Reflecting a trend in the health sector and highlighting professional requirements, medical institutions have increasingly come to value the concepts of social capital and health promotion, in a working environment that is high-risk, knowledge-intensive, extremely stressful, and competitive (Ommen et al., 2009; Pelikan, Krajic, & Dietscher, 2001). Social capital operates in interpersonal relationships, explaining individual prosocial behaviors in communities and encouraging cooperation and coordination to achieve collective community benefits. Numerous scholars have identified social capital as a relevant intangible asset of hospitals, as well as a critical contributing factor to the quality of the work environment for employees (Ommen et al., 2009).

In addition to treating diseases, the general view in the health sector is that healthcare services provided by hospitals should also contribute to improving health and life quality. Modern medical institutions must integrate the concepts, values, and standards of health promotion into the organizational structure and culture of hospitals to establish a supportive institution for enhancing the health of patients and their family members, employees, and the community at large.

Findings in numerous studies have indicated that, because of the high-risk, extremely stressful, and competitive environment of modern hospitals, doctors and nursing personnel tend to have a negative perception of the quality of their work life, for example, job satisfaction (Ommen et al., 2009). Applying the concepts of social capital and health promotion may provide both employers and employees with a practical solution to the workplace difficulties experienced by medical personnel.

Although applying the concepts of social capital and health promotion in hospitals is considered by many to be very relevant and essential, there have not been many studies conducted in which the relationships among social capital, health promotion, and job satisfaction in hospitals have been explored and analyzed. Therefore, in this study we reviewed relevant literature to help researchers and practitioners enhance their understanding of the theories and knowledge of these concepts. In addition, we proposed a research model to illustrate the relationships among the relevant concepts, and by means of which the fit between the empirical data and the proposed model might be examined. Finally, we have sought to provide hospital managers with suggestions and insight regarding the application of social capital and health promotion in hospital routines and practices.

Literature Review

Social Capital

Bourdieu (1985) described social capital as the aggregate of actual or potential resources, which are linked to possessing a durable network of relatively institutionalized relationships of mutual acquaintance or recognition. Coleman (1990) pointed out that social capital includes several aspects of social structure that facilitate certain actions of individuals within that structure. Putnam, Leonardi, and Nanetti (1993) wrote that social capital refers to the features of social structure, such as networks, norms and social trust, which facilitate coordination and cooperation for mutual benefits.

Social capital may exert a contextual effect on the health of an individual through several mechanisms (Kawachi, Kennedy, & Glass, 1999). Lindstrom and Janzon (2007) examined social capital as a social and contextual factor. A society in which there are high levels of social capital usually results in a society with high levels of civic engagement, social participation, social trust, institutional trust, and interpersonal reciprocity. Furthermore, social capital can help organizations solve conflicts, expedite the learning process, and integrate tacit knowledge (Zigan, Macfarlane, & Desombre, 2009).

Social capital has usually been measured according to the level of social trust. Social trust refers to the expectation that an individual or institution will act competently, fairly, openly, and considerately. (Mohseni & Lindstrom, 2007; Putnam, 1993). Because social trust reflects features of social capital that can be measured objectively, and because numerous researchers have used social trust to measure social capital in previous studies, in this study we also used social trust as the measure of social capital.

Trust

Kreitner, Kinicki, and Buelens (1992, p. 338) defined trust as “having reciprocal faith in each other’s intentions and behavior”. Mayer, Davis, and Schoorman (1995, p. 712) defined trust as “the willingness of a party to be vulnerable to the actions of another party based on the expectation that the other will perform a particular action important to the trustor, irrespective of the ability to monitor or control that other party”. Generally, trust can be divided into interpersonal trust and institutional trust. Interpersonal trust is a type of general trust in others, involving an individual or group relying on the word, promise, or verbal or written statement of another individual (Rotter, 1967). Institutional trust mainly concerns the trust of citizens in institutions, particularly the public institutions within society (Lindstrom & Janzon, 2007).

Paul and McDaniel (2004) wrote that interpersonal trust is crucial for healthcare delivery because healthcare providers depend on collaboration as a primary means to reduce complexity. Such complexity results from the comorbidity of a patient’s conditions that requires providers to deal simultaneously with multiple problems. Russell (2005) argued that the performance of any healthcare system is based on institutional trust, which enables individuals to trust healthcare providers without possessing any personal knowledge of them. Mohseni and Lindstrom (2007) suggested that trust in the healthcare system is a significant factor associated with care-seeking behavior.

Health-promoting Hospitals

Health promotion is the process of enabling people to increase control over and to improve their health (World Health Organization, 1986). A health-promoting hospital (HPH) can be regarded as an institution at which interventions emphasize several functions of a hospital. That is, an HPH is (a) a physical and social environment; (b) a workplace; (c) a provider of health services; (d) a setting for training; (e) an advocate and change agent for health promotion; and (f) a model for developing a healthy organization (Pelikan, Krajic, & Dietscher, 2001). The concepts, values, and standards of health promotion are incorporated into the hospital’s organizational structure and culture to enhance healthcare quality, living and work conditions, as well as the satisfaction of employees, patients, and patients’ relatives (Aujoulat, Le Faou, Sandrin-Berthon, Martin, & Deccache, 2001).

In the Ottawa Charter for Health Promotion (World Health Organization, 1986) active developments of health promotion in schools, communities, hospitals, and workplaces are introduced and illustrated and five fields of health action are set out. The first model project for hospitals based on the Ottawa Charter was implemented in Vienna between 1986 and 1996. In 1990, the international network of HPH was established. In 1991, in the Budapest Declaration (World Health Organization, 1991) the common vision, concept, and strategy of an HPH international network was announced, and a European health-promoting hospital (EHPH) was initiated in 1993 as the first international HPH project.

In 1989, the concept of health promotion was adopted for the first time in Taiwan in an annual Department of Health report presented by the Executive Yuan. In 2001, to integrate the promotion of health programs and to realize optimal universal healthcare, the Bureau of Health Promotion was officially established to manage the relevant tasks of health promotion in Taiwan. The Taiwanese HPH network was established in 2006, becoming an official member of the international network of the World Health Organization (WHO). The Taiwanese Association for Health-promoting Hospitals was established in 2007, with the objective of assisting hospitals in carrying out health-promoting projects. Currently, more than 60 hospitals are members of the HPH network, indicating that the concept of HPH has been recognized and valued by managers of medical institutions in Taiwan.

The Relationship Between Institutional Trust and Interpersonal Trust

When a patient knows little about a new doctor or health plan, the patient is likely to begin the relationship with a general attitude about doctors or health plans (Mechanic, 1996). This emerging individual trust is based on generic characteristics of the institution (Hall, Dugan, Zheng, & Mishra, 2001). Newly formed relationships are particularly likely to have an influence on both interpersonal and, institutional trust in that, knowing little about new physicians, nurses, or other staff members, a patient may begin the relationship with general attitudes about the individual physicians/nurses/staff, the departments with which they are affiliated, or even the organization as a whole. Moreover, in numerous studies researchers have shown that when an individual trusts the institution this can enhance the development of interpersonal trust (Mohseni & Lindstrom, 2007). In summary, institutional trust has been found to positively affect interpersonal trust. Therefore, we proposed the following hypothesis:
H1: Institutional trust will have a positive effect on interpersonal trust.

The Relationship Between Institutional Trust and Health Promotion

Health promotion is a process of quality improvement. Pelikan, Krajic, and Dietscher (2001) expressed the view that an HPH should develop a comprehensive health-related quality strategy. For instance, WHO (2005) described a strategy to implement the HPH concept through a combination of the European Foundation for Quality model (EFQM) and the Balanced Scorecard (BSC) approach. In summary, institutional trust has been found to have a positive impact on improvement in quality of relevant practices at a health-promoting hospital. Therefore, we proposed the following hypothesis:
H2: Institutional trust will have a positive effect on health promotion.

The Relationship Between Trust and Job Satisfaction

Gill (2008) showed that trust affects the job satisfaction of employees. Tan and Tan (2000) found that employees’ trust in their supervisors was related to the satisfaction of those employees with the supervisors. Paillé, Bourdeau, and Galois (2010) demonstrated that trust and job satisfaction are positively correlated. In addition, Ommen et al. (2009) found that interpersonal trust significantly affected job satisfaction. Rowe and Calnan (2006) identified institutional trust as valuable to organizations in promoting efficiency, team work, and job satisfaction. In summary, both interpersonal trust and institutional trust have been found to have a positive impact on job satisfaction. Therefore, we proposed the following hypotheses:
H3: Interpersonal trust will have a positive effect on job satisfaction.
H4: Institutional trust will have a positive effect on job satisfaction.

The Relationship Between Health Promotion and Job Satisfaction

According to Aujoulat et al. (2001), the goals of an HPH are to improve both healthcare quality and satisfaction of staff. Delobelle, Onya, Langa, Mashamba, and Depoorter (2010) conducted a pilot HPH project in South Africa, with the objectives of creating a safe and supportive health environment and of promoting the health and well-being of hospital staff and patients, thereby reflecting staff job satisfaction and retention. Wilson, DeJoy, Vandenberg, Richardson, and McGrath (2004) and DeJoy, Wilson, Vandenberg, McGrath-Higgins, and Griffin-Blake (2010) have shown how a healthy workplace can affect the psychological work adjustment of employees, in areas such as perceived job satisfaction, and can also affect the health and well-being of employees. In summary, health promotion has been found to influence job satisfaction positively. Therefore, we proposed the following hypothesis:
H5: Health promotion will have a positive effect on job satisfaction.

Method

Participants

Full-time employees of 16 hospitals in Taiwan that had implemented HPH practices were the participants in this study. We distributed and collected 3,042 copies of a questionnaire. Forms that contained incomplete or irregular answers were discarded, leaving 2,884 valid questionnaires (response rate, 95%). Of these 2,884 respondents, 558 were male (19.3%) and 2,326 were female (80.7%). Most respondents were within the age range of between 18 and 34 years (55.8%), followed by between 35 and 40 years (29.0%), between 45 and 54 years (12.7%), and older than 55 years (2.5%). Most respondents reported holding a bachelor’s degree (84.3%), followed by master’s degree (8.7%), senior high school degree (6.1%), and doctor’s degree (0.9%). Nurses comprised the biggest group of respondents (35.8%), followed by administrative staff (32.0%), medical technicians (21.9%), and physicians (10.3%). There were 1,050 respondents (36.4%) who had from 0 to 5 years of professional experience, 644 (22.3%) had between 6 and 10 years, and 637 (22.1%) had between 11 and 15 years. The mean scores of the constructs were all near the middle of the 5-point Likert-type scales, showing a reasonable dispersion in their distributions across the ranges.

Measurement

All items of the questionnaire we used in the study were rated on 5-point Likert-type scales, ranging from 1 = very strongly disagree to 5 = very strongly agree. The six items used to measure interpersonal trust were based on Lindstrom and Janzon (2007) and Mohseni and Lindstrom (2007). The five measurement items of institutional trust were based on Lindstrom and Janzon (2007) and Mohseni and Lindstrom (2007). The 10 measurement items of health promotion were based on the WHO manual and self-assessment forms for implementing health promotion in hospitals in Europe (World Health Organization, 2006). The six measurement items of job satisfaction were based on Ommen et al. (2009).

Statistical Analysis

To examine the proposed model empirically, structural equation modeling (SEM) was used to validate the model and hypotheses. The data analysis was performed according to the two-step approach recommended by Anderson and Gerbing (1988). First, the assessment of the measurement model is performed, assessing reliability, discriminant validity, and convergent validity of the scales. Second, the structural model involves validating individually the series of path relationships linking the constructs.

Results

Measurement Model Results

Convergent validity was validated by examining Cronbach’s α, composite reliability, and the average variance extracted (AVE) from the measures (Hair, Anderson, Tatham, & Black, 1998). Cronbach’s α of the subscales ranged from 0.87 to 0.94, which was above the acceptability value of 0.7 (Nunnally, 1978). The composite reliability values ranged from 0.85 to 0.94 and the AVE ranged from 0.50 to 0.65, all of which were within the commonly accepted range and greater than 0.5 (Hair et al., 1998). In addition, all factor loadings of the measures in our research model were significant at the level of .001, and the goodness-of-fit indices were all excellent.

According to Fornell and Larcker (1981), discriminant validity can also be tested among all constructs by comparing the AVE of each construct with the squared correlation of that construct and all of the other constructs. All squared correlations between two constructs were less than the AVE of both constructs. Therefore, our results confirmed that the discriminant validity of the constructs in the study was satisfactory.

Structural Model Results

The goodness-of-fit statistics are summarized in Table 1. The goodness-of-fit indices are nearly within acceptable thresholds, except for / df, which is slightly higher than the commonly cited threshold. Therefore, the summary of the overall goodness-of-fit indices demonstrated a good overall fit of the structural model to the data. In Table 2 the estimated standardized path coefficients and their significance in the structural model are shown. All proposed hypotheses were supported. As expected, institutional trust (0.619) had a significant influence on interpersonal trust, accounting for 38.3% of the variance in the construct. Institutional trust (0.571) had a significant influence on health promotion, accounting for 32.6% of the variance in the construct. Consistent with our expectations, interpersonal trust (0.156), institutional trust (0.478), and health promotion (0.322) all had a significant impact on job satisfaction, accounting for 66.1% of the variance in the construct.

According to standardized indirect and total effects in the proposed model, institutional trust had the strongest overall effect on job satisfaction, followed by health promotion and interpersonal trust in that order. In summary, institutional trust, interpersonal trust, and health promotion were crucial predictors of job satisfaction.

Conclusion and Discussion

Our results indicate that institutional trust is an essential prerequisite for fostering interpersonal trust and health promotion in hospitals. In addition, institutional trust, interpersonal trust, and health promotion were all found to have significantly positive effects on job satisfaction. Accordingly, our results in this study provide insight by examining aspects of health promotion in hospitals that have not been addressed in previous studies.

Firstly, our findings imply that social capital plays a key role in job satisfaction of employees in the healthcare sector, meaning that organizations should continue focusing on dyadic trust while building institutional trust and interpersonal trust (Tan & Tan, 2000). Practical programs that can be implemented by hospitals to build institutional and interpersonal trust in the workplace include: (a) ensuring that an open-communication channel is established and maintained and establishing online submission forms for employee complaints; (b) listening to employees’ complaints and expressions of dissatisfaction, conducting a survey that would include a scale to rate burnout of employees, adjusting job descriptions, and designing compensation and reward schemes; (c) hosting employee meetings to advocate and promote significant policies and the hospital’s vision, listening to the opinions of lower level employees, and considering all suggested options; (d) improving employee clubs and benefits, and organizing trips or other activities for employees and their family members.

Secondly, our results confirm that health promotion has a significant positive effect on job satisfaction. Programs that may achieve this goal will replace slogans with actions and can consist of: (a) implementing a food guideline and promoting healthy eating in hospital cafeterias. Employees will appreciate plans for dining that are financially subsidized by the employer and that not only meet their physiological needs, but also promote a healthier lifestyle; (b) establishing amenities for exercise and organizing sports activities, such as arranging team games for employees, advocating health promotion as a physical and mental condition necessary for medical personnel, and arranging routine physical examinations, nutrition consultations, and encouraging weight loss for those who are obese; (3) empowering all employees, particularly newcomers, to avoid illnesses where possible, to manage effectively any illness from which they do suffer, and to live in a healthy manner through the promotion of health.

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Chung-Hung Tsai, Tzu Chi College of Technology, No. 880, Sec. 2, Chien-Kuo Road, Hualien 970, Taiwan, ROC. Email: [email protected]