Descriptive statistics, correlations and reliability of the scales: social support of the superiors, social support of peers, Empowerment global and job satisfaction (N = 370).
\r\n\t
",isbn:"978-1-83962-501-5",printIsbn:"978-1-83962-500-8",pdfIsbn:"978-1-83962-502-2",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"4cbb2249cfca82e925cd46bee62b5b24",bookSignature:"Prof. Bernhard Resch",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10487.jpg",keywords:"Neonatal Infections, Early Onset Sepsis, Late-Onset Sepsis, Respiratory Tract Infections, Gastrointestinal Infections, Bacterial Meningitis, Viral Meningitis, Encephalitis, Measles, Rotavirus, Varicella, Pneumococcal Invasive Infection",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"November 11th 2020",dateEndSecondStepPublish:"December 9th 2020",dateEndThirdStepPublish:"February 7th 2021",dateEndFourthStepPublish:"April 28th 2021",dateEndFifthStepPublish:"June 27th 2021",remainingDaysToSecondStep:"3 months",secondStepPassed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Professor of Pediatrics specialized in neonatal intensive care medicine and neonatal infections, deputy head of the Division of Neonatology at Medical University Graz, international well-known clinical researcher, editor, book author, and reviewer for all pediatric high ranking journals.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"66173",title:"Prof.",name:"Bernhard",middleName:null,surname:"Resch",slug:"bernhard-resch",fullName:"Bernhard Resch",profilePictureURL:"https://mts.intechopen.com/storage/users/66173/images/system/66173.png",biography:'Born in Graz, Austria, Prof. Resch received his medical degree at the Karl-Franzens-University Graz in 1988. Following post-doc studies at the Division of Neonatology, and the Department of Pediatric Surgery of the University Hospital Graz, he became consultant of Pediatrics in 1997 and consultant of Neonatal and Pediatric Intensive Care Medicine in 2000. Since 2004, he is Professor of Pediatrics and since 2008, Head of the Research Unit of Neonatal Infectious Diseases and Epidemiology of the Medical University Graz. Since 2012 he is Deputy Head of the Division of Neonatology of the Medical University of Graz. His main research fields include neonatal infectious diseases, RSV infection, periventricular leukomalacia of the preterm infant, the neonatal microbiome and the role of probiotics.\nHe is a member and board member of several scientific societies including ESPID, past president of the Austrian Society of Perinatal Medicine, and member of the editorial board of several international journals including "BMC Infectious Diseases" and "Frontiers in Pediatrics"',institutionString:"Medical University of Graz",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"5",totalChapterViews:"0",totalEditedBooks:"3",institution:{name:"Medical University of Graz",institutionURL:null,country:{name:"Austria"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"205697",firstName:"Kristina",lastName:"Kardum Cvitan",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/205697/images/5186_n.jpg",email:"kristina.k@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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Although there exists a standard triple therapy (surgical, chemo and radiation), the average survival time for patients with GBM is less than 2 years. Due to the presence of blood-brain barrier (BBB), a naturally made special structure of the vascular wall inside brain parenchyma, it allows only smaller molecules get through the BBB into brain parenchyma, which makes it even more difficult for the chemotherapeutic agent to reach the target tumor cells. In addition, due to the infiltration nature of this tumor, surgical resection with GTR (gross total resection) without damage the brain function is almost impossible to archive. Radiation therapy may produce some partial control of the tumor; at the same time, it not only induces radiation necrosis but also causes additional mutation of the tumor. On the other hand, in contrast to mutations of many other solid tumors from other organ systems, most glioma-associated mutations offer slightly better prognosis for the patients, making the target therapy to those mutations less significant and less important. As mentioned above, it is vitally important and necessary to develop a minimally invasive and greatly effective method for treating the glioblastoma. In this regard, novel GBM treatments including immunotherapy are being investigated [1]. Key challenges in glioma-specific immunotherapy as with many other cancers are the limited immunogenicity of the cancer cells and the immunosuppressive environment of the tumor. Although specific antigens have been identified in several cancers, brain tumors, such as GBM, are considered poorly immunogenic [1]. In addition, the tumor’s heterogeneity and its consistent mutations may contribute further to its poor immunogenicity [1].
Immunotherapy has garnered increasing support in recent years as a treatment for brain tumors. The immune system has a tremendous capacity for targeting and eliminating tumor cells while sparing normal tissues. Following decades of preclinical development and success in other solid and blood-borne neoplasms, many immunotherapies are now being investigated in patients with GBM. Immunotherapeutic classes currently under investigation in patients with GBM include various vaccination strategies, adoptive T-cell immunotherapy, immune checkpoint blockage, monoclonal antibodies, and cytokine therapy. Trails include patients with either primary or recurrent GBM.
Over the past decade, the FDA has approved emerging immunotherapies for a variety of cancers [2]. At present, many studies have proven that the brain is no longer an immune-exempt organ, and there are many interactions between tumors and the brain immune system [3, 4]. The fully functional T-cell bank plays an important part in maintaining immune surveillance and initiating antitumor immune responses. However, glioblastoma (GBM) is particularly good at destroying antitumor immunity and causing severe T-cell dysfunction. In GBM patients, both local and systemic immunosuppressive disorders impair any possible antitumor response. Woroniecka et al. [5] have analyzed and summarized the categories and molecular mechanisms of T-cell dysfunction in GBMs, including senescence, tolerance, anergy, exhaustion, and ignorance.
Adoptive T-cell therapy for brain tumors has received increasing attention as a breakthrough emerging therapy. Adoptive T-cell therapy refers to engineering specific T cells to target the tumor cells and recognize tumor-specific antigens, and eventually cause tumor cells to die through the immune response. Because T-cell immune response is strong and specific, it can distinguish tumor tissue from healthy tissue, and can target malignant cells to prevent distant metastasis, and T cells can proliferate to maintain therapeutic effect. Currently, T-cell immunotherapy includes three types of tumor infiltrating lymphocytes (TIL), T-cell receptor (TCR), and chimeric antigen receptor (CAR). Among them, CAR T-cell therapy is the only therapy that has made significant progress in clinical application. Chimeric antigen receptor T (CAR T) cell therapy refers to using the patient’s own T lymphocytes, which have been re-engineered, loaded with receptors and co-stimulatory molecules that recognize tumor antigens, and expanded into the patient’s body after in vitro expansion to identify and attack their own tumor cell. GBM cells can express a variety of antigens, such as human epidermal growth factor receptor 2 (HER2), interleukin 13 receptor subunit α-2 (IL13Rα2), ephrin-A2 (EphA2), and epidermal growth factor receptor variant III (EGFRvIII), which have been successfully targeted using chimeric antigen receptors T cells (CARs-T) in preclinical models [6].
Studies have shown that CAR T cells targeting EGFRvIII play a role in the treatment of GBM, and multiple trials are ongoing or under preparation. A Phase I study involving 10 patients with relapsed GBM demonstrates the safety and feasibility of EGFRvIII CAR T-cell therapy [7]. IL13Rα2-CARsT cells can produce cytokines, including interferon γ (IFNγ) and tumor necrosis factor-α (TNF-α), and display cytolytic activity by generating a pro-inflammatory microenvironment in mice bearing gliomas. Phase I trials (NCT00730613) for recurrent GBM have been completed and promising results have been shown [8]. Another IL13Ra2-targeted CAR T-cell therapy for patients with recurrent GBM has also shown significant effects [1, 2, 3, 4, 5, 6, 7]. Ahmed and colleagues reported a Phase I study involving 17 HER2 + GBM patients treated with HER2-specific CAR-modified virus-specific T cells, which achieved safety, feasibility, and anti-GBM activity endpoint [9].
Although CAR T cells have high therapeutic potential, complex GBM biological characteristics and tumor microenvironment make CAR T-cell therapy also face challenges.
CAR T cells cannot target intracellular proteins, and tumors may shed their targets and escape treatment. There may also be insufficient proliferation of T cells, resulting in treatment that is not durable. Some researchers are engineering and modifying T cells to improve their antitumor efficacy. Interleukin 12 is an effective pro-inflammatory cytokine. Yeku designed a CAR T cell that carries and expresses IL-12, and proved that the CAR T cell has enhanced proliferation ability, decreased apoptosis, and increased cells toxicity, thereby enhancing antitumor efficacy in ovarian peritoneal cancer [10]. Kevin Bielamowicz et al. created trivalent T cells with three specific CAR molecules (trivalent CAR T cells) to overcome the patient’s antigenic variability in glioblastoma. Compared with monovalent and bivalent CAR T cells, trivalent CAR T cells mediate powerful immune synapses by forming more microtubule tissue centers between CAR T cells and tumor targets, and show stronger cytotoxicity according to each patient [6].
In the future, with the continuous deepening of research, adoptive T-cell strategies will definitely open up a bright path for GBM immunotherapy.
ALT therapy has now evolved to leverage advances in gene engineering and retroviral delivery. Patient-derived T cells can be engineered with antigen-specific T-cell receptors (TCRs) or tumor-specific chimeric antigen receptors (CARs) to confer target recognition independent of and in addition to naturally occurring TCRs. The best studied of these T-cell modifications are CARs. CARs are synthetic receptors that couple the single-chain Fv fragment of a monoclonal antibody with various T-cell signaling molecules, thus endowing T cells with the antigen-specific recognition of the humoral compartment, the intracellular signaling required for cytotoxicity, and the co-stimulation necessary for sustained activity. As such, CAR T cells recognize target antigens without a need for MHC peptide presentation, circumventing one major mechanism of tumor immune escape-MHC downregulation. CAR T-cell therapy has demonstrated promising results and FDA approval for hematological malignancy is expected shortly [11].
Clinically, adoptive T-cell therapy has demonstrated its effectiveness with CAR-based treatment for CD19C B-cell malignancies. A clinical trial for 11 recurrent GBM patients has demonstrated infusions of autologous adoptively transferred human cytomegalovirus (CMV)-specific T cells increased OS to > 57 weeks, with four patients maintaining no progression throughout the study period [12].
Peptide vaccination concerns generation of vaccine based on peptide sequences representing a tumor antigen-specific target. Peptide vaccinations offer the advantage of high specificity and ease of antigen generation. Limitations include poor immunogenicity of peptide [1].
Rindopepimut (CDX-110) is a 14mer amino acid peptide that spans the EGFRvIII mutation site conjugated with keyhole limpet hemocyanin (KLH). In a small single-arm Phase II multicenter trail, 18 patients with newly diagnosed GBM completing standard of care therapy were vaccinated with rindopepimut combined with granulocyte-macrophage colony-stimulating factor (GM-CSF) resulting in a median OS of 26 months [4]. Overall, this vaccine was well tolerated with minimal toxicity.
Another randomized Phase II trial including 65 newly diagnosed EGFRvIII-positive patients with GBM was undertaken. Patients again received rindopepimut combined with GM-CSF following tumor resection and TMZ chemoradiation. The median OS was 24.6 months. Randomized Phase III clinical trial currently underway and initial Phase III data showed increased progression-free survival (PFS) and OS from point of diagnosis [1].
The epidermal growth factor receptor (EGFR) gene expression is associated with a malignant phenotype in multiple cancers, like colon cancer, non-small cell lung cancer, head and neck squamous cell carcinoma, and GBM [13].
The EGFR gene amplification has been reported to be the most common genetic alteration in primary GBMs (40–70%) [13]. In approximately about 50–60% of GBMs with EGFR overexpressed, there is a specific type of EGFR gene variant generally called as EGFR variant III (EGFRvIII) [14]. EGFRvIII is the most common result of gene rearrangement after EGFR gene amplification [15, 16, 17]. Histone modification of gene enhancer on chromosome 7p12 leads to EGFRvIII formation [18]. Juxtaposition of EGFR exon 1 and 8 forms a novel glycine residue between these two exons. Deletion of EGFR exon 2–7 yields a truncated transmembrane protein receptor that lacks the extracellular ligand-binding domain but retains the constitutional tyrosine kinase activity that stimulates malignant growth [19, 20]. At present, there is no evidence of EGFRvIII expression in wild type human tissues [17, 21, 22, 23, 24, 25]. Thus, EGFRvIII serves as a unique tumor-specific antigen and is a candidate for targeted therapy [26]. EGFRvIII can show ligand-independent activity and continuously activate downstream signaling pathway [27, 28], which promotes proliferation, reduces apoptosis, enhances tumor cell xenograft ability, and increases angiogenesis and invasion [22, 27, 29, 30, 31].
According to current research, antibodies that target EGFRvIII for the treatment of gliomas include ABT-414 and AMG-595.
Depatuxizumab mafodotin (depatux-m, ABT-414) is a tumor-specific selection antibody drug conjugate (ADC) composed of an anti-EGFR antibody ABT-806 and a potent microtubule inhibitor (MMAF). Studies by Philips et al. have shown that ABT-414 can selectively kill the tumor cells with EGFRwt or EGFRvIII overexpressed tumor in vivo xenograft models and in vitro. ABT-414 combined with radiotherapy and chemotherapy can significantly inhibit tumor growth in vivo [32]. At present, the clinical trials for the treatment of glioma with ABT-414 mainly include NCT02343406, NCT02573324, NCT02590263, and NCT01800695.
AMG 595 is an antibody-drug conjugate comprising a fully humanized, anti-EGFRvIII monoclonal antibody linked to the maytansinoid DM1, a semisynthetic derivative of maytansine. AMG595 binds to EGFRvIII but not native EGFR; after binding, the AMG595-EGFRvIII complex is internalized via the lysosomal pathway, leading to the release of DM1 and mitotic arrest and potent growth inhibition [13]. AMG 595 exhibited favorable pharmacokinetics and is a unique therapy with possible benefit for some patients with EGFRvIII-mutated GBM with limited therapeutic options [26].
As early as 1863, Rudolf Virchow reported the inflammatory infiltration in tumor tissues and proposed an important connection between cancer and the immune system [33]. In the following researches, the concept of “immune checkpoint molecules” was proposed. One of the important physiological functions of the immune checkpoint molecule is to keep the activation of the immune system within the normal range. Dysfunction of immunological checkpoint molecules can lead to immune evasion in many human tumors. Nowadays, immune checkpoint therapies are attracting a lot of attention from scientists who are devoted to cancer treatment.
It has been recognized that coinhibitory receptors on T cells play an essential role in attenuating the strength and duration of T cell-mediated immune responses. These inhibitory receptors are referred to as immune checkpoint molecules, which are responsible for maintaining self-tolerance and preventing autoimmune reactions [34]. To date, the two most intensely investigated coinhibitory molecules are CTLA-4 (that acts early in T-cell activation) and PD1 (that blocks T cell at late stages of the immune response). It has been demonstrated that blockade of CTL4 and PD1 could induce tumor regression and promote long-term survival in mouse glioma models [34].
Among a lot of immune checkpoint molecules, the membrane-bound molecules programmed death 1 (PD-1) and its ligand PD-L1 (PD-1/PD-L1) are the two most popular markers.
The programmed cell death ligand 1 (PD-L1) protein belongs to the B7 family, and is widely expressed in almost all tumor cells as well as many normal cells. The combination of PD-L1 and PD-1 provides a strong inhibitory signal that inhibits the proliferation, activation, and infiltration of cytotoxic T lymphocytes (CTLs) [35, 36], thereby mediating the immunosuppressive effects of tumors. This is considered to be the major negative regulatory mechanism of CTLs in the cancer microenvironment. More importantly, in addition to binding to PD-1, PD-L1 can also bind to other co-stimulatory molecules such as CD28, CD80, and CTLA-4 in cancer cells [37], which indicates that PD-L1 can mediate a broader and more complex immune regulation mechanism. Therefore, it is important to analyze the expression and cell distribution of PD-L1 in GBM tissues.
Glioblastoma (GBM) creates immune evasion and suppression, thereby evading the body’s immune system and promoting tumor growth. Despite standard management composed of the maximal surgical resection with the combination of radiation therapy and chemotherapy, the median survival time of GBM patients is only 12–15 months after diagnosis [38]. At present, it is found that immunological checkpoint proteins can be blocked by related checkpoint inhibitors, thus becoming a viable target for tumor therapy. Therefore, it is very meaningful to explore new immunotherapy to counteract the immunosuppressive effects in GBM, and necessary to explore new immunotherapy to counteract the immunosuppressive effects in GBM.
The PD-1 ligand, PD-L1 (also known has B7-H1), has been observed to be expressed in GBMs and GBM-associated macrophages, but the positivity rate in GBMs is controversial and highly variable, probably due to the selections of different antibodies by those researches [34, 39, 40]. Berghoff et al. [41] used a non-commercial anti-PD-L1 antibody, 5H1, showed membranous PD-L1 expression in 37.6% of newly diagnosed and 16.7% of recurrent GBMs, and diffuse/fibrillary PD-L1 expression in 84.4% of newly diagnosed and 72.2% of recurrent GBMs. However, in a study with 1035 GBM specimens using SP142 antibody, the positive rate of PD-L1 was only 19% [42]. Our own data, using the same standard in NSCLC (cutoff value was ≥1% of tumor cells expression), showed PD-L1 (clone number 28-8) expressed in 52% (69/133) of GBMs (see Figure 1).
The positive staining of PD-L1 in tumor cells by immunohistochemical stain. The brown color of the glioma cell membrane indicates the positive staining.
Many studies have investigated the association between PD-L1 expression levels and the prognosis of GBM patients. But the results from different studies are non-conclusive. Nduom et al. [43] discovered that positive PD-L1 expression was associated with a poor prognosis, though this result has limited significance. Two recent studies have suggested that positive PD-L1 immunostaining in human GBM tissue means a poor prognosis [44, 45]. However, Berghoff et al. proposed the PD-L1 was not a negative predictor of survival [41], and Lee et al. [46] found the PD-L1 expression did not appear to be an independent factor for unfavorable prognosis according to multivariate analysis.
Efforts aimed at inhibiting the PD-1/PDL1 pathway have shown more promising results. In a preclinical study using the GL261 glioma mouse model, combination of anti-PD-1 antibodies and radiotherapy doubled median survival and elicited long-term survival in 15–40% of mice compared with either treatment alone [34]. Clinically, pembrolizumab, a PD-L1 antibody has been approved by the FDA, to apply in the treatment of metastatic melanoma and NSCLC. In GBM, nivolumab, another PD-1 antibody, developed for GBM patients is being tested with two clinical trials [34].
A randomized Phase III study aimed at testing nivolumab versus bevacizumab in recurrent GBM patients will also test combination therapy of nivolumab and ipilimumab. Another two Phase I/II trials will analyze the effectiveness of combinatorial pembrolizumab and bevacizumab, and combinatorial pembrolizumab with MRI-guided laser ablation in recurrent GBM patients. In addition, MED14736, a humanized PD-L1 mAb, is currently being tested in clinical trials for GBM patients combined with radiotherapy and bevacizumab [34].
Currently, immunological checkpoint inhibitor drugs associated with PD-L1 for the treatment of glioblastoma are undergoing relevant clinical trials. Nivolumab is a fully humanized IgG4 subtype programmed death-1 (PD-1) immune checkpoint inhibitor antibody that binds with high affinity to PD-1 receptors on T cells and blocks their interaction with PD-L1 and restores T-cell antitumor function. There are several clinical trials of nivolumab for GBMs. The first large-scale randomized clinical trial of Checkmate 143(NCT 02017717) evaluated the safety and efficacy of nivolumab in GBM patients. In addition, the trial included a study comparing nivolumab monotherapy with bevacizumab in patients with recurrent GBM [47]. However, in the third phase of the clinical trial, 369 patients with first recurrence of GBM were recruited and it was found that nivolumab failed to prolong OS in patients compared with bevacizumab [48].
Pembrolizumab is another humanized monoclonal IgG4 anti-PD-1 antibody. Pembrolizumab was evaluated in 29 patients with high-grade malignant gliomas, including overall response rate (ORR) on contrast MRI, characterizing toxicities, progression-free survival (PFS), and overall survival (OS) [49]. Another trial about pembrolizumab showed that this drug is well tolerated, but the anti-PD-1 monotherapy was not effective for most GBM patients [50, 51].
In addition, other PD-L1 immune checkpoint inhibitor drugs for GBM that are being studied include durvalumab, atezolizumab, pidilizumab, and so on. Durvalumab is a fully humanized immunoglobulin G1k monoclonal antibody that blocks the binding of PD-L1 to PD-1 and CD80, thereby enhancing the identification and killing of tumor cells by T cells. Atezolizumab is a humanized immunoglobulin G1 (IgG1) monoclonal antibody directly targeting PD-L1. It prevents the interaction of PD-L1 with the receptors PD-1 and B7.1 by binding to L1. Currently, three open clinical trials (NCT 01375842, NCT02458638, and NCT03174197) are investigating atezolizumab in GBM patients. Pidilizumab is a humanized immunoglobulin (Ig) G1 monoclonal antibody directed against human PD-1 to block the combination between PD-1 and its ligands, PD-L1 and PD-L2. NCT01952769 is an ongoing clinical trial evaluating pidilizumab for GBM [52].
In future, besides PD-L1, more immune checkpoint inhibitors will be put into clinical trials to target this highly malignant brain tumor in future. Overall, the combination of various immune checkpoint modulators has shown promising effectiveness in the treatment of some solid tumors. The application of combinatorial checkpoint modulators in GBM and other tumors therefore requires further investigation into the interplay of co-stimulatory and coinhibitory molecules [34].
Although still in its infancy, immunotherapy for cancers has already shown significant effect against some types of malignancy, such as melanoma and lung cancer. Current open clinical trials of immunotherapy for GBM predominantly focus on dendritic cell (DC) vaccines and antibodies targeting immunosuppressive checkpoints have achieved promising immune activity and clinical responses. However, durable and sustained response remains rare, highlighting the need for novel promising approaches including gene therapy and combinatorial immunotherapeutic treatment [12].
Current obstacles for immune therapy for GBM lie in: (1) finding drugs to penetrate the BBB; (2) identifying specific, suitable, and immunogenic tumor antigens; and (3) identifying appropriate pre- and post-therapeutic biomarkers to reliably evaluate the treatment effect [34]. Additional research is necessary in the future to overcome those difficulties and identify a good treatment option or options for patients with GBM.
Classically, organizational psychology has focused on studying negatively charged behaviors such as absenteeism, turnover and work stress, among others [1]. Today, a paradigm shift has allowed us to move from a negative perspective to a more positive one. As a result, positive psychology has emerged, as a movement that currently affects this research effort to better translate organizational projects, and expand and improve psychosocial well-being and quality of life in organizations [2]. This approach to positive psychology, at the level of enhancing the knowledge of a full organizational life, characterized by “positive employees” working in “positive organizations,” is the ideal ground for characterizing so-called “healthy organizations.” This concept of “healthy organizations” describes the great commitment made by organizations in defining strategies and actions characterized by good practices. These measures of a systematic, methodical, clearly delineated and proactive nature aim to improve the processes and outcomes of the organization so as to affect the welfare of both employees and the organization. This bravery on the part of the organization presupposes, however, the introduction of resources and the implementation of good experiences in the search for improvements in the work environment, in order to promote the health of employees and the financial health of the organization [3].
According to this model, healthy organizations consider the following three interrelated components: (1) social resources in the working group (e.g., social support) and structural resources for the execution of tasks (e.g., autonomy); (2) healthy active professionals experiencing high levels of psychosocial well-being; (3) healthy organizational outcomes such as high performance and quality of service [4]. In an attempt to explain each of these three dimensions: (1) strategies aimed at creating social resources in the working group are another strategy adopted by organizations, which can be provided in the form of social support. Social support can be provided to professionals by superiors [5, 6] or by the contributors themselves [7, 8]. Social support can, however, be more “emotional” in the more or less engaging configuration of active emotions with other members, both inside and outside the organization [9, 10]. But it can also have an “instrumental” configuration, through the more or less tangible manner of these interactions that facilitate the achievement of results, work execution, financial assistance and other facilitated aids or assets. In a second dimension, facilitated access to information channels (strategic, technical and practical), support (guidance, monitoring and feedback), resources (material, human or financial) and opportunities (to learn and grow in the organization) are organizational structures of which enable employees to perform their work activities and tasks freely, independently and autonomously. These structurally empowered environments, according to Kanter [11], are conducive to a global perception of greater autonomy and control by employees in carrying out their work, whose execution is more effectively predicted (global empowerment) [12]. Therefore, managers, by providing substantiated infrastructures (increased access to information, resources, support and opportunity), provide their subordinates with the support tools they need to perform their assigned activities and tasks with complete freedom and success. In turn, employees, as people who deserve this trust, must have the skills, abilities and talents necessary to perform these activities and tasks as successfully as possible. The end result is an overall perception of job effectiveness, based on the employees’ perception of global empowerment. This assumption clearly requires managers to implement organizational strategies, which are essential for the promotion of truly empowered social support climates, to trigger high levels of well-being at work. (2) Active and healthy professionals with high levels of psychosocial well-being—employees’ perception of global empowerment enables them to understand greater freedom and independence in the execution and management of their own work. It also allows them to feel more autonomous in decision-making without having to submit to higher authorization. This subjective state favors the appearance of job satisfaction. On the other hand, the social support given by superiors and peers results in professionals having a perception of being loved, cared for, esteemed and valued, based on a social network of mutual assistance [13]. The integration into social groups that establish friendship bonds and guarantee the necessary support to face the demands of work favors the appearance of positive attitudes at work, such as job satisfaction. These two dimensions, namely structured working conditions with sufficient resources to perform tasks independently (i.e., autonomy) and support working group (i.e., social support), are a reliable way to engage people in healthy activities. An increased sense of autonomy and a supportive climate allow employees to experience high levels of job satisfaction, psychosocial well-being and health at work [14, 15] in acting as risk-protecting agents against contracting diseases of a psychosomatic nature. (3) Healthy organizational outcomes, such as high performance and quality of service—the overall perception of empowerment and social support are decisive factors for more effective individual performance [10, 11], quality of life at work [16] and consequent achievement of personal goals [11], such as greater professional and/or personal achievement. In other words, job satisfaction is an indirect indicator of work efficiency and quality of service [12].
In the specific context of health, satisfaction is an important attitude that can benefit patient care [17, 18], particularly the quality of service provided [19, 20, 21]. Job satisfaction also has a positive effect on decreasing turnover intent [22, 23] and absenteeism [24, 25], results that, as we know, are detrimental to individuals and the organization. The above studies confirm and reinforce the general idea advocated by Kanter’s structural empowerment theory (1977) that adequately trained work environments increase motivation and job satisfaction.
The impact of healthy work environments on job satisfaction attitudes has been evidenced in systematic literature reviews [26] and also in numerous studies [27, 28, 29, 30, 31, 32].
These empirical efforts have been widely expressed in comparative country studies—mostly in North America, the United Kingdom and Western Europe—with samples of nurses, physicians and other health professionals e.g.,[17, 33]. Many efforts have been made to prove that professionals working in workplaces that are structured tend to exhibit high levels of job satisfaction (e.g., [34], updated in 2011; [35]). These studies have underlined that a person’s perception of control and responsibility in a confrontation with work is an antecedent factor that determines the advent of job satisfaction. The findings also show a significant positive relationship between empowerment and job satisfaction (for a systematic review, see [36]), regardless of the design adopted or the sample described. Other studies have highlighted the importance of the correlation between empowerment and job satisfaction. This relationship is fundamental in promoting improvements in the quality of care provided but also in retaining people at the organization (e.g., [37, 38, 39, 40, 41]). All these studies reinforce the idea, originally defended by Kanter’s [11] structural empowerment theory that empowered work environments foster motivation and job satisfaction.
In general, positive work attitudes (e.g., job satisfaction) establish a positive and meaningful relationship with work contexts characterized by active social dynamics [42, 43]. An illustrative example is social support, whether from superiors (e.g., [5, 6]) or from peers (e.g., [7, 44]). In particular, there are several systematic literature reviews (e.g., [34, 44, 45, 46]) that have shown that social support, whether provided by superiors or colleagues, is a predictive factor of job satisfaction, work involvement and carer commitment to the organization. These findings have shown that integration into social groups may not only enable the carer to establish bonds of friendship but also ensure the technical support he or she needs to meet the demands of the job. Thus, the positive social interactions that are established, not only between supervisors and health-care providers but also between the health-care providers and work colleagues (peers), in terms of orientation, follow-up, constructive feedback and focus on quality, can be a powerful source of job satisfaction.
This study intends to use only the first two allowances of the above model describing healthy organizations: (1) social resources in the working group (e.g., social support) and structural resources for the execution of tasks (e.g., autonomy); (2) healthy active professionals experiencing high levels of psychosocial well-being through job satisfaction. The permissive Healthy organizational outcomes such as high performance and quality of service would be a consequence of the attitude toward job satisfaction, which will not be evaluated in this study.
The goal is to understand the extent to which social resources in the work group (social support from superiors and peers) and the employees’ perception of global empowerment correlate with job satisfaction (attitude, a characteristic of active and healthy professionals, who perceive a high psychosocial level).
In a descriptive-correlational nature and following a quantitative methodology a model of structural equations was created to evaluate a sample composed of 370 health professionals—physicians, nurses, medical assistants and health technicians—from a private group five-star hospital health service in southern Portugal. It is a convenience sample that allows to draw valid conclusions, since it corresponds to about 50% of the universe of the target population.
With a mean age of 33.49 years (DP = 8.96), this sample is predominantly female (71.4%), in which the participants work in an inpatient regimen (40%), outpatient (38.4%) or another type of regimen (21.6%). The majority work full time (87.6%), in a shift work regime (78.9%) and in fixed schedule (21.1%). The majority of the participants (82.7%) worked in their profession and in the private health group for more than a year (75.7%), in an exclusive regime (80.8%), the rest (19.2%) work not only in this institution, but also in other institutions.
The information was collected through a questionnaire survey. After the request for authorization, the ethics committees of the two hospitals of this private health group approved the study. The research questionnaires were then applied to health professionals who agreed to participate individually during normal working hours in a period of time created for this purpose. Each participant received the informed consent and the questionnaire in independent envelopes, in order to guarantee the desired anonymity and confidentiality at all moments of the information collection.
Global empowerment- assessed through two items from the Global Empowerment subscale of Conditions of Work Effectiveness Questionnaire II (CWEQII2) by Laschinger et al. [12], on a Likert scale ranging from (1)—totally disagree and (5)—I totally agree.
Social support-evaluated through eight items of the social support subscale of the Job Content Questionnaire (JCQ) of Karasek and Theorell [47]: (a) social support of superiors (4 items); and (b) social support of peers (4 items) on a scale ranging from 1 (totally disagree) to 4 (totally agree).
Satisfaction in work-evaluated through the Job Satisfaction Scale (JSS) developed by Lima et al. [48] of eight items that ranged from 1 (totally disagree) to 7 (totally agree).
Descriptive statistics (mean, standard deviation, asymmetry and kurtosis), correlations between the variables under study (Pearson’s coefficients), internal consistency coefficients (Cronbach’s alpha) and the saturated structural equations model, tested to determine the relationships between global empowerment, social support of superiors and peers, and job satisfaction, were performed using the Software for Statistics and Data Science (STATA), version 13. To obtain a global representation of the relationship between social, superior and peer support, global empowerment and professional satisfaction, a saturated model of relationships was projected. This model was submitted to a structural equations test and redesigned from the standardized coefficients. The maximum likelihood (ML) method was used as a parameter estimation procedure to determine the effects (direct and indirect) and mediation [49, 50].
Table 1 presents the descriptive statistics (mean, standard deviation, asymmetry and kurtosis) and the correlations (Pearson’s coefficient) of the studied variables, as well as the reliability coefficients and Cronbach’s alpha of the scales used.
Variables | 1 | 2 | 3 | 4 |
---|---|---|---|---|
1. Social support from superiors | (0.92) | |||
2. Social support from peers | 0.36** | (0.87) | ||
3. Global empowerment | 0.52** | 0.38** | (0.80) | |
4. Job satisfaction | 0.61** | 0.47** | 0.67** | (0.88) |
Media | 3.41 | 3.40 | 3.42 | 4.53 |
Standard deviation | 0.66 | 0.56 | 0.85 | 1.02 |
Asymmetry | 0.80 | 0.59 | 0.35 | 0.19 |
Kurtosis | 0.35 | −0.23 | −0.03 | −0.34 |
Descriptive statistics, correlations and reliability of the scales: social support of the superiors, social support of peers, Empowerment global and job satisfaction (N = 370).
Note: Alpha of Cronbach’s values was presented in parentheses diagonally. All coefficients are significant “**” (p < 0.01).
The mean value of the social support of the superiors was 3.41 (DP = 0.66) and the peers were 3.40 (DP = 0.56), indicating a tendentially positive level of support in the work environment. Global empowerment with an average of 3.42 (DP = 0.85) indicates a reasonable level of perceived global empowerment. Finally, health professionals are very satisfied at work (M = 4.53, DP = 1.02). The values of asymmetry and kurtosis are less than 1, not disrespecting the parameters that characterize normality in the data distribution (|SK| < 3 and |KU| < 10) [51]. The internal consistency of the scales used, assessed using Cronbach’s alpha, show appropriate reliability [52]. As expected, a moderate, positive and very significant correlation was observed between work satisfaction and social support of supervisors (r = 0.61, p < 0.01), of colleagues (r = 0.47, p < 0.01) and global empowerment (r = 0.67, p < 0.01).
With the aim of presenting a global representation of the relationship between global empowerment, social support (of supervisors and peers), and professional satisfaction, the following relationship model was projected: (1) social support (superior and peers) were considered exogenous and predictive variables; (2) global empowerment, an endogenous and exogenous mediator variable; (3) professional satisfaction, endogenous variable and outcome. This model was empirically tested from an analysis of structural equations based on correlations. The analysis carried out had the following steps: (1) design of an over-identified model and (2) redesign of the model from the significant coefficients observed in the previous model, following the guidelines emitted by Acock [49]. For this purpose, a saturated structural equation model was tested, and items that did not present significant weights were then eliminated to determine the relationships between global empowerment, social support of superiors and peers, and satisfaction at work. The estimation of the effects (direct and indirect) as well as the mediation, used the maximum likelihood estimation (ML) method, the adjustment indices of the model and the Sobel test [49, 50].
Figure 1 shows a suitable final model. The adjustment index of the model, evaluated through the chi-square was significant (X2 (2.1) = 79.271, p < 0.01). Values between 2 and 3 indicate a good fit of the model, so the values obtained showed an adjusted model.
Validated final model (N = 370). All coefficients are significant (p < 0.01).
The CFI and TLI indexes were all higher than 0.90 (CFI = 0.972; TLI = 0.953) as these values usually range from 0 to 1, the results show a satisfactory adjustment.
The adjustment indicator values, Standardized Root Mean Square Residual (SRMR) was less than 0.05 (SRMR = 0.035) and the coefficient Root Mean Square Error of Approximation (RMSEA) was from 0.087 [90% CI: 0.067–0.108], tend to hang between 0.05 and 0.08, being acceptable values up to 0.10, The results obtained are satisfactory [53, 54]. Figure 1 also shows the standardized coefficients obtained in the structural equations model, as well as the explained variance (R2) of the variables global empowerment and professional satisfaction. Global empowerment had a positive and significant predictive effect (p < 0.01) on the social support of the supervisor and the peers. Beta values were 0.48 for supervisory support and 0.24 for peer support. The total variance of global empowerment, explained by support from superiors and colleagues, was 38%. The professional satisfaction had a positive and significant predictive effect of global empowerment (β = 0.53, p < 0.01), support of supervisors (β = 0.27, p < 0.01) and support of peers (β = 0.26, p < 0.01). The total of the variance of professional satisfaction, explained by the global empowerment, support of superiors and peers, was 75%.
Regarding the mediating role, global empowerment mediated the influence of superior and peer support on job satisfaction. Support from superiors had a direct and indirect impact on professional satisfaction. Regarding the total effect of superior support on professional satisfaction, 48.2% (27/56) was direct, while 51.8% (29/56) was indirect. Peer support had a direct and indirect impact on job satisfaction. Concerning the total effect of peer support in professional satisfaction, 65% (26/40) was direct, while 35% (14/40) was indirect (Table 2).
Direct effects | Coef. | SE | z | Beta |
---|---|---|---|---|
Empowerment | ||||
Support of the superiors → | 0.62 | 0.07 | 8.49 | 0.48 |
Support of the peers → | 0.36 | 0.09 | 3.95 | 0.24 |
Satisfaction | ||||
Support of the superiors → | 0.45 | 0.11 | 4.64 | 0.27 |
Support of the peers → | 0.48 | 0.10 | 4.39 | 0.26 |
Empowerment → | 0.87 | 0.11 | 8.17 | 0.53 |
Indirect effects | ||||
Empowerment | ||||
Support of the superiors → | (No path) | |||
Support of the peers → | (No path) | |||
Satisfaction | ||||
Support of the superiors → | 0.54 | 0.09 | 6.15 | 0.29 |
Support of the peers → | 0.31 | 0.09 | 3.65 | 0.14 |
Empowerment | (No path) | |||
Total effects | ||||
Empowerment | ||||
Support of the superiors → | 0.62 | 0.07 | 8.49 | 0.48 |
Support of the peers → | 0.36 | 0.09 | 3.95 | 0.24 |
Satisfaction | ||||
Support of the superiors → | 1.01 | 0.10 | 10.29 | 0.56 |
Support of the peers → | 0.79 | 0.10 | 6.56 | 0.40 |
Empowerment | 0.87 | 0.11 | 8.17 | 0.53 |
Direct, indirect effect and total effect of the variables studied (N = 370).
Note: All coefficients are significant (p < 0.01).
Assuming that job satisfaction is a fundamental attitude at work and an indirect indicator of efficiency and quality of service [12], it was intended to evaluate 370 health professionals working in a private hospital group in the south of Portugal. This study was supported by the Healthy and Resilient Organization Model (HERO; [3] in [4]), which provides an interrelationship between three main components: (1) resources in the working group (e.g., social support) and structural resources for the execution of tasks (e.g., autonomy); (2) healthy active professionals experiencing high levels of psychosocial well-being; and (3) healthy organizational results such as high performance and quality of service. In a similar way, it was intended to understand the extent to which social resources in the work group (social support from superiors and peers) and structural resources for the execution of tasks (globally empowered) relate to job satisfaction (experience high levels of psychosocial well-being) in a private hospital group in southern Portugal.
The results showed the role played by social relations in organizations through the positive and significant relationship between social support (from superiors and peers) and job satisfaction. This finding is corroborated by other studies [21, 44, 55, 56]. The predictive effect of social support (from superiors and peers) on job satisfaction was equally evidenced and similar to other findings in this area [34, 44, 46, 57]. This relevant role played by social relations, as has been highlighted in the literature [42, 43], has practical implications for superiors and colleagues, who play a key role in following up and giving constructive feedback to employees regarding the quality of care. Another interesting finding was the positive and significant relationship between global empowerment and job satisfaction. These results are consistent with Kanter’s structural empowerment model [11] and with some investigations [12, 37, 38, 39, 41, 58, 59]. One practical implication of this result obtained through perceived global empowerment (highlighted by the perception of structured work environments characterized by providing easier access to information, resources, opportunities and support) is the need for managers to include this variable in the management of health institutions. This measure of creating healthy environments is crucial for promoting job satisfaction, which in turn is a critical factor in individual and organizational success. Another interesting finding was the mediating effect of global empowerment between social support (from superiors and colleagues) and job satisfaction. These findings are an indication that the global perception of effectiveness at work [12] is a factor that cannot be overlooked by these health institutions, since it can reduce the magnitude of the relationship between social support (independent variable) and job satisfaction (dependent variable). This shows the prevailing power of global empowerment from the point of view of working conditions.
The above shows that carers react emotionally to certain situations that arise from these structural conditions, which in turn influences their attitudes and behaviors [11, 12]. The findings also show the direct effect of social support on job satisfaction. Whether social support came from superiors or peers, the magnitude observed was very similar. This underlines the fact that social support fostered in the workplace, whether affective or instrumental in nature, has the genuine ability, by itself, to have an effect on job satisfaction without having to be mediated by other variables. An important implication for the managers of these institutions is that they should consider creating organizational environments that prioritize the integration of teams (whether superiors or peers) through fostering support and interaction. This strategy is decisive in promoting greater social support perceived in the institution in order to directly achieve job satisfaction. This measure, applicable to the participants in this study, can be extended to all health institutions. The creation of healthy social environments is essential in providing job satisfaction (indirect indicator of quality of service), in order to maximize available resources as well as the excellence of care provided. On the other hand, private health organizations, due to their exponential growth and the high demands from stakeholders, especially patients, who expect a timely response and quality of service, have the additional challenge of promoting employee well-being, so that they can feel motivated, supported and valued, and thus better meet the expectations and challenges that have been created for them.
The findings obtained in the present study should, however, be cautiously interpreted since the cross-sectional design does not allow conclusions to be drawn about the causality that a longitudinal study enables. The second limitation is that global empowerment is not the only mediating factor in the relationship between social support and job satisfaction, as there are other variables that will certainly play an equally relevant role, in mediating in this relationship. Studies of a longitudinal nature could help in better understanding the causal relationships between these variables in health care. A complementary qualitative analysis could also better explain the quality of the emotional and instrumental relationship between subordinates and peers.
The social support of superiors and peers and global empowerment seem to be two important determinants of job satisfaction in health care. The two types of social support, superior and peer, seem to affect job satisfaction both directly and indirectly through global empowerment. These findings are corroborated by Kanter’s theory of structural empowerment [11]. The results show the relevance of social support (from supervisors and peers) that directly and indirectly influences positive attitudes such as job satisfaction. These findings suggest the need to invest in training and the development of social skills. These interventions are essential in fostering a culture of socio-affective support, follow-up and constructive feedback, to provide quality care but also to develop employee commitment to the organization. These results show the indispensability of an organizational culture characterized by greater effectiveness through the creation of infrastructures that enable the sharing of information, support, opportunities and resources that provide health professionals with greater autonomy and influence in their work and participation in decision-making, with a view to continuous improvement and professional development. A culture imbued with social support and empowerment fosters better management of the resources available at the unit and encourages motivation and job satisfaction by encouraging employees to feel needed, responsible and free to use their skills, abilities and skills. Moreover, it helps employees realize that they can count on organizational support, conveying the trust and respect that employees need to identify with the organization’s goals and projects.
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