Job security among healthcare workers in Guangdong, China

Objective The objective of this study was to explore the sense of job security and its influencing factors among healthcare workers in Guangdong, China. Methods This cross-sectional study used stratified random sampling to enroll healthcare workers employed by hospitals across Guangdong province between September 2020 and October 2020. Results A total of 4,173 questionnaires were distributed, and 4,076 were returned for an effective recovery rate of 97.68%. The overall score for the sense of security was 64.85 ± 20.09, and the item means score was 2.95 ± 0.91. Multiple-linear regression analysis showed that work experience (years), education level, job position, specialty unit, employment type, marital status, job satisfaction, WPV frequency, daily sleep duration, weekly overtime hours, average monthly earnings (RMB), hospital level, and region were significantly associated with senses of poor security among healthcare workers (all P < 0.05). Conclusions Hospital workers in Guangdong reported relatively low levels of job security. Levels of job security were significantly associated with multiple factors which could be addressed by hospital practices to improve the sense of job security among healthcare workers.


. Introduction
Safety is the most basic physiological need of human beings (1), and lack of job security not only affects job satisfaction, but also leads to the lack of job safety and quality (2). Poor doctor-patient relationships are a significant concern for healthcare workers in China (3,4). Approximately two-thirds of physicians have reported disputes or doctor-patient conflicts which threatened their physical safety (5). A recent article published in the Lancet examining the safety of healthcare workers in China concluded that medical workers in China have a very low sense of security (6).
The recent coronavirus pandemic only made safety concerns among hospital workers in China more apparent (7). A Chinese report on workplace violence in hospitals showed that 100% of nurses expressed lack of job security (8). An American study reports that 34.4% of medical workers experienced physical violence within 12 months, and 13.5% suffered physical attacks (9). Among those who suffered verbal or physical violence, 9.4% did not want to continue working in the medical industry.
As the above data indicate, job security is an important factor which influences the retention of nurses (10). Yan et al. (11) found that there is a relationship between job He et al. .
insecurity, quality of life and turnover intention whereby reduced job insecurity was associated with a lower quality of life and higher turnover intention. A cross-sectional survey which included 403 medical staff members as research objects found that job insecurity was an important predictor of job burnout (12). Similarly, a Chinese study that included 453 nurses found that occupational stress was inversely correlated with psychological security (13). Moreover, over two-thirds of doctors in China report symptoms of burnout in a recent systematic review (14). Workplace Violence (WPV) is defined by the International Labor Organization (ILO) as the assault of threat of assault to a staff member in a work-related environment that threatens their safety, wellbeing or health (15,16). The domestic incidence rate of WPV among medical workers in China is 61.9% (17,18). Further, 68.6% of the healthcare workers in pediatrics in China have experienced WPV at least once over the course of a year (19). Related studies have shown that WPV harms individual mental health and job performance (20) and that anxiety among healthcare workers increased significantly after experiencing WPV (21, 22).
Pienaar's Job Insecurity Scale (JIS-8) is commonly used abroad, and includes two dimensions: emotional job insecurity and cognitive job insecurity (23). However, the reliability and validity of Pienaar's job insecurity scale (JIS-8) has not been verified among workers in China or among healthcare workers. Cong et al. (24) compiled a job security scale for workers in China that includes the dimensions of sense of control and interpersonal security. However, this scale does not take into consideration the professional characteristics of medical staff.
In order to better study job security among healthcare workers in China, a scale was adopted in this study, which was compiled through qualitative and quantitative research on the experience of safety by medical staff (25). This scale better reflects the professional characteristics of the medical staff as compared to currently available surveys. Using this scale, this study examined perceptions of job security among healthcare workers in hospitals of Guangdong province and used these data to identify factors which may influence job security in this population.

. . Study design and populations
This cross-sectional study used stratified random sampling to enroll healthcare workers from hospitals in Guangdong Province between September 2020 and October 2020. This study was conducted stratified random sampling on three groups of hospitals, primary, secondary and tertiary, as classified by the Chinese government. The June 2018 list of general hospitals published by the Commission of Health and Family Planning was used to obtain the names and contact information for 204 primary, 224 secondary, and 76 tertiary hospitals in Guangdong. Hospitals from each of the four regions were included and the sampling ratio of primary hospitals: secondary hospitals: tertiary hospitals was determined to be about 2

. . Instruments and procedure
Staff were administered a questionnaire that included items on gender, age (years), work experience (years), education level, job position, specialty unit, professional title, employment type, marital status, job satisfaction, WPV frequency, daily sleep duration, weekly overtime hour, average monthly earnings (RMB), hospital level and region within the province.
The sense of job security scale (25) included 22 items across five dimensions: patients, self, organizational management, social support and environment. A Likert 5-level scoring method was used, and each item was given a score on a discrete scale from 1 to 5. A score of 1 was given if the participant very strongly agreed with that item and a score of 5 was given if the participant very strongly disagreed with that item. The total score ranged from 22 to 110, with score ≥ 44 indicating a high level of job security, while score < 44 indicating a low level of job security. The total Cronbach's alpha coefficient was 0.939, the split-half reliability was 0.96, and the test-retest reliability was 0.967, indicating good internal consistency.
The questionnaire service (https://www.wenjuan.com) was used to administer each survey. Before beginning the survey, each participant was introduced to the software interface and the purpose of this survey and gave written informed consent. In order to avoid repeat submissions, a single account, device and IP address can only be used once to take the questionnaire. The questionnaire service was used to export the data, and the data was manually screened and reviewed by two independent evaluators.

. . Statistical analysis
According to Kendall's empirical estimation method, the sample size N should be 5-10 times of the number of independent variables (26). The number of independent variables in the subject was 22, indicating that the maximum required sample size according to this method is 220. Reasonably, up to 20% of the questionnaires could be invalid, so a sample size of at least 275 was used.
SPSS version 23.0 (IBM, Armonk, NY, USA) was used for statistical analysis. Continuous variables were described as mean ± SD or median values with interquartile range depending on normality of the variables. Categorical variables were presented The scores from each different dimension, self, organizational management, patient, social support, and environment, are shown in Table 2. Gender, work experience (years), education level, job position, specialty unit, employment type, marital status, job satisfaction, WPV frequency, daily sleep duration, weekly overtime hour, average monthly earnings (RMB), hospital level and region were all significantly correlated to job security (all P < 0.05) ( Table 1). Between these variables, the tolerance limit was 0.1 or higher, ranging from 0.53 to 0.96. The variance inflation factor (VIF) ranged from 1.04 to 1.89, which was below the reference value of 3. Therefore, there was no multicollinearity among the independent variables. Multiple linear regression analysis showed that work experience (years), education level, job position, specialty unit, employment type, marital status, job satisfaction, WPV frequency, daily sleep duration, weekly overtime hours, average monthly earnings (RMB), hospital level, and region are significantly and independently associated with job security among healthcare workers (all P < 0.05) ( Table 3).

. Discussion
This study showed that these hospital workers perceived their workplace as relatively unsafe. Multiple-linear regression analysis showed that work experience (years), education level, job position, specialty unit, employment type, marital status, job satisfaction, WPV frequency, daily sleep duration, weekly overtime hours, average monthly earnings (RMB), hospital level, and region were significantly associated with feelings of poor safety and security among healthcare workers. This data may provide a reference for hospital managers to formulate policies that improve workplace safety.
Prior research demonstrates that effective team leadership is an essential factors for the team atmosphere (27). Therefore, the department directors and the head nurses can play a critical role in building feelings of job security among staff members.
Surprisingly, inexperience, as demonstrated by fewer years on the job, was associated with relatively high feelings of job security, a finding which was inconsistent with some reports (28). This discrepancy may be due to the relationship between age and career development. Older workers are more likely to have greater work experience and higher levels of education which can increase job security, but they are also more likely to experience sleep disturbances which negatively impact performance and job satisfaction. This is supported by the finding that sleep duration was inversely related to job security in this study.
In Guangdong, the State Council's regulation states the working week is 8 h a day for 40 h a week and any work exceeding these house is overtime work. In this study, over half of those surveyed worked 5 h of overtime a week. Previous studies showed that 61.2% of healthcare workers worked 5 h of overtime per week (29), while survey results of healthcare workers in Lanzhou show a rate more comparable to this study's 50% rate (30). According to the White Paper on the Occupational Status of Chinese doctors published in 2018, doctors in tertiary hospitals in China work an average of 51.5 h per week (5). Moreover, almost 60% of the healthcare workers in Ningbo Grade A hospitals work more than 8 h a day, 12.4% more than 10 h a day, and 4.8% more than 12 h a day (31). Overwork is more likely to cause errors or medical disputes, and thus weaken the sense of job security of healthcare workers (32).
Furthermore, this study found that employment at primary hospitals was associated with worse job security as compared with secondary and tertiary hospitals. In China, primary hospital are local community hospitals with fewer resources than the larger more specialized secondary and tertiary hospitals (33). The public and government officials generally equate patient volumes with the quality of care and as such large patient volumes have become a prerequisite to aquiring funding for high-quality training and research (34). Career development opportunities such as those offered by tertirary hospitals have been shown to be associated with greater levels of job security among hospital workers (35).
More than half of the healthcare workers in this survey experienced WPV during the yearlong study period. This suggests that medical departments need WPV training, and the hospital should strengthen personal safety protection measures among healthcare workers (36), especially in the department of surgery. Furthermore, the department in which a healthcare worker was employed was significantly associated with job security. This indicates that healthcare workers in high-risk departments, such as the emergency and critical care and obstetrics and gynecology departments, need more supports than other lower risk departments such as dermatology.
Additionally, home and environmental factors were shown to have a significant association with job security in this study. Married healthcare workers and those with higher incomes had greater levels job security on average than   workers who were divorced or who had lower incomes. This confirms that marriage and family life can have a strong stabilizing influence on healthcare workers' lives and outlook (37). Since higher incomes are needed to support families, it follows that higher incomes were also associated with greater job security. The survey results show that contract workers account for almost 6 in 10 workers, indicating that most of the healthcare workers in this survey belong to the contract system. Although the public hospitals claim to follow a policy of equal pay for equal work, contract staff have reduced benefits, fewer sick days, and higher stress (38). Hospitals in eastern Guangdong were ranked the lowest in this study, while those in northern Guangdong were ranked highest. These differences may be related to the economic development of each region, suggesting that hospital managers should adopt localized strategies.
This study had some limitations. This was a survey-based research study that captured the attitudes of medical workers toward their sense of job security in the workplace at a single point in time. As such, it is unknown if the trends observed in this study persist throughout the year or over time. Guangdong has a rapidly growing economy, and as such conditions may change rapidly that can improve the sense of job security among workers. Additional research should be carried out to understand the dynamic factors that influence the sense of job security among hospital workers and identify which strategies most improve the job security of healthcare workers.

. Practice implication
Department managers should focus on the department construction. Efforts to build department unity and enhance collaboration may improve the mental health of healthcare workers and foster a sense of job security. Hosptials should equip key departments with one-button alarm devices and increase the intensity of security in high risk areas (39). Additionally, social support is key to mental health and worker wellbeing and should be a focus of hospital remediation efforts to mitigate the effects of unavoidable WPV (40).

. Conclusions
In conclusion, the total job security score for healthcare workers in this study was relatively low. Education level, employment duration, job satisfaction, the frequency of WPV, daily sleep duration, overtime hours, professional category, departments, employment type, marital status, and locality of employment were significantly associated with feelings of poor safety and security among healthcare workers. A multi-center study with larger sample size is needed in future to make further conclusions about these results.

Data availability statement
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Ethics statement
The studies involving human participants were reviewed and approved by the Guangdong Provincial People's Hospital Ethics Committee. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions
LM and HH conceived and designed the study. SW, QZ, ZB, and XY collected the data. WL did the statistical analysis and produced the tables and figures. QH wrote the initial draft. All authors subsequently