Study of the Effect of Health System Reform Plan Administration on the Satisfaction Level among Medical Doctors and Nurses in Tabriz State Hospitals, East Azerbaijan, Iran

Having three orientations, the Health System Reform Plan (HSRP) has been administered to financially support and protect people, provide fair health services and promote the quality of health services. To be unsatisfied about health and medical services brings undesirable outcomes. The present investigation aimed to study the effect of Health System Reform Plan (HSRP) on the satisfaction level among medical doctors and nurses of Tabriz state hospitals, East Azerbaijan province, Iran in a period from 21th February; 2015 to 22th June; 2015. Statistical population included those patients who referred to Tabriz state hospitals. We used stratified sampling method. To collect data we used questionnaire being presented to the samples after assessing its validity and reliability. We also utilized descriptive and inferential statistics in a way that we used descriptive method to classify, summarize and interpret of obtained data. Then after demonstrating the abnormality of data by Kolmogorov-Smirnov test we used linear and multiple regressions to test research hypothesis and effect from the perspective of inferential method. Obtained results confirmed the research hypothesis and explained that the administration of HSRP affected medical doctors’ level of satisfaction. Also, according to the results of multiple regression tests, doctors and nurses’ satisfaction level was placed at the top of most affected issues from HSRP.


INTRODUCTION
Humans have the right to be healthy which everyone can demand it. The main goal of providing health services is to guarantee healthiness among individuals. This aim can be fulfilled through provision of appropriate and needed health services. An efficient health system can achieve its visions only by creating favorable level of health services. It is said that the only way to assess a health system is to assess its services. In order to evaluate health and medical services it is vital to have medical staff's opinions including doctors and nurses. The level of medical staff's (doctors and nurses) satisfaction, as an interfering agent in promotion of medical services quality, is an effective factor in making health services and specially hospitals more efficient. This satisfaction even can be discerned among patients. The main goal of medical and health services is to promote and guarantee health in society. The rapid increasing in medical and care costs and limitation of resources have changed hospitals to be one of the most important as well as highly-priced organizations. For this sake, hospitals need more efficient, knowledgeable and creative managing system. An effective management makes hospitals more efficient, improves its performance and finally promotes the quality of 22 ABCMED 9(3): [21][22][23][24][25][26][27][28][29][30] and level of satisfaction in terms of the services they provide in order to be more competitive and have more patients and also lower the costs and increase incomes have become more popular recently [18,13]. Therefore, hospitals ought not to present the services regardless of the existing needs and demands of effective agents on their efficiency. Satisfaction is an important factor in promotion of health systems quality. Dissatisfaction and being ignorant about medical staffs' opinion can undermine patients' recovery process [1,17]. Job satisfaction is a vital factor to achieve success in work life. It results in more efficiency and more sense of satisfaction. It plays pivotal role in achieving organizational aims and personal and social health. If people have job satisfaction it will lead into high quality of their jobs and cuts down their absence and leave from job brings them mental and physical health. It also directly affects their positive attitudes toward nurses, colleagues, clients and patients [7,8,12]. Hence, nurses compromise the great bulk of human resources in hospitals, their job satisfaction is fundamental in promoting the quality of delivered services. Thus, it would be beneficial to carry out scientific investigation in this filed and implement gained results in different aspects of nursing profession [4,5,15] Therefore, the Iranian Ministry of Health and Medical Education, after a six months pilot study, initiated Health System Reform Plan (HSRP) in April 2014 according to its mission, national policies and especially Iranian 20-years Vision plan, announced general policies by Supreme Leader, legal articles in Fifth national 5-year development plan and 11 th government policies. HSRP acquired 3 orientations including: people's financial protection and support, equality in having access to health services and promotion of delivered health services. By this we gradually see Supreme Leader's policies to come into action and also observe the promotion of health system. Announced health general policies by Supreme Leader put great emphasis on making health basic insurance more public in a way that it would cover basic medical issues of all layer of society and reduce medical costs on behalf of people [11].
The present research actually tries to evaluate the effect of HSRP on the satisfaction level among medical doctors and nurses who work in Tabriz State hospitals from 21 th February; 2015 to 22 th June; 2015.

MATERIALS AND METHODS
Statistical population included: 232 official and contractual working nurses in hospitals and again 104 official and contractual working medical doctors. For this, we used Cochran formula to calculate statistical samples of both populations.
In order to select sample size we used simple sampling method through Cochran Formula considering 95% confidence level and 5% error that follows: To assess the level of satisfaction among stakeholders we used researcher's made 360 degree feedback questionnaire that acquired 2 dimensions of nurses' satisfaction and medical doctors' satisfaction. The questionnaire included 14 items as well 14 questions, one for each item, depicted in Table 3-4.  In this research we distributed questionnaire in work field to gather data [5]. The questionnaire included the following questions:

Questionnaire Scales
The utilized scale in this questionnaire was in a type of the Likert Scale with 5 answering ranges ranged as: too weak, weak, average, much and so much. To assess the validity we used handed the questionnaire to 5 academic experts and necessary reforms were done [9,10].
To calculate confidence ratio of measuring tools we used Cronbach's Alpha coefficient. For this we used SPSS (Version16) software. The obtained values for variables were 0.85 <α<0.95. The questionnaire was considered to be valid because the values were higher than 0.7.
There were 9 questions in questionnaire related to medical doctors and its Cronbach's coefficient was 0.772 while that of nurse were 5 questions and its coefficient was 0.891.

Data Analysis
To gather and classify data we used SPSS software and the obtained results were explained and depicted in different tables.

Findings
The demographic features of nurses and medical doctors were as following Statistical description of sample population.

Evaluating data normality
Utilizing Kolmogorov-Smirnov Test (K-S test) we checked out data normality. We did the test either for whole data and then for each variable. The results are depicted in Table 4  Based on gained results from Table 4-13 and hence the p-value for the tests was higher than our accepted level (α =0.05) therefore we reject data abnormality and can use parametric methods to evaluate hypotheses. Accordingly we used linear regression to evaluate the existing effects.

Research Hypotheses Test
The main hypotheses test: Administration of HSRP is effective on stakeholders' satisfaction in Tabriz  As depicted in Table 14-4, the coefficient of determination was 0.157. It means that 15.7 % of observed dispersion in dependent variable can be justified by independent variable and additionally it is less than the level of significance (0.05) that was 0.000. Therefore we can say with 95% level of confidence that the administration of HSRP was effective on the level of satisfaction among stakeholders. Thus the H 0 hypothesis is rejected and(researcher's hypothesis) H 1 is confirmed.   As seen in Table 4-16 the coefficient of determination came to be 0/261. It means that 26.1 percent of observed dispersion in dependent variable can be justified by independent variable and in addition it is less than the level of significance (0.05) that was 0.000. Therefore we can say with 95% level of confidence that the administration of HSRP was effective on the level of satisfaction among stakeholders. Thus the H 0 hypothesis is rejected and H 1 is confirmed. As it can be observed from table 4-18 the coefficient of determination was 0.337. It means that 33.7 of observed dispersion in dependent variable can be justified by independent variable. Here the P-value was 0.026 and was lower than 0.05. So with 95% confidence level we can say that administration of HSRP satisfied referring patients to Tabriz state hospitals. Thus the H 0 hypothesis is rejected and H 1 (researcher's hypothesis) is confirmed. As depicted in Table 4-20, the coefficient of demonstration was 0.138. It means that 13.8 % of dispersion in dependent variable is justified by independent variable. The P-value was 0.025 that was lower than 0.05. Therefore, with 95% level of confidence we can say that the administration of HSRP was effective on making nurses in Tabriz state hospitals more satisfied. Thus the H 0 hypothesis is rejected and H 1 (researcher's hypothesis) is confirmed.

DISCUSSION AND CONCLUSION
The aim of present study was to investigate the effect of administering HSRP on the level of satisfaction among medical doctors and nurses working in Tabriz state hospitals. Testing the hypothesis was carried out according to a directive by Iranian Ministry of Health and Medical Education from seven perspectives. Administration of HSRP was assessed by 26 questions. Stakeholders' satisfaction including medical doctors and nurses was evaluated by 14 questions by having 360 degree feedback orientation. Findings showed that R 2 value was 0.157. It means that 15.7% of stakeholders' satisfaction can be fulfilled by successful administration of HSRP. As mentioned, Beta value was 0.396 and P-value was less than 0.05. Therefore, it can be said that changes in independent variable (the successful administration of HSRP) can affect the dependent variable (stakeholders' satisfaction) at the level of 0.396.
Based on 360 degree feedback orientation stakeholders' satisfaction depends on the satisfaction of three groups of nurses, doctors and patients and the satisfaction of these two groups also goes back to the variety of factors including: admission process, number of doctors and nurses, number of medical working teams, total number of medical staff, physical space, complaints handling, dismiss process, quality and quantity of hospital facilities, number of referrals, quality of medical services, salary changes, responding to the needs, patients' manner of behaving, trainings and instructions about plans, accommodation, satisfaction from office closure, self-assessment, and so on. Moreover, as it has been mentioned in theoretical and operational models sections of HSRP, one should seek out its successful administration in fulfillment of factors including decrease in charges of hospitalized patients, supporting doctors residency in deprived areas, presence of resident specialists in hospitals, promotion of hoteling, promotion of visiting services, financial support of refractory patients and supporting natural childbirth. The present study showed that successful administration of HSRP was effective on the level of satisfaction among stakeholders.

First Subordinate Hypothesis
The hypothesis was measured by HSRP questionnaire with 26 questions and with 9 questions of stakeholders' questionnaire we measured the level of satisfaction among doctors. R 2 was calculated to be 0.261. it suggest that 26.1% of changes related to the level of satisfaction among working medical doctors in Tabriz state hospitals is caused by the successful administration of HSRP. Furthermore, Beta value came to 0.511 and the P value was less than 0.05 therefore it can be said that changes in independent variable (here the successful administration of HSRP) was effective on the changes of dependent variable (level of satisfaction among medical doctors of Tabriz state hospitals) at the level of 0.511. Third subordinate hypothesis: by means of 26 questions of HSRP questionnaire and 5 questions about the level of satisfaction among nurses we assessed the hypothesis. R 2 value came to be 0.138. It means that 13.8 % of changes in the level of satisfaction among nurses can be demonstrated by the successful administration of HSRP. The calculated Beta value was 0.195 and the P-value was less than 0.05,therefore, we can conclude that changes in independent variable (successful administration of HSRP) was effective on the changes in dependent variable (the level of satisfaction among working nurses in Tabriz state hospitals) at the level of 0.195.