THE EFFECT OF MORAL FOUNDATIONS AND PERSONALITY DIMENSIONS OF HEALTH WORKERS ON PATIENT SATISFACTION WITH HEALTHCARE SERVICES UTICAJ MORALNIH OSNOVA I DIMENZIJA LIČNOSTI ZDRAVSTVENIH RADNIKA NA ZADOVOLJSTVO PACIJENATA ZDAVSTVENOM USLUGOM Authors

Background/Aim. Working with people in medical practice requires knowledge of the basic principles of personality psychology. The aim of this research was to examine the influence of moral foundations and personality dimensions of health workers on patient satisfaction with health service, as well as determining the factors influencing their satisfaction. Methods. The research was conducted using the Big Five Inventory (BFI), the Moral Foundations Questionnaire (MFQ) and the Questionnaire of patient satisfaction with healthcare service, from October 2014 to March 2016. The survey involved 693 respondents: 329 healthcare workers (44 males and 285 females) and 364 patients (154 males and 210 females). Results. With the increase of the openness of healthcare professionals, the patients' satisfaction was also growing. Regarding moral foundations of healthcare workers, there was an opposite trend ? with lower authoritativeness of healthcare workers, patient satisfaction was greater. Finally, with more pronounced purity of healthcare workers there was a decrease in the level of patients? satisfaction with the received healthcare service. Conclusion. There is a direct association between the moral foundations and personality dimensions of health workers, and patients? satisfaction with healthcare service. Thus, any strategy for improving the quality of healthcare service should take into account personal characteristics of healthcare workers. Healthcare professionals are expected to fulfill their life and professional tasks in as a human way as possible, since preservation of the health and helping to overcome an illness, in case it develops, are the basic values of every human being. It should result in more clearly defined priorities for improvement of the quality of work of healthcare workers.


Introduction
The subject of this research was to determine the degree of user satisfaction with provided health services in primary healthcare institutions, and the results of the research should form the basis for planning activities that would improve the quality of work and patient satisfaction as the main output results.Assessment of user satisfaction is one of the basic elements of improving the quality of work of health institutions and a prerequisite for a quality health care 1 .In order to motivate health professionals for the targeted activities it is necessary to know the basic principles of motivation psychology and mechanisms for developing internal motivation, which should be acted on by all employers as well as on the level of the State.Patient satisfaction could be used as an instrument for measuring the success of a healthcare institution and for improving the quality of health care itself 2 .The programs of satisfaction of the users of health services are studied and applied in the health sector as instruments for achieving patient satisfaction 2 .The aim of research was to examine the influence of moral foundations and personality dimensions of health workers on patient satisfaction with health service.

The quality of the health care
In accordance with the above stated subject and aim of the research, taking into account the existing literature, the following was determined that the extraversion dimension (BF1), the neuroticism dimension (BF2), the openness dimension (BF3), the agreeableness dimension (BF4), the conscientiousness dimension (BF5) of health workers affects patient satisfaction with healthcare service, also care (MFQ1), fairness (MFQ2), loyalty (MFQ3), authoritativeness (MFQ4) and purity (MFQ5) of health workers affects patient satisfaction with healthcare service.

Methods
The research was conducted as a survey, by distributing questionnaires with a prior consent of the ethics committees of the health centers "Novi Sad", "Kula" and "Dr.Đorđe Lazić".The Health Center "Novi Sad", the largest health center in the region, with the largest number of employees (1,465), with 33 facilities (some of which are in urban and some in suburban settlements), and the largest number of services provided (8,835,567 in 2016) and the most intensive patient turnout (of all ages -from the youngest, to the working age and pensioners), was taken as representative.In Novi Sad, there is no general hospital as a secondary-level healthcare, expect Military hospital in Petrovaradin, for that reason the Health Center "Novi Sad" plays a major role in bridging the gap between the primary and tertiary level health care.

Research instruments
Three instruments were selected in accordance with the research objectives and based on the theoretical and empirical backgrounds 13 : Big Five Inventory (BFQ) 14 , one of personality testing questionnaires, developed by Italian authors Caprara, Barbaranelli and Borgogni.It consists of 44 statements, to which a respondent answers on a Likert scale ranging from to 5 (Cronbach Alpha = 0.857 in this research); Moral Foundations Questionnaire (MFQ), by Jonathan Haidt, which consists of 32 statements, divided into two groups, (Cronbach Alpha = 0.893 in this research), and the answers are given in Likert format in the range of (not veryrelevant) to 5 (strongly relevant), and ranging from 1 (disagree strongly) to (agree strongly); and the patient satisfaction questionnaire , and an ad hoc questionnaire constructed only for the purposes of this research, whichconsisted of questions,(Cronbach Alpha = 0.752 in this research)with answers offered in Likert-scale format, ranging from 1 (not at all relevant) to 5 (extremely relevant).According the Cronbach alpha coefficients we can say that instruments we used in this research are reliable.One independent study panel consisted of health workers from the three medical institutions, while the other panel included patients treated in these institutions 15 .Firstly, it was necessary to translate and culturally adapt the selected instruments.Two translators, whose mother tongue was Serbian and who were familiar with the research, independently translated both the questionnaires from English into Serbian.The two versions were compared, and after back-translation and final correction and validation by a university professor in psychology and management the versions were finally accepted.The questionnaires were filled in anonymously in order to obtain as sincere responses as possible.

Study sample
The survey was conducted in the period from October 2014 to March 2016.A total of questionnaires were distributed, 758 were returned, of which 693 were valid.Of these, respondents were health workers (154 doctors and 175 nurses), 44 of whom were male and 285 female, and 364 were patients, of whom 154 were male and 210 female.In order to confirm or reject the research hypotheses, the obtained results were subjected to the structural equation modeling (SEM) analysis.The analysis was performed in the WARPLS 4.0 program because it allows determining also non-linear relationships between the variables included in the structural model.

Results
On Table 1 are shown data obtained from patients.Out of the total number of 364 patients treated in the studied health centers, the largest number stated that they were the most satisfied when the doctor was well organized (4.64), then spontaneous (4.50), attentive and open (4.41).While patients reportedly disagreed with the statement that medical staff had violated their national or social rights (2.10), they were not satisfied with the lenght of time they spent on examinations (2.32), and they did not agree with the statement that health services were equally accessible to all (2.76).

N-Number
The basic parameters of the SEM analysis presented in Table 4 show that the suggested model was statistically significant and that all relevant parameters suggesting significance of the analysis were within the limits that make the model acceptable (Table 4) The obtained results indicate that openness (p = 0.14, P <0.01), as well as authoritativeness (p = 0.15, P <0.01) and purity (p = 0.14, P <0.01) of health workers significantly affect patient satisfaction with the quality of services (Figure 1, Table 5).Other personality dimensions and moral foundations of health workers did not show statistical significance.

Discussion
The quality of the health service can be defined as the degree to which the health service for the individual and the population increases the likelihood of the desired health outcomes, although it is consistent with the current professional knowledge 11 .The categories of healthcare quality indicators such as equipment, facilities, human resources and qualifications were originally developed by Donabedian 12 , while Lohr spent many years devising and expanding this scheme.It is important to keep in mind that researchers suggested that these variables are not a direct measure of quality.Instead, resources are there only to help us determine whether the quality is good or not.The originality of this research lays in establishing direct connections between moral foundations and personality dimensions of health workers and patient satisfaction with primary health service.By analyzing the data, we noticed that if the healthcare worker is more open, the patient is more satisfied.The characteristic of openness is defined by attention to inner feelings, preferences of diversity, enthusiasm, originality, broad interests, and if these characteristics are more pronounced among health workers, patients are more satisfied.Analyzing the authoritativeness factor, which was distinguished by the SEM analysis, it could be noticed that with lower authoritativeness of healthcare workers, patient satisfaction increases.This moral foundation is formed on the basis of the long history of primates and hierarchical social interactions, based on the virtues of leadership, including respect for the rule of laws and respect for tradition 9 .Health workers who tend to violate strict rules and norms, and oblige patients have more satisfied patients, as opposed to those who act strictly according to the rules and do not oblige patients.Frequently, strictness of healthcare workers leads themselves to an undesirable situation, when while respecting the rules they cannot meet every patient's expectations.Analyzing the factor of purity of health workers, it was found that the trait of purity was in a negative correlation with patient satisfaction.This moral foundation is based on the psychology of disgust and contamination.These are basically religious concepts which lead us to aim to live in a sublime, less physical and kinder world.It advocates the idea that the body is a temple that can be desecrated by immoral activities. 9.Purity primarily refers to the respect of the Hippocratic Oath, which implies that health workers should help everyone who asks for help, regardless of religious, gender and national affiliations.Health workers who work according to established standards and norms, without undue concessions, cause less patient satisfaction.Health workers who work outside established standards, who want to grant sick leave although they consider it unnecessary and who are prone to corruption, cause more satisfaction with patients.Although this is in disagreement with literature data, the practice has shown a positive correlation between these phenomena.All this is due to the fact that many patients do not visit a doctor because they are really sick, but for the reasons of getting a sick leave, obtaining documents for going to a disability pension, or getting medical records for the need of collecting medical insurance.Moral psychology is a rapidly growing field, yet progress is limited by the quality and availability of existing measures.The effects of emotion and cognition on moral judgment or investigating the neurological basis of moral judgment demands a validated, standardized stimuli set that covers the moral domain. 16imilar results were published by Huseinspahić (2011), researching the effect of quality of health care as a prerequisite for patient satisfaction.He also partially confirmed that the level of patient (dis)satisfaction is a result of the overall perception of the quality of health services, i.e. confirmation or non-assertion of preferences in terms of the technical and functional dimensions of the quality of health services. 17Also results were published by Shan (2016), patient satisfaction with health care is low in Heilongjiang in China.The fundamental problem of the poor satisfaction of patient is the lack of trust.In addition, inequality of protector of patients' rights, and perceived poor quality of services also contribute to patient dissatisfaction with health care.9] From the attached results of this research, as well as from the research work in the region and on the other continent, it is clearly seen that there is a problem in the health care system, which should be improved by the state in order to make the health care system better, and patients are more satisfied.The medical standard generates conflict zones and ethical dilemmas, while the freedom of choice over the type of medical procedure preferred makes a reference to the manner of understanding, acceptance and application of the new. 20Ethics comes with the message the concept of health from a personal issue, limited to the satisfaction or dissatisfaction of patient.

Limitations and directions for further research
The research could have been carried out on a larger sample, the sample could have included respondents from the whole Republic of Serbia, the research could have been carried out by regions and other instruments could have been used to obtain results and other instruments could be used to produce results and can be extended to the secondary and tertiary levels of health care.On the basis of the mentioned limitations, proposals for further research are suggested: examine the motivation of health workers, examine the emotional status of health workers, how the emotional characteristics of the service providers affect the quality of services in the health systems, and use other questionnaires for this purpose, conduct a research, in which receivers of health services would assess the expertise of health providers, conduct a survey, in which health workers would report their satisfaction with their work and correlate the findings with patient satisfaction, examine the ethics of health workers in cases of patients' taking sick leave.

Conclusions
There is a direct association between the moral foundations (authority and purity), personality dimensions (openness) of health workers, and patient satisfaction with health service.Thus, any strategy for improving the quality of healthcare services should take into account moral and personal characteristics of health workers.The research put emphasis on interpersonal relationships, since humanity is one of the main predispositions of a good healthcare system and quality health care.

Figure 1 :
Figure 1: The influence of the moral foundation and personality dimensions of health workers on patient satisfaction with health service

Figure 1 : 1 :
Figure 1: The influence of the moral foundation and dimension of the personality of health workers on the satisfaction of patients with a healthy service

Table 2 ,
both doctors and nurses score highest on the dimension of conscientiousness (5.66) and lowest on the dimension of neuroticism (3.96).

Table 3
, healthcare workers have the most prominent dimension of empathy for patients (29.32 for doctors and 29.29 for nurses), and the least significant dimension of authoritativeness (28.13 for doctors and 28.13 for nurses).