

If a conducive work environment that fosters career development and up-skilling the personnel at the health centres in the rural areas is provided, then aspects such as service delivery would be improved. Furthermore, at the policy level, there may be a need to consider the remuneration of healthcare workers to bring it in line with the nature of their work.

At the policy level, there is also a need to improve the supply of medication and service at the healthcare institutions. The results indicate that the availability of medicines leads to health practitioners being satisfied with their jobs. The policy, therefore, needs to ensure that the health institutions have adequate stocks for treatment of patients.

The study identifies the three primary healthcare system inputs: human resources, physical capital and consumables. As people ultimately deliver all medical services, effective human resources management will play a vital role in the success of health sector reform. This study identified some factors that are critical to the promotion of service delivery within health institutions and employee satisfaction of healthcare employees. The focus of policy-makers and healthcare practitioners should be on enhancing these factors. These factors receiving due attention from policy and management initiatives would lead to employee satisfaction and quality service by employees in the public health sector.

This study had some limitations. A cross-sectional research design was followed which limited the research in terms of cause and inferences to be made about the antecedents and outcomes of employee satisfaction in the healthcare sector over the long term. For future research, we recommend longitudinal studies to detect trends in the employee satisfaction of healthcare workers. The sample of this study only included healthcare professionals of KwaZulu-Natal. The results cannot therefore be generalised to healthcare professionals from other South African provinces. Future studies can benefit from expanding this research across the entire healthcare industry in South Africa to allow for more occupation-specific comparisons. The results of the study also lend itself for more in-depth qualitative research to explain the quantitative results in more detail.

Employee satisfaction has an effect on the quality of services provided in public healthcare institutions. Line management and human resource managers should strive to improve the employee satisfaction determinants in the workplace, such as working conditions, remuneration, availability of medication and equipment, safety and recognition, as these will result in improved quality of services offered to patients. In addition, provision of work-related training, although it is not one of the significant determinants of employee satisfaction, will have a positive impact on the quality of their service.

The results also indicate that the quality of healthcare services in public institutions in rural areas and in clinics is better than those in the urban areas and hospitals in both areas. This is an important finding and shows the need to decongest public hospitals, perhaps through investment in more hospitals. Training more clinical and support staff should be considered as an option for reducing the work overload of health professionals in hospitals and urban public health facilities.